Oxygenation - BSuazo.pdf

Care of Patients with Problems in Oxygenation Bobby B. Suazo, MSc, MSN, PGCert, RN Lecturer/Clinical Instructor College of Nursing Liceo de Cagayan University  The Concept of Oxygenation  Oxygenation – mechanisms that facilitate or...

Care of Patients with Problems in Oxygenation Bobby B. Suazo, MSc, MSN, PGCert, RN Lecturer/Clinical Instructor College of Nursing Liceo de Cagayan University  The Concept of Oxygenation  Oxygenation – mechanisms that facilitate or impair the body’s ability to supply oxygen to cells.  Respiration – an act of inhaling and exhaling air to transport oxygen to alveoli.  So oxygen may be exchanged for carbon dioxide  Carbon dioxide expelled from the body ❑ Ventilation – actual exchange of oxygen & carbon dioxide.  The Concept of Oxygenation cont.  Breathing – contributes to vital oxygenation.  What impairs the body’s ability to supply oxygen to cells? ❑ Adequate oxygenation depends on a healthy & intact respiratory system.  Steps in Oxygenation  Ventilation – the process of moving gases into and out of the lungs.  Perfusion – the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs.  Diffusion – exchange of respiratory gases in the alveoli and capillaries. What are the primary functions of the respiratory system?  Primary Functions  Delivers oxygen to the bloodstream and removes excess carbon dioxide from the body.  Gas exchange (O2 & CO2).  Sound production & resonation  Protection (from dust and microbes entering the body through mucus production, cilia, and coughing).  Remember that we need the cardiovascular system to work intimately with the respiratory system because the cardiovascular system helps us transport these gases (O2 & CO2).  Airways & Lungs  Upper respiratory tract  Lower respiratory tract  Two lungs are part of the lower airway & share space in the thoracic cavity with the heart & great vessels, trachea, esophagus & bronchi.  Upper Respiratory Tract Nasal cavity Nasopharynx Oropharynx Pharynx laryngopharynx larynx Trachea  Upper Respiratory Tract cont.  Upper Respiratory Tract ❖ Nasal cavity ✓ Covered with mucous membrane produces fluid for moistening ✓ Contains blood vessels for warming ✓ Hairs to filter the air ✓ Smell odor (olfactory nerve) Function of the sinuses ??? Lighten the skull & voice  Upper Respiratory Tract cont. ❖ Pharynx (Throat) ✓ Carries food & air ✓ Warming & humidifying ✓ Taste (olfactory nerve) ✓ Hearing(air entrance to the middle ear) ✓ Protection (Tonsils) ✓ Speech  Upper Respiratory Tract cont. ❖ Larynx (Voice Box) ✓ Vocal cords (pitch, volume, resonance) ❖ Glottis & Epiglottis ❖ Glottis ✓ Space between the vocal cord ✓ Helps to breathe, speak, & make sounds.  Upper Respiratory Tract cont. ❖ Epiglottis ✓ Cartilage that keeps the food & liquid out of the respiratory tract ✓ When swallowing covers, the entrance of the larynx ✓ Humidifying ✓ Filtering ✓ Warming  Upper Respiratory Tract cont. ❖ Trachea ✓ C-shaped rings of cartilage ✓ Keep the trachea open & allow the esophagus to expand during swallowing ✓ Humidifying ✓ Filtering ✓ Warming  Upper Respiratory Tract cont. ❖ Trachea cont. ✓ Cough reflex (vagus nerve) ✓ Mucociliary escalator (push mucus & particles upwards towards the larynx, cough, sneeze, or blow).  Lower Respiratory Tract ❖ Lung ✓ Bronchial & alveolar structures ✓ Right & left lobes ✓ Right lung – larger with (3) lobes ✓ Left lung – smaller with (2) lobes ✓ Why is the right lung bigger than the left lung?  Pleura (Serous Membrane) ✓ Visceral pleura covers the lung (inner layer) ✓ Parietal pleura lines the thoracic cavity & contains nerve endings (outer layer) ✓ Pleural fluids between the two layers of the pleura  Pleura (Serous Membrane) ✓ Lubricate the thorax and lungs ✓ Allow layers to slide smoothly over each other as the chest expands & contracts (inspiration & expiration). Lower Respiratory Tract  Bronchi & Bronchioles ❖ Bronchi (Singular—Bronchus) ✓ Each bronchus leads into a lung and ✓ branches into smaller and smaller bronchioles ✓ resembling an inverted tree.  Brochi & Bronchioles ❖ Bronchioles ✓ Fine tubes that allow passage of air. ✓ Epithelium of bronchioles covered with cilia & mucus to trap and remove dust and other particles. ✓ Bronchioles end in tiny air sacs called alveoli.  How do your bronchi work with your Respiratory System? ✓ Air passes from the mouth to your trachea ✓ Your trachea divides into your L & R bronchi ✓ Bronchi carry air into your lungs ✓ At the end of the bronchi – ✓ Bronchioles carry air to small sacs in the lungs (alveoli)  Some Facts About the Alveoli ✓ Wrapped in tiny blood vessels (capillaries) ✓ Typical adult consist of about 480 million ✓ Give the lung a big surface area (60-80 square meters). ✓ Surfactant lines the alveoli walls and helps prevent them from collapsing.  Alveoli ❖ Type I cells ✓ Alveolar wall (the barrier between air & the alveolar surface) ✓ Gas exchange (O2 & CO2) ❖ Type II cells ✓ Surfactant ✓ Lipid-type substance that coats the alveoli  Alveoli ❖ Type III cells ✓ Alveolar macrophages (defense mechanism) ✓ Phagocytic cells that ingest foreign matter  Alveoli cont. ❖ Alveoli are grouped in clusters. Pulmonary ❖ A network of artery capillaries surrounds each alveolus. Pulmonary vein Capillaries  Gas Exchange O2 ✓ Gas exchange takes place CO2 in the alveoli. ✓ Oxygen diffuses into the blood. ✓ Carbon dioxide in the blood diffuses into the alveolus. Capillary  Why are we talking about pulmonary surfactants? ❖ Synthesized by type II cellular cells ❖ Reduces surface tension (prevents alveolar collapse during expiration) ❖ Prevents bacterial invasion ❖ Cleans alveoli surface  Surface Tension ❖ Liquid molecules line the alveolar walls and attract each other ❖ This attractive force is called surface tension ❖ These attractive forces MUST BE overcome to expand lung ❖ SURFACTANT reduces surface tension  Factors Affecting Ventilation  Compliance  Resistance  If fresh gas is not delivered to the alveoli and blood is not delivered to the alveolar capillaries, or if the alveolar surface is damaged, oxygenation or CO2 elimination may be impaired.  Compliance What is lung compliance?  lungs’ ability to stretch  lungs’ ability to expand  Compliance cont.  Elastance  ability of a structure to return to its resting position after being stretched  Elastic recoil  magnitude of the force to return to its resting position  Decreased compliance occurs if the lungs and the thorax are stiff.  How do lungs adapt and why? Compliance of the lungs occurs due to elastic forces. A. Elastic forces of the lung tissue itself B. Elastic forces of the fluid that lines the inside walls of alveoli and other lung air passage A B Elastin + Collagen Fibres Is provided by the substance called surfactant that is present inside walls of the alveoli.  Compliance cont. What would influence elastance and elastic recoil? ❖ Disease ❖ Pulmonary Fibrosis ❖ Aging ❖ Emphysema (COPD) ❖ Obesity ❖ Pneumothorax  Resistance What is resistance?  force opposes flow from one point to another (opposition of the flow of gases)  dynamic force - involved only during movement  Resistance cont.  Primary factors that determine resistance are:  Size and radius (or diameter) of the airway  Flow rate  Secretions/water in the airway system  Could having a tracheostomy affect resistance?  Resistance cont.  Flow into and out of the lungs will be adversely affected by obstructed airways  Airways get smaller & shorter during exhalation = greater resistance ASTHMA  Causes of Increased Resistance  Small endotracheal tube  Bronchospasm  Mucosal edema  Airway obstruction (mucus, tumor, or a foreign body)  Secretions Which river has the most resistance? How do we relate this to our lungs?  Factors Affecting Ventilation Work of Breathing The amount of oxygen required by the respiratory muscles to breath Resistance + Compliance = Work of Breathing Nursing Alert: Watch for signs of increased work of breathing Accessory muscles Grunting Difficulty speaking  RR - HR - BP How can we reduce the WOB?  Ventilation & Perfusion (V/Q)  V/Q ratio V – amount of air reaching the alveoli  Q – flow of blood in the surrounding capillaries  Gas exchange is most efficient where V/Q match.!  Imbalances in this ratio can lead to critical respiratory conditions.!  Ventilation & Perfusion (V/Q)  V/Q match (normal)  Unoxygenated blood returns to the R side of the heart  through the PA to the lungs for gas exchange  V/Q Ratio Mismatch  V/Q ratio mismatch ❑ Resulting from V/Q dysfunction (respiratory disorders) ❑ Ineffective gas exchange between the alveoli & pulmonary capillaries affects all body systems. ❑ What are the effects? ❑Changes the amount of O2 delivered to living cells.  V/Q Ration Mismatch cont. ❑ Two main types of V/Q mismatch: ❑ Inadequate perfusion (dead-space ventilation) ❑ Inadequate ventilation (shunt)  V/Q Ratio Mismatch cont.  Inadequate perfusion (dead-space ventilation)  Alveoli are well-ventilated but poorly perfused  O2 does not efficiently transfer to the blood  What are the causes?  Pulmonary embolism  COPD  V/Q Ratio Mismatch cont.  Inadequate ventilation (shunt)  Pulmonary circulation is adequate  Not enough O2 is available in the alveoli for normal diffusion.  Leading to poorly oxygenated blood.  What are the causes?  Pneumonia  Atelectasis  Pulmonary edema  Common Symptoms Associated with a V/Q Mismatch ❑ Dyspnea (SOB) – most common ❑ Cyanosis ❑ Tachycardia ❑ Tachypnea ❑ Decreased exercise tolerance ❑ Confusion or altered mental status ❑ Chest pain ❑ Palpitations ❑ Wheezing or cough  Assessment 1. History 2. Physical Assessment 3. Inspection 4. Palpation 5. Auscultation 6. Percussion Pediatric Considerations Mouth & nose - structures are smaller & more easily obstructed than in adults. Pharynx - infants’ & children’s tongues occupy more space in the mouth than adults.  Pediatric Considerations cont. ❑ Trachea – (windpipe) ❑ Narrower tracheas that are obstructed more easily by swelling. ❑ Softer and more flexible in infants and children.  Pediatric Considerations  Cricoid cartilage  lessdeveloped and less rigid  narrowest part of the infant’s or child’s airway.  Diaphragm  chest wall is softer  infants & children depend more heavily on the diaphragm for breathing.  Respiratory Rates Infant: 30 – 60 breaths/min Child: 20 – 30 breaths/min Adult: 12 – 20 breaths/min  Assessment  Inspection ✓ Back & front ✓ Chest symmetry ✓ Tracheal deviation ✓ Skin & nail beds color ✓ Clubbing fingers ✓ RR & pattern ✓ Using accessory muscles ✓ Nasal flaring ✓ Purses of the lips during breathing  Assessment ❖ Types of Breathing ❖ Men, children, infants, athletes & singers usually use abdominal or diaphragmatic breathing. ❖ Women usually use chest or intercostal breathing. ❖ Eupnea – normal breathing pattern  Assessment ❖ Abnormal Respiratory Patterns ❖ Tachypnea – respiratory rate >20 breaths/min ❖Lung disease ❖Pain ❖Sepsis ❖Obesity ❖Anxiety ❖Respiratory distress ❖Fever  Assessment ❖ Abnormal Respiratory Patterns ❖ Bradypnea – respiratory rate 4 lpm for a duration of more than 4 hours.  Infection Control ✓ Low-flow oxygen devices, e.g., cannula & face masks, do not present a significant infection control risk & need not be routinely changed on the same patient. ✓ These devices are for single-patient use only. ✓ They should, however, be replaced whenever they are visibly soiled or the device’s function is compromised.  Devices Used to Administer Oxygen to Adult Patients DEVICE % O2 FiO2 O2 Flow Tubing Humidity Device Nasal 24 – 40% 0.24 – 0.40 Up to 6.0 Small Bore Bubble humidifier if flow > 4lpm for > 4 Cannula lpm hours (pre-filled with sterile water Venturi 24 – 50% 0.24 – 0.50 4 – 12 Small Bore Mask* lpm** DO NOT HUMIDIFY Aerosol Face 28 – 98% 0.28 – 0.98 ≤ 10 lpm Wide Bore Pre-filled Mask (AFM) Nebulizer Reservoir / FiO2 based on Total Mixed (1” corrugated Bottle Aerosol setting Gas Flow = aerosol tubing Trach Mask 20 – 60 lpm (ATM) / FiO2 is precise Use Double Face Tent System for FiO2 ≥ 0.60)  Devices Used to Administer Oxygen to Adult Patients DEVICE % O2 FiO2 O2 Flow Tubing Humidity Device Simple*** DO NOT Oxygen Mask 35-50% 0.35 – 0.50 5 – 10 lpm Small Bore HUMIDIFY Non- 10 – 15+ Small Bore DO NOT Rebreather 90 – 100% 0.90 – 1.0 HUMIDIFY Face Mask lpm with Reservoir Manual 90 – 100% 0.90 – 1.0 10 – 15+ Small Bore DO NOT Resuscitator (~40% (~0.40 lpm HUMIDIFY Laerdal Bag, without without Emergency valve & mask reservoir) Use and for with reservoir reservoir) artificial airways  Devices Used To Administer Oxygen To Pediatric Patients DEVICE % O2 FiO2 O2 Flow Tubing Humidity Device Nasal 24 – 40% 0.24 – 0.40 Up to 6.0 Small Bore Bubble Cannula lpm humidifier Imprecise prefilled with FiO2 * sterile water Venturi 24 – 50% 0.24 – 0.50 4 – 12 Small Bore Mask* lpm** DO NOT HUMIDIFY Aerosol 28 – 98% 0.28 – 0.98 ≤ 10 lpm Wide Bore Pre-filled Face Mask Nebulizer FiO2 based on Total Mixed (1” corrugated Reservoir / (AFM) setting Gas Flow = aerosol Bottle Aerosol FiO2 is precise 20 – 60 lpm tubing) Trach Mask Use Double (ATM) / System for FiO2 ≥ 0.60  Devices Used to Administer Oxygen to Pediatric Patients DEVICE % O2 FiO2 O2 Flow Tubing Humidity Device Simple*** Small DO NOT Oxygen Mask 40 – 60% 0.40 – 0.60 5 – 10 lpm Bore HUMIDIFY Manual 90 – 100% 0.90 – 1.0 10 – 12 lpm Small DO NOT Resuscitator (~40% without (~0.40 without Emergency Bore HUMIDIFY Use and for Laerdal Bag, reservoir) artificial valve & mask reservoir) airways with reservoir  Nursing Diagnosis & Planning Activity Decreased Cardiac Fatigue Intolerance Output Impaired Gas Ineffective Impaired Verbal Exchange Breathing Pattern Communication Ineffective Airway Risk for Infection Ineffective Health Clearance Maintenance Risk for Aspiration Risk for Suffocation Risk for Imbalance Fluid Volume  Interventions & Therapies  Independent  Deep breathing exercises  Positioning  Encouraging smoking cessation  Monitoring activity tolerance  Promoting secretion clearance  Suctioning  Assisting with activities of daily living  Interventions & Therapies cont.  Collaborative ▪ Pharmacologic therapy ▪ Corticosteroids ▪ Reduce bronchial inflammation ▪ Anticholinergics (Bronchodilators) ▪ e.g., Ipratropium Bromide Inhaler & Ventolin ▪ Relax the smooth muscles of the airway ▪ Decrease mucus secretion  Upper Respiratory Infection (URI) What causes it?  Virus (or bacteria) enter the respiratory system How it happens?  Passfrom person-to-person  Respiratory droplets  Hand-to-hand contact Yes, URIs are contagious.!  Upper Respiratory Infection (URI) o Common cold o Epiglottitis o Laryngitis o Pharyngitis (sore throat) o Sinusitis (sinus infection)  Upper Respiratory Infection (URI) ▪ Common cold ▪ affects your nose, throat, sinuses, & trachea ▪ acute illness caused by a virus (rhinovirus) ▪ “widespread” ▪ self-limiting  Upper Respiratory Infection (URI) ▪ Signs & Symptoms ▪ Stage 1: Early (Days 1 to 3) ▪ tickly or sore throat ▪ sneezing ▪ runny nose ▪ nasal congestion ▪ cough  Upper Respiratory Infection (URI) ▪ Signs & Symptoms ▪ Stage 2: Active (Days 4 to 7) ▪ Peak; symptoms worsen ▪ body aches ▪ headache ▪ runny eyes & nose ▪ fatigue ▪ fever (common in children)  Upper Respiratory Infection (URI) ▪ Signs & Symptoms ▪ Stage 3: Late (Days 8 to 10) ▪ Begins to wind down ▪ Some symptoms can persist ▪ If symptoms worsen, see an MD  What happens to your body when you get cold? ▪ Virus attacks ▪ Attach cells inside the nose, nasal passages, & sinuses ▪ Infect other cells and prepare to invade (replication) ▪ Cells send distress signals ▪ Trigger the immune system to start fighting (2 days) ▪ Cytokines (chemical messenger) ▪ WBC, vessels, & brain to shut down the virus  What happens to your body when you get cold? ▪ Your blood vessels dilate ▪ Allows more blood flow & brings more WBC to fight the virus ▪ Blood vessels dilate and swell (inflammation) ▪ S/s: nasal congestion, feel achy, puffy, red, and filled with fluid ▪ “Painful part of a cold”  What happens to your body when you get cold? ▪ White cells start fighting ▪ By enlarging the blood vessels even more ▪ Area gets hotter, wetter, and less comfortable for the virus to settle in ▪ Some WBCs make antibodies (future virus reinvasion). ▪ The fluid flushes out ▪ Runny nose (clear the virus & excess fluid). ▪ Secretions turn green and less clear  Management & Treatment ▪ There is no cure – let it run its course.! ▪ Over-the-counter (OTC) medications ▪ Pain relievers (headaches and fever) ▪ Decongestants ▪ Antihistamines (sneezing and runny nose) ▪ Cough expectorants (Guaifenesin; thin & loosen mucus) ▪ Prevention ▪ Hand washing & hand sanitizers, cleaning frequently use surfaces ▪ Adequate hydration, nutrition, & rest.  Upper Respiratory Infection (URI) ▪ Epiglottitis ▪ inflammation and swelling of your epiglottis ▪ blocks the airflow of air into the lungs ▪ Medical emergency.!  Upper Respiratory Infection (URI) ▪ Causes ▪ Bacterial infection (common) ▪ Streptococcus pneumoniae ▪ Staphylococcus aureus ▪ Streptococcus A, B, & C ▪ Haemophilus influenzae type b (Hib) bacteria (children) ▪ Chemical burns ▪ Trauma ▪ Consuming hot beverages  Upper Respiratory Infection (URI) ▪ Signs & Symptoms ▪ Fever, Unusual high-pitched sound when breathing in (stridor) ▪ Four D’s ▪ Dysphagia (difficulty swallowing) ▪ Dysphonia (hoarseness) ▪ Drooling (involuntary) ▪ Distress (difficulty breathing or lack of O2  Management & Treatment ▪ Protect the airway is the first step! ▪ Provide O2 ▪ If the airway is blocked (ET insertion) or a tracheostomy ▪ Treating infections ▪ Broad-spectrum antibiotics (don’t delay) ▪ Ceftriaxone (Rocephin); Cefuroxime, & Cefotaxime ▪ More targeted antibiotics (once the culture is back) ▪ IV fluids  Upper Respiratory Infection (URI) ▪ Laryngitis ▪ Inflammation of the voice box from overuse, irritation, or infection ▪ Vocal cords (inside the larynx) are inflamed or irritated ▪ distort sound ▪ hoarseness ▪ undetectable (some cases) ▪ Acute or chronic  Upper Respiratory Infection (URI) ▪ Causes ▪ Acute ▪ Improve after the underlying cause gets better ▪ Viral infections ▪ Vocal strain (overusing the voice) ▪ Bacterial infections (rare)  Upper Respiratory Infection (URI) ▪ Causes ▪ Chronic (>3 weeks) ▪ Cause vocal cord strain & injuries ▪ Growth on the vocal cords (polyps or nodules ▪ Inhaled irritants ▪ Acid reflux ▪ Excessive ETOH use ▪ Habitual overuse of voice ▪ Smoking  Upper Respiratory Infection (URI) ▪ Signs and Symptoms ▪ Hoarseness ▪ Weak voice or voice loss ▪ Tickling sensation and rawness in your throat ▪ Sore throat ▪ Dry throat ▪ Dry cough  Management & Treatment ▪ Acute laryngitis often gets better on its own within a week or so. ▪ Voice rest, drinking fluids, & humidifying your air (help improve symptoms). ▪ Chronic laryngitis is aimed at treating the underlying causes, such as Acid reflux, smoking, or excessive use of ETOH. ▪ Antibiotics ▪ Corticosteroids ▪ Pain killers  Management & Treatment ▪ Self-care (relieve symptoms & reduce strain on voice) ▪ Breathe moist air ▪ Drink plenty of fluids ▪ Rest your voice ▪ Moisten your throat ▪ Avoid whispering ▪ Avoid decongestants  Upper Respiratory Infection (URI) ▪ Pharyngitis (Sore throat) ▪ Inflammation of the pharynx ▪ Viral or bacterial infections ▪ Acute (3-10 days) ▪ Chronic (>10 days)  Upper Respiratory Infection (URI) ▪ Symptoms & Causes ▪ Sore throat ▪ Dry, scratchy throat ▪ Pain when swallowing & speaking ▪ If an infection is causing the sore throat ▪ Fever & nasal congestion ▪ Headache ▪ Cough & hoarseness ▪ Fatigue  Upper Respiratory Infection (URI) What causes a sore throat? Pharyngitis may be a sign of these conditions:  Management & Treatment ▪ Treatment depends on the cause ▪ Viral infections (self-limiting) ▪ Adequate rest, hydration, & nutrition ▪ OTC medicines ▪ Other treatments ▪ Antibiotics ▪ Antihistamines ▪ Antacids  Upper Respiratory Infection (URI) ▪ Sinusitis ▪ AKA rhinosinusitis ▪ Inflammation or swelling of the tissue lining of the sinuses ▪ Bacterial infections ▪ viral infections (common) ▪ Fungus ▪ Allergies  Upper Respiratory Infection (URI) ▪ Symptoms ▪ Postnasal drip; nasal congestion ▪ Runny nose with thick yellow or green mucus ▪ Facial pressure ▪ Pressure or pain in your teeth. ▪ Ear pressure or pain ▪ Fever ▪ Halitosis or a bad taste in your mouth ▪ Headache  Upper Respiratory Infection (URI) ▪ Types of Sinusitis ▪ Acute Sinusitis (symptoms last