1245 Oxygenation

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What does the MEDULLA measure & how does it become impaired?

• senses increase in CO2 levels & H+ ions (if this happens you need to blow off CO2 → ⬆ respirations)
• Impaired by chronic CO2 elevations = ⬆ respirations for too long so the chemoreceptors become desensitized

What are 3 things that can cause chronic ⬆ in CO2 levels?

1. COPD
2. Emphysema
3. Chronic asthma/bronchitis

What do the CHEMORECEPTORS measure & where can they be found?

• sense decrease in O2 levels → ⬆ respirations
• found in aortic arch & carotid bodies

What do PROPRIOCEPTORS respond to?

• respond to body movement and increase ventilation

What is the primary stimulus in a healthy patient?

Medulla

What is the primary stimulus in a patient with COPD or increased CO2?

Chemoreceptors

What 4 things are essential for normal respiratory function to occur?

1. Airway system intact/integrity
2. Properly functioning alveolar-capillary system = exchange of CO2 & O2
3. Properly functioning cardiovascular & hematological systems = Hgb & blood flow to carry O2
4. Healthy tissues = to receive O2

What are the 5 steps in Gas Exchange?

1. Ventilation
2. Diffusion (Alveolar→Capillary)
3. Perfusion
4. Gas Transport (O2 & CO2)
5. Diffusion (Capillary→Tissue)

What is ventilation?

• Movement of air in & out of lungs
aka: pulmonary respiration or breathing

What is diffusion (step 2) in gas exchange & what factors affect it?

1. Alveolar→Capillary
2. Movement of gas from areas of higher concentration to areas of lower concentration
• Factors affecting include alveolar surface area, alveolar capillary membrane integrity

What is perfusion?

• is the process by which oxygenated capillary blood passes through body tissues.
• Amount of blood flow - Influenced by position & activity level

What are the transport details for the two types gas?

1. Oxygen
• 3% plasma bound
• 97% oxyhemoglobin
2. CO2
• 5-10% plasma bound
• 5-30% carboxyhemoglobin
• 60-90% bicarbonate

What is diffusion (step 5) in gas exchange & what is it influenced by?

1. Capillary→Tissue
2. Influence by
• Quality of RBCs
• Tissue chemistry

What can affect diffusion?

- fluid in the lungs
- pulmonary edema
- atelectasis (collapsing of alveoli / can lead to pneumonia)

What are the 8 HEALTH FACTORS affect respiratory function?

1. renal disease = fluid overload
2. heart damage = flow of blood, ⬇ tissue perfusion
3. lung disease = COPD, pneumonia, cancer
4. neuromuscular disease = non-intact medulla
5. brain injury
6. anemia = ⬇ O2 to tissues, & ⬇ CO2 to lungs
7. skeletal problems = Ex. hunched elderly not enough expansion
8. obesity or pregnancy = distended so can't expand lungs

What are the 2 development considerations for infants & children?

1. Infant = short airways, aspiration risk
2. Children = eustachian tubes, bronchi, and bronchioles elongated and less angular; frequent colds and infections

What four things can affect the respiratory system in older adults?

- stiffer lung tissue
- decrease muscle strength
- skeletal alterations
- digestive changes (bowel obstruction, diverticulitis)

What five MEDICATIONS can affect the respiratory system?

1. narcotics & sedatives = ⬇ RR & depth, ⬆ risk of pneumonia & aspiration
2. ACE inhibitors = can cause cough
3. Amiodarone = cardiac drug (may cause pulmonary fibrosis, especially in IV administration)
4. Bronchodilators (O2↑, cough, mucus)
5. Oxygen = need order but can give in ER situation

What five lifestyle, environmental & psychological factors can affect respiratory function?

1. activity levels (SOB w/activity)
2. smoking = ⬇ functional Hgb, ⬇ cilia movement
3. air pollution
4. occupational exposure = asbestos, radiation, etc.
5. psychological issues = anxiety, stress

In taking a history what 8 areas should be addressed

1. Defer if evidence of distress
2. Usual breathing pattern (what is normal for them?)
3. Cough
4. Sputum = what color? smell? when do they have it?
5. Chest pain = what happens when they take a deep breath?
6. Dyspnea = do they have conversational dyspnea?
7. Fever
8. Fatigue

What 4 things should you do in a physical exam?

1. Inspect = skin, chest, respiratory rate & rhythm
2. Palpate
3. Percuss
4. Auscultate

What are six signs of HYPOXIA?

decreased oxygen
- restlessness (early sign)
- altered LOC, confused
- dizziness
- behavioral changes

later symptoms:
- cyanosis
- if allowed to continue → resp/cardiac arrest

If patient has signs of hypoxia but a normal PO2, what should you look at?

Hemoglobin
- their Hgb can be carrying good O2 but there just isn't enough O2, so that is why they are having respiratory problems

What is pulse oximetry?

1. Measure SaO2
2. Normal 95-99%
3. Treat if <92% (correlates to pO2 of 80)
4. Must know Hgb

What is SaO2?

how much oxygen the hemoglobin molecule can hold

At what % of SaO2 does the patient need treatment?

lower than 92%

SaO2of 92% = PO2 of 80%

What is pO2?

- partial pressure of oxygen
- measure oxygen (O2) in blood (artery) Normal range (80-100 mmHg)
- % of oxygenation of Hgb molecule

What is SaO2?

- measure as a percentage the amount of hemoglobin molecules which are oxgenated (oxyhemoglobin) in arterial blood. Normal range (>95%)

what are pulmonary function studies?

- Group of tests that measure lung volumes, identify gas exchange problems, evaluate neuromuscular problems & dyspnea
- high pressure = narrowed airways

What are four noninvasive pulmonary studies?

1. Spirometry
2. Peak expiratory flow
3. Chest xray
4. Sputum for cytology/culture = needs to be from deep down, send to lab promptly, get sputum before start of antibiotics

What does a Spirometer Test measure?

Lung volume and Airflow

What does Peak Expiratory Flow measure and what does it record?

Evaluates asthma

Records highest flow

what are six invasive pulmonary function studies?

1. Arterial Blood Gases (do Allen's test first)
2. Bronchoscopy
3. CT Scan = looking for tumor or infection (b/c they take up the dye
- Check iodine allergy if contrast to be used
4. Ventilation - Perfusion scan
5. Skin tests
6. Thoracentesis

How is a Bronchoscopy performed & what is a patient at risk for after a Bronchoscopy?

1. Visualize structures
2. Remove substances (biopsy lesion/secretion, plugs)
3. NPO before (about 6 hours)
4. No food or fluids until gag returns = b/c numbed back of throat → lay on side, have suction b/c of risk of aspiration. Give H2O first b/c easy to aspirate
*** risk for aspirations due to the numbing of the throat

What is a Ventilation-Perfusion Scan used for & how is it performed?

- To check for Pulmonary Embolism (instead can use CAT scan w/contrast)
Perform:
1. Radioactive substance injected & inhaled
2. Measure blood flow & airflow
3. 8 hours to eliminate

How does a skin test evaluate the pulmonary function?

- evaluates antigen-antibody reactions

What is a Thorancentesis done for & how is it performed?

- To remove pleural fluid in the intrapleural space (done with respiratory distress)
- Used for pleural effusions
- need to eliminate primary problem so it doesn't happen again
Performed:
1. Usually performed at bedside
2. Needle or catheter inserted into intrapleural space to aspirate fluid
3. Monitor respirations after
a. Improvement
b. Distress

What are two nursing diagnoses?

1. RC: Atelectasis

2. Ineffective Breathing Pattern related to excessive or thick secretions secondary to pneumonia AEB:
RR=32 & Oxygen saturation = 88%

* use only 1 respiratory diagnosis. could add activity diminished (due to respiratory problems)

What are two outcomes?

1. Pt. will improve atelectasis by end of shift AEB:
Lung sounds with less rhonchi & No complaints of dyspnea

2. Pt. will have improved breathing patterns by end of shift AEB: RR = 18-22 & Oxygen saturation greater than 92%

What are two teaching interventions?

1. Stop smoking (unless have quit for >1 year)
2. Avoid pollutants

What are five interventions to promote optimal function?

1. Control anxiety
2. Nutrition
3. Vaccines (flu & pneumonia)
4. Balance activity & rest
5. Pulmonary rehab

What are three ways to promote comfort?

1. Positioning = 30-45° angle. 90° high fowler if in distress
2. Adequate fluids = 2-3 liters/24 hours. helps to thin secretion and to cough up secretions
3. Humidified air = makes patient more comfortable

What are four ways to promote proper breathing?

1. Deep breathing → hold & cough. can ⬆ pulse ox. helps expand alveoli. Best thing for atelectasis. helps with hypoventilation
2. Incentive spirometer = same as deep breathing
3. Purse lip breathing = helps get rid of CO2 trapped in alveoli. Sitting or walking
4. Abdominal breathing = use of abdominal/accessory muscles

What are 3 ways to promote or control coughing?

1. Voluntary
2. Involuntary
3. Medications
a. Expectorant = loosen secretion (Ex. Guaifanesin (Robitussin))
b. Suppressant = dry, irritating cough (Ex. Codeine,
Dextromethorphan (Robitussin DM))
c. Lozenges = Local anesthetic/numb back of throat

What is an EXPECTORANT & some examples?

- loosens secretions

- Mucinex
- Guaifanesin (Robitussin)

What is a SUPPRESSANT & some examples?

- suppresses cough (dry, irritated cough)

- Dextromethorphan (Robitussin DM)
- Codeine (Need Rx)

How does smoking affect the respiratory system?

↓ functional Hgb
↓ cilia movement

How long can an endotracheal tube stay in for?

14 days max

need trach tube after

What affect can Amiodarone have on the respiratory system?

can cause pulmonary fibrosis

What affect can ACE Inhibitors have on the respiratory system?

can cause a dry irritating cough

What affect can Narcotics or Sedatives have on the respiratory system?

Decreases stimulation to breathe

What is suctioning & what are some general rules (6)?

- device to clear secretions
- can relieve or promote (b/c you are suctioning out O2) respiratory distress
- you want them to cough but not too much b/c they lose too much O2
- DO NOT suction on the way down
- give the patient O2/deep breathing
- After taking out suction ***1st thing is to give them O2

How long can you do suction for?

10 - 15 sec

on way up only

How many times can you do suction?

3 times

How long do you have to wait between suctioning?

1 min

How do you know a patient isn't tolerating suctioning (3)?

PO2 goes ↓ and stays ↓
cyanosis
can't stop coughing

What do BRONCHODILATORS do & what are some examples?

- open narrow airways
- hope to get increase in secretions
Ex. albuterol (Proventil), montelukast (Singulair),
theophylline (Slo-bid), tiotropium (Spiriva)

What are STEROIDS for, what can they cause & what are 2 examples?

• anti-inflammatory & swelling

can cause:
-hyperglycemia
-infection
-osteoporosis
-impaired wound healing
-hunger
-more awake-fullness

Ex. budesonide (Pulmicort) & prednisone

What do MAST CELL STABILIZERS do & what are some examples?

- inhibits histamine release from mast cells (in allergic type reactions)
Ex. Cromolyn sodium (Intal, Nasalcrom)

What do ANTIHISTAMINES do & what are some examples?

- inhibit histamines
Ex. Diphenhydramine (Benadryl), Loratadine (Claratin) & Cetrizine (Zyrtec)

What are the 3 types of inhalers & how do you use?

- Nebulizer (aerosol medication)
- Metered Dose Inhaler (MID) (use spacers)
- Dry Powder Inhaler
- use bronchodilator first, b/c it opens the airway & ↑ surface area so steroid can be absorbed

What are spacers (2)?

- used with metered dose inhaler
- distributes medicine further into lungs

What are the 3 benefits of supplement O2?

1. ⬆ O2 availability
2. Reduces work of breathing
3. Decreases work of heart

What are the risks with Supplemental Oxygen?

1. damage pulmonary tissue (esp. for extended periods of time)
2. impairs stimulus to breath in COPD pts = may knock out respiratory drive) -in COPD patients look at respiratory rate
3. constricts retinal blood vessels (esp. in younger patients)
4. combustion = teach patient
5. ⬆ infection = bugs like O2
6. level of tolerance can change over time

What are the 2 therapeutic goals when using supplemental O2?

1. Arterial pO2 between 80 -100mmHg
2. Arterial pCO2 <45mmHg

What are the 4 desired responses with supplemental O2?

Normal heart rate & rhythm
Normal respiratory rate
Alert & oriented
Normal color

What's a normal CO2 level?

35-45mmHg

What's the normal level of PO2

80-100mmHg

What percentage is room air O2?

21%

With a nasal cannula, how much oxygen do you get with 1 Liter? How much % increase between Liters?

24% and goes up 4% per Liter
ex. 1L = 24%, 2L = 28%, 3L = 32%

A simple face mask delivers what % of O2 & who may it be used for?

35-60% @ 6-10L/min

- may be used for a mouth breather that is non responsive
- less comfortable

A partial breather delivers what % of O2 & how does it work?

- 70-90% @10-15L/min (prob closer to 70%)
- reservoir bag mixes 100% O2 with some expired air (breathe in & get O2 from bag & from room air)
- partial bag deflation indicates optimal function
- flow meter set at 10-15 L/min

A non-rebreather delivers what % of O2 & how does it work?

- 60-100% (@15L/min) (probably closer to 90-100% b/c both vents occlude so not getting any room air)
- inhale only oxygen from reservoir (so if bag gets twisted patient will not get O2)
- exhale through side ports
- set flow meter at 15L/min

what is a venturi mask (4)?

1. Adjust dial to change diameter of tube and size of side ports
2. Set flow meter according to dial
3. Delivers precise oxygen concentration (most precise device)
4. most appropriate for COPD patient

What oxygen device delivers the most precise O2?

Venturi Mask

use on COPD patients

What should you do with a COPD patient on oxygen?

use least amount as possible

what are 3 artificial airways?

- when patient can't maintain own airway
1. oral = keeps tongue away from back of throat (only when unconscious otherwise they choke)
2. Nasopharyngeal = very pliable
3. Endotracheal = mouth to trachea, usually have NG tube to decrease the risk of aspiration. patient can't talk, usually ICU, Max of 14 days → tacheostomy

what are 3 interventions related to O2 therapy?

1. Assess = Respirations, pulse oximeter, skin, mucous membranes
2. Use nasal cannula with meals if possible= nurse must be able to convert between oxygen devices
3. Hygiene = Face, nares, mask (skin care)
4. humidified air usually changed q 24 hour b/c bacteria likes this environment

What are 4 components of tracheostomy care?

1. Cleaning = around outside site (careful of pressure ulcers)
a. Inner cannula = disposable is daily, non-disposable is cleaned 2-3 times per days
b. Insertion site skin
2. Communication
3. Tube security - should have trach ties
4. Emergency Equipment
a. Obturator at bedside
b. Spare trach tube at bedside

What is Hypoxemia?

decreased O2 concentration
- deficient oxygenation of blood

What is Hypoxia?

O2 deficiency in body tissues / decreased O2 intake
- inadequate amount of oxygen available to the cells

What is Atelectasis?

incomplete or collapsed or airless condition of lung/part of lung

What is Pleural Effusion?

Fluid in the thoracic cavity between the visceral and parietal pleura

What is Pneumothorax, how does it happen & what do you do to correct?

- Collection of air or gas in the pleural cavity
- lung is punctures & air moves into pleural space
- use a chest tube to correct

Describe Crackles

• frequently heard on inspiration, they are soft, high-pitched discontinuous popping sounds
• Air passing over retained airway wet secretions or sudden opening of collapsed airway
• Fine or coarse
Ex. pneumonia, CHF, bronchitis, COPD

Describe Wheezes

• Continuous musical sounds heard predominantly during expiration that is caused by narrowing of passage way
Ex. asthma, tumors or a build up of secretions

Describe Rhonchi

• Low-pitched wheezing, snoring, or squeaking sound in someone w/ partial airway construction (mucus)

What is the normal hemoglobin level?

Males 14-18
Females 12-16

What four things should you assess on a patient receiving O2?

Respirations
Pulse Oximeter
Skin
Mucus Membranes

When checking Pulse Oximetry, what lab should you know?

hemoglobin

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