Care Of Clients With Problems In Oxygenation (Part 1) PDF

ST. ANTHONY’S COLLEGE Nursing Department San Jose, Antique CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION (Part 1) CZERWIN S. JUALES,DPA,MAN,RN,CHA Course Instructor OXYGENATION Oxygen – required to sustain life The cardiac and respiratory s...

ST. ANTHONY’S COLLEGE Nursing Department San Jose, Antique CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION (Part 1) CZERWIN S. JUALES,DPA,MAN,RN,CHA Course Instructor OXYGENATION Oxygen – required to sustain life The cardiac and respiratory systems function to supply the body’s oxygen demands. Cardiopulmonary physiology involves delivery of deoxygenated blood to the right side of the heart and to the pulmonary circulation and oxygenated blood from the lungs to the left side of the heart and the tissues. OXYGENATION Blood is oxygenated through the mechanism of ventilation, perfusion and transport of respiratory gases. Most cells in the body obtain their energy from chemical reactions involving oxygen and the elimination of carbon dioxide. The exchange of respiratory gases occurs between the environmental air and the blood BREATHING – is the effort required for expanding and contracting the lungs PROCESS OF OXYGENATION  Ventilation  Is the process of moving gases into and out of the lungs  It requires coordination of the muscular and elastic properties of the lung and thorax PROCESS OF OXYGENATION  Perfusion  is the process of nutritive delivery of arterial blood to a capillary bed in the biological tissues. The word is derived from the French verb "perfuser" meaning to "pour over or through." PROCESS OF OXYGENATION  Ventilation  Is the process of moving gases into and out of the lungs  It requires coordination of the muscular and elastic properties of the lung and thorax PROCESS OF OXYGENATION Diffusion – Movement of MOLECULES from an area of HIGHER concentration to an area of LOWER concentration – Oxygen diffuses from the ALVEOLUS to the CAPILLARY until the PO2 in the capillary is equal to that in the alveolus. BLOOD FLOW REGULATION CARDIAC OUTPUT- the amount of blood ejected from the left ventricle each minute Normal CARDIAC OUTPUT= 4-6 L/min The circulating volume of blood changes according to the OXYGEN and METABOLIC needs of the body  CONDUCTION SYSTEM The rhythmic RELAXATION and CONTRACTION of the ATRIA and VENTRICLES depend on CONTINUOUS, ORGANIZED transmission of electrical impulse – Sinoatrial (SA) Node the “PACEMAKER” of the heart in the RIGHT ATRIUM OF THE HEART where impulses are initiated at 60-100 bpm – Atrioventricular (AV) Node Mediates impulses between the atria and the ventricles – Bundle of His – Purkinje Network  NURSING PROCESS I. ASSESSMENT I. NURSING HISTORY - should focus on the client’s ability to meet oxygen needs  FATIGUE a SUBJECTIVE sensation in which the client reports loss of endurance Ask the patient to rate the fatigue in a scale of 1 to 10, with 10 being the worst level and 1 representing no fatigue  DYSPNEA ▪ Clinical sign of HYPOXIA and manifests as breathlessness ▪ A SUBJECTIVE sensation of difficult or uncomfortable breathing ▪ PHYSIOLOGICAL DYSPNEA- is shortness of breath associated with exercise or excitement ▪ PATHOLOGICAL DYSPNEA- is the inability to catch a breath without relation to activity or exercise ▪ ORTHOPNEA- is an abnormal condition in which the person must use multiple pillows when lying down or must sit with the arms elevated and leaning forward to breath  COUGH A sudden, AUDIBLE EXPULSION of air from the lungs. The person breathes in, the GLOTTIS is partially closed, and the accessory muscles of expiration CONTRACT to expel the air forcibly Protective REFLEX to clear the TRACHEA, BRONCHI and the LUNGS of irritants and secretions. the CARINA, the point of bifurcation of the right and left mainstem bronchus, is the most sensitive area for COUGH PRODUCTION  COUGH ▪ Classifications a. TIME when the client most frequently coughs i. Chronic Sinusitis – cough only in the AM ii. Chronic Bronchitis – generally cough all day b. Productive/Nonproductive i. Productive ▪ inspect FOR COLOR, CONSISTENCY, ODOR AND AMOUNT ▪ HEMOPTYSIS- bloody sputum  WHEEZING ▪ HIGH-PITCHED musical sound caused by high-velocity movement of air through a narrowed airway ▪ Associated with ASTHMA  PAIN ▪ Presence of chest pain needs to be thoroughly evaluated with regard to LOCATION, DURATION, RADIATION and FREQUENCY. ▪ PLEURITIC CHEST PAIN – caused by an inflammation or infection in the pleural space and is described as KNIFELIKE; associated with inspiration  ENVIRONMENTAL/GEOGRAP ▪ HICAL EXPOSURES Cigarette smoking, asbestos, coal, cotton fibers, fumes or chemical irritants  RESPIRATORY INFECTIONS ▪ Should contain information about the client’s FREQUENCY and DURATION of Respiratory tract infections Average: 4 COLDS/year  RESPIRATORY INFECTIONS ▪ Should contain information about the client’s FREQUENCY and DURATION of Respiratory tract infections Average: 4 COLDS/year ▪ Ask for family history of LUNG CANCER or cardiovascular disease RISK FACTORS  NURSING PROCESS I. ASSESSMENT I. NURSING HISTORY - should focus on the client’s ability to meet oxygen needs II. PHYSICAL EXAMINATION  INSPECTION ▪ Perform head-to –toe observation of the client for skin & mucous membrane color, general appearance, level of consciousness, adequacy of systemic circulation, BREATHING patterns and CHESTWALL MOVEMENT ▪ Clubbing of fingers – chronic hypoxemia  INSPECTION ▪ Flaring nares – Air hunger, dyspnea ▪ Pale conjunctivae - Anemia ▪ Cyanotic mucous membrane – decreased oxygenation (hypoxia) ▪ Chest Retractions – Increased work of breathing, dyspnea ▪ Asymmetry – Chest wall injury  PALPATION ▪ To elicit any areas of TENDERNESS, abnormal masses or lumps, tactile fremitus, presence and quality of peripheral pulses, and CAPILLARY REFILL  PERCUSSION ▪ To detect the presence of ABNORMAL FLUID or AIR in the lungs ▪ Enables the nurse to identify normal and abnormal heart & lung sounds AUSCULTATION  NURSING PROCESS I. ASSESSMENT I. NURSING HISTORY - should focus on the client’s ability to meet oxygen needs II. PHYSICAL EXAMINATION II. DIAGNOSIS Diagnosis  Ineffective Airway Clearance  Ineffective Breathing Pattern  Impaired Gas Exchange EXAMPLE: Ineffective Airway Clearance r/t thick bronchial secretions aeb dyspnea, and cough with sputum  Diagnostic Tests EXERCISE STRESS TEST ▪ Used to evaluate the cardiac response to PHYSICAL STRESS. ▪ These provide information on myocardial response to INCREASED OXYGEN requirements and determine adequacy of coronary blood flow ▪ Result is reflected in the ECG tracing  PULMONARY FUNCTION TEST ▪ Determine the ability of the lungs to efficiently exchange OXYGEN and CARBON DIOXIDE ▪ A NOSE CLIP is used to prevent air from being inhaled or exhaled through the nose. ▪ Client breathes through a mouthpiece attached to a SPIROMETER for measuring lung volume.  ARTERIAL BLOOD GAS TESTS ▪ Performed in conjunction with pulmonary function test to determine the oxyhemoglobin saturation. ▪ Provide information about adequacy of tissue oxygenation  OXIMETRY ▪ Noninvasive & READILY available ▪ Measures capillary OXYGEN saturation (percentage of hemoglobin saturated with oxygen) ▪ Makes use of noninvasive sensor: attached to the finger, toe or bridge of the nose  Chest X-ray Examination ▪ Consists of a radiograph of the thorax that allows the physician to observe the lung fields for abnormal findings  BRONCHOSCOPY ▪ Visual examination of the tracheobronchial tree through a narrow, flexible, fiberoptic bronchoscope. ▪ It is performed to obtain BIOPSY and fluid or SPUTUM samples and to remove MUCOUS plugs or FOREIGN BODIES that have become lodged in the airways. ▪ Client is kept NPO before procedure  THROAT CULTURES ▪ Sample is obtained by SWABBING the oropharynx and TONSILLAR regions with a sterile swab.  SPUTUM SPECIMEN ▪ Obtained to identify the TYPE of organism growing in the SPUTUM ▪ Sputum Culture and Sensitivity (C&S) ▪ identifies a specific microorganism and its drug resistance and sensitivities ▪ Sputum Acid-Fast Bacillus (AFB) ▪ Obtained on 3 consecutive days in the early morning. ▪ Used to check for Tuberculosis infection  THORACENTESIS ▪ Surgical perforation of the chest wall and pleural space with a needle to aspirate fluid for diagnostic or therapeutic purpose. ▪ Performed with aseptic technique using local anesthetic  PLANNING ▪ Client maintains a patent airway ▪ The client achieves and maintains adequate gas exchange and ventilation ▪ The client mobilizes pulmonary secretions  NURSING PROCESS I. ASSESSMENT I. NURSING HISTORY - should focus on the client’s ability to meet oxygen needs II. PHYSICAL EXAMINATION II. DIAGNOSIS III. PLANNING IV. IMPLEMENTATION  HEALTH PROMOTION ▪ Maintaining the client’s optimal level of health is important in reducing the number and/or severity of respiratory symptoms. ▪ Prevention of respiratory infections is foremost in maintaining optimal health.  Influenza & Pneumococcal Vaccine ▪ Influenza Vaccine ▪ Annual vaccination is recommended for older clients and clients with chronic illnesses ▪ It is 70% to 90% effective in healthy young adults ▪ Takes about 1 – 2 weeks after vaccination for antibody development ▪ Persons who should not be vaccinated include those with a known hypersensitivity to eggs or other components of the vaccine  Influenza & Pneumococcal Vaccine ▪ Pneumococcal Vaccine ▪ Recommended for clients at increased risk of developing pneumonia, those with chronic illnesses or immunosuppression, those living in nursing homes and clients over the age of 65 ▪ Revaccination has been recommended after 5-10 years due to declining antibody levels as well as for clients vaccinated before 1983. (new formula from 14-valent to 23 valent vaccine)  ENVIRONMENTAL MODIFICATIONS ▪ Avoid exposure to second hand smoke ▪ Assist smoker in successful smoking cessation or alterations in behavior patterns, such as smoking outside ▪ Use mask to reduce inhalation of particles Breathing and Coughing Exercises Abdominal and Diaphragmatic Breathing Pursed Lip Breathing Coughing  Hydration Adequate hydration maintains the moisture of respiratory mucous membranes. Medications a c Cough Suppressant- is a medication that suppresses or t stops the cough reflex s Expectorants – are medications that decrease the viscosity of the secretions making them easier to cough out. Lozenge – usually a tablet that is held in the mouth while it dissolves. It contains local anesthetic that acts on the sensory nerve endings on the throat, thus stopping the irritation that causes coughing  Incentive Spirometer  Measure the flow of air inhaled through the mouthpiece. a  It improves ventilation. c t s  EVALUATION ▪ Modify nursing care plan if unsuccessful ▪ Do not hesitate to notify the physician about a client’s deteriorating oxygenation status. ▪ Continuous evaluation allows the nurse to determine whether new or revised therapies are required and if new nursing diagnoses have developed and require a new plan of care