Oxygenation Ms.Nirmala Priyadarshanie B.Sc. Nursing (Hons)

Oxygenation

Ms.Nirmala Priyadarshanie

B.Sc. Nursing (Hons)

Learning Objectives

• Student will be able to :– Identify Anatomy of the Respiratory System– Describe Respiratory Physiology– Identify Respiratory Pathophysiology– Describe Factors Affecting Oxygenation– Identify Alterations in Cardiac Functioning– Describe Respiratory Assessment– Identify Focused History and Physical Examination– Obtain Nursing History– Formulate Nursing Diagnoses– Describe Initial Management

– Respiratory System Anatomy– Respiratory Physiology– Respiratory System Purpose– Respiratory Pathophysiology– Factors Affecting Oxygenation– Alterations in Cardiac Functioning– Respiratory Assessment– Focused History and Physical Examination– Nursing History– Nursing Diagnoses– Initial Management

Out Line

Cardiovascular Physiology

• Structure and function– Myocardial pump– Myocardial blood flow– Coronary artery circulation– Systemic circulation– Blood flow regulation: cardiac output,

preload, afterload, contractility– Conduction system

Upper Respiratory System

Lower Respiratory System

Respiratory System Anatomy

• Lung– Right lung 3 lobes

– Left lung 2 lobes

Respiratory System Anatomy

• Bronchioles– Smallest airways

– Walls consist entirely of smooth muscle (no cartilage present)

– Constriction increases resistance to airflow

– Dilation reduces resistance to airflow

Respiratory System Anatomy

• Alveoli– Air sacs

– Site of oxygen and carbon dioxide exchange with blood

Respiratory System Anatomy

Respiratory System Anatomy

• Diaphragm

Respiratory System Anatomy

• Pleura– Double-walled

membrane

– Visceral layer covers lung

– Parietal layer lines inside of chest wall, diaphragm

Respiratory Physiology

• Structure and function (cont'd)– Breathing: inspiration, expiration– Lung volumes and capacities– Pulmonary circulation– Respiratory gas exchange: oxygen,

carbon dioxide– Regulation of respiration

Respiratory System Purpose

• Takes in oxygen

• Disposes of wastes– Carbon dioxide– Excess water

O2 + Glucose

CO2 + H2O

The Cell

Functions of the Respiratory System

A. Primary functions -1. The respiratory system provides oxygen for metabolism in the tissues.2. The respiratory system removes carbon dioxide, the waste product of metabolism.

B. Secondary functions -1. The respiratory system facilitates sense of smell.2. The respiratory system produces speech.3. The respiratory system maintains acid-base balance.

Physiology

• When you inhale, air enters through the nose or mouth. As air is breathed through the nose, it is warmed, moistened and filtered by the hairs that line the nostrils. The air then passes into the nasal passages. Air from the nasal passages and mouth enters the pharynx and passes downward to the larynx.

Respiratory System Physiology

Inspiration• Active process• Chest cavity expands• Intrathoracic pressure falls

• Air flows in until pressure equalizes

Expiration• Passive process• Chest cavity size decreases• Intrathoracic pressure rises

• Air flows out until pressure equalizes

Respiratory System Physiology

–Automatic Function• Primary drive: increase in arterial CO2

• Secondary (hypoxic) drive: decrease in arterial O2

Normally we breathe to remove CO2 from the body, NOT to get oxygen in

Respiratory Pathophysiology

• Airway (Obstruction)– Tongue

– Foreign body airway obstruction

– Anaphylaxis/angioedema

– Upper airway burn

– Maxillofacial/laryngeal/ tracheobronchial trauma

– Epiglottitis

– Aspiration

– Asthma

– Chronic Obstructive Airway Disease

• Emphysema

• Chronic bronchitis

Respiratory Pathophysiology

• Gas Exchange Surface (Blood Flow or Gas Diffusion)– Pulmonary Edema

• Left-sided heart failure

• Toxic inhalations

• Near drowning

– Pneumonia

– Pulmonary Embolism• Blood clots

• Amniotic fluid

• Fat embolism

Respiratory Pathophysiology

• Thoracic Bellows (Ventilation)– Chest Trauma

• Simple rib fractures

• Pneumothorax

• Hemothorax

• Sucking chest wound

• Diaphragmatic hernia

– Pleural effusion

– Spinal cord trauma (High C-spine lesion)

– Neurological/neuro-muscular disease

• Poliomyelitis

• Myasthenia gravis

• Muscular dystrophy

• Guillian-Barre syndrome

Respiratory Pathophysiology

• Control System (Decreased Respiratory Drive)– Head trauma– CVA– Depressant drug toxicity

• Narcotics

• Sedative-hypnotics

• Ethyl alcohol

Factors Affecting Oxygenation

• Physiological factors: cardiac– Conduction disturbances– Impaired valvular function– Myocardial hypoxia– Cardiomyopathic conditions– Peripheral tissue hypoxia

Factors Affecting Oxygenation (cont'd)

• Physiological factors: respiratory– Hyperventilation– Hypoventilation– Hypoxia

Factors Affecting Oxygenation (cont'd)

• Additional physiological factors– Decreased oxygen-carrying capacity– Decreased inspired oxygen

concentration– Hypovolemia– Increased metabolic rate– Conditions affecting chest wall

movement

Factors Affecting Oxygenation (cont'd)

• Additional physiological factors– Musculoskeletal abnormalities– Trauma– Neuromuscular diseases– Central nervous system alterations– Chronic disease

Alterations in Cardiac Functioning

• Conduction disturbances– Atrial and ventricular dysrhythmias

• Altered cardiac output– Heart failure

• Impaired valvular function

• Myocardial ischemia– Angina, MI, acute coronary

syndrome

Alterations in Respiratory Functioning

• Hyperventilation

• Hypoventilation

• Hypoxia

Developmental Factors

• Infants and toddlers

• School-age children and adolescents

• Young and middle adults

• Older adults

.

Lifestyle Factors

• Nutrition

• Exercise

• Smoking

• Substance abuse

• Stress

Environmental Factors

• Residence location

• Occupation

Respiratory Assessment

• Initial Assessment (A, B, C, D)

• Manage life threats

• Complete focused history and physical

Initial Assessment

• Airway– Listen to patient breathe, talk

• Noisy breathing is obstructed breathing

• But all obstructed breathing is not noisy

• Snoring = Tongue blocking airway

• Stridor = “Tight” upper airway from partial obstruction

Initial Assessment

• Airway

– Anticipate airway problems with• Decreased LOC

• Head trauma

• Maxillofacial trauma

• Neck trauma

• Chest trauma

OPEN—CLEAR—MAINTAIN

Initial Assessment

• Breathing– Is patient moving air?

– Is air moving adequately?

– Is the patient’s blood being oxygenated?

Initial Assessment

• Breathing– LOOK

• Symmetry of chest expansion

• Increased respiratory effort

• Changes in skin color

– LISTEN• Air movement at

mouth, nose• Air Movement in

peripheral lung fields

– FEEL• Air movement at

mouth, nose• Symmetry of chest

expansion

– RATE• Tachypnea• Bradypnea

– POSITIONING• Orthopnea• Tripod position

Initial Assessment

• Breathing– Signs of respiratory distress

• Nasal flaring• Tracheal tugging• Retractions• Neck, pectoral muscle use on inhalation• Abdominal muscle use on exhalation

– Skin Color• Pale, cool moist skin (Early sign of hypoxia)• Cyanosis (Late, unreliable sign of hypoxia)

Initial Assessment

• Breathing– If trauma patient has compromised breathing,

bare chest, assess for:• Open pneumothorax

• Flail chest

• Tension pneumothorax

Respiratory Assessment

• Circulation– Is heart beating?– Is there major external hemorrhage?– Is patient perfusing?– Effects of hypoxia:

• Adults (early): tachycardia

• Adults (late): bradycardia

• Children: bradycardia

Initial Assessment

• Circulation– Don’t let respiratory failure distract you from

assessing for circulatory failure– Low oxygen or high carbon dioxide levels can

depress cardiovascular function

Respiratory Assessment

• Disability– Restlessness, anxiety, combativeness = hypoxia

Until proven otherwise– Drowsiness, lethargy = hypercarbia

Until proven otherwise

Just because the patient stops fighting, he’s not necessarily getting better!!!

Focused History and Physical Examination

• Chief Complaint– Dyspnea

• Subjective sensation that breathing is excessive, difficult, or uncomfortable

– Respiratory Distress• Objective observations that indicate breathing is

difficult or inadequate

Focused History and Physical Examination

• History of Present Illness (OPQRST)– Gradual or sudden onset?

– What aggravates or alleviates?

– How long has dyspnea been present?

– Coughing? Productive cough?

– What does sputum look/smell like?

– Pain present? What does pain feel like? How bad? Does it radiate? Where?

Focused History and Physical Examination

• Past HistoryIf Then???Hypertension, MI, Diabetes CHF with Pulmonary Edema

Chronic Cough , Smoking, COPD

“Recurrent” Flu

Allergies, Acute Episodes of SOB Asthma

Lower Extremity Trauma, Pulmonary Embolism

Recent Surgery, Immobilization

Focused History and Physical Examination

• Medications If Then???“Breathing” Pills, Inhalers Asthma or COPD

Aminophylline

Ipratropium

Terbutaline

Salbumatol

Focused History and Physical Examination

• Medications If Then???

Lasix, hydrodiuril, digitalis CHF

Coumadin Pulmonary embolism

Focused History and Physical Examination

• Crackles (Rales)– Fine, “crackling”

– Fluid in smaller airways, alveoli

• Rhonchi– Coarse, “rumbling”

– Fluid, mucus in larger airways

• Stridor– High pitched, “crowing”– Upper airway restriction

• Wheezing– “Whistling”– Usually more pronounced on

exhalation– Generalized: narrowing,

spasm of the smaller airways– Localized: foreign body

aspiration

Nursing History

• Fatigue

• Dyspnea

• Cough

• Wheezing

• Pain

• Environmental or geographical exposures

Nursing History (cont'd)

• Respiratory infections

• Health risks

• Medications

Assessment of Oxygenation

• Physical examination– Inspection– Palpation– Percussion– Auscultation

Assessment of Oxygenation (cont'd)

• Diagnostic tests: blood studies– Complete blood count– Cardiac enzymes– Cardiac troponin I– Serum electrolytes– Cholesterol

Assessment of Oxygenation (cont'd)

• Diagnostic tests: cardiac function– Electrocardiogram (ECG)– Exercise stress test– Electrophysiological study (EPS)– Echocardiography– Cardiac catheterization

Assessment of Oxygenation (cont'd)

• Diagnostic tests: ventilation studies– Pulmonary function– Peak expiratory flow rate (PEFR)– Arterial blood gases– Oximetry– Chest x-ray– Bronchoscopy– Lung scan

Assessment of Oxygenation (cont'd)

• Diagnostic tests: ventilation studies (cont'd)– Thoracentesis– Throat cultures– Sputum specimens

.

Nursing Diagnoses

• Ineffective airway clearance

• Ineffective breathing pattern

• Decreased cardiac output

• Impaired gas exchange

• Risk for infection

• Ineffective tissue perfusion

• Impaired spontaneous ventilation

.

Planning

• Goals and outcomes– Client’s lungs are clear on auscultation– Client coughs productively

• Setting priorities

• Continuity of care

.

Implementation: Health Promotion

• Body weight• Diet• Exercise• Stress reduction• Occupational safety• Smoke-free• Regular physical examinations

Implementation: Health Promotion (cont'd)

• Vaccinations/immunizations– Influenza– Pneumonia

Implementation: Acute Care

• Dyspnea management

• Airway maintenance– Mobilization of secretions– Suctioning– Artificial airways

Implementation: Acute Care (cont'd)

• Maintenance and promotion of lung expansion– Positioning– Incentive spirometry– Chest tubes

Implementation: Acute Care (cont'd)

• Maintenance and promotion of oxygenation: oxygen therapy– Safety precautions– Oxygen supply– Methods of oxygen delivery– Home oxygen therapy

Implementation: Acute Care (cont'd)

• Restoration of cardiopulmonary functioning—CPR

Initial Management

• Patient Responsive/Breathing Adequate– Oxygen may be indicated– Oxygenate immediately if patient has:

• Decreased level of consciousness• Possible shock• Possible severe hemorrhage• Chest pain• Chest trauma• Respiratory distress or dyspnea• History of any kind of hypoxia

Initial Management

• Patient responsive, breathing inadequate– Open/maintain airway– Place nasopharyngeal airway– Assist ventilations

• Mouth to Mask

• 2-person Bag-valve Mask

• Manually Triggered Ventilator

• 1-person Bag-valve Mask

Initial Management

• Patient unresponsive, breathing adequate– Open/maintain airway– Place nasopharyngeal or oropharyngeal airway– Suction airway as needed– Provide oxygen by non-rebreather mask– Frequently reassess

Initial Management

• Patient unresponsive, breathing inadequate• Open/maintain airway• Place nasopharyngeal or oropharyngeal airway• Suction airway as needed• Assist ventilations

– Mouth to Mask

– 2-person Bag-valve Mask

– Manually Triggered Ventilator

– 1-person Bag-valve Mask

• Frequently reassess

Initial Management

• Patient not breathing– Open airway– Place nasopharyngeal or oropharyngeal airway– Ventilate patient

• Mouth-to-Mask

• 2-Person Bag-Valve Mask

• Manually Triggered Ventilator

• 1-Person Bag-Valve Mask

– Frequently reassess

Initial Management

• Golden Rules– If you think about giving O2, give it!!!

– If you decide to give oxygen, give a lot of it!!!– If you can’t tell whether a patient is breathing

adequately, he isn’t !– If you’re thinking about assisting a patient’s

breathing, you probably should be!

Implementation: Restorative Care

• Hydration

• Coughing techniques

• Respiratory muscle training

• Breathing exercises

Evaluation

• Client care

• Client expectations

Summery……..!

Questions??