Oxygen, Nutrition, bowel and bladder elimination

• Respiration


  • Movement of air into and out of the lungs (Ventilation or Breathing)
  • Exchange of O2 and CO2 between the lungs and the blood
  • Transport of these gases
  • Exchange of O2 and CO2 between the blood and the tissues
• Functions of the Respiratory System

  • Gas exchange
  • Regulation of blood pH
  • Voice production
  • Olfaction
  • Protection
• Upper Respiratory Tract


  • Nose, Pharynx and Larynx
  • Functions: Transport gases to lower airways, Protects lower airways, Warming, filtration and humidification of air
• Lower Respiratory Tract


  • Trachea, Bronchi and Lungs
  • Functions: clearance mechanism (coughing), immunologic response, exchange of gases
• Factors Affecting Oxygenation


  • Physiological factors
  • Decreased oxygen-carrying capacity
  • Hypovolemia
  • Decreased inspired oxygen concentration
  • Increased metabolic rate
  • Developmental
  • Lifestyle factors (Nutrition, Hydration, Exercise, Smoking, Substance abuse, Stress)
  • Environmental
• Hypoventilation


  Occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide
• Hyperventilation


  A state of ventilation in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism
• Hypoxia


  Inadequate tissue oxygenation at the cellular level
• Assessment of Client with Respiratory Disorders

  • Health History
  • Signs and Symptoms
• Signs and Symptoms


  • Dyspnea
  • Cough
  • Sputum Production
  • Chest Pain
  • Wheezing
  • Clubbing Fingers
  • Hemoptysis
  • Cyanosis
• Physical Assessment of Upper Respiratory Structures

  • Nose and Sinuses
  • Pharynx and Mouth
  • Trachea
• Physical Assessment of Upper Respiratory Structures

  • Chest Configuration
  • Breathing Patterns and Respiratory Rate
  • Breath Sounds
• Diagnostic Procedures


  • Pulmonary Function Tests
  • Arterial Blood Gas
  • Pulse Oximetry
  • Chest X-Ray
  • Pulmonary Angiography
  • Cultures
  • Sputum Studies
  • Computed Tomography (CT Scan)
  • Magnetic Resonance Imaging
  • Fluoroscopic Studies
• Measures to Promote Adequate Respiratory Function

  • Deep breathing and coughing exercises
  • Positioning
  • Maintain a patent airway
  • Maintain adequate hydration
  • Avoid environmental pollutants
  • Perform Chest Physiotherapy
• Chest Physiotherapy (CPT)


  • Technique used to mobilize or loose secretions in the lungs and respiratory tract
  • Consists of external mechanical maneuvers, such as chest percussion, postural drainage, vibration, to augment mobilization and clearance of airway secretions, diaphragmatic breathing with pursed lips, coughing and controlled coughing
• Indications of Chest Physiotherapy

  • Cystic fibrosis
  • Bronchiectasis
  • Atelectasis
  • Lung abscess
  • Neuromuscular diseases
  • Pneumonias in dependent lung regions
• Contraindications of Chest Physiotherapy

  • Increased ICP
  • Unstable head or neck injury
  • Active hemorrhage with hemodynamic instability or hemoptysis
  • Recent spinal injury or injury
  • Empyma
  • Bronchoplueral fistula
  • Rib fracture
  • Fail chest
  • Uncontrolled hypertension
  • Anticoagulation
  • Rib or vertebral fractures or osteoporosis
• Assessment for Chest Physiotherapy

  • Know the normal range of patient's vital signs
  • Know the patient's medications
  • Know the patient's medical history
• Contraindications of Chest Physiotherapy

  • Increased ICP
  • Unstable head or neck injury
  • Active hemorrhage with hemodynamic instability or hemoptysis
  • Recent spinal injury or injury
  • Empyema
  • Bronchoplueral fistula
  • Rib fracture
  • Fail chest
  • Uncontrolled hypertension
  • Anticoagulation
  • Rib or vertebral fractures or osteoporosis
• Assessment for Chest Physiotherapy

  • Nursing care and selection of CPT skills are based on specific assessment findings
  • Know the normal range of patient's vital signs
  • Know the patient's medications
  • Know the patient's medical history
  • Know the patient's cognitive level of functioning
  • Beware of patient's exercise tolerance
• Techniques in Chest Physiotherapy

  1. Percussion

  2. Vibration

  3. Postural Drainage

  4. Coughing

  5. Controlled Coughing Technique

  6. Steam Inhalation
• Percussion


  Chest percussion involves striking the chest wall over the area being drained to loosen pulmonary secretions so that they can be expectorated with ease
• Vibration


  The nurse uses rhythmic contractions and relaxations of arm and shoulder muscles while holding the patient's chest as the patient exhales to help loosen respiratory secretions
• Procedure: Percussion & Vibration

  1. Instruct the patient use diaphragmatic breathing

  2. Position the patient in prescribed postural drainage positions

  3. Percuss or clap with cupped hands or chest wall for 5 minutes over each segment

  4. Avoid clapping over spine, liver, spleen, breast, scapula, clavicle or sternum

  5. Instruct the patient to inhale slowly and deeply. Vibrate the chest wall as the patient exhales slowly through the pursed lips

  6. Place one hand on top of the other affected over area or place one hand place one and on each side of the rib cage

  7. Tense the muscles of the hands and hands while applying moderate pressure downward and vibrate arms and hands

  8. Relieve pressure on the thorax as the patient inhales

  9. Encourage the patient cough, using abdominal muscles, after three or four vibrations

  10. Allow the patient rest several times

  11. Listen with stethoscope for changes in breath sounds

  12. Repeat the percussion and vibration cycle according to the patient's tolerance and clinical response: usually 15-30 minutes
• Postural Drainage


  Positioning techniques that drain secretions from specific segments of the lungs and bronchi into the trachea
• Contraindications of Postural Drainage

  • Unable to tolerate the position required
  • Taking anticoagulation drugs
  • Recently vomited up blood
  • Had a recent rib or vertebral fracture
  • Have severe osteoporosis
  • Unable to produce any secretions
• Procedure: Postural Drainage


  1. The patient's body is positioned so that the trachea is inclined downward and below the affected chest area

  2. Postural drainage is essential in treating bronchiectasis and patients must receive physiotherapy to learn to tip themselves into a position in which the lobe to be drained is uppermost at least three times daily for 10-20 minutes

  3. The treatment is often used in conjunction with the technique for loosening secretions in the chest cavity called chest percussion

  4. Use specific positions so the force of gravity can assist in the removal of bronchial secretions from affected lung segments to central airways by means of coughing and suctioning

  5. The patient is positioned so that the diseased area is in a near vertical position, and gravity is used to assist the drainage of specific segment

  6. The positions assumed are determined by the location, severity, and duration of mucous obstruction

  7. The exercises are performed two to three times a day, before meals and bedtime. Each position is done for 3-15 minutes

  8. The procedure should be discontinued if tachycardia, palpitations, dyspnea, or chest occurs. These symptoms may indicate hypoxemia. Discontinue if hemoptysis occurs

  9. Bronchodilators, mucolytics agents, water, or saline may be nebulized and inhaled before postural drainage and chest percussion to reduce bronchospasm, decrease thickness of mucus and sputum, and combat edema of the bronchial walls, thereby enhancing secretion removal

  10. Perform secretion removal procedures before eating

  11. Make sure patient is comfortable before the procedure starts and as comfortable as possible, he or she assumes each position

  12. Auscultate the chest to determine the areas of needed drainage

  13. Encourage the patient to deep breath and cough after spending the allotted time in each position

  14. Encourage diaphragmatic breathing throughout postural drainage: this helps widen airways so secretions can be drained
• Postural Drainage Positions - Adult

  • Bilateral High Fowler's
  • Apical-right upper lobe-anterior segment: Sitting on side of the bed, Supine with head elevated
  • Left upper lobe-anterior: Supine with head elevated
  • Right upper lobe-posterior: Side-lying with right side of the chest elevated on pillows
  • Left upper lobe-posterior: Side-lying with left side of the chest elevated on pillows
  • Right Middle lobe-anterior segment: Three-fourth supine position with dependent lung in Trendelenburg's position
  • Right Middle lobe-posterior segment: Prone with thorax and abdomen elevated
  • Both lower lobes-anterior segments: Supine in Trendelenburg's position
  • Left lower lobe lateral position: Right side-lying in Trendelenburg's position
  • Right lower lobe-lateral segment: Left side-lying in Trendelenburg's position
  • Right lower lobe-posterior segment: Prone with right side of chest elevated in Trendelenburg's position
  • Both lower lobes-posterior segment: Prone in Trendelenburg's position
• Postural Drainage Positions - Child

  • Bilateral-Apical segments: Sitting on nurse's lap, leaning slightly forward flexed over pillow
  • Bilateral-middle anterior segments: Sitting on nurse's lap, leaning against nurse
  • Bilateral-anterior segments: Lying supine on nurse's lap, back supported with pillow
• Coughing


  Coughing gently or making short grunting noises with the mouth slightly open will help loosen the mucus
• Controlled Coughing Technique


  Inhale deeply through the nose, pause, cough 2 to 3 sharp staccato cough with proper hand/arm placement, breathe in easily through the nose
• Steam Inhalation


  Inhaling the warm vapors of boiling water to reduce viral load, prevent severity of infection, relieve inflammation and congestion, soften thick mucus, aid expectoration, provide heat and moisture, relieve spastic condition of larynx and bronchi, decrease edema of respiratory tract
• Methods for giving steam inhalation

  • Open Jug Method
  • Steam Tent
  • Electric steam inhaler
• The spout of the inhaler must be placed in such a way that it does not directly point towards the face of the patient
• Making a steam tent

  1. Place a screen on either sides on the patient's bed

  2. Stretch blankets or sheets across them thus forming a canopy

  3. Direct the steam into the tent from the spout of the kettle
• Never point the spout toward the face of the patient
• Using a steam tent

  1. Give steam for 20-30 min at a time

  2. Repeat every 4 hrs

  3. Require continuous observation to avoid scalding of the patient
• Electric steam inhaler


  Small electric vaporizers can be used to give steam inhalation
• Using an electric steam inhaler

  1. Fill the jar with water

  2. The water boils and the medicated steam is directed through the spout which is inhaled by the patient
• The spout of the inhaler must be placed in such a way that the patient cannot touch it or put his face too near