NLE Respiratory Nursing — Respiratory Assessment & DiagnosticsConcept Map

Related concepts

Concept connections

• Physical Assessment→AuscultationAuscultation is the final and most diagnostically rich component of physical assessment; breath sounds directly indicate respiratory pathology
• Auscultation→Nursing DiagnosesAdventitious sounds (crackles, wheezes, stridor) form the basis for respiratory nursing diagnoses such as Ineffective Airway Clearance and Impaired Gas Exchange
• Arterial Blood Gas Analysis→Oxygen TherapyABG results (particularly PaO2 and pH) directly guide oxygen delivery device selection and flow rate adjustment; ABG interpretation determines adequacy of current therapy
• Oxygen Therapy→COPD ManagementCOPD patients require special oxygen management with Venturi mask at SpO2 target 88-92% to avoid suppressing hypoxic drive and causing CO2 retention
• Pulse Oximetry→Arterial Blood Gas AnalysisSpO2 measures saturation only; when SpO2 trends concern the nurse or with acute changes, ABG is required to assess ventilation (PaCO2) and acid-base status
• Pulmonary Function Tests→Obstructive vs Restrictive Disease ClassificationFEV1/FVC ratio is the gold standard for distinguishing obstructive disease (ratio <70%) from restrictive disease (normal/high ratio); determines underlying mechanism
• Chest X-Ray→Physical AssessmentChest X-ray findings (consolidation, hyperinflation, pneumothorax) correlate with and confirm physical assessment findings (dullness, hyperresonance, absent breath sounds)
• Chest Tube Systems→Pneumothorax ManagementWater-seal chest tubes are the definitive treatment for pneumothorax; proper management prevents complications like tension pneumothorax and re-expansion pulmonary edema
• Nursing Priorities→Physical AssessmentContinuous respiratory assessment using inspection, palpation, percussion, auscultation enables early detection of deterioration and guides intervention timing
• Inspection→Work of BreathingAssessment of accessory muscle use, retractions, nasal flaring, and tripod positioning indicates severity of respiratory distress and need for intervention escalation
• Percussion→Pleural Effusion DetectionDullness on percussion over lung bases with blunted costophrenic angles on X-ray confirms pleural effusion; physical finding guides diagnostic imaging
• Crackles→Fluid in AlveoliCrackles are the clinical hallmark of fluid within alveoli; heard in pneumonia, pulmonary edema, and heart failure; guides nursing diagnosis and intervention
• Wheezes→Airway ObstructionWheezes indicate narrowed airways from bronchospasm or secretions; primary findings in asthma and COPD exacerbation; guides bronchodilator therapy decisions
• Stridor→Upper Airway EmergencyStridor heard without stethoscope indicates upper airway obstruction and is a medical emergency requiring immediate airway assessment and intervention
• ROME Method→Clinical Decision MakingSystematic ROME interpretation (Respiratory Opposite, Metabolic Equal) enables rapid identification of acid-base disorder type and guides targeted interventions
• Compensation Mechanism→Acid-Base Severity AssessmentPresence of compensation indicates chronic disorder; absence of compensation suggests acute condition; determines urgency of intervention
• Oxygen Delivery Device Selection→FiO2 RequirementsDevice choice is determined by required FiO2; low-flow systems suit stable patients; high-flow systems (Venturi, non-rebreather) suit acute hypoxemia
• Humidification→High-Flow OxygenFlows above 4 L/min require humidification to prevent mucosal drying, nosebleeds, and skin breakdown behind ears; standard safety practice
• Allen Test→Radial Artery SafetyAllen test confirms adequate collateral circulation from ulnar artery before radial ABG draw; negative test mandates alternative site to prevent hand ischemia
• Post-Sampling Pressure Application→Hematoma PreventionMinimum 5 minutes firm direct pressure (longer if anticoagulated) prevents hematoma formation at arterial puncture site; critical patient safety measure
• Peak Expiratory Flow Monitoring→Asthma Control AssessmentTraffic-light zone system (green ≥80%, yellow 50-79%, red <50% of personal best) guides patient self-management and determination of exacerbation severity
• Tidaling→Chest Tube FunctionGentle tidaling (fluctuation with respiration) in water-seal chamber is normal; sudden loss may indicate lung re-expansion or obstruction; guides assessment
• Air Leak Detection→Chest Tube TroubleshootingContinuous bubbling in water-seal indicates air leak; clamp test determines if leak is patient-side or system-side; guides corrective action
• Chest Tube Positioning→System FunctionDrainage system must remain below chest level at all times; elevation risks backflow of drainage into pleural space and undoes therapeutic effect
• Emergency Dressing→Dislodged Tube ManagementSterile occlusive dressing taped on 3 sides only (not all 4) acts as flutter valve to allow air escape while preventing re-entry; critical to prevent tension pneumothorax
• Monitoring Trends→Early Deterioration DetectionConsistent observation of declining SpO2, rising respiratory rate, and rising CO2 signals muscle fatigue and impending respiratory failure; guides escalation of care
• Hypoxic Drive→COPD Oxygen ManagementChronic CO2 retention in COPD creates hypoxic drive to breathe; excess oxygen suppresses this drive and causes dangerous CO2 accumulation; therefore target SpO2 88-92%

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