NURSING FUNDAMENTALS FOCUS VIII

OXYGENATION

OBJECTIVES
List and discuss the major body structures. Discuss functions responsible for proper oxygenation Describe factors that may alter ones O2 balance. Identify the behaviors indicating negative O2 balance. Review the common diagnostic tests medically prescribed in order to determine the client s oxygenation status. Explain the major purpose of the tests and the related nursing responsibilities.

STAGGERING STATISTICS
Pulmonary Diseases Lung CA TB Pneumonia

Chronic Airflow Limitation (formerly COPD)

STAGGERING STATISTICS

Cardiovascular Diseases # 1 killer

HTN 65 million Artheriosclerosis Arteriosclerosis Stroke Hypercholesterolemia 107 million - a risk factor for CVD AMI 7.5 Million per year, 460,000 die Americans paid 393.5 billion in 2005 for CVD related medical costs

RESPIRATORY SYSTEM

PROCESS OF BREATHING

Inspiration
Air flows into lungs

Expiration
Air flows out of lungs

NORMAL OXYGENATION PROCESS

Cardiovascular:

NORMAL OXYGENATION PROCESS

Systemic:

NORMAL OXYGENATION PROCESS

INSPIRATION
Diaphragm and intercostal muscles contract Thoracic cavity size increases Volume of lungs increases Intrapulmonary pressure decreases Air rushes into the lungs to equalize pressure

EXPIRATION
Diaphragm and intercostal muscles relax Lung volume decreases Intrapulmonary pressure rises Air is expelled

GAS EXCHANGE
Occurs after the alveoli are ventilated Pressure differences (gradient) on each side of the respiratory membranes affect diffusion
Alveoli: PO2 100mmHg PCO2 40mmHg Venous blood: PO2 60mmHg PCO2 45mmHg

O2 diffusion from alveoli pulmonary blood vessels CO2 diffusion from pulmonary blood vessels alveoli

ADEQUATE O2 BALANCE
Maintenance of adequate O2 balance Gas Exchange

OXYGEN TRANSPORT
Transported from the lungs to the tissues 97% of O2 combines with RBC Hgb oxyhemoglobin carried to tissues Remaining O2 is dissolved and transported in plasma and cells (PO2)

NORMAL OXYGENATION PROCESS

Cell environment / O2 carrying capacity: O2 Carrying capacity of blood is expressed by:
Red blood cells (#) Hematocrit
% of blood that is RBCs Men 40-54% Women 37-50%

Hemoglobin

CARBON DIOXIDE TRANSPORT

Must be transported from tissues lungs Continually produced in the process of cell metabolism 65% carried inside RBCs as bicarbonate (HCO3 ) 30% combines with Hgb carbhemoglobin 5% transported in plasma as carbonic acid (H2CO3)

FACTORS THAT INFLUENCE RESPIRATORY FUNCTION

Age Environment Lifestyle Health status Medications Stress

COMMON MANIFESTATIONS 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

ABNORMAL RESPIRATORY PATTERNS

Tachypnea (rapid rate) Bradypnea (abnormally slow rate) Apnea (cessation of breathing) Kussmauls breathing Cheyne-Stokes respirations Biots respirations

ALTERATIONS IN EASE OF BREATHING

Orthopnea

Dyspnea

OBSTRUCTED OR PARTIALLY OBSTRUCTED AIRWAY

Partial obstruction
low-pitched snoring during inhalation

Complete obstruction
extreme inspiratory effort with no chest movement

ADEQUATE O2 BALANCE
Example of Obstructive Disease: Asthma

ADEQUATE O2 BALANCE
Example of Restrictive Disease: Hemothorax

INADEQUATE O2 BALANCE

Behaviors of Negative O2 balance

Hypoventilation or hyperventilation Stridor, audible sounds with respiration, wheezing, coughing Hypoxia Change in mental status Change vital signs Cyanosis Decrease in GI motility Change in renal function Hypercapnia

NURSING RESPONSIBILITIES
Determine adequacy of cardiopulmonary function:
Nursing assessment

HEART
Respiratory assessment PMH LIFESTYLE

HEART
Have client describe
specific location, onset and duration of the problem

Explore associated signs and symptoms Ask - activities that worsen or ease the problem Rate the severity of discomfort or incapacity Talk - treatments or interventions used to alleviate
the problem and their effectiveness

HEART PROBLEMS

Artheroscleosis = Coronary Artery Disease (CAD)

NURSING MEASURES TO PROMOTE RESPIRATORY FUNCTION

Ensure a patent airway Positioning Encourage deep breathing, coughing Ensure adequate hydration

NURSING RESPONSIBILITIES
Physical Assessment:
Lung auscultation and breathing pattern
Abdominal assessment Urine output

Skin and mucous membranes

Heart sounds Circulation Edema DVT

LUNG SOUNDS
Diminished or absent Crackles course and fine
discontinuous course bubbling fine crackling sound at the middle or end of inspiration

Rhonchi
a continuous sonorous sound

Wheezes
high pitch musical sounds

Pleural friction rub

grating rubbing, sound

COMMON TESTS AND NURSING RESPONSIBILITIES

Measure adequacy of ventilation and gas exchange
Complete Blood Count (CBC) phlebotomy
Arterial Blood Gases (ABG) arterial puncture Pulmonary Function Tests preparation by teaching

COMMON TESTS AND NURSING RESPONSIBILITIES

Tests to determine abnormal cell growth or infection in respiratory system:

Sputum culture growing microorganisms from sputum Throat culture growth of microorganisms from throat material

COMMON TESTS AND NURSING RESPONSIBILITIES

Tests to visualize structures of respiratory system:
Bronchoscopy Chest radiographs

CHEST XRAY
Adenocarcinoma

COMMON TESTS AND NURSING RESPONSIBILITIES

Thorancentesis

NURSING RESPONSIBILITIES
Medications Incentive spirometry Chest PT Postural drainage Oxygen therapy Artificial airways Airway suctioning Chest tubes

BASIC NURSING INTERVENTIONS

Airway Maintenance:
Facilitate effective coughing Suctioning airways Liquefying and mobilizing sputum

BASIC NURSING INTERVENTIONS

Maintenance and promotion of proper lung expansion:
Re-expanding collapsed lungs - Closed Chest Tube Drainage

CHEST TUBES

BASIC NURSING INTERVENTIONS

Improving Activity Tolerance:
Determine etiology Assess appropriateness of activity level When appropriate gradually increase activity Ensure the client changes position slowly Observe for symptoms of intolerance Syncope with activity refer to MD Perform ROM exercises with activity intolerance if is immobile

BASIC NURSING INTERVENTIONS

Mobilization of Pulmonary Secretions
Auscultate breath sounds, monitor respiratory patterns, monitor ABGs Position client to optimize respiration Pulmonary toileting Incentive spirometry Suctioning

INCENTIVE SPIROMETRY

BASIC NURSING INTERVENTIONS

Mobilization of Pulmonary Secretions
Encourage activity and ambulation as tolerated Encourage increased fluid intake Chest physiotherapy O2 Medications as ordered

BASIC NURSING INTERVENTIONS

O2 Therapy: Low flow High flow Humidification Nasal cannula Simple mask Nonrebreathing mask Partial rebreathing

BASIC NURSING INTERVENTIONS

Effective Breathing Techniques
Position for maximal respiratory function Pursed lip breathing

Diaphragmatic or abdominal breathing

BASIC NURSING INTERVENTIONS

Stress and anxiety reduction:
Remove pertinent cause of anxiety at that moment - help client gain control over respiration - reassure client not in immediate danger

Chronic clients

exacerbations and remissions goal is to reduce general level of anxiety learn to control episodes of anxiety to improve quality of life
desensitization program guided mastery

ADMINISTRATION OF PRESCRIBED MEDICATIONS

Expectorants Mucolytics Bronchodilators Cough suppressants Corticosteroids Antihistamines Antibiotics Vasoconstrictors

BASIC NURSING INTERVENTIONS

Physical Exercise health teaching
Activity and rest -a priority! Activity stimulates respiratory function Rest conserves energy and reduces metabolic demand
MDs treatment plan
guidelines for activity may simply call for activity as tolerate.

prioritize activities arrange need items conveniently Provide emotional support and encouragement
gradually increase activity

Simplify daily life Work at a steady state Conserve energy

ADEQUATE O2 BALANCE

Behaviors of Negative O2 balance Cardio Vascular Disease

Arterial
Venous: Impaired tissue perfusion

ADEQUATE O2 BALANCE
Behaviors of Negative O2 balance CV
Restlessness, dizziness, syncope, bradycardia,

decreased urine cold and clammy skin, cyanosis, slow capillary refill Decreased cardiac output

COMMON TESTS AND NURSING RESPONSIBILITIES

Tests to determine adequacy of cardiovascular function:

CBC Lipid profile Coagulation studies EKG/ECG Angiography Doppler blood flow studies

BASIC NURSING INTERVENTIONS

Cardiovascular
Modify risk factors
Preventing vasoconstriction

Diet Exercise Co morbidities

Positioning Cold temperatures Nicotine

BASIC NURSING INTERVENTIONS

Cardiovascular
-

Prevent complications

Promoting rest

Risk DVT Position changes Early ambulation Obstruction removal Bypass surgery

Schedule rest periods Assistance with ADLs Monitor Vitals with activity Place items, i.e. call light, water pitcher, strategically Quiet environment, decrease stimuli

BASIC NURSING INTERVENTIONS

Cardiovascular
Positioning to improve CO
Position semi to high fowlers-> decrease venous return and preload, decease preload-> decreases risk of heart congestion

Avoiding Valsalva maneuver

Teach client to avoid valsalva maneuver - Hold breath while turning or moving in bed-> assist - Bearing down during BM-> stool softeners and diet

BASIC NURSING INTERVENTIONS

Cardiovascular
Avoid stimulants
Avoid appetite suppressants, cold meds, coffee, tea, chocolate

Maintaining fluid balance

Assess fluid status, monitor I&O, assess breath sounds, JVD, pitting edema in dependent areas, fluid and NA+ restriction, daily Wgt with diuretic therapy, electrolyte monitoring-> MD

BASIC NURSING INTERVENTIONS

Cardiovascular
Increase O2 supply

Administer O2 Educate client NO SMOKING!

Position to facilitate breathing

ADMINISTRATION OF PRESCRIBED MEDICATIONS

Anti coagulants Vasodilator Medications Inotropic Medications Anti Dysrhythmics Anti hypertensives

BASIC NURSING INTERVENTIONS

Dietary control
Assess nutritional status Consider a dietician referral to assess nutritional needs related to clients Chronicity of CAL and CAD and nutrition

BASIC NURSING INTERVENTIONS Weight control

Evaluate the clients physiological status in relation to condition More than body requirements Less than body requirements