Oxygen Needs
 Altered function of any system affects oxygen needs.
 Oxygen needs are affected by:
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Respiratory system status
Circulatory system function
Red blood cell count
Nervous system function
Aging
Exercise
Fever
Pain
Drugs
Smoking
Allergies
Pollutant exposure
Nutrition
Alcohol
Patients at Risk for Poor Oxygenation
 Hypoxemia
 Insufficient oxygen in the blood
 Patients at risk
 Immobile
 Cardiac or pulmonary disease
Risk Factors for Poor Oxygenation
 Postoperative
 Sleep apnea
 Morbidly obese
 Neuromuscular disease
 Decreased consciousness
 Kyphoscoliosis
 ALTERED RESPIRATORY FUNCTION
 Respiratory function involves three processes.
• Air moves into and out of the lungs.
• O2 and CO2 are exchanged at the alveoli.
• The blood carries O2 to the cells and removes CO2 from them.
 Hypoxia means that cells do not have enough oxygen.
• Anything that affects respiratory function can cause hypoxia.
• The brain is very sensitive to inadequate O2.
• Hypoxia is life-threatening.
 Adults normally have 12 to 20 respirations per minute.
• They are quiet, effortless, and regular.
• Both sides of the chest rise and fall equally.
 Tachypnea is rapid breathing.
• Respirations are 24 or more per minute.
 Bradypnea is slow breathing.
• Respirations are fewer than 12 per minute.
 Apnea is the lack or absence of breathing.
 Hypoventilation means respirations are slow, shallow, and sometimes
irregular.
 Hyperventilation means respirations are rapid and deeper than normal.
 Dyspnea is difficult, labored, or painful breathing.
 With Cheyne-Stokes respirations:
• Respirations gradually increase in rate and depth.
• Then they become shallow and slow.
• Breathing may stop (apnea) for 10 to 20 seconds.
 Orthopnea means breathing deeply and comfortably only when sitting.
 Biot’s respirations are rapid and deep respirations followed by 10 to 30
seconds of apnea.
 Kussmaul respirations are very deep and rapid respirations.
 ASSISTING WITH ASSESSMENT AND DIAGNOSTIC TESTS
 Altered respiratory function may be an acute or chronic problem.
 The doctor orders tests to find the cause of the problem.
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Chest x-ray (CXR)
Lung scan
Bronchoscopy
Thoracentesis
Pulmonary function tests
Arterial blood gases (ABGs)
 Pulse oximetry measures the oxygen concentration in arterial blood.
• The normal range is 95% to 100%.
• A sensor attaches to a finger, toe, earlobe, nose, or forehead.
• An alarm sounds if:
• O2 concentration is low
• The pulse is too fast or slow
• Other problems occur
• A good sensor site is needed.
• Use SpO2 when recording the oxygen concentration value:
• S = saturation
• p = pulse
• O2 = oxygen
Pulse Oximeter
 Measures oxygen saturation of hemoglobin
 95% to 100% - normal
 Below 90% - complications
 Below 85% - probable hypoxemia
 70% or below - life-threatening emergency
Pulse Oximeter
 Monitor the patient!
 Many variables interfere with accurate values!
 PROMOTING OXYGENATION
 To get enough oxygen, air must move deep into the lungs.
• Air must reach the alveoli, where O2 and CO2 are exchanged.
 Measures to meet oxygen needs are found in care plans.
 Positioning
• Breathing is usually easier in semi-Fowler’s and Fowler’s positions.
• Persons with difficulty breathing often prefer the orthopneic position.
• Frequent position changes are needed.
 Deep breathing and coughing
• Deep breathing moves air into most parts of the lungs.
• Coughing removes mucus.
• Deep-breathing and coughing exercises:
• Help persons with respiratory problems
• Are done after surgery and during bedrest
• Help prevent pneumonia and atelectasis
 The goal of incentive spirometry is to improve lung function.
• Atelectasis is prevented or treated.
Capillary Refill
 Indication of the peripheral circulation
 Cyanosis (problem with oxygen delivery)
 Skin
 Nailbeds
 Mucous membranes
 Lips
Capillary Refill
 Capillary refill varies with age, but will return to normal within 2 to 3 seconds.
 Check capillary refill on all four extremities
Oxygen Therapy
 Pressure gauge shows the amount of oxygen in the cylinder
 Never modify a gauge or part to make it fit!
 Humidification is not necessary in liter flows below 5
 Chain tank to a carrier or base
Oxygen Therapy
 Avoid sparks, post oxygen signs
 Remove smoking materials
 Follow all safety precautions
 ASSISTING WITH OXYGEN THERAPY
 Oxygen is treated as a drug.
 The doctor orders:
• The amount of oxygen to give
• The device to use
• When to give it
 The person may need:
• Oxygen constantly
• Oxygen for symptom relief
 You do not give oxygen.
• You assist the nurse in providing safe care.
 Oxygen is supplied as follows:
• Wall outlet
• Oxygen tank
• Oxygen concentrator
• Liquid oxygen system
 These oxygen devices are common:
• Nasal cannula
• Simple face mask
• Partial-rebreather mask
• Non-rebreather mask
• Venturi mask
 Talking and eating are hard to do with a mask.
 Moisture can build up under the mask.
• Keep the face clean and dry.
• Masks are removed for eating.
 The oxygen flow rate
• The flow rate is the amount of oxygen given.
• It is measured in liters per minute (L/min).
• The nurse or respiratory therapist sets the flow rate.
• When giving care and checking the person:
• Always check the flow rate.
• Tell the nurse at once if it is too high or too low.
• Know your center’s policy about nursing assistants adjusting oxygen flow
rates.
 Oxygen administration set-up
• If not humidified, oxygen dries the airway’s mucous membranes.
• Distilled water is added to the humidifier.
• Bubbling in the humidifier means that water vapor is being produced.
 You assist the nurse with oxygen therapy.
• You do not give oxygen.
• You do not adjust the flow rate unless allowed by your state and center.
Suction
 Patient cannot breathe during suctioning
 Do not exceed 10 seconds for suctioning, insertion, and removal
 A Yankauer (tonsil tip) is used for mouth and throat
 Flexible catheter is used for the nose, mouth, and throat
 Persons who cannot cough or whose cough is too weak to remove
secretions need suctioning.
 These routes are used to suction the airway:
• Oropharyngeal
• Nasopharyngeal
• Lower airway
 If not done correctly, suctioning can cause serious harm.
• Hypoxia and life-threatening problems can occur.
• Cardiac arrest can occur.
• Infection and airway injury are possible.
Small Volume Nebulizer
 A nebulizer converts liquid medicine into a mist
 Loosens and lubricates secretions
 It may be large, small, ultrasonic, or placed inside ventilator tubing
Continuous Positive
Airway Pressure
 CPAP maintains positive pressure during the respiratory cycle
 Pressure opens partially or fully closed alveoli
 Provides more surface area for gas exchange
 Improves oxygenation and prevents premature airway closure
Bilevel Positive Airway Pressure
 BiPAP is similar to CPAP
 Maintains positive airway pressure during inspiration and expiration
 Higher pressure during inhalation
 Reduces pressure during exhalation
 BiPAP reduces effort of breathing
Postural Drainage
 Drains secretions from lungs
 For patients with cystic fibrosis or certain types of pneumonia
 Can be used to treat other conditions
 PCT assists with positioning patient
Advanced Respiratory Procedures
 ASSISTING WITH RESPIRATORY THERAPY
 Some persons need artificial airways, suctioning, mechanical ventilation,
and chest tubes.
 The goals for respiratory rehabilitation are to help the person:
• Reach his or her highest level of function
• Live as independently as possible
• Return home
 Artificial airways keep the airway patent (open).
• Intubation means inserting an artificial airway.
 These airways are common:
• Oropharyngeal airway
• Endotracheal (ET) tube
• Tracheostomy tube
 Care for persons with artificial airways involves:
• Vital signs are checked often.
• Observe for hypoxia and other signs and symptoms.
• If an airway comes out or is dislodged, tell the nurse at once.
• Frequent oral hygiene is needed.
• Follow the care plan.
 Persons with ET tubes cannot speak. (Some tracheostomy tubes allow
speech.)
• Follow the care plan.
• Always keep the signal light within reach.
Caring for an Intubated Patient
 Elevate head
 Turn head to one side
 Suction oral secretions
 Provide oral and nasal care
 Reposition at least every 2 hours
 Monitor for and prevent pressure ulcers
Caring for an Intubated Patient
 Monitor vital signs and capillary refill
 Monitor insertion site for redness, irritation, or breakdown
 Monitor for signs of respiratory distress
 Reassure the patient and family
 Develop a method for communicating with the patient
 Tracheostomies are temporary or permanent.
• A tracheostomy has three parts (the obturator, the inner cannula, and
the outer cannula).
• The cuffed tracheostomy tube is used for mechanical ventilation.
• The tube must not come out (extubation).
• The tube must remain patent (open).
• Call for the nurse if:
• You note signs and symptoms of hypoxia or respiratory distress
• The outer cannula comes out
• Nothing must enter the stoma.
• Follow Standard Precautions and the Bloodborne Pathogen Standard
when assisting with tracheostomy care.
 The care of a tracheostomy involves:
• Cleaning the inner cannula to remove mucus and keep the airway patent
• Cleaning the stoma to prevent infection and skin breakdown
• Applying clean ties or a Velcro collar to prevent infection
 When secretions collect in the upper airway, they can:
• Obstruct airflow into and out of the airway
• Provide an environment for microbes
• Interfere with O2 and CO2 exchange
 Usually, coughing removes secretions.
Caring for a Tracheostomy Patient
 Some patients breathe room air
 Others use a ventilator or a bag valve mask
 Tracheostomy care is a sterile procedure
 Keep the stoma and cannula clean
Caring for a Tracheostomy Patient
 Secure the outer cannula
 Prevent water and objects from entering the lungs
 Prevent infection
Caring for a Laryngectomy Patient
 Deep breathing and coughing every 2 hours
 Monitor the patient’s skin color
 Watch for:
 Cyanosis
 Color changes in nailbeds or mucous membranes
 Respiratory distress
Caring for a Laryngectomy Patient
 Watch for:
 Restlessness
 Dyspnea
 Anxiety
 Increased heart rate
 Lethargy
 Disorientation
Chest Tubes
 The doctor inserts chest tubes to remove air, blood, or fluid from the pleural
space.
• Pneumothorax is air in the pleural space.
• Hemothorax is blood in the pleural space.
• Pleural effusion is the escape and collection of fluid in the pleural space.
• Chest tubes attach to a drainage system.
• Water-seal drainage keeps the system airtight.
Caring for a Chest Tube Patient
 Keep bottle lower than heart
 Make sure that nothing pulls on tube
 Keep tube taped to chest
 Keep junction of chest and drainage tube taped together
 Position drainage system upright
 Reposition patient every 2 hours
Caring for a Chest Tube Patient
 Keep the tube patent
 Coil tubing on the bed
 Don’t disconnect a drain connected to a vacuum regulator
 Keep patient mobile
 Keep oxygen and suction at bedside
 Keep emergency equipment in room
Caring for a Chest Tube Patient
 Inform RN of abnormal signs or symptoms
 If chest tube comes out, cover site with 4 x 4 gauze or petroleum gauze
 If a drainage bottle breaks, clamp proximal tube with a rubber-tipped clamp
Mechanical Ventilation
 Mechanical ventilation may be needed for a variety of health care problems.
• Mechanical ventilation is started in the hospital.
• Alarms sound when something is wrong.
• When any alarm sounds on a mechanical ventilator:
• First check to see if the person’s tube is attached to the ventilator. If
not, attach it to the ventilator
• Then tell the nurse at once about the alarm.
• Do not reset alarms.
• Persons needing mechanical ventilation are very ill.
Caring for a Mechanically Ventilated Patient
 Make sure the alarm is on at all times
 Respond immediately
 Provide oral and nasal care
 Monitor mucous membranes for pressure, irritation, and breakdown
Caring for a Mechanically Ventilated Patient
 Observe for changes
 Respiratory rate and depth
 Shortness of breath
 Use of accessory muscles
Caring for a Mechanically Ventilated Patient
 Count spontaneous respirations and ventilator‑ delivered breaths
 Check for tube displacement
 Make sure the tube is taped securely
 Visually inspect the chest
 Should appear symmetrical
Caring for a Mechanically Ventilated Patient
 Monitor patient for pain
 Elevate head 60 to 90
 Elevation of head of the bed increases risk of skin breakdown on the torso
 Elevate heels off surface of bed
 Suction, if permitted