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Oxygenationrzd6ty
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Upper Respiratory Problems
Lower Respiratory Problems
Obstructive Pulmonary Diseases
Acid Base Balance and ABGs
Week 5 Objectives
Oxygenation
Summarize the nursing process in care of patients with alterations in oxygenation.
Classify priorities in the care of patients with alterations in oxygenation using the following
applicable concepts: oxygenation, nutrition, perfusion, fluid/electrolyte regulation,
infection/inflammation, tissue integrity, pain, metabolism, elimination, safety, and intracranial
regulation.
Identify interprofessional collaboration/team management for needs of the patient with
alterations in oxygenation.
Examine the pharmacologic, nutritional, developmental, and teaching needs of the patient with
alterations in oxygenation.
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Topics Covered
Lewis Ch. 25:
Lewis Ch. 26:
Lewis Ch. 27:
ATI Ch. 17:
ATI Ch. 19:
ATI Ch. 20:
*ATI Ch. 21:
*ATI Ch. 22:
ATI Ch. 23:
ATI Ch. 45:

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Assessment: Respiratory System
Upper Respiratory Problems
Lower Respiratory Problems
Respiratory Diagnostic Procedures
Respiratory Management and Mechanical Ventilation
Acute Respiratory Disorders
Asthma
Chronic Obstructive Pulmonary Disease
Tuberculosis
Acid-Base Imbalances
Upper Respiratory Problems
Disorders of:
Nose
Sinuses
Hollow cavities in the skull
Pharynx
Cavity behind the nose and mouth
Larynx
Hollow organ that holds the vocal cords
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Upper Respiratory Problems
Acute Viral Rhinitis
The common cold
200 different rhinoviruses
Most prevalent infectious disease
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Average adult: 1 – 3 colds each year
Spread by airborne droplets and direct hand contact
Can survive 3 days on inanimate objects
Symptoms begin 2 – 3 days after infection and last 2 – 14 days
Typical recovery 7 – 10 days
Runny nose, watery eyes, nasal congestion, sneezing, cough, sore throat, fever, headache, and
fatigue

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Acute Viral Rhinitis
Nursing Management
Sore Throat
Warm salt water gargles, ice chips, lozenges
Raw Nose
Petroleum jelly
Nasal Congestion
Saline nasal spray
Postnasal Drip/Cough
Antihistamine and decongestant therapy
Intranasal decongestant sprays: 3 days only
Prevent rebound congestion
Cough suppressants (dextromethorphan)
Expectorants (guaifenesin)
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Drug Therapy
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Drug Therapy
9
Which of the following would be an expected outcome for a client recovering from an upper
respiratory tract infection? The client will:
Maintain a fluid intake of 800 mL every 24 hours
Experience chills only once per day
Cough productively without chest discomfort
Experience less nasal obstruction and discharge
10
The nurse teaches the client how to instill nasal drops. Which of the following techniques is
correct?
The client uses sterile technique when handling the dropper.
The client blow the nose gently before instilling drops.
The client uses a new dropper for each installation
The client sits in a semi-Fowler’s position with the head tilted forward after the administration of
the drops

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Upper Respiratory Problems
Influenza
Flu season: September – April
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20,000 deaths annually
Flu A
Most common and most virulent
Infects humans and animals
Can cause epidemics and pandemics
Flu B
Only infects humans
Can cause epidemics but disease is milder
Flu C
Mild illness in humans only
No epidemics or pandemics
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Upper Respiratory Problems
Influenza
Can be transmitted from animals to humans by direct or indirect contact
Transmitted between humans:
Infected droplets and inhalation of aerosolized particles
To a lesser extent, direct contact with contaminated surfaces
Incubation period: 1 – 4 days
Peak transmission risk:
 1 day before onset of symptoms and continuing for 5 – 7 days
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Common Cold vs. Flu
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Common Cold vs. Flu
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Nursing Management
Influenza
Vaccination
Changed on a yearly basis
Best time to receive is in September
Takes 2 weeks for full protection
Most frequent adverse effect: soreness at injection site
Alternatives available for people who are allergic to eggs
Treatment: antiviral medication
Relenza (zanamivir)
Oral inhalation, q12 hours for 5 days
Tamiflu (oseltamivir)
Oral capsule, BID for 5 days
Rapivab (peramivir)
Intravenous, one dose
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Upper Airway Problems
Acute Pharyngitis
Inflammation of the pharyngeal walls
Gargle with warm salt water (0.5 tsp in 8 oz. H20)
Caused by viral, bacterial, or fungal infection
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Viral: 90% of cases
Use Tylenol and Motrin
Increase fluids
Bacterial: group A beta-hemolytic streptococci
Penicillin 7 – 10 days to prevent rheumatic fever
Contagious until antibiotics taken for 24 – 48 hours
Fungal: Candida infections
Prolonged use of antibiotics or inhaled corticosteroids
Nystatin (anti-fungal) swish and swallow
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Lower Respiratory Problems
Acute Bronchitis
Inflammation of the bronchi in the lower respiratory tract
Most are caused by viruses
Cough (up to 3 weeks), clear secretions, headache, fever, malaise, hoarseness, myalgias, dyspnea,
and chest pain
Assessment:
Normal breath sounds or crackles and wheezes (on expiration with exertion)
CXR: not indicated because it is normal in bronchitis
Treatment:
Cough suppressants, oral fluid intake, bronchodilator inhalers for wheezing
Teaching:
No smoking, avoid second hand smoke, wash hands frequently
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Lower Respiratory Problems
Pneumonia
Types of Pneumonia
Community-Acquired
Empiric Antibiotic Therapy should be started ASAP
Hospital-Acquired (nosocomial pneumonia)
Includes Ventilator-associated pneumonia (VAP)
Antibiotic therapy can be adjusted after results of sputum cultures
Multi-drug resistant (MDR) organisms
Methicillin resistant staphylococcus aureus (MRSA)
Gram-negative bacilli
Aspiration
Abnormal entry of material from the mouth or stomach into the trachea and lungs
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Pneumonia
Pathophysiology
Organisms trigger inflammatory response in lungs
Edema of airways
Fluid leaks into alveoli
Hypoxia results (tachypnea, dyspnea, tachycardia)
Consolidation
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Occurs in bacterial pneumonia
Alveoli become filled with fluid and debris
Mucus production increases
Obstructs airflow and impairs gas exchange
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Pneumonia
Clinical Manifestations
Cough, fever, chills, dyspnea, tachypnea, pleuritic chest pain
Fine or coarse crackles
Elderly
May not have classic symptoms
Confusion or stupor
Hypothermia instead of fever
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Pneumonia
Diagnostic Studies
History
Physical Exam
Chest X-Ray
Shows typical pattern characteristic of infecting organism
Sputum for culture and gram stain
Obtained BEFORE starting antibiotics
Do not delay antibiotics
Blood Cultures if seriously ill
Arterial Blood Gas
Hypoxemia (PaO2 <75), hypercapnia (PaCO2 >45), acidosis (pH <7.35)
Leukocytosis if bacterial infection
Increased WBC with presence of bands
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Pneumonia
Interprofessional Care
Pneumococcal vaccine
Streptococcus pneumoniae
Prompt treatment with antibiotics
Response in 48 – 72 hours
Decreased temp., improved breathing, reduced chest discomfort
Supportive measures
Oxygen
Analgesics
Antipyretics
Balance rest and activity
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Pneumonia
Nursing Management
Health Promotion
Hand washing, nutrition, rest, exercise, sneeze into elbow
AVOID cigarette smoke
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At risk (chronically ill, elderly) get pneumococcal and influenza vaccines
Acute Care
Pulse Ox for O2 therapy
Sputum Culture
Antibiotics
Fluids to mobilize secretions
Early ambulation but ensure adequate rest
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A patient with bacterial pneumonia is to be started on intravenous antibiotics. Which of the
following diagnostic tests must be completed before antibiotic therapy begins?
Urinalysis
Sputum Culture
Chest Radiograph
Red Blood Cell Count
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Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. Bed
rest serves which of the following purposes?
It reduces the cellular demand for oxygen
It decreases the episodes of coughing
It promotes safety
It promotes clearance of secretions
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The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the
following?
Decreased cardiac output
Pleural effusion
Inadequate peripheral circulation
Decreased oxygenation of the blood
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A client with pneumonia is experiencing pleuritic chest pain. Which of the following
describes pleuritic chest pain?
A mild but constant aching in the chest
Severe mid-sternal pain
Moderate pain that worsens with inspiration
Muscle spasm pain that accompanies coughing
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Which of the following measures would most likely be successful in reducing pleuritic chest
pain in a client with pneumonia?
Encourage the client to breathe shallowly
Have the client practice abdominal breathing
Offer the client incentive spirometry
Teach the client to splint the rib cage when coughing
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Which of the following mental status changes may occur when a client with pneumonia is
first experiencing hypoxia?
Coma
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Apathy
Irritability
Depression
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A client with pneumonia has a temperature ranging between 101 F and 102 F (38.3 C and
38.8 C) and periods of diaphoresis. Based on this information, which of the following nursing
interventions would be a priority?
Maintain complete bed rest
Administer oxygen therapy
Provide frequent linen changes
Provide fluid intake of 3L/day

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Which of the following would be an appropriate expected outcome for an elderly client
recovering from bacterial pneumonia?
A respiratory rate of 25 to 30 breaths/minute
The ability to perform activities of daily living without dyspnea
A maximum loss of 5 to 10 pounds of body weight
Chest pain that is minimized by splinting the ribcage
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Lower Respiratory Problems
Tuberculosis (TB)
Infectious disease caused by Mycobacterium tuberculosis
Gram positive, acid-fast bacillus (AFB)
Spread by airborne particles (droplet nuclei) when people sneeze, talk, breathe etc.
Is NOT spread by direct contact
Usually involves lungs but can occur in any organ
Leading cause of mortality in patients with HIV infection
Occurs disproportionately in poor, underserved, minorities
Homeless, inner-city residents, prisons, shelters, IV drug users
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Tuberculosis (cont.)
Classification
PRIMARY TB INFECTION
Bacteria inhaled and inflammatory response initiated
Immune system encapsulates organisms, walling off the infection and preventing spread of
disease
LATENT TB INFECTION
Positive skin test but asymptomatic
Cannot transmit disease to others
Can develop active disease in future
ACTIVE TB DISEASE
Immune response was inadequate
Primary TB
Active disease develops within first 2 years
Reactivation TB
Disease occurring 2 or more years after initial infection
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Tuberculosis (cont.)
Symptoms develop 2 – 3 weeks after infection or reactivation
Initial dry cough that becomes productive
Fatigue
Malaise
Anorexia
Unexplained weight-loss
Low-grade fevers
Night sweats
Extrapulmonary TB
Symptoms depend on organs infected
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Tuberculosis (cont.)
Diagnostic Studies
Tuberculin Skin Test (Mantoux test)
Standard method to screen people for TB
Inject 0.1mL PPD intradermally on ventral surface of forearm
Read/palpated 48 – 72 hours later
Induration
Chest X-ray
Cannot diagnose TB based on X-ray alone
Bacteriologic Studies
3 consecutive sputum specimens sent for smear and culture
Obtained on different days
Indicates presence of active disease
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Tuberculosis (cont.)
Interprofessional Care
Treated on an outpatient basis
Most can work and resume normal lifestyle
Smear + patients are considered infective for 2 weeks after starting treatment
Restrict visitors, no public transportation or public places
Hospitalization warranted for severely ill or debilitated
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Tuberculosis (cont.)
Drug Therapy – Active TB
2 month initial phase with 4 drugs
Isoniazid (INH)
Rifampin
Pyrazinamide
Above 3 drugs can all cause non-viral hepatitis
Do baseline LFT’s and then every 2 – 4 weeks
Ethambutol
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Directly Observed Therapy is preferred due to nonadherence
Expensive but essential public health measure
Typically public health nurse at a clinic
Fixed-dose combination drugs can be used
Simplifies therapy to increase compliance
Initial therapy is followed by continuation therapy
18 – 31 weeks
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Tuberculosis (cont.)
Drug Therapy – Latent TB
Drug therapy helps prevent TB infection from becoming active TB disease
Fewer bacteria are present, so treatment is easier
One drug only
9 months of daily isoniazid (INH)
Inexpensive, effective, taken by mouth
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Tuberculosis (cont.)
Nursing Management
Screening programs for high risk groups
If TST is positive, need a chest X-ray to look for active disease
Positive diagnosis needs to be reported to public health department
Admitted patients need to be on “airborne precautions”
Negative pressure room with 6-12 airflow exchanges per hour
HCP must wear HEPA masks
Get fit tested every year or when manufacturer is changed
Patient should cough into tissue and then dispose into paper bag or flush
Standard isolation mask when patient is out of room
Screen close contacts of patient
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Which of the following symptoms is common in clients with active tuberculosis?
Weight loss
Increased appetite
Dyspnea on exertion
Mental status changes
41
The nurse obtains a sputum specimen from a client with suspected tuberculosis for
laboratory study. Which of the following laboratory techniques is most commonly used to
identify tubercle bacilli in sputum?
Acid-fast staining
Sensitivity testing
Agglutination testing
Dark-field illumination
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The nurse should teach clients that the most common route of transmitting tubercle bacilli
from person to person is through contaminated
Dust particles
Droplet nuclei
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Water
Eating Utensils
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What is the rationale that supports multidrug treatment for clients with tuberculosis?
Multiple drugs potentiate the drugs’ actions
Multiple drugs reduce undesirable drug side effects
Multiple drugs allow reduced drug dosages to be given
Multiple drugs reduce development of resistant strains of the bacteria
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The client with tuberculosis is to be discharged home with community health nursing followup. Of the following interventions, which would have the highest priority?
Offering the client emotional support
Teaching the client about the disease and its treatment
Coordinating various agency services
Assessing the client’s environment for sanitation
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Which of the following techniques for administering the Mantoux test is correct?
Hold the needle and syringe almost parallel to the client’s skin
Pinch the skin when inserting the needle
Aspirate before injecting the medication
Massage the site after injecting the medication
46
Which of the following family members exposed to tuberculosis would be at highest risk for
contracting the disease?
45 year old mother
17 year old daughter
8 year old son
76 year old grandmother
47
A client has a positive reaction to the Mantoux test. The nurse correctly interprets this
reaction to mean that the client has
Active tuberculosis
Had contact with Mycobacterium tuberculosis
Developed a resistance to tubercle bacilli
Developed passive immunity to tuberculosis
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In which areas of the United States is the incidence of tuberculosis highest?
Rural farming areas
Inner city areas
Areas where clean water standards are low
Suburban areas with significant industrial pollution
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The nurse should include which of the following instructions when developing a teaching
plan for clients who are receiving rifampin and INH for treatment of tuberculosis?
Take the medications with antacids
Double the dosage if a drug dose is forgotten
Increase intake of dairy products
Limit alcohol intake
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The public health nurse is providing follow up care to a patient with tuberculosis who does
not regularly take his medication. Which nursing action would be most appropriate for this
client?
Ask the patient’s spouse to supervise the daily administration of the medications
Visit the client weekly to ask him whether he is taking his medications regularly
Notify the physician of the patient’s noncompliance and request a different prescription
Remind the patient that tuberculosis can be fatal if it is not treated promptly
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Obstructive Pulmonary Diseases
Asthma
Persistent but variable inflammation of the airways
Inflammation results in bronchoconstriction, airway hyper-responsiveness, and edema of the
airways
Exposure to allergens or irritants initiates the inflammatory cascade
Early Phase Response
30 – 60 minutes after exposure
Runny nose, itching, bronchial spasms, airway narrowing, mucus production
Late Phase Response
Occurs 4-6 hours after early phase response
Occurs in 50% of asthmatics
Symptoms develop again or worsen
Treatment: corticosteroids
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Asthma
Clinical Manifestations
Wheezing
Cough
Dyspnea
Chest tightness
Expiration may be prolonged
Physical exam:
Expiratory wheeze
Hives or eczema
Runny nose, swollen nasal passages
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Asthma
Drug Therapy
Anti-inflammatory Drugs
Corticosteroids (ie. fluticasone)
Inhaled corticosteroids: 1st line therapy
Use a spacer to minimize oropharyngeal candidiasis, hoarseness, dry cough
Oral corticosteroids are used for exacerbations
Women should supplement with calcium and Vit D d/t decreased bone mineral density
Leukotriene Modifiers
Singulair (montelukast)
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For prophylaxis and maintenance (NOT exacerbations)
Anti – IgE
Xolair (omalizumab)
Given SC q 2 – 4 weeks
Has risk of anaphylaxis
Anti – interleukin 5
Nucala (mepolizumab)
For patients who have history of severe attacks despite medication
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Asthma
Drug Therapy
Bronchodilators
Beta-adrenergic Agonists
Short-acting ones are considered rescue medications
Albuterol
Onset of action in minutes and last 4 – 8 hours
Can cause tachycardia, anxiety, palpitations, tremors
Not for long-term control
Long-acting ones are used for long-term control
Serevent Diskus
Effective for 12 hours
Should also be taking Inhaled Corticosteroids as well
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Asthma
Inhalation Devices for Drug Delivery
Reduces systemic side effects and onset of action is quicker
Metered Dose Inhalers (MDI)
Small, hand-held, pressurized
Spacer could be used to improve amount of drug delivered to lungs
Dry Powder Inhalers
Easier to use than MDIs
Medicine delivered by patient’s inspiratory effort
Nebulizers
Small machine that converts drug solutions into mists
Easy to use
Potential for bacterial growth—WASH daily.
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Asthma
Nursing Management
Health Promotion
Avoid personal triggers
Cigarette smoke, pet dander
Avoid irritants
Cold air, aspirin, foods, cats, indoor air pollution
Prompt treatment of URI and sinusitis
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Weight loss for obese patients
2 – 3 L fluid/day
Good nutrition
Adequate rest
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Asthma
Peak Expiratory Flow Rate (PEFR)
Patient must measure peak flow daily
Green Zone (80% - 100% of patient’s personal best)
Remain on usual meds
Yellow Zone (50% - 80% of personal best)
Caution: Something is triggering the asthma
Red Zone (50% or less of personal best)
STOP: Serious problem
Arrange for medical care
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A 34 year old woman with a history of asthma has been admitted to the emergency
department. The nurse notes that the client is dyspneic, with a respiratory rate of 35
breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields
reveals greatly diminished breath sounds. Based on these findings, what action should the
nurse take to initiate care of the client?
Initiate oxygen therapy and reassess the client in 10 minutes
Draw blood for an arterial blood gas analysis and send the client for a chest x-ray
Encourage the client to relax and breathe slowly through the mouth
Administer bronchodilators
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A client with acute asthma is prescribed short term corticosteroid therapy. What is the
rationale for the use of steroids in clients with asthma?
Corticosteroids promote bronchodilation
Corticosteroids act as an expectorant
Corticosteroids have an anti-inflammatory effect
Corticosteroids prevent the development of respiratory infections
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Which of the following would be an appropriate expected outcome for an adult client with
well controlled asthma?
Chest x-ray demonstrates minimal hyperinflation
Temperature remains lower than 100 F (37.8 C)
Arterial blood gas analysis demonstrates a decrease in PaO2
Breath sounds are clear
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Which of the following health promotion activities should the nurse include in the discharge
teaching plan for a client with asthma?
Incorporate physical exercise as tolerated into the daily routine
Monitor peak flow numbers after meals and at bedtime
Eliminate stressors in the work and home environment
Use sedatives to ensure uninterrupted sleep at night
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Acid-Base Balance
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* Acid– a substance that contains H+ ions that can be released
* Base– a substance that can accept or trap H+ ions
Examples:
1) Carbonic Acid releases H+ to form bicarbonate
*H2CO3 gives up H+ to become HCO32) Bicarbonate traps H+ to form carbonic acid
*HCO3- gains H+ to form H2CO3

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BLOOD PLASMA: 7.35-7.45 (slightly alkaline)
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Narrow range of normal pH is maintained by the lungs and the kidneys
1 Respiratory: (primary regulator of H2CO3)
CO2 is produced by cellular metabolism and is excreted by exhalation
H2CO3 becomes CO2 + H20
Acidosis (high CO2): increase respirations to blow off CO2 and become alkaline
Alkalosis (Low CO2): decrease respirations to retain CO2 and become acidic
Quick response but short term. Need kidneys for long-term adjustments in pH.

2 Renal: (primary regulator of HCO3-)
Acidosis (increased H+)
Kidneys excrete H+
Kidneys form/conserve HCO3Alkalosis (decreased H+)
Kidneys retain H+
Kidneys excrete HCO3This occurs more slowly than respiratory regulation. May take several days.

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Respiratory Acidosis
ABG VALUES
* pH decreased (below 7.35)
* PaCO2 increased (above 45)
ALMOST ALWAYS DUE TO HYPOVENTILATION
• COPD, Pulmonary edema, inadequate mechanical ventilation, burns
• Clinical Manifestations:
• Confusion/disorientation
• Dyspnea
• Hyperkalemia
• Coma
• Treatment:
• Improve ventilation

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Respiratory Alkalosis
ABG Values
* pH increased (above 7.45)
*PaCO2 decreased (below 35)
Hyperventilation/anxiety are common cause
• High fever, excessive ventilation by mechanical ventilation, ASA overdose
• Clinical Manifestations:
• Lightheadedness
• Paresthesias
• Palpitations
• Tinnitus
• Treatment:
• Breathe more slowly or into a closed system, sedative, treat underlying cause

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Metabolic Acidosis
ABG values
* pH below 7.35
* HCO3 less than 22
*PaCO2 less than 35
Caused by accumulation of acid or loss of base
• DKA, diarrhea, lactic acidosis, ASA or antifreeze ingestion, fistulas
• Clinical manifestations:
• Headache
• Confusion
• Drowsiness
• Hyperventilation/Kussmaul’s (compensatory)
• Nausea/vomiting
• Treatment:
• Treat underlying metabolic deficit, administration of bicarbonate

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Metabolic Alkalosis
ABG results
* pH increased (above 7.45)
* HCO3- increased (above 26)
Caused by a direct increase in base or a metabolic loss of acid
• Vomiting, gastric suction, diuretics, antacid ingestion
• Clinical manifestations:
• Dizziness
• Tingling of fingers and toes
• Drowsiness
• decreased respirations (compensatory)
• Treatment:
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• Treat underlying cause, replace electrolytes (K+, Ca++, Cl-), can give NACL

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Interpreting ABG’s
Values to Know
pH: 7.35-7.45
PaCO2: 35-45 mmHg
HCO3: 22-26 mEq/L
70
Interpreting Arterial Blood Gasses
1 1) Is the pH acidotic or alkalotic?
pH < 7.35 is acidotic
pH > 7.45 is alkalotic

2 2) Is it a respiratory or metabolic cause?
PaCO2 is respiratory
HCO3- is metabolic

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Interpreting Arterial Blood Gasses
1 3) Is the body compensating?
If the problem is respiratory, the kidneys will compensate by increasing or decreasing HCO3If the problem is metabolic, the lungs will regulate CO2 levels

2 4) Has compensation occurred?
Absent: if pH is abnormal, one component is abnormal, and second component is normal
Partial: if pH is abnormal, one component is abnormal, second component beginning to
change
Complete: pH normal, one component abnormal, second component changed to move ph to
normal range

72
ABG Results
pH
7.25
PaCO2
74
HCO3
33
73
ABG Results
pH
7.49
PaCO2
38
HCO3
28
74
ABG Results
pH
7.31
PaCO2
25
HCO3
12
16
2/22/2022
75
ABG Results
pH
7.29
PaCO2
48
HCO3
22
76
ABG Results
pH
7.52
PaCO2
26
HCO3
21
77
ABG Results
pH
7.3
PaCO2
37
HCO3
18
78
ABG Results
pH
7.5
PaCO2
59
HCO3
44
79
ABG Results
pH
7.22
PaCO2
80
HCO3
34
80
ABG Results
pH
7.48
PaCO2
44
HCO3
32
17