MedSurg Mod 6: Oxygen Therapy Modalities and Pulmonary Embolism Flashcards
What is oxygen therapy
administration of O2 at a concentration greater than Room air
What is Room air at sea level
21%
RA (room air) decreases with ___
elevation
Goal of Oxygen therapy
increase O2 availability to the lungs and tissues in order to reduce effort of breathing and cardiac stress
Low Flow Oxygen Therapy
Room Air AND Supplemental oxygen - oxygen is not meeting complete need as RA is involved to help
Inconsistent or unknown O2 concentration
Delivery options: Nasal cannula, simple mask, partial rebreather, non rebreather
High Flow oxygen therapy
TOTAL inspired air
precise O2 concentration
delivery options - Venturi mask, mechanical ventilation
Why can we know exact high flow concentrations but not low flow
We do not have total control over low flow since something like a nasal cannula may give air but some of it is given via RA - so we cannot find exactly what is breathed in and it changes due to lack of control
with high flow we are meeting or exceeding needs and we know exactly what they are getting
Nurses can apply __ flow systems without an order like…
low flow systems like nasal cannula, simple mask, partial rebreather, non rebreather
O2 is considered a ___
medication
In order for emergency use of O2 by the nurse, the nurse should know…
- the clinical indicators for applying each type of low flow system
- how to correctly apply each of the systems
- the appropriate oxygen regulation for each system
With a venti/venturi mask what controls flow
A Rate Valve
they come in different colors and give precise oxygen percentages
they take into account room air and give precise amounts so we know exactly what someone gets
What is the difference between Partial Rebreather and Nonrebreather masks
partial has a bag capturing exhalation which some is rebreathed back in but a nonrebreather always has fresh air coming in due to a valve
What treatment is given to someone with O2 sat of 95-100%
no treatment
What treatment is given to someone with O2 sat 91-94 % (Mild hypoxemia)
Nasal cannula or simple mask
What treatment is given to someone with O2 sat of 86% to 91% (moderate hypoxemia)
partial rebreather or non rebreather or venturi mask
What treatment is given to someone with O2 sat < or equal to 85% (severe hypoxemia)
partial rebreather or a nonrebreather mask as a temporary measure until they are intubated
Oxygen Toxicity
case where someone is getting too much O2
there are very vague responses that can be similar looking to hypoxia
not common but must be assessed for
What are s/s of Oxygen toxicity
HA
substernal discomfort
dyspnea
alveolar atelectasis
paresthesia
restlessness, anxiety
fatigue, malaise, confusion
progressive respiratory difficulties
refractory hypoxemia
Assessments for O2 toxicity
chest tightness
respiratory rate
breath sounds
O2 saturation
numbness and tingling of extremities
activity level
general attitude
change in mentation
Interventions for O2 toxicity
monitor O2 flow setting
monitor total therapy time
assess before therapy
assess with changes in therapy
ensure therapy is initiated/maintained at correct “dose”
recommend therapy changes based on assessments
treat other symptoms
What to educate the patient about regarding O2 use at home
maintaining therapy at prescribed settings as ordered
when to notify the provider
safety precautions like discouragement of smoking and danger of o2 to facilitate combustion
When should someone on O2 at home notify a physician
frequent HA
increased anxiety
blue tinge to lips and nail beds
drowsiness
confusion
restlessness
slow, shallow, difficult, irregular or significant change in established breathing pattern
Positive End Expiratory Pressure / Continuous Positive Airway Pressure / Bilevel Positive Airway pressure (PEEP/CPAP/BiPAP)
Gives an extra boost in pressure to help prevent micro atelectasis / keep alveoli open
BiPAP and CPAP are more common
What are the benefits of PEEP/CPAP/BiPAP
it maintains a slight positive lung pressure and maintains slightly expanded lung tissue to prevent micro atelectasis
it also allows a lower percentage of O2 to be effective
BiPAP is more commonly used when?
for sleep apnea to prevent times of no gas exchange
PEEP is more commonly used when?
for those with spontaneous or mostly mechanical ventilation
PEEP
positive end expiratory pressure
maintains airway pressure above atmospheric airway pressure at the END OF EXPIRATION
may be used with either spontaneous or mechanical ventilation
CPAP
continuous positive airway pressure
maintains a positive airway pressure throughout THE WHOLE RESPIRATORY CYCLE
used with spontaneous ventilation NO MECHANICAL
BiPAP
bilevel positive airway pressure
similar to CPAP, still noninvasive
delivers 2 levels of pressure with the higher one DURING INHALATION
can be used for a variety of situations including COPD< sleep apnea, pneumonia, etc
What are some safety precautions to educate patients using O2 about
No open flames
No combustible products
exercise care with electrical devices
use explosion proof plugs
storage precautions like cart/collar cylinders, avoid bumping cylinders together/at all, keep in well ventilated area, post no smoking signs around
Always remember what for nursing interventions regarding O2 therapty
look at the WHOLE patient - do not rely on saturation numbers alone
monitor VS and note color of nail beds, lips, and ears for signs of cyanosis
look for respiratory retraction and nasal flaring
false low/high O2 readings
What may cause a false low O2 sat reading
cold extremities or finger
hypothermia or hypovolemia
What may cause a false high O2 sat reading
anemia (may have enough O2 but not enough O2 anyway due to relativity)
carbon monoxide poisoning
The benefit of Incentive spirometry is ?
it maintains alveoli open for efficient gas exchange
How to use IS?
- EXHALE (BREATHE OUT) NORMALLY
- Put mouthpiece in mouth and close lips tight
- INHALE SLOWLY AND DEEPLY through the mouthpiece to raise indicator
- When you cannot inhale any longer, remove the mouthpiece and hold your breath for at least 5 seconds if possible
- exhale normally
* cough is not necessarily a part of this but can be for breaking up secretions to make it easier*
IS is all about…
breathing in
Pulmonary embolism (PE)
an embolus that clogs an artery (or arteries) in the PULMONARY VASULCAR SYSTEM
PE does not…
block airways! it blocks the blood flow
What is the vascular problem in PE and the respiratory response
blood flow obstructed –> poor perfusion of lung tissue
air gets into lungs but enough O2 cannot get into the obstructed blood stream –> SOB
Where do PE usually originate from?
Most originate in the venous system from the inferior vena cava –> right atrium –> right ventricle –> lung vasculature
Generally is a clot originates in the left hear it will impact …
the brain
Basic Diagnostics for PE
CXR - dilated pulmonary artery seen
Spiral CT Scan
EKG - sinus tachycardia and right heart strain
d-Dimer test - rules out blood clot - negative <0.5 micrograms/mL
VQ scan comparing the ventilation (air) and perfusion (blood) in each of several specific lung fields
What is the gold standard diagnostic for PE
Pulmonary Angiogram (Arteriogram)
d-DIMER test can indicate…
breakdown products of clots - if there are none then it rules out a clot
Pulmonary Angiogram (Arteriogram)
Pic of the lung vessels
dye is injected through a catheter that is threaded through the vena cava into the right side of the heart
allows for direct visualization of obstruction using fluoroscopy
allows for accurate assessment of perfusion deficit
requires specially trained teams to do
Risk Factors for PE
Age 50+
venous stasis
prolonged immobility
hypercoagulability
previous history of thrombophlebitis
damage to vessel walls
orthopedic surgery - hip > knee for PE
certain disease states like heart disease, trauma, postoperative, diabetes mellitus, and COPD
other conditions like pregnancy, post partum, supplemental estrogen, birth control pill, obesity, and constrictive clothing
How fast can death occur with a PE
within 1 hour of onset
Priorities regarding PE
- early recognition of clinical picture
2. Early treatment
the Clinical picture of PE depends on what 3 things
- size of the clot and amount of obstruction
- location of clot
- the amount of lung tissue affected
What is the human response to PE like?
non specific and non diagnostic
S/S of PE
anxiety and fear
chest pain that is sudden, pleuritic, substernal and may become worse with deep breaths, coughing, eating, bending and stooping
chest pain that worsens with exertion but wont recede with rest
cough that may produce bloody sputum
crackles and or a rub near the area of the embolus
sudden dyspnea (when the clot lodges)
syncope
tachycardia
tachypnea
diaphoresis
PE is often referred to as what
the great imitator of other conditions
since its s/s are so general
PE Severity Index
A scale that can provide indication of the outcome for a patient who suffers a PE, and although not its main purpose - it can also give early indication of impending PE if you check patient status against the predictors and notice early changes in those dimensions like climbing heart and respiratory rate or decreasing O2 sat before any complains of substernal chest pain
It can even find mortality
With PE, more complexity =…
higher mortality
What is nursing care
the diagnosis and treatment of human responses to actual or potential health problems
Nursing Interventions to Prevent PE
identify presence of risk factors
early ambulation
reposition frequently
active and passive leg exercises
AE hose / SCDs (may not help but do not hurt)
change in IV sites according to best practices
patient and family education on avoiding prolonged sitting, legs and feet in dependent position, knees crossed, adequate hydration, wearing AE hoses and SCDs, etc
recognition of PE clinical presentations
Emergency INDEPENDENT Nursing Interventions for PE
VS
Assess lung sounds
Assess RR/Effort
Administer O2 via low flow systems
high fowlers position
EKG to check dysrhythmia and R sided failure
Emergency WITH ORDER Nursing Interventions for PE
establish IV access
labs: H&H, electrolytes, d-DIMER
Medications: morphine, sedation, anti anxiety
What is the goal of nursing interventions for PE
to stabilize pulmonary and cardiovascular systems
Do lung sounds sound different with PE?
no because it is a blood problem not an airway problem
Emergency Medical Management of PE
protect airway
manage pain and anxiety
confirm diagnosis
pharmacology like thrombolytic drugs’ like t-PA or anticoagulants like heparin and warfarin
surgery like an intravenous catheter embolectomy for major and massive PE or implantation of an umbrellas filter into the inferior vena cava (greenfield)
IVC Filter (Intravenous Catheter/Umbrella Filter)
Grabs clots and traps them so the body can break them down over time
the body will make its own t-PA over time to break the clots and the filter remains in place except for once it is needed to be removed (via the femoral artery)
Post PE Nursing Interventions after a Post embolectomy or Umbrella catheter
routine post op care:
assessment, activity, ROM, AE/SCD, C/T/DB, skin and incision care, hydration, O2 prn
Post PE Nursing Interventions for all post PEs
monitor labs - PT/INR/PTT, platelets
monitor pulmonary parameters
monitor respiratory effort
evaluate all assessment data against previous data - intervene as appropriate, alert PCP, document
patient and family education
What should the Patient be educated on regarding anti coagulation medication post-PE
importance of labs as ordered and dosing as ordered
safety such as s/s of bleeding in joints or brain, OTC interference or interactions, and alert of HCPs
self care
notify MD if/when…
Patient education for post op PE
activity
incision care
notify MD if/when
Patient education for Post-PE
alert all future HCP of PE history
stay active and get out of bed ASAP after illness
on long car or plane trips take breaks and walk at least every 2 hours
change positions often
do leg exercises if you are on bed rest
dont cross your legs
get immediate medical attention if an emergency occurs
