Nursing: Respiratory System and Oxygenation

Nursing Care of the Respiratory Client

• Respiratory System replenishes the body's oxygen supply and eliminates waste in the form of carbon dioxide.
• Breathing delivers air to the lungs, where gas exchange occurs.
• There is required Circulatory and Respiratory interaction.
• Hypoxemia means low oxygen levels in the blood.
• Hypoxia means low oxygen levels in tissue.

Oxygenation

• Respiratory system function is normally effortless.
• Respiratory system functions changes with activity like: sleep, walking, talking, and strenuous activity.
• Breathing involves inspiration and expiration.
• The Upper respiratory tract cleanses inspired air and prevents infection and aspiration.
• Gas exchange happens in the Lower respiratory tract.
• There is a required Circulatory and Respiratory interaction.
• Factors affecting respiratory function/oxygenation includes age, body position, and environment.
• Lifestyle and habits can affect respiratory function/oxygenation
• Some clients may experience increased difficulty breathing. Medical conditions can affect respiratory function like restrictive and obstructive conditions

Assessing Respiration

• Normal respiration/breathing is effortless and changes with activity.
• Coughs can indicate altered respiratory functions. Use the ASK pneumonic to assessment:
• Sputum production.
• Dyspnea, which is SOB shortness of breath.
• Chest pain can indicate altered respiratory functions.
• Emotional responses of anxiety, fear, and panic may accompany breathing issues.

Physical Assessment

• Inspection/Observation involves assessing the client's position, rate, color, presence of clubbing, and barrel chest.
• Clubbing is an increase in the soft tissue of the fingers
• Auscultation involves listening to the client's lungs.
• Palpation and Percussion is primarily performed by a physician.
• Palpation can detect vibrations felt when a client repeats "99"; increased vibrations may indicate consolidation, and decreased vibrations may indicate trapped air.
• Percussion involves tapping to diagnose consolidation of fluid or trapped air.

Oxygenation Assessment

• Pulse Oximetry measures arterial oxygen saturation (SaO2), is non-invasive, can be intermittent or continuous, and assesses therapeutic effects.
• Normal is considered ≥95%.
• <94% usually indicates the need for O2 supplement need.
• Arterial Blood Gasses (ABGs) are the most reliable indicator of gas exchange; pH (7.35-7.45), pCO2 (35-45mmHg), and HCO3 (22-26mEq/L).

Oxygenation: Diagnostic Tests and Procedures

• Sputum samples are sent to the lab if a client has a productive cough, is febrile, and shows signs of infection.
• • The sample is used for cytology, culture and sensitivity (C&S), and acid-fast bacilli (AFB).
• Chest X-rays are used to identify pathological changes related to breathing problems
• Lung Scans and Angiography are specialized tests to study blood flow and ventilation and determine capacity and patency.
• CT scans can be ordered with or without contrast dye, but there are contraindications such as allergy to the dye, impaired kidney function, and use of metformin.
• V/Q scans use radioisotopes to assess perfusion and ventilation, and mostly for the diagnosis of PE.

More Diagnostic Tests

• Bronchoscopy retrieves specimens, removes mucus plus, and retrieves copious amounts of sputum/phlegm.
• Thoracentesis aspirates fluid or air from the pleural space using a needle.
• It can obtain fluid or tissue, relieve compression, and instill medication.
• Pulmonary Function Tests (PFTs) mainly obtain baseline data, monitor lung function, and measure effectiveness of interventions. Spirometry measures lung volumes and flows.
• Skin testing can identify allergic-related respiratory issues as well as test for TB exposure.

Nursing Interventions

• Cardiac and Respiratory assessment is a very important Nursing Intervention includes:
  • Assessing and Monitoring vital signs.
  • Monitoring lab values.
  • Medication administration.
  • Suction
• Teach patients:
• Cough and deep breathing exercises.
• Pursed lip breathing.
• Incentive Spirometer (IS) and Acapella use.
• Ensure client can perform task necessary to take medications as prescribed both physically and mentally.
• Lifestyle Modifications, and understanding their Disease process

Incentive Spirometry

• When using incentive spirometry, position the client in high Fowler's position and instruct them to exhale completely
• Seal the lips around the mouthpiece, inhale to maximum capacity, hold breath for about 5 seconds, and repeat 5-10 times every hour while awake
• Encourage client to self use and Document teaching success and client's use.

Acapella

• When using the acapella device, position the client in high Fowler position.
• instruct them to seal lips around mouthpiece.
• instruct them to Inhale through the nose fully
• instruct them to Exhale slowly with enough force to cause vibrations.
• Encourage use 5 to 10 times each hour while awake

Oxygen Safety

• Nursing care should include knowing where to find the fire extinguisher.
• Patient education of fire hazards include educating client to wear cotton gown/socks and not to use volatile, flammable materials , educate/post "No smoking" signs around the patient, and Ensure that all electrical machinery is grounded.
• Important: Oxygen is combustible
• Equipment must be grounded, no smoking or open flames, and no petroleum products.
• Use the lowest oxygen concentration/flow and the goal is to achieve this using oxygen therapy.

Oxygen Therapy

• Oxygen, like other medications, requires a prescription
• It is primarily used to reverse hypoxemia.
• Fundamentals:
• Improved tissue oxygenation.
• Decreased work of breathing.
• Decreased work of the heart in patients with cardiac disease
• Prescribed as flow in liters per minute or concentration as percentage/fraction of inspired oxygen (FiO2).

Low Flow Oxygen Systems

• Oxygen will Mix with room air.
• Delivers a Fraction of inspired air (FiO2) that is not an accurate/exact reading.
• Delivery rate and measure depends on respiratory rate and tidal volume, which is the volume of air that is inhaled and exhaled in one breath.
• Nasal Cannula: 1-6L/min (humidity effective at 4L/min)
• Simple Face Mask: 6-10 L/min
• Non-Rebreather Mask: 10-15 L/min
• Venturi Mask: 3-12L/min
• Room air is always 21% oxygen

Nasal Cannula

• Oxygen concentration provided approximately 22% -44%.
• Flow can be at 1-6 L/min
• The client must have patent nares.
• Ensure prongs are placed correctly and Assess for irritation.
• Water soluble gel can be used
• Humidify Oxygen if using 3/4-6 L/min
• Reassess adjusting as needed

Face Mask

• Short term use for emergency situations.
• Oxygen concentration provided approximately 40% - 60%.
• should be 6 – 10/12 L/min
• must fit snuggly
• Must be at least 5L/min to prevent client from rebreathing exhaled carbon dioxide
• Assess and provide skin care
• Increased risk for aspiration, should wear NC when eating

Non-Rebreather Mask

• Provides up to 90/95% concentration.
• Flow rate is 10-15 L/min
• Must use sufficient flow to keep 02 reservoir inflated.
• Used for critically ill patient.
• Ensure mask is a snug fit.

Venturi Mask

• Most reliable and accurate concentration, with a concentration of 24% - 50% and a flow rate of 3-12 L/min
• Color coded adapters/different size adapters/adjustable dial mixes room air and adjusts what is drawn in when client inhales
• Ensure a snug fit.
• If client can tolerate, their usual Nasal cannula can be used for eating and drinking

More Oxygen Therapy

• Face Tent/Shovel Mask (8-12 L/min delivers 30%-55% FiO2)
• It can be humidified for patient comfort
• They are useful for claustrophobic clients or for after anesthesia recovery and are a short term use device
• Oxygen concentration delivered in the Oxymizer reservoir nasal cannula has a Flow rate of 4 – 15 L/min, which saves on needed oxygen supply.
• High flow systems deliver accurate FiO2 and are used for critically ill patients when FiO2 is critical to regulate.
• The flow rate is not dependent on the patient’s respiratory rate
• Aerosol Mask: Delivers 90% or more of concentration with a flow of 40-50 L/min

Additional Oxygen Therapy Protocols

• Anti-embolitic stockings; TED stockings/compression stockings can be another therapy which:
• Compresses deep veins.
• Promotes venous return and Prevent deep vein thrombosis (DVT).
• Must measure for proper size (around ankle, largest part of calf, and length).
• Should be applied prior to getting out of bed the first thing in the AM.
• Removed every 8 hours for 30 minutes
• Reassess skin and CSM.
• Sequential Compression Therapy with Compression boots (CVM boots) is used for 24-48 hours for post-op DVT prevention patients.

Suction

• Suctioning occurs when a client cannot expectorate secretions or a foreign substance. Suctioning methods include:

• Oral

• Oropharyngeal

• Nasopharyngeal

• Tracheostomy

• Artificial airways

  • OPA (oropharyngeal airway)

• NPO (Nasopharyngeal airway)

• Nasopharyngeal and Nasotracheal suctioning require PPE and using wall or portable suction set at 80-120 mmHG with water based lubricant. Limit the process of suctioning to 10 - 15 seconds

  • Note If on O2 supplement, adjust flow up during suctioning, should adjust flow up during suctioning and then back when completed, using a sterile aseptic technique.
  • Be aware Risk of vomiting from stimulating the gag reflex

• Oropharyngeal suctioning uses a clean technique

• Yankar suction is helpful.

• Possible complications include: Hypoxia, ICP, Dysrhythmias, Vasovagal response – bradycardia/hypotension, trauma, and infection