Oxygenation-Week 3 PDF

Oxygenation-Week 3 3125 Fundamentals of Nursing  Class Objectives: Describe the structure and function of the cardiopulmonary system. (CO 1)...

Oxygenation-Week 3 3125 Fundamentals of Nursing  Class Objectives: Describe the structure and function of the cardiopulmonary system. (CO 1) Describe the physiological Reading: Fundamentals of processes of ventilation, perfusion, Nursing, P&P, 11th ed., and exchange of respiratory gases. pages 971-1039 (CO 1,5) + You do not have to read Identify the clinical outcomes or be responsible for occurring as a result of Nasotracheal hyperventilation, hypoventilation, suctioning. and hypoxia (CO 5, 6) Endotracheal or Assess for risk factors affecting a Tracheostomy client's oxygenation (CO 2, 5, 6) Suctioning, trach Care, Describe nursing interventions used chest tubes pages to promote oxygenation in the 1008-1037! You will not primary care, acute care, and need to know the restorative/continuing care settings Cardiovascular (1, 3, 5, 6) physiology or Evaluate a client's responses to conduction system oxygenation therapies (6, 8) pages 973-975. Case Study + Mr. Edwards age 62 is admitted to the hospital with a + 6-day history of chest pain, fatigue and shortness of breath. Chest X-ray confirms he has community- acquired right upper lobe pneumonia. + He has an intermittent productive cough with occasional thick, yellow sputum + Lying down increases his shortness of breath and coughing + You are his nursing student assigned to his care today History + Alcohol abuse, sedentary lifestyle, 40- year history of smoking 2 packs per day + COPD + Works outside the home, used to help around the house and garden, but unable to participate at this time Current VS: BP 142/84, HR 110, RR 26, O2 Sat 86% on RA Rates chest pain with breathing at 4/10 and is very anxious Fatigues easily and needs assistance to transfer from bed to chair. RR increased to 32 during transfer Case Study +Keep Mr. Edwards in mind and we will come back!! + Oxygen is a basic human need. + When oxygen levels decrease, the body cannot carry out basic vital functions. + Disturbances in gas exchange are often from ineffective gas exchange (lungs) or ineffective pump (heart) + Blood is oxygenated through the mechanisms of ventilation, perfusion, and transport of respiratory gases. + Cardiovascular system distributes oxygen to the cells and tissues. + Oxygenation involves three steps: ventilation perfusion diffusion + Ventilation-moving gases in and out of the lungs Air flowing into the lungs during inspiration (inhalation) Out of the lungs during exhalation (expiration) Requires coordination of the muscular and elastic properties of the lungs and thorax. Major inspiratory muscle of respiration is the diaphragm. It is innervated by the phrenic nerve Spinal cord injuries at the level of the 4th cervical vertebra most likely will be on a mechanical ventilator due to loss of diaphragm function. Perfusion + Ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs Diffusion + Moving respiratory gases from one area to another by concentration gradients + For exchange of gases to occur, the organs, nerves and muscles of respiration need to be intact and the central nervous system has to regulate the respiratory cycle + https://www.youtube.com/watch?v=GVU_zANtroE Respiratory physiology-structure and function + Work of breathing-The effort required to expand and contract the lungs. The amount of energy expended on breathing depends on: the rate and depth of breathing the ease in which the lungs can be expanded (compliance) airway resistance. + Lung volumes-variation in tidal volume and other lung volumes are associated with alterations in health status. Normal lung volumes are determined by age, gender, and height. Tidal volume is the amount of air exhaled following a normal inspiration. Residual volume is the amount of air left in the alveoli after a full expiration. Forced vital capacity is the maximum amount of air that can be removed from the lungs during expiration. + Pulmonary circulation primary function is to move blood to and from the alveolar capillary membrane for gas exchange. Respiratory physiology + Diffusion of respiratory gases occurs at alveolar capillary membrane. + Oxygen transport Hemoglobin transports 97% of O2. + Carbon dioxide transport Venous blood transports CO2 back to the lungs to be exhaled. + Regulation of ventilation CNS controls respiratory rate, depth and rhythm. Cardiovascular physiology-Structure and function + Myocardial pump Ventricles fill with blood during diastole and empty during systole Stroke volume is the volume of blood ejected from the ventricles during systole + Myocardial blood flow + Valves ensure blood flow is one way. + In ventricular diastole the atrioventricular valves (mitral and tricuspid) open. + Systolic phase- semilunar valves (aortic and pulmonic) open + Coronary artery circulation + Supplies the myocardium with O2, nutrients, and removes waste. + Coronary arteries fill during diastole. + Left coronary artery get the most blood supply. *** review only not tested on cardiac physiology and conduction Cardiovascular physiology-Structure and function + Systemic circulation + Arteries deliver nutrients and O2 + Veins remove waste from tissues. + Blood flow regulation + The amount of blood ejected from the left ventricle each minute Is the cardiac output. + Cardiac output increases in times of greater oxygen and metabolic needs (exercise) Conduction system + Electrocardiogram (ECG) is a measurement of electrical activity of the conduction system Factors Affecting Oxygenation + Physiological + Developmental + Lifestyle + Environmental Factors affecting oxygenation-Physiological factors + Can be respiratory or cardiac + Decreased oxygen-carrying capacity + What carries the majority of oxygen to tissues?? + What might cause a decrease? What are some symptoms? + Hypovolemia Conditions such as shock, severe dehydration, fluid loss and reduction in circulating volume Factors affecting oxygenation- Physiological factors +Decreased inspired oxygen concentration FiO2 is the fraction of inspired oxygen concentration Caused by airway obstruction limiting diffusion to alveoli. High altitudes or hypoventilation from opioid overdoses +Increased metabolic rate-increases demand Pregnancy, wound healing, exercise increase body’s oxygen demand. What are some conditions affecting chest wall movement?? Alterations in respiratory functioning Hypoventilation +Alveolar ventilation decreases the body retains CO2. +Atelectasis-collapse of alveoli causes less of the lung to be ventilated leading to hypoventilation. +In patients with COPD, excessive amounts of O2 can cause hypoventilation +Hypoxic drive to breathe (PaO2) is decreased S&S- mental status changes, dysrhythmias, cardiac arrest. Alterations in respiratory functioning Hyperventilation Causes?? S&S-rapid respiration, sighing breaths, numbness, tingling of the hands/feet, light headedness, loss of consciousness. Hypoxia + Inadequate tissue oxygenation at the cellular level. + Decreased inspired oxygen for ex. high altitudes. + Life threatening-can cause fatal cardiac dysrhythmias. + Cyanosis-late sign in hypoxia + S&S-restlessness, apprehension, decreased LOC, behavioral changes, Alterations in cardiac functioning + Disturbances in conduction + Fatal dysrhythmias caused by conduction disturbances: + Ventricular tachycardia + Ventricular fibrillation Altered cardiac output + Left-sided heart failure-decreased left ventricular function leading to decreased cardiac output>pulmonary congestion>crackles in lung bases, hypoxia, cough, SOB on exertion + Right-sided heart failure—systemic back up in the systemic circulation>weight gain, distended neck veins, peripheral edema Alterations in cardiac functioning Impaired valvular function Valve disease Stenosis or regurgitation Myocardial ischemia or Acute Coronary Syndrome (ACS) +Angina-chest pain from imbalance between O2 supply and demand. Transient +Myocardial infarction (MI)-inadequate coronary perfusion>cellular death after 20 minutes Factors influencing oxygenation The developmental stage of a patient and the normal aging process affect tissue oxygenation + Infants and toddlers + School-age children and adolescents + Young and middle-aged adults + Older adults Factors influencing oxygenation Lifestyle factors: Can you list 3??? Environmental factors: Can you list 3?? Critical Thinking + Knowledge of cardiac and respiratory physiology and oxygen supply and demand provides a scientific basis for how you approach an assessment for your patient. + Critical thinking attitudes ensure that you approach patient care in a methodical and logical way. + The use of professional standards provides valuable guidance in the care and management of patient. Assessment Nursing history + Health risks + Pain + Fatigue + Dyspnea + Cough Assessment Health Risks-any family history of lung cancer or cardiovascular disease Pain-presence of chest pain requires thorough assessment location, intensity, duration, radiation, frequency, and associated Fatigue-subjective may be an early sign of worsening of the chronic underlying condition Dyspnea-what is this? Cough-productive, non-productive? Hemoptysis-if present what is it associated with? GI tract, upper respiratory, sinus Assessment Environmental and occupational factors-what questions would you ask?? Smoking-direct or second-hand exposure Respiratory infections- how often, immunizations, TB exposure Allergies-food, drug, airborne allergens(pet dander, pollen, mold) Medications-include ALL Physical Exam + Inspection + Palpation + Percussion + Auscultation Inspection + Observe head to toe + Assess the client’s skin and mucous membranes + LOC, overall appearance + Breathing patterns, chest wall movement + What is the normal adult respiratory rate at rest? + Abnormal breathing Tachypnea, bradypnea, Kussmaul’s, Cheyne-Stokes Palpation + Identifies tenderness, fremitus, thrills, heaves, PMI + Palpation of extremities-presence and quality of peripheral pulses, skin temperature, color, capillary refill, edema + NEVER PALPATE BOTH CAROTID ARTERIES AT THE SAME TIME!!! Percussion + Detects the presence of abnormal fluid or air + You probably will not see this routinely performed by nurses Auscultation + Identifies presence of normal and abnormal heart and lung sounds + Cardiac Normal S1 and S2, any extra sounds? + Lungs-Adventitious breath sounds Wheezing, crackles, rhonchi + You will learn your heart and lung sounds in Health Assessment Cardiac function tests: Holter monitor, ECG stress test, Thallium stress test, Electrophysiological study (EPS), Cardiac catheterization and angiography. Ventilation and oxygenation studies: ABG’s, Pulmonary function test, Peak expiratory Flow Rate, Bronchoscopy, lung scan, Thoracentesis (surgical removal of fluid or tissue for analysis using local anesthetic), sputum culture. Tuberculosis skin testing (PPD) Take Action/Implementation Health promotion + Vaccinations annual flu for 6 months and older Pneumococcal vaccine for 65 or older, smoker COVID vaccine + Healthy lifestyle-low fat, high fiber, maintain healthy weight, exercise, eliminate smoking. + Environmental pollutants-avoid pollens, secondhand smoke, understand “triggers” Take Action/Implementation Acute care + Dyspnea management + Oxygen therapy, steroids, bronchodilators + Airway maintenance + Airway patent (trachea, bronchi, large airways) are free from obstruction. + Mobilization of pulmonary secretions + Repositioning, suctioning, postural drainage (pg. 995) + Maintain hydration for secretion motility + Humidification + needed for >4L/min + Use sterile water for infection control Take Action/Implementation + Nebulization-method of providing aerosolized medications + Coughing and deep- breathing techniques maintain a patent airway + Huff cough stimulates natural cough reflex + Quad cough or manually assisted cough for cystic fibrosis and spinal cord injuries + Chest physiotherapy (CPT) uses percussion with cupped hands forcefully to the back to break up thickened secretions. Take Action/Implementation + Acute care Positive expiratory pressure (PEP): + Acapella and Flutter devises are commonly used PEP devices + Allows air to be inhaled easily but forces the patient to exhale against resistance. Maintenance and promotion of lung expansion: + Ambulation-immobility + Positioning-frequent repositioning Why is this important What is the recommended elevation of the head in bed in degrees? + Incentive spirometry-used to prevent atelectasis in patients who had surgery, or prolonged bed rest. + How do you instruct the client in it’s use?? Take Action/Implementation + Acute care Artificial airways + for decreased LOC, obstruction, prolonged ventilation support Endotracheal and tracheal airway- Endotracheal tube (ET) tube is a short- term artificial airway used for mechanical ventilation, relieving an obstruction, or clear to secretions. Take Action/Implementation Tracheostomy tubes-used for long-term assistance + Such as from prolonged ventilation + Upper airway obstruction + Airway clearance problems. Can be temporary. Usually heals well + Patient cannot speak without a speaking valve + Written communication may be used + Care and cleaning discussed in lab next semester Take Action/Implementation + Acute care Airway suctioning + Open suction involves the use of a new sterile catheter for each suction session. + Oropharyngeal and nasopharyngeal suctioning + Orotracheal and nasotracheal suctioning + Tracheal suctioning + Closed suction is a suction catheter system included in the ventilator circuit of a patient on a mechanical ventilator.  Take Action/Implementation + Acute care Maintenance and promotion of oxygenation + Oxygen therapy + Relieve or prevent hypoxia + Deliver lowest amount possible to achieve adequate tissue oxygenation + Dosage or concentration of oxygen is monitored continuously + Oxygen requires a HCP order. + Safety precautions + oxygen is HIGHLY combustible! + Supply of oxygen is supplied by tanks or through a wall piped system. Methods of oxygen delivery +Nasal cannula +High-flow nasal cannula +Oxygen masks Restoration of cardiopulmonary functioning +Cardiopulmonary resuscitation (CPR) +C-A-B chest compression, early defibrillation, establish an airway, and rescue breathing + Restorative and continuing care + Cardiopulmonary rehabilitation + Respiratory muscle training + Breathing exercises + Pursed-lip breathing + Diaphragmatic breathing + Home oxygen therapy + Indications include a decrease in PaO2 (partial pressure of oxygen) of 55 or less, or an arterial saturation rate of 88% or less on room air + Or if during exercise a patient has decreased PaO2 to 55 or less, and arterial saturation rate of 88% or less. + Administered via nasal cannula or face mask. + Compressed gas cylinders, liquid oxygen, and oxygen concentrators. Planning and outcomes identification Outcomes Setting priorities-use Maslow’s Hierarchy In acute care maintaining a patent airway has a higher priority than improving exercise tolerance. Often when you improve effects of the priority problem the lower priorities issues improve as well Teamwork and collaboration-time is limited. Who would you collaborate with in the hospital setting? Evaluation Through the patient’s eyes Patient outcomes: compare the patient’s actual progress with the expected outcomes of the actions to determine the effectiveness of the nursing care and the patient's health status. Continuously reevaluate your patient’s oxygenation status Examples of evaluative methods: Ask the patient the degree of breathlessness monitor pulse oximetry and pulse rate ask the patient which interventions help reduce dyspnea Safety Guidelines Know a patient’s baseline range of vital signs. Limit the introduction of the catheter to 2 times with each suctioning procedure. Perform tracheal suctioning before pharyngeal suctioning whenever possible. Use caution when suctioning patients with a head injury. The use of normal saline instillation into the airway before suctioning is not recommended. Review institutional policy before stripping or milking chest tubes. The most serious tracheostomy complication is airway obstruction. Patients with COPD who are breathing spontaneously should cautiously receive high levels of oxygen therapy. Case Study + Let’s revisit Mr. Edwards + Look at your clinical packet and we will discuss how to complete some of this paperwork Additional Information + Complete Blood Count (CBC) White Blood Cell Count (WBC): 15.5 x 10³/µL (4.5-11.5 x 10³/µL) Red Blood Cell Count (RBC): 4.45 x 10⁶/µL (4.6-6.0) Hemoglobin (Hgb): 13.2 g/dL (14-18 g/dl) Hematocrit (Hct): 40.5% (40-54%) Platelets: 220 x 10³/µL (150,000-450,000) Neutrophils: 82% (50-70%) Lymphocytes: 12% (18-42%) Monocytes: 4% (2-11%) Basic Metabolic Panel (BMP): Sodium (Na): 138 mEq/L (136-145) Potassium (K): 4.2 mEq/L (3.5-5.1) Chloride (Cl): 102 mEq/L (98-106) Bicarbonate (HCO₃): 24 mEq/L (24-30) Blood Urea Nitrogen (BUN): 18 mg/dL (10-20 mg/dL) Creatinine (Cr): 0.9 mg/dL (0.6-1.2 mg/dL) Glucose: 120 mg/dL (70-106 mg/dL) Chest X-Ray: + Findings: right upper lobe consolidation, consistent with bacterial pneumonia + Sputum Culture: Organism Identified: Streptococcus pneumoniae Antibiotic Sensitivity: Sensitive to Penicillin, Ceftriaxone, and Azithromycin. Other Labs + C-Reactive Protein (CRP): 35 mg/L (101 or mild pain + What might be your priority hypothesis/Nursing Diagnosis? + What is a reasonable goal? + What is your action plan? + How will you know it worked or did not work? + See pages 989-990