nursing - oxygenation

Oxygenation

Nursing Fundamentals Focus VIII

Objectives

• List and discuss the major body structures.• Discuss functions responsible for proper oxygenation• Describe factors that may alter ones O2 balance.• Identify the behaviors indicating negative O2 balance.• Review the common diagnostic tests medically

prescribed in order to determine the client’s oxygenation status.

• Explain the major purpose of the tests and the related nursing responsibilities.

Staggering statistics

• Pulmonary Diseases• Lung CA -

• TB –

• Pneumonia –

• Chronic Airflow Limitation (formerly COPD) –

Staggering statistics

• Cardiovascular Diseases – # 1 killer• HTN – 65 million• Artheriosclerosis• Arteriosclerosis• Stroke• Hypercholesterolemia

• 107 million - a risk factor for CVD• AMI – 7.5 Million per year, 460,000 die• Americans paid 393.5 billion in 2005 for

CVD related medical costs

Respiratory System

Process of Breathing

•Inspiration•Air flows into lungs

•Expiration•Air flows out of lungs

Normal Oxygenation Process• Cardiovascular:

Normal Oxygenation Process• Systemic:

Normal Oxygenation Process

Inspiration

• Diaphragm and intercostal muscles contract • Thoracic cavity size increases• Volume of lungs increases• Intrapulmonary pressure decreases• Air rushes into the lungs to equalize pressure

Expiration

• Diaphragm and intercostal muscles relax• Lung volume decreases• Intrapulmonary pressure rises• Air is expelled

Gas Exchange

• Occurs after the alveoli are ventilated• Pressure differences (gradient) on each side of the

respiratory membranes affect diffusion• Alveoli:

• PO2 100mmHg• PCO2 40mmHg

• Venous blood:• PO2 60mmHg• PCO2 45mmHg

• O2 diffusion from alveoli pulmonary blood vessels• CO2 diffusion from pulmonary blood vessels alveoli

Adequate O2 Balance• Maintenance of adequate O2 balance Gas Exchange

Oxygen Transport

• Transported from the lungs to the tissues• 97% of O2 combines with RBC Hgb

oxyhemoglobin carried to tissues • Remaining O2 is dissolved and transported in

plasma and cells (PO2)

Normal Oxygenation Process

• Cell environment / O2 carrying capacity:

• O2 Carrying capacity of blood is expressed by:• Red blood cells (#)• Hematocrit

• % of blood that is RBCs• Men 40-54%• Women 37-50%

• Hemoglobin

Carbon Dioxide Transport

• Must be transported from tissues lungs• Continually produced in the process of cell

metabolism

• 65% – carried inside RBCs as bicarbonate (HCO3-)

• 30% – combines with Hgb carbhemoglobin• 5% – transported in plasma as carbonic acid (H2CO3)

Factors that Influence Respiratory Function

•Age•Environment•Lifestyle•Health status•Medications•Stress

Common Manifestations of Impaired Respiratory Function

•Hypoxia•Altered breathing patterns•Obstructed or partially obstructed airway

Hypoxia

• Condition of insufficient oxygen anywhere in the body• Rapid pulse• Rapid, shallow respirations and dyspnea• Increased restlessness or lightheadedness• Flaring of nares• Substernal or intercostal retractions• Cyanosis

Abnormal Respiratory Patterns

• Tachypnea (rapid rate)• Bradypnea (abnormally slow rate)• Apnea (cessation of breathing)• Kussmaul’s breathing• Cheyne-Stokes respirations• Biot’s respirations

Alterations in Ease of Breathing

•Orthopnea

•Dyspnea

Obstructed or PartiallyObstructed Airway

•Partial obstruction• low-pitched snoring during inhalation

•Complete obstruction• extreme inspiratory effort with no chest

movement

Adequate O2 Balance

•

Example of Obstructive Disease: Asthma

Adequate O2 Balance

•

Example of Restrictive Disease: Hemothorax

Inadequate O2 Balance

• Behaviors of Negative O2 balance • Hypoventilation or hyperventilation• Stridor, audible sounds with respiration,

wheezing, coughing• Hypoxia• Change in mental status• Change vital signs• Cyanosis• Decrease in GI motility• Change in renal function• Hypercapnia

Nursing Responsibilities

• Determine adequacy of cardiopulmonary function:

• Nursing assessment

• HEART

• Respiratory assessment

• PMH

• LIFESTYLE

HEART•Have client describe

• specific location, onset and duration of the problem

•Explore associated signs and symptoms

•Ask - activities that worsen or ease the problem

•Rate the severity of discomfort or incapacity

•Talk - treatments or interventions used to alleviate the problem and their effectiveness

Heart Problems

Artheroscleosis = Coronary Artery Disease (CAD)

Nursing Measures to Promote Respiratory Function

•Ensure a patent airway•Positioning•Encourage deep breathing, coughing•Ensure adequate hydration

Nursing Responsibilities

• Physical Assessment:

• Lung auscultation and breathing pattern

• Abdominal assessment

• Urine output

• Skin and mucous membranes

• Heart sounds

• Circulation

• Edema

• DVT

Lung sounds• Diminished or absent• Crackles course and fine

• discontinuous course bubbling • fine crackling sound at the middle or end of inspiration

• Rhonchi• a continuous sonorous sound

• Wheezes• high pitch musical sounds

• Pleural friction rub• grating rubbing, sound

Common Tests and Nursing Responsibilities

•Measure adequacy of ventilation and gas exchange

• Complete Blood Count (CBC) phlebotomy

• Arterial Blood Gases (ABG) arterial puncture

• Pulmonary Function Tests preparation by teaching

Common Tests and Nursing Responsibilities

•Tests to determine abnormal cell growth or infection in respiratory system:

• Sputum culture• growing microorganisms from sputum

• Throat culture • growth of microorganisms from throat

material

Common Tests and Nursing Responsibilities

• Tests to visualize structures of respiratory system:

• Bronchoscopy

• Chest radiographs

Chest Xray

Adenocarcinoma

Common Tests and Nursing Responsibilities

Thorancentesis

Nursing Responsibilities

• Medications• Incentive spirometry• Chest PT• Postural drainage • Oxygen therapy• Artificial airways• Airway suctioning• Chest tubes

Basic Nursing Interventions

• Airway Maintenance:

• Facilitate effective coughing• Suctioning airways• Liquefying and mobilizing sputum

Basic Nursing Interventions

• Maintenance and promotion of proper lung expansion:

Re-expanding collapsed lungs- Closed Chest Tube Drainage

Chest Tubes

Basic Nursing Interventions

• Improving Activity Tolerance:• Determine etiology• Assess appropriateness of activity level• When appropriate gradually increase activity• Ensure the client changes position slowly• Observe for symptoms of intolerance• Syncope with activity

• refer to MD• Perform ROM exercises with activity

intolerance if is immobile

Basic Nursing Interventions

• Mobilization of Pulmonary Secretions

• Auscultate breath sounds, monitor respiratory patterns, monitor ABG’s

• Position client to optimize respiration• Pulmonary toileting• Incentive spirometry• Suctioning

Incentive spirometry

Basic Nursing Interventions

• Mobilization of Pulmonary Secretions• Encourage activity and ambulation as

tolerated• Encourage increased fluid intake• Chest physiotherapy• O2• Medications as ordered

Basic Nursing Interventions

• O2 Therapy:

• Low flow• High flow• Humidification• Nasal cannula• Simple mask• Nonrebreathing mask• Partial rebreathing

Basic Nursing Interventions

• Effective Breathing Techniques

• Position for maximal respiratory function

• Pursed lip breathing

• Diaphragmatic or abdominal breathing

Basic Nursing Interventions

Stress and anxiety reduction:• Remove pertinent cause of anxiety at that moment - help client gain control over respiration - reassure client not in immediate danger

• Chronic clients• exacerbations and remissions• goal is to reduce general level of anxiety• learn to control episodes of anxiety to improve

quality of life• desensitization program• guided mastery

Administration of Prescribed Medications

• Expectorants• Mucolytics• Bronchodilators• Cough

suppressants• Corticosteroids• Antihistamines• Antibiotics

• Vasoconstrictors

Basic Nursing Interventions

• Physical Exercise health teachingActivity and rest -- a priority!Activity stimulates respiratory functionRest conserves energy and reduces metabolic

demand• MD’s treatment plan

• guidelines for activity • may simply call for activity as tolerate.

• prioritize activities• arrange need items conveniently• Provide emotional support and encouragement

• gradually increase activity

• Simplify daily life• Work at a steady state• Conserve energy

Adequate O2 Balance

• Behaviors of Negative O2 balance Cardio Vascular Disease

• Arterial• Venous:• Impaired tissue perfusion

Adequate O2 Balance

• Behaviors of Negative O2 balance CV

• Restlessness, dizziness, syncope, bradycardia, decreased urine

• cold and clammy skin, cyanosis, slow capillary refill

• Decreased cardiac output

Common Tests and Nursing Responsibilities

• Tests to determine adequacy of cardiovascular function:

• CBC

• Lipid profile

• Coagulation studies

• EKG/ECG

• Angiography

• Doppler blood flow studies

Basic Nursing Interventions

Cardiovascular• Modify risk factors

• Preventing vasoconstriction

•Diet •Exercise•Co morbidities

•Positioning•Cold temperatures•Nicotine

Basic Nursing Interventions

• Cardiovascular- Prevent

complications

• Promoting rest

•Risk DVT•Position changes•Early ambulation•Obstruction removal•Bypass surgery

•Schedule rest periods•Assistance with ADL’s•Monitor Vitals with activity•Place items, i.e. call light, water pitcher, strategically•Quiet environment, decrease stimuli

Basic Nursing Interventions

Cardiovascular• Positioning to

improve CO

• Avoiding Valsalva maneuver

- Position semi to high fowlers-> decrease venous return and preload, decease preload-> decreases risk of heart congestion

- • Teach client to avoid

valsalva maneuver - Hold breath while turning or moving

in bed-> assist - Bearing down

during BM-> stool

softeners and diet

Basic Nursing Interventions

Cardiovascular• Avoid stimulants

• Maintaining fluid balance

•Avoid appetite suppressants, cold meds, coffee, tea, chocolate

•Assess fluid status, monitor I&O, assess breath sounds, JVD, pitting edema in dependent areas, fluid and NA+ restriction, daily Wgt with diuretic therapy, electrolyte monitoring-> MD

Basic Nursing Interventions

Cardiovascular

• Increase O2 supply

• Administer O2 • Educate client

NO SMOKING!

• Position to facilitate breathing

Administration of Prescribed Medications

• Anti coagulants

• Vasodilator Medications

• Inotropic Medications

• Anti Dysrhythmics

• Anti hypertensives

Basic Nursing Interventions

• Dietary control

• Assess nutritional status

• Consider a dietician referral to assess nutritional needs related to clients

• Chronicity of CAL and CAD and nutrition

Basic Nursing Interventions

•Weight control

• Evaluate the client’s physiological status in relation to condition

• More than body requirements

• Less than body requirements