Oxygenation

 Anatomy & Physiology

o Describe the factors that are essential to normal functioning of the
Respiratory System
 Integrity of airway system to transport it to and from the lungs
 Properly functioning alveolar system in the lungs to oxygenate
venous blood and remove carbon dioxide from the blood
 Properly functioning cardiovascular system and blood supply to
carry nutrients and wastes to and from body cells

o Describe the process of ventilation, gas exchange, and the transport of

respiratory gases
 Pulmonary respiration=movement of air into and out of the lungs
 Respiration= involves gas exchange between atmospheric air in the
alveoli and blood in the capillaries
 Perfusion=the process by which oxygenated capillary blood passes
through body tissues
o Inspiration
 The active phase, involves movement of muscles and the thorax to
bring air into the lungs
 Diaphragm contracts and descends, lengthening the thoracic
cavity, external intercostals contract, lifting the ribs upwards
and outwards, sternum is pushed forward, chest is enlarged
o Expiration
 The passive phase, is the movement of air out of the lungs
 Relaxation or recoil of muscles, diaphragm moves up, and
ribs move down
 Gas Exchange

 Profusion: Hypoxia
o Hypoxia
 Dyspnea
 Manifestations
 Elevated BP
 Increased pulse and respiration
 Pallor or cyanosis (pallor=pale, cyanosis=blue)
o Other Common Signs
o Early signs
 Restlessness
 Anxiety
 Tachycardia/Tachypnea –rapid and shallow unnormal breathing
o Late signs:
 Bradycardia
 Extreme restlessness
 Dyspnea – shortness of breath
 Confusion and Drowsiness occur as very late signs
 Ways to check for hypoxia if pulse ox isn’t available:
o 1. If they have dark skin, it will be more difficult to see cyanosis, so pull
down the eyelid and see if the skin is pink…if it is blue it is cyanotic
o 2. Check mucous membranes in the mouth
o 3. Check capillary refill
 Perfusion: Hypoventilation
o Chronic
 Affects all body systems
 Altered thought processes
 Headaches
 Chest pain
 Enlarged heart
 Clubbing of the digits
 Anorexia
 Constipation
 Decreased UOP
 Decreased libido
 Muscle pain and weakness

 Factors Affecting Respiratory Function

o Levels of Health
 Acute
 Ex: panic attack, allergic reaction, bronchitis
 Chronic
 Ex: COPD, asthma
o Developmental Considerations
o Medications
 ** some can increase or decrease breathing rate
 albuterol increase in respiratory rate and heart rate
o Lifestyle
 Exercise, stress, smoking
o Environment
 Scared/anxious in high altitude, pollution
o Psychological Health
 Stress, anxious, panicing
 Assessment-USE NURSING PROCESS
o Nursing history (finding out when it happen and what triggered it)
 Current and past respiratory problems
 Lifestyle, risk factors for impaired oxygen status
 Presence of cough and sputum or pain
 Medications for breathing
o Physical examination
 Nurse observes rate, depth, rhythm, and quality of respirations
  Must expose chest of patient in order to observe respirations
 Inspects variations of shape of thorax

See notes for info on above and below diagrams

 Diagnostic Procedures
o Review Box 39-1
o Tests
 Sputum specimens
 On pneumonia patients
 Throat cultures
 For strep throat
 Visualization procedures
 Venous and arterial blood specimens
 Pulmonary function tests (Box 39-2)
 Thoracentesis- puncture chest wall to remove fluid
  Procedure
 Nursing Responsibilities
o ***ABG= arterial blood gas taken if sever lab results found
o Strider= dangerous, sounds like a dog bark (more common in pediatric
unit)

HCP orders nurse to take sputum culture

-best time of day is in the morning before breakfast
-how to collect= don’t contaminate with saliva, take samples before
administering antibiotics, if you forget and do it after, be honest and tell HCP
 Diagnosis and Expected Outcomes
o Name 3 nursing diagnoses for a patient with altered respiratory function

o Describe 3 corresponding expected outcomes for a patient with altered

respiratory function

 Implementation
o Describe ways that nurses promote adequate respiratory functioning in
the patient.
 Promoting optimal function
 Put the head of the bed up, administer o2 after assessment
o DO NOT ever give patient O2 without assessing them
first

 Promoting proper breathing

 Promoting and controlling coughing

 Promoting comfort

o **Mild respiratory distress head to toe assessment

o **Sever respiratory distress focused assessment
o **Pulse ox can be used for baseline, call doc after you assess and implement

*****For test purposes, 2L of O2 is administered to patient via nasal canula (in reality,
amount is based on patient’s severity)

 Interventions
o CPT
 To losen up any secretions, done by a respiratory therapist or a
nurse and is conducted by clapping the back of the patient
o Medications
o Oxygen Therapy
 Determine mode and amount of O2
o Managing Chest Tubes
 Document color and amount of drainage
o Artificial Airways
o Clearing Airway Obstructions/Suctioning
  Trach
o CPR
 ***Cant do respiratory therapy right after patient eats ***
 Percussion, Vibration, & Drainage
o POSITIONS FOR CPT AND OTHER SITUATIONS

o Percuss
 Cover area with towel or gown to reduce discomfort
 Ask client to breathe slowly and deeply
 Alternately flex and extend wrists rapidly to slap the posterior
chest
 Percuss each affected lung segment for 1-2 minutes
o Vibration
 Place hands, palms down, on chest area to be drained
 Ask client to inhale deeply and exhale slowly
 During exhalation vibrate the hands
 Vibrate during five exhalations
 After each vibration, ask client to cough and expectorate
secretions
o Postural drainage
 Place client in appropriate positions to allow gravity to drain
affected areas of lung
 Lower lobes require drainage more often than upper lobes
 Usually scheduled before meals to prevent vomiting
 o Mucous Clearance Device
 Used instead of your hands for clapping in CPT
 Clients with excessive secretions (cystic fibrosis, COPD)
 Flutter device one example
 Client inhales slowly, holds cheeks firm while exhaling fast
 Vibrations loosen mucus for expectoration
 Incentive Spirometry
o Improves pulmonary ventilation
 Used to strengthen lungs
 Usually after surgery
 Educate patients on how to use it and how often to use it
 Take baseline
 Document the use of incentive spirometer
 In notes, write everything you do and teach!
o Counteracts effects of anesthesia or hypoventilation
o Loosens respiratory secretions
o Facilitates respiratory gaseous exchange
o Expands collapsed alveoli
 Medications used for patients with respiratory disorders
o Bronchodilators
o Anti-inflammatory drugs (glucocorticoids, leukotriene modifiers)
o Expectorants
o Cough suppressants
o Others that improve cardiovascular function (e.g., digitalis glycosides);
must be monitored closely
 Digoxin, lasixs

o TABLE 39-2
 Oxygen Therapy
o **Everytime you enter a room, ensure O2 machine is functioning properly
o Check vital signs and oxygen saturation level
o Ordered for clients with hypoxemia, anemia, blood loss
o Primary care provider specifies concentration, method of delivery, liter
flow per minute; may call for titration to achieve therapeutic level
o Nurse may initiate in emergency, then call provider
o Portable or wall outlet; humidifier for high flow to prevent drying
 Small bottle of water attached to oxygen machine
 Keeps nose moist
o Safety precautions
 Handle and store with caution to prevent falls and breakage
 Highly flammable
 No smoking in room with oxygen; no-smoking signs
 Avoid faulty electrical equipment and static
o BP machine, IV pump, remove from work and mark
accordingly if not working properly
 Avoid use of volatile flammable materials nearby (nail
polish remover, oil, alcohol)
 Ensure grounding of all electrical equipment
 Fire extinguishers available and staff trained in use
 Oxygen Delivery Systems
o Nasal cannula supplemental O2
o Simple face mask
 Partial rebreather mask
 Non-rebreather mask
 Venturi mask
o Face tent
o Transtracheal catheter
o Noninvasive positive pressure ventilation
 Most common type is continuous positive airway pressure (CPAP)
 Bilevel positive airway pressure (BiPAP)
o Used in sleep apnea, COPD, etc.
o Refer to procedure “Administering Oxygen by Cannula, Face Mask, or
Face Tent”
 Chest Tubes
***check to make sure there is drainage, put mark with time and na,e on machine,
document color and amount of drainage
 Chest Tubes and Drainage Systems
o Negative pressure between pleural layers lost by disease, surgery, trauma; leads to
 Pneumothorax (air)
 Hemothorax (blood)
o Pleural effusion (excessive fluid in pleural space)
o Chest tube to restore pressure and drain fluid or blood
 Pneumothorax tube (upper chest)
 Hemothorax tube (lower chest)
 Care of Patient with Chest Tube
o Maintain patency of system
o Monitor VS, observe dressing q 4 h, ask about pain and medication if needed
o Encourage deep breathing/coughing q 2 h (except with lung removal)
o Reposition q 2 h; when on affected side, provide rolls to protect patency of tubing
o Assist with ROM exercise
o Ensure secure placement of device and keep chamber below client’s chest
o Check system often
o Assess drainage tube and chamber; measure per schedule
o Avoid aggressive manipulation or clamping (can produce tension pneumothorax)
o If tube becomes disconnected, submerge the end in 1 inch sterile saline or water
o If chest tube is pulled out, immediately cover with dry sterile dressing; do not occlude opening
completely as this can cause tension pneumothorax
 Artificial Airways
o For client whose airway has or may become obstructed
o Oropharyngeal and nasopharyngeal
 Easy to insert; low risk of complications
 Oropharyngeal for unconscious clients
 Nasopharyngeal for alert clients with gag reflex
o Tracheostomy – anesthesia or ventilation
 Opening into trachea; client cannot speak
o Tube with outer and inner cannula, obturator, flange with tubes or ties
o Cuffed tracheostomy tubes
 Airtight seal; prevents aspiration and air leakage
o Nursing care involves cleaning and suctioning
o Humidity may need to be provided
 Mist collar, Swedish nose
 Suctioning
o Suctioning through a yanker is the only tool we can use as nurses
o **Seizure precaution
o Aspirating secretions through a catheter connected to suction machine or
wall suction outlet
o Assess for signs of respiratory distress
o Client inability to cough up and expectorate secretions, dyspnea, poor
skin color, bubbling or rattling breath sounds, decreased O2 saturation
o Can lead to hypoxemia, trauma to airways, nosocomial infection, cardiac
dysrhythmia
o Decrease complications by
 Hyperinflation
 Hyperoxygenation
 Hyperventilation
 Gently rotate catheter, withdraw while suctioning, suction for 5-10
seconds
 Airway Obstruction/CPR
o A: AIRWAY
o B: BREATHING
o C: CIRCULATION
o Review CPR Techniques
o ***do skills within scope of practice
o AUTOMATIC fail for giving medication/invasive procedure to patient
(changing dressing) without faculty