Respiratory Assessment and Intervention

• Impaired gas exchange results from the destruction of alveolar walls.
• Impaired gas exchange is associated with an oxygen saturation level of less than 90% and dyspnea.
• Impaired airway clearance can be caused by bronchoconstriction and increased mucus production.
• Impaired airway clearance is associated with thick sputum, prolonged coughing, adventitious breath sounds, and dyspnea.
• Activity intolerance is related to O2 levels and the need for more O2 during exercise or activity.
• Evidences of activity intolerance include complaints of fatigue, decreasing O2 saturation levels with activity, and slow gait.
• Acute chest pain is related to damage to the heart muscle.
• Evidence showing acute chest pain includes a pain rating of 7 out of 10, increased respiratory rate, and diaphoresis.
• Ineffective tissue perfusion is caused by decreased O2 levels in the blood.
• Ineffective tissue perfusion is associated with fatigue with exercise and cyanosis.

Analysis of Cues Related to Oxygenation and Perfusion

• Palpitations, when accompanied by chest pain, dyspnea, fatigue, dizziness, loss of consciousness, or ECG changes, are likely related to oxygenation and perfusion issues and could indicate hyperthyroidism or anxiety.
• Dyspnea, accompanied by chest pain, exercise intolerance, edema, cough, wheezing, altered breath sounds, changes in lipid panel, cardiac enzyme, ECG, echocardiogram, cardiac catheterization, chest x-ray, and pulmonary function tests, is likely related to oxygenation and perfusion and could indicate anxiety deconditioning.
• Fatigue, with chest pain and edema, along with exercise intolerance, and changes in lipid panel, cardiac enzyme, ECG, echocardiogram, and cardiac catheterization tests, may indicate hypothyroidism, diabetes, infection, cancer, or depression.
• Chest pain may include radiating pain, diaphoresis, nausea, vomiting, dyspnea, exercise tolerance, changes in lipid panel, echocardiogram, and cardiac catheterization tests.
• Possible conditions to consider with chest pain include musculoskeletal problems, anxiety, pleuritis, trauma, gastroesophageal reflux disease, peptic ulcer, pancreatitis, or tumors.
• Cough, along with chest pain, dyspnea, exercise intolerance, wheezing, mucus, secretions, abnormal breath sounds, and changes in chest x-ray and pulmonary function tests, may be related to ACE inhibitor use, allergies, GERD, or sinusitis.
• Wheezing, with cough, dyspnea, exercise intolerance, mucus, secretions, abnormal breath sounds, and changes in x-ray and pulmonary function tests, may be related to GERD.

Face Masks

• Partial rebreather and non-rebreather masks include a flexible 1 L reservoir bag with O2 inlet and are referred to as reservoir masks because they have a valve system and deliver higher levels of inspired O2.
• Simple face masks allow room air to be inspired with the delivered O2.
• Simple face masks do not include a reservoir bag.
• An increase of 1 L/min of O2 relates to an approximate 5% increase in O2 concentration delivered.
  • 5 L/min = 40% O2 concentration
  • 6 L/min = 45% O2 concentration
  • 7 L/min = 50% O2 concentration
  • 8 L/min = 55% O2 concentration
  • Higher than 8 L/min = 60% O2 concentration
• Partial rebreather masks allow some exhaled air to enter the reservoir.
• Because exhaled air comes from the respiratory dead space.
• Because exhaled air comes from the respiratory dead space, it has small amounts of carbon dioxide.
• Flow rates and percentage oxygenation values for partial rebreather masks:
  • 5-15 L/min = 70% to 90% (10L/min needed to maintain reservoir inflation)
• Non-rebreather masks have a one-way valve preventing exhaled air from entering the reservoir bag.
• Additional one-way valves allow air to be exhaled through the mask, but room air cannot be inhaled through the valves in non-rebreather masks.
• Non-rebreather mask flow rates should be higher than 10L/min to maintain bag inflation.
• Non-rebreather mask flow rates and percent O2 values range from 10 L/min to 15 L/min = 60% to 100%.
• Venturi masks are designed to ensure the accuracy of the O2 concentration delivered.
• Venturi masks are often used for patients who retain CO2, like COPD patients.
• Color-coded adaptors or a dial with a liters per minute setting can be attached to Venturi masks.
• Venturi mask flow rates and percentage oxygenation values range from 4-12 L/min = 24%-60%.

Face Mask Nursing Checklist

• Evaluate the patient's tolerance and make any necessary adjustments to the fit.
• Ensure no large gaps or openings between the mask and skin.
• Ensure the bag is filled before placing it on the patient.
• Conduct a focused respiratory assessment 15-30 minutes after initiating therapy and at regular intervals thereafter.
• Evaluate the patient's response to O2.
• Contact the health care provider to adjust the plan of care if the patient deteriorates.

Positive Pressure Devices

• Patients unable to maintain an open airway require forced air and O2, administered through a mask over the nose or nasal pillows at the nares.
• CPAP (continuous positive airway pressure) provides the same pressure during both inhalation and exhalation.
• BiPAP (bilevel positive airway pressure) provides continuous bilevel positive airway pressure, using higher pressure during inhalation and lower pressure during exhalation.

Device Nursing Evaluation

• Nasal Cannula:
  • Subjective: patient reports less dyspnea
  • Objective: patient more alert, decreased respiratory rate and less accessory muscle use, and improved SpO2
• Face Mask:
  • Objective: patient reports less dyspnea.
  • Objective: patient more alert, decreased respiratory rate and less accessory muscle use, and improved SpO2 and PaO2 on arterial blood gases.
• BVM Device:
  • Subjective: patient reports less dyspnea.
  • Objective: patient more alert, decreased respiratory rate and less accessory muscle use, and improved SpO2 and PaO2 on arterial blood gases.
• CPAP/BiPAP:
  • Subjective: patient reports compliance and less daytime somnolence.
  • Objective: echocardiogram and cardiac catheterization findings.

Types of Airways

• Pharyngeal airways are used for:
  • Decreased levels of consciousness
  • Loss of muscle tone
  • Frequent suctioning needs
• Tracheal airways are used for:
  • Inability to breathe effectively
  • Need for positive pressure mechanical ventilation
  • Long-term airway patency problems
  • Need for general anesthesia
  • Blocked upper airway

Types of Tubes

• Pharyngeal airways:
  • Nasopharyngeal tube
    • Inserted through the nose
    • Protects nares and provides a guide for catheter insertion when frequent suctioning is required
  • Oropharyngeal tube
    • Inserted through the mouth so the airway goes over the tongue
    • Should be removed from the airway every 4 to 8 hours
    • Secured in place with a holder or tape
• Tracheal airways:
  • Endotracheal Tube
    • Semirigid, curved tube with a cuff at the distal end
    • Inflated cuff prevents aspiration of gastric contents into the lungs
    • Placed through the mouth
    • Sealed with a balloon at the end of the tube
  • Tracheostomy Tube
    • Plastic polymer or metal tube that fits through a stoma in the neck
    • Most have an outer cannula with an attached flange and cuff and a removable inner cannula
    • Facility policy dictates specific items, such as a BVM device, O2, suction equipment, extra inner and outer cannulas with obturators, and an extra tracheostomy care kit, and are kept at the bedside in case of tracheostomy dislodgement.