Chapter 40
Oxygenation
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Scientific Knowledge Base





Oxygen is needed to sustain life.
The cardiac and respiratory systems supply
the oxygen demands of the body.
The exchange of respiratory gases occurs
between the environment and the blood.
Respiration is the exchange of oxygen and
carbon dioxide during cellular metabolism.
Neural and chemical regulators control the
rate and depth of respiration in response to
changing tissue oxygen demands.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
2
Case Study


Mr. King, a 62-year-old man, entered the emergency
department with a 6-day history of chest pain,
shortness of breath, cough, and generalized malaise.
His wife and son are with him. Mr. King works in
sales and lives with his wife. He has a history of
chronic obstructive pulmonary disease (COPD) and
alcohol abuse but at present is not drinking.
Mr. and Mrs. King have been heavy smokers for
more than 40 years. Mr. King used to help out with
the housework and loves to tinker in the garden;
however, lately he has been unable to participate in
any of the activities. His wife states, “All he seems
able to do is sit in this chair and watch TV.”
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
3
Respiratory Physiology
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
4
Steps in Oxygenation
Ventilation
Perfusion
Diffusion
The process of moving gases into
and out of the lungs
The ability of the cardiovascular
system to pump oxygenated blood
to the tissues and return
deoxygenated blood to the lungs
Exchange of respiratory gases in
the alveoli and capillaries
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
5
Case Study (cont’d)


John Smith is the nursing student assigned to his first
hospital-based clinical experience. He has some
experience in health assessment and patient
teaching related to health promotion activities from a
recent rotation at a clinic. In the previous experience,
patients were encouraged to adjust their at-risk
health behaviors, such as smoking or poor diet.
John feels confident when he arrives in the clinical
area this morning because Mr. King has similar
health needs to the clinical experiences he has had.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
6
Respiratory Terminology





Work of breathing = The effort required to
expand and contract the lungs.
Inspiration and expiration
Surfactant = Chemical produced in the lungs
to maintain the surface tension of the alveoli
and keep them from collapsing.
Atelectasis = Collapse of the alveoli that
prevents the normal exchange of oxygen and
carbon dioxide.
Compliance and airway resistance
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
7
Respiratory Physiology
Inspiration/expiration Pulmonary circulation
Inspiration = An active process
stimulated by chemical
receptors in the aorta; a
passive process for expiration
Moves blood to and from the
alveolar capillary membranes
for gas exchange
Oxygen transport
Carbon dioxide
transport
Lungs and cardiovascular
system
Diffuses into red blood cells
and is hydrated into carbonic
acid
Lung volumes: tidal, residual, forced vital capacity (FVC);
spirometry
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
8
Respiratory Gas Exchange




The thickness of the
alveolar capillary
membrane affects the
rate of diffusion.
Oxygen transport =
Lungs + cardiovascular
(CV) system
Hemoglobin carries O2
and CO2
Carbon dioxide
transport
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
9
Case Study (cont’d)

When John goes to meet Mr. King and
performs his morning assessment, he finds
that Mr. King is overwhelmed. This patient is
in a great deal of respiratory distress. It
seems that every breath is a struggle for him.
Everything that John planned to do for Mr.
King seems less important. The patient is
extremely anxious. His wife is at his side,
anticipating John’s every move and
demanding some action.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
10
Regulation of Respiration

Neural regulation



Central nervous system controls the respiratory
rate, depth, and rhythm.
Cerebral cortex regulates the voluntary control of
respiration.
Chemical regulation


Maintains the rate and depth of respirations based
on changes in the blood concentrations of CO2
and O2, and in hydrogen ion concentration (pH)
Chemoreceptors sense changes in the chemical
content and stimulate neural regulators to adjust.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
11
Case Study (cont’d)


John’s knowledge of the physiology of pulmonary conditions will
assist him in caring for Mr. King. Mr. King’s history reveals risk
factors in addition to the 40-year history of smoking 2 packs per
day. Also, he continues to smoke. John knows that shortness of
breath shows that the infection is obstructing his alveolar
capillary membrane, preventing oxygenation of blood in some
parts of his lung. He also is aware of the preexisting COPD.
With John’s experience working with patients who are addicted
to inhaled nicotine, he recognizes the difficulty of quitting.
John knows that the most effective time to encourage patients to
stop smoking is when they are in an acute care setting with an
illness exacerbated by smoking.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
12
Cardiovascular Physiology


Cardiopulmonary physiology involves delivery
of deoxygenated blood (blood high in carbon
dioxide and low in oxygen) to the right side of
the heart and then to the lungs, where it is
oxygenated.
Oxygenated blood (blood high in oxygen and
low in carbon dioxide) then travels from the
lungs to the left side of the heart and the
tissues.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
13
Cardiovascular Physiology (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
14
Case Study (cont’d)


John’s attitude about his nursing care reflects his
respect for the patient’s autonomy and balances this
with continually educating Mr. King about the risk
factors of smoking. John knows the impact of support
systems in assisting patients coping with chronic
illness.
He uses creativity and independent thinking to
incorporate community and family resources into the
plan of care for Mr. King. John will need to inquire
about his social supports and the availability in his
community of programs to help him quit smoking.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
15
Cardiovascular Physiology
Myocardial pump
Myocardial blood flow
Two atria and two ventricles
As the myocardium stretches,
the strength of the subsequent
contraction increases
(Starling’s law).
Unidirectional through four
valves
Coronary artery
circulation
Coronary arteries supply the
myocardium with nutrients and
remove wastes.
S1: mitral and tricuspid close
S2: aortic and pulmonic close
Systemic circulation
Arteries and veins deliver
nutrients and oxygen and
remove waste products.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
16
Blood Flow Regulation
Cardiac output
Stroke volume
Amount of blood ejected Amount of blood ejected
from the left ventricle
from the left ventricle with
each minute
each contraction
Cardiac output (CO) =
Stroke volume (SV) × Heart rate (HR)
Preload
End-diastolic pressure
Afterload
Resistance to left
ventricular ejection
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
17
Conduction System
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
18
Conduction System (cont’d)
Autonomic nervous
system
Sympathetic nervous
system
Influences the rate of impulse
generation and the speed of
conduction pathways
Increases the rate of impulse
generation and impulse
transmission and innervates all
parts of the atria and ventricle
Parasympathetic system
Conduction system
Decreases the rate and
innervates atria, ventricles, and
sinoatrial and atrioventricular
nodes
Originates with the sinoatrial
(SA) node or pacemaker and is
transmitted to the atrioventricular
(AV) node, bundle of His, and
Purkinje fibers
An electrocardiogram (ECG) reflects the electrical conduction
system of the heart.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
19
Normal Electrocardiogram Waveform
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
20
Factors Affecting Oxygenation

Physiological factors

Decreased oxygen-carrying capacity
 Hypovolemia
 Decreased inspired oxygen concentration
 Increased metabolic rate

Conditions affecting chest wall movement


Pregnancy, obesity, neuromuscular disease,
musculoskeletal abnormalities, trauma, CNS
alterations
Influences of chronic diseases
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
21
Case Study (cont’d)



John reviews the standards set by the American
Cancer Society to identify that tobacco use accounts
for at least 30% of ALL cancer deaths and 87% of
lung cancer deaths.
In 2011, ~221,130 new cases of lung cancer and
~156,940 deaths from lung cancer were reported in
the United States.
He uses this information and the resources at
www.cancer.org to assist in educating Mr. King and
his wife about cancer statistics and methods to quit
smoking.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
22
Alterations in Respiratory
Functioning
Hyperventilation
Hypoventilation
Ventilation in excess of that
required to eliminate carbon
dioxide produced by cellular
metabolism
Alveolar ventilation
inadequate to meet the
body’s oxygen demand or to
eliminate sufficient carbon
dioxide
Hypoxia
Cyanosis
Inadequate tissue oxygenation Blue discoloration of the skin
at the cellular level
and mucous membranes
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
23
Alterations in Cardiac Functioning
Disturbances in conduction
Caused by electrical impulses
that do not originate from the SA
node (dysrhythmias)
Altered cardiac output
Insufficient volume is ejected into
the systemic and pulmonary
circulation; the result of left-sided
or right-sided heart failure
Impaired valvular function
Acquired or congenital disorder of
a cardiac valve by stenosis or
regurgitation
Myocardial ischemia
Coronary artery flow to the
myocardium insufficient to meet
myocardial oxygen demands;
results in angina, myocardial
infarction (MI) and/or acute
coronary syndrome (ACS)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
24
Nursing Knowledge Base

Factors influencing oxygenation:

Physiological
 Developmental
 Lifestyle
 Environmental
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
25
Developmental Factors




Infants and toddlers
School-aged children and adolescents
Young and middle-aged adults
Older adults
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
26
Lifestyle Factors
Nutrition
Cardioprotective nutrition = Diets rich in fiber;
whole grains; fresh fruits and vegetables; nuts;
antioxidants; lean meats; and omega-3 fatty acids.
Exercise
People who exercise for 30 to 60 minutes daily
have a lower pulse rate and blood pressure,
decreased cholesterol level, increased blood flow,
and greater oxygen extraction by working muscles.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
27
Lifestyle Risk Factors

Smoking



Substance abuse


Associated with heart disease, COPD, and lung cancer
The risk of lung cancer is 10 times greater for a person who
smokes than for a nonsmoker.
Excessive use of alcohol and other drugs impairs tissue
oxygenation.
Stress

A continuous state of stress or severe anxiety increases the
metabolic rate and oxygen demand of the body.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
28
Environmental Factors


The incidence of pulmonary disease is higher
in smoggy, urban areas than in rural areas.
A patient’s workplace sometimes increases
the risk for pulmonary disease.


Coccidioidomycosis
Asbestosis
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
29
Critical Thinking

Professional standards:

Agency for Healthcare Research and Quality
(AHRQ)
 American Cancer Society (ACS)
 American Heart Association (AHA)
 American Lung Association (ALA)
 American Thoracic Society (ATS)
 American Nurses Association ANA)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
30
Assessment
In-depth history of a patient’s normal and
present cardiopulmonary function
Past impairments in circulatory or respiratory
functioning
Methods that a patient uses to optimize
oxygenation
Review of drug, food, and other allergies
Physical examination
Laboratory and diagnostic tests
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
31
Case Study (cont’d)


John Smith begins his morning care for Mr.
King. He finds Mr. King restless and anxious.
John notices that as the day progresses, Mr.
King’s coughs are weaker, less sputum is
produced, and Mr. King is becoming more
fatigued.
What are five assessment steps John could
take?
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
32
Assessment: Nursing History
Chest pain
Fatigue
Dyspnea
Cough
Wheezing
Smoking
Respiratory infection
Allergies
Health risks
Medications
Environmental/geographical exposures
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
33
Case
Study
(cont’d)
Ask Mr. King how long he has “I have been short of breath for 1 week,
been short of breath.
and it has gotten worse.”
Take Mr. King’s vital signs.
Pulse rate is 120 beats/min
Temperature is 102° F
Respiratory rate is 36 breaths/min Blood
pressure is 110/45 mm Hg
Arterial oxygen saturation (SpO2 ) is 82%;
Mr. King is dyspneic
Ask Mr. King how long he has “I usually cough when I wake up in the
had his cough and whether it morning. Three days ago, I noticed that I
is a productive cough.
was coughing up thick mucus that has not
stopped.”
Auscultate Mr. King’s lung
fields.
Expiratory wheezes, crackles, and
diminished breath sounds over the right
lower lobe are audible.
Ask Mr. King to produce a
sputum sample.
Sputum is thick and discolored (yellowgreen).
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
34
Physical Examination
Inspection
Palpation
Skin and mucous
membranes, level of
consciousness (LOC),
breathing patterns, chest
wall movement
Chest, feet, legs, pulses
Percussion
Auscultation
Presence of abnormal
fluid or air; diaphragmatic
excursion
Normal and abnormal
heart and lung sounds
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
35
Quick Quiz!
1. A patient complains of chest pain. When
assessing the pain, you decide that its origin
is cardiac—rather than respiratory or
gastrointestinal—when it
A. Does not occur with respiratory variations.
B. Is peripheral and may radiate to the scapular
region.
C. Is aggravated by inspiratory movements.
D. Is nonradiating and occurs during inspiration.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
36
Diagnostic Tests
Blood tests Imaging
Noninvasive
CBC
 Chest x-ray
 Cardiac
 Cardiac
enzymes
catheterization
 Serum
electrolytes
 Cholesterol


TB skin test
 Holter monitor
 ECG
 Thallium stress test
 EPS
 PFT
CBC, Complete blood count; ECG, electrocardiography; EPS, evoked potential studies; PFT, pulmonary function testing;
TB, tuberculosis.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
37
Nursing Diagnosis and Planning
Activity
intolerance
Impaired gas
exchange
Decreased
Fatigue
cardiac output
Impaired
Impaired verbal
spontaneous
communication
ventilation
Ineffective
Ineffective
Ineffective health
airway clearance breathing pattern
maintenance
Risk for
Risk for infection
Risk for
aspiration
suffocation
Risk for imbalanced fluid volume
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
38
Case Study (cont’d)


Nursing diagnosis: Ineffective airway
clearance related to pulmonary secretions
Goals:


Pulmonary secretions will return to baseline levels
within 24 to 36 hours.
Mr. King’s oxygenation status will improve in 36
hours.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
39
Case Study (cont’d)

Respiratory status: gas exchange






Mr. King’s sputum will be clear, white, and thinner in
consistency within 36 hours.
Mr. King’s lung sounds will be at baseline within 36 hours.
Mr. King’s respiratory rate will be between 16 and 24 breaths
per minute within 24 hours.
Mr. King will be able to clear airway secretions by coughing
in 24 hours.
Mr. King’s SpO2 will be greater than 85% within 24 hours.
Mr. King’s perceptions of dyspnea will improve.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
40
Implementation: Health
Promotion

Vaccinations


Healthy lifestyle


Influenza, pneumococcal
Eliminating risk factors, eating right, regular
exercise
Environmental pollutants

Secondhand smoke, work chemicals, and
pollutants
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
41
Implementation: Acute Care
Mobilization of
Dyspnea
Airway
pulmonary
management
maintenance secretions
Hydration
Humidification Nebulization
Coughing and
Chest physiotherapy
deep-breathing
(postural drainage)
techniques
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
42
Case Study (cont’d)

Airway management:



Have Mr. King deep breathe and cough every 2
hours while awake.
Have Mr. King change position frequently if on bed
rest. If able, have him ambulate 10 to 15 minutes
every 8 hours, and encourage him to sit up in a
chair as often as he is able to tolerate.
Encourage Mr. King to increase his fluid intake to
2800 mL/24 hours if his cardiac condition does not
contraindicate it and to avoid caffeinated
beverages and alcohol; recommend water.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
43
Percussion
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
44
Implementation: Suctioning
Techniques

Oropharyngeal and nasopharyngeal


Orotracheal and nasotracheal


Used when the patient can cough effectively but is
not able to clear secretions
Used when the patient is unable to manage
secretions
Tracheal

Used with an artificial airway
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
45
Tracheal Care
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
46
Artificial Airways

Oral airway


Endotracheal and tracheal airways


Prevents obstruction of the trachea by
displacement of the tongue into the oropharynx
Short-term use to ventilate, relieve upper airway
obstruction, protect against aspiration, clear
secretions
Tracheostomy

Long-term assistance, surgical incision made into
trachea
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
47
Artificial Airways (cont’d)
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
48
Maintenance and Promotion
of Lung Expansion


Ambulation
Positioning


Incentive spirometry


Reduces pulmonary stasis, maintains ventilation
and oxygenation
Encourages voluntary deep breathing
Noninvasive ventilation

Maintains positive airway pressure and improves
alveolar ventilation
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
49
Promotion of Lung Expansion
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
50
Case Study (cont’d)


Two days later, when John auscultates Mr.
King’s lungs, he finds that the lung sounds
are clear.
What three other steps could John take as
nursing actions of evaluation?
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
51
Quick Quiz!
2. A patient with a tracheostomy has thick
tenacious secretions. To maintain the airway,
the most appropriate action for the nurse
includes
A. Tracheal suctioning.
B. Oropharyngeal suctioning.
C. Nasotracheal suctioning.
D. Orotracheal suctioning.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
52
Case Study (cont’d)



John asks Mr. King to keep track of his fluid
intake.
John asks Mr. King to ambulate for 10
minutes every 4 hours.
John asks Mr. King to keep track of deep
breathing every 2 hours while awake.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
53
Maintenance and Promotion
of Lung Expansion

Chest tube




A catheter placed through the thorax to remove air
and fluids from the pleural space, to prevent air
from re-entering, or to re-establish intrapleural and
intrapulmonic pressures
Pneumothorax
Hemothorax
Special considerations
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
54
Chest Tubes
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
55
Case Study (cont’d)



Mr. King has kept track of his fluid intake, and
he has averaged 2800 mL/24 hours. He is
coughing thin secretions.
Mr. King ambulates once every 8 hours.
Mr. King’s diary documented deep breathing
every 2 hours while awake 85% of the time.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
56
Maintenance and Promotion
of Oxygenation

Oxygen therapy



Safety precautions
Supply of oxygen


To prevent or relieve hypoxia
Tanks or wall-piped system
Methods of oxygen delivery


Nasal cannula
Oxygen mask
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
57
Oxygen Delivery
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
58
Venturi Face Mask
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
59
Home Oxygen Systems

Indications
Arterial partial pressure (PaO2) of 55 mm Hg or less
–or–
 Arterial oxygen saturation (SaO2) of 88% or less on room air
at rest, on exertion, or with exercise




Administered via nasal cannula or face mask
T tube or tracheostomy collar used if patient has a
permanent tracheostomy
Beneficial effects for patients with chronic
cardiopulmonary disease
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
60
Quick Quiz!
3. When evaluating a post-thoracotomy patient
with a chest tube, the best method to properly
maintain the chest tube would be to
A. Strip the chest tube every hour to maintain
drainage.
B. Place the device below the patient’s chest.
C. Double clamp the tube except during
assessment.
D. Remove the tubing from the drainage device
to check for proper suctioning.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
61
Restoration of Cardiopulmonary
Functioning

Cardiopulmonary resuscitation (CPR)
1. Circulation
2. Airway
3. Breathing

Defibrillation (automatic external defibrillator
[AED])
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
62
Case Study (cont’d)



Both Mr. and Mrs. King are interested in preventing
future hospitalizations and in learning what they can
do to maintain their health.
John reviewed teaching strategies with them, with the
goal of Mr. and Mrs. King verbalizing the steps they
need to take to improve their health and reduce the
risk for future hospitalizations.
John established evaluation strategies to measure
the success of patient teaching.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
63
Restorative and Continuing Care

Cardiopulmonary rehabilitation



Controlled physical exercise; nutrition counseling;
relaxation and stress management; medications;
oxygen; compliance; systemic hydration
Respiratory muscle training
Breathing exercises


Pursed-lip breathing
Diaphragmatic breathing
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
64
Case Study (cont’d)

John cares for Mr. King throughout his hospital stay.
Mr. King is afebrile, his white blood cells are within
normal limits, and his sputum cultures are negative
on the day of discharge. He does not require
supplemental oxygen. He is able to describe ways to
prevent respiratory infections because they
aggravate airways and precipitate an episode of
acute respiratory failure. Because he now practices
pursed-lip breathing, his breathing is more controlled,
relieving his subsequent anxiety.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
65
Evaluation

Ask about






Degree of breathlessness
If distance ambulated without fatigue has increased
Rating the breathlessness from 0 to 10
Which interventions reduce dyspnea
Frequency of cough and sputum production
Perform



Observe respiratory rate before, during, and after any
activity.
Assess any sputum produced.
Auscultate lung sounds for improvement in adventitious
sounds.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
66
Case Study (cont’d)



While John is observing Mr. King preparing for
discharge, it is evident that Mr. King is using the
various breathing techniques that they have worked
on together.
Mr. King is able to go home with improved activities
of daily living.
His wife appears even less anxious and states that
she feels as though for the first time they have taken
a step (even though small) toward improving the
quality of their lives.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
67
Safety Guidelines





Patients with sudden changes in their vital signs,
level of consciousness, or behavior are possibly
experiencing profound hypoxia.
Perform tracheal suctioning before pharyngeal
suctioning whenever possible.
Use caution when suctioning patients with a head
injury.
The routine use of normal saline instillation into the
airway before ET and tracheostomy suctioning is not
recommended.
Check your institutional policy before stripping or
milking chest tubes.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
68