A nurse is caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory findings should the nurse expect?
A.
Irregular respirations with frequent periods of apnea
B.
Irregular respirations greater than 20/min
C.
Regular, rapid, shallow respirations
D.
Regular respirations fewer than 12/min
The Correct answer and Explanation is:
The correct answer is A. Irregular respirations with frequent periods of apnea.
Explanation:
Cheyne-Stokes respirations are a type of abnormal breathing pattern often observed in patients who are near the end of life or have severe neurological impairment. This pattern is characterized by a cyclical fluctuation in the depth and rate of breathing, with periods of regular breathing followed by periods of apnea.
Key Features of Cheyne-Stokes Respirations:
- Cyclical Pattern: The breathing pattern typically starts with shallow breaths that gradually become deeper and more rapid until they reach a peak. After this peak, the breaths then gradually become shallower again before stopping altogether for a brief period of apnea (a pause in breathing). This cycle then repeats.
- Period of Apnea: During the apnea phase, which can last for several seconds to a minute, there is a complete absence of breathing. This is a crucial feature that helps distinguish Cheyne-Stokes respirations from other abnormal breathing patterns.
- Irregularity: The respiratory rate is irregular, with variations in both the depth and rate of breaths. The pattern can fluctuate significantly, which makes it distinct from regular, consistent respiratory patterns.
Why the Other Options Are Incorrect:
- B. Irregular respirations greater than 20/min: While irregular respirations are part of the pattern, Cheyne-Stokes respirations are not simply defined by a high respiratory rate. Instead, they involve a cyclical pattern of breathing and apnea. The rate of breathing in Cheyne-Stokes respirations can vary, but the defining feature is the cycle of increasing and decreasing depth with periods of apnea.
- C. Regular, rapid, shallow respirations: This describes a different breathing pattern and does not capture the cyclical nature of Cheyne-Stokes respirations. Regular, rapid, and shallow breathing might be indicative of other conditions such as hyperventilation or anxiety but not Cheyne-Stokes respirations.
- D. Regular respirations fewer than 12/min: This option describes a regular, slow breathing pattern which is not characteristic of Cheyne-Stokes respirations. Cheyne-Stokes respirations are irregular and involve alternating periods of deep and shallow breaths, not a consistent slow rate.
In summary, Cheyne-Stokes respirations are identified by their distinctive cyclical pattern, including irregular respirations with frequent periods of apnea.