Post on 16-Jan-2016
OxygenationOxygenation
Chapter 40Chapter 40
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ANATOMY AND PHYSIOLOGY ANATOMY AND PHYSIOLOGY REVIEWREVIEW
• CARDIOVASCULAR/RESPIRATORY CONNECTION– BOTH SYSTEMS MUST BE FUNCTIONING FOR
EITHER SYSTEM TO WORK• heart structure/function• lung structure/function• CNS innervation to chest, diaphragm• Peripheral and cardiac circulation• Adequate volume and hemoglobin• Acid-base balance & regulation• CO2 response/ O2 response
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ALTERATIONS IN OXYGENATIONALTERATIONS IN OXYGENATION
• PHYSIOLOGICAL→ DECREASE IN OXYGEN CARRYING
CAPACITY• ↓ Transport HGB & HCT• ↓ VOLUME R/T BLOOD LOSS• ↓ Binding of O2 [CO]• ↓ Intake of O2 [altitude]• ↑ DEMAND [exercise, fever, illness]
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ALTERATIONS IN OXYGENATIONALTERATIONS IN OXYGENATION
• PHYSIOLOGICAL→ ↓CHEST WALL MOVEMENT
• PREGNANCY• OBESITY• MUSCULOSKELETAL CHANGES [kyphosis]• TRAUMA [ rib fracture]• CNS ABNORMALITIES [C4 spinal trauma]
ALTERATIONS IN OXYGENATIONALTERATIONS IN OXYGENATION
• Physiological→ Changes in Delivery of O2– Diffusion in lungs [alveolar]
• atelectasis, ↓surface area, ↓blood supply, pressure• Secretions [pneumonia, COPD]
– Transport to tissues• Cardiac output• circulation [PVD, trauma, volume, vasoconstriction]• Cardiac perfusion
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ALTERATIONS IN OXYGENATIONALTERATIONS IN OXYGENATION
• PHYSIOLOGICAL– CHRONIC DISEASES
• COPD: CO2 drive absent R/T chronic high pCO2– Dependent on paO2 drive; ↓compliance, atelectasis,
↓clearance of airways
• POLYCYTHEMIA: response to chronic hypoxemia
– CONDUCTION DISTURBANCES– HEART FAILURE
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ALTERATIONS IN RESPIRATORY ALTERATIONS IN RESPIRATORY FUNCTIONINGFUNCTIONING
We breathe to take in O2 and eliminate CO2 • HYPERVENTILATION:
– in excess of what is needed to eliminate CO2
• HYPOVENTILATION: – inadequate to meet O2 needs OR to eliminate CO2
• HYPOXIA• INADEQUATE TISSUE OXYGENATION
• HYPOXEMIA• DECREASED OXYGEN CONCENTRATION IN THE
ARTERIAL BLOOD
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SPECIAL OXYGEN CONSIDERATIONS SPECIAL OXYGEN CONSIDERATIONS ACROSS THE LIFE SPANACROSS THE LIFE SPAN
• INFANTS AND TODDLERS– SURFACTANT [newborn]– Risk for URI– Shorter airways
• OLDER ADULTS– DEGENERATIVE PROCESSES
• Compliance, chest wall movement, accumulated pollutants, cardiac and perfusion changes, alveolar changes, cilia decrease
– CHRONIC DISEASE• HTN, Respiratory, Cardiac, Renal…
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LIFESTYLE FACTORSLIFESTYLE FACTORS
• NUTRITION
• EXERCISE
• SMOKING
• SUBSTANCE ABUSE
• STRESS
• ENVIRONMENTAL FACTORS
Nursing ProcessNursing Process
• Nursing History: Ability to meet O2 needsCardiac function
Respiratory function
Pain
Fatigue
Dyspnea
Cough
Wheezing
Respiratory Infections
Allergies
Risk Factors
Medications
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PHYSICAL PHYSICAL ASSESSMENTASSESSMENT
• INSPECTION– GENERAL APPEARANCE– LOC– SYSTEMIC CIRCULATION– BREATHING PATTERNS– CHEST WALL MOVEMENT
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PHYSICAL PHYSICAL ASSESSMENTASSESSMENT
• PALPATION– THORACIC EXCURSION– AREAS OF TENDERNESS– EXTREMITIES– CAPILLARY REFILL
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PHYSICAL PHYSICAL ASSESSMENTASSESSMENT
• PERCUSSION– AREAS OF CONSOLIDATION
• AUSCULTATION– NORMAL V. ABNORMAL LUNG SOUNDS
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PHYSICAL PHYSICAL ASSESSMENTASSESSMENT
• DIAGNOSTIC TESTS– PULSE OXIMETER– PEAK EXPIRATORY FLOW RATE– ARTERIAL BLOOD GASES– CHEST X-RAY– SPUTUM SPECIMEN– PULMONARY FUNCTION TESTING– BRONCHOSCOPY– VENTILATION-PERFUSION LUNG SCAN [V/Q]– THORACENTESIS– CT / MRI
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Case Study #1Case Study #1
• 36 yo male visiting from Austin, TX with sudden onset” dizzy, confused, headache and hard to breathe” this afternoon. No obvious trauma. No significant medical history; friend states “he’s in great shape – an athlete – he comes here to bike and climb. He’s climbing the fourteeners!”
• VS: T 37.3; P90, R36, B/P 108/58, SPO2 80% on RA• Assessment: pale, anxious, confused, c/o headache.
Oriented to person only. Sinus tachycardia; deep, labored resp. with fine crackles at bases. Extremities cool to touch and pale.
What’s going on?What’s going on?
• What is abnormal?
• What do you think the cause is?
• What should the interventions be?
• Nursing diagnosis for this patient?
Nursing DiagnosesNursing Diagnoses
• Activity Intolerance
• Impaired Gas Exchange
• Ineffective Airway Clearance
• Ineffective Breathing Pattern
• Risk for Infection
GoalsGoals• Pt will:
– Maintain airway– Clear secretions effectively– Increase hydrations [to mobilize secretions]– Improve Oxygenation [SPO2]– Increase activity tolerance– Report decreased Dyspnea [scale 0-10]– Decrease risk factors– Show resolution/ improvement in underlying
cause
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INTERVENTIONSINTERVENTIONS
• HEALTH PROMOTION– VACCINATIONS– HEALTHY LIFESTYLE BEHAVIOR– ENVIRONMENTAL AWARENESS– EDUCATION
• Reduce risk factors
Case study #2Case study #2
• 72 yo female Denver resident c/o SOB [dyspnea], dizziness and fatigue. Family reports she seems “pleasantly confused” today. HX of DM with renal failure treated with oral Glucophage
• VS: T 36.2C, P 86, R30, B/P 160/88, SPO2 90 on RA• Labs: Na+ 136, K+ 3.0, HCT 40, Hgb 14; • ABG: ph 7.32, PaO2 80, PCO2 46, HCO3- 18• Assessment: Oriented to person, knows she is ‘not at
home’. Lungs clear, respirations rapid and deep w/o use of accessory muscles. Other findings WNL for age
What to do?What to do?
• Any more info you need? Labs?
• What in her history raises a flag?
• What is the problem?
• What interventions are appropriate?
• Nursing diagnoses for this patients?
InterventionsInterventions
• Focus on:• treating underlying cause [abx, O2]• adaptation [meds, breathing techniques]• preventing complications [TC&DB, IS]
– managing Dyspnea [O2, position, activity]– Maintaining Airway [Suction, cough, IS]– Mobilizing Secretions [hydration, TC&DB,
meds]– Prevent infection/complication
Case Study #3Case Study #3
• 18 yo DU freshman student c/o “choking”, increased thick secretions, weak productive cough. HX of CF [cystic fibrosis]
• VS: T 38.2C, P100, R 36, B/P 110/70, SPO2 80% on RA• Assessment Rhonchi, rales over all lung fields, uses
accessory muscles, thick yellow secretions produced with weak rattling cough. Other systems WNL
What’s going on?What’s going on?
• Main problem? Why?
• Abnormal findings?
• Nursing diagnosis?
• Interventions for this client?– Education/referrals?
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INTERVENTIONS IN ACUTE AND INTERVENTIONS IN ACUTE AND CHRONIC CARECHRONIC CARE
• POST OPERATIVE CARE– INTERVENTIONS TO PREVENT
PNEUMONIA• TC&DB Q2h• NASAL O2 TO KEEP O2 SAT >90%• IS Q2h WA• SPLINT INCISION• PAIN MEDICATION
Case study #4Case study #4
• 28 yo female post-op trauma pt. with Rt tibia fracture, Rt rib fracture, liver laceration [repaired]. C/O “pain all over 8/10 this am. SOB [dyspnea], dizziness
• VS: T 37.4C, P88, R 30, B/P [supine =118/78, sitting= 100/64, SPO2 85% on RA
• Labs: Hct 58% BUN 28 mg/100 ml; others WNL• Assessment: dry mucous membranes, skin tenting, cap
refill <3 sec; pulses +2 bilat and equal, RL BK cast, Rt upper abdominal incision CDI, Rt ribs bruised. Lungs CTA. Hypoactive BS X4 quadrants, rapid shallow respirations
What is wrong?What is wrong?
• Abnormal Findings?
• History?
• Nursing diagnoses?
• Interventions?
OxygenOxygen
• Yes, it is a medication
• Can cause harm
• Ordered by Physician
• Standing orders - emergency
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NASAL CANNULANASAL CANNULA
• O2 DELIVERY UP TO 6L/M (6 liters per minute)– MUST BE HUMIDIFIED >4L/M– ROOM AIR = 21% O2– ROOM AIR + 3L O2 = 32% O2
• APPROX. 3 – 4%/LITER
– Potential trauma to nares, ears
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OXIMEIZEROXIMEIZER
• 8 – 10 LITERS PER MINUTE
• DO NOT HUMIDIFY – CONTAINS A FILTER THAT HUMIDIFIES
THE OXYGEN
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OXIMIZEROXIMIZER
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SIMPLE FACE MASKSIMPLE FACE MASK
• DELIVERS OXYGEN CONCENTRATIONS AT 40 – 60%
• CONTROLLED BY LITER FLOW– 5 – 8 LITERS PER MINUTE– Short term– Not for Pts with CO2 retention
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SIMPLE FACE MASKSIMPLE FACE MASK
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NON REBREATHER MASKNON REBREATHER MASK
• DELIVERS THE HIGHEST LEVEL OF OXYGEN POSSIBLE WITH A MASK– 95 – 100%– LITER FLOW 10 – 15 LITERS PER MINUTE– ONE WAY VALVE BETWEEN RESERVOIR
AND MASK • PREVENTS ROOM AIR FROM MIXING WITH O2
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NONREBREATHER MASKNONREBREATHER MASK
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VENTURI MASKVENTURI MASK
• DELIVERS OXYGEN FROM 24 – 50%
• CAN “DIAL IN” OXYGEN LEVEL– 4L/MIN = 24%– 8L/MIN = 35%
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OXYGEN FACE TENTOXYGEN FACE TENT
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TRANSTRACHEAL OXYGENTRANSTRACHEAL OXYGEN
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Case study # 5Case study # 5• 58 yo male c/o dyspnea “it hurts to breathe”, fatigue. HX
of URI 2 weeks ago, untreated [“probably bronchitis – I get it every year”]; smokes 1 pack/day X 40 years. Morning cough productive of thick green sputm. Pt states “that’s new – I always cough in the morning but I don’t spit notheing up”
• VS: & 37.8C, P76, R28, B/P 176/84• Labs: Na+ 138, Hct 58%, BUN 28; others WNL Sputm
sample sent for C&S, pending. CXR shows bilateral lower lobe infiltrates
• Assessment: Pale, dry mucous membranes, cap refill 3 sec; dull & decreased lung sounds bilateral bases
What is wrong?What is wrong?
• Abnormal Findings?
• History?
• Nursing diagnoses?
• Interventions?
• Additional info you need?
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INTERVENTIONS IN ACUTE AND INTERVENTIONS IN ACUTE AND CHRONIC CARECHRONIC CARE
• DYSPNEA– PATIENT ASSESSMENT– APPLY OXYGEN?– UNDERLYING CAUSE
• ASTHMA• CHRONIC HEART FAILURE• COPD
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ASSESSMENT FINDINGSASSESSMENT FINDINGS
• THICK SECRETIONS– DO THEY NEED OXYGEN?– UPPER AIRWAY?– LOWER AIRWAY?– ASSESS SECRETIONS
• HUMIDIFY• HYDRATION• NEBULIZER• CHEST PHYSIOTHERAPY• SUCTIONING
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ASSESSMENT FINDINGSASSESSMENT FINDINGS
• WHEEZING (WHY ARE THEY WHEEZING?)– OXYGEN?– BRONCHODILATOR– CONTINUED ASSESSMENT
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AIRWAYAIRWAY
• NATURAL
• ARTIFICIAL– NASAL– ORAL– ENDOTRACHEAL– TRACHEOSTOMY
ARTIFICIAL AIRWAYSARTIFICIAL AIRWAYS
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CARE OF THE PATIENT WITH AN CARE OF THE PATIENT WITH AN ARTIFICIAL AIRWAYARTIFICIAL AIRWAY
• ORAL AIRWAY– MAINTAINS AN OPEN AIRWAY
• DURING DECREASED LEVEL OF CONSCIOUSNESS• SEDATION• SEIZURES
– MADE OF HARD PLASTIC• ATTEND TO ANY PRESSURE AREAS ON LIPS, MOUTH,
TONGUE• HOLLOW TO FACILITATE SUCTIONING
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NASOTRACHEAL, NASOPHARYNGEAL OROPHARYNGEAL, OROTRACHEAL
SUCTIONING
• WHEN PATIENT IS UNABLE TO COUGH UP THICK PULMONARY SECRETIONS
• PASS CATHETER THROUGH NOSE [less gagging] OR MOUTH
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NASAL AIRWAYNASAL AIRWAY
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CARE OF THE PATIENT WITH AN CARE OF THE PATIENT WITH AN ENDOTRACHEAL TUBEENDOTRACHEAL TUBE
• PROVIDER MAY NEED ASSISTANCE DURING INTUBATION [e.g. provide O2, SX]– INTUBATION IS INSERTING THE TUBE– EXTUBATION IS REMOVING THE TUBE
• ORAL CARE IS A PRIMARY CONCERN FOR THE NURSE CARING FOR THIS PATIENT
• TUBE MUST BE SECURE– NO PRESSURE AREAS ON FACE, LIPS OR MOUTH
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ENDOTRACHEAL TUBEENDOTRACHEAL TUBE
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CARE OF THE PATIENT WITH AN CARE OF THE PATIENT WITH AN ENDOTRACHEAL TUBEENDOTRACHEAL TUBE
• TUBE MUST BE CLEAR OF SECRETIONS
• SUCTION PRN TO KEEP TUBE PATENT– Limit time! 15 sec– To instill or not to instill NS?
• CHANGE TAPE AND REPOSITION TUBE EVERY 24H
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TRACHEOSTOMY TUBETRACHEOSTOMY TUBE
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CARE OF THE PATIENT WITH A CARE OF THE PATIENT WITH A TRACHEOSTOMYTRACHEOSTOMY
• TUBE MUST BE CLEAR OF SECRETIONS
• SUCTION PRN TO KEEP TUBE PATENT
• CHANGE DRESSING AND INNER CANNULA EVERY 24H– IF INNER CANNULA IS NOT DISPOSABLE,
REMOVE, CLEAN AND REPLACE
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SLEEP APNEASLEEP APNEA
• OBSTRUCTIVE SLEEP APNEA– one or more pauses in breathing or shallow
breaths while you sleep.– can last from a few seconds to minutes. – occur 5 to 30 times or more an hour. – normal breathing then starts again, sometimes
with a loud snort or choking sound
• CENTRAL SLEEP APNEA– less common type of sleep apnea. – area of your brain that controls breathing doesn't
send the correct signals– no effort to breathe for brief periods.
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CPAP / BiPAPCPAP / BiPAP
• Congestive heart failure
• Lung disorders resulting in high CO2
• Patients for whom intubation is not possible
• Sleep apnea
• Surfactant deficiency/ atelectasis
• Less invasive than intubation, trach
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CARE OF THE PATIENT CARE OF THE PATIENT WITH A CHEST TUBEWITH A CHEST TUBE
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CHEST TUBESCHEST TUBES
• PURPOSE– RE-EXPAND THE LUNG
• HOW?– RELEASE AIR– DRAIN FLUID
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CONDITIONS REQUIRING A CHEST CONDITIONS REQUIRING A CHEST TUBE INSERTIONTUBE INSERTION
• PNEUMOTHORAX: Air in pleural space– SPONTANEOUS– TENSION– TRAUMA– POST CHEST SURGERY
• Hemothorax: Fluid/ Blood in pleural space– INFECTION– BLEEDING INTO THE PLEURAL CAVITY
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Heimlich valve
•one-way, rubber flutter valve•proximal end attaches to the chest tube, •distal end connects to a suction device or is left open to the atmosphere.• allows outpatient treatment of a pneumothorax.
HEIMLICH VALVEHEIMLICH VALVE
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CARE OF THE PATIENT WITH A CARE OF THE PATIENT WITH A CHEST TUBECHEST TUBE
• PATIENT ASSESSMENT– RESPIRATORY RATE– CHEST EXCURSION– SYMMETRY– OXYGENATION (PULSE OXIMETER)– BREATH SOUNDS– CREPITUS
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CARE OF THE PATIENT WITH CARE OF THE PATIENT WITH A CHEST TUBEA CHEST TUBE
• ASSESS PATIENT AND SYSTEM– DRAINAGE [amount, type, etc]– DRESSING [DRY AND INTACT?]– TUBE [KINKED? Straight?]– BE SURE IT DOES NOT DRAG ON THE FLOOR– VERIFY SUCTION [Bubbling = working] & WATER
SEAL [fluctuation w/ breathing, bubbling = air from pleural space or dislodged tube] ORDERS
– NEVER RAISE COLLECTION CHAMBER ABOVE CHEST [INSERTION POINT]!
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EvaluationEvaluation
• Ask pt. to demonstrate techniques [cough, breathing]
• Assess dyspnea, cough, sputum, SPO2, respiratory rate/ depth/effort
• Goal met? Not met? Partially met?
• Revision or continuation of plan?
Try ThisTry This
• Divide into 6 groups
• For each scenario, determine:
• What you think is going on
• Priority Nursing Diagnosis
• Goals
• The focus of your interventions– E.g. mobilize secretions, teach to TC&DB