SACR-NCM103 ALTERED OXYGENATION

ALTERED OXYGENATION: Respiratory

Brief Review of System

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SACR-NCM103 ALTERED OXYGENATION

Upper Respiratory Tract

Lower Respiratory Tract

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SACR-NCM103 ALTERED OXYGENATION

Lung Volumes & Capacities

Lung volumes amount of air exchanged during ventilation Tidal volume (TV) amount of air that moves in & out of the lungs during normal breathing (500mL) Inspiratory reserve volume (IRV) maximum amount of inhaled air in excess of the normal TV (3000mL) Expiratory reserve volume (ERV) maximum amount of exhaled air in excess of the normal TV (1100mL) Residual volume (RV) amount of air remaining in the lungs after forced expiration; increases with age (1200mL) Lung capacities 2 or more lung volumes Vital capacity (VC) = TV+IRV+ERV (amount of air than can be exhaled from maximal inspiration) 4600mL Inspiratory capacity = TV+IRV (maximum amount of inhaled air at the beginning of normal expiration & distending the lungs to its maximum) 3500mL Functional residual capacity = RV+ERV (amount of air remaining in lungs after normal expiration) 2300mL Total lung capacity = sum of all lung volumes; total amount of air that the lungs can hold average pair of human lungs can hold about 8L of air, but only a small amount of this capacity is used during normal breathing

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SACR-NCM103 ALTERED OXYGENATION

Factors Affecting Lung Volume

Larger volumes
males taller people non-smokers athletes people living at high altitudes (the body's diffusing capacity increases in order to be able to process more air)
Smaller volumes Females shorter people Smokers non-athletes people living at low altitudes (atmosphere is less dense at higher altitude, therefore, the same volume of air contains fewer molecules of all gases

Effects of Aging
Progressive loss of elastic recoil of lungs due to elastin & collagen fiber changes Increased respiratory muscle workload due to calcification of soft tissues in chest wall Total lung capacity remains constant Increased residual lung volume result of changes in aging

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Physical Assessment
Inspection: Symmetry of Chest Expansion Size of chest (barrel chest, pigeon chest, deformities, flail segment/paradoxical movement) Signs of Increased Respiratory Effort Changes in Skin Color (including nail beds) Clubbing of fingernails Include listening to patients speech Palpation Trachea slightly movable & quickly returns to midline after displacement Tactile fremitus transmission of vibration of air movement through chest wall during phonation (99 method) Thoracic excursion

Percussion: Resonant low-pitched hollow (normal lung sound) Hyperresonant louder & lower-pitched; presence of increased amount of air (emphysema, pneumothorax) Dull- thudlike Tympanic hollow (tension-pneumothorax) Flat soft high-pitched Auscultation:
Bronchial, bronchovesicular, vesicular

Adventitious Breath sounds: Stridor - High pitched crowing sound, usually heard on inspiration, indication of a tight upper airway Wheezing - Whistling sound, usually heard on expiration, indication of narrowing of lower airways (bronchospasm, edema, foreign material) Ronchi - Rattling sound, caused by mucus in larger airways Rales - Fine crackling sound, indication of fluid in the alveoli

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Diagnostics
A. Chest X-ray (Chest radiography; Serial chest x-ray) Visualization of the chest, lungs, heart, large arteries, ribs, and diaphragm while standing in front of the machine Two views are usually taken:

1. Antero-posterior view - x-rays pass through the chest from the back 2. Lateral view - x-rays pass through the chest from one side to the other
Nursing Interventions:

1. Instruct client to hold his breath while x-ray is taken 2. Inform client that test is performed in the radiology
3.

department (in hospitals, mobile x-rays may be used) & the film plate may feel cold Instruct client to wear a hospital gown and remove all jewelries

B. Pulmonary Function Tests (PFT)

1. a group of tests measuring lung function Measure of diffusion capacity client breathes in a harmless gas for a very short time (one breath) the concentration of the gas in the air exhaled is measured the difference in the amount of gas inhaled and exhaled can help estimate how quickly gas can travel from the lungs into the blood Body plethysmograph - most accurate Client sits in a sealed, clear box that looks like a telephone booth while breathing in and out into a mouthpiece Changes in pressure inside the box help determine the lung volume

2.

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Cont(PFT)
3. Spirometry test measures airflow; client will breathe through a tight fitting mouthpiece and will have nose clips Nursing Interventions: Instruct client to: a. breathe into a mouthpiece that is connected to an instrument (spirometer) b. eat a light meal before the test c. not to smoke for 4 - 6 hours before the test d. stop using bronchodilators or inhaler medications 6-8hrs prior e. Inform client that temporary shortness of breath or lightheadedness may be felt

C. Peak Expiratory Flow Rate (PEFR)

measures how fast a person can exhale it is one of many tests that measure how well the airways work requires a peak expiratory flow (PEF) monitor, a small handheld device with a mouthpiece at one end and a scale with a moveable indicator (usually a small plastic arrow) commonly used to diagnose and monitor lung diseases such as asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), & emphysema Home monitoring helps determine whether treatments are working or detect when your condition is getting worse. This allows anticipation on when breathing will become worse and to take medications or to call health care providers before symptoms become too severe

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A decrease in peak flow indicates blocked or narrowed airways A significant fall in peak flow can signal the onset of a lung disease esp. when accompanied by persistent coughing, SOB, or wheezing PEFR measurements are not as accurate as the spirometry Nursing Interventions: o Inform client that repeated efforts may cause lightheadedness o Loosen any tight clothing that might restrict breathing o Sit up straight or stand while performing the tests o Instruct client on proper procedure to do this test: Breathe in as deeply as possible. Blow into the instrument's mouthpiece as hard and fast as possible. Do this 3 times, and record the highest flow rate

D. Throat Culture
Also known as throat swab culture a laboratory test to isolate and identify organisms that may cause infection in the throat; when throat infection is suspected, particularly strep throat back of the throat is swabbed with a sterile cotton swab near the tonsils Nursing Interventions:
Instruct client not to use antiseptic mouthwashes before the test Inform client that he may experience a gagging sensation when the back of the throat is swabbed Instruct to resist gagging and closing the mouth during procedure (test only takes a few seconds)

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SACR-NCM103 ALTERED OXYGENATION

E. Bronchoscopy (Fiber Optic Bronchoscopy)

views the airways and diagnose lung disease may also be used during the treatment of some lung conditions flexible bronchoscope is usually used (less than in wide and about 2ft long) scope is passed through the mouth or nose, and then into the lungs rigid bronchoscope requires general anesthesia flexible bronchoscope uses local anesthesia (spray if via mouth and throat; numbing jelly if via nose) IV meds may be given to help relax the client

Cont(Bronchoscopy)
Nursing Interventions:
Inform client that spraying of local anesthesia will cause coughing at first, which will stop as the anesthetic begins to work Inform client that as the anesthesia wears off, the throat may be scratchy for several days Instruct client on NPO 6-12hrs prior (withhold ASA or Ibuprofen if client takes it on a regular basis or as ordered) Place client on NPO 1-2hrs after the procedure or until (+) for gag reflex

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F. Sputum Culture
Sputum - secretion produced in the lungs and the bronchi; what comes up with deep coughing This mucus-like secretion may become infected, bloodstained, or contain abnormal cells that may lead to a diagnosis Nursing Interventions: Drinking a lot of water and other fluids the night before collection may help Perform back tapping or chest clapping on client to aid in loosening the sputum Instruct client on proper specimen collection Collect morning specimen Gargle with water only before specimen collection cough deeply and spit sputum in a sterile cup Send specimen to lab ASAP

G. Oximetry
measures oxygen concentration (%) in the blood used in the evaluation of various medical conditions affecting heart & lung functions most commonly used = pulse oximeters because they respond only to pulsations, such as those in pulsating capillaries of the area tested pulse oximeter works by passing a beam of red and infrared light through a pulsating capillary bed ratio of red to infrared blood light transmitted gives a measure of the oxygen saturation in the blood Principle: oxygenated blood is bright red while the deoxygenated blood is blue-purple Other types: intracardiac oximetry - blood that is within the heart or on whole blood that has been removed from the body More recently, using a similar technology to oxymetry, carbon dioxide levels can be measured at the skin as well

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SACR-NCM103 ALTERED OXYGENATION

Alterations in Respiratory Function

Pulmonary Tuberculosis
contagious bacterial infection that mainly involves the lungs, but may spread to other organs Cause: Mycobacterium tuberculosis Mode of transmission: inhalation of air droplets from a cough or sneeze of an infected person primary stage of the infection is usually asymptomatic

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SACR-NCM103 ALTERED OXYGENATION

Mycobacterium tuberculosis Droplet inhalation Deposited into pulmonary parenchyma Immunocompetent individual Alveolar macrophage ingestion Activation of tubercle defenses Bacilli remains dormant In macrophages Infection is self-limited Primary tuberculosis Incomplete prophylaxis Complete prophylaxis Bacilli remain inactive Immunocompromised individual

Inability of pulmonary macrophages to contain bacilli

PTB

Pathophysiology

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SACR-NCM103 ALTERED OXYGENATION

High-risk individuals Elderly Infants Immunosuppressed (AIDS, chemotherapy, or antirejection medicines given after a organ transplant) Are in frequent contact with people who have the disease Live in crowded or unsanitary living conditions Have poor nutrition The appearance of drugresistant strains of TB

S/Sx Limited to minor cough Fever and night sweats Fatigue Unintentional weight loss Excessive sweating, especially at night Coughing up blood Phlegm-producing cough Wheezing Chest pain Breathing difficulty

Cont(PTB)
Dx: Chest x-ray seen on upper lobes (due to higher O2 concentration) Sputum cultures (Acid-Fast Stain) confirmatory test Empyema Tuberculin skin test (Mantoux Test) ID purified protein derivative (PPD) 48-72hrs interpretation (+) = 15mm induration (5mm for immunosuppressed clients) Bronchoscopy Thoracentesis (very rare occasions) Chest CT Scan Complications: Miliary TB - widespread dissemination of Mycobacterium tuberculosis from hematogenous spread Pleural Effusion collection of fluid in the pleural cavity Empyema purulent drainage It results from an untreated pleuralspace infection

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Cont
Tx: Multi-drug therapy = to prevent development of resistance (RIPES) Rifampicin inhibits RNA synthesis of the bacilli Isoniazid remarkably potent to the bacilli; prophylaxis; given with Vit. B6 Pyrazinamide (PZA) inhibits cell growth Ethambutol inhibits cell growth Streptomycin 1st drug found to be effective against PTB; given by injection
Nursing Management: 1. Give meds before meals 2. Maintenance therapy = after 6months 3. Client not communicable after 2wks 4. Rifampicins SE: reddish/orange body secretions (urine) 5. PZA prone to hyperuricemia so oral fluids 6. Ethambutol - A/E: optic neuritis so vision/visual changes C/I: pedia cannot report any visual disturbances 7. Streptomycin A/E: ototoxic ( tinnitus) nephrotoxic = oliguria neurotoxic = seizure precautions

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Asthma
Chronic inflammatory airway disease Exposure to allergens (dust, smoke, animal dander, pollen, volatile organic compounds, food, meds, etc) Cold air, exercise, & emotional upset can produce bronchospasm Pathophysiology: allergens immune response (mast cells, eosinophils, T lymphocytes) mucus production bronchospasm inflammation excessive mucus production narrowing of airways bronchoconstriction asthma attack

Manifestations: (asthma attacks differ from 1 person to another) Episodic wheezing Feelings of chest tightness Cough may be accompanied by wheezing Prolonged expiration Increased RR Severe attacks = severe dyspnea (use of accessory muscles) Distant breath sounds (due to air trapping) Loud wheezing Fatigue develops Moist skin Anxiety/panic attack Client is able to speak 1-2 words before taking a breath Complication: respiratory failure (onset marked by inaudible breath sounds, diminished wheezing, coughing becomes ineffective

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Cont
Dx: careful Hx & physical assessment

Spirometry Inhalation challenge test measures the level of airway responsiveness (histamine, or exposure to nonpharmacologic agent)
Tx/ Nursing Management: goal = prevention of attack episodes

Pharmacologic
Quick-relief not for daily use; relaxes bronchial muscles (albuterol, terbutaline via MDI or nebulizer) Long-term meds taken on daily basis; anti-inflammatory (cromolyn via MDI), corticosteroids (budesonide via MDI), bronchodilators (theophylline)

Mgt:
Bronchodilators Rest & relaxation techniques O2 = low flow (1-2Lpm) Nebulize Chest physiotherapy & controlled breathing (IPPB) High-fowlers/ orthopneic Immunotherapy Avoid allergens Liberal fluid intake

Meds: Aminophylline Steroids Theophylline relaxes bronchial muscles Histamine antagonist Mucolytics acetylcysteine (Fluimucil) Antibiotics

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Chronic Obstructive Pulmonary Disease (COPD)

clinical syndrome of chronic dyspnea as a result of expiratory airflow obstruction due to chronic bronchitis or emphysema (often both) Causes: long-term smoking (leading cause) & Alpha1-antitrypsin deficiency (only known inherited form of the disease) Risk factors: Exposure to certain gases or fumes in the workplace Exposure to heavy amounts of second hand smoke and pollution Frequent use of cooking gas without proper ventilation Low socioeconomic status Male Living in heavily industrialized urban areas Recurrent respiratory illnesses Family history of chronic bronchitis and emphysema (e.g., alpha1antitrypsin deficiency) Emotional stress and repressed emotions have also been shown to contribute

Chronic Bronchitis (Blue Bloaters)

chronic cough, resulting from excessive tracheobronchial mucus production and impaired mucus elimination, on most days for 3 months of a year, for 2 consecutive years Some people, even those with severe COPD, have few or no symptoms Pathophysiology: hallmarked by hyperplasia (increased number) and hypertrophy (increased size) of the goblet cells (mucous gland) of the airway increase mucus secretion airway obstruction cyanosis infiltration of the airway walls with inflammatory cells (neutrophils) scarring airway wall thickening narrowing of the small airway metaplasia (abnormal change in the tissue) & fibrosis (further thickening and scarring) of lower airway limitation of airflow cyanosis

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Chronic Bronchitis Illustration

Emphysema (Pink Puffers)

enlarged air spaces distal to the terminal bronchioles with destruction of the alveolar walls; there is also a loss of elastic recoil in the lung Pathophysiology:
exact mechanism for the development of emphysema is not understood, although it is known to be linked with smoking and age enlarged air sacs (alveoli) of the lungs reduces lung surface area lung elasticity small bronchioles collapse dead air space formation (blebs) air trapping dyspnea

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SACR-NCM103 ALTERED OXYGENATION

Emphysema Illustrations

Emphysema vs. Chronic Bronchitis

Characteristic Definition Pink Puffers - alveolar wall destruction leads to air spaces (blebs) - usual - 40-50y/o Blue Bloaters - inflammation of bronchi mucus production (goblet cells) & chronic cough - usual - 30-40y/o; mid-age disability

Smoking Hx Age of onset Clinical Features Color Barrel Chest Weight loss SOB

- acyanotic - cyanosis w/ edema - dramatic - may be present - severe (advanced) - infrequent (often overweight) - compensatory - predominant early symptom pursed-lip breathing Sputum - may be absent - copious sputum production Lung x-ray - overinflated lucent - dirty lungs Heart involvement - none, late cor pulmonale - cor pulmonale (RV) ABGs - mild-mod hypoxemia - (+)hypoxemia

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Dx: physical assessment Chest x-ray or Chest CT Scan = confirmatory PFTs, TST Lab: Arterial Blood Gas (ABG)
Below Acidosis Acidosis Alkalosis
Respiratory Alternate arrows Metabolic Same arrows

Above pH = 7.35 7.45 HCO3 = 22 26mEq/L PCO2 = 35 45mmHg Alkalosis Alkalosis Acidosis

Compensation pH compensatory system uncompensated abnormal no change partially abnormal change Fully normal change

Management: STOP SMOKING Improve oxygenation

Decrease CO2 retention (airway clearance)

Monitor respiratory patterns & assess breath sounds Low flow O2 (1-3Lpm) High fowlers position Energy conservation techniques facilitate coughing pursed-lip breathing technique Maintain adequate hydration & room humidity

Meds: bronchodilators - to increase airflow and reduce dyspnea

sometimes theophylline - requires frequent blood monitoring for toxicity inhaled steroids Antibiotics - during flare-ups of symptoms Alpha1-antitrypsin replacement therapy

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SACR-NCM103 ALTERED OXYGENATION

Pleurisy
inflammation of the lining of the lungs that causes pain when you take a breath or cough normally smooth lining of the lungs (the pleura) become rough, they rub together with each breath, and may produce a rough, grating sound called a "friction rub." Causes: may develop when you have lung inflammation due to infections such as pneumonia or tuberculosis Asbestos-related disease Certain cancers Chest trauma Pulmonary embolus - blockage of an artery in the lungs by fat, air, blood clot, or tumor cells Respiratory tract infections

S/Sx: main symptom = chest pain Some people feel the pain in the shoulder Deep breathing, coughing, and chest movement makes the pain worse fluid may collect inside the chest cavity & may cause the following: Coughing Cyanosis Shortness of breath, tachypnea Dx: Complete Blood Count (CBC) Activity intolerance (fatigue) RBC = 4.5M 5.4M Risk for infection Risk for injury (bleeding) Fluid volume deficit (dehydration) WBC = 5K 10K Platelets = 150k 450k Hematocrit = 35 45%

Risk for injury (CVA/Thrombosis) Actual infection Risk for injury (CVAclot formation) Fluid volume excess

Thoracentesis - procedure to remove fluid from the space between the lining of the outside of the lungs (pleura) and the wall of the chest; local anesthesia Pleural Biopsy - procedure to remove a sample of the tissue lining the lungs and the inside of the chest wall to check for disease or infection Ultrasound of the chest or Chest x-ray Sputum exam

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Tx: depends on what is causing the pleurisy Bacterial infections = antibiotics (some bacterial infections require a surgical procedure to drain all the infected fluid) acetaminophen or anti-inflammatory drugs such as ibuprofen (for pain control) Thoracentesis Complications: Collapsed lung due to thoracentesis Complications from the original illness Nursing Management: Health teachings (infection, work environment, splinting ribcage with pillow) Position client on affected side Thoracentesis: Instruct client not to cough, breathe deeply, or move during the test to lung puncture Instruct to report SOB &/or chest pain during procedure Apply pressure on puncture site & monitor for bleeding

Tracheostomy
Tracheostomy used for severe lung disorder, neurological problem, or infection makes it impossible to breathe, to keep the windpipe open and supply air a small opening (stoma) through the skin on the throat a breathing tube is directly inserted into the windpipe (trachea). The trache tube is sometimes sewn to the skin around the stoma It can also be held in place with trache ties Some trache tubes have an inflatable cuff near the outer end to keep it from coming out and to prevent air leaks

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trache tube parts Obturator - used to pass the trache into the windpipe outer cannula (tube) - has a plastic "trache plate" that lies against the skin of the neck and holds the trache in place Inner cannula that fits inside the outer one and locks into place Obturator and clamp should always be at bedside

Tracheostomy Care
clean the inner cannula on a daily basis Observe proper precautions & handwashing before & after care Whenever the tube threatens to become clogged with mucus, suction it clear Materials: kidney basin a small brush (like a toothbrush) or twisted OS H2O2 &/or sterile NSS 4x4 gauze pad scissors

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Procedures: Place a trache bib under the trache plate with a gauze pad (upright U) Unlock the inner cannula and remove it by pulling it gently out and down Put a clean wet inner cannula (if reserve is available) as replacement & lock in place Clean the dirty cannula by soaking it in H2O2 Scrub it with the small brush when bubbling stops Rinse well the inner cannula by pouring the sterile NSS Return in place & lock if client has no reserve

Endotracheal (ET) Tube

most common artificial airway used for short-term airway management or mechanical ventilation may be inserted either orally or nasally has a cuff that is inflated with air to hold the tube in place in the trachea amount of air in the cuff should be checked every 8hrs to ensure that the cuff is not exerting too much pressure on the trachea walls client with ET tube must be closely monitored: to ensure that the tube remains patent that skin breakdown does not occur from the tube (either the oral or nasal cavity) infection is prevented

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Intubation Illustrations
1 ET tubes 2 Intubation

3 ET tube
Placement

4 Securing the ET tube

Securing Apparatuses for ET Tube

ETAD

Thomas Tube Holder

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Nursing Management
RNs prepare all needed materials needed for intubation &/or assist in placement by securing patients position (head tilted on supine) Sterile suction kit, a bottle of sterile NSS, sterile gloves, a clean bite block if necessary, and tape already torn into appropriately-sized pieces, laryngoscope Documentation (note also tube distance at clients lips) All waste should be properly disposed Complete airway check every 8hrs & prn The insertion point (in cm) of the ET tube should be confirmed to be the same as prior to the procedure, unless the purpose of the procedure was to change the depth of the tube (via X-ray)

Cont
Primary portion of ET tube management is suctioning every 2hrs or prn Client should be hyperoxygenated prior to suctioning Color and amount of any sputum return should be noted Oral cavity should also be suctioned Thorough oral care every 8hrs and prn If client has a bite block, it must be removed and cleaned or replaced every 8hrs tube should be repositioned so as not to continuously exert pressure in the same area If the tube is taped to the client's face, tape must be removed and replaced on the opposite side of the face at least once per day and prn

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Devices for Oxygen Administration

nasal cannula (NC) - thin tube with two small nozzles that protrude into the nostrils
It can only provide oxygen at low flow rates, 2-6 litres per minute (LPM), delivering a concentration of 28-44%.

simple face mask - basic mask used for nonlife-threatening conditions but which may progress in time
Often set to deliver oxygen between 2-10 LPM The final oxygen concentration delivered by this device is dependent upon the amount of room air that mixes with the oxygen

non-rebreather mask- utilized for those requiring high-flow oxygen, but do not require breathing assistance
It has an attached reservoir bag where oxygen fills in between breaths, and a valve that largely prevents the inhalation of room or exhaled air.

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Cont
bag-valve-mask (Ambubag) - used in CPR or if client is in critical condition An oxygen reservoir bag is attached to a central cylindrical bag, attached to a valved mask administers almost 100% concentration oxygen at 815 Lpm The central bag is squeezed manually to deliver a "breath" anaesthetic machine - used for general anesthesia allows a variable amount of oxygen to be delivered, along with other gases including air, nitrous oxide and inhalational anaesthetics

Done!
You must have control of the authorship of your own destiny. The pen that writes your life story must be held in your own hand.

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