• OSCAR (oxygenation, safety, comfort, alimentation, rest & relaxation)
• Maslow
• Basic Life Support/CPR/CAB's

• Respiratory Rate & Depth
• Lung Compliance
• Lung Elasticity (elastic recoil)
• Airway Resistance

• Heart
• Arteries
• Veins
• Capillaries
• Coronary Arteries
• Electric Conduction

• Diffusion
• Perfusion
• Hypoxemia
• Hypoxia

• Stress
• Allergic Reaction
• Air Quality
• Altitude
• Lifestyle/Nutrition/Exercise
• Medications
• Temperature

• Calcification of costal cartilage leads to diminshed expansion and recoil
• Diminished cough reflex leading to difficulty expelling mucus or foreign material
• Diminished ability to increase ventilation when oxygen demand increases
• Fewer Cilia
• Declining immune response
• GERD (reflux)

• Heart muscle loses contractile strength
• Heart valves become thicker and more rigid
• Increased vascular resistance
• Dysrhythmias

• Respiratory Infections
  -upper tract (cold, flu)
  -lower tract (bronchitis, pneumonia, TB)
• Pulmonary System Abnormalities
  -structural
  -airway inflammation and obstruction
  -alveolar-capillary membrane disorders
  -atelectasis (collapsed alveoli) 

• Pulmonary Circulation Abnormalities
  -Thrombus (blood clot)/Embolus (moving blood clot - serious)
  -Edema
• Clotting Disorders 
• Central Nervous System Abnormalities
• Neuromuscular Abnormalities

• Hypertension
• Congestive Heart Failure
• Atherosclerosis
• Peripheral Vascular Disease
• Anemia
• Dysrhythmias
  -Artieral Fibrilation (A-fib)
  -Heart Block 

• Chronic Obstructive Pulmonary Disease (COPD)
  -Bronchitis
  -Emphysema
• Asthma
• Pneumonia 

• Hypoventilation
• Dyspnea or Shortness of Breath
• Increased Risk for Infection (stasis of secretions)
• Sleep Apnea - upper airway constriction when lying down
• Increased risk for Artherosclerosis and Hypertension

■ Life expectancy increases.
■  Blood pressure and heart rate decrease.
■  Circulation to the extremities improves within 2
hours.
■  Carbon dioxide levels in the blood begin to drop within 4 hours.
■  Oxygen levels in the blood begin to improve within 8 hours.
■  Digestion improves.
●  Coughing, congestion, and shortness of breath decrease.
●  Overall energy increases.
●  Lungs increase ability to clean themselves, thereby reducing the risk of infection.
■  Risk of heart attack decreases and returns to that of a nonsmoker in 1 year.
■  Risk of lung and other cancers, stroke, and chronic obstructive lung disease decreases.

• Once a person stops smoking the body begins to repair the damage
• Even long time smokers will benefit from stopping
• Suggested Nursing Dx: Ineffective Health Maintenace

• History of lung disease?
• History of frequent respiratory tract infections?
• Allergies?
• Dyspnea-on exertion? at rest? when speaking?
• How many pillows do you use at night? c/o snoring?
• cough - productive/non-productive?
• smoke (1st and 2nd hand)
• flu and pneumonia vaccine
• occupational or environmental hazards
• lifestyle

• History of cardiac or lung disease/medications
• chest pain/palpitations
• shortness of breath
• fatigue/syncope (dizziness)
• edema
• weight gain (unexplained & excessive - 1- 3 lbs in a day)
• lifestyle

• TPR and B/P (vitals)
• Breathing Patterns
• Pain
• Pulse Oximetry
• Respiration Effort
• Cough
• Clubbing (change in nail shape, nail plate angle is 180° or more)
• Diagnostics
• Laboratory
• Cytology
• Radiology
• Skin Tests

• Dry, Productive, Hacking
• What are the other clinical findings?
• Assess sputum color, amount, odor, presence of blood, time of day
• Obtain samples

• Oxygen Saturation (SaO₂)
• Measures light absorption by hemoglobin in the circulaitng red blood cells and calculates percentage of oxygenated hemoglobin.
• Should be >94%
• Monitoring can be intermittent or continuous
• Usually placed on finger, but can also use toe, ear lobe
• Movement, light, poor circulation and fingernail polish can affect

• TPR, B/P (vitals)
• Apical Pulse (rate-regular or irregular, rhythm, murmurs)
• Pulse Deficit (difference between apical and radial pulses)
• Pallor/Cyanosis

• Skin Integrity
• Color
• Temperature
• Hair Distribution (no hair on limbs may mean poor circulation - not enough oxygen getting to cells so hair can grow)
• Peripheral Pulses
• Edema (if with no pulse in extremity, may mean clot)
• Capillary Refill (if more than 3 seconds, problem w/circulation)

• Shortness of Breath
• Anxiety
• Tachypnea
• Tachycardia
• Pallor to cyanosis
• Adventitious breath sounds
• Confusion

• RBC count (varies with altitude)
  -Male: 4.7 to 6.1 million cells/mcL
  -Female: 4.2 to 5.4 million cells/mcL
• WBC count
  -4,500 to 10,000 cells/mcL
  (higher may mean infection, lower may mean immunocompromised)
• Platelets: 150,000 - 400,000/ mm3 

• Hemoglobin (part of RBC that carries oxygen - low may indicate anemia)
  (varies with altitude)
  -Male: 13.8 - 17.2 gm/dL
  -Female: 12.1 - 15.1 gm/dL 

• Tuberculin Skin Testing
• Allergy Testing
• Cytologic Studies: Sputum for Culture (what microorganism) and Sensitivity (what antibiotic and strength will be effective)
• PT/PTT/INR (Coagulation)
• Arterial Blood Gases (ABG's) - most accurate measurement of blood oxygenation (measures pressure of O₂ gas in blood)

• Pulmonary Function Test
• Spirometry (measures inhalation)
• Peak Flow Monitoring (measures exhalation)
• Radiologic Studies (chest x-ray, CAT scan)
• Doppler studies
• EKG (electrical activity of heart)
• Echocardiogram (ultrasound of the heart)

• Ineffective Breathing Pattern r/t pain
• Ineffective Airway Clearance r/t ineffective cough
• Impaired Gas Exchange r/t poor vascular circulation
• Risk for Aspiration r/t ineffective swallow secondary to CVA
• Activity Intolerance r/t build up of secretions in airways secondary to bronchitis

• Illness Prevention
• Health Restoration
  -Facilitate airway
  -Maximize lung expansion
  -Clear secretions
  -Maximize oxygenation
• Facilitate Coping 

• Patient will show no s/s respiratory distress such as shortness of breath while ambulating in hall
• Patient will effectively expectorate secretions after one teaching session
• Lung sounds will be clear to auscultation in all fields
• Respiratory Rate will be between 16 and 20 breaths/minute by 1400
• Oxygen Saturation will be between 95 and 100% on 2L, NC
• Patient will demonstrate spontaneous respirations by tomorrow at noon (if person was on ventilator)

• Decrease Anxiety/Pain
• Position for maximum lung excursion
• Incentive spirometry (inhalation)
• Mobilizing Secretions
  -Deep breathing and coughing
  -Hydration
  -Chest Physiotherapy and Postural Drainage
• Oxygen therapy (cannula, mask, humidified)
• Suctioning
• Aspiration Precautions
• Medicate as ordered 

• Goal met: Patient ambulated to nurse's desk and back to room with no dyspnea. Oxygen saturation remained at 98%, respiratory rate 20 breaths/minute
• Goal partially met: Patient effectively coughed up a large amount of yellow thick secretions after continuous verbal reminders
• Goal not met: Rhonchi ausculated in Right Upper Lobe
• Goal Partially Met: 100 community citizens arrived at clinic and received flu vaccine
• Goal Met: Patient using incentive spirometer 10x every hour while awake

• Fatigue r/t decreased oxygen carrying capacity of the blood secondary to anemia a.e.b. Hbg 9.2, Hct 29
• Ineffective Tissue Perfusion (cerebral) r/t hypoventilation as manifested by slurred speech and drowsiness, SaO₂ of 91%
• Activity Intolerance r/t abnormal heart rate (atrial fibrillation) a.e.b. patient becomes weak and SOB on exertion

• Elevate legs
• Ambulate or perform ROM
• Apply TEDS or Compression Devices

• Turn and reposition
• Avoid prolonged flexion of hips, legs and knees
• Hydrate
• Encourage smoking cessation
• Anticoagulant therapy (Lovenox/Heparin - injection, Coumadin - PO)

(Hydration good for most patients EXCEPT for CHF and renal failure)

• A disorder usually associated with long-term smoking
• Abnormal inflammatory response of the lungs to noxious particles or gases
• Airflow limitation that is not fully reversible
• Bronchitis (chronic): chronic productive cough
• Empysema: permanent enlargement of the air spaces and destruction of lung walls. Increase residual volume/decreased chest compliance and elastic recoil

• Ineffective Airway Clearance r/t expiratory airflow obstruction, ineffective cough, and/or infection
• Impaired Gas Exchange r/t alveolar hypoventilation

• Encourage slow, deep breathing and coughing to mobilize pulmonary secretions
• Teach pursed lip breathing and orthopnic position
• Postural drainage and Chest PT followed by deep breathing and coughing
• Encourage fluids to liquefy secretions for easier expectoration
• Administer broncodilators as ordered
• Administer Oxygen as ordered

• Decreased Cardiac Output r/t pump failure a.e.b. HR 110 O₂ Sat 88% on room air, cyanotic nail beds
• Risk for Activity Intolerance r/t cardiac insufficiency and pulmonary congestion as evidenced by rales ausculated in bilateral lower lungs

• Pneumonia is an acute inflammation of the lung tissue caused by a microbial organism
• Ineffective airway clearance r/t retained secretions and excessive mucus as evidenced by ineffective cough, adventitious breath sounds, dyspnea

• An abnormally low level of red blood cells, hemoglobin, or both
• Causes of anemia include blood loss, abnormal destruction of red blood cells, and deficiencies of red blood cell production (iron deficiency, vitamin B12 deficiency, folic acid deficiency, aplastic anemia, and anemias of chronic disease and chemotherapy)

• Angina (chest pain)
• Fatigue/Weakness/General Malaise
• Restlessness/Anxiety
• Dyspnea
• Nail beds, skin, mucous membranes and conjunctiva become pale
• Tachycardia
• Cold intolerance

• Ineffective Tissue Perfusion
• Activity Intolerance
• Imbalanced Nutrition, Less than Body Requirements

• Assist with ambulation and activities
• Encourage foods that are high in iron such as red meats, eggs, whole grains, green leafy vegetables, legumes, cooking w/iron cookware
• Provide oxygen as needed
• Administer Iron Supplementation as ordered
• Monitor laboratory results (to see if interventions are working)

• Continuous Positive Airway Pressure
• Pressure keeps airways open during inspiration when muscles collapse
• Used most often with sleep apnea (also with premature infants)
• BiPAP uses two levels of pressure, one for inspiration and another for expiration

• Measures inhalations
• Useful to teach patients to deep breath and cough
• Used for patients who are at high risk for atelectasis or pneumonia