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- 1. JUDITH M. WILKINSON LESLIE S. TREAS KAREN BARNETT MABLE H. SMITH FUNDAMENTALS OFFUNDAMENTALS OF NURSINGNURSING Copyright © 2016 F.A. Davis Company Chapter 36:Chapter 36: OxygenationOxygenation
- 2. Copyright © 2016 F.A. Davis Company Oxygenation Oxygen •Atomic number: 8 •Atomic mass: 16
- 3. Copyright © 2016 F.A. Davis Company Pulmonary System • Airways and lungs • Ventilation – Movement of air into/out of the lungs • Respiration – Exchange of oxygen/carbon dioxide – Alveolar capillary/capillary cell membrane
- 4. Copyright © 2016 F.A. Davis Company ClickerCheck Which diagnostic test/exam would best measure a client’s level of hypoxemia? a.Chest x-ray b.Pulse oximeter reading c.ABG d.Peak expiratory flow rate
- 5. Copyright © 2016 F.A. Davis Company ClickerCheck (cont’d) Correct answer: C The term “hypoxemia” means low blood oxygen level. Arterial blood gas sampling is the most direct way in which the level of oxygen in the blood can be measured.
- 6. Copyright © 2016 F.A. Davis Company Factors That Influence Pulmonary Function • Life span and development (e.g., respiratory distress syndrome, upper respiratory infections [URIs], adolescent smoking, cardiac insufficiency) • Environment (e.g., stress, allergies) • Lifestyle (e.g., nutrition, exercise, substance abuse) • Medications • Smoking
- 7. Copyright © 2016 F.A. Davis Company Factors That Influence Pulmonary Function (cont’d) • Pulmonary system abnormalities (structure, airway inflammation/obstruction, alveolar-capillary membrane disorder, atelectasis) • Pulmonary circulation abnormalities • Central nervous system abnormalities • Neuromuscular abnormalities
- 8. Copyright © 2016 F.A. Davis Company Assessing Oxygenation Status Physical examination •Breathing pattern •Respiratory effort •Pulse oximetry •Using inspection, palpation, percussion, and auscultation
- 9. Copyright © 2016 F.A. Davis Company ClickerCheck The term “Kussmaul” refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx. a.True b.False
- 10. Copyright © 2016 F.A. Davis Company ClickerCheck (cont’d) Correct answer: B The term for this sound of respiratory distress is “stridor.”
- 11. Copyright © 2016 F.A. Davis Company Assessing Oxygenation Status • Diagnostic testing • Arterial blood gases (ABGs) – PO2, PCO2 • Peak flow monitoring
- 12. Copyright © 2016 F.A. Davis Company Interventions for Optimal Oxygenation • Use of a mechanical ventilator • Use of chest tube drainage systems • Administering respiratory medications
- 13. Copyright © 2016 F.A. Davis Company Interventions for Optimal Oxygenation (cont’d) Promoting respiratory function •Immunizations/prevent URIs •Positioning: maximum lung excursion •Incentive spirometry •Aspiration precautions
- 14. Copyright © 2016 F.A. Davis Company Interventions for Optimal Oxygenation (cont’d) • Mobilizing secretions – Deep breathing and coughing – Hydration – Chest physiotherapy • Oxygen therapy – Cannula – Mask – Transtracheal catheter
- 15. Copyright © 2016 F.A. Davis Company Interventions for Optimal Oxygenation (cont’d) • Using artificial airways – Oropharyngeal – Nasopharyngeal – Endotracheal tubes – Tracheostomy tube • Artificial airway patency – Suctioning
- 16. Copyright © 2016 F.A. Davis Company ClickerCheck In caring for a client with a tracheostomy, the nurse would give priority to the nursing diagnosis of a.Risk for ineffective airway clearance b.Anxiety related to suctioning c.Social isolation related to altered body image d.Impaired tissue integrity
- 17. Copyright © 2016 F.A. Davis Company ClickerCheck (cont’d) Correct answer: A While other diagnoses may be applicable, maintaining a patent airway by tending to excessive secretions is a priority.
- 18. Copyright © 2016 F.A. Davis Company Think Like a Nurse Ms. Saunders (MeetYour Patients) has adequate blood oxygen levels based on a pulse oximeter reading of 98%. Can you conclude that organ and tissue oxygenation are adequate? Explain your thinking.
Notas do Editor
- <<Instructor: Review these definitions with the students.>>
- <<Instructor: Review these definitions with the students.>>
- <<Instructor: Select the most appropriate answer to this question using your clicker.>>
- <<Instructor: The correct answer is C.>>
- <<Instructor: Review each bulleted item while referring to the following notes.>> Life span and development Normal development influences lung, heart, and circulatory function, all of which affect oxygenation. Developmental factors have less effect on function in young and middle adults than in older adults. Environment: Stress, allergic reactions, altitude, and temperature affect oxygenation. Stress: Stress suppresses the immune system and inflammatory response. A chronically suppressed immune and inflammatory response increases the risk for all infections, including respiratory. Allergic reactions: Pulmonary allergens include such things as dust, dust mites, cockroach particles, pollen, molds, newsprint, tobacco smoke, animal dander, and sometimes foods. Altitude: Low oxygen levels at high altitudes can cause hypoxemia and hypoxia. Lifestyle Pregnancy Occupational exposure to hazards Nutrition, obesity, exercise Smoking and substance abuse Medications Many drugs can interfere with pulmonary function by depressing respirations. Respiratory depressants generally act by depressing central nervous system (CNS) control of breathing or by weakening the muscles of breathing. Smoking Tobacco smoke constricts bronchioles, increases fluid secretion into the airways, causes inflammation and swelling of the bronchial lining, and paralyzes cilia. Leads to reduced airflow and increased production of secretions that are not easily removed from the airways.
- <<Instructor: Review each bulleted item while referring to the following notes.>> Pulmonary system abnormalities Structural abnormalities Airway inflammation and obstruction Alveolar-capillary membrane disorders Atelectasis Pulmonary circulation abnormalities Pulmonary embolus Pulmonary hypertension Central nervous system abnormalities Trauma and stroke (cerebrovascular accident) are the most commonly seen CNS problems in adults. Spinal cord injuries interfere with nerve transmission between the brain and the area below the level of the injury and may, for example, limit diaphragm function. Neuromuscular abnormalities They can affect gas exchange by interfering with the regulation of breathing or by limiting movement of the muscles involved with breathing. Any condition that alters CNS function can interfere with the regulation of breathing. Trauma, stroke, and medications are the most common causes.
- <<Instructor: Review each bulleted item while referring to the following notes.>> Breathing pattern: Assess for normal and altered breathing patterns. Eupnea Tachypnea Bradypnea Apnea or periodic breathing Kussmaul’s breathing Biot’s breathing Cheyne–Stokes respirations Respiratory effort: A patient experiencing shortness of breath or dyspnea requires a thorough assessment. Ask closed questions the patient can answer with yes, no, or only a few words. Ask whether the shortness of breath began suddenly or gradually, how severe it is right now, and whether it is getting better or worse. Pulse oximetry: This is a noninvasive estimate of arterial blood oxygen saturation (SaO2). SaO2 reflects the percentage of hemoglobin molecules carrying oxygen. The normal value is 95% to 100%. Less than 94% is considered abnormal in healthy people and should be investigated to determine the cause. Pulse oximetry works by measuring light absorption by hemoglobin in the circulating red blood cells.
- <<Instructor: Select the most appropriate answer to this question using your clicker.>>
- <<Instructor: The correct answer is B.>>
- <<Instructor: Review each bulleted item while referring to the following notes.>> Arterial blood gases PO2 (partial pressure of oxygen) is the amount of oxygen available to combine with hemoglobin to make oxyhemoglobin. PCO2 (partial pressure of carbon dioxide, PCO2) is a measure of the CO2 dissolved in the blood. Normal arterial PCO2 is 35 to 45 mm Hg. Peak flow monitoring Peak expiratory flow rate (PEFR) measures the amount of air that can be exhaled with forcible effort. Patients with asthma use PEFR monitoring to detect subtle changes in their condition, often before symptoms occur. A peak flow meter is used to monitor these changes (Fig. 36-6). Peak flow is expressed in liters per minute. Patients with asthma are often asked to measure their peak flow daily and with the onset of any symptoms. Treatment protocols describe the use and frequency of medications based on individualized peak flow rates.
- <<Instructor: Review each bulleted item while referring to the following notes.>> Mechanical ventilator A machine that assists a patient to breathe. Usually the patient is intubated before he is placed on the ventilator. An endotracheal tube or a tracheostomy tube is connected by oxygen tubing to the ventilator. Before initiating ventilation, be certain that the healthcare team is aware of advance directives and consults with family members. Use of chest tube drainage systems The purpose of a chest-drainage system is to remove air or fluid from the pleural space without allowing it to re-enter. This is accomplished by means of a valve in the line or by a water-sealed compartment. Flow of air and fluid must be in one direction: from the patient to the collection system. Administering respiratory medications Medications are used to improve respiratory function. Examples include bronchodilators, anti-inflammatory agents such as corticosteroids, cough suppressants, expectorants, and decongestants. Do not give over-the-counter cough and cold medicines to children younger than the age of 4 years. There is a risk of serious and even life-threatening side effects. Safety and effectiveness for children ages 5 through 11 years is still in question.
- <<Instructor: Review each bulleted item while referring to the following notes.>> Immunizations/prevent URIs Upper respiratory infections (URIs) may be viral or bacterial. Teach clients that viral infections usually last about 10 to 21 days and are self-limiting. URIs may, however, lead to other respiratory diseases and seriously compromised oxygenation in children, older adults, and people who have other illnesses. Positioning An upright or elevated position pulls abdominal organs down, allowing maximum diaphragm excursion and lung expansion. Incentive spirometry Designed to encourage patients to take deep breaths by reaching a goal-directed volume of air. Incentive spirometry is usually reserved for patients at risk for developing atelectasis or pneumonia, for example, patients who have had abdominal, chest, or pelvic surgery, patients on prolonged bedrest, or patients with a history of respiratory problems. Aspiration precautions Risk for patients with a decreased level of consciousness, diminished gag or cough reflex, or difficulty with swallowing. You should keep a suction setup available for routine and emergency use. Preventing aspiration requires you to have practical knowledge about positioning, enteral and oral feedings, and administering medications.
- <<Instructor: Review each bulleted item while referring to the following notes.>> Mobilizing secretions Coughing promotes deep inhalation and forceful expulsion of secretions. Interventions that help enhance coughing and mobilize secretions include Deep breathing, coughing exercises, and hydration Chest physiotherapy moves secretions to the large, central airways for expectoration or suctioning. It involves postural drainage, chest percussion, and chest vibration. In many institutions, respiratory therapists routinely perform chest physiotherapy. Oxygen therapy Various devices (e.g., mask, cannula) are used to deliver oxygen to a patient. They differ in the amount of oxygen they can deliver and the degree to which they enclose the patient. Low-flow devices are the nasal cannula, simple face masks, and rebreather masks. High-flow devices include Venturi masks, aerosol face masks, face tents, and tracheostomy collars—all capable of reaching up to 100% oxygen concentration (Stich & Cassella, 2009). Oxygen may be delivered through the tracheostomy via a collar or an adapter. A transtracheal catheter is a catheter placed into the tracheostomy to deliver O2 directly into the trachea. Because oxygen cannot be humidified through this device, it is rarely used.
- <<Instructor: Review each bulleted item while referring to the following notes.>> Oropharyngeal Use in unconscious patients because they are likely to trigger gagging, vomiting, or laryngospasm in responsive patients with intact airway reflexes. C-shaped, hard plastic devices are available in infant, pediatric, and adult sizes. To select the appropriate size, hold the airway next to the patient’s face. The length of the airway should extend from the front of the teeth to the end of the jawline (Fig. 36-11). Nasopharyngeal Flexible rubber tubes are inserted through a nostril into the pharynx. Patients who are semiconscious can tolerate nasal airways because they do not stimulate the gag reflex. They are available in a variety of pediatric and adult sizes. Endotracheal tubes Endotracheal airways are pliable tubes inserted into the trachea through the following routes: Orotracheal tube—the mouth Nasotracheal tube—the nose Tracheostomy tube—an opening directly into the trachea Tracheostomy Several types of tracheostomy tubes, made of various materials May be cuffed or uncuffed and may have a single or double lumen Suctioning Pharyngeal suctioning is performed to prevent oral and nasal secretions from entering the lower airway when the patient is too weak to cough up secretions. Suctioning the pharynx triggers a cough, which helps loosen and mobilize secretions. The patient’s condition determines whether you suction the pharynx through the mouth or nose. Most patients find oropharyngeal suctioning more comfortable than the nasal approach. In tracheal suctioning, a catheter is passed beyond the pharynx into the trachea to remove secretions from the lower airways. The trachea may be suctioned through the mouth, nose, or an endotracheal airway. In the healthcare setting, deep tracheal suctioning is a sterile procedure.
- <<Instructor: Select the most appropriate answer to this question using your clicker.>>
- <<Instructor: The correct answer is A.>>
- <<Instructor: Discuss this patient scenario with the students.>>