Exam 3 Flashcards
Managing Physiologic Responses to Terminal Illness
-Pain:
Establish a regimen of analgesics to provide optimal pain relief
-Dyspnea:
Treat underlying pathology, monitor response, manage anxiety, conserve energy
-Nutrition and Hydration:
Anorexia vs. cachexia
Family may want to make their favorite meal, and the patient doesn’t like it.
-Delirium:
Treat underlying factors contributing to delirium
Change in the last 24 hours that is drastic. (Change in medications, infections, electrolytes that are off). Correctible problems, need to have it treated.
-Depression:
Emotional, spiritual and medical support
Dying
-Some people decline gradually others go quickly
-There are changes you can expect to see as the body stops working.
-Children and teens can stay fairly active until near the end.
-1 to 3 months before death:
Sleep or doze more
Eat and drink less
Withdraw from people and stop doing things they usually do
Talk less or at times need to talk more
What is seen 1 to 2 weeks before death?
- May feel tired or drained all the time and spend more time in bed
- Change in sleep-wake patterns
- Little appetite and thirst or even interest in these, therefore less urine and stool output
- Changes in blood pressure, breathing and heart rate
- Body temperature dysregulation: cool, warm, moist or pale skin
- Congested breathing: If they have congested breathing we can suction, but not deep suction into the trachea.
- Confusion or seem in a daze
- May have more pain
Days to hours before death
Not wanting food or drink Stop having urine output or stool Grimace, groan or scowl Unfocused gaze May seem to drift in and out of awareness Irregular or week pulse Rapid or Cheyne-Stokes breathing until there is none Skin cool or mottled
Care of the body after death
-Organ and tissue donation: The floor nurse caring for the patient does not broach this subject. You MUST call a specially trained professional.
-Autopsy: Can be requested or required.
Required if cause of death is the result of criminal violence, suicide, accidental cause (car accident), suspicious death, work place injury, suspected drowning, unexpected death of an infant or child, or while in custody of the police or a local, state or federal institution.
Can be requested by a family for other reasons, but they must pay for it.
-You have to listen for a heart beat for a couple of minutes. We do not fill out the death certificate or determine the cause of death. Two nurses can pronounce the death.
-If the person dies of criminal activity or unobserved death then they cannot remove any of the tubes. They can cut it but leave it in so that the coroner can tell whether the damage done was done my intubation or by other things the nurse has done rather than the initial cause of injury.
Post Mortem Care
-Ensure that the family or loved ones wishes, rituals or customs are respected whenever possible.
-Allow them to assist with final bathing of the body if they desire
-Physical changes in the body can set in rapidly:
Close the eyes and mouth. Leave denture in to support the shape of the mouth.
Remove tubes and IV unless autopsy required
Clean the body and cover with a clean sheet with arms on the outside.
Elevate the HOB some to prevent discoloration of the face.
Place padding under the body in case sphincters relax-No diaper
-Allow the family or loved ones all the time they need with the body.
-Give jewelry and personal property of the deceased to the family and have them sign the appropriate forms.
-Ask the family if they have made arrangements with a mortuary or if they would like you to call one of their choosing.
-Contact the mortuary and they will usually come to pick up the body.
-Contact the appropriate personnel to take the body to the hospital morgue.
Grief
- Loss, Grief, and Bereavement
- Loss: losing a loved one
- Grief: personal feelings that accompany an anticipated or actual loss
- Stage of grief (Kubler-Ross and other grief theories): People don’t move through the stages of grief in a linear fashion, it loops back and forth over time.
- Mourning: individual, family, group and cultural expressions of grief and associated behaviors
- Bereavement: period of time in which mourning takes place
- Professional caregivers are not immune to grief!
- Our care turns from the patient to the family.
Grieving
- Does not follow a prescribed course.
- Just be present-don’t offer platitudes
- Highly visible losses generally stimulate help from others.
- Grief may come out as anger-don’t take it personally
- Grief work is just that, work.
- Refer people to grief resources such as Solace House
Spirituality
- Ask him or her if you and the health care team met their expectations and if there is anything else you can do to enhance their spiritual well-being or enable them to practice important religious rituals.
- Most health care workers are uncomfortable talking about spirituality and beliefs.
- Most hospitals have a pastoral care office-use this resource.
- An individuals spiritual beliefs are very personal. Avoid making assumptions even if you think you are of the same faith or if you have studied about different faith traditions that that individual follows it the same way as others.
- Be sure not to preach. The hospital isn’t the place.
- Are your spiritual needs being met? Can we do anything to meet them?
rituals
- Rituals help express a communal emotion in a shared way
- Late 19th century- memorials for deaths and took pictures with the dead
- think about: What would I want for my death?
Palliative care
- An approach to care of the seriously and/or chronically ill that is comprised of comprehensive symptom management, psychological care, and spiritual support to enhance quality of life.
- can be provided along with curative treatment and does not depend on prognosis.
a resource for anyone living with a serious - illness, such as heart failure, chronic obstructive pulmonary disease, cancer, dementia, Parkinson’s disease, and many others. - Palliative care can be helpful at any stage of illness and is best provided from the point of diagnosis.
- In addition to improving quality of life and helping with symptoms, palliative care can help patients understand their choices for medical treatment.
- The organized services available through palliative care may be helpful to any older person having a lot of general discomfort and disability very late in life.
- Palliative care can be provided along with curative treatment and does not depend on prognosis.
WHO-World Health Organization & death and dying
- Affirms life and regards dying as a normal process.
- Neither hastens or postpones death.
Integrates psychological and spiritual aspects of care. - Offers a support system to help patients live as actively as possible until death.
- Enhances the quality of like.
- Uses a team approach to meet the needs of patient and families.
- Expresses nursing attitude
Palliative Care Trigger Tool (just know this exists)
Does this patient meet any of the following criteria?: (Check all that apply)
- DNR/DNI
- Would not be surprised if the patient died within 12 months.
- ICU stay > 7days, readmission to ICU within 30 days with same diagnosis
- Two or > hospitalizations for the same illness within 3 months
- Admission from long-term care facility or medical foster home
- Prolonged dysfunction of multiple organs (MODS)
- Advanced dementia (bedbound and non-verbal)
- Intracerebral Hemorrhage requiring mechanical ventilation
- Unsuccessful wean and/or prolonged ventilator dependence
Hospice
- A coordinated comprehensive program of holistic interdisciplinary services provided by professional care givers and trained volunteers to terminally ill patient and their families at the end of life.
- provided for a person with a terminal illness whose doctor believes he or she has 6 months or less to live if the illness runs its natural course.
- Someone is available 24/7 for support, but the patient must have a family caregiver to provide care when the patient is no longer able to function alone.
Hospice: core principles
- Provision of interdisciplinary care. Medical and nursing services available at all times.
- Affirms life, but never denies death as a normal process of life.
- Education and support is provided, it honors wishes and supports choices.
- The patient and family are a unit of care.
- A physician-directed service.
- Bereavement follow-up after patient’s death.
- Home care of the dying is preferred.
Support system for dying patients
- nurse
- hospice aide
- social worker: Can assist with finding resources for legal and financial needs.
- chaplin
- grief support
- volunteer
- your personal physician
- hospice physician
Barriers to Improving End of Life Care
Clinicians’ Attitudes toward Death & Dying:
Reluctant to discuss death with patients
Avoid discussion in hopes patient would discover on their own
Awareness contexts
Communication:
Providing bad news
Responding to difficult questions
. They may feel that their job is to fix or cure and death represents a failure.
Glaser and Strauss’ four awareness contexts of the patient, provider and family in regards to discussion of terminal illness or death and dying
. Closed awareness is when the patient is unaware of their terminal state but others are aware.
- Suspected awareness is when the patient suspects what others know and attempts to find out details about their current health condition.
- Mutual pretense awareness is when the patient, the family and the providers are all aware that the patient is dying but all pretend otherwise.
- Open awareness is when the patient, family, and provider are aware the patient is dying and openly acknowledge that reality.
- Communication may also be a barrier to improving end of life care particularly if providers do not know how to respond when providing bad news to patients or responding to difficult questions regarding prognosis.
Methods of Stating End-of-Life Preferences
Advance directives:
- Written documents, individual of sound mind
- Document preferences regarding EOL care to be followed when individual cannot communicate their wishes
- The documents are generally completed in advance of serious illness, but may be completed after a diagnosis of serious illness if the signer is still
Durable power of attorney for health care:
- Legal document
- Signer appoints another to make medical decisions on his/her behalf
- make medical decisions on his or her behalf when he or she is not longer able to speak for him or herself. This is also known as a health care power of attorney or a proxy directive.
Living will:
- Individual documents treatment preferences
Provides instructions for care when individual cannot communicate wishes
- This is also known as a medical directive or treatment directive.
Physician Orders for Life-Sustaining Treatment (POLST):
- Translates patient preferences expressed in advance directives to medical orders that are transferrable across settings and readily available to all health care providers including emergency medical personnel.
- Sometimes advance directives are barriers to improving end of life care for patients because these documents must be followed even if it could potentially result in decreased QOL for the patient.
Infants and Toddlers with death and dying
- Gauging pre-verbal children and their view of death is impossible
- No concept of death based on their cognitive abilities
- Egocentricity of toddlers and their vague separation of fact and fantasy make it impossible for them to comprehend the “absence of life”
- May repeat the statement, “Grandpa is dead; he went to heaven,” but may still expect him to return over a period of a few months
- Behavior related to reacting to their parents’ reactions and anxiety
regression in speech, toileting, Crying, control with food and drink, hitting, biting, with drawl
Encourage parents to stay with the patients as often as possible!
Interventions for this population include:
- Physical comfort
- Consistent caregivers/routine
- Familiar objects
- Family needs of children of all ages:
- Feelings of anger, guilt, anxiety, and helplessness are normal
- They worry about pain and comfort of their child
- Help families identify that their feelings are normal and identify ways to cope
- Respite, seek assistance out side of the family
Preschool Children 3-5yr with death and dying
- Egocentric and have a tremendous sense of self-power
- Believe their thoughts can cause actions
- Struggle with the meaning of “Death”, may see it as a departure or sleep, reversible
- Often will feel that they are sick as a punishment for being bad, especially if parents are unable to stay with them or be present during painful procedures
- Greatest fear of death is separation from parents
- Play provides the preschooler with relief from feelings of grief
- very literal. Telling them “grandma went to sleep” could cause fear that if they go to sleep that they will be gone from everyone just as Grandma is.
- Important to remember that sibling have needs too.
- Developmental level must be considered
- Displaced and isolated in the process
- Feelings of being left out
- Nurses and Child Life can help identify ways to involve the siblings in the caring process
- All interaction with the dying sibling when possible
- Encourage devoted time to the well siblings
- Identify family member or friend to sit with the sibling to keep them busy
- A lot of care goes to caregivers
- Provide consistent caregiver and routine
- Include siblings
- Encourage playtime
School Age children 6-12
- Better understanding of causality and advanced perception of time
- May still associate misdeeds or bad thoughts with causing death
- Clarify the meaning of their statements!!
- Death is personified as devil, God, ghost or boogeyman
- Preoccupied with details: “When you die your body decays in the ground.”
- Understanding that death is universal, irreversible, and nonfunctional
- Attitude towards death are influenced by attitudes and reactions of others
- It is very important for parents to clarify the meaning of their statements and to repeatedly ask the child what they think and what things mean to them.
- Realize death is permanent
- askWhat do you already know?
Fear:
- Reason for illness
- Communicability of the disease to themselves or others
- Consequences of the disease on functioning and relationships
- Process of dying is often more scary than the finality of death
Anticipatory preparation:
- Industry: help give them control
- Understand what is happening
- Participate in what is being done and what to stop and when
Behavior:
- Exhibit fear through verbal uncooperativeness
- Staff could interpret as stubborn, rude, impolite
- Plea for control, “fight or flight”
Adolescent Children 13-17 yrs with death and dying
- Strive for group acceptance and independence from parent constraints
- May feel alienated from peer associates and lean on them for emotional support
- Feeling of being alone
- Support groups or other means of networking are great for this group.
- Mature understanding of death
- Question death and related topics: Religious meaning, Afterlife
- Difficult to accept/cope because of formation of identity
- Tend to think they will NEVER die young
- Allow for as much self-control and independence as possible
- Answer questions HONESTLY! They will call BS on you and never trust you AGAIN!
- Respect their need for privacy, solitude, and personal expression of emotions
- Help facilitate conversations between parents and child
- THIS in many ways is how we as adults deal with death. You never can read someone’s mind.
- Key Points: Listen, Ask, don’t judge, don’t assume and DON’T TAKE IT PERSONALLY
Oxygenation 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
Oxygenation: Assessment History
- Pain
- Fatigue
- Cough
- Wheezing
- Environmental/geographical exposures
- Smoking
- Respiratory infections
- Allergies
- Health Risks
Oxygenation: Physical Assessment
- Inspection, Palpation, Percussion, Auscultation
- Observe the rate, depth, rhythm, and quality of respirations
- Note the position the client assumes when breathing
Pulse Oximetry
-Monitor patient’s oxygen saturation(SaO2) by using a pulse oximeter
- Pulse Oximetry Findings:
- Expected range is 95-100%
- Acceptable levels are 91-100%
Pulse Oximetry Interventions
- If less than 90%:
- Confirm probe placement
- Check oxygen delivery system
- Place client in semi-fowler’s or fowler’s position
- Encourage deep breathing
- Remain with client to reduce anxiety
Hyperventilation
- Lungs remove carbon dioxide faster than it is produced by cellular metabolism
- Caused by anxiety, drugs, acid-base imbalance, fever, or chemically can induce
- Measure by ABG
- S/S include rapid respirations, sighing breaths, numbness and tingling of the hands/feet, light-headedness, loss of consciousness
Hypoventilation
- Occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide
- Can be caused by slow or shallow breathing, diseases of the respiratory muscles, drugs, or anesthesia
- Determine by ABG
- S/S include mental status changes, dysrhythmias, potential cardiac arrest
Hypoxia
- Caused by:
- Decreased hemoglobin level
- Diminished level of inspired O2
- Inability to extract oxygen from the blood
- Decreased diffusion of oxygen from the alveoli to the blood(pneumonia)
- Poor tissue perfusion(shock)
- Impaired ventilation(rib fractures or chest trauma)
Hypoxia Signs and Symptoms
- Apprehension and restlessness
- inability to concentrate
- decreased level of consciousness and dizziness
- behavioral changes
- increased pulse rate and depth of respiration
- dysrhythmias
- cyanosis
Symptoms: RAT BED Restlessness Anxiety Tachycardia/Tachypnea Bradycardia Extreme Restlessness Dyspnea (Severe)
Pediatric Symptoms: FINES Feeding difficulty Inspirator stridor Nare Flare Expiratory Grunting Sternal Retractions
Hypoxia
- Caused by:
- Decreased hemoglobin level
- Diminished level of inspired O2
- Inability to extract oxygen from the blood
- Decreased diffusion of oxygen from the alveoli to the blood(pneumonia)
- Poor tissue perfusion(shock)
- Impaired ventilation(rib fractures or chest trauma)
Hypoxia Signs and Symptoms
- Apprehension and restlessness
- inability to concentrate
- decreased level of consciousness and dizziness
- behavioral changes
- increased pulse rate and depth of respiration
- dysrhythmias
- cyanosis
Symptoms: RAT BED Restlessness Anxiety Tachycardia/Tachypnea Bradycardia Extreme Restlessness Dyspnea (Severe)
Pediatric Symptoms: FINES Feeding difficulty Inspirator stridor Nare Flare Expiratory Grunting Sternal Retractions
Cyanosis
- Blue discoloration of the skin and mucous membranes
- Caused by desaturated hemoglobin
- Late sign of hypoxia
Nursing Diagnosis/Patient problem related to oxygenation
- activity intolerance
- decreased cardiac output
- fatigue
- impaired gas exchange
- impaired verbal communication
- impaired verbal communication
- ineffective airway clearance
- risk for aspiration
- ineffective breathing pattern
- ineffective health maintenance
Planning (oxygenation)
- During planning, use critical thinking skills to synthesize information from multiple sources
- Goals and outcomes
- Realistic expectations, goals, and measurable outcomes
- Setting priorities
- Teamwork and collaboration
Acute Care Interventions for oxygenation
- Dyspnea management-manage/determine underlying cause, treat with oxygen therapy or medications(such as inhalers)
- Airway maintenance- requires adequate hydration to prevent thick, tenacious secretions. The best way to maintain thin secretions is adequate fluid intake of 1500-2500ml/day. The nurse can determine hydration by looking at the color, consistency and ease of mucus expectoration.
- Humidification is the process of adding water to gas, necessary for patients receiving greater than 4L via nasal cannula. May also be necessary to add to lower amounts of oxygen if the air is dry. Bubbling oxygen through water adds humidity.
- Nebulization adds moisture or medications to air by mixing particles with the air. It improves the clearance of pulmonary secretions. It is used for the administration of bronchodilators and mucolytic agents to the patient. aerosol
- mobilization of secretions- Postural drainage consists of drainage, positioning, and turning to aid is mobilizing secretions. High-fowlers is most often used for bilateral drainage. In the presence of pulmonary abscess or hemorrhage, position the patient with the affected lung down to prevent drainage toward the healthy lung. For bilateral lung disease, the best position depends on the severity of the disease.
- Coughing and Deep Breathing techniques
- Ambulation- Encourage early ambulation to promote lung expansion
- immobility is a major factor in developing atelectasis, ventilator associated pneumonia and functional limitations. After one week of bedrest muscle strength declines by as much as 20% which results in increased 02 demand and weakened respiratory muscles. Encourage and assist to sit, dangle, stand and walk.
- Positioning- Frequent changes in position, semi or high fowler’s position
- Frequent changes of position are simple and cost-effective methods for reducing stasis of pulmonary secretions and decreased chest wall expansion, both of which increase the risk of pneumonia. The 45-degree semi-Fowler’s is the most effective position for promoting lung expansion and reducing pressure from the abdomen on the diaphragm.
Coughing Techniques
- quad cough
- huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. With practice the patient inhales more air and is able to progress to the cascade cough.
- The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough.
Cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then the patient opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum.
Breathing excercises- pursed lip breathing
- Deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse
- Instruct the patient to sit up, take a deep breath and exhale slowly as if they are breathing through a straw
Breathing Exercises- Diaphragmatic breathing
- Relaxing intercostal and accessory respiratory muscles while taking deep inspirations
- Place one hand on the breastbone and the other hand on the abdomen
- Inhale slowly making the abdomen push out, exhale and the abdomen should go
- Diaphragmatic breathing/belly breathing is a technique that encourages deep breathing to increase air to the lower lungs.
Incentive Spirometry
- 5-10 breaths per session every hour while awake
- Encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume.
- It promotes deep breathing and prevents or treats atelectasis in the postoperative patient.
- There is solid evidence to support the use of lung expansion with incentive spirometry in preventing postoperative pulmonary complications following surgery.
- encourages patients to use visual feedback to maximally inflate their lungs and sustain that inflation.
Diagnostic studies for oxygenation (dont need to know, just be familiar)
- Arterial Blood Gases-provides information for assessment of patient’s respiratory and metabolic acid/base balance and adequacy of oxygenation. Taken from the radial, brachial or femoral arteries
- Pulmonary Function Test-determines the ability of the lungs to efficiently exchange oxygen and carbon dioxide, used to differentiate pulmonary obstructive from restrictive disease
Peak expiratory Flow rate-reflects change in large airway sizes, good predictor of overall airway resistance. - Sputum specimen-can be for culture and sensitivity testing(identifies drug resistance to determine correct antibiotic), acid-fast bacillus(detection of TB), or cytology(identify lung CA-differentiates types of cancer cells)
- chest X-ray
Implementation: Health Promotion (oxygenation)
- Vaccinations: Influenza, pneumococcal
- Healthy lifestyle- Eliminating risk factors, eating right, regular exercise
- Environmental pollutants- Secondhand smoke, work chemicals, and pollutants
Maintenance and Promotion of Oxygenation
- Oxygen therapy- To prevent or relieve hypoxia
- Supply of oxygen- Tanks or wall-piped system
- Methods of oxygen delivery:
Nasal cannula
Oxygen masks
education on O2 Therapy
- Secure tanks so they don’t fall over
- Check portable cylinders before use
- Check oxygen tubing length for patient needs
- Determine that all electrical equipment in the room is functioning properly
- Keep oxygen-delivery systems 10 feet from any open flames
methods of oxygen delivery- nasal canula
- Simple device used for oxygen delivery
- Can deliver 1-6L of oxygen
Nursing Actions:
- Assess patency of nares
- Ensure a proper fit
- Greater than 4L needs to be humidified
advantages and disadvantages of nasal canulas
Advantages:
- Safe and simple to use
- Easily tolerated
- Delivers low concentrations of oxygen while allowing patients to eat, drink, speak and drink
- Disposable
Disadvantages:
- Can have a drying effect
- Can dislodge easily
- Monitor for skin breakdown over the ears and nostrils
- can have a drying effect if greater than 4L/min
Methods of oxygen delivery: simple face mask
- Minimum flow rate of 5L/min
- Delivers 5-8L/min
Nursing Actions:
- Assess proper fit for a secure fit over nose and mouth
- Nasal cannula during meals
- Monitor for skin breakdown
advantages and disadvantages of simple face mask
Advantage:
- easy to apply
- Simple delivery method
Disadvantage:
- flow rates less than 5L/min can result in rebreathing CO2
- Not for anxious or claustrophobic patients
- Eating, drinking and talking are impaired
- Potential for skin breakdown due to moisture and pressure
suctioning
adult: a long dentist tool looking thing
infant/pediatric: mom sucks in through mouth? bulb nose suction
- WTF?
breathing patterns
- Tachypnea: Greater than 20 breaths per minute
- Bradypnea: Less than 12 breaths per minute
- Apnea: Absence of breathing for 15 seconds or longer
- Orthopnea: abnormal condition in which it is easier to breathe when sitting up or leaning forward
- Dyspnea: Subjective sensation of difficult or uncomfortable breathing
Structure and function of ventilation and perfusion
Ventilation
- Process of moving gases into and out of the lungs
- Requires coordination of the muscular and elastic properties of the lung and thorax
Perfusion
- The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs
- Responsible for moving the respiratory gases from one area to another
gas exchange
Diffusion
- Process for the exchange of respiratory gases in the alveoli and the capillaries of the body tissues
- Occurs at the alveolar capillary membrane
oxygen transport
- consists of the lungs and cardiovascular systems
- depends on ventilation, perfusion, and rate of diffusion
- hemoglobin is the key carrier for oxygen and transports 97% of the body’s oxygen, decreased levels affect the body’s ability to transport oxygen
Pulmonary Circulation
Function is to move blood to and from the alveolar capillary membrane for gas exchange
Lung Volume
- Determined by age, gender, and height
- Tidal volume
- Can be affected by patient’s health status and activity
Developmental factors for oxygenation: infants
Premature(less than 35 weeks):
- Not fully developed alveolar surfactant system
- Characterized by atelectasis
- Immature pulmonary circulation
Term:
- small airway structures makes it easy for infection to spread rapidly
- obstruction
-Infants and toddlers are at risk for upper respiratory tract infections as a result of frequent exposure to other children, an immature immune system, and exposure to secondhand smoke.
High risk for respiratory distress
-Is a collapse of the alveoli that prevents the normal exchange of oxygen and carbon dioxide
Developmental factors for oxygenation: toddlers
- Upper Respiratory Infections(URI)
- Airway Obstruction: Small objects being in the airway.
- Drowning: Can occur in small amounts of water, never leave alone in bath tub.
Developmental factors for oxygenation: school-age children
- Tonsillitis
- Upper Respiratory Infections(URI)
- Viral Infections: Croup and pneumonia
- Asthma
- School-age children and adolescents are exposed to respiratory infections and respiratory risk factors such as cigarette smoking or secondhand smoke.
Developmental factors for oxygenation: adolescents
- Lifestyle choices
- Vaccines
- Asthma
Developmental factors for oxygenation: adults
- lifestyle choices
- Smoking
- Lack of exercise
- Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking.
Developmental factors for oxygenation: older adults
- Reduced lung expansion: cartilage starts to become more rigid, lungs have less recoil ability and alveoli lose elasticity
- Less effective cough reflex
- Declining immune response
- Older adults cardiac and respiratory change with the aging process
- Chest wall and airways become more rigid and less elastic
- Amount of air exchanged is decreased
- Mucous membranes are drier and more fragile
- Decreases in muscle strength and endurance
- Decrease in efficiency of the immune system
- The cardiac and respiratory systems undergo changes throughout the aging process. The changes are associated with calcification of the heart valves, SA node, and costal cartilages. The arterial system develops atherosclerotic plaques. Osteoporosis leads to changes in the size and shape of the thorax. The trachea and large bronchi become enlarged from calcification of the airways. The alveoli enlarge, decreasing the surface area available for gas exchange. The number of functional cilia is reduced, causing a decrease in the effectiveness of the cough mechanism, putting the older adult at increased risk for respiratory infections
What is the most common oxygen delivery device you will see/use?
Nasal Canula
What does LPM stand for?
Liters Per Minute
True or False? LPM is the same thing as percentage of oxygen.
False: The LPM is the flow rate not the amount of oxygen you will be giving.
What is the normal range to set the flow meter in LPM for a regular nasal cannula?
1-6 Liters Per Minute
What does FiO2 stand for?
Fraction of Inspired Oxygen
What is the percentage of oxygen (or FiO2)) range for a nasal cannula?
25-45%
What FiO2 is the air you are breathing right now?
21%
True or False? A basic nasal cannula is a low flow device meaning that we can’t give an exact % of oxygen.
True
The amount of FiO2 a patient actually receives with a low flow device fluctuates based on what?
Tachnypea, we cannot control how much FiO2 a patient gets by putting two prongs in their nose. Must be able to take good deep breaths for themselves.
Nasal cannulas do NOT help with the removal of what gas?
Ventilation, removal of CO2
High flow nasal cannulas can deliver PEEP (positive end expiratory pressure), what does that help to do?
PEEP: Positive Expiratory in Pressure, keeps the alveoli open at the end of expiration by continuing to apply pressure. Assists with ventilation, removal of CO2.
Nugget of Knowledge
PEEP helps to keep the alveoli open at the end of expiration by continuing to apply pressure which helps to assist with ventilation. Remember that VENTILATION means the movement of air into and out of the alveoli and OXYGENATION is the action of oxygen diffusing passively from the alveoli to the pulmonary capillaries and then it binds to the hemoglobin in RBCs.
What type of patient could really benefit from a high flow nasal cannula per the video?
COPD patients, removal of CO2 is huge.
How many liters can a high flow nasal cannula be set at?
60 LPM
What percentage of O2 can a high flow nasal cannula provide?
Up to 100% FiO2
True or False? Leaving a patient on 100% FiO2 for a long period of time can cause oxygen toxicity.
True
Standard or Low Flow Nasal Cannulas
do NOT provide humidity to the patient. Therefore, they can be very “drying” to the nasal passage which can lead to discomfort and even nose bleeds. Adding humidity (also called a “bubbler”) can help alleviate discomfort and lessen the risk of nose bleeds. Here is a 2-minute video that describes the basic idea and set up for a bubbler.
What are three advantages of using a nasal cannula versus a mask from the patient’s perspective?
Nasal Cannula is already heated and humidified, keeps the patient’s nasal from drying out. Greatest advantage is the PEEP effect. Patient can eat drink, eat, and communicate.
Patients with COPD become tolerant to high CO2 levels in their lungs, what stimulates a patient with COPD to take a breath?
Their drive to breath is different than a healthy patient without COPD. Get very tolerant to CO2. The hypoxic drive is what causes them to breath. (Hypoxemia) Too much oxygen knocks out their drive to breath.
True or False? A simple face mask is most often used in a patient who could use a nasal cannula, but the patient is a “mouth breather”
True, the mask goes over the nose and mouth.
What is the percentage of oxygen (or FiO2)) range for a simple mask?
35-60%
How many LPM can a simple face mask be set at?
6-10 LPM
Why would it be important to check the O2 saturations before putting on oxygen and again after the oxygen is on?
To check SPO2 on room air as well as what it is on oxygen.
If the patient’s SpO2 is dropping on the monitor, what is the first assessment you would want to perform?
Check to see if the nasal cannula is even in their nose.
True or False? It is important to perform a skin assessment around the nares, back of the ears, cheeks and any place where the device is in contact with the skin, at least once a shift if the patient is wearing any type of oxygen device (nasal cannula, mask, trach collar, etc..)
True
True or False? It is incredibly important to actually count the respiratory rate of a patient who is having respiratory issues and not just guess a number between 12-20.
True, do not guess the number
When administering a nebulizer, it is important to do what task first before turning on the oxygen?
Put the medication in the chamber
What are you looking for to know that you have enough liters of oxygen flowing for a nebulizer treatment?
Look for mist
When you enter a room where a patient is using oxygen, what assessments should be made?
Always make sure that you are checking to see the nasal canula is actually on. Check for edema and do a skin assessment.
The two different types of flow meters behind the patients bed
One is for oxygen and one is for medical air. The medical air can be used to give a nebulizer treatment for a patient who doesn’t need supplemental oxygen. Medical air is the same FiO2 as room air (21%) and cannot be used with an oxygen device (nasal cannula, mask, etc…) because it is no different than breathing room air. Look at the label on the wall—green is oxygen, yellow is medical air
Documentation of End-of-Life Care
- Time and date of death and actions taken to respond to the impending death.
- Name of health care provider certifying the death.
- People notified of the death and person who comes to declare time of death.
- Name of person making request for organ or tissue donation.
- Special preparations of the body.
- Medical tubes, devices, or lines left in or on the body.
- Personal articles left on and secured to the body.
- Personal items given to the family with description, date, time, to whom given.
- Location of body identification tags
- Time of body transfer and destination
- Any other relevant information or family requests that help clarify special circumstances.
- Verify with health care agency.
Types of Loss
- Loss of possessions or objects: Extent of grieving depends on value of object, sentiment attached to it, or its usefulness.
- Loss of known environment: Loss occurs through maturational or situational events or by injury/illness. Loneliness in an unfamiliar setting threatens self-esteem, hopefulness, or belonging.
- Loss of significant other: Close friends, family members, and pets fulfill psychological, safety, love, belonging, and self-esteem needs.
- Loss of an aspect of self: Illness, injury, or developmental changes result in loss of a valued aspect of self, altering personal identity, and self concept.
- Loss of life: Loss of life grieves those left behind. Dying people also feel sadness or fear pain, loss of control, and dependency on others.
