Oxygenation: Needs and Factors

• Oxygen is a basic need for life
• Brain damage and serious illness can occur quickly without enough oxygen
• PSWs assist but do not "give" oxygen and should never adjust oxygen levels
• Respiratory function involves air moving in and out of the lungs, O2 and CO2 exchange in the alveoli, and blood carrying O2 to cells and removing CO2
• Cells, tissues, and organs die without oxygen (O2)
• The inability to excrete carbon dioxide (CO2) leads to death
• The respiratory and cardiovascular systems work together to deliver oxygen and excrete carbon dioxide
• Proper oxygenation and CO2 excretion requires healthy respiratory and cardiovascular systems
• Any body system malfunction can affect oxygenation

Factors Affecting Oxygen Needs

• Respiratory system function needs an open airway and adequate alveoli for gas exchange
• Circulatory system function requires adequate RBC count, hemoglobin to carry oxygen, and bone marrow to produce RBCs
• Nervous system function needs healthy respiratory muscles, and brain signals for breathing
• Aging causes weakened muscles, less elastic lungs, and coughing difficulties
• Exercise increases oxygen demand
• Fever increases oxygen needs
• Pain increases oxygen needs and can be complicated by chest or abdominal surgery
• Nutrition is needed for RBC production
• Drugs can depress the respiratory center (e.g., morphine)
• Substance abuse increases risk of respiratory depression or arrest
• Smoking can damage lung tissue, cause lung cancer, and COPD
• Allergies can result in swelling of the upper airway, chronic bronchitis, asthma, and death
• Pollutant exposure damages lungs
• Alcohol depresses the cough reflex and increases risk of aspiration

Signs and Symptoms of Altered Respiratory Function

• Shortness of breath (SOB) can be acute or chronic
• Unable to breathe can cause anxiety
• Struggling to breathe is exhausting
• Shortness of breath on exertion (SOBOE) occurs with activity
• Orthopnea is the need to sit up to breathe

How to Observe a Patient

• Observe any abnormal breathing pattern
• Observe their cough - how often?
• Observe their cough - is it productive or non-productive?
• Observe their cough - does it produce mucous?
• Observe their cough - is it a dry cough?
• Observe the Colour, odour, consistency, bloody
• Observe any noisy respirations like wheezing, gurgling
• Examine Chest pain
• Check Cyanosis (blue) or grey/pale hue to the skin in lips, nail beds, skin, mucous membranes
• Check for changes in vital signs that include increased HR, increased RR, decreased SpO2
• Observe the body position, the client wants to sit up and forward

Abnormal Respiratory Patterns

• Tachypnea is rapid breathing, more than 24 breaths per minute
• Bradypnea is slow breathing, fewer than 12 breaths per minute
• Apnea is the lack or absence of breathing
• Kussmaul respirations are deep and rapid respirations characteristic of diabetic acidosis
• Hypoventilation includes slow, shallow, and sometimes irregular breaths
• Hyperventilation includes respirations that are rapid and deeper than normal
• Dyspnea is difficult, labored, or painful breathing
• Cheyne-Stokes involves respirations that gradually increase in rate and depth, then become shallow and slow, ceasing for 10-20 seconds and is common when death is near
• Orthopnea includes breathing deeply and comfortably only when sitting

Hypoxia

• Hypoxia is a deficiency of oxygen in the cells, impairing their function
• Anything affecting respiratory function can cause hypoxia
• The brain is very sensitive to an inadequate oxygen supply
• Early signs of hypoxia includes restlessness, dizziness, disorientation

Promoting Oxygenation

• Air must reach the alveoli for O2 and CO2 exchange
• Disease and injury can prevent air from reaching the alveoli
• Pain and immobility interfere with deep breathing and coughing
• Narcotics can interfere with deep breathing and coughing
• The care plan outlines measures to promote oxygenation
• Fowler's and semi-Fowler's make breathing easier
• Clients with difficulty breathing often prefer the orthopneic position
• Frequent position changes (at least every 2 hours), prevents lying on one side too long

Coughing and Deep Breathing

• Deep breathing moves air into most parts of the lungs
• Coughing removes mucus
• Deep breathing and coughing prevents pneumonia and atelectasis
• Pain, injury, or surgery may make exercises difficult
• Post-surgery, bed rest, lung disease, and paralysis increase atelectasis risks
• Deep breathing and coughing occurs every 1-2 hours or four times a day, as ordered

Incentive Spirometry

• Incentive spirometry (sustained maximal inspiration [SMI]) is a machine measuring inhaled air
• Incentive spirometry provides a visual guide to improve lung function
• The client takes a slow, deep breath until the balls rise, holds for 3 seconds, and exhales slowly
• Care plan or supervisor will give instructions, which includes: how often the client should use it, the desired height, and the number of breaths needed

Assisting with Oxygen Therapy

• Oxygen is treated as a drug
• Some clients need oxygen constantly, while others need it for symptom relief
• Support workers do not give oxygen, but assist the nurse in providing safe care
• Support workers may be trained to transfer oxygen and provide oral suction

Oxygen Sources

• Three main delivery systems of oxygen:
  • Oxygen concentrator: Filters oxygen from room air, needs to plugged into a grounded electrical outlet
  • Oxygen cylinder: Contains compressed oxygen, placed at the bedside
  • Liquid oxygen system: Portable unit filled from a stationary container, can be worn over the shoulder

Oxygen Therapy and Safety

• Support staff assist with oxygen therapy.
• Support staff do not administer oxygen.
• Support staff are responsible for safe client care when receiving oxygen, and must always follow safety guidelines.
• Keep oxygen source away from heat and open flame.
• Physicians, nurses, or respiratory therapists teach clients and families about oxygen safety
• Ensure clients are warn of dangers and the safety hazards.
• All concerns are reported to the supervisor.
• Oxygen is flammable

Oxygen Administration Devices

• Oxygen is delivered most commonly by: nasal cannula, simple face mask, partial-rebreather mask, non-rebreather mask and venturi mask
• Moisture builds up under masks, so make sure that the face is clean and dry
• This can cause skin breakdown under the mask
• Masks are removed for eating
• When masks are removed for eating, oxygen is given by cannula during meals or is changed from mask to nasal cannula

Oxygen Administration Setup

• If oxygen is not humidified, it can dry out the airway's mucous membranes
• Distilled water is often added to the humidifier

Oxygen Flow Rates

• The O2 flow rate is the amount of oxygen given, measured in liters per minute (L/min)
• The doctor orders the flow rate or a range for the nurse to adjust
• The nurse or respiratory therapist sets the flow rate
• The nurse and care plan tell you the person's flow rate
• Know the flow rate that is ordered, and check that the flow rate is correct
• In the event of an incorrect flow rate, tell the supervisor immediately

Collecting Sputum Specimens

• Sputum is mucus from the respiratory system, not saliva
• Sputum is studied for blood, microbes, and abnormal cells
• The client must cough up sputum from the bronchi and trachea
• It can be painful or hard to do
• Collect the specimen in the morning
• Instruct the client not to use mouthwash prior to procedure
• Provide privacy because the procedure can be embarrassing
• Follow Standard Practices

Artificial Airways

• Artificial airways keep the airway open, and are needed when airways are obstructed from the body, disease, injury, secretions, or aspiration
• Artificial airways are needed for mechanical ventilation
• Artificial airways are needed by some clients who are semi-conscious or unconscious
• Artificial airways are needed when the client is recovering from anesthesia
• Intubation means inserting an artificial airway

Types of Artificial Airways

• Oro-pharyngeal airway: Inserted through the mouth and into the pharynx
• Naso-pharyngeal airway: Inserted through the nostril
• An endo-tracheal (ET) tube: Inserted through the mouth or nose and into the trachea
• A cuff is inflated to keep the airway in place
• Tracheostomy tube is inserted through a surgically created opening into the trachea; cuffed tubes are common
• Vital signs should be checked often on patients with artificial airways
• Observe for hypoxia and other signs and symptoms.
• If an airway comes out or is dislodged, tell the nurse at once.
• Frequent oral hygiene is needed.
• Comfort and reassure the client.
• Follow the care plan for communication methods.

Care Measures for Clients With Artificial Airways

• Vital signs should be checked often
• Observe for hypoxia and other signs and symptoms
• In the event that an airway comes out or is dislodged, tell the nurse at once
• Frequent oral hygiene is needed
• Follow the care plan
• Comfort and reassure the client
• Follow the care plan for communication methods
• Always keep the call bell within reach
• Use touch to show you care, if appropriate for your client's culture and ethnicity

Tracheostomy

• Tracheostomies can be temporary or permanent
• A tracheostomy tube has three parts: obturator, inner cannula, and outer cannula
• The obturator is used to guide the insertion of the outer cannula
• The inner cannula is inserted and locked in place
• The outer cannula is not removed
• The tube must not come out (extubation)
• A loose tube can damage the trachea
• The tube must be remain patent
• If the client is unable to cough up secretions, suctioning is needed

Safety Measures for Clients With Tracheostomies

• Call for the nurse or supervisor if you note signs and symptoms of hypoxia or respiratory distress, or if the outer cannula comes out
• Nothing must enter the stoma
• Tracheostomy care involves cleaning the inner cannula to remove mucus and keep the airway patent
• Tracheostomy care involves cleaning the stoma to prevent infection and skin breakdown
• Tracheostomy care involves applying clean ties or a Velcro collar to prevent infection
• The trachea dressing should never have anything that can be inhaled
• Stoma or tube should always be covered when the client goes outside
• Never cover the stoma with plastic or leather
• Clients should take tub baths instead of showers
• Water should never enter the stoma
• Medical Alert jewellery should always be worn
• Secretions can collect in the upper airway
• Retained secretions can obstruct airflow, create a microbes environment, interferes with gas exchange, and hypoxia can occur
• Persons who cannot cough or have a cough that is too weak to remove secretions need suctioning
• Suction is the process of withdrawing or sucking up fluid (secretions)

Suctioning the Airway

• These routes are used to suction the airway: oro-pharyngeal, naso-pharyngeal and lower airway
• Oro-pharyngeal suctioning involves suctioning the mouth and pharynx
• Naso-pharyngeal Involves suctioning the nose and pharynx
• Lower airway is when the suction catheter is passed through an endotracheal (ET) or tracheostomy tube

Safety Measures for Suctioning

• If not done correctly, suctioning can cause serious harm
• Clients may be unable to breathe during suctioning
• Hypoxia and life threatening complications can arise
• Client's lungs are hyperventilated prior to suctioning by use of an ambu bag
• Ensuring that suctioning is within your scope of practice for your province or agency

Mechanical Ventilation

• Mechanical ventilation is using a machine to move air into and out of the lungs
• Mechanical ventilation is needed for hypoxia caused by weak muscle effort, airway obstruction, and damaged lung tissue
• Mechanical ventilation is needed for nervous system diseases and injuries affecting the respiratory centre
• Mechanical ventilation is needed for drug overdoses that depress the brain's breathing control centre

Chest Tubes

• The doctor inserts chest tubes to remove air, blood, or fluid
• Chest tubes attach to a drainage system
• The system must be airtight
• Water-seal drainage keeps the system airtight

Caring for Chest Tubes

• Keep the drainage system below the level of the chest
• Keep tubing coiled on the bed
• Check vital signs as directed
• Prevent tubing kinks
• Observe chest drainage
• Turn and reposition the client carefully
• Assist with deep breathing, coughing, incentive spirometry
• Keep sterile petrolatum gauze at bedside