The nurse can assess Cheyne-Stokes respiration by its characteristics of respirations that are:
A.
harsh and rattling.
B.
long periods of fast deep breaths.
C.
shallow followed by periods of apnea.
D.
Wheezing and labored.
The Correct Answer and Explanation is:
The correct answer is C. shallow followed by periods of apnea.
Cheyne-Stokes respiration is a type of abnormal breathing pattern characterized by a distinct cyclical pattern of respiration. This pattern involves a progression of breathing that includes:
- Shallow Breaths: The respiration starts with shallow, gradual breaths that become progressively deeper. This phase of the breathing pattern is often characterized by an increasing depth of breaths.
- Peak of Breathing: After the shallow breaths gradually become deeper, there is a peak where the breaths are at their deepest. This is the point where the volume of air exchanged is at its maximum.
- Gradual Decrease: Following the peak, the breaths gradually become shallower again, eventually returning to a very shallow breathing pattern.
- Apnea Periods: After this shallow breathing phase, there is a period of apnea, which is a temporary cessation of breathing. This period of no breathing can last for several seconds to a minute or more, after which the cycle begins again.
This pattern can be indicative of several underlying conditions, particularly those involving the brainstem or severe heart failure. It is commonly observed in patients with central nervous system disorders or in end-of-life situations. Cheyne-Stokes respiration is distinct from other abnormal breathing patterns due to its rhythmic and cyclical nature.
In contrast:
- A. Harsh and rattling: This description is more characteristic of rhonchi, which are continuous, low-pitched sounds that are often associated with mucus in the airways.
- B. Long periods of fast deep breaths: This description might suggest Kussmaul breathing, which is associated with metabolic acidosis and involves rapid and deep breaths without a cyclical pattern.
- D. Wheezing and labored: This describes a breathing pattern that is more indicative of asthma or chronic obstructive pulmonary disease (COPD), where there is difficulty with airflow and wheezing is common.
In summary, Cheyne-Stokes respiration is best identified by its characteristic pattern of alternating periods of shallow breathing and apnea, reflecting its cyclical nature and its underlying pathophysiology.