Respiratory Assessment

Respiratory Assessment ● Done at least once every 8 hours ● Those with chronic physical conditions have findings that are different than expected ● Observe overall changes and monitor for subtle changes, such as chest pain when breathing, shortness of breath, cough, change in sputum color, or sleep disorders ● Consider implementing incentive spirometry, coughing, and deep breathing as interventions Tools ● ● ● ● A watch for counting the respiratory rate A stethoscope for auscultation A pulse oximeter that gives a real-time look at the oxygen level; also provides a pulse Incentive spirometers improve ventilation of the lungs, loosen secretions for expectoration, and promote the exchange of gases by expanding collapsed alveoli ○ During use, the client should sit upright comfortably ○ Have them seal the mouthpiece with their lips and inhale slowly and deeply ○ Have them hold their breath for 2-6 seconds before releasing it ○ This should be done 4-10 times per hour Anatomy Landmarks ● Angle of Louis: Located at the manubriosternal junction before the body of the sternum; useful for rib identification ● Midsternal line: Located down the center of the sternum ● Midclavicular line: A vertical line from the middle of the clavicle over the nipple and down to the lower ribs on the left and right chest wall ● Axillary lines: Anterior, midaxillary, and posterior; down the axilla to the lower rib cage ● Posterior lines: ○ Scapular line: Drawn down through the inferior angle of the scapula ○ Vertebral line: Located down the spinous process of the spine Lobes of the Lungs ● Right upper lobe: Begins slightly above the clavicle and extends to the fourth rib ● Right middle lobe: Extends to the sixth rib ● Right lower lobe: More lateral and extends to the eighth rib ○ The liver is just under this lobe ● Left upper lobe: Starts slightly above the clavicle and extends to the sixth rib ● Left lower lobe: A wedge-shaped ending at the eighth rib Path of Respiration 1. 2. 3. 4. 5. 6. Through the nose Past the paranasal sinuses/through the mouth past the oropharynx structures Past the larynx Reaches the trachea To the right and left bronchus Bronchial passages divide into bronchi, bronchioles, and alveoli Organs of Respiration ● The diaphragm and intercostal muscles are used for breathing ● The oropharynx structures include the uvula, tonsils, adenoids, epiglottis, and glottis ● The trachea divides into the right and left bronchi, which are connected to the upper lobes ○ The right is wider and straighter, making aspiration more likely on the right ● Alveoli are tiny sacs where the exchange of oxygen and carbon dioxide takes place ● Each lung is covered in a separate double-walled pleura or serous membrane ○ The visceral pleura is attached to the outer surface of the lung ○ The parietal pleura is attached to the thoracic cavity and diaphragm ● The lungs are protected by the thoracic vertebrae, ribs, and mediastinum Physiology ● Following inspiration, the respiratory system moves oxygen from areas of high to low concentration, then oxygenates the cells ● Once oxygen reaches the alveoli and is exchanged through capillaries, carbon dioxide is removed from the respiratory system after it moves from the pulmonary capillaries to the alveoli, and back up through the trachea Observe Client ● ● ● ● Perform a visual and auditory inspection Are they sweating? Do they have a strained look on their face? Do you hear noises while they breathe? Position of Breathing ● What position is best for their ease of breathing? ● Clients with respiratory conditions may lean forward in a sitting position while grabbing their knees or use pillows to prop themselves up, helping them to breathe comfortably. Expected Findings ● A relaxed posture, either sitting or standing Expected Variation ● Thoracic breathing, where the chest rises and expands with inspiration and falls and contracts with expiration; is more common in females ● Abdominal/diaphragmatic breathing is more common in males ○ Diaphragmatic breathing: The abdomen moves out with expiration and in with inspiration Unexpected Findings ● Clients with COPD will sit in a tripod position ○ Tripod position: Body learning forward and hands resting on their knees/a table ○ Aids in expiration; uses abdominal, intercostal, and neck muscles to breathe ● Pay attention to the muscles around the neck and throat, which may be hypertrophied from forced respirations ● Intercostal muscle retractions: The muscles between the ribs pull in toward the center of the body; used if breathing is difficult ○ Infraclavicular and supraclavicular muscle retractions may also occur ● Extra muscle work requires additional energy and oxygen use; can lead to fatigue and greater distress if not resolved Assess the Level of Consciousness ● Observe for signs of hypoxia ● Assess consciousness by asking several pointed questions about their current condition and past medical history ● Note their facial expression, which may be anxious or confused with a lack of oxygen Expected Findings ● Clients should look relaxed and comfortable Unexpected Findings ● A client may seem anxious, agitated, or confused, which are manifestations of hypoxia ● Frequent sighing can indicate hyperventilation or an altered respiratory disorder Assess Skin and Fingers for Hypoxia Expected Findings ● Lighter skin tones will have a pinkish hue to the cheeks and nail beds ● Darker skin tones will have darker pigmentation in the oral mucosa and nail beds Unexpected Findings ● In respiratory distress, the skin can be cool, damp, and cyanotic (in late-stage hypoxemia) ○ Cyanosis: Pale or blue around the lipids, nail beds, and mucous membranes ○ Can appear as an ashen or dusky blue tone of the oral mucosa or nail beds ● In long-term hypoxia, there may be clubbing of the ends of phalanges and a ruddy/dark red appearance to the lower extremities ● General pallor can mean anemia, which can result in decreased oxygen levels and give darker skin an ashen appearance ● The client may have dyspnea and orthopnea (difficulty breathing while lying supine), which may require them to have two or more pillows when resting or have the head of the bed elevated Check Respiratory Rate ● ● ● ● Breathing should be smooth, even, and silent without the use of accessory muscles Count the rate for one minute while observing the depth, rhythm, and effort of breathing Eupnea: Expected respiratory rate Placing your hands on the ribs during respirations can help with counting Affecting Factors ● Anxiety and fear can cause tachypnea ● Sedation or injury can cause bradypnea Check Pulse Oximetry ● Measures the oxygen content of the hemoglobin in arterial blood ● Expected to be greater than or equal to 95% ● A value below 90% is a medical emergency ○ Indicates decreased perfusion of the tissues ● Oximeter reading is unreliable in cases of hypothermia, cardiac arrest, shock, peripheral vascular disease, or other conditions resulting in hypoperfusion Intervention Needed: Hyperventilating Assessment Measure Respiratory Rate ● Hyperventilation: Breathing faster and deeper than usual; causes more carbon dioxide to be exhaled than is made through cellular metabolism, resulting in an imbalance ○ Manifestations of hyperventilation include numbness and tingling of the extremities, heart palpitations, chest pain, and lightheadedness ○ Unconsciousness if left uncorrected ● Low levels of carbon dioxide in the blood (hypocarbia) result in respiratory alkalosis Measure Oxygen Saturation ● Measure and record oxygen saturation and respiratory rate Nursing Actions Hyperventilation can be helped by offering support. Instruct Clients to Sit Down ● Assist the client in a position of comfort ● Sitting to avoid falls or elevating the head of the bed Assist Client in Slow Breathing ● Instruct them to maintain eye contact and focus on your voice ● Instruct them to breathe in through their nose and out through their mouth ● It may help to have them breathe in and out of a paper bag or rebreather mask ○ Carbon dioxide is then inhaled back into the lungs Determine and Treat the Cause ● Causes include nausea, pain, anxiety, exercise, or a medical condition ● Find and treat the underlying cause Notify Provider ● Use SBAR format to inform of new findings and client condition ● Include any interventions and the client’s response to them Recheck Status ● ● ● ● ● Recheck respiratory status following intervention Auscultate the anterior, lateral, and posterior lung fields Count respirations, note the rhythm and depth of respirations Assess the oxygen saturation level Ask about their perception of their breathing, anxiety, and any manifestations Health History Interview Client Report ● Client’s report of illness, distress, or concern, including SOB ● Do you have any difficulties breathing or problems with your lungs? ● Do you have a history of respiratory problems (COPD, pneumonia, asthma, anemia, pulmonary emboli)? ● Are you ever short of breath or have noisy breathing, cough, or sputum? ● Do you have chest pain with inspiration or expiration? ● Do you need to sit up to help with breathing? ● Do you have difficulty breathing when lying flat in bed? ● Do you ever cough up blood? ● Do you ever have chest tightness? ● Have you ever been exposed to any type of environmental contaminant? ● Do you smoke? Pipes, cigars, cigarettes, or vape? ● How much per day (packs)? ● Does anyone in your immediate family have respiratory problems? Anterior Chest Assessment ● Position the client sitting or lying on their back ● If they are in respiratory distress, elevate the head of the bed or exam table ● While inspecting the chest, look at the overall shape, configuration, skin color, and respiratory effort/rate Chest Shape and Configuration ● ● ● ● ● Make note of symmetry, including ribs, muscles, and movement The shape of the chest is wider than it is deep The anteroposterior (AP) diameter is less than the transverse diameter; a ratio of 1:2 The rib cage should be angled slightly downward For obese and pregnant patients, place your hands on the ribs during a breath Expected Findings ● ● ● ● Uses the color of the skin, mucous membranes, and nail beds A client with fair skin should have a pinkish hue to them A client with darker skin can have a reddish-purple tone to them The skin should be dry and warm to the touch Expected Variations ● Scoliosis can cause compromised oxygen exchange due to poor lung expansion Unexpected Findings Barrel Chest ● ● ● ● Hyperinflation of the lungs due to COPD or aging The anterior/posterior to transverse diameter is equal The ribs lay horizontally The client may sit in a tripod position Funnel Chest ● Pectus excavatum; a marked sunken sternum and costal cartilage ● Usually begins at the second intercostal space ● Should not cause respiratory distress Pigeon Chest ● Pectus carinatum; protrusion of the sternum with a backward sloping of the ribs ● Should not cause respiratory distress Chest Expansion and Respiration Quality ● Note the expansion of the chest during inspiration ○ Observe the symmetry and smoothness ● Look for any delay in expansion, which impairments like pneumonia could cause Expected Findings ● Breathing should be smooth, even, and relaxed Unexpected Findings ● Chronic conditions can alter findings; a client with asthma, emphysema, and COPD can have a large, inflated chest or noisy breath sounds ● Tachypnea or bradypnea ● Hypoventilation: Irregular, shallow respirations at a rate that is less than expected ● Hyperventilation: Rapid, deep breathing at a rate greater than 24 breaths per minute ○ Often related to a disease process or extreme exertion ○ Can lead to lightheadedness, dizziness, sighing, and numbness of extremities ● Cheyne-Stokes breathing: A “start-stop” breathing pattern ○ May have deeper breathing that may quicken, then hypoventilation and apnea ○ End-of-life breathing pattern ○ Occurs if the CNS is grossly affected by the lack of oxygen or disease progression ● Ataxic breathing: Irregular breathing; varying depths of respiration and periods of apnea ○ Can be caused by brain injury, meningitis, and respiratory depression Auscultation Client Position and Stethoscope Placement ● Start right-to-left or left-to-right; compare one side to the other ○ The first rung of the “ladder” is at the clavicles ● Assess breathing posture, type of breathing, use of accessory muscles, and retractions 1. Place the diaphragm of the stethoscope directly on the skin to prevent friction 2. It can be placed on the right or left side of the anterior chest 3. Listen first on one side, and then the opposite at the same level 4. Ask the client to take 1-2 slow, deep breaths through their mouth with each placement 5. While auscultating, note the intensity of the airflow, pitch, and duration of breath sounds Order of Positions to Auscultate 1. Above the clavicle at the midclavicular line 2. Second intercostal space at the midclavicular line 3. Fourth intercostal space at the midclavicular line and laterally to the nipple line 4. Along the anterior axillary line at the sixth intercostal space 5. Between the midclavicular and anterior axillary line at the eighth or nine intercostal space ● Midsternal line: Down the center of the sternum ● Anterior axillary line: The vertical line extending downward from the anterior axillary fold (front of the armpit) ○ Anterior, midaxillary, and posterior axillary lines are down from the axilla to the lower rib cage ● Midclavicular line: Invisible vertical line from the middle of the clavicle over the nipple and down to the lower ribs on the left and right chest wall. Inspection (Palpation) and Auscultation 1. Inspect the anterior chest as the client breathes for overall appearance, posture, and effort. 2. Place your hands on the client’s anterolateral chest wall along their lower rib cage with your thumbs pointing toward their xiphoid process. Observe your thumbs moving apart during inspiration to assess for equal chest expansion. 3. Instruct the client to take a regular breath through their mouth every time they feel your stethoscope touch their chest. Reassure the client that they can take a break if needed. 4. Position your stethoscope just above the center of the clavicle or midclavicular line. Listen closely during inspiration and expiration. Repeat on the opposite side of the chest. 5. Move the stethoscope down to the second intercostal space at the midclavicular line and auscultate during inspiration and expiration. Repeat on the opposite side of the chest. 6. Move the stethoscope down to the fourth intercostal space at the midclavicular line and auscultate during inspiration and expiration. Repeat on the opposite side of the chest. 7. Move the stethoscope down to the sixth intercostal space at the midclavicular line and auscultate during inspiration and expiration. Repeat on the opposite side of the chest. If the client is female, you’ll need to instruct them to move their breast to the side to enable direct listening on the chest wall. Palpation Expected Findings ● The thumbs should move apart and back together symmetrically ● Movement should be smooth and even Unexpected Findings ● Hesitancy in the movement of one side ○ Hesitancy can indicate trauma, atelectasis, guarding to reduce pain, or pneumonia ● Sensation of grating ○ Grating indicates a pleural friction rub SOB & Congested Cough with Intercostal Retractions Obtain Further Information ● Inspect the chest for symmetry or intercostal retraction ● Determine the amount of restlessness and anxiety ● Auscultate the movement of air in and out of the lungs on the anterior, later, and posterior fields; determine if there are any adventitious breath sounds ● Notify the provider if there is an area with no breath sounds Questions for a Congested Cough ● Is the cough productive or nonproductive? ○ If it is productive, what color is the sputum? ● Is the cough acute or chronic? ● Is the cough intermittent or constant? Measure Oxygen Saturation & Respiratory Rate ● A low oximetry meaning can mean the client is hypoxic or not well oxygenated ● Count the respiratory rate for a full minute due to an irregular breathing pattern ● These abnormal findings can indicate respiratory distress Check Temperature ● Determine if the client is febrile and possibly has a pulmonary infection Assess Nail Bed and Mucous Membranes ● If the nail beds and mucous membranes are dusky, ashen, or cyanotic, it can be an indication of respiratory distress or hypoxia Additional Nurse Actions Positioning ● Ask the client to sit more upright to improve breathing with respiratory distress ● Encourage them to sit in the tripod position to expand the ribs and improve oxygenation ● Be sure the neck is not extended too far, which can restrict breathing Oxygen Therapy ● Oxygen can be delivered via nasal cannula or by face mask ● Monitor oxygen saturation continually while oxygen is on Cough and Deep Breathe ● Ask the client to cough and deep breathe to clear and maintain a patent airway to decrease atelectasis (collapse of all or part of a lung) ● This should be done every hour (2 if sleeping) if a large volume of mucus is produced ● Increases intrathoracic pressure to expel the mucus in and around the alveoli, allowing alveolar reexpansion ● Ask the client if they have chest pain when coughing or a burning sensation with inhaling Incentive Spirometry ● Every hour, ask the client to use the spirometer 4-10 times ● This encourages deep breathing and decreases/prevents atelectasis ○ If followed with coughing, it helps to mobilize secretions to expectorate Mindfulness ● Be mindful of anxiety and help the client to breathe with you ○ Demonstrate and voice the technique Pulmonary Hygiene ● The use of respiratory treatments and medications if prescribed ● Can include suctioning (nebulizer treatments to improve secretion clearance) and physiotherapy (ex. postural drainage, chest percussion, and vibration to clear secretions) ● Humidifying the air can moisten, loosen, and help expectorate sputum Hydration ● Prevents the development of mucous plugs in the airways by thinning secretions ○ Rapid fatigue and respiratory distress can occur otherwise ● 1,500-2,500 mL of fluids are recommended daily Recheck Status ● Carry out the ordered interventions and ensure their efficacy ● Determine if the treatment needs to be changed Posterior/Lateral Chest Shape & Configuration ● Watch the shape and movement of the posterior thorax while the client takes slow, deep breaths in and out through their mouth ● Assess for symmetry, retractions, or accessory muscle use ● Determine if any deformities can impair respiratory function, like scoliosis and kyphosis ○ Scoliosis: Lateral curvature of the spine ○ Kyphosis: Posterior curvature of the thoracic spine (hunchback shape) Expected Findings ● ● ● ● The ribs should slope downward at a 45-degree angle Thoracic chest expansion should be equal with each breath Bilateral scapulae should be symmetrical The spinous processes should appear straight Expected Variations ● With COPD, the chest can have a barrel shape, appearing like continuous inspiration ● With scoliosis/kyphosis, the chest wall expansion will be unequal Unexpected Findings ● Unequal posterior expansion can indicate thoracic trauma, such as a rib fracture or pneumothorax (collapsed lung) ● Pneumonia or inflammation of the pleura can inhibit chest expansion Breathing Posture and Type of Breathing Expected Findings ● The client will sit in a comfortable position Unexpected Findings Posture ● Chronic pulmonary diseases cause clients to sit in specific positions or inability to sit still ● Hypoxia can appear as confusion through breathing patterns and personality behaviors ○ There may be an absence of breath sounds in many lung regions Retractions ● Can indicate respiratory distress ● More noticeable in the lower intercostal spaces ○ Tugging or retractions can appear at the sides of the chest, though Palpation ● Place your thumbs at the level of T0 or T10 with the palms and fingers placed toward the posterolateral walls ● Gently slide the thumbs up slightly to elevate a small amount of skin ● The thumbs should move apart symmetrically as the client inspires deeply ● They should then return to the beginning position afterward Expected Findings ● Symmetric movement of the thumbs away from each other and back to the start ● Smooth and even expansion should be felt Unexpected Findings ● Unequal movement of one side, hesitancy, and a grating sensation ● Unequal movement can indicate trauma or a pneumothorax Auscultate ● Position the client upright, which may require a pillow or blanket roll ● On the posterior chest, be aware of the thoracic vertebrae and their location to assist with identifying the lobes ● Starting from above the scapula to the third thoracic vertebrae are the bilateral upper lobes ● The bilateral lower lobes are located at the tenth thoracic vertebrae ● The right middle lobe is best auscultated from the right lateral chest along the midaxillary line, which may require lifting the right arm ● While auscultating, compare both sides Respiratory Posterior Chest Inspection and Auscultation ● Allow the client to take a full breath at each location but be aware of lightheadedness 1. Start about 3 inches to one side of the spine around C7, listen for inspiration and expiration, and then go to the opposite side 2. Reposition your stethoscope two inches lower and auscultate, and then move to the opposite side 3. Continue repositioning and auscultating at two-inch lower intervals until you reach the lower thoracic spine area 4. Auscultate the lateral sides slightly below the axillary area, again comparing sides 5. Move down to the seventh or eighth rib at the axillary line, auscultate, then repeat on the opposite side of the chest Breath Sounds Four Types of Breath Sounds Tracheal ● Heard over the trachea of the anterior neck area Bronchial ● Heard to the right and left of the trachea and larynx ● Auscultated over the anterior chest only Bronchovesicular ● Heard over the right and left major bronchi ● Place the stethoscope between the first and second intercostal space to the left and right of the sternum when auscultating the anterior chest ● Move between the scapulae and vertebral column when auscultating the posterior chest Vesicular ● Auscultated over the anterior and posterior chest wall ● Heard over a large % of the bilateral lung fields, from the clavicle to the lower rib cage Expected Findings ● Tracheal breath sounds have a loud intensity and high-pitch ○ Inspiration and expiration duration are equal ● Bronchial breath sounds have a loud intensity and high-pitch ○ Inspiration is shorter than expiration ● Bronchovesicular sounds, especially on the right, have a moderate intensity and pitch ○ Inspiration and expiration duration are equal ● Vesicular breath sounds have a more intense and loud airflow in the upper anterior lobes but a softer intensity with a low pitch throughout the other lobes ○ Soft-sounding noises, like wind blowing through trees ○ Inspiration is longer than expiration Unexpected Findings ● Decrease in breath sounds, which could be because of shallow breathing, airway obstruction from a foreign body, tumor, or respiratory disorder ● Adventitious breath sounds; extraneous sounds that are heard ○ Can be the result of mucus in the airway or the popping open of an airway that has partially collapsed ○ If heard, ask the client to take a deep breath and cough to clear the airway ○ If the adventitious breath sounds still remain, determine the type of sound, when it is heard, and where it occurs ● Adventitious breath sounds include: Pleural Friction Rub ● Low-pitched, coarse, grating sound ● Heard on inspiration and expiration ● Caused by inflammation of the pleura; painful Crackles/Rales ● ● ● ● Intermittent rattling, cracking, popping, or bubbling sound Can be fine and high-pitched or coarse and low-pitched Not able to be cleared by coughing Lung conditions like an increase in fluid, inflammation, or consolidations can take up the space around partially inflated alveoli, producing crackles ● Clients with pneumonia, chronic pulmonary disease, or heart failure can have crackles Fine Crackles ● Heard at the end of inspiration ● The entering air causes alveoli to pop open Coarse Crackles ● Heard during inspiration and are loud ● Similar to the sound of blowing into liquid through a straw ● It is the result of reinflating alveoli or air passing through mucus-filled airways Wheezes ● ● ● ● Whistling, high-pitched sounds made when air flows through narrowed airways The client can have inspiratory wheezes, expiratory wheezes, or both Chronic conditions, such as asthma or bronchitis can cause bronchiole edema Distress may be shown depending on the severity of airway swelling and the cause Rhonchi ● A continuous, low-pitched, snoring-type sound; can be heard with inspiration/expiration ● Caused by fluid, mucus, or growth in larger airways ● Can sometimes be cleared with coughing Stridor ● A high-pitched crowing sound that can be heard without a stethoscope ● Result of upper airway obstruction caused by inflammation or a foreign body ● Can be life-threatening Minimal Air Movement Measure Oxygen Saturation ● A pulse oximeter reading below 90% indicates that the tissues are not receiving enough oxygen and require immediate intervention Observe the Rate and Depth of Respirations ● Hypoventilation can refer to a slower rate, shallower depth, or both ● Moves only a small amount of air through the chest and can make auscultation difficult ● Stridor involves a blockage of a large airway and can result in minimal air exchange Inspect the Chest for Movement and Symmetry ● Inspect the anterior and posterior chest and observe the depth of respirations ● Note the movement of the rib cage during inspiration ● A decrease in movement or unequal rise may indicate a disease process Observe the Effort of Breathing ● A decreased airflow through the lungs can present as nasal flaring and the use of accessory muscles in an attempt to maintain adequate levels of oxygen ● Accessory muscle use can include intercostal retractions, observed as pulling in of the soft tissue between the ribs during inspiration ● Infraclavicular and supraclavicular retractions may be used to increase airflow ○ This may be seen by the rising of clavicles and sinking of the skin above/below ● May include pursed-lip breathing Additional Nurse Actions Elevate the Head of the Bed ● Elevating to a semi- or high-Fowler’s position can improve lung expansion ● Assist the client into a tripod position to expand the lung field and improve air exchange ● Ensure that any other condition does not contraindicate any position assumed Instruct to Breathe Deep and Cough ● Can help to clear any mucus in the airways ● An incentive spirometer can be used to facilitate deep breathing Apply Oxygen ● May be delivered via nasal cannula, face mask, or tent depending on the amount ● Some have a chronically low oxygen saturation (< 95%) due to diseases like COPD ○ An increase in the flow rate of oxygen delivery might not be recommended Notify the Provider ● Assessments should be done frequently until stabilization, then at least every 2 hours ● Document and notify if breath sounds progressively diminish or adventitious ones form Documentation ● Provides an accurate picture of the client’s condition ● Documentation for respiratory distress should have the type of breath sounds auscultated, type of breathing inspected, respiratory rate, oximeter reading, and action taken Recheck Status ● Reassess lung sounds, mental status, signs of cyanosis, work of breathing, respiratory rate, and oxygen saturation level ● Determine if the client must change positions ● Note if adventitious sounds are newly present or diminishing Health Promotion Noting Social Habits & History ● Does the client use tobacco products, or are they exposed to secondhand smoke at home? ● Have they received the proper vaccines, such as influenza, pneumococcal, and COVID19? When was the last time one was given? ● Are they exposed to any environmental or occupational conditions that may impact their respiratory or general health? Tobacco Use ● Routine assessments regarding tobacco use and exposure to secondhand smoke along with counseling is recommended ● Tobacco use is associated with respiratory disease development, heart disease, peripheral vascular disease, increased risk of stroke, and cancers of the colon, bladder, kidney, stomach, liver, and pancreas ● Secondhand smoke exposure can lead to asthma, heart disease, lung cancer, respiratory infections, and ear infections ○ Can contribute to sudden infant death syndrome (SIDS) ○ Smoking during pregnancy contributes to preterm births and low birth weights ● Prepare a smoking cessation plan that includes cognitive and pharmacologic therapies ● Assess interest in quitting and offer resources for assistance Immunization Influenza ● ● ● ● Influenza is a viral illness that can be mild to severe and have disabling effects for days CDC recommends a yearly influenza vaccine to everyone above 6 months The vaccine takes up to 14 days to become effective The client may develop a sore arm or flu-like symptoms for a day or two Pneumonia ● People with chronic illnesses or above 65 are encouraged to get the pneumonia vaccine ● Helps to prevent respiratory infections caused by Streptococcus pneumoniae ● Can cause hypoxia and tachycardia; can result in death COVID-19 ● Highly infectious respiratory illness caused by SARS-CoV-2 ● Manifestations can appear 2-14 days after exposure ● Symptoms can be mild to moderate, including cough, fever, fatigue, shortness of breath, loss of taste or smell, illness, or death ● Those with underlying medical conditions are at the greatest risk for severe illness ● Primary vaccination includes a series of one to two injections ● Adverse effects can range from minimal discomfort at the injection site to mild fever and malaise, which usually go away in a few days ● Following primary vaccines, boosters are recommended to keep up with the latest strains