Pulmonary Nursing
Chapter 21
Oxygenation
Oxygenation
• Oxygen: measures approximately 21% in the Earth’s
atmosphere
• Each cell of the human body uses oxygen to metabolize
nutrients and produce energy
• Without oxygen, cell death occurs rapidly
Anatomy and Physiology of Breathing
• Inspiration and expiration
• Ventilation: movement of air in and out of lungs;
facilitates respiration
• Respiration: exchange of oxygen and carbon dioxide
Anatomy and Physiology of Breathing
(cont’d)
• External and internal respiration
• External respiration takes place at most distal
point in airway: between the alveolar-capillary
membranes
• Internal respiration occurs at the cellular level
between hemoglobin and body cells
How Your Lungs Work
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Assessing Oxygenation
• Physical assessment
• Monitoring the client’s respiratory rate
• Observing breathing pattern and effort
• Checking chest symmetry
• Auscultating lung sounds
Patient Assessment
• If patient becomes restless – this can
be an early indication that the patient’s
oxygenation status is compromised
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Assessing Oxygenation (cont’d)
• Arterial blood gases measure:
• Partial pressure of oxygen dissolved in plasma (PaCO2)
• Percentage of hemoglobin saturated with oxygen (SaO2)
• The pH of blood
• Level of bicarbonate (HCO3)
Arterial Blood Gases
Arterial Blood Gases Disadvantges
• The procedure is invasive and painful
• Careful monitoring by nurse to prevent
complications after arterial puncture
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Why Do an Aterial Blood Gas
(ABG)?
• Arteries have greater oxygen content than
veins and responsible for carrying 02 to all
cells.
• ABGs are ordered to assess the client in acute
respiratory distress or to evalute the progress
of a patient receiving medical treatment
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Assessing Oxygenation
• Pulse oximetry
• Composed of a sensor and a microprocessor
• Noninvasive, transcutaneous technique for
periodically or continuously monitoring the oxygen
saturation of blood
Pulse Oximetry
• The SPO2 range for a
patient who is adequately
oxygenated would be
• 95% - 100%
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Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
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Promoting Oxygenation
• Positioning: high Fowler’s position – first step raise
the head of the bed to promote breathing
• Breathing techniques
• Deep breathing – inhale as much air as possible,
hold breath briefly- then exhale slowly
• Incentive spirometry – deep inhalation with
device to reach a goal level, hold breath briefly
– remove mouthpiece and exhale normally
• Pursed-lip breathing –inhale thru nose slowly ,
purse lips, contract abdomen, exhale through
pursed lips slowly
Promoting Oxygenation
Diaphragmatic breathing
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Oxygen Therapy
• Oxygen sources
• Wall outlet – hospitals, rehab
• Portable tanks – before using “crack” the tank to
remove any dust and debris from the outlet
• Liquid oxygen unit
• Oxygen concentrator – portable, used in LTC
Pulmonary Nursing
Chapter 36
Airway Management
The Airway
• The respiratory system
• The importance of a clear airway
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The Airway and Related Structures
• Structures that protect the airway from
inhaled substances
• Epiglottis – acts as a “lid”that closes
during swallowing directs fluid and food
towards esophagus rather than
respiratory tract
• Tracheal cartilage – keeps airway open
• Mucous membrane – lines respiratory
passages –traps particulate matter
• Cilia – collects debris that collects in the
lower airway upwards
Gerontologic Considerations
Respiratory celia becomes less
efficient with age, pre-disposing
older adults to a high incidence
of pneumonia
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The Airway (cont’d)
• Definition of sputum:
Mucus raised to the level of the upper airways
Natural Airway Management
• Liquefying secretions
• Encouraging adequate hydration
• Inhalation therapy
• Mobilizing secretions
• Chest physiotherapy (page 813 –Fundamentals)
• Postural drainage; Percussion
• Vibration
Aerosol Therapy
Lung Segments and Corresponding Postural
Drainage Positions
Performing Postural Drainage
Performing Percussion
Natural Airway Management (cont’d)
• Suctioning secretions
• Nasopharyngeal suctioning
• Nasotracheal suctioning
• Oropharyngeal suctioning
• Oral suctioning
Variations in Suction Pressure
Natural Airway Management (cont’d)
• Suctioning secretions (cont’d)
• Oropharyngeal suctioning
• Oral suctioning
Yankeur-Tip Suction Device for
Oral Suctioning
Artificial Airway Management
• Oral airway
• Tracheostomy
• Tracheostomy tube
• Tracheostomy suctioning
• Tracheostomy care
A Cuffed Tracheostomy Tube
General Gerontologic Considerations
• Pathologic pulmonary changes in older
adults
• Age-related changes affecting the older
adult’s respiratory system
• Pneumonia in older adults
• Cough in older adults
General Gerontologic Considerations (cont’d)
• Respiratory secretions in older adults
• Dysphagia in older adults
• Cardiac dysrhythmias in older adults
Skills for Respiratory Disorders
• Oxygen Therapy
• Goal of oxygen therapy is to prevent or relieve hypoxia.
• Any patient with impaired tissue oxygenation can benefit from
controlled oxygen administration.
• Oxygen is not a substitute for other treatments and should be used
only when indicated.
• Oxygen should be treated as a drug.
• Oxygen is expensive and can have dangerous side effects.
• The dosage or concentration of oxygen should be ordered and
continuously monitored.
Skills for Respiratory Disorders
• Oxygen Therapy (continued)
• Oxygen is a colorless, odorless, and tasteless gas that will not
burn or explode.
• If combined with other factors, such as an electrical spark or
fire, it will support combustion and ignite.
• Oxygen therapy is frequently initiated by a respiratory
therapist, who is a health care professional licensed to deliver
treatment that will improve a patient’s ventilation and
oxygenation needs.
• The signs and symptoms manifested by patients who might
require oxygen will vary according to the degree of oxygen
deficiency.
Oxygen Therapy (cont’d)
• Equipment used in oxygen administration
• Flowmeter – enables the nurse to regulate the
quantity of oxygen delivered
• Oxygen analyzer
• Humidifier
Oxygen Therapy -Common Delivery
Devices
•Nasal cannula – 2 to 5ML - low flow/low
concentration of oxygen/with higher flow can cause
the nasal mucosa to dry
•Masks
o Simple mask
o Partial rebreather mask –monitor bag if collapses during
inspiration call respiratory therapist
o Non-rebreather mask
o Venturi mask -higher flow rate
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Oxygen Therapy (cont’d)
• Common delivery devices (cont’d)
• Face tent
• Tracheostomy collar
• T-piece
• Additional delivery devices
• Nasal catheter
Administering Oxygen Safely
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Comparison of Oxygen Delivery Devices
Device
Common
Range
Uses
Nasal cannula
2-6 L/min
Lower admin/can be drying to mucosa
Simple mask
5-8 L/min
Higher concentrations than nasal
cannula, requires humidification
Partial
rebreather
6-10 L/min
Required min of 6L/min increase amt
of 02 with lower liter flows – monitor
that bag is inflated at all times
Nonrebreather
6-10 L/min
Delivers highest fraction of inspired O2
with a mask (risk oxygen toxicity)
Venturi
4- 8 L/min
Delivers exact amount of prescribed
oxygen
Face tent
8-12 L/min
Inconsistent fraction of inspired 02,
comfortable for clients with facial
trauma
Oxygen Therapy (cont’d)
• Additional delivery devices (cont’d)
• Oxygen tent
• CPAP mask – keeps the aveoli partially inflated even during
expiration (nighttime use for sleep apnea)
• Transtracheal oxygen
• Oxygen hazards
• Fire potential
• Oxygen toxicity
Skills for Respiratory Disorders
• Oxygen Therapy (continued)
• Transtracheal oxygen delivery
• A newer method of oxygen delivery is the transtracheal catheter, which is
inserted directly into the trachea between the second and third tracheal
cartilages.
• Delivery does not interfere with drinking, eating, or talking.
• Oxygen is delivered throughout the respiratory cycle.
• It is recommended for patients with heart failure or chronic obstructive
pulmonary disease.
• The transtracheal opening should be inspected and cleaned regularly.
Transtracheal Catheter
A transtracheal catheter may be inserted into the trachea between
2nd and 3rd tracheal cartilages.
Skills for Respiratory Disorders
• Oxygen Therapy (continued)
• Care of the tracheostomy
• A tracheostomy is an artificial opening made by a surgical incision
into the trachea.
• It is performed to provide the patient with a patent airway.
• After the surgical procedure is performed, the physician inserts a
tracheostomy tube and secures it in place with cotton tape around
the patient’s neck.
• Sterile gauze is placed around the opening under the flange of the
outer tube for skin protection.
Skills for Respiratory Disorders
• Oxygen Therapy (continued)
• Care of the patient with a tracheostomy collar and T-piece/tube
• This requires constant humidification to the airway.
• The T-piece/tube is a T-shaped device with a
15 mm connection with large-lumen tubing.
• A tracheostomy collar is a curved device with an adjustable strap that fits
around the patient’s neck; an exhalation port remains open at all times and
another connects to large-bore tubing.
A, Trach tube (fenestrated) with inner cannula removed and cap in
place to allow speech.
B, Trach tube with obturator for insertion and syringe for inflation of
cuff.
T-piece/tube.
Tracheostomy collar.
• Hyperbaric oxygen therapy (HBOT)
• Delivery of 100% oxygen at 3 times the normal
atmospheric pressure within an airtight chamber
• Helpful for significant burn injuries, gangrene
because it provides 15 times the amount of oxygen
to tissues when compared to breathing room air
Nursing Implications
• Nursing diagnoses: hypoxemia or hypoxia
• Ineffective breathing pattern
• Impaired gas exchange
• Anxiety
• Risk for injury (related to oxygen hazards)
General Gerontologic Considerations
• Reduced gas exchange and efficiency in ventilation;
major age-related changes occur in the respiratory
system
• Respiratory muscles become weaker and the chest wall
becomes stiffer as a result of calcification of the
intercostal cartilage
General Gerontologic Considerations (cont’d)
• Diminished cough and gag reflexes, increased use of
accessory muscles for breathing, increased mouth
breathing, snoring
• Inactive, debilitated, or chronically ill clients or smokers
are at a higher risk for respiratory infections and
compromised respiratory function
Antitussives
• Antitussives act in one of 3 ways:
• Depress the cough center in the brain
• narcotic and opioids; codeine, hydrocodone
• Anesthetize stretch receptors in the respiratory tract
• Nonopioids; diphenhydramine, dextromethorphan
• Soothe irritated areas in the throat
• Uses:
• Relief of overactive or nonproductive cough
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Antitussives (cont.)
• Adverse Reactions
• Constipation, drowsiness, dry mouth, nausea, postural
hypotension
• Drug Interactions
• Opioids have addictive effects with other CNS depressants;
use reduced dose
• Increase analgesic effect of ASA
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Decongestants
• Decongestants – encourage sinus drainage, improves
nasal air passage and reduces the feeling of nasal
stuffiness
• Directly affect alpha receptors of blood vessels in the nasal
mucosa, causing vasoconstriction
• Uses: relieve nasal congestion from allergies and upper
respiratory infections
• Adverse reactions – nervousness, nausea, dizziness
• Drug interactions – will interact with MAO
inhibitors, tricyclic antidepressants, antihistamines,
caution with htn patients
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Expectorants
• Expectorants (Guaifenesein, Mucinex, Robitussin
• Decrease the thickness of respiratory secretions, thereby
facilitating expectoration
• Uses: treat productive cough, assist with thick mucus
• Adverse reactions - GI upset, dizziness, headache
• Drug interactions – No interactions noted with
Guaifenesein, etc.
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Topical Intranasal Steroids –
(Flonase, Nasonex, Nasacort AQ)
• Action
• Anti-inflammatory effect to reduce nasal congestion
• Uses
• Treatment of allergic, mechanical, or chemically induced
local nasal inflammation or nasal polyps when usual
treatment has failed to work
• Adverse reactions
• Asthma, headache, lightheadedness, loss of sense of
smell, nasal irritation and dryness, nausea, nosebleeds,
perforation of nasal septum, altered sense of taste and
smell
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Asthma
• Asthma is a condition that involves increased
inflammation, swelling, and mucus production that
lead to bronchiolar constriction. The person is able
to breathe air into the lungs but has difficulty
breathing out. Wheezing results because the person
works to force air out through narrowed, mucusfilled passages during expiration.
• The four classes of asthma severity include mild
intermittent, mild persistent, moderate persistent,
and severe persistent.
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COPD
• COPD is a chronic, disabling disorder that causes
destruction of alveolar walls. This destruction creates
unequal areas of ventilation and perfusion in the
body, and oxygen and carbon dioxide exchange is
impaired. Patients experience difficulty in expiration.
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Asthma and COPD Medications
• Prophylactic treatment (prevention)
• Cromolyn sodium (used to manage bronchial asthma)
• Nedocromil sodium
• Actions:
• Slows down destruction of sensitized mast cells; also
may provide hyposensitization (decrease in allergic
response)
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Asthma and COPD Medications
(cont.)
• Bronchodilators
• Sympathomimetics aka adrenergic stimulants (Albuterol)
• Relax smooth muscle of bronchi (dilate)
• Vasoconstriction of blood vessels in body (decreases
mucosal and sub mucosal edema)
• Increase the rate and force of heart contraction
• Uses:
• Relief of symptoms of bronchospasm in acute or chronic
asthma, bronchitis, and COPD
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Asthma and COPD Medications
• Xanthines (Aminophylline, Theophylline)
• Relax smooth muscle in the bronchi and blood vessels in the lungs
• Directly act on the kidney to produce an increase in urine production
• CNS effects
• Uses
• Adjunctive therapy for bronchospasm in acute and chronic bronchial
asthma, bronchitis, emphysema
• Treatment of neonatal apnea
• Acute pulmonary edema
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Asthma and COPD Medications
• Leukotriene Receptor Inhibitors (Singulair, Accolate)
• Reduce symptoms of asthma by blocking receptors for
cysteinyl leukotrienes C4, D4, and E4
• Uses
• Treat acute or chronic asthma in patients unable to take
inhaled glucocorticoids
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Asthma and COPD Medications
• Corticosteroids - Block reaction to allergens and reduce
airway hyper responsiveness
• Inhibit cytokine production, protein activation, and inflammatory
cell migration and activation ( works on the inflammatory response)
• Uses
• Inhaled long-term asthma control (Pulmicort, Flovent, AeroBid)
• Systemic (Prednisolone) often used to get quick control of the
disease when beginning long-term therapy or to speed recovery from
severe episodes
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Administering Medications to
Mucous Membranes
• Absorption
• Easily absorbed
• Easily reaches therapeutic levels
• Different mucous membranes have different drug sensivitivies
• Blood supply under mucous membranes varies
• Technique
• Use aseptic or clean technique
• Wear gloves
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• Nose
• Act locally to treat minor congestion or infection
• Spray absorbs quicker than drops
• Nasonex, Flonase, Afrin
• Respiratory
• Nebulizers/Aerosols
• Medication diluted according to instructions and delivered using oxygen
• Breath slowly and deeply until medication gone
• Clean between uses
• Metered-dose inhalers
• Deliver specific amounts of corticosteroids/bronchodilators to
nasal/lung tissue
Pulmonary Edema
Pulmonary edema is an abnormal buildup
of fluid in the lungs. This buildup of fluid
leads to shortness of breath.
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Nutrition
• Principles of diet therapy for pulmonary edema
• Sodium restriction
• Fluid restriction
• Texture
• Nutritional adequacy
• Little or no alcohol
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