Nurs. 1245- Oxygenation

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Physiology Neurological Control

1.Medulla is primary stimulus in healthy person to breathe
-senses increase of CO2 and H+ ion
2. Chemoreceptors-measure O2 receptors
-aortic arch and carotid bodies
-sense decrease O2 levels
3. Proprioceptors
-respond to body movement and increase ventilation
- usually seen w/ increased activity

Chronic CO2 levels seen in COPD
-retain CO2, so have high levels, medulla eventually quits
-then chemoreceptors take over, making stimulus to breathe O2 when it's normally CO2

Essential for Normal Respiratory Function

-airway system integrity
-properly functioning alveolar-capillary system
-properly functioning cardiovascular & hematological systems
-healthy tissues

Steps in Gas Exchange

1. Ventilation- air moves in & out of lungs
2. Diffusion (Alveolar-> capillary)
-gas moves from areas of high to low concentration. Alveolar surface area, alveolar capillary membrane integrity affect it.
3. Perfusion- amt. of blood flow
-influenced by position and activity level
4. Gas Transport
-Oxygen-3% plasma bound, 97% oxyhemoglobin
-CO2- 5-10% plasma bound, 5-30% carboxyhemoglobin, 60-90% bicarbonate
5. Diffusion (Capillary-> Tissue)
-influnced by quality of RBCs and tissue chemistry

Factors Affecting Respiratory FX

Levels of health- renal disease, heart damage, lung disease, neuromuscular disease, brain injury, anema, skeletal problems, obesity
Lifestyle- activity levels, smoking
Enviornment- air pollution, occupational exposure
Psychological

Developmental Considerations

-infant-short airways, aspiration risk
-Children- eustachian tubes, bronchi, and bronchioles elongated and less angular; frequent colds and infections
-Older Adults- stiffer lung tissues, decrease muscle strength, skeletal alterations, digestive changes

Medications

1. Narcotics & sedatives- decrease stimulus to breathe
2. ACE inhibitors- dry cough
3. Amiodarone- pulmonary fibrosis
4. Bronchodilators- dilate bronchioles
5. Oxygen- need order

Nursing Assessment

History-
defer if evidence of distress
usual breathing pattern
cough
sputum
chest pain
dyspena
fever
fatigue
weight loss

Physical Exam

Inspect- skin, chest, RR and rhythm
Palpate
Percuss
Auscultate

Hypoxia

-decreased O2
Restlessness (early sign)
altered LOC
Dizziness
Behavioral Changes
Respiratory arrest (late sign)

Noninvasive Diagnostic tests

Pulse Ox- measure SaO2
normally 95-99%
Treat if <92%
Must know Hgb
Chest Xray
Sputum for Cytology

Pulmonary Fx Studies

-group of test that measure lung volumes, identify gas exhange problems, evaluate neuromuscular problems and dyspena

Spirometry- lung volume and airflow
Peak Expiratory Flow- evaluates asthma, records highest flow

Invasive Diagnostic Tests

1. ABGs.
pO2- O2 in blood, btwn 80-100
2. Bronchoscopy- scope to respiratory tract
-visualize structures, remove susbtances, NPO before (4-8 hrs), no food or fluids until gag returns
3. CT scan
-check iodine allergy if contrast to be used
-check metformin level
-if allergic to iodine, get certain prep; steroids and benedryl
4. Ventilation- Perfusion Scan
-radioactive substance injected and inhaled
-measure to blood flow and airflow
-8 hrs to eliminate
5. Skin Tests
-evaluate antigen-antibody reactions

Thoracentesis

-usually @ bedside
-needle or catheter inserted into intrapleural space to aspirate fluid
-monitor respirations after- improve or distress?
-may puncture lung and cause pneumothorax

Interventions

1. Teaching
-stop smoking, avoid pollutants
2. Promote Optimal Function
-control anxiety, nutrition, vaccines, balance activity and rest, pulmonary rehab

Promote Comfort

Positioning- semi-fowlers or fowlers position
Adequate fluids- 2-3L/24 hrs
Humidified Air- breeds bugs, changed every 24 hrs

Promote Proper Breathing

Deep breathing
Incentive Spirometry- forces deep breathing by intake
Purse Lip breathing- sitting or walking, helps Co2 retainers get rid of CO2
Abdominal Breathing

Promote or Control Coughing

Voluntary- cough and deep breathe
Involuntary
Medications
-Expectorant- loosen secretions (Robitussin)
-Suppressant- cough suppressent (Codeine, Robitussin DM)
-Lozenges- tickles for back in throat. Local anesthetic

Perform Chest PT

Cup hands, pad areas on position or chest to loosen secretions

Suctioning

-Device to clear secretions
-Can relieve or promote respiratory distress
-suction 10-15 seconds, wait 1 minute inbetween, done 3x only

Respiratory Medications

1. Bronchodilators- open narrowed airways
-albuterol (Proventil)
-montelukast (Singulair)
-theophylline (Slo-bid)
-tiotropium (Spriva)
2. Steroids
-Anti-inflammatory
-budesonide (pulmicort)
-prednisone
3. Mast Cell stablizers- inhibits histamine release from mast cells
-Cromolyn sodium (instal, Nasalcrom)
4. Antihistamines- inhibit histamines
-Diphenhydramine (Benadryl)
-Loratadine (claratin)
-Cetrizine (zyrtec)

Types of Inhalers

1. Nebulizer
2. Metered Dose Inhaler (MDI)
3. Dry power Inhaler (has tablet or capsule that is punctured in inhaler and released)
Use:
steps vary
bronchodilatort first-> opens up more surface area

Supplemental Oxygen

Benefits: increase oxygen, reduces work of breathing, decreases work of heart
Risks: damages pulmonary tissue, impairs stimulus to breathe, constricts retinal blood vessels, combustion, increase infection
Therapeutic goal:
-Arterial pO2 btwn 80-100 mmHg
-Arterial pCO2 < 45 mmHg
Desired Response:
Normal HR and rhythm
Normal RR
A & O
Normal Color

Nasal Cannula

ROOM AIR= 21%

1L= 24%
2L= 28%
3L= 32%
4L= 36%
5L= 40%
6L= 44%
-may need humdification
-check pressure points and pad them

Simple Face Mask

-delivers 35-60% O2 @ 6-10L/min
-less comfortable

Partial Non-Rebreather

-Reservoir bag mixes 100%O2 w/ some expired air
-70-90% O2
0Partial bag deflation indicates optimal fx
-flow meter set at 10-15 L/min

Non-Rebreather

-exhale through side ports
-inhale only oxygen from reservoir
-60-100% O2
-set flow meter at 15L/min

Venturi Mask

-adjust dial to change diameter of tube and size of side ports
-set flow meter according to dial
-delivers precise oxygen concentration
-most precise O2 concentration delivered by mask

Interventions related to O2 Therapy

Assess- RR, pulse ox, skin, mm
Use NC w/ meals if possible- must be able to convert btwn O2 devices
Hygiene- face, nares, mask

Artifical Airways

-oral
-nasopharyngeal
-endotracheal- intubated for 14 days

must have no gag reflex

Trach Care

-Cleaning- inner cannula, insertion site skin
-Communication
-Tube security
-Emergency Equipment- obturator at bedside, spare trach tube at bedside

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