LECTURE 7&8 Oxygenation.pptx

NUR 118 Lecture 7 & 8 Gaseous Transfer Oxygenation Objectives • Identify structures of the upper and lower airway • Distinguish Between External and Internal Respirations • Respiratory Assessment: • INSPECTION • 6 characteristics observed • 9 Breathing Patterns • 8 observations that indicate respiratory effort • PALPATION • Pain, masses, respiratory excursion • AUSCULTATION • Technique • Normal lung Sounds • Abnormal lung Sounds Objectives • Definitions of Diagnostic Tests • Gaseous Transfer Nursing Interventions • Health Promotion, Smoking Cessation, Pulmonary Hygiene, Suctioning, Positioning, Purse-Lipped Breathing, Incentive Spirometer, Peak Flow Meter • Signs & Symptoms of Hypoxia • COPD • Chronic Bronchitis • Emphysema • Sleep Apnea Objectives • Differentiate between normal stimulus to breathe and the “hypoxic drive” • Situations for applying supplemental O2 (no order) • When to suction using yankauer, and suction catheter • Medications: codeine, guifanesin • List labs and diagnostics related to gaseous transfer Respiratory System Upper & Lower Respiratory Physiology • Structure and function – Breathing: inspiration, expiration – Lung volumes and capacities – Pulmonary circulation – Respiratory gas exchange: oxygen, carbon dioxide – Regulation of respiration Mosby Inhalation vs. Exhalation Inhalation • Diaphragm contracts (flattens) • Ribs move upward and outward • Sternum moves outward • Enlarging the size of the thorax wkg 113 rev Exhalation • Diaphragm relaxes • Ribs move downward and inward • Sternum moves inward • Decreasing the size of the thorax wkg 113 rev *Ventilation, Respiration, Oxygenation • Ventilation: • The movement of air into and out of the lungs • Through Breathing = Inhale & Exhale • Respirations: • The exchange of O2 and CO2 in the lungs • External: exchange is in lungs, at alveoli • Internal: exchange is at body organs & tissues • Oxygenation: • How well the cells, tissues and organs of the body are supplied with oxygen Ventilation = Movement of air into and out of lungs Adequacy of Ventilation What Supports the Movement of Air • Airway • Compliance of lungs • Alveoli aerating • Adequate perfusion of blood to lung tissue • Adequacy of muscles • Atmospheric oxygen – approx. 21% • Adequate fluid intake Mosby items and derived items © 2005 by Mosby, Inc. Factors Affecting Ventilation • Rate - How fast you breathe • Depth - How much lungs expand to take in air • Hyperventilation - Fast & Deep - Too much air = Loss of CO2 • Hypoventilation - Slow & Shallow - Too little air = Low O2 • Lung elasticity - Ability of lung to recoil - Loss = Inhibits deflation • Lung compliance - Ease of Lung inflation - Loss r/t H20 (edema) - scaring • Airway resistance - Airflow in Airways - Large diameter = Good Air Flow • Decrease in diameter = ^ resistance • R/T - Secretions - Bronchospasms - Inflammation - Obstruction Factors Affecting Ventilation Continued • Hyperventilation - Fast - Deep breathing = amount of air in & out of the lungs • Results in: • Loss of CO2 causing decreased blood CO2 (Hypocarbia) • Hypoventilation - Slow - Shallow breathing = amount of air in lungs • Results in: • High blood CO2 (Hypercarbia) Not exhaling enough CO2 • Low blood Oxygen (Hypoxemia) Not inhaling enough O2 to alveoli • Low tissue oxygen (Hypoxia) blood Due to hypoxemia, low O2 in What Happens with Inadequacy of Ventilation • Hypoxemia- low O2 levels in blood - POOR ALVEOLAR DIFFUSION • Normal arterial 80 – 100 mmHG = < 80 • Hypoxia – low O2 levels in tissues - HYPOXEMIA OR CIRCULATION ISSUE • Pulse Oximetry < 90% • Hypercarbia - elevated CO2 levels in the blood - HYPOVENTILATION • Normal arterial PaCO2 35 – 45 mmHG = > 45 • Hypocarbia - Low CO2 levels in the blood - HYPERVENTILATION • Normal arterial PaCO2 35 – 45 mmHG = < 35 Mosby items and derived items © 2005 by Mosby, Inc. Hypoxemia vs. Hypoxia Hypercarbia vs Hypocarbia Respiration • Exchange of gases, O2, CO2 • External Respiration • Gas Exchange occurs In the lungs in the Alveoli • Internal Respiration • Gas Exchange occurs in the Body organs and tissues EXTERNAL RESPIRATION RESPIRATION INTERNAL Factors Affecting Oxygenation • Oxygen transport • CO2 Transport • Physiological Respiratory Factors • Hyperventilation • Hypoventilation • Hypoxia Mosby items and derived items © 2005 by Mosby, Inc. Factors Influencing Pulmonary Function • Developmental Stage • Environment • Lifestyle • Medications • Pathophysiological Conditions Pathophysiological Conditions • URI • Influenza • LRI • Structural Abnormalities • Airway Inflammation and Obstruction • Alveolar-Capillary Membrane Disorders • Atelectasis • Pulmonary Embolism • CNS abnormalities • Neuromuscular abnormalities • Sleep Apnea • COPD General Survey = What do you see? Focus Nursing HX • Current respiratory problems • Past medical HX • Medications • Allergies • Lifestyle • Smoking • Environment • Health practices (immunizations) • Excessive Reports of snoring from partner and early morning H/A • Fatigue • Dyspnea • Cough • Wheezing • Pain • Environmental exposure • Respiratory infections • Health Risks • Medications 24 PHYSICAL EXAMINATION •Inspection •Palpation •Percussion •Auscultation Assessment : Inspection (LOOK) • Color of skin & mucous membranes • Inspect throat - palate - tonsils pharynx - nose • Cough & sputum - COCAF • Count respirations = Respiratory Rate • Note rhythm, depth, pattern, effort* • Observe for symmetry of chest movements * ASSESSING COUGH & SPUTUM COUGHING IS A NATURAL RESPONSE (REMEMBER PRIMARY BODY DEFENSE) TO REMOVE DEBRIS FROM AIRWAY COUGHING BECOMES AN ISSUE WHEN IT BECOMES PRODUCTIVE. THE DEBRIS/SPUTUM/MUCOUS/FLUID OBSTRUCTS OR SETTLES OR LIMITS VENTILATION THUS OXYGENATION • DRY - PRODUCTIVE - HACKING • WHEN DOES IT HAPPEN & HOW LONG • ALLERGIES - URI - ASTHMA - CHRONIC ILLNESS - AIRWAY OBSTRUCTION • ANYTHING MAKE IT WORSE OR BETTER • EXPOSURE - SMOKING - REST - MEDS - NEBULIZERS • COCAF SPUTUM • COLOR - WHITE - CLEAR - YELLOW - HEMOPTYSIS - FROTHY • ODOR - FOUL SMELL CAN MEAN BACTERIAL PNEUMONIA - LUNG ABSCESS • CONSISTENCY - THICK - TENACIOUS (SPUTUM) - WATERY & THIN (SALIVA) Inspection - AP Diameter The diameter of the chest from front to back should half the width of the chest • AP = Transverse/Lateral Transverse/Lateral should be twice as wide as front to back • Barrel Shape – COPD - emphysema • The alveoli has lost its elasticity so lung tissue does not recoil back to normal • "Barrel Chest ” 1:1 develops d/t Lungs are overinflated, and pushing the chest wall out Pectus Excavatum (EX-CAVA_TUM) Pectus Carinatum- (CAR-INA-TUM) Inspection (LOOK) - Clubbing & Cyanosis 3/13/21 31 Assess Breathing Patterns • Eupnea • Tachypnea • Bradypnea • Dyspnea • Orthopnea • Apnea • Kussmaul’s Respirations • Biot’s Respirations • Cheyne-Stokes Respirations • Stridor = EMERGENCY Assessing Respiratory Effort • Nasal flaring - https://youtu.be/iiX6vQ2F6ao • Retractions https://www.youtube.com/watch?v=5OR-0zuw9v0 • Use of accessory muscles - https://youtu.be/iv7zgdlFrgs https://www.youtube.com/watch?v=U5nrX-RN7hQ • Grunting • Orthopnea • Body position (to facilitate respirations) • Conversational dyspnea • Stridor • Wheezing • Diminished or Absent Palpation - (FEEL) • Palpate anterior, posterior, lateral chest • Expectation: • Chest is non-tender • no masses • Normal Chest Excursion • Symmetric expansion Percussion • Expected Sound over lungs • Resonance – low pitched, hollow sounds • Unexpected over lungs • Dull - organs • Flat - bones • Hyperresonance Auscultating - (LISTEN) - Lung Sounds Auscultation • Instruct to take slow deep breaths through open mouth • Expect: Lung sounds clear to auscultation �Normal Lung sounds: • Bronchial: over trachea • Broncho-vesicular: over sternum in front, between clavicles posteriorly • Vesicular: heard over lower lung fields Auscultation: Abnormal Lung Sounds • Adventitious Lung Sounds: • • • • • • Rales (crackles) Rhonchi Wheezes Stridor Pleural friction rub Grunting https://youtu.be/KRtAqeEGq 2Q https://youtu.be/1rve-sxs3W k Diagnostic Tests & Procedures • CBC • Allergy Testing • Sputum • TB • Culture • PPD • ABG’s • Peak Flow Meter • CXR • Pulse Oximetry • Sleep Studies • Bronchoscopy • Ct Scan • Thoracentesis • Pulmonary Function Tests Labs & Diagnostics CBC • WBC - Infection • Hemoglobin and Hematocrit – • O2 carrying capacity of blood Sputum culture & sensitivity • Infection • Sleep study for Sleep Apnea • Chest x-ray • May do CT scan • Pulmonary Function Tests • Pulse oximetry - 02 sat • Bronchoscopy • Arterial Blood Gases – ABG’s Pulmonary Function Tests PFT’s • Tidal Volume • Vital Capacity • Residual Volume • Total Lung Capacity https://www.youtube.com/watch?v=teqX9U2BzYc Diagnostic Tests - Peak Flow = EXHALE Peak Flow Meter = Exhale • Measures the amount of air that can be exhaled with Forcible effort • Patients with asthma use PEFR monitoring to detect subtle changes in their condition • Green – all clear • Yellow – caution – take bronchodilator • Red – severe reduction in peak flow – go to ED https://www.youtube.com/watch?v=055fSYXgN KU Problem Statements • Ineffective Airway Clearance • Ineffective Breathing Pattern • Impaired Gas Exchange Interventions • Position for maximum ventilation • HIGH FOWLER'S - ORTHOPNEIC • Mobilize Secretions • Coughing, deep breathing, chest PT • Maintain hydration - Increase fluids to thin secretions • • • • • • Assist with incentive spirometry Respiratory Medications Support Smoking Cessation Teaching - Health promotion - diet & exercise Provide Oxygen Therapy if needed Suction if needed Position for Maximum Ventilation • Positioning • HOB ^ High Fowler’s • Orthopneic Position • When patient on side, provide pillows to support upper arm • Frequent position changes to keep all areas of lungs well ventilated Pulmonary Hygiene • Percussion • Vibration • Postural Drainage Nursing Interventions: Mobilizing Secretions Nursing Interventions: Incentive Spirometer = Inhale The purpose of incentive spirometry is to: • facilitate sustained slow deep breath • prevent and reverse atelectasis when used regularly and appropriately. • helps to liquefy, loosen and prevent pneumonia. Pursed Lip Breathing • Slows Breathing Down • Keeps Airway open longer to get rid of CO2 • Improves O2 and CO2 exchange and ventilation Pursed Lip Breathing Interventions: Health Teaching/Education • Weight Reduction • Diet – low NA+, cholesterol • Exercise • Stress Reduction • Occupational Safety • Vaccines – influenza, pneumonia • Teach infection control • Limit exposure to crowds NURSING INTERVENTIONS Managing Medications • Antibiotics • Cough medications • Suppressants - codeine • Expectorants - guaifenesin • Vitamins- C • Corticosteroids • Bronchodilators Respiratory Medications codeine guaifenesin •Classification: antitussive, opioid analgesic •This is an opioid analgesic, used here in liquid form to suppress cough •Same implications as you learned: respiratory depression, sedation, constipation, hypotension •Classification: Expectorant •reduces viscosity of tenacious secretions by increasing respiratory tract fluid Respiratory Medications Classification: Corticosteroids Prednisone - Solumedrol Flovent Inhibits & suppresses inflammation Suppresses immune system Side effects: HTN - Wt. Gain - Moon Face - Infection risk - Oral Thrush (fungal) Classification: Bronchodilators Atrovent - Ventolin - Albuterol Relax the muscle bands in airway Keeps airways dilated (OPEN) Helps to clear mucus when open Side effects: Dry mouth - Trembling nervousness - palpitations Tachy - muscle cramps - n/v/d Smoking Cessation • Inquire at every contact with patient • Provide resources for quitting • Medications? Suctioning: Oral, Nasopharyngeal, Tracheal •If patient is unable to mobilize/remove secretions •Done PRN* •Assess at risk patient every 2 hours •Pre-oxygenation with 100% O2 •Duration of each suction pass should be limited to ten seconds and only on way out •The number of passes should be Suction Catheter Yankauer NURSING INTERVENTIONS Oxygen therapy • Not an independent NI- EXCEPT in an emergency! • Oxygen indication- to prevent and treat hypoxia. • Example of conditions are: • Difficulty ventilating all areas of their lungs • Impaired gas exchange • Heart failure • MI • Prescription must include: • Concentration • Liters/% of O2 per minute • Method of delivery NURSING INTERVENTIONS Nasal Cannula Simple Face Mask Partial Non-Rebreather Rebreather Non- Venturi Mask Face Tent Trach Collar • Hypoxemia • Hypoxia • Low arterial blood oxygen levels • Poor diffusion across alveolar membranes Etiology: • Heart Failure - COPD • Sleep Apnea • Anemia - Asthma Pneumonia - PE • Inadequate oxygenation of organs or tissues Etiology: • Hypoxemia • circulatory/resp. disorders • Low Hemoglobin • Hypercarbia • Hypocarbia • Excess of CO2 dissolved in blood • Low level of CO2 in blood • Etiology • Etiology hypoventilation COPD - Sleep Apnea hyperventilation • Anesthetic effect • Stimulating effect Signs of Hypoxia Early S/S: • Restlessness • Anxiety/Apprehension • Confusion S/S • Tachycardia • Tachypnea • Shortness of breath • Cyanosis • Decreased LOC • Abnormal lung sounds = (Adventitious) Hypoxia - Interventions RAPID ASSESSMENT - HAPPENS SIMULTANEOUSLY • • • • • • • HOB UP - HIGH FOWLER’S CALL FOR HELP COUNT RESPIRATIONS PULSE OXIMETRY STAT APPLY OXYGEN IF PULSE OXY <90% CHECK VITAL SIGNS LISTEN TO LUNG SOUNDS COPD CHRONIC BRONCHITIS Chronic Bronchitis: Etiology: Smoking (90% of cases) Occupational exposures - Air pollution - Asthma - CF Inflammation and hypersecretion of mucus in bronchi & bronchioles caused Signs & Symptoms: by chronic exposure to irritants - Chronic cough causing airway obstruction Thick, tenacious sputum Rhonchi in the Bronchi Wheezing Hypoxemia & Hypoxia = Dusky Cyanosis Tachycardia - Tachypnea Dyspnea - SOB COPD CHRONIC BRONCHITIS Etiology: Smoking (90% of cases) Occupational exposures - Air pollution - Asthma - CF Signs & Symptoms: Chronic frequent cough Thick, tenacious sputum Rhonchi in the Bronchi Wheezing Hypoxemia & Hypoxia = Dusky Cyanosis Tachycardia - Tachypnea Dyspnea - SOB Diagnosis: PFT - C-X ray - ABG Treatment: Bronchodilators Corticosteroids Expectorant Anti Infectives if r/t infection Controlled Oxygen delivery or BiPAP Pulmonary rehabilitation Stop smoking Decrease exposures to irritants Get Vaccinations COPD EMPHYSEMA • Emphysema • Destruction of alveoli, narrowing of bronchioles, and air trapping of air resulting in loss of lung elasticity Etiology: Smoking (90% of cases) Occupational exposures - Air pollution - Asthma - CF Signs & Symptoms: Difficulty exhaling - Grunting Purse lipped breathing Barrel chest - Hyperinflation Weight loss - Thin Tripod positioning Clubbing - From chronic hypoxia • Infrequent cough • Hypoxia - Hypercarbia (Pink) • Dyspnea - SOB • • • • • • COPD EMPHYSEMA Etiology: Diagnosis: Smoking (90% of cases) Occupational exposures - Air pollution - Asthma - CF PFT - C-Xray - ABG Signs & Symptoms: Difficulty exhaling - Grunting Purse lipped breathing Barrel chest - Hyperinflation Weight loss - Thin Tripod positioning Clubbing - From chronic hypoxia • Infrequent cough • Hypoxia - Hypercarbia (Pink) • Dyspnea - SOB • • • • • • Treatment: Bronchodilators Corticosteroids Expectorant Anti Infectives if r/t infection Controlled Oxygen delivery or BiPAP Pulmonary rehabilitation Stop smoking Decrease exposures to irritants Get Vaccinations COPD CNS Stimulation to Breathe Normal Person: • Increased levels of CO2 COPD=chronic bronchitis, emphysema • Decreased levels of O2 **Control of Breathing - Without Illness • Respiratory centers in brainstem control breathing using feedback from chemoreceptors and lung receptors (pp 959 in text) • Chemoreceptors detect changes in blood pH, O2, CO2 • ABG’s • High CO2 levels stimulate breathing to eliminate the excess CO2 ** It is the blood CO2 level that provides the primary stimulus to breathe** for people without illness (NORMAL HEALTH) or COPD **Hypoxic Drive - PATIENTS WITH COPD • Refers to people with COPD, Chronic Obstructive Pulmonary Disease • Chronic Bronchitis • Emphysema • **Their stimulus to breathe is low arterial O2 levels • (instead of high CO2 levels) • There are limits to the amount of supplemental O2 we can give them • If we give them too much O2, it cuts down their stimulus to breathe – they can become hypoxic - RAISING THEIR O2 STOPS THEIR STIMULUS TO BREATHE • Rationale: their body is used to high levels of CO2, so high levels do not stimulate them to breathe Obstructive Sleep Apnea Signs & Symptoms • Snoring • Periods of apnea lasting 10-120 seconds • Daytime sleepiness • Morning Headache • Unrefreshing sleep • Dry mouth in am Risk Factors Implications • • • • • • • Small upper airway Overweight Large neck size Age > 40 Smoking Alcohol Genetic Medical • HTN • CAD • MI • CHF • Memory problems • Depression • Daytime drowsiness Diagnosis • Sleep Studies • overnight at testing center • Or at home Treatment • CPAP • BIPAP • Lateral positioning • Dental Appliances • Weight loss • No smoking • No alcohol NURSING INTERVENTIONS • Assessment- recognizing symptoms • Promoting-Teaching • side lying positioning for sleep, to allow full relaxation and avoid blockage of airway • weight loss of at least 10% of the patient's current body weight • Use of oral mouth guards that push the tongue down and pull the jaw forward to open more space at the back of the throat • Continuous positive airway pressure (CPAP) therapy. Patient in Respiratory Distress Interventions • Reposition • Head of bed up - High Fowler’s • Pull up in bed • Orthopneic position • Check O2 Saturation via pulse oximetry • < 90% and patient symptomatic: • Apply supplemental O2 • • • • • Patient is dyspneic Restless Cyanotic Gray We will usually start with nasal cannula • Done as emergency, we will get order later • We can have someone call Respiratory Therapist, may give • Vital Signs • Lung Sounds • Crackles • Rhonchi • Wheezes • Call primary care provider • Use SBAR • Possible prescriptions: • CXR • ABG’s • Nebulizer treatments • Cultures • Antibiotics • Corticosteroids IV Other Interventions • Remember, this is an emergency situation: ABC • We need to get O2 levels up • Suctioning – if necessary • During emergency we do not use postural drainage, cupping, clapping, we will do this later when patient is more stable • ** Remember iCare, pp 972 in textbook** NURSING INTERVENTIONS Oxygen therapy • Not an independent nursing intervention - EXCEPT in an emergency! • Oxygen indication- to prevent and treat hypoxia. • Examples of conditions are: • O2 sat < 88-90%* • Restlessness, confusion • Cyanosis • MI • Start low with 2L NC & monitor Airway suctioning A procedure routinely done in most care settings, including acute care, sub-acute care, long term care, and home settings. • Suctioning is performed when the patient is unable to effectively move secretions from the respiratory tract. • This may occur with excessive production of secretions or ineffective clearance, which leads to the accumulation of secretions in the upper and lower respiratory tract. • This can lead to possible airway obstruction and ineffective airflow. • This ultimately leads to an impaired exchange of gases like oxygen and carbon dioxide, which is necessary for optimal cellular function Suctioning • Only done as needed - PRN • Is an independent nursing intervention • Upper Airway • Secretions in mouth or back of throat that can not be expectorated • May be heard as gurgling, moist conversations • We can use yankauer to suction & clear • Lower Airway • Will use suction catheter • A sterile procedure • Pre-oxygenate with 100% O2 • Duration of each suction pass should be limited to ten seconds and only on way out • The number of passes should be limited to three or less Suction Catheter LOWER AIRWAY Yankauer UPPER AIRWAY Suctioning: Oral, Nasopharyngeal, Tracheal •If patient is unable to mobilize/remove secretions •Done PRN* •Assess at risk patient every 2 hours •Pre-oxygenation with 100% O2 •Duration of each suction pass should be limited to ten seconds and only on way out •The number of passes should be Possible Complications of Suctioning • Mucosal trauma • Hypoxia • Bronchospasm • Atelectasis • Infection • Pneumothorax • Hypotension or hypertension • Cardiac dysrhythmias • Increased intracranial pressure

LECTURE 7&8 Oxygenation.pptx

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