10.1 Monitoring, measurement and evaluation of breathing
Objective
After studying this chapter, you should be able to:
• List the basic methods of physiological measurement;
• Describe the basic types of breathing
• Identify changes in the quality of breathing;
• Apply the principles for measurement of breathing in clinical practice;
• Demonstrate this procedure using a model or simulator in the laboratory and later in clinical practice;
• Assess the risks of potential complications;
• Evaluate the significance of changes in the measured values of breathing.
Purpose
• To collect information about the patient’s condition;
• To assess the patient's condition;
• Incidence of respiratory disorders;
• Incidence of pathological values in the monitored physiological function;
• To prevent other diseases.
Theoretical notes
Breathing (respiration) - process of oxygen intake and release of carbon dioxide. External respiration – the gas exchange between the lungs and blood and internal respiration – the gas exchange between the blood and body tissues. For correct breathing, the following must be in order for:
• Pulmonary ventilation (free airway, functional breathing muscles, vacuum in the pleural cavity, functional respiratory centre);
• Transport of gas across the alveolar-capillary membrane, i.e. external respiration – (functional alveoli, normal respiratory gases and blood pH);
• Perfusion – the gas exchange between blood and alveolar air only occurs when there is contact of blood and air in a sufficiently large area of alveolar-capillary membrane for a sufficiently long time;
• Transport of respiratory gases via blood (sufficient haemoglobin, functional blood circulation);
• Transfer across cell membranes in the periphery of the internal respiration;
• Diffusion – the properties of the membrane, concentration gradient and the area size all contribute to the diffusion rate or the diffuse flow; The diffuse membrane reacts differently to different gases; Carbon dioxide diffuses more easily than oxygen (20x);
during an illness, the transfer of oxygen is affected more than the transfer of carbon dioxide.
Two types of breathing are recognized: Chest (thoracic) and abdominal (diaphragmatic) Respiration consists of inspiration (inspirium) and exhale (exspirium). Pulmonary ventilation expresses the flow of air through the airways to the lungs and back.
Hyperventilation is deep and rapid breathing. Hypoventilation is shallow breathing (see table 10.1-3). The correct operation of the brain centre, nerves and the respiratory muscles is required for proper regulation of respiratory activity. The respiratory centre is located in the medulla oblongata and has two sections: Inspiratory (inhalation), which is larger, as inhalation is active and expiratory (exhalation), which is smaller, because exhalation is passive. Normal breathing (eupnoea) takes place automatically, without the person realizing it. During inspiration, which usually takes 1-1.5 seconds, the diaphragm contracts, the ribs move upward and the sternum moves outward. The anterior-posterior diameter of the chest increases; in the pleural cavity, the reduced diaphragm creates a vacuum that sucks the air into the lungs and enables them to expand. Exspirium, which usually takes 2-3 seconds, is characterized by the release of the diaphragm, the lungs shrink due to their own resilience, the ribs move downward reducing the volume of the chest and the lungs are compressed.
Factors affecting respiration
• Age – the respiratory rate gradually decreases with old age;
• Physical activity – physical activity increases metabolism and thus increases the body’s oxygen demand;
• Stress, fear and worry accelerate breathing;
• Altitude – there is less oxygen in the air the higher the altitude, thus increasing the need for oxygen to the body;
• Medications - certain groups of drugs decrease the respiratory rate, e.g. opiates;
• Smoking, sedentary job and lack of exercise, all affect breathing in a negative way;
• Diseases – lung disease (e.g. airway obstruction), heart disease, anaemia, metabolic disease, disease of central nervous system, intoxication.
Scoring breathing
• Respiratory rate – normal breathing is regular, rhythmic. It is called eupnoea.
Physiological breath values for each age category are listed in Table 10-1 – 1; and the deviations in the frequency of breathing are listed in Table 10.1 -2;
• The depth of breathing can be determined by observing the movements of the chest and the abdomen. Normal breathing depth represents about 500 ml of air – known as lung volume (LV). The maximum volume that can be inhaled from the end-inspiratory level is called the inspiratory reserve volume (IRV), the maximum volume of air that can be exhaled from the end-expiratory position is called the expiratory reserve volume (ERV).
The sum of these volumes is called lung vital capacity (VC), its average physiological
value is 4-5 litres. Changes in the depth of breathing are referenced in Table 10.1-3. An overview of static indicators of lung volume and capacity is referenced in Table 10.1-5.
Individual volumes and derived quantities are referenced in Fig. 10.1-1.
• Breathing regularity – monitoring of alternating inspiration and expiration rhythm.
Rhythm can be regular and irregular. The most common rhythm disorders in breathing are referenced in Table 10.1-4;
• Nature of breathing – this concerns the evaluation of the effort a person must make when breathing and the evaluation of sound phenomena (whistling, bubbling), that may accompany breathing. Shortness of breath (dyspnoe) – laboured breathing, when a patient feels short of breath. Inspiratory dyspnoea is characterized by slow, laboured breathing while pulling in the intercostals and supraclavicular fossas. The expiratory dyspnoea is characterized by severe slow exhalation with active participation of the respiratory muscles.
Age category No. of breaths/min – average values
Newborn 40-60
Infant 25-30
Child up to 10 years old Approx. 20
Adult 16-18
Fig 10.1-1: Respiratory rate according to age
Marked changes in frequency Medical term Average breath values/min
Eupnoea Normal respiration 16-18
Tachypnea Hyperventilation ≤ 25
Bradypnoea Slow respiration ≥ 12
Apnea Respiratory arrest 0
Fig 10.1-2: Evaluation of respiratory rate
Change in depth of breathing Medical term
Deep breathing Hyperpnoea (hyperventilation)
Shallow breathing Hypopnoea (hypoventilation)
Fig 10.1-3: Evaluation of the depth of breathing
Disorder Description Occurrence
Kussmaul respiration Deep, regular, loud Acidosis, diabetic coma, sepsis, uraemia
Cheyne-Stokes respiration
Progressively deeper and sometimes faster breathing, followed by a gradual decrease resulting in apnea.
Acidosis, salicylate intoxication, severe damage to the central nervous system Biot’s respiration
Normal, shallow breathing with apnea periods, the depth of breath is approx. the same.
Overall serious condition, encephalitis, sepsis
Fig 10.1- 4: Most frequent respiratory rhythm disorders
Abbreviatio n
Indicator Value
TLC Total lung capacity (VC + RV) 6,700 ml
RV Residual volume 1,700 ml
VC Vital capacity 5,000 ml
FRC Functional residual capacity (ERV+RV) 2,900 ml
IC Inspiratory capacity (IRV + VT) 3,800 ml
ERV Expiratory reserve volume 1,200 ml
IRV Inspiratory reserve volume 3,300 ml
VT Tidal volume 500 ml
Fig 10.1-5: Overview of lung volume and capacity indicators
BASIC VOLUMES DERIVED RESPIRATORY (VOLUMES) CAPACITY POSITIONS
Fig. 10.1-1: Lung volumes and derived quantities
(Fyziologie tělesné zátěže vybrané kapitoly [online]. 2006 [cit. 2011-11-09]. Dýchací systém. Dostupné z www:
<http://is.muni.cz/elportal/estud/fsps/js07/fyzio/texty/ch05s02.html>.
Patient preparation
Monitoring, measuring and recording breathing depends on the overall condition of the patient.
• The patient should relax for at least 10 minutes before measuring;
• The intention to measure the patient’s breathing is never announced ahead due to the possibility of influencing the frequency and depth of breathing; (evaluation of breathing is not easy, because striated muscles are involved, whose activity is controlled by will power).
Preparation of aids
Observe using a seconds hand, (stopwatch or medical watch), nursing documentation, daily report.
Procedure
• The patient is put in an appropriate position, lying down or sitting.
• Assessment of the skin and mucous membrane colour.
• Assuming a position, the patient begins to breathe.
• It is recommended to pretend to measure the heart rate while actually monitoring and measuring the breathing.
• Monitoring of specific chest movements (thoracic breathing – dominant chest movements, diaphragmatic breathing – dominant abdomen movements).
• The respiratory rate is measured by observing the patient or by placing a hand on the chest.
• Monitor chest respiratory movements for a full minute.
• Observe any additional respiratory phenomena.
• When measuring, do not talk to the patient.
• The measured values are recorded in the nursing documentation and the daily report.
Patient care after the procedure
Patient care after measuring the frequency and quality of breathing is not specific. Try to communicate with the patient and in the case of difficult or laboured breathing, inform the doctor immediately and record this into the nursing documentation. Follow by administering drugs according to the doctor's prescription.
Care of aids after use
If measuring the respiratory rate with a watch with a seconds hand, put it into a designated place so as not to damage it.
Complications of the procedure
• Inadequate patient rest before measuring.
• Measurement of breathing immediately after smoking, eating or in pain.
• Patient restlessness.
• Possible respiratory disorders.
• Insufficient time for measuring breathing.
Task
Practice listening to respiratory phenomena when on clinical practice.
Describe breathing in inflamed bronchi and lungs based on the listening findings.
Describe asthmatic breathing based on listening findings.
Prepare a respiratory curve chart for these types of breathing: Kussmaul, Biot and Cheyne- Stokes.
Control questions:
Choose the correct name for the abbreviations and the breathing volumes:
Abbreviation Name Volume in ml
VT VC RV
1. Which 3 factors are involved in the diffusion of blood gases?
2. What is perfusion?
3. What is respiration typical for diabetic coma, characterized by a deep, loud, regular breathing called?
4. What is a form of respiration with similar exhalations and inhalations similar in depth, and interrupted with apnoea pauses called?
5. Complete the third column with the Latin name for the respiration rates and individual age categories:
Age category Respiration rates/min. Latin name
for respiration rate Child up to 12 years old 20 breaths/min
Infant 10 breaths/min
Adult 40 breaths/min
Newborn 50 breaths/min
Infant 30 breaths/min
Child up to 10 years old 35 breaths/min
Adult 0 breaths/min
Newborn 20 breaths/min
10.2 Monitoring, measurement and evaluation of body temperature
Objective
After studying this chapter, you should be able to:
• List the most common types of thermometers;
• Maintain and check their functions;
• Name the various methods for measuring body temperature;
• Evaluate the resulting measured values of body temperature;
• Describe the system of body temperature regulation;
• Demonstrate this procedure using a model or simulator in the laboratory and later in clinical practice;
• Assess the risks of potential complications;
• Evaluate the significance of changes in the measured values of body temperature;
• Implement nursing care in those changes.
Purpose
• To collect information about the patient’s condition;
• To assess the patient's condition;
• Incidence of thermoregulation disorders;
• Incidence of pathological values in the monitored physiological function;
• To prevent other diseases
• To prevent extensive heat loss from the skin surface.
Theoretical notes
Factors affecting body temperature include:
• Basal metabolism – produces the minimum amount of energy necessary to sustain life.
The value of basal metabolism is dependent on the sex and age and the following generally applies: The younger the person, the higher the value of basal metabolism;
• Increased muscle activity – including tremor. Maximum muscle activity can increase production of heat by up to 50 times;
• Increased temperature of cells (temperature) – increased cell metabolism, based on the changes in the chemical processes in the cell caused for example, by viruses. The increase of body temperature by 10C requires 12% more chemical reactions;
• Thyroid hormones – increased thyroxine flooding can excessively increase cellular metabolism throughout the body;
• Adrenal hormones – whose hormones (adrenalin and noradrenalin) affect the liver and muscle cells, thus increasing their activity;