Care of the Patient with Respiratory Conditions

Before diving into caring for a patient with a respiratory condition, it is important to have an understanding of the parts and functions of our respiratory system.

Our bodies get oxygen from the air we breathe, and our organs need this oxygen to keep working. When we breathe out, we are getting rid of gases that are harmful to our bodies and must be cleared off. When someone takes a breath in, known as inhalation, their chest rises, and when they breathe out, the chest falls. Some of the other work that the respiratory system does is to protect our airways from unsafe particles that could irritate it. It also warms the air that we breathe in so that it has the same temperature as our body and adds moisture to it so that it has the moisture level that our bodies need (Cleveland Clinic, 2024).

Other parts of our respiratory system include the sinuses, throat, larynx, bronchial tubes,  diaphragm, and lungs. The sinuses make up empty spaces behind the nose and in the cheeks and help warm the air we breathe in and add moisture to it. The throat gathers the air from the nose and passes it down to the lungs. The larynx, or voice box, keeps the airways open during breathing. The two big bronchial tubes join the windpipe to the lungs and are lined with tiny hairs that move things like phlegm up. We have a left and right lung and they are the biggest part of the respiratory system. The lungs, which get bigger when we breathe in and get smaller when we breathe out, take oxygen from the air and move it into the bloodstream, where it is spread all over the body. The lungs move the waste product carbon dioxide from the blood into the air that you are going to breathe out (Cleveland Clinic, 2021).

Everyone, from the very young to the very old, can get respiratory conditions. Respiratory distress in children, particularly in newborns and infants, needs to be treated quickly because illness in young children can get worse much faster compared to adults. Respiratory arrest, where the child stops breathing, is the most common reason for cardiac arrest in children (Main Line Health, 2023).

Aging causes changes in our bodies; all organs, including the respiratory system, are affected. As people get older, the diaphragm becomes weaker and cannot help the lungs expand as they used to. This means that the person cannot breathe in the same amount of oxygen as before and breathe out the same amount of carbon dioxide. The rib cage also becomes thinner. Changes in the lung tissue can cause air to get trapped in the lungs (Medline Plus, 2023).

Around one-third of older people will live in a nursing home at some time in their lives. Nursing home residents are often women who are 85 years of age or older. The chances of living in a nursing home increase with age (American Geriatrics Society's Health in Aging Foundation, n.d.). Pneumonia is a common condition among nursing home residents and often results in the patient being admitted to hospital. Nursing home patients who are admitted to the hospital with pneumonia have a high risk for serious complications, including a decline in function and death (Griffith et al., 2020).

The entire body is affected when the respiratory system does not work correctly. Respiratory conditions include diseases of the airways that carry oxygen to the lungs. Lung conditions cause damage to the lung tissue. This damage leads to scarring or inflammation and makes it hard or impossible for the lungs to expand fully. Lung circulation conditions involve the blood vessels in the lungs. Common conditions include the following.

Flu: Influenza is probably the respiratory condition that we are all most familiar with. It is a condition that affects the nose, throat, and lungs. Most people who get the flu recover from it completely. However, for some people, the complications of the flu can be serious and life-threatening. Those most at risk of developing complications from the flu are:

• Children under two years of age.
• Older people or those who are over 65 years of age.
• People who are living in nursing homes.
• Pregnant women.
• Persons with damage to their immune systems.
• People with chronic health conditions such as asthma, diabetes, heart disease, kidney disease, and liver disease.
• Those who have a body mass index (BMI) of 40 or greater. 

If a person is at risk for flu complications, they should be advised to see their health care provider. If they develop emergency signs of the flu, they must get immediate medical help. In adults, these emergency signs can include:

• Problems with breathing or shortness of breath.
• Chest pain.
• Continuing dizziness.
• Having a seizure.
• Other health conditions that signal the patient has become worse.
• Serious weakness or muscle aches (Mayo Clinic, 2022).

Asthma: This is a major respiratory condition that cannot be spread from person to person. Asthma is caused by the tightening of the small airways in the lungs. This leads to coughing and wheezing when breathing out and sometimes when breathing in. Shortness of breath can occur not only when the person is doing something, but it can also happen when they are resting, and they may experience chest tightness, which makes it hard to take a deep breath. When the symptoms worsen, this is called an asthma attack, which should not be ignored (World Health Organization [WHO], 2023). CNAs can help patients avoid triggers such as mold and pet dander. If the patient experiences an asthma attack, it is important to keep them comfortable (Pressbooks, n.d.).

Bronchitis: This is a condition where there is irritation of the airways that go to the lungs. The airways swell and fill up with mucus. Most often, bronchitis is caused by a virus infection, and this is called acute bronchitis. Chronic bronchitis can be caused by smoking. The main symptom of bronchitis is constant coughing, which usually brings up mucus. Some people can have a dry cough where there is no mucus. Other symptoms of bronchitis include wheezing, a whistling or rattling noise when the patient breathes, having a fever, feeling short of breath, a runny nose, no energy, and feeling tired. Those with bronchitis should be encouraged to drink extra fluids to help thin mucus. They should also be positioned for comfort (Pressbooks, n.d.).

Cancer: Lung cancer is a form of cancer that starts in the patient's lungs. Lung cancer is usually found in older people. Most of those with the condition are 65 years of age or older. Smoking is the main risk factor for lung cancer. The risk increases with the length of time the person smokes and the number of packs a day smoked. Caring for a patient with lung cancer can be hard. The job of the caretaker depends on the amount of care the patient needs. Things to be looked at are how advanced the cancer is, what treatments the patient is getting, and how their general health is. Emotional care is also needed. Having lung cancer can cause a patient to have many different feelings, including sadness, anger, and depression. Listening to the patient talk about their feelings, hopes, fears, and concerns is one of the most helpful things a caretaker can do (Marks, 2022). Patients who have lung cancer should be reminded not to smoke, should be positioned for comfort, and should participate in activities of daily living (ADLs) as tolerated (Pressbooks, n.d.).

Chronic obstructive pulmonary disease (COPD): COPD is not a single disease; it includes a group of diseases that cause blockage to the airflow and breathing problems. It includes conditions such as emphysema and chronic bronchitis. It is a serious condition and is the fourth leading cause of death in this country. In the United States, cigarette smoke is the number one cause of COPD. The symptoms of the condition include persons who cough or wheeze often, having a lot of phlegm, sputum, or mucus, shortness of breath, and finding it hard to take a deep breath. Some patients with COPD may have to use a portable oxygen tank if the oxygen levels in their blood are low. As a caretaker, it is important to know how the oxygen tank works and who and when to call for help if there are problems (Centers for Disease Control and Prevention [CDC], 2023). Patients with COPD should be encouraged to maintain a healthy weight by participating in exercises as they are able, and they should also be encouraged to quit smoking (Pressbooks, n.d.).

Congestive Heart Failure (CHF): CHF occurs when the heart does not pump blood adequately. Because the heart cannot keep up with the demands of the body, it returns to the heart too quickly and starts to back up or get congested. To make up for this congestion, the heart may beat faster and become bigger. People with CHF may experience shortness of breath, swelling, tiredness, coughing, and weight gain (Johns Hopkins Medicine, n.d.).

Croup: Croup is a respiratory infection that can be spread easily from patient to patient. It is found mostly in babies and young children, usually those younger than three years of age (Cleveland Clinic, 2023a).

Cystic Fibrosis: Cystic fibrosis is an inherited disease. Most patients are diagnosed with the condition by the time they are two years of age. However, there are some that are diagnosed when they are adults. People with this condition can have a whole range of symptoms that include very salty-tasting skin, coughing that can last for a long time, often with phlegm, repeated lung infections and pneumonia, wheezing or difficulty breathing, not growing or gaining weight, having problems with bowel movements or having many large, greasy stools, nasal polyps, constant sinus infections, an increase in the size of fingertips and toes, rectal prolapse, and infertility in men.

Pneumonia: Pneumonia is a condition of the lungs. The small air sacs in the lungs fill up with fluid or pus, and this will cause symptoms such as coughing, problems with breathing, chills, and fever. Pneumonia can be mild or serious, and people who are ill with pneumonia may have to be admitted to a hospital. The signs of pneumonia are coughing, which can produce greenish, yellow, or at times bloody mucus, a fever, with sweating and shaking, chills, shortness of breath, tightness in the chest, fast, shallow breathing, complaints of sharp chest pain that is worse when the patient tries to take a deep breath or when coughing, no appetite, poor energy and tiredness, and confusion, which is more common in older people with pneumonia. Since pneumonia can often look like the flu, it is better to see a primary care provider when the symptoms start to get a proper diagnosis. Children and older people should see a primary care provider at the beginning of symptoms. The two most at-risk age groups are children under two years of age and people who are older than 65 years. If you are caring for someone in these age groups or for someone of any age who has a chronic health condition or a weak immune system, make sure that they get medical attention as soon as possible. Patients with pneumonia need a lot of rest, and at home, they will need help with getting meals ready and other chores. They must be reminded not to overdo everyday activities until they are fully better (American Lung Association, 2023a). Depending on the type of pneumonia, patients may need an altered diet and should be reminded to take antibiotics if prescribed (Pressbooks, n.d.).

Tuberculosis (TB): TB is a disease caused by bacteria that mostly affects the lungs. TB spreads in the air when those with lung TB cough, sneeze, spit, talk, or sing. It only takes a few germs inhaled in the air to cause a person to get TB. The good news is that TB can, in nearly all cases, be cured by taking antibiotics. However, if it is not treated correctly, it can lead to death. The signs to look for can be general, such as heavy sweating when sleeping at night, known as 'night sweats,' having chills and fever, losing weight without meaning to, poor appetite, and feeling weak or tired; the symptoms that are found in the lungs include a cough that is continuous for more than three weeks, coughing up blood or sputum, and chest pain (Medline Plus, 2022).

Patricia is in her late seventies and has been residing in the rehabilitation unit for the last week after having major surgery. John, the CNA who has been helping to care for Patricia off and on the past week, notices that Patricia seems a bit more tired than usual. John asks Patricia if she is feeling okay, and Patricia responds, "Everything is fine." John makes a mental note to check on Patricia more frequently throughout his shift. John stops by an hour and a half later to check on Patricia again. She is sleeping soundly, but he notices that she appears flushed and coughs in her sleep while he is in the room. Because he knows she is tired and Patricia is sleeping soundly, John decides not to disturb her.

Later in this shift, John brings Patricia a glass of water, which she requested, and when he walks into the room, Patricia says, "Good morning, John! Nice to see you today." John is confused, as it is evening time, and knows he had just talked to Patricia earlier in the day. He chalks it up to Patricia being slightly confused after just waking up.

He continues routine checks on her throughout his shift but leaves without saying anything to the nurse or other healthcare providers. After the shift change, Patricia's condition seems to worsen. Aaron, the night shift CNA, immediately reports to the nurse that Patricia appears fatigued, flushed, and confused. After vitals were taken, it was determined that Patricia had a high fever and a cough and needed to be seen by a primary care provider to determine the cause. Patricia was diagnosed with pneumonia and was transferred to the medical-surgical floor to receive the appropriate treatment.

While Patricia did receive the appropriate care, it was delayed. John recognized that Patricia was not at her baseline but did not report that to the nurse or healthcare provider. If he had, Patricia may have gotten a pneumonia diagnosis earlier on and started treatment sooner.

Depending on work area, qualifications, and experience, some of these tasks are associated with caring for someone with a respiratory issue and include the following (American Geriatrics Society's Health in Aging Foundation, n.d.):

• Helping patients with ADLs such as bathing, grooming, toileting, dressing, and feeding.
• Maintaining a clean and safe setting for patients and their families.
• Noting how the patient is behaving to spot changes in their physical or mental condition and reporting these to the patient's primary care nurse.
• Taking the patient's vital signs at the times they are ordered.
• Regular checks on equipment that is being used with the patient such as pulse oximeters, blood pressure monitors, respiratory rate monitors, and oxygen delivery devices. These would include nasal cannulas and face masks. Regular skin checks under face masks and tubing are necessary to look for redness and skin irritation. One of the most common places a patient with a face mask or oxygen tubing will develop redness is around the ears.
• Being a resource for other members of the healthcare team.

Patients with respiratory conditions not only have problems with breathing, but this affects everything else that they do. They become tired more easily and have less energy to do everyday things such as bathing, dressing, and even eating. They also have anxiety when they cannot get enough oxygen.

Having empathy is important when caring for patients with respiratory conditions. Empathy is being able to value and share the feelings of other people. It helps the caregiver to connect with the patients they are looking after and their families. Empathy makes it easier to talk with patients and those close to them and to be able to offer comfort and support(Moudatsou et al., 2020).

A CNA needs to communicate well with patients, their families, nurses, primary care providers, and therapists. Sometimes, it's easy to think, "Maybe I'm wrong, I should not say anything." It is wise to keep in mind that everyone is wrong from time to time, including primary care providers, nurses, and therapists, and in the interests of the patient, it is better to speak up and voice your concerns.

Providing comfort and support does not mean that the CNA forgets about professional boundaries. A professional boundary is a safe space between the patient and the CNA. In the relationship between the patient and the CNA, the patient is, to some degree, helpless and needs care, while the CNA has a certain amount of power because they can give the care that the patient needs. Some examples of crossing professional boundaries include:

• Sharing personal information with the patient.
• Keeping secrets with or for a patient.
• Acting as if you are the only one who knows how to care for the patient.
• Showing favoritism by spending more time with one particular patient.
• Complaining or making jokes about your employer or other team members to a patient.
• Sharing information about a patient or the time you spend with them on social media (Nyhus, 2021).

To prevent crossing professional boundaries, the CNA should:

• Treat all the patients you are caring for with the same dignity and respect.
• Always speak and act professionally.
• Keep patient information confidential and only talk about patients with coworkers when it is needed.
• Ask for information about a patient on a need-to-know basis.
• Nothing about the patient, or even hints about the patient's care, should be posted on social media (Nyhus, 2021).

A CNA must have all the information they need to know to provide safe and complete care to a patient. However, if some facts do not have anything to do with patient care, the CNA should not ask about them. CNAs also need to be good at organizing and keeping track of patient information such as patient vital signs, special needs of a patient, and supplies needed.

Callie is helping to train a new CNA who is coming to work on the cardiac unit. They are doing a room check to make sure that it has everything that is needed for the patient. Callie points out to Brian, the new CNA, that first, they look to see if the correct signs are on the patient's room door. This patient is on oxygen and is on contact precautions, and both signs are on the door. They then use the hand sanitizer, which is immediately outside the room door, to clean their hands before entering the room.

Callie approaches the patient's bed, says the patient's name in a soft voice, "Ms. Brown," and gently touches her arm. Callie asks the patient if she needs anything, and Ms. Brown raises her right index finger. Callie tells Brian that this means 'no.' Callie explains to Brian that since Ms. Brown has a tracheostomy and still uses a ventilator for part of the day, her healthcare team uses different gestures to make it easier for Ms. Brown and her caregivers to communicate with each other. Callie points to a picture chart on the wall next to the patient's bed that has different gestures that are used with Ms. Brown and what each one means. Callie says that this also helps the patient's family members communicate with the patient, and family and healthcare team members know the exact meaning of each gesture, so there is no confusion.

After introducing Brian to Ms. Brown, Callie explained to the patient that they were checking to make sure nothing was missing from her room. First, Callie notes the bag-valve-mask on the wall next to the ventilator. Callie tells Brian that this must always be there. It is used to help the patient to breathe in an emergency. If it is ever found missing from any patient's room who is on a ventilator, the nurse or respiratory therapist must be informed immediately.

Callie points to the sealed tracheostomy kit on the bedside table and tells Brian that it must always be there in case the tube in the patient's airway falls out. The nurse and respiratory therapist check this every shift. However, if the CNA ever finds that this kit is missing or has been opened and not replaced, they must inform the nurse immediately. Callie also tells Brian never to remove any piece of equipment from a patient's room, even if it looks like it has already been opened. Let the nurse know.

Brian asks what he should do if he finds the ventilator alarm sounding. Should he call the nurse and turn it off? Callie tells him to call the nurse immediately but not to turn off the alarm. Stay with the patient, stay calm, and let them know that their nurse is on the way.

When checking the other supplies in the room, Callie found that there were no small gloves in the glove container. Brian wants to know if it's okay for someone with small hands to use the medium size gloves. Callie says that this is not a good practice. Every CNA should have properly fitting gloves so they can easily do care activities. Wearing the wrong size gloves could be uncomfortable for the CNA and the patient and make doing care harder. Callie reminds Brian that it is the CNA's responsibility to make sure that all the supplies needed for patient care, such as gowns, gloves, and masks, are available.

Callie makes eye contact with Ms. Brown, tells her that they are leaving, and asks if there is anything she needs. Ms. Brown indicates that she wants the lights lowered. Callie does this and tells her the time when she will be back to check on her. Ms. Brown looks at the clock on the opposite wall. Callie explains to Brian that it is important to let the patient know that they are not alone and when they can expect to see their CNA again. This helps the patient to be less anxious. If, for some reason, the CNA cannot get back at that time, they should ask someone else, such as the nurse, to check on the patient or to find someone to check on them.

There are many roles and responsibilities of a CNA, especially when caring for someone with a respiratory condition. CNAs can assist with ADLs and other necessary tasks that are essential for self-care. CNAs are also able to help monitor and report vital signs, ensuring the patient is in stable condition. They also help to make sure the patient's environment is safe and promote well-being. Comfort is an essential part of health and well-being, and CNAs play an important role in helping patients maintain comfort. Providing emotional support and companionship is an important part of care.

Caring for someone with a respiratory condition can be hard work. The CNA needs to know about the patient's respiratory problems and other health conditions that the patient has. It is important not to divide the patient into separate conditions. Look at the patient as a whole person and realize that the patient is affected by everything that is going on with them.

• Alberta Health Service (2020). Quick Tips for communicating with a patient on a ventilator. Alberta Health Services. Visit Source.
• American Geriatrics Society’s Health in Aging Foundation. (n.d.). Caregiver Guide: Problems of Daily Living. HealthinAging.org. Visit Source.
• American Lung Association. (2023a). How is Pneumonia Treated? American Lung Association. Visit Source.
• American Lung Association. (2023b). Nutrition Tips for Anyone with Lung Disease. American Lung Association. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2023). Basics About COPD. Centers for Disease Control and Prevention. Visit Source.
• Centers for Disease Control and Prevention (CDC). (2024). About Handwashing. Centers for Disease Control and Prevention. Visit Source.
• Cleveland Clinic. (2021). Bronchi. Cleveland Clinic. Visit Source.
• Cleveland Clinic. (2022). Diaphragmatic Breathing. Cleveland Clinic. Visit Source.
• Cleveland Clinic. (2023a). Croup. Cleveland Clinic. Visit Source.
• Cleveland Clinic. (2023b). Pursed Lip Breathing. Cleveland Clinic. Visit Source.
• Cleveland Clinic. (2024). Respiratory System. Cleveland Clinic. Visit Source.
• Douedi, S., & Douedi, H. (2023). Precautions, Bloodborne, Contact, and Droplet. In: StatPearls [Internet]. StatPearls Publishing. Visit Source.
• Emory. (2022). CNA Study Guide. Emory Test Prep. Published Monroe, IL 2022.
• Elsevier. (n.d.). Respiratory: Oxygen therapy (for nursing assistant training). Osmosis. Visit Source.
• Griffith, M. F., Levy, C. R., Parikh, T. J., Stevens-Lapsley, J. E., Eber, L. B., Palat, S. T., Gozalo, P. L., & Teno, J. M. (2020). Nursing Home Residents Face Severe Functional Limitation or Death After Hospitalization for Pneumonia. Journal of the American Medical Directors Association, 21(12), 1879–1884. Visit Source.
• Johns Hopkins Medicine. (n.d.). Congestive Heart Failure: Prevention, Treatment and Research. Johns Hopkins Medicine. Visit Source.
• Main Line Health. (2023). Pediatric Respiratory Illness. Main Line Health. Visit Source.
• Marks, J. (2022). Caring for Someone with Lung Cancer: What to Know. Verywell Health. Visit Source.
• Mayo Clinic. (2022). Influenza (flu) Overview. Mayo Clinic. Visit Source.
• Medline Plus. (2022). Tuberculosis. Medline Plus. Visit Source.
• Medline Plus. (2023.) Aging Changes in the lungs. Medline Plus. Visit Source.
• Moudatsou, M., Stavropoulou, A., Philalithis, A., & Koukouli, S. (2020). The Role of Empathy in Health and Social Care Professionals. Healthcare (Basel, Switzerland), 8(1), 26. Visit Source.
• Nyhus, J, (2021). What new nurses should know about Professional Boundaries. Nursegrid. Visit Source.
• Pressbooks. (n.d.). 11.10 Respiratory System. WisTech Open. Visit Source.
• Raimonde, A. J., Westhoven, N., & Winters, R. (2023). Tracheostomy. In: StatPearls [Internet]. StatPearls Publishing. Visit Source.
• Steris Healthcare. (2023). What are the types of Fowler's position? Steris Healthcare. Visit Source.
• World Health Organization (WHO). (2023). Asthma. World Health Organization. Visit Source.