Oxygenation I. NURS 356 - Tagged.pdf

Oxygenation & Artificial Airways Nancy Hannafin Copyright © 2011 Copyright Wolters © 2019 Kluwer Wolters Health All Kluwer | Lippincott Williams & Wilkins...

Oxygenation & Artificial Airways Nancy Hannafin Copyright © 2011 Copyright Wolters © 2019 Kluwer Wolters Health All Kluwer | Lippincott Williams & Wilkins Rights Reserved Objectives Describe the function and role the respiratory and cardiovascular system in Describe oxygenation Discuss Discuss the role of the nurse in assessment and management of respiratory function Identify Identify the use of appropriate oxygen delivery devices and the use of artificial airways. Identify the nursing considerations, including important teaching points for patients Identify with alteration in respiratory function. Discuss the role of oxygen as a medication in patients with alterations in respiratory Discuss function Describe Describe the therapeutic nursing interventions to promote respiratory health Copyright © 2019 Wolters Kluwer All Rights Reserved Upper Airway Function: warm, filter, humidify inspired air Components o Nose o Pharynx o Larynx o Epiglottis Copyright © 2019 Wolters Kluwer All Rights Reserved  Lower Airway/Tracheobronchial Tree  Functions: conduction of air, mucociliary clearance, production of pulmonary surfactant  Components o Trachea o Right and left mainstem bronchi o Segmental bronchi o Terminal bronchioles o R. lung 3 lobes, L lung 2 lobes Copyright © 2019 Wolters Kluwer All Rights Reserved The Organs of the Respiratory Tract Copyright © 2019 Wolters Kluwer All Rights Reserved Factors Essential to Normal Functioning of the Respiratory System  Integrity of the airway system to transport air to and from lungs  Properly functioning alveolar system in lungs o Oxygenates venous blood o Removes carbon dioxide from blood  Properly functioning cardiovascular and hematologic systems o Carry nutrients and wastes to and from body cells Copyright © 2019 Wolters Kluwer All Rights Reserved Breath Sounds  Vesicular: low-pitched, soft sound during expiration heard over most of the lungs  Bronchial: high-pitched and longer, heard primarily over the trachea  Bronchovesicular: medium pitch and sound during expiration, heard over the upper anterior chest and intercostal area  Adventitious breath sound, must be describe along with the anatomical position for future assessment Copyright © 2019 Wolters Kluwer All Rights Reserved Pulmonary Ventilation  Inspiration: the active phase of ventilation o Involves movement of muscles and the thorax to bring air into the lungs  Expiration: the passive phase of ventilation o Movement of air out of the lungs  Bradypnea: abnormally slow rate  Apnea: cessation of breathing  Orthopnea: the inability to breathe except in an upright or standing position  Dyspnea: difficult or uncomfortable breathing Copyright © 2019 Wolters Kluwer All Rights Reserved Process of Ventilation  The diaphragm contracts and descends, lengthening the thoracic cavity.  The external intercostal muscles contract, lifting the ribs upward and outward.  The sternum is pushed forward, enlarging the chest from front to back  Increased lung volume and decreased intrapulmonic pressure allow air to move from an area of greater pressure (outside lungs) to lesser pressure (inside lungs).  The relaxation of these structures results in expiration. Copyright © 2019 Wolters Kluwer All Rights Reserved Gas Exchange (Respiration)  Refers to the intake of oxygen and release of carbon dioxide  Made possible by respiration and perfusion  Occurs via diffusion (movement of oxygen and carbon dioxide between the air(gas) and blood)  Diffusion - O² & CO² at alveoli  Perfusion - O² & CO² at tissue o Copyright © 2019 Wolters Kluwer All Rights Reserved Factors Influencing Diffusion of Gases in the Lungs  Change in surface area available  Thickening of alveolar-capillary membrane  Solubility and molecular weight of the gas  Atelectasis: Incomplete lung expansion or collapse of alveoli. o Obstruction of the airway, mucus airway constriction, external compression, immobility o Pneumonia, pulmonary edema COVID related atelectasis Copyright © 2019 Wolters Kluwer All Rights Reserved Alterations in Respiratory Function  Hypoxia: inadequate amount of oxygen available to the cells  Dyspnea: difficulty breathing  Hypoventilation: decreased rate or depth of air movement into the lungs Copyright © 2019 Wolters Kluwer All Rights Reserved Alternation in Respiratory function  Hypoxia: Inadequate amount of oxygen is available to cells o Often caused by Hypoventilation  Inadequate alveolar ventilation to meet body's demand  Common symptom - Dyspnea  Early signs: Anxiety, restlessness, confusion, drowsiness, tachycardia  Late signs: Elevated BP, resp. rate, bradycardia, pallor, cyanosis  Chronic Hypoxia: headaches, chest pain, enlarged heart, clubbing of fingers Copyright © 2019 Wolters Kluwer All Rights Reserved Hypoxia Acronym Copyright © 2019 Wolters Kluwer All Rights Reserved Alterations in Respiratory Function Cyanosis: Bluish discoloration of (the skin, nailbeds, & mucous membranes- due to reduced hgb-oxygen saturation) tissues Dark skin pigmentation ~ need to assess nail beds, conjunctiva and mucous membranes for cyanosis Late sign of hypoxia: life-threatening; cerebral cortex can only tolerate hypoxia for 3-5 minutes before permanent damage occurs Skin color is not a reliable measure of oxygenation status. Need to assess further Peripheral cyanosis result of vasoconstriction and stagnant blood flow (Maybe normal) Central cyanosis, NEVER normal Copyright © 2019 Wolters Kluwer All Rights Reserved Abnormal (Adventitious) Lung Sounds  Rales: intermittent sounds occurring when air moves through airways that contain fluid Classified as fine, medium, or coarse  Wheezes: continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors o Classified as sibilant or sonorous Copyright © 2019 Wolters Kluwer All Rights Reserved Respiratory Functioning in the Older Adult  Bony landmarks are more prominent due to loss of subcutaneous fat.  Kyphosis contributes to appearance of leaning forward.  Barrel chest deformity may result in increased anteroposterior diameter.  Tissues and airways become more rigid; diaphragm moves less efficiently.  Older adults have an increased risk for respiratory diseases, especially pneumonia. Copyright © 2019 Wolters Kluwer All Rights Reserved Kyphosis Barrel Chest Copyright © 2019 Wolters Kluwer All Rights Reserved Promoting Proper Breathing  Deep breathing  Use of incentive spirometry  Pursed-lip breathing  Diaphragmatic breathing Copyright © 2019 Wolters Kluwer All Rights Reserved Nursing Interventions Promoting Adequate Respiratory Functioning  Teach about a pollution-free environment  Promote optimal function  Promote comfort, Pain management, 6th VS  Promote proper breathing  Manage chest tubes (NURS360.adult II)  Promote and control coughing  Suction the airway (NURS360. adult II)  Meet oxygenation needs with medications and O² delivery systems Copyright © 2019 Wolters Kluwer All Rights Reserved Deep Breathing & Coughing  Abdominal (Diaphragmatic) & Pursed-lip breathing  Controlled / Huff Cough Copyright © 2019 Wolters Kluwer All Rights Reserved Incentive Spirometer SMI(sustained maximal inspiration device) Volume oriented Flow-oriented Copyright © 2019 Wolters Kluwer All Rights Reserved Incentive Spirometry  Visual reinforcement for deep breathing measure the flow of air inhaled through the mouthpiece o Promote ventilation o Counteract the effects of anesthesia or hypoventilation o Loosen respiratory secretions o Facilitate respiratory gaseous exchange o Expand collapse alveoli Copyright © 2019 Wolters Kluwer All Rights Reserved Tidal Volume Copyright © 2019 Wolters Kluwer All Rights Reserved Promoting Comfort Positioning o Frequent position changes q. 2 hrs. Maintaining adequate fluid intake Providing humidified air Performing chest physiotherapy Copyright © 2019 Wolters Kluwer All Rights Reserved  Oxygen Therapy: Oxygen as a medication  Class: o Naturally occurring atmospheric gas  Mechanism of Action: o Reverses hypoxemia  Duration of Action: o Onset: Immediate o Peak effect: not applicable o Duration: less than 2 minutes  Supply Copyright © 2019 Wolters Kluwer All Rights Reserved Oxygen as a Medication  Drug Interactions: o None  Contraindications: o Patients with COPD, emphysema who may not tolerate Oxygen concentrations 35%  Adverse reactions: o Level of consciousness and resp. depression in patients with chronic CO2 retention Copyright © 2019 Wolters Kluwer All Rights Reserved  Oxygen Delivery Systems  Nasal cannula  Nasopharyngeal catheter  Transtracheal catheter  Simple mask  Partial rebreather mask  Nonrebreather mask  Venturi mask  Goal of oxygen therapy: to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects Copyright © 2019 Wolters Kluwer All Rights Reserved Oxygen Safety Oxygen is a medication, HCP order or protocol is necessary for administration. Oxygen supports combustion, however it will not explode Display an “Oxygen in Use” and/or “No Smoking” sign. Educated client on home safety of oxygen Copyright © 2019 Wolters Kluwer All Rights Reserved Oxygen Delivery Systems Low Flow vs High Flow Low flow systems do not High flow systems provide a provide enough O2 to meet flow rate that is adequate to the total inspiratory meet the entire inspiratory demands. Part of the tidal rate and tidal volume volume is supplied by regardless of the respiratory inspiring room air. pattern. It provides oxygen concentrations of 24-100% at Included: nasal cannula, 8-15L/minute simple face mask, partial rebreather Included: Venturi mask, aerosol mask, non-rebreather, tracheostomy collar and T- piece, bag valve mask Copyright © 2019 Wolters Kluwer All Rights Reserved Nasal Cannula Flow (L/min) FiO2  1/L 21-24%  2/L 25-28%  3/L 28-32%  *4/L 32-36%  5/L 36-40%  6/L 40-44% Copyright © 2019 Wolters Kluwer All Rights Reserved  Partial Face Mask Rebreather Copyright © 2019 Wolters Kluwer All Rights Reserved Nonrebreather Mask  Delivers the highest oxygen concentration via mask 80- 95%  10-15L/min  One-way valves Copyright © 2019 Wolters Kluwer All Rights Reserved Venturi Mask: High Flow System  Venturi Mask: wide-bore tubing and color-coded jet adapters that correspond to a precise oxygen concentration and liter flow  Delivers oxygen concentration that vary from 24-40% at liter flows of 4-6L/min Copyright © 2019 Wolters Kluwer All Rights Reserved Precautions for Oxygen Administration Avoid Place Check Avoid Avoid Avoid open Place “no Check to see Avoid wearing Avoid using flames in the smoking” that electrical and using oils in the area patient’s signs in equipment in synthetic (oils may room. conspicuous the room is in fabrics (builds ignite places. good working up static spontaneously order. electricity). in oxygen). Copyright © 2019 Wolters Kluwer All Rights Reserved Noninvasive Positive-Pressure Ventilation  BI-PAP  Uses positive pressure o Keeps alveoli open o Improves gas exchange without airway intubation.  BiPAP cycling machine o Delivers a set inspiratory positive airway pressure each time the client begins to inspire. o At exhalation, it delivers a lower set end-expiratory pressure. o Together the two pressures improve tidal volume.  Inhale = pressure rises  Exhale = pressure drops Copyright © 2019 Wolters Kluwer All Rights Reserved Continuous Nasal Positive Airway Pressure Delivers a set positive airway pressure o With each inhalation and exhalation Effect is to open collapsed alveoli Clients who may benefit: o Atelectasis after surgery o Cardiac-induced pulmonary edema o Sleep Apnea Copyright © 2019 Wolters Kluwer All Rights Reserved  Administering Inhaled Medications  Bronchodilators: open narrowed airways  Nebulizers: disperse fine particles of liquid medication into the deeper passages of the respiratory tract  Meter-dose inhalers: deliver a controlled dose of medication with each compression of the canister  Dry powder inhalers: breath-activated delivery of medications Copyright © 2019 Wolters Kluwer All Rights Reserved Obstructive Lung Disease Chronic Airflow Limitation o Asthma o COPD  emphysema  chronic bronchitis Copyright © 2019 Wolters Kluwer All Rights Reserved Asthma Airway obstruction after initial insult from allergen that binds to IgE Inflammation: o Bronchial constriction o Airway edema o Mucus hypersecretion o Air trapping o Hyperinflation o Epithelial desquamation and fibrosis Copyright © 2019 Wolters Kluwer All Rights Reserved Asthma Triggers Viral respiratory infections Allergens Exercise Cold air Emotional stress Environmental exposure Copyright © 2019 Wolters Kluwer All Rights Reserved Chronic Obstructive Pulmonary Disease (COPD) Progressive airflow obstruction that is not fully reversible o 4th leading cause of death in U.S. The disease is characterized by both: o Chronic bronchitis:  productive cough > 3 months for 2 consecutive years o Emphysema:  abnormal, permanent enlargement of airspaces distal to the terminal bronchioles with destruction of airway walls Typically, one condition predominates Copyright © 2019 Wolters Kluwer All Rights Reserved COPD risk factors Smoking accounts for more than 90% of the risk for COPD o 15 to 30% of smokers develop the disease Air pollution; poorly ventilated homes Occupational exposure: coal, gold, dust 1st degree relatives who smoke Copyright © 2019 Wolters Kluwer All Rights Reserved Smoking risk  Lung capacity decreases 20mL/year with aging o smoking doubles the decline (40 mL/year) o (toxic O2 radicals)  cause inflammation  promote enzymes that cause lung remodeling or fibrosis.  Smoking cessation o The only intervention that SLOWS (not reverse) the progression of COPD  Cigarette history in, “Pack years” o Packages/day X years smoked Copyright © 2019 Wolters Kluwer All Rights Reserved Normal Peak Flow throughout adult life Copyright © 2019 Wolters Kluwer All Rights Reserved Copyright © 2019 Wolters Kluwer All Rights Reserved Physical Assessment and Clinical Manifestations Unplanned weight DOE, PND, pedal loss edema, productive Loss of muscle mass cough, barrel chest, decreased breath in the extremities sounds, prolonged Enlarged neck expiratory phase muscles Morning headache & Slow moving drowsiness (d/t hypercapnia Slightly stooped posture Sits with forward- bend Copyright © 2019 Wolters Kluwer All Rights Reserved Keys to management Smoking Cessation #1  Vaccination: o influenza & pneumococcal, COVID  Nutritional support: o high-protein, high carb*, calorie dense, small frequent meals  O2 therapy: o goal of O2 sat > 90% for a minimum of 15 hrs/daily o Improves quality of life, exercise tolerance, cognitive functioning, emotional status, sleep quality. o Low flow O2: 1 to 2 liters/min. WHY? Copyright © 2019 Wolters Kluwer All Rights Reserved Keys to Management Activity intolerance Health Teaching  Interventions to increase  Instruct the client: activity level: o Pursed-lip and o Encourage client to pace diaphragmatic breathing activities and promote o Support of family and self-care. friends o Do not rush through o Relaxation therapy morning activities. o Professional counseling o Gradually increase access activity.  Lifestyle changes o Use supplemental oxygen therapy.  smoking cessation o Note: once FEV1 falls o Complementary and below 50% ability to alternative therapy perform ADL is limited Copyright © 2019 Wolters Kluwer All Rights Reserved Type of Artificial Airways  Oropharyngeal: keep the upper air passages open when they become obstructed by secretions or tongue. o They stimulate the gag reflex o Used for clients with altered LOC - overdose, general anesthesia, head injury  nasopharyngeal airway: keep upper airway passages open. o Should be well lubricated before insertion o Tolerated better by alert clients o Reposition to prevent necrosis of the mucosa  Endotracheal tube  Tracheostomy tube Copyright © 2019 Wolters Kluwer All Rights Reserved Type of Artificial Airways  Endotracheal tube: terminates just superior to the bifurcation of trachea into the bronchi o inserted through nose or mouth and into the trachea with the guide of a laryngoscope Copyright © 2019 Wolters Kluwer All Rights Reserved  Artificial Airways  Tracheostomy – for clients receiving long-term airway support  Surgical incision in the trachea just below the larynx  Curved tube inserted to extend through the stoma into the trachea Copyright © 2019 Wolters Kluwer All Rights Reserved Nursing Care  Assess respiratory status: o Rate o Rhythm o Depth o Equality of chest excursion o Lung sounds o Level of consciousness o Skin color Copyright © 2019 Wolters Kluwer All Rights Reserved Guidelines for Obtaining a Nursing History Determine Determine why the patient needs nursing care. Determine Determine what kind of care is needed to maintain a sufficient intake of air. Identify Identify current or potential health deviations. Identify Identify actions performed by the patient for meeting respiratory needs. Make Make use of aids to improve intake of air and effects on patient’s lifestyle and relationship with others. Copyright © 2019 Wolters Kluwer All Rights Reserved Question #1 Which respiratory organ is the site of gas exchange? A. Mediastinum B. Parietal pleura C. Alveoli D. Diaphragm Copyright © 2019 Wolters Kluwer All Rights Reserved Answer to Question #1 Answer: C. Alveoli Rationale: At the end of the terminal bronchioles, there are clusters of alveoli that are the site of gas exchange. The wall of each alveolus is made of a single-cell layer of squamous epithelium. This thin wall allows for exchange of gases within the capillaries covering the alveoli. Copyright © 2019 Wolters Kluwer All Rights Reserved Question #2 Tell whether the following statement is true or false. Pulmonary ventilation is the process by which oxygenated capillary blood passes through body tissues. A. True B. False Copyright © 2019 Wolters Kluwer All Rights Reserved Answer to Question #2 Answer: B. False Rationale: Perfusion is the process by which oxygenated capillary blood passes through body tissues. Copyright © 2019 Wolters Kluwer All Rights Reserved Question #3 Tell whether the following statement is true or false. Wheezes are continuous, musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. A. True B. False Copyright © 2019 Wolters Kluwer All Rights Reserved Answer to Question #3 Answer: A. True Rationale: Wheezes are continuous, musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. Copyright © 2019 Wolters Kluwer All Rights Reserved Question #4 Which lung value is the amount of air contained within the lungs at maximum inspiration? A. Vital capacity B. Total lung capacity C. Residual volume D. Peak expiratory flow rate Copyright © 2019 Wolters Kluwer All Rights Reserved Answer to Question #4 Answer: B. Total lung capacity Rationale: Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Vital capacity is the amount of air displaced by maximal exhalation. Residual volume is the amount of air left in the lungs at maximal expiration. Peak expiratory flow rate is the maximum flow attained during the forced expiratory maneuver. Copyright © 2019 Wolters Kluwer All Rights Reserved