5. CH 38 Oxygenation - Summary Fundamentals of Nursing: the Art and Science of Nursing Care PDF

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OXYGENATION CHAPTER 38 Perfusion • Hypoxia  Occurs when there’s either a problem with ventilation, respiration or perfusion  A condition in which an inadequate amount of oxygen is available to cells – Most common symptom > Dyspnea: difficulty breathing Manifestations • Elevated BP • Increased PR and RR • Pallor or cyanosis – Other Common Signs • Anxiety • Restlessness • Confusion • Drowsiness  Hypoxia is often caused by hypoventilation Perfusion: Hypoventilation (decreased rate or depth of air movement into lungs) • Hypoxia can also be a chronic condition – Affects all body systems • Altered thought processes • Headaches • Chest pain • Enlarged heart • Clubbing of the digits • Anorexia • Constipation • Decreased UO • Decreased libido • Muscle pain and weakness of extremities Factors affecting respiratory function • Levels of Health: Pathological conditions  Acute  Chronic o For example, people with renal or cardiac disorders often have compromised respiratory functioning because of fluid overload and impaired tissue perfusion. o People with chronic illness often have muscle wasting and poor muscle tone, and these problems affect all the muscles, including those of the respiratory system = inadequate pulmonary ventilation and respiration = inadequate functioning of the heart. o Anemia also = impaired respiratory function > because it doesn’t supply oxygen to the tissues efficiently. o Myocardial infarction = lack of blood supply to the heart muscle = ineffective contraction of the heart muscle = decreased perfusion of tissues = decreased gas exchange o Physical changes such as scoliosis influences breathing patterns and may cause air trapping o People who are obese are often short of breath during activity > less participation in exercise = the alveoli ate the base of the lungs are rarely stimulated to expand fully • Developmental Considerations  Older Adults o Pathological conditions

o The tissues and airways of the respiratory tract (including the alveoli) become less

elastic. o The power of the respiratory and abdominal muscles is reduced; therefore, the

diaphragm moves less efficiently. o The chest is unable to stretch as much = decline in maximum inspiration and expiration. o These alterations increase the risk for diseases especially pneumonia and other chest infections. o Respond less effective during physical or emotional stress. o Decreased physical activity, physical deconditioning, decreased elasticity of the

blood vessels, and stiffening of the heart valves can lead to a decrease in the overall function of the heart. •

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Medications  Drugs that affect the CNS such as opioids, which are chemical agents that depress the medullary respiratory center, decrease rate and depth of respirations.  Narcotic or sedative can lead to respiratory depression or arrest.  Other medications that decrease heart rate can alter the flow of blood to body tissues. Lifestyle  Sedentary activity patters do not encourage the expansion of alveoli and deep breathing.  Regular physical activity = increase heart rate and lung health status, improve muscle fitness including those of respirations, and reduce risk of heart disease.  Cultural considerations in treating illness.  Cigarette smoking, active or passive, is a major contributor to lung disease and respiratory distress, heart disease and lung cancer.  Smoking is the most important risk factor for chronic COPD. Environment  High correlation between air pollution and cancer lung disease.  Exposure to air pollution S/S: stinging of eyes and nasal passages, coughing, choking, headache, and dizziness.  Occupational exposure to asbestos, silica, or coal dust, as well as environmental

pollution, can lead to chronic pulmonary disease.  Chronic exposure to radon, radiation, asbestos, and arsenic can lead to lung cancer. •

Psychological Health  Stress > hyperventilation = pt. has lower levels of arterial carbon dioxide.  Generalized anxiety can produce enough bronchospasm to produce and episode of bronchial asthma.

Assessment • Nursing history – Current and past respiratory problems – Lifestyle, risk factors for impaired oxygen status – Presence of cough and sputum or pain – Medications for breathing • Physical examination – Nurse observes rate, depth, rhythm, and quality of respirations – Inspects variations of shape of thorax – Note pt.’s VS (PR, RP, BP)

Diagnostic Procedure • Tests – Sputum specimens – Throat cultures – Visualization procedures – Venous and arterial blood specimens – Pulmonary function tests  Group of test to assess respiratory function – Thoracentesis  Procedure of puncturing the chest wall and aspirating pleural fluid.  Performed by physician or advanced practice professional.  May be performed to obtain a specimen for diagnostic purposes or to remove fluid that is accumulated in the pleural cavity and is causing respiratory difficulty and discomfort  Surgical asepsis is required, and standard precautions. • Procedure  Usually with the pt. sitting on a chair or the edge of the bed with the legs supported and the arms folded and resting on a pillow on the bedside table.  If unable to sit up, the pt. may lie on the unaffected side with the hand of the affected side raised above the shoulder.  The location where the needle is inserted depends on where the fluid is present and where the practitioner can best aspirate.  Skin is cleansed with an antimicrobial agent in the selected spot.

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A local anesthetic is administered and then the needle is inserted between the ribs through the intercostal muscles and fascia and into the pleura.  After the needle or catheter is removed, a small sterile dressing is placed over the entry site.  When using a catheter, the fluid drained goes into a bottle in which a partial vacuum has been created.  With the catheter technique, the catheter may be threated through the needle, allowing the needle to be withdrawn and reducing the risk of puncturing the lung.  Sterile technique as well. Nursing Responsibilities  The nurse is responsible for collecting baseline data before the procedure.  Preparing the pt. physically and emotionally for the procedure.  Urge the pt. to remain as still as possible to diminish the risk for accidental injury to the lung.  Administer analgesics before the procedure as ordered.  Observe the pt.’s reactions during the procedure.  Monitor the pt.’s color, PR, RR.  Fainting, nausea and vomiting may occur.  Ensure that specimens, if obtained, are taken to the lab immediately.  After the procedure, asses the pt. for changes in VS, especially respirations. o If a large amount of fluid was removed, respirations become easier. o If the lung was punctured, respiratory distress becomes acute.  Notify the physician if there’s blood in

the sputum, or the pt. has severe coughing.

Diagnosis and Expected Outcomes 1. Name 3 nursing diagnoses for a patient with altered respiratory function  Alterations in Oxygenation as the Problem – Diagnoses  Ineffective Airway Clearance  Decrease Cardiac Output  Impaired Gas Exchange  Alterations in Oxygenation as the Etiology  Activity Intolerance related to imbalance between oxygen supply and demand  Anxiety related to feeling of suffocation  Fatigue related to impaired oxygen transport system  Imbalanced Nutrition: Less than body Requirements, related to difficulty breathing

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Disturbed Sleep Pattern related to orthopnea and bronchodilators *Orthopnea: people that can breathe more easily in an upright position. 2. Describe 3 corresponding expected outcomes for a patient with altered respiratory function  Demonstrate improved gas exchange in the lungs by an absence of cyanosis or chest pain and a pulse oximetry reading more than 95%  Relate the causative factors, if known, and demonstrate a method of coping with these factors  Preserve cardiopulmonary function by maintaining an optimal level of activity  Demonstrate self-care behaviors that provide relief from symptoms and prevent further cardiopulmonary problems Implementation – Nursing Interventions • Describe ways that nurses promote adequate respiratory functioning in the patient.  Promoting optimal function of the cardiopulmonary systems  Promoting proper breathing  Promoting and controlling coughing  Promoting comfort  Perform chest physiotherapy  Suction the airways  Meet respiratory needs with medications  Provide supplemental oxygen  Manage chest tubes  Use artificial airways  Clearing obstructed airways  Administering CPR Percuss • Percussion of lung areas involves the use of a cupped palm to loosen pulmonary secretions so • • • • • •

that they can be expectorated with greater ease. Hand is held in a rigid, dome-shaped position and then strike the area over the lung lobes to be drained in a rhythmic pattern. Position the pt. in a lateral, supine or prone position, based on the lobes to be treated. Proper hand and pt. positioning ensure no experience of pain. Percussion is never done one bare skin or performed over surgical incisions, below the ribs or over the spine or breast because may cause tissue damage. Each area is percussed for 30-60 sec. several times a day, or 3-5 min if the patient has tenacious secretions. Pt. and family education on percussion for the pt. or use of mechanical device.

Vibration  Use manual compressions and tremor on the pt.’s chest wall to help loosen respiratory secretions, which can be expectorated more easily.  The practitioner uses rhythmic contraction and relaxation of arms and shoulders muscles while holding the hands flat on the pt.’s chest wall as the pt. exhales.  Ask client to inhale deeply and exhale slowly  During exhalation vibrate the hands  Vibrate during five exhalations  After each vibration, ask client to cough and expectorate secretions  Can be done for several mins. several times a day.  Never done over the pt.’s breasts, spine, sternum and lower rib cage to avoid discomfort.  Pt. and family education on vibration for the pt. or use of mechanical device.

Postural drainage  Place client in appropriate positions to allow gravity to drain affected areas of lung by coughing.  Lower lobes require drainage more often than upper lobes.  Usually scheduled before meals to prevent vomiting.  Vibration, percussion or both often precede postural drainage.  Have tissues and an emesis basin close at hand for the pt. use when coughing and expectorating secretions.  Can be done 2-4 times a day for 20-30 mins.  Stop if the pt. begins to feel weak or faint.  Appropriate positions:  High Fowler’s position to drain apical sections of the upper lobes of the lungs.  Lying position, half on the ABD, and half on the side, right and left, to drain the posterior sections of the upper lobes of the lungs.  Lying on the left side with a pillow under the chest wall to drain the right lobe of the lung.  Trendelenburg position to drain the lower lobes of the lungs.

Mucus Clearance Device • Clients with excessive secretions (cystic fibrosis, COPD) • Flutter device one example • Client inhales slowly, holds cheeks firm while exhaling fast • Vibrations loosen mucus for expectoration Incentive Spirometry • Provides visual reinforcement for deep breathing by the pt. • Assist the pt. to breathe slowly and deeply and to sustain maximal inspiration. • Pt. can measure one’s own progress. • Improves pulmonary ventilation. • Optimal gas exchange is supported and secretions can be cleared and expectorated • Counteracts effects of anesthesia or hypoventilation • Loosens respiratory secretions • Expands collapsed alveoli • Pt. needs teaching on equipment use. Cough Medications

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Bronchodilators  Inhaled medication administered to open narrowed airways.  Typically administered via nebulizer, metered dose inhaler, or dry power inhaler. Anti-inflammatory drugs (glucocorticoids, leukotriene modifiers) Expectorants  Drugs that facilitate the removal of respiratory tract secretions by reducing the viscosity of the secretions.  Ex: for pts. with extremely tenacious (thick) secretions that need the secretions to be liquefied for their cough to be effective.  Ex: Robitusin  Inappropriate to use for a person without congestion Cough suppressants  Drugs that depress the cough reflex.  To appropriately treat an irritating, nonproductive cough in people without congestion.  If use to treat a productive cough, secretions may be retained, leading to pulmonary infection.  Codeine is the preferred cough suppressant present in most cough medications.  Codeine can be addictive. Require prescription for use.  Drowsiness is a side effect. Not to use when the person needs to be alert, such as driving. Others that improve cardiovascular function (e.g., digitalis glycosides); must be monitored closely

Oxygen Therapy • Check vital VS and oxygen saturation level • Ordered for pts. with hypoxemia, anemia, blood loss • Primary care provider specifies concentration, method of delivery, liter flow per minute; may call for titration to achieve therapeutic level • Nurse may initiate in emergency, then call provider • Portable or wall outlet; humidifier for high flow to prevent drying • Safety precautions:  Handle and store with caution to prevent falls and breakage  Highly flammable o No smoking in room with oxygen; no-smoking signs o Avoid faulty electrical equipment and static o Avoid use of volatile flammable materials nearby (nail polish remover, oil, alcohol) o Ensure grounding of all electrical equipment o Fire extinguishers available and staff trained in use Oxygen Delivery System • Nasal cannula  Most commonly used oxygen delivery device.  Disposable.  Does not impede eating or speaking.  Used easily in the home setting.  For pts. with chronic lung disease, limit rate to the minimum needed to raise arterial oxygen saturation to a level that provides adequate oxygen delivery to the tissues (88-92%) and not higher.  Check frequently that both prongs are in the pt.’s nares.  Disadvantages: can be dislodged easily and can cause dryness of the nasal mucosa. And if the pt. breathes through the mouth is difficult to determine the amount of oxygen administration. • Simple face mask  Monitor the pt. frequently to check placement of the mask.  Provide support the pt. if claustrophobia is a concern.

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 Secure a medical order to replace the mask with a nasal cannula during mealtime. Partial rebreather mask  Set flow rate so that the mask remains two-thirds full during inspiration.  Keep the reservoir bag free of twists or kinks. Non-rebreather mask  Maintain flow rate so that the reservoir bag collapses only slightly during inspiration.  Check that the valves and rubber flaps are functioning properly (open during expiration and closed during inhalation).  Monitor SaO2 with pulse oximeter. Venturi mask  Requires careful monitoring to verify FiO2 at flow rate ordered.  Check that air intake valves are not blocked. Face tent  Light, portable structure made of clear plastic attached to a motor-driven unit.  The motor helps to circulate and cool the air in the tent.  The tent is either over the top part of the bed so that the pt.’s head and thorax are inside, or over the entire bed.  It has side openings through which nursing care can be administered.  Commonly used with children, for example with pneumonia, who need a cool and highly humidified airflow.  Quickly creates moisture, leading to damp clothing and linens, and possibly hypothermia.  Frequent assessment of the child’s temperature, pajamas, and bedding is necessary. Transtracheal catheter  Pts. using continuous supplemental oxygen therapy in the home have this alternative.  A small catheter is inserted into the trachea under local anesthesia, and then the catheter is attached to the oxygen source.  Does not interfere with talking, eating, or drinking.  Deliver oxygen throughout the respiratory cycle rather than just at inspiration.  The pt. or family must assume responsibility for daily catheter care.  Pts. usually report improved mobility, comfort, and appearance and lower cost with delivery system.  Needs instruction regarding safety precautions. Noninvasive positive airway pressure (PAP) ventilation  Uses mild air pressure to keep airways open.  Can help the body better maintain CO2 and O2 levels in the blood.  May be used to treat sleep apnea, obstructive sleep apnea, obesity hypoventilation syndrome, COPD and heart failure.  Also used to treat infants whose lungs have not fully developed.  Most common type is continuous positive airway pressure (CPAP)  Provides continuous mild air pressure to keep airways open.  Bilevel positive airway pressure (BiPAP)  Changes the air pressure while the pt. breathes in and out.  Both therapies use a mask or other device that fits over the nose or nose and mouth.  Straps keeps the mask in place.  Adjustment to this takes time.  Pts. report feeling strange wearing a mask on the face at night or feeling the flow of air.  Nursing support and education to encourage pt. to ease into use of the device so that pt. persist with the therapy. Refer to procedure “Administering Oxygen by Cannula, Face Mask, or Face Tent” Skills Page 1449  Encourage pt. to breathe through the nose with the mouth close

Chest Tubes and Drainage Systems

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Negative pressure between pleural layers lost by disease, surgery, trauma; leads to:  Pneumothorax (air) o When draining air, the tube is placed higher in the chest.  Hemothorax (blood)  Pleural effusion (excessive fluid in pleural space) o When draining fluids, the tube is inserted lower in the lung because fluids settle at the base of the lungs. Chest tube to restore pressure and drain fluid or blood and allow pressed lung to re-expand  Pneumothorax tube (upper chest)  Hemothorax tube (lower chest) Nursing Responsibilities  Assisting with insertion and removal of a chest tube.  Once in place, monitor the pt.’s respiratory status, and VS  Check dressing, and maintain patency and integrity of the drainage system.

Care of Patient with Chest Tube • Maintain patency of system • Monitor VS, observe dressing q 4 h, ask about pain and medication if needed • Encourage deep breathing/coughing q 2 h (except with lung removal) • Reposition q 2 h; when on affected side, provide rolls to protect patency of tubing • Assist with ROM exercise • Ensure secure placement of device and keep chamber below client’s chest • Check system often • Assess drainage tube and chamber; measure per schedule • Avoid aggressive manipulation or clamping (can produce tension pneumothorax) • If tube becomes disconnected, submerge the end in 1 inch sterile saline or water • If chest tube is pulled out, immediately cover with dry sterile dressing; do not occlude opening completely as this can cause tension pneumothorax Artificial Airways • Used to preserve a functioning airway in pts. who are unable to maintain a patent airway without assistance. • For client, whose airway has or may become obstructed. • Oropharyngeal and nasopharyngeal  Easy to insert; low risk of complications  Oropharyngeal for unconscious pts. and removed once pt. regains consciousness.  Nasopharyngeal for alert pts. with gag reflex. Allows for frequent nasotracheal suctioning without trauma to the nasal passageway. • Tracheostomy – anesthesia or ventilation  Opening into trachea; unable to speak.  Communications needs are part of the nursing assessment for this pt.  Identify appropriate alternate communication strategies to ensure pt.’s needs are conveyed. Keep communication tools close at hand, along with the call light or bell.  Prevent anxiety by offering frequent reassurance and explanations and anticipate the pt.’s needs. • Tube with outer and inner cannula, obturator, flange with tubes or ties. • For insertion, put on gloves, mask and googles. Pt. in se...