Professional Documents
Culture Documents
NUR 107
2014
Oxygenation
O2 CO2
Copyright 2012
by Pearson
Education, Inc.
OXYGENATION
O2
is tasteless, colorless
Accounts 21% atmospheric air
Oxygen use: maintain adequate cellular
oxygenation.
For
Hypoxemia
the blood
O2 flow rates vary attempt to maintain
SaO2 > 92%
HYPOXEMIA
Late signs
Early signs
Tachypnea
Tachycardia
Restlessness
Elevated BP
Skin Pallor
Respiratory distress
Nasal
flaring
Use of accessory muscles
Adventitious lung sounds
Cyanosis
Confusion & stupor
Bradypnea
Bradycardia
Hypotension
Cardiac dysrhythmias
OXYGENATION
Assess/monitor
OXYGEN TOXICITY
May
OXYGEN TOXICITY
Intervention
Decrease oxygen as soon as condition permits
Use lowest oxygen necessary to maintain
adequate SaO2
Monitor ABGs
Use CPAP, BiPAP or PEEP while on a ventilator
Helps to decreases the amt. of oxygen
needed for an adequate low level without
compromising lung compliance
OXYGEN-INDUCED
HYPOVENTILATION
May
STRUCTURES OF THE
UPPER
Nose
RESPIRATORY TRACT
passages
Pharynx
Tonsils and adenoids
Larynx: epiglottis,
glottis,
vocal cords
Sinuses/nasal
upper and
lower
Right: upper,
middle, and lower
Alveoli
Pleura membranes
Pul. capillary network
STRUCTURES OF THE
LOWER
Trachea
RESPIRATORY SYSTEM
Bronchi / bronchioles
AVEOLI
Copyright 2012 by Pearson Education, Inc.
LUNG COMPLIANCE
Compliance
lung recoil
Ability of the lungs and thorax to expand
Necessary for normal inspiration &
expiration
Continual tendency of the lung to collapse
away from the chest wall
Decreased in diseases such as
pulmonary edema, congenital structural
abnormalities, fx ribs
Decreases with aging
VENTILATION
Inspiration
- inhalation
Expiration - exhalation
Ventilation is dependent
upon:
Clear airway
Intact CNS
Intact respiratory center
Adequate pulmonary
compliance/recoil
Thoracic capacity to
contract/expand
INSPIRATION
Diaphragm
EXHALATION
Diaphragm
GAS EXCHANGE
Occurs
OXYGEN TRANSPORT
Oxygen
CARBON DIOXIDE
TRANSPORT
Must
RESPIRATORY
REGULATION
Neural
TIDAL VOLUME
Degree
CONTINUED
Inspiratory
CONTINUED
Vital
Capacity
The
RESPIRATORY
ALTERATIONS
Hypoxia
Insufficient
SIGNS/SYMPTOMS OF
HYPOXEMIA
Early
Tachycardia
Tachypnea
Restlessness
Skin pallor
Elevated BP
Sx resp. distress
Nasal flaring
Acsessory muscles
adv, Lung sounds
Late
Confusion, stupor
Cyanosis skin &
mucous membranes
Bradypnea
Bradycardia
Hypotension
Cardiac dyshythmias
HYPERCARBIA
Hypercarbia
Hypoventilation,
CO2 accumulation
Cyanosis
Bluish discoloration of the skin, nailbeds,
and mucous membranes, due to reduced
Hemoglobin conc.
CARDIOVASCULAR
ALTERATIONS
Conditions
that Affect:
The function of the heart as a pump
Blood flow to organs and tissues
Composition of the blood and its
ability to transport 02 and C02
CARDIOVASCULAR ALTERATIONS
Decreased
Cardiac Output
MI, Heart Failure, Pulmonary
Edema
Impaired Tissue Perfusion
Ischemia, TIA-stroke, Pulmonary
Emboli
Blood Alterations
Hypovolemia, Anemia
RESPIRATORY EFFORTS
Accessory
Muscles:
Increase lung volume during inspiration
Clients with COPD, especially emphesyma,
frequently use accessory muscles to increase
lung volume.
Nurse might observe clavicles being elevated
when breathing; retractions
Results in energy expenditure which increases
metabolic rate
Increase metabolic rates increase the need for
more O2 & the need to eliminate CO2
FACTORS INFLUENCING
RESPIRATORY FUNCTION
Age
Environment
Lifestyle,
Activity
Health status
Medications
Stress, Emotions
Body position
Body temp./ Environment temp
BREATHING PATTERNS
During
Breathing Patterns
SYMPTOMS OF IMPAIRED
RESPIRATORY FUNCTION
Hypoxia
Altered
breathing patterns
Obstructed or partially obstructed
airway
HYPOXIA
Condition
of insufficient oxygen
anywhere in the body
Rapid pulse
Rapid, shallow respirations and
dyspnea
Increased restlessness or
lightheadedness
Flaring of nares
Substernal or intercostal retractions
Cyanosis
ALTERED BREATHING
PATTERNS
Apnea cessation of breathing
Kussmauls
breathing
hyperventilation r/t metabolic acidosis
Body attempts to blow off CO2
Cheyne-stokes waxing & waning
respirations
Biots respirations shallow clusters of
breaths that are interrupted by apnea
Orthopnea inability to breath except in an
upright position
Dyspnea diff. breathing (SOB)
OBSTRUCTED AIRWAY
Complete
abnormal
Partial obstruction
Low-pitch snoring sound during inhalation
Complete obstruction
No chest movement
Inability to cough or speak
Sternal & intercostal retractions
Stridor high-pitch sound during inspiration
ASSESSMENT
Health
PHYSICAL ASSESSMENT
Breathing pattern to be assessed without clients
awareness.
Normal respiratory rate ranges 12-20bpm.
Rate greater than 20 (tachypnea) indicates
hypoxemia (low serum oxygen levels) hypercapnia
(high serum CO2 levels) or anxiety.
PHYSICAL ASSESSMENT
Health
PHYSICAL ASSESSMENT
Considerations
PHYSICAL ASSESSMENT
Environment-
ASSESS CHEST
CONFIGURATION
1.
2.
3.
4.
5.
x
ASSESSMENT
Cyanosis
ASSESSMENT
Assess
LISTEN TO BREATH
SOUNDS
Abnormal
breath sounds
Normal breath sounds vs. Adventious
Crackles, wheezes, friction rubs
Voice Sounds vocal resonance
Bronchophony intense & clear sound
Egophony distorted voice sounds
Whispered pectoriloquy a subtle
sound
SPUTUM
Lungs reaction to irritants or nasal
discharge
Bacterial infection - thick, yellow, green,
rust color sputum
Viral infection thin, mucoid sputum
Lung tumor pink-tinged sputum
Pulmonary edema profuse, frothy
sputum
Lung abcess, bronchietosis foul
smelling sputum c bad breath
x
COUGH
Timing;
HEMOPTYSIS
Blood tinged sputum
Review CXR, chest angiography,
bronchospcopy, pt. history & physical.
Determine the source of blood (gums, throat
lungs, stomach)
From lungs bright red, frothy
From nose or throat preceded by
sniffling, blood possibly visible in nose
From stomach vomiting vs. coughing;
dark coffee grounds color
CLUBBING
Sign
CLUBBING
NURSING MEASURES TO
PROMOTE RESPIRATORY
FUNCTION
Ensure
a patent airway
Encouraging
deep
breathing, coughing
Ensuring adequate
hydration
Positioning
THERAPEUTIC MEASURES TO
PROMOTE RESPIRATORY
FUNCTION
Medications
Incentive spirometry
Chest PT
Postural drainage
Oxygen therapy
Artificial airways
Airway suctioning
Chest tubes
ASSESSMENT OF COPD
Questions
COPD
Chest
TREATMENT
Goal
NURSING DIAGNOSES
Focus
NURSING INTERVENTIONS
Teach
NURSING INTERVENTIONS
Evaluate
Activity Intolerance
Teach family to assess patient orientation
Teach patient and family about COPD,
stress healthy behaviors, smoking
cessation, and signs of potential problems
Promote health sleep patterns
Decrease feelings of powerlessness
ASTHMA
Chronic Inflammation of airways leading to
intermittent obstruction
Progressive airway obstruction unresponsive to
treatment leads to emergency situation
Form of obstructive pulmonary disease
ETIOLOGY
Intrinsic etiologies-physical and psychological
stress, exercise induced
Extrinsic etiologies- air pollutants, allergic response,
cold and dry air, medications
Widespread spasms of bronchiole smooth muscle
with airway edema
ASSESSMENT
Severe dyspnea/wheezing with expiration
Cough/Feeling of chest tightness
Increased heart rate and blood pressure
Extreme restlessness, anxiety, agitation
Tachypnea and use of accessory muscles
PLANNING AND
IMPLEMENTATION
Assess
EXPECTED OUTCOMES/EVAL
Absence of dyspnea, chest tightness, wheezing
Respiratory rate of 12 to 24
Bilaterally clear and equal lung sounds
Afebrile
Adequate air clearance of clear thin secretions
INCENTIVE SPIROMETRY
B
A
CHEST PHYSIOTHERAPY
OXYGEN THERAPY
OXYGEN THERAPY
Nasal cannula
Copyright 2012 by Pearson Education, Inc.
Partial rebreather
mask
OXYGEN THERAPY
Nonrebreather mask
Copyright 2012 by Pearson Education, Inc.
Venturi mask
OXYGEN HOOD
Oxygen Mask
OxygenTent
HUMIDIFIER VIDEO
ARTIFICIAL AIRWAYS
Nasopharyngeal Airway
Oropharyngeal Airway
ARTIFICIAL AIRWAYS
TRACHEOSTOMY TUBE
pneumothorax or
hemothorax
Tubes are inserted into
the pleural cavity to drain
fluid/blood and restore
negative pressure
Closed system with a
suction control chamber &
water seal chamber
PNEUMOSTAT
For
pneumothorax
with small amounts
of fluid drainage
One way valve
prevents back flow
HEIMLICH CHEST
DRAINAGE VALVE
Used
DESIRED OUTCOMES
Maintain
a patent airway
Improve comfort and ease of breathing
Maintain or improve pulmonary
ventilation and oxygenation
Improve ability to participate in
physical activities
Prevent risks associated with
oxygenation problems
pH
7.35 7.45
PaCO2
ABGS
35 45 mm Hg
PaO2
80 100 mm
Hg
ARTERIAL BLOOD
GASES
SaO2
92 98%
HCO3
22 26 mEq/L
Base excess (BE)
-2.0 to 2.0 mEq/L
CaO2
16-22 nL O2/dL
OXYGEN SAFETY
No
NANDA NURSING
DIAGNOSES
Anxiety
Fatigue
Activity
intolerance
Imbalanced nutrition: less than body
requirement
NURSING INTERVENTIONS
Respiratory
assessment
Appropriate application of oxygen delivery
systems
NASAL CANNULA
delivers O2 at concentrations of 24-40%
Flow rate 1-6 L/min
Safe and simple method, easy to apply
Flow rates may vary depending on depth of
clients breathing; dislodges easily
NC may cause nasal skin breakdown
Provide humidification for flow rates
SIMPLE MASK
Covers nose & mouth
Delivers 40% 60%
5 8 L/ min
For short-terms oxygen therapy
Minimum flow rate or 5 to ensure flushing of CO2 from
the mask
Mask may be poorly tolerated
NON-REBREATHER MASK
Also covers nose & mouth
One-way valve and two exhalation ports
Delivers 80%-95% O2
10 15 L/min
Reservoir bag to stay 2/3 full during inspiration
& expiration
Delivers highest concentration possible
VENTURI MASK
Also
Delivers 60%-75% O2
6 11 L/min
Reservoir bag with no valve, allows rebreathing
up to 1/3 of exhaled air mixed with room air
Complete deflation of reservoir bag during
inspiration causes CO2 build up
AEROSOL MASKS
Fits loosely over face or neck (tracheostomy
collars)
Delivers 24% - 100% O2
Best for clients who do not tolerate other masks;
facial trauma & burns
Deliver high humidity
NURSING CARE
Assess O2 need
Monitor appropriateness of oxygen therapy
Document therapy response
Monitor O2 Sats, ABGs
Promote good oral hygiene
Rest, decrease environmental stimul
Support the anxious clieints
NURSING CARE IN
RESPIRATORY DISTRESS
Fowlers position
Complete a focus respiratory assessment
Promote adequate oxygenation: deep breathing &
supplemental oxygen
Promote airway clearance: coughing, suctioning
Stay with client
Decrease anxiety
QUESTION
You are caring for a client who had
abdominal surgery 24 hours ago. This
client has a 10yr old history of COPD.
What interventions are necessary to
maintain a patent airway????