Oxygenation
Chapter 40
3/22/2016
NRS 105.320 S2009
2
ANATOMY AND PHYSIOLOGY
REVIEW
• CARDIOVASCULAR/RESPIRATORY
CONNECTION
– BOTH SYSTEMS MUST BE FUNCTIONING FOR
EITHER SYSTEM TO WORK
•
•
•
•
•
•
•
3/22/2016
heart structure/function
lung structure/function
CNS innervation to chest, diaphragm
Peripheral and cardiac circulation
Adequate volume and hemoglobin
Acid-base balance & regulation
CO2 response/ O2 response
3
3/22/2016
NRS 105.320 S2009
4
3/22/2016
5
3/22/2016
6
3/22/2016
7
ALTERATIONS IN OXYGENATION
• PHYSIOLOGICAL
→ DECREASE IN OXYGEN CARRYING
CAPACITY
•
•
•
•
•
3/22/2016
↓ Transport HGB & HCT
↓ VOLUME R/T BLOOD LOSS
↓ Binding of O2 [CO]
↓ Intake of O2 [altitude]
↑ DEMAND [exercise, fever, illness]
8
ALTERATIONS IN OXYGENATION
• PHYSIOLOGICAL
→ ↓CHEST WALL MOVEMENT
•
•
•
•
•
3/22/2016
PREGNANCY
OBESITY
MUSCULOSKELETAL CHANGES [kyphosis]
TRAUMA [ rib fracture]
CNS ABNORMALITIES [C4 spinal trauma]
9
ALTERATIONS IN OXYGENATION
• Physiological→ Changes in Delivery of O2
– Diffusion in lungs [alveolar]
• atelectasis, ↓surface area, ↓blood supply, pressure
• Secretions [pneumonia, COPD]
– Transport to tissues
• Cardiac output
• circulation [PVD, trauma, volume, vasoconstriction]
• Cardiac perfusion
ALTERATIONS IN OXYGENATION
• PHYSIOLOGICAL
– CHRONIC DISEASES
• COPD: CO2 drive absent R/T chronic high pCO2
– Dependent on paO2 drive; ↓compliance, atelectasis,
↓clearance of airways
• POLYCYTHEMIA: response to chronic hypoxemia
– CONDUCTION DISTURBANCES
– HEART FAILURE
3/22/2016
11
ALTERATIONS IN RESPIRATORY
FUNCTIONING
We breathe to take in O2 and eliminate CO2
• HYPERVENTILATION:
– in excess of what is needed to eliminate CO2
• HYPOVENTILATION:
– inadequate to meet O2 needs OR to eliminate CO2
• HYPOXIA
• INADEQUATE TISSUE OXYGENATION
• HYPOXEMIA
• DECREASED OXYGEN CONCENTRATION IN THE
ARTERIAL BLOOD
3/22/2016
12
SPECIAL OXYGEN CONSIDERATIONS
ACROSS THE LIFE SPAN
• INFANTS AND TODDLERS
– SURFACTANT [newborn]
– Risk for URI
– Shorter airways
• OLDER ADULTS
– DEGENERATIVE PROCESSES
• Compliance, chest wall movement, accumulated pollutants,
cardiac and perfusion changes, alveolar changes, cilia
decrease
– CHRONIC DISEASE
• HTN, Respiratory, Cardiac, Renal…
3/22/2016
13
LIFESTYLE FACTORS
•
•
•
•
•
•
3/22/2016
NUTRITION
EXERCISE
SMOKING
SUBSTANCE ABUSE
STRESS
ENVIRONMENTAL FACTORS
14
Nursing Process
• Nursing History: Ability to meet O2 needs
Cardiac function
Respiratory function
Pain
Fatigue
Dyspnea
Cough
Wheezing
Respiratory Infections
Allergies
Risk Factors
Medications
PHYSICAL
ASSESSMENT
• INSPECTION
– GENERAL APPEARANCE
– LOC
– SYSTEMIC CIRCULATION
– BREATHING PATTERNS
– CHEST WALL MOVEMENT
3/22/2016
16
PHYSICAL
ASSESSMENT
• PALPATION
– THORACIC EXCURSION
– AREAS OF TENDERNESS
– EXTREMITIES
– CAPILLARY REFILL
3/22/2016
17
PHYSICAL
ASSESSMENT
• PERCUSSION
– AREAS OF CONSOLIDATION
• AUSCULTATION
– NORMAL V. ABNORMAL LUNG SOUNDS
3/22/2016
18
PHYSICAL
ASSESSMENT
• DIAGNOSTIC TESTS
–
–
–
–
–
–
–
–
–
–
3/22/2016
PULSE OXIMETER
PEAK EXPIRATORY FLOW RATE
ARTERIAL BLOOD GASES
CHEST X-RAY
SPUTUM SPECIMEN
PULMONARY FUNCTION TESTING
BRONCHOSCOPY
VENTILATION-PERFUSION LUNG SCAN [V/Q]
THORACENTESIS
CT / MRI
19
3/22/2016
20
Case Study #1
• 36 yo male visiting from Austin, TX with sudden onset”
dizzy, confused, headache and hard to breathe” this
afternoon. No obvious trauma. No significant medical
history; friend states “he’s in great shape – an athlete –
he comes here to bike and climb. He’s climbing the
fourteeners!”
• VS: T 37.3; P90, R36, B/P 108/58, SPO2 80% on RA
• Assessment: pale, anxious, confused, c/o headache.
Oriented to person only. Sinus tachycardia; deep,
labored resp. with fine crackles at bases. Extremities
cool to touch and pale.
What’s going on?
•
•
•
•
What is abnormal?
What do you think the cause is?
What should the interventions be?
Nursing diagnosis for this patient?
Nursing Diagnoses
•
•
•
•
•
Activity Intolerance
Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Pattern
Risk for Infection
Goals
• Pt will:
– Maintain airway
– Clear secretions effectively
– Increase hydrations [to mobilize secretions]
– Improve Oxygenation [SPO2]
– Increase activity tolerance
– Report decreased Dyspnea [scale 0-10]
– Decrease risk factors
– Show resolution/ improvement in underlying
cause
INTERVENTIONS
• HEALTH PROMOTION
– VACCINATIONS
– HEALTHY LIFESTYLE BEHAVIOR
– ENVIRONMENTAL AWARENESS
– EDUCATION
• Reduce risk factors
3/22/2016
25
Case study #2
• 72 yo female Denver resident c/o SOB [dyspnea],
dizziness and fatigue. Family reports she seems
“pleasantly confused” today. HX of DM with renal failure
treated with oral Glucophage
• VS: T 36.2C, P 86, R30, B/P 160/88, SPO2 90 on RA
• Labs: Na+ 136, K+ 3.0, HCT 40, Hgb 14;
• ABG: ph 7.32, PaO2 80, PCO2 46, HCO3- 18
• Assessment: Oriented to person, knows she is ‘not at
home’. Lungs clear, respirations rapid and deep w/o use
of accessory muscles. Other findings WNL for age
What to do?
•
•
•
•
•
Any more info you need? Labs?
What in her history raises a flag?
What is the problem?
What interventions are appropriate?
Nursing diagnoses for this patients?
Interventions
•
•
•
•
Focus on:
treating underlying cause [abx, O2]
adaptation [meds, breathing techniques]
preventing complications [TC&DB, IS]
– managing Dyspnea [O2, position, activity]
– Maintaining Airway [Suction, cough, IS]
– Mobilizing Secretions [hydration, TC&DB,
meds]
– Prevent infection/complication
Case Study #3
• 18 yo DU freshman student c/o “choking”, increased
thick secretions, weak productive cough. HX of CF
[cystic fibrosis]
• VS: T 38.2C, P100, R 36, B/P 110/70, SPO2 80% on RA
• Assessment Rhonchi, rales over all lung fields, uses
accessory muscles, thick yellow secretions produced
with weak rattling cough. Other systems WNL
What’s going on?
•
•
•
•
Main problem? Why?
Abnormal findings?
Nursing diagnosis?
Interventions for this client?
– Education/referrals?
INTERVENTIONS IN ACUTE AND
CHRONIC CARE
• POST OPERATIVE CARE
– INTERVENTIONS TO PREVENT
PNEUMONIA
•
•
•
•
•
3/22/2016
TC&DB Q2h
NASAL O2 TO KEEP O2 SAT >90%
IS Q2h WA
SPLINT INCISION
PAIN MEDICATION
31
Case study #4
• 28 yo female post-op trauma pt. with Rt tibia fracture, Rt
rib fracture, liver laceration [repaired]. C/O “pain all over
8/10 this am. SOB [dyspnea], dizziness
• VS: T 37.4C, P88, R 30, B/P [supine =118/78, sitting=
100/64, SPO2 85% on RA
• Labs: Hct 58% BUN 28 mg/100 ml; others WNL
• Assessment: dry mucous membranes, skin tenting, cap
refill <3 sec; pulses +2 bilat and equal, RL BK cast, Rt
upper abdominal incision CDI, Rt ribs bruised. Lungs
CTA. Hypoactive BS X4 quadrants, rapid shallow
respirations
What is wrong?
•
•
•
•
Abnormal Findings?
History?
Nursing diagnoses?
Interventions?
Oxygen
•
•
•
•
Yes, it is a medication
Can cause harm
Ordered by Physician
Standing orders - emergency
NASAL CANNULA
• O2 DELIVERY UP TO 6L/M (6 liters per
minute)
– MUST BE HUMIDIFIED >4L/M
– ROOM AIR = 21% O2
– ROOM AIR + 3L O2 = 32% O2
• APPROX. 3 – 4%/LITER
– Potential trauma to nares, ears
3/22/2016
35
3/22/2016
NRS 105.320 S2009
36
OXIMEIZER
• 8 – 10 LITERS PER MINUTE
• DO NOT HUMIDIFY
– CONTAINS A FILTER THAT HUMIDIFIES
THE OXYGEN
3/22/2016
37
OXIMIZER
3/22/2016
NRS 105.320 S2009
38
SIMPLE FACE MASK
• DELIVERS OXYGEN
CONCENTRATIONS AT 40 – 60%
• CONTROLLED BY LITER FLOW
– 5 – 8 LITERS PER MINUTE
– Short term
– Not for Pts with CO2 retention
3/22/2016
39
SIMPLE FACE MASK
3/22/2016
NRS 105.320 S2009
40
NON REBREATHER MASK
• DELIVERS THE HIGHEST LEVEL OF
OXYGEN POSSIBLE WITH A MASK
– 95 – 100%
– LITER FLOW 10 – 15 LITERS PER MINUTE
– ONE WAY VALVE BETWEEN RESERVOIR
AND MASK
• PREVENTS ROOM AIR FROM MIXING WITH O2
3/22/2016
41
NONREBREATHER MASK
3/22/2016
NRS 105.320 S2009
42
VENTURI MASK
• DELIVERS OXYGEN FROM 24 – 50%
• CAN “DIAL IN” OXYGEN LEVEL
– 4L/MIN = 24%
– 8L/MIN = 35%
3/22/2016
43
3/22/2016
NRS 105.320 S2009
44
OXYGEN FACE TENT
3/22/2016
NRS 105.320 S2009
45
3/22/2016
NRS 105.320 S2009
46
TRANSTRACHEAL OXYGEN
3/22/2016
47
3/22/2016
NRS 105.320 S2009
48
3/22/2016
49
3/22/2016
50
3/22/2016
51
Case study # 5
• 58 yo male c/o dyspnea “it hurts to breathe”, fatigue. HX
of URI 2 weeks ago, untreated [“probably bronchitis – I
get it every year”]; smokes 1 pack/day X 40 years.
Morning cough productive of thick green sputm. Pt states
“that’s new – I always cough in the morning but I don’t
spit notheing up”
• VS: & 37.8C, P76, R28, B/P 176/84
• Labs: Na+ 138, Hct 58%, BUN 28; others WNL Sputm
sample sent for C&S, pending. CXR shows bilateral
lower lobe infiltrates
• Assessment: Pale, dry mucous membranes, cap refill 3
sec; dull & decreased lung sounds bilateral bases
What is wrong?
•
•
•
•
•
Abnormal Findings?
History?
Nursing diagnoses?
Interventions?
Additional info you need?
INTERVENTIONS IN ACUTE AND
CHRONIC CARE
• DYSPNEA
– PATIENT ASSESSMENT
– APPLY OXYGEN?
– UNDERLYING CAUSE
• ASTHMA
• CHRONIC HEART FAILURE
• COPD
3/22/2016
54
ASSESSMENT FINDINGS
• THICK SECRETIONS
– DO THEY NEED OXYGEN?
– UPPER AIRWAY?
– LOWER AIRWAY?
– ASSESS SECRETIONS
•
•
•
•
•
3/22/2016
HUMIDIFY
HYDRATION
NEBULIZER
CHEST PHYSIOTHERAPY
SUCTIONING
55
ASSESSMENT FINDINGS
• WHEEZING (WHY ARE THEY
WHEEZING?)
– OXYGEN?
– BRONCHODILATOR
– CONTINUED ASSESSMENT
3/22/2016
56
AIRWAY
• NATURAL
• ARTIFICIAL
– NASAL
– ORAL
– ENDOTRACHEAL
– TRACHEOSTOMY
3/22/2016
57
ARTIFICIAL AIRWAYS
3/22/2016
58
CARE OF THE PATIENT WITH AN
ARTIFICIAL AIRWAY
• ORAL AIRWAY
– MAINTAINS AN OPEN AIRWAY
• DURING DECREASED LEVEL OF CONSCIOUSNESS
• SEDATION
• SEIZURES
– MADE OF HARD PLASTIC
• ATTEND TO ANY PRESSURE AREAS ON LIPS, MOUTH,
TONGUE
• HOLLOW TO FACILITATE SUCTIONING
3/22/2016
59
3/22/2016
60
NASOTRACHEAL, NASOPHARYNGEAL
OROPHARYNGEAL, OROTRACHEAL
SUCTIONING
• WHEN PATIENT IS UNABLE TO COUGH
UP THICK PULMONARY SECRETIONS
• PASS CATHETER THROUGH NOSE
[less gagging] OR MOUTH
3/22/2016
61
NASAL AIRWAY
3/22/2016
62
CARE OF THE PATIENT WITH AN
ENDOTRACHEAL TUBE
• PROVIDER MAY NEED ASSISTANCE DURING
INTUBATION [e.g. provide O2, SX]
– INTUBATION IS INSERTING THE TUBE
– EXTUBATION IS REMOVING THE TUBE
• ORAL CARE IS A PRIMARY CONCERN FOR THE
NURSE CARING FOR THIS PATIENT
• TUBE MUST BE SECURE
– NO PRESSURE AREAS ON FACE, LIPS OR MOUTH
3/22/2016
63
ENDOTRACHEAL TUBE
3/22/2016
64
CARE OF THE PATIENT WITH AN
ENDOTRACHEAL TUBE
• TUBE MUST BE CLEAR OF SECRETIONS
• SUCTION PRN TO KEEP TUBE PATENT
– Limit time! 15 sec
– To instill or not to instill NS?
• CHANGE TAPE AND REPOSITION TUBE
EVERY 24H
3/22/2016
65
TRACHEOSTOMY TUBE
3/22/2016
66
3/22/2016
67
3/22/2016
68
3/22/2016
69
CARE OF THE PATIENT WITH A
TRACHEOSTOMY
• TUBE MUST BE CLEAR OF SECRETIONS
• SUCTION PRN TO KEEP TUBE PATENT
• CHANGE DRESSING AND INNER CANNULA
EVERY 24H
– IF INNER CANNULA IS NOT DISPOSABLE,
REMOVE, CLEAN AND REPLACE
3/22/2016
70
SLEEP APNEA
• OBSTRUCTIVE SLEEP APNEA
– one or more pauses in breathing or shallow
breaths while you sleep.
– can last from a few seconds to minutes.
– occur 5 to 30 times or more an hour.
– normal breathing then starts again, sometimes
with a loud snort or choking sound
• CENTRAL SLEEP APNEA
– less common type of sleep apnea.
– area of your brain that controls breathing doesn't
send the correct signals
– no effort to breathe for brief periods.
3/22/2016
71
CPAP / BiPAP
• Congestive heart failure
• Lung disorders resulting in high CO2
• Patients for whom intubation is not
possible
• Sleep apnea
• Surfactant deficiency/ atelectasis
• Less invasive than intubation, trach
3/22/2016
72
3/22/2016
73
3/22/2016
74
CARE OF THE PATIENT
WITH A CHEST TUBE
3/22/2016
75
CHEST TUBES
• PURPOSE
– RE-EXPAND THE LUNG
• HOW?
– RELEASE AIR
– DRAIN FLUID
3/22/2016
76
CONDITIONS REQUIRING A CHEST
TUBE INSERTION
• PNEUMOTHORAX: Air in pleural space
– SPONTANEOUS
– TENSION
– TRAUMA
– POST CHEST SURGERY
• Hemothorax: Fluid/ Blood in pleural space
– INFECTION
– BLEEDING INTO THE PLEURAL CAVITY
3/22/2016
77
3/22/2016
78
3/22/2016
79
3/22/2016
80
3/22/2016
81
3/22/2016
82
Heimlich valve
•one-way, rubber flutter valve
•proximal end attaches to the chest
tube,
•distal end connects to a suction
device or is left open to the
atmosphere.
• allows outpatient treatment of a
pneumothorax.
3/22/2016
83
HEIMLICH VALVE
3/22/2016
84
3/22/2016
85
3/22/2016
86
CARE OF THE PATIENT WITH A
CHEST TUBE
• PATIENT ASSESSMENT
– RESPIRATORY RATE
– CHEST EXCURSION
– SYMMETRY
– OXYGENATION (PULSE OXIMETER)
– BREATH SOUNDS
– CREPITUS
3/22/2016
87
CARE OF THE PATIENT WITH
A CHEST TUBE
• ASSESS PATIENT AND SYSTEM
–
–
–
–
–
DRAINAGE [amount, type, etc]
DRESSING [DRY AND INTACT?]
TUBE [KINKED? Straight?]
BE SURE IT DOES NOT DRAG ON THE FLOOR
VERIFY SUCTION [Bubbling = working] & WATER
SEAL [fluctuation w/ breathing, bubbling = air from
pleural space or dislodged tube] ORDERS
– NEVER RAISE COLLECTION CHAMBER ABOVE
CHEST [INSERTION POINT]!
3/22/2016
88
Evaluation
• Ask pt. to demonstrate techniques [cough,
breathing]
• Assess dyspnea, cough, sputum, SPO2,
respiratory rate/ depth/effort
• Goal met? Not met? Partially met?
• Revision or continuation of plan?
Try This
•
•
•
•
•
•
Divide into 6 groups
For each scenario, determine:
What you think is going on
Priority Nursing Diagnosis
Goals
The focus of your interventions
– E.g. mobilize secretions, teach to TC&DB