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Oxygenation P & A
Terms in this set (90)
Absence of respiration; a potentially serious sleep disorder in which breathing repeatedly stops and starts; may be obstructive or central in origin
What is the nurses role for respiration?
Nurses are responsible for promoting normal respiratory function regardless of the practice area.
the process of moving air in and out of lungs
1)Coordination of muscles
2)Elastic properties of lung
-Oxygen and carbon dioxide move between the alveoli and the blood
-the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure.
partial pressure of oxygen
(PO2): The pressure exerted by oxygen gas on surrounding structures; may be measured in the alveolus (PAO2), artery (PaO2), or vein (PvO2)
partial pressure of carbon dioxide
(PaCO2): The pressure exerted by carbon dioxide gas on surrounding structures; may be measured in the alveolus (PACO2), artery (PaCO2), or vein (PvCO2)
- determine the percentage of hemoglobin that has combined with oxygen
-The pulse oximeter uses infrared light to determine the percentage of hemoglobin that combines with oxygen.
-An SpO2 greater than 95% is considered normal, whereas values lower than 93% usually indicate the need for oxygen therapy and further assessment.
arterial oxygen saturation
(SpO2): Percent of hemoglobin saturated with oxygen; measured by pulse oximeter
What are the Accessory Muscle?
The ease in which the lungs expand
What can decrease compliance?
interstitial/ pleural fibrosis
cogenital/ traumatic structural abnormalities
pressure in the intrapleural space?
756mmHG - (4 mmHg)
pressure in the intrapulmonary space?
760 mmHg (0mmHg)
Steps in the gas exchange process? 4
2)diffusion across alveolar - cap. membrane
3)Transport of gases in circulation ( perfusion )
4)Diffusion between systemic capillary bed and cells of the body
The respiratory process
1)Diaphragm descends causing negative pressure
2) Negative pressure draws air from the area of greater pressure (the atm) into the area of lesser pressure ( the lungs)
3)At the alveoli, gas exchange occurs
4)The diaphragm relax and the lungs recoil
5) As the lungs recoil, pressure within the lungs become higher causing the air in the lungs (which now contains CO2) to move from the alveoli in the lungs into the atmosphere.
Arterial Blood Gas
ABG's- measurement of the dissolved O2 and CO2 in the arterial blood that helps to indicate the acid-base state and how well oxygen is being carried to the body
amount of air inhaled or exhaled per breath
air left in lung after an max exhalation (1000-1200ml)
Functional residual capacity
volume of air left in lungs after a normal exhalation (2000-2400ml)
volume of air exhaled after a max inhale (4500-4800ml)
TLC total lung capacity
total volume of air in lungs following a max inhale (5000-6000ml)
alveolar ventilation is inadequate to meet body's O2 demand or eliminate sufficient CO2
state where lungs remove CO2 faster than it is produced
inadequate tissue oxygenation
Gas transport O2
-Small amounts of oxygen are physically dissolved in plasma (3% of O2),
-most oxygen that the blood carries to the tissues is attached to hemoglobin molecules on red blood cells (97% of O2)
Normal Partial pressures
PaCO2 between 35-45 mmhg
pa CO2 between 80-100 mmHg
Oxygen saturation (SA02) between 95-100 percent
chemoreceptors and CO2
-in the aortic arch and carotid arteries (peripheral receptors) and the medulla (central receptors) are sensitive to circulating blood levels of carbon dioxide and hydrogen ions.
-Carbon dioxide plays the primary role in determining the frequency and depth of ventilation.
-If PaCO2 levels in the blood increase, chemoreceptors (peripheral and central) are stimulated, causing more deep and rapid breathing.
-Breathing slows when PaCO2 decreases.
-Normal breathing is usually regular and smooth because carbon dioxide levels remain fairly constant.
Upper Respiratory Defenses
-A major function of the upper respiratory tract is to warm and humidify inspired air.
- cleans inspired air. The nose is a highly effective filter for foreign particles. It traps dust and irritants in hairs lining the nostrils or in the mucous layer of the nasal passages.
-protects the lower respiratory tract from infection and from injury due to aspiration.
-epiglottis acts as a trapdoor by preventing large particles of food or foreign matter from being accidentally aspirated.
Lower Respiratory Defense
-further filter and clean incoming air. An epithelial layer containing millions of ciliated cells and mucus-producing glands lines these airways.
-The mucous membrane produces a "mucus blanket" that efficiently traps bacteria and microscopic foreign particles.
-protects the airways by constantly sweeping potentially harmful material out of the lungs.
-specialized scavenger white blood cells called macrophages help decrease the risk of infection by engulfing bacteria and other particles that may have bypassed the mucous blanket
sneeze and cough function?
-reflexes also protect the lungs and airways. -
-Irritants trapped in the nose stimulate sneezing; -
-helps to expel trapped material from the nasal passages, thereby decreasing irritation and helping to prevent infection.
-Coughing clears the lower airways much like sneezing helps to cleanse the nose.
Breathing rates by age
Newborn &infant 30-60
1-5 y 20-30
6-10 y 18-26
10 y-adult 12-20
Older adult (60 y and older) 16-25
FACTORS AFFECTING RESPIRATORY FUNCTION
-POLLENS AND ALLERGENS
An upright posture (standing or sitting erectly) allows for the greatest ease of lung expansion. The diaphragm can move up and down most readily when the abdominal organs are not pressing against it.
The percentage of oxygen humans breathe, referred to as the fraction of inspired oxygen concentration (FiO2), remains stable at around 21% when breathing "room air"
-Oxygen partial pressure decreases steadily as altitude increases.
-Lower oxygen pressure at higher elevations means that less oxygen is available to the lungs for gas diffusion.
-even healthy people are likely to experience shortness of breath and activity intolerance at higher elevations.
POLLENS AND ALLERGENS
Specific substances that cause allergic responses can affect respiration, sometimes severely. The body attempts to rid itself of substances perceived as harmful by releasing chemical mediators that cause an inflammatory response
-Any process that reduces the diameter of the conducting airways causes increased airway resistance.
-Breathing then requires more effort because air must move through a narrower passage.
-They can become plugged by foreign material, mucus, or abnormal growths.
-Children who aspirate small objects experience airway obstruction
RESTRICTED LUNG MOVEMENT
-conditions that cause lungs to stiffen or may restrict expansion of the chest.
-Stiffer lungs (or lungs not allowed to expand fully) tend to collapse, and their alveoli also collapse. -
-reduces the amount of space available for gas exchange.
-Oxygen has greater difficulty passing through thickened alveolar walls.
-Because stiff lungs require more work to expand, the respiratory muscles consume an increased amount of oxygen.
-alveoli collapse, leading to a complete or partial collapes of lobe or lungs
-reduces the amount of space available for gas exchange.
-is usually a reflexive response to irritation in the airways.
-There is not a "normal" cough.
-Any cough, regardless of how obvious its origin, is most often an indication that the lungs or airways are being subjected to some form of irritation.
-may be a natural consequence of irritation, but it is never really normal.
-normally produced in such small amounts that a cough from a healthy person is dry and nonproductive.
-Raising mucus with a deep cough indicates that the lungs are attempting to clear away irritants
Shortness of Breath
A person who is unable to breathe sufficiently to meet the body's oxygen and metabolic demands experiences the discomfort of breathlessness. This subjective feeling of labored breathing and breathlessness is known as dyspnea.
Levels of Dyspnea
Level I-The patient can walk 1 mile at own pace before experiencing shortness of breath.
Level II-The patient becomes short of breath after walking 100 yards on level ground or climbing a flight of stairs.
Level III-The patient becomes short of breath while talking or performing ADLs.
Level IV-The patient is short of breath during periods of no activity.
Orthopnea-The patient is short of breath lying down.
Nursing Assessment of a pt with dyspnea
Forcing the patient with dyspnea to speak can worsen shortness of breath. Be sensitive to the patient's ability to answer questions; if necessary, wait on less important questions until a better time.
Normal pattern identification
-the nurse must take care in eliciting information about normal breathing patterns.
-Patients who indicate that their breathing is ordinarily fine or unremarkable may have adjusted to a baseline breathing pattern that is abnormal for most people.
-Observe the rate and pattern of respiration.
-Very slow breathing can cause hypoxemia (low oxygen levels in the blood) and hypercapnia (abnormally high carbon dioxide in the blood).
-breathing too fast causes excessive elimination of carbon dioxide, which causes dizziness and possibly respiratory alkalosis.
- Rapid breathing by the severely debilitated patient may lead to exhaustion.
- assess abnormalities such as swelling or tenderness.
-used to determine the extent and pattern of thoracic expansion and to note the position of the trachea.
-Increased tactile fremitus can be present in consolidation in the lung,
-decreased fremitus may occur with pleural effusion, pulmonary edema, emphysema, or bronchial obstruction.
-normally equally loud on both sides of the chest.
-Absent or distant-sounding breath sounds in any area of the lung can indicate airway obstruction or can mean that fluid or air has accumulated in the pleural space.
-A "silent chest" in a patient with asthma who is experiencing severe shortness of breath is a grave sign of poor ventilation and impending respiratory failure
early signs of Hypoxemia
use of accessory muscles
OUTCOME IDENTIFICATION AND PLANNING
-The patient will demonstrate knowledge regarding prevention of respiratory dysfunction.
-The patient's tissues will have adequate oxygenation.
-The patient will mobilize pulmonary secretions.
-The patient will effectively cope with changes in self-concept and lifestyle.
late signss of hypoxemia
think of the brain becoming more and more deprived of O2
confusion/ altered mental status
decreased blood pressure / heartrate
decreased respiratory rate
-Ineffective Breathing Pattern r/t presence of tracheobronchial secretions secondary to infection (Pneumonia)
- Ineffective Airway Clearance r/t shallow coughing and thickened mucus (COPD)
-Impaired Gas Exchange r/t alveolar/capillary membrane changes secondary to inflammatory process in lungs
-Activity intolerance r/t imbalance between O2 supply and demand secondary to inefficient work of breathing
-Healthy life style
-Prevent respiratory infections (vaccines)
-Breathing and coughing exercise
Pursed-lip breathing helps patients with obstructive lung diseases such as COPD or asthma by causing a back pressure in the airways, which eases exhalation and prevents air trapping.
-Chest physiotherapy commonly is prescribed to help clear excessive bronchial secretions from airways.
-premise that mucus can be shaken from the walls of the airways and helped to drain from the lungs. -useful for many patients with cystic fibrosis, COPD, lobar collapse, bronchiectasis, and mucous plugging.
-Contraindications are pneumonia hemoptysis, and pneumothorax
Cannula (nasal prongs)
22%-44% when operated at 1-6 L/min
1. convenience and patient comfort
2. "rule of four" used to estimate concentration: For each L/min of O2, concentration increases by 4% (e.g., 1 L/min provides 22%, 2 L/min provides 26%)
3. Limit maximum O2 flow to 6 L/min to minimize drying of nasal mucosa; use humidifier prn
4. Nasal passages must be patent for the patient to receive O2: Mouth breathing does not appreciably diminish delivered O2
5. Delivered O2 concentration can vary depending on the patient's breathing pattern; relatively consistent O2 delivery with quiet, steady breathing
-suspension of microscopic liquid droplets in air or oxygen.
-To add moisture to oxygen delivery systems
-To hydrate thick sputum and prevent mucous plugging
-To administer various drugs to the airways
-A large-volume nebulizer or an ultrasonic nebulizer will deliver a moist fog continuously to the airways.
Venturi (Venti) mask
24%-50% when operated at 3-8 L/min as specified by manufacturer
1. Provides precise and consistent O2 concentration
2. Essential to adjust mask according to specifications to ensure accurate O2 delivery
3. Noisy; like all masks, may cause claustrophobia
Cannula, for who?
a low flow used for the pt with chronic airflow limitations and for long term O2 use
40%-60% when operated at 6-10 L/min
1. Most common midrange O2 delivery device
2. Minimum of 5 L/min O2 required to prevent the patient from rebreathing exhaled carbon dioxide
3. actual delivered O2 concentration varies with breathing pattern
4. Not suitable for the patient with COPD because of potential for excessive oxygenation
way dosage of oxygen is expressed in liters/min
Up to 90% + when operated at 10-15 L/min
1. Used for critically ill patient
2. Use sufficient flow to keep O2 reservoir inflated
Venturi mask, who?
Used for pt at risk for or experiencing acute respiratory failure
22%-90% + when operated at 7-12 L/min
1. Precise O2 delivery for newborns and small infants
2. Minimum O2 flow of 7 L/min flushes infant's exhaled carbon dioxide
3. Oxygen must be prewarmed and humidified to prevent infant heat loss
4. Frequent analysis needed to prevent excessive oxygenation
1. Primarily used by small child unable to wear mask or cannula
2. Mainly used as "mist tent" to deliver high humidity to children with croup
3. Extremely inefficient O2 delivery system; O2 delivery fluctuates because leaks are common
Simple Face mask, who?
Used for short-term )2 therapy or to deliver )2 in an emergency
-decreasing patient anxiety and getting the patient to breathe at a slower rate.
-the patient may use a paper bag as a rebreathing device. The patient breathes in and out of the bag for several breaths.
-In the process of rebreathing the exhaled carbon dioxide from the bag, the patient's PaCO2 can gradually slow the rate of breathing until it returns to normal.
-The dizziness and tingling sensations should disappear
Bilevel positive airway pressure
-therapy uses a mechanical ventilator to assist inspiration.
-The patient's inspiratory effort triggers the ventilator, which pushes air into the lungs.
-The positive pressure helps to prevent and treat atelectasis by helping to open underinflated alveoli
-Experiration 5 mmHg
Continuous positive airway pressure
-uses oxygen under constant pressure to accomplish this objective.
-often used at night to decrease periodic hypoxemia associated with sleep apnea.
- delivered via specially fitted masks or nasal prongs that are attached to a machine that delivers appropriate pressure
most frequently used for the pt with a deterioratig respiratory status who might require intunation
Oxygen tent, for who?
used instread of a tight fitting maske for young pt or pt with facial trauma or burns
Why us CPAP or BiPAP?
Shorter ICU/hospital stays
Avoidance of invasive ventilation
but may cause face/nasal injury, skin breakdown, dry membranes, aspiration
-Encourages voluntary deep breathing by providing visual feedback
-Utilized to prevent or treat atelectasis
adequate air is brought into the alveoli
the oxygen contained in the air is not able to pass int the capillaries surrounding the alveoli.
results in low oxygen levels (hypoxemia)
physiological factors affecting oxygenation
-decreased oxygen carry capacity
-decreased inspired oxygen concentration
-hypovolemia(low blood volume)
-increased metabolic rate(fever, exercise)
-conditions affecting chest wall movement
-administered for treatment of hypoxia
-O2 therapy is ordered by the HCP;
-titration orders at times accompany initial order
effect is assessed by both oxygenation saturation/ ABG analysis and improvement in patient's clincal status
effective coughing technique that conserves energy, reduces fatigue, and facilitates mobilization of secretions.
-pt takes 3 or 4 breaths using pursed lips and leaning slightly forward, the pt should cough 3 or 4 times during exhalation
Inhale slowly to raise and maintain flow rate indicatory between 600 and 900 marks
-Client should hold breath for 5 seconds, then exhale thru pursed lips
-10x an hour
Long term solution
A solution to a short term problem, like seizure, anaphylaxis or a severe asthma attack
Types of Trach tubes
1)Cuffed- blocks any air from flowing around the tube and assures that the pt is well oxygenated
2)Cuffless/Fenestrated- often used as the final step before trach removal, permits speaking and coughing, providing an experimental trial
1)Assess the pt and explain procedure
2)Assist the pt to upright position
3)Perform hand hygiene and don protective garb
4)Prepare suctioning equipment and turn on suction
6)Insert the catheter w/o suctioning on
7)Once inserted apply suction intermittently while rotating and withdrawing the catheter
9)Listen to lung sounds
10)Document procedure, pt response, and effectiveness
Why chest tube?
-drainage device the physician places in the pleural space to drain fluid, air, or blood.
-normally the pressure within the thoracic cavity is negative compared to atmospheric pressure. This negative pressure moves air into a person's lungs on inhalation.
-Any interruption in this negative pressure gradient may necessitate the need for a chest tube. The fluid buildup from a disease process may inhibit the lung's ability to expand normally; the fluid must be drained from the pleural space
inserts the chest tube into the intrapleural space.
- It is sutured in place and covered with an occlusive sterile dressing.
- connected to the collection/water seal system by a rubber tube that can be 2 to 4 feet long.
=The water seal prevents air from entering the pleural space as the patient inspires.
- keep the extra tubing looped at the level of the patient; otherwise, fluid can accumulate in dependent loops.
-3-5 min on each segment lung segment
-Pt takes slow, deep breathing following by vigorous coughing
5. A patient is having difficulty coughing up secretions, has rhonchi in the lungs, has respiratory rate of 28, and has dyspnea. The nurse recognizes these as symptoms of which nursing diagnosis?
Ineffective Breathing Pattern
Ineffective Airway Clearance
Impaired Gas Exchange
Impaired Deep Breathing
b. Ineffective airway clearance is when a patient is unable to clear secretions or obstructions from the respiratory tract or clear the airway, as evidenced by adventitious lung sounds. Ineffective breathing pattern is the state in which a patient's inspiratory or expiratory pattern does not provide adequate ventilation. With impaired gas exchange, there must be evidence that there is an excess or deficit in oxygen absorption or carbon dioxide elimination usually validated by the arterial blood gas. Although deep breathing may be impaired, there is no evidence to support this conclusion. Increased respiratory rate and reported difficulty breathing could be related to any of these nursing diagnoses.
A nurse is performing nasotracheal suctioning on a patient who has respirations of 30, audible respiratory secretions in the airway, and decreased breath sounds. Which order of steps is most appropriate?
A) Put on the sterile gloves in the kit.
B) Pour the sterile saline into the suction cup.
C) Position the patient in a semi-Fowler's position.
D) Attach the catheter to the suction tubing.
c, b, a, d. The patient is first prepared for the procedure by explaining the procedure and positioning to prevent aspiration of secretions. The nurse considers the sequence of the procedure using principles of sterile technique. The cup should be filled prior to placing gloves because the saline is usually poured from a clean container. The gloves are placed next, and the nondominant hand is then contaminated when the catheter is connected to the clean suction tubing. The nurse uses the sterile hand holding the catheter for suctioning the patient.
10. The nurse is teaching the patient about using the incentive spirometer for the first time. Which instructions will be included in the teaching?
A) "Seal your lips tightly around the mouthpiece."
B) "Observe the indicator for progress toward the goal."
C) "Exhale slowly around the mouthpiece and breath normally."
D) "Inhale deeply through the mouth and hold breath for 2 to 3 seconds."
a, d, b, c. The incentive spirometer can be confusing to some patients as they may expect to blow into the device; explain that it works by "sucking in" rather than blowing out. The goal is to get the patient to breathe more deeply and ventilate better. Explain that bigger breaths in help expand the lungs; the goal amount of inhalation can be increased as improvements are made. The mouth must be sealed around the mouthpiece during deep inhalation; it can be released during exhalation. It is normal for proper use of the incentive spirometer to induce coughing in the patient with atelectasis or impaired gas exchange.
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