Chapter 3 – Respiratory System
Health promotion and disease prevention are important components of a healthy respiratory system. To determine appropriate interventions, you should carefully consider all of the collected data, both subjective and objective. As part of subjective data collection, you should inquire about risk factors, social determinants, and other considerations.
The inquiry part is integrated throughout the assessment. Many of the probing questions may be asked when doing the subjective assessment. However, some of the questions will be formulated based on your critical reflection of data collected during the subjective and objective assessment. It is this data that will inform your clinical judgment and the health promotion needed for a specific patient.
Handwashing and Immunization: Self-Care Behaviours
Handwashing and immunization are two important factors that affect respiratory health. Regular handwashing is important in healthcare and work settings, when returning home, prior to making and eating food, and before and after elimination.
Probing questions related to handwashing and immunization include:
- Tell me about when you wash your hands?
- What is involved in washing your hands? (You may need to probe further: What are the steps involved? How long do you do it for?)
- Are you up to date on your vaccines?
- When was your last vaccine? What was it for? (You may need to probe about specific vaccines such as influenza [flu], pneumonia, and COVID-19.)
- Have you had tuberculosis testing and when was your last chest x-ray? (You should ask about the results, if relevant). Asking these questions is important part of screening.
You may need to provide education about proper handwashing practices: when and how. Tell the client that it is important to wash hands frequently, but always when leaving a building, returning home, before and after meals, and before and after using the washroom. Tell them to wet their hands with water, lather with soap for 20 seconds, rinse and dry their hands, and then turn off the tap with their elbow or a paper towel. Consider how to make it fun with children: you could tell them to sing a song that lasts 20 seconds (e.g., Happy Birthday).
With regard to vaccines, consider the recommended schedule based on age and region. In Canada, vaccine schedules are determined by provinces and territories. More information can be found at:
If a client is not up-to-date on their vaccines, you should inquire about the reasons why. If a client is , explore further in a non-judgmental manner. Respond to their specific concerns with objective facts and refer to vaccines in a positive way. Vaccine hesitancy can be the result of misinformation, so it is important to assess the client’s knowledge and intervene as necessary. Vaccine hesitancy may also be associated with cultural beliefs, and can also be influenced by the client’s relationships with others. More information about vaccine hesitancy can be found at:
Smoking and Vaping
First-hand, second-hand, and third-hand smoke are major risk factors that negatively affect the respiratory system. The chemicals in smoke cause inflammation of the blood vessels, and contribute to plaque buildup and narrowing of the blood vessels. Prenatal exposure and exposure to smoke as a child has particularly harmful effects. In addition to the risks of respiratory diseases (e.g., asthma), these children are also predisposed to hypoxia and conditioning the brain to nicotine.
More recently, vaping has become common among adolescents and young adults as well as people trying to quit smoking cigarettes. Vaping involves the inhalation of heated aerosols from a vaping device (e.g., electronic cigarettes, vape pens); the aerosols frequently contain nicotine (Miech et al., 2019). Although vaping aerosols may contain less chemicals than cigarettes, there are still many toxins in vaping that can cause lung damage among other health problems (Park et al., 2021).
Probing questions related to smoking and vaping include:
- Do you smoke cigarettes or any tobacco-related products? Do you vape? If the answer is affirmative, ask probing questions: how much do you smoke (how many packs a day)? How many years? Can you tell me about the reasons that you began smoking? (if they vape, you can ask the same questions, but refer to the word they use).
- If you do not currently smoke, have you ever smoked? If the answer is affirmative, ask similar probing questions, including why the client quit.
- If relevant: Have you ever tried quitting? If the answer is affirmative, ask probing questions: What made you want to quit? How long did you quit for? Did you use any strategies to help you quit?
- If relevant: Have you ever thought of quitting? If the answer is negative, respond in a non-judgmental way: “If you ever want to discuss quitting let me know; there are many resources to help you.”
Client interest in quitting smoking/vaping and collaborative intervention are both important for a successful outcome. The intervention must be tailored to the client. Many options are available: counselling, cognitive-behavioural therapy, support groups, pharmacology treatments (e.g., nicotine replacement therapy), smartphone applications, and short text message services. Sometimes even a brief discussion about the risks and a recommendation to quit smoking or vaping is sufficient.
You should consider both relational and structural health promotion approaches related to smoking and vaping. For example, a client’s success in cessation can be affected by their intimate and physically close relationships with family, friends, and work colleagues. Another issue to consider is that access to smoking or vaping cessation resources can be costly and are not necessarily covered by provinces and territories. Many primary care clinics offer group support and counselling at no charge, so it can be helpful to encourage clients to access these resources. You may also advocate for healthy social policy around smoking and vaping cessation and support and participate in the development of educational campaigns and resources about how smoking affects health.
Indoor and Outdoor Pollution
Indoor and outdoor air pollution can affect respiratory health and exacerbate respiratory conditions. They may include motor vehicle emissions, living close to a highway, radon or asbestos in the home, chemicals such as glue, paint, asbestos, and other household or workplace products, and air quality/smog/ozone.
Probing questions related to pollution include:
- Tell me about any indoor and outdoor air pollution you are exposed to?
- Do you have any concerns about how indoor or outdoor pollution is affecting your health?
- Have you noticed that your breathing is affected in any specific indoor or outdoor spaces or on hot days? (Air pollutants and humidity associated with hot weather can aggravate breathing problems).
- Do you wear a mask when using chemicals?
Any client concerns about exposure to pollutants should be addressed. Some clients need education about safe storage and use of chemicals such as household cleaning products, and keeping windows closed and avoiding exercise on days when the outdoor air quality is low. You might recommend hard-surfaced floors or rugs, because carpets can trap pollutants.
Nurses play an important role in the underlying structures that influence healthy environments and pollution. Because the environment has such important effects on health and wellbeing, the Canadian Nurses Association (2017) has developed a position statement about Nurses and Environmental Health. In addition to intervening with actions focused on individual behaviours, nurses can be involved in larger structural approaches involving education campaigns, healthy social policy, and scientific research related to the environment.
A healthy diet is important for respiratory health because nutrients and hydration are the fuel the lungs need to breathe and function. Water is a main component of the lungs, and water is essential for the delivery of oxygen throughout the body. Normal fluid losses occur with respiration, and increases this fluid loss, so adequate hydration is essential to effective respiratory functioning. A healthy diet is also important to help maintain an ideal body weight. When a person is obese, the lungs work harder to breathe deep because of the excess weight pushing against the thorax.
Probing questions related to diet include:
- Tell me about your usual diet?
- What have you eaten in the last 24 hours? Is that your usual diet?
- How much fluids do you typically drink in a day? What fluids do you drink (e.g., water, caffeinated beverages, alcohol)?
- Do you live in an area where fresh food and drinking water is difficult to access?
- Do you have enough money to buy healthy food?
You may assess a client’s familiarity with Health Canada’s Food Guide (Government of Canada 2021) and discuss how they might draw upon it to guide their food choices: https://food-guide.canada.ca/en/. Be aware that this new guide still has a Eurocentric element to it; you should collaborate with the client about its relevance in the context of their cultural food practices. A snapshot of the guide is now available in dozens of languages: https://www.canada.ca/en/health-canada/services/canada-food-guide/resources/snapshot/languages.html. Many resources have also been developed related to healthy eating and food safety for Indigenous People:
Some key elements to consider are:
- Water should be the drink of choice: hydration can help keep mucus thin.
- High intake of fruit and vegetable.
- Canada’s Food Guide recommends a dinner plate with half vegetables/fruit, one-quarter protein, and one-quarter whole grains.
Some respiratory-related conditions require specific diets. For example, clients with cystic fibrosis often require increased caloric intake to maintain a healthy weight and enzymes to support the pancreas. In clients with COPD, it is important to also maintain a healthy weight and ensure nutrients such as Vitamin D, C, and E (Berthon & Wood, 2015).
From a structural health promotion approach, consider a client’s access and financial ability to purchase healthy food. These are elements of food security, and the rising cost of food globally has made it difficult to ensure everyone is food secure. In many remote regions of Canada’s North, access to nutritious food is limited in terms of availability, and even when available, the costs are excessive.
A sedentary lifestyle that involves limited activity/exercise is a risk factor that contributes to respiratory conditions and the overall health of the lungs. Exercise, including aerobic and strength-training, strengthens the lungs and the respiratory muscles, making the lungs more efficient at transporting oxygen.
Guidelines vary based on age and health, but individuals should generally participate in about 30 to 60 minutes of aerobic activity five to seven times per week.
Probing questions related to activity include:
- Do you have any concerns about your level of activity or exercise?
- Tell me about your daily pattern of activity? What activities are you involved in?
- What exercise do you engage in? How long do you engage in this type of exercise? How many days of the week do you participate in exercise? If the client plays sports, ask about their use of protective equipment, if relevant.
Collaborate with the client to create an activity/exercise care plan that is specific to their needs and goals. Start at a realistic and attainable level, depending on the client’s physical capabilities and energy level, and then begin to increase the time and duration of the physical activity. Many interventions are available to support clients to achieve their activity goals: community walking groups, fitness apps, and joining a local gym or group activity. The participACTION website is a helpful resource related to activity guidelines: https://www.participaction.com/en-ca. Consider activity interventions from a structural health promotion approach, considering the financial costs associated with many of these resources.
Stress and Distressing Emotions
Stress and distressing emotions are subjective and can affect a person physically, mentally, socially, and financially.
Stress and other negative emotions affect the respiratory system. Stressful states such as anxiety and anger stimulate the sympathetic nervous system and stimulate the body to breathe faster. This can exacerbate existing respiratory conditions such as asthma.
Probing questions related to stress and negative emotions include:
- Tell me about any stress that affects your breathing? Have you had anxiety or panic attacks affect your breathing? If the client’s answer is affirmative to either question, probe further with questions such as:
- Tell me more?
- How does it affect your breathing?
- How often do you experience this?
- What do you do when you experience this?
When considering interventions for a client, consider their daily patterns of living and any disruptions to these patterns, which can be stressful.
Various strategies can help reduce stress, including:
- Engaging in regular physical activity.
- Getting adequate sleep.
- Spending time with family and friends.
- Taking time for personal interests and hobbies.
- Practicing relaxation techniques such as meditation, deep breathing exercises, and tai chi.
- Using pursed lip breathing techniques: this involves taking a slow deep breath in through the nose for two counts and then pursing the lips while breathing out for four counts. It helps with stress and also increases oxygenation and reduces carbon dioxide.
Use relational and structural health promotion perspectives to further assess a client’s stress and how best to act. Stress does not exist in a vacuum: how it is experienced, perceived, and managed is affected by relationships with others. All clients occasionally experience stress, but structural aspects influence how a client may be more at risk for stress. For example, racism is a major determinant that leads to highly stressful experiences, so use of an anti-racist approach to stress and stress management will help you understand how the client is influenced and how best to support them. Other determinants of health related to socioeconomic status can influence access to resources to cope with stress. When collaborating with clients to develop stress management techniques, you must be aware of these broader structural influences.
Activity: Check Your Understanding
Berthon, B., & Wood, L. (2015). Nutrition and respiratory health feature review. Nutrients, 7(3), 1618-1643. https://doi.org/10.3390/nu7031618
Canadian Nurses Association (2017). Nurses and environmental health. https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/nurses-and-environmental-health-position-statement.pdf
Government of Canada (2021). Canada’s food guide. https://food-guide.canada.ca/en/
Miech, R., Johnston, L., O’Malley, P., & Bachman, J. (2019). Adolescent vaping and nicotine use in 2017-2019 – US national estimates. New England Journal of Medicine, 380(2), 192-193. https://doi.org/10.1056/NEJMc1814130
Park, J., Alexander, L., & Christiani, D. (2021). Vaping and lung inflammation and injury. The Annual Review of Physiology, 84(18). https://doi.org/10.1146/annurev-physiol-061121-040014
is when a person is reluctant or refuses to receive a vaccine.
is rapid and deep breathing.