Oxygenation

OxygenationOxygenation

Chapter 40Chapter 40

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ANATOMY AND PHYSIOLOGY ANATOMY AND PHYSIOLOGY REVIEWREVIEW

• CARDIOVASCULAR/RESPIRATORY CONNECTION– BOTH SYSTEMS MUST BE FUNCTIONING FOR

EITHER SYSTEM TO WORK• heart structure/function• lung structure/function• CNS innervation to chest, diaphragm• Peripheral and cardiac circulation• Adequate volume and hemoglobin• Acid-base balance & regulation• CO2 response/ O2 response

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ALTERATIONS IN OXYGENATIONALTERATIONS IN OXYGENATION

• PHYSIOLOGICAL→ DECREASE IN OXYGEN CARRYING

CAPACITY• ↓ Transport HGB & HCT• ↓ VOLUME R/T BLOOD LOSS• ↓ Binding of O2 [CO]• ↓ Intake of O2 [altitude]• ↑ DEMAND [exercise, fever, illness]

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• PHYSIOLOGICAL→ ↓CHEST WALL MOVEMENT

• PREGNANCY• OBESITY• MUSCULOSKELETAL CHANGES [kyphosis]• TRAUMA [ rib fracture]• CNS ABNORMALITIES [C4 spinal trauma]


• Physiological→ Changes in Delivery of O2– Diffusion in lungs [alveolar]

• atelectasis, ↓surface area, ↓blood supply, pressure• Secretions [pneumonia, COPD]

– Transport to tissues• Cardiac output• circulation [PVD, trauma, volume, vasoconstriction]• Cardiac perfusion

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• PHYSIOLOGICAL– CHRONIC DISEASES

• COPD: CO2 drive absent R/T chronic high pCO2– Dependent on paO2 drive; ↓compliance, atelectasis,

↓clearance of airways

• POLYCYTHEMIA: response to chronic hypoxemia

– CONDUCTION DISTURBANCES– HEART FAILURE

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ALTERATIONS IN RESPIRATORY ALTERATIONS IN RESPIRATORY FUNCTIONINGFUNCTIONING

We breathe to take in O2 and eliminate CO2 • HYPERVENTILATION:

– in excess of what is needed to eliminate CO2

• HYPOVENTILATION: – inadequate to meet O2 needs OR to eliminate CO2

• HYPOXIA• INADEQUATE TISSUE OXYGENATION

• HYPOXEMIA• DECREASED OXYGEN CONCENTRATION IN THE

ARTERIAL BLOOD

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SPECIAL OXYGEN CONSIDERATIONS SPECIAL OXYGEN CONSIDERATIONS ACROSS THE LIFE SPANACROSS THE LIFE SPAN

• INFANTS AND TODDLERS– SURFACTANT [newborn]– Risk for URI– Shorter airways

• OLDER ADULTS– DEGENERATIVE PROCESSES

• Compliance, chest wall movement, accumulated pollutants, cardiac and perfusion changes, alveolar changes, cilia decrease

– CHRONIC DISEASE• HTN, Respiratory, Cardiac, Renal…

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LIFESTYLE FACTORSLIFESTYLE FACTORS

• NUTRITION

• EXERCISE

• SMOKING

• SUBSTANCE ABUSE

• STRESS

• ENVIRONMENTAL FACTORS

Nursing ProcessNursing Process

• Nursing History: Ability to meet O2 needsCardiac function

Respiratory function

Pain

Fatigue

Dyspnea

Cough

Wheezing

Respiratory Infections

Allergies

Risk Factors

Medications

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PHYSICAL PHYSICAL ASSESSMENTASSESSMENT

• INSPECTION– GENERAL APPEARANCE– LOC– SYSTEMIC CIRCULATION– BREATHING PATTERNS– CHEST WALL MOVEMENT

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• PALPATION– THORACIC EXCURSION– AREAS OF TENDERNESS– EXTREMITIES– CAPILLARY REFILL

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• PERCUSSION– AREAS OF CONSOLIDATION

• AUSCULTATION– NORMAL V. ABNORMAL LUNG SOUNDS

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• DIAGNOSTIC TESTS– PULSE OXIMETER– PEAK EXPIRATORY FLOW RATE– ARTERIAL BLOOD GASES– CHEST X-RAY– SPUTUM SPECIMEN– PULMONARY FUNCTION TESTING– BRONCHOSCOPY– VENTILATION-PERFUSION LUNG SCAN [V/Q]– THORACENTESIS– CT / MRI

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Case Study #1Case Study #1

• 36 yo male visiting from Austin, TX with sudden onset” dizzy, confused, headache and hard to breathe” this afternoon. No obvious trauma. No significant medical history; friend states “he’s in great shape – an athlete – he comes here to bike and climb. He’s climbing the fourteeners!”

• VS: T 37.3; P90, R36, B/P 108/58, SPO2 80% on RA• Assessment: pale, anxious, confused, c/o headache.

Oriented to person only. Sinus tachycardia; deep, labored resp. with fine crackles at bases. Extremities cool to touch and pale.

What’s going on?What’s going on?

• What is abnormal?

• What do you think the cause is?

• What should the interventions be?

• Nursing diagnosis for this patient?

Nursing DiagnosesNursing Diagnoses

• Activity Intolerance

• Impaired Gas Exchange

• Ineffective Airway Clearance

• Ineffective Breathing Pattern

• Risk for Infection

GoalsGoals• Pt will:

– Maintain airway– Clear secretions effectively– Increase hydrations [to mobilize secretions]– Improve Oxygenation [SPO2]– Increase activity tolerance– Report decreased Dyspnea [scale 0-10]– Decrease risk factors– Show resolution/ improvement in underlying

cause

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INTERVENTIONSINTERVENTIONS

• HEALTH PROMOTION– VACCINATIONS– HEALTHY LIFESTYLE BEHAVIOR– ENVIRONMENTAL AWARENESS– EDUCATION

• Reduce risk factors

Case study #2Case study #2

• 72 yo female Denver resident c/o SOB [dyspnea], dizziness and fatigue. Family reports she seems “pleasantly confused” today. HX of DM with renal failure treated with oral Glucophage

• VS: T 36.2C, P 86, R30, B/P 160/88, SPO2 90 on RA• Labs: Na+ 136, K+ 3.0, HCT 40, Hgb 14; • ABG: ph 7.32, PaO2 80, PCO2 46, HCO3- 18• Assessment: Oriented to person, knows she is ‘not at

home’. Lungs clear, respirations rapid and deep w/o use of accessory muscles. Other findings WNL for age

What to do?What to do?

• Any more info you need? Labs?

• What in her history raises a flag?

• What is the problem?

• What interventions are appropriate?

• Nursing diagnoses for this patients?

InterventionsInterventions

• Focus on:• treating underlying cause [abx, O2]• adaptation [meds, breathing techniques]• preventing complications [TC&DB, IS]

– managing Dyspnea [O2, position, activity]– Maintaining Airway [Suction, cough, IS]– Mobilizing Secretions [hydration, TC&DB,

meds]– Prevent infection/complication

Case Study #3Case Study #3

• 18 yo DU freshman student c/o “choking”, increased thick secretions, weak productive cough. HX of CF [cystic fibrosis]

• VS: T 38.2C, P100, R 36, B/P 110/70, SPO2 80% on RA• Assessment Rhonchi, rales over all lung fields, uses

accessory muscles, thick yellow secretions produced with weak rattling cough. Other systems WNL

What’s going on?What’s going on?

• Main problem? Why?

• Abnormal findings?

• Nursing diagnosis?

• Interventions for this client?– Education/referrals?

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INTERVENTIONS IN ACUTE AND INTERVENTIONS IN ACUTE AND CHRONIC CARECHRONIC CARE

• POST OPERATIVE CARE– INTERVENTIONS TO PREVENT

PNEUMONIA• TC&DB Q2h• NASAL O2 TO KEEP O2 SAT >90%• IS Q2h WA• SPLINT INCISION• PAIN MEDICATION

Case study #4Case study #4

• 28 yo female post-op trauma pt. with Rt tibia fracture, Rt rib fracture, liver laceration [repaired]. C/O “pain all over 8/10 this am. SOB [dyspnea], dizziness

• VS: T 37.4C, P88, R 30, B/P [supine =118/78, sitting= 100/64, SPO2 85% on RA

• Labs: Hct 58% BUN 28 mg/100 ml; others WNL• Assessment: dry mucous membranes, skin tenting, cap

refill <3 sec; pulses +2 bilat and equal, RL BK cast, Rt upper abdominal incision CDI, Rt ribs bruised. Lungs CTA. Hypoactive BS X4 quadrants, rapid shallow respirations

What is wrong?What is wrong?

• Abnormal Findings?

• History?

• Nursing diagnoses?

• Interventions?

OxygenOxygen

• Yes, it is a medication

• Can cause harm

• Ordered by Physician

• Standing orders - emergency

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NASAL CANNULANASAL CANNULA

• O2 DELIVERY UP TO 6L/M (6 liters per minute)– MUST BE HUMIDIFIED >4L/M– ROOM AIR = 21% O2– ROOM AIR + 3L O2 = 32% O2

• APPROX. 3 – 4%/LITER

– Potential trauma to nares, ears

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OXIMEIZEROXIMEIZER

• 8 – 10 LITERS PER MINUTE

• DO NOT HUMIDIFY – CONTAINS A FILTER THAT HUMIDIFIES

THE OXYGEN

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OXIMIZEROXIMIZER

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SIMPLE FACE MASKSIMPLE FACE MASK

• DELIVERS OXYGEN CONCENTRATIONS AT 40 – 60%

• CONTROLLED BY LITER FLOW– 5 – 8 LITERS PER MINUTE– Short term– Not for Pts with CO2 retention

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SIMPLE FACE MASKSIMPLE FACE MASK

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NON REBREATHER MASKNON REBREATHER MASK

• DELIVERS THE HIGHEST LEVEL OF OXYGEN POSSIBLE WITH A MASK– 95 – 100%– LITER FLOW 10 – 15 LITERS PER MINUTE– ONE WAY VALVE BETWEEN RESERVOIR

AND MASK • PREVENTS ROOM AIR FROM MIXING WITH O2

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NONREBREATHER MASKNONREBREATHER MASK

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VENTURI MASKVENTURI MASK

• DELIVERS OXYGEN FROM 24 – 50%

• CAN “DIAL IN” OXYGEN LEVEL– 4L/MIN = 24%– 8L/MIN = 35%

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OXYGEN FACE TENTOXYGEN FACE TENT

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TRANSTRACHEAL OXYGENTRANSTRACHEAL OXYGEN

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Case study # 5Case study # 5• 58 yo male c/o dyspnea “it hurts to breathe”, fatigue. HX

of URI 2 weeks ago, untreated [“probably bronchitis – I get it every year”]; smokes 1 pack/day X 40 years. Morning cough productive of thick green sputm. Pt states “that’s new – I always cough in the morning but I don’t spit notheing up”

• VS: & 37.8C, P76, R28, B/P 176/84• Labs: Na+ 138, Hct 58%, BUN 28; others WNL Sputm

sample sent for C&S, pending. CXR shows bilateral lower lobe infiltrates

• Assessment: Pale, dry mucous membranes, cap refill 3 sec; dull & decreased lung sounds bilateral bases

What is wrong?What is wrong?

• Abnormal Findings?

• History?

• Nursing diagnoses?

• Interventions?

• Additional info you need?

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INTERVENTIONS IN ACUTE AND INTERVENTIONS IN ACUTE AND CHRONIC CARECHRONIC CARE

• DYSPNEA– PATIENT ASSESSMENT– APPLY OXYGEN?– UNDERLYING CAUSE

• ASTHMA• CHRONIC HEART FAILURE• COPD

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ASSESSMENT FINDINGSASSESSMENT FINDINGS

• THICK SECRETIONS– DO THEY NEED OXYGEN?– UPPER AIRWAY?– LOWER AIRWAY?– ASSESS SECRETIONS

• HUMIDIFY• HYDRATION• NEBULIZER• CHEST PHYSIOTHERAPY• SUCTIONING

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ASSESSMENT FINDINGSASSESSMENT FINDINGS

• WHEEZING (WHY ARE THEY WHEEZING?)– OXYGEN?– BRONCHODILATOR– CONTINUED ASSESSMENT

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AIRWAYAIRWAY

• NATURAL

• ARTIFICIAL– NASAL– ORAL– ENDOTRACHEAL– TRACHEOSTOMY

ARTIFICIAL AIRWAYSARTIFICIAL AIRWAYS

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CARE OF THE PATIENT WITH AN CARE OF THE PATIENT WITH AN ARTIFICIAL AIRWAYARTIFICIAL AIRWAY

• ORAL AIRWAY– MAINTAINS AN OPEN AIRWAY

• DURING DECREASED LEVEL OF CONSCIOUSNESS• SEDATION• SEIZURES

– MADE OF HARD PLASTIC• ATTEND TO ANY PRESSURE AREAS ON LIPS, MOUTH,

TONGUE• HOLLOW TO FACILITATE SUCTIONING

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NASOTRACHEAL, NASOPHARYNGEAL OROPHARYNGEAL, OROTRACHEAL

SUCTIONING

• WHEN PATIENT IS UNABLE TO COUGH UP THICK PULMONARY SECRETIONS

• PASS CATHETER THROUGH NOSE [less gagging] OR MOUTH

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NASAL AIRWAYNASAL AIRWAY

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CARE OF THE PATIENT WITH AN CARE OF THE PATIENT WITH AN ENDOTRACHEAL TUBEENDOTRACHEAL TUBE

• PROVIDER MAY NEED ASSISTANCE DURING INTUBATION [e.g. provide O2, SX]– INTUBATION IS INSERTING THE TUBE– EXTUBATION IS REMOVING THE TUBE

• ORAL CARE IS A PRIMARY CONCERN FOR THE NURSE CARING FOR THIS PATIENT

• TUBE MUST BE SECURE– NO PRESSURE AREAS ON FACE, LIPS OR MOUTH

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ENDOTRACHEAL TUBEENDOTRACHEAL TUBE

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CARE OF THE PATIENT WITH AN CARE OF THE PATIENT WITH AN ENDOTRACHEAL TUBEENDOTRACHEAL TUBE

• TUBE MUST BE CLEAR OF SECRETIONS

• SUCTION PRN TO KEEP TUBE PATENT– Limit time! 15 sec– To instill or not to instill NS?

• CHANGE TAPE AND REPOSITION TUBE EVERY 24H

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TRACHEOSTOMY TUBETRACHEOSTOMY TUBE

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CARE OF THE PATIENT WITH A CARE OF THE PATIENT WITH A TRACHEOSTOMYTRACHEOSTOMY

• TUBE MUST BE CLEAR OF SECRETIONS

• SUCTION PRN TO KEEP TUBE PATENT

• CHANGE DRESSING AND INNER CANNULA EVERY 24H– IF INNER CANNULA IS NOT DISPOSABLE,

REMOVE, CLEAN AND REPLACE

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SLEEP APNEASLEEP APNEA

• OBSTRUCTIVE SLEEP APNEA– one or more pauses in breathing or shallow

breaths while you sleep.– can last from a few seconds to minutes. – occur 5 to 30 times or more an hour. – normal breathing then starts again, sometimes

with a loud snort or choking sound

• CENTRAL SLEEP APNEA– less common type of sleep apnea. – area of your brain that controls breathing doesn't

send the correct signals– no effort to breathe for brief periods.

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CPAP / BiPAPCPAP / BiPAP

• Congestive heart failure

• Lung disorders resulting in high CO2

• Patients for whom intubation is not possible

• Sleep apnea

• Surfactant deficiency/ atelectasis

• Less invasive than intubation, trach

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CARE OF THE PATIENT CARE OF THE PATIENT WITH A CHEST TUBEWITH A CHEST TUBE

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CHEST TUBESCHEST TUBES

• PURPOSE– RE-EXPAND THE LUNG

• HOW?– RELEASE AIR– DRAIN FLUID

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CONDITIONS REQUIRING A CHEST CONDITIONS REQUIRING A CHEST TUBE INSERTIONTUBE INSERTION

• PNEUMOTHORAX: Air in pleural space– SPONTANEOUS– TENSION– TRAUMA– POST CHEST SURGERY

• Hemothorax: Fluid/ Blood in pleural space– INFECTION– BLEEDING INTO THE PLEURAL CAVITY

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Heimlich valve

•one-way, rubber flutter valve•proximal end attaches to the chest tube, •distal end connects to a suction device or is left open to the atmosphere.• allows outpatient treatment of a pneumothorax.

HEIMLICH VALVEHEIMLICH VALVE

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CARE OF THE PATIENT WITH A CARE OF THE PATIENT WITH A CHEST TUBECHEST TUBE

• PATIENT ASSESSMENT– RESPIRATORY RATE– CHEST EXCURSION– SYMMETRY– OXYGENATION (PULSE OXIMETER)– BREATH SOUNDS– CREPITUS

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CARE OF THE PATIENT WITH CARE OF THE PATIENT WITH A CHEST TUBEA CHEST TUBE

• ASSESS PATIENT AND SYSTEM– DRAINAGE [amount, type, etc]– DRESSING [DRY AND INTACT?]– TUBE [KINKED? Straight?]– BE SURE IT DOES NOT DRAG ON THE FLOOR– VERIFY SUCTION [Bubbling = working] & WATER

SEAL [fluctuation w/ breathing, bubbling = air from pleural space or dislodged tube] ORDERS

– NEVER RAISE COLLECTION CHAMBER ABOVE CHEST [INSERTION POINT]!

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EvaluationEvaluation

• Ask pt. to demonstrate techniques [cough, breathing]

• Assess dyspnea, cough, sputum, SPO2, respiratory rate/ depth/effort

• Goal met? Not met? Partially met?

• Revision or continuation of plan?

Try ThisTry This

• Divide into 6 groups

• For each scenario, determine:

• What you think is going on

• Priority Nursing Diagnosis

• Goals

• The focus of your interventions– E.g. mobilize secretions, teach to TC&DB

Oxygenation

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