oxygenation Flashcards
overview of oxygenation
- Respiration
- Upper respiratory tract
- Lungs
- Ventilation
- Diffusion of Oxygen
- Circulation
- Heart
- CO=HRxSV (increase one will increase cardiac output)
- Blood vessels
- Blood
- Transports O2, nutrients, wastes
- Regulation of body temperature, pH
- Prevention of infection (white blood cells) & blood loss (platelets)
- Heart
factors that affect oxygenation - age
- Infant
a. Premature infants incapable of making surfactant
b. Lungs fluid filled in utero, infant takes first breath
c. Lungs fully expand in 2 weeks
d. Airways small in diameter, likely to collapse - Child
a. Diaphragmatic breathing until age 5
b. Limited ability to increase stroke volume - Older adult
a. Lungs
i. Increased chest wall stiffness
ii. Decreased lung volume
iii. V/P mismatch
iv. increased risk of aspiration due to GE reflux
b. Circulation
i. Decrease in maximal HR, SV, RBC production
ii. Increased systolic BP
factors that affect oxygenation - environment
- Altitude, heat, cold can affect respiration & circulation
- Air pollution
- Carbon monoxide
factors that affect oxygenation - lifestyle
- Diet—obesity increases work of breathing, can lead to increased BP
- Cigarette smoking, substance abuse
- Exercise vs sedentary lifestyle
factors that affect oxygenation - stress
- Hyperventilation
- Epinephrine, bronchiole dilatation, increased blood flow
factors that affect oxygenation - health status
- Conditions affecting chest wall movement—pregnancy, obesity
- MS abnormalities—scoliosis, kyphosis
- Trauma—upper abdominal incision, chest wall trauma
- Disease of musculoskeletal system—muscular dystrophy
- Disease of nervous system—SC injury, Myasthenia gravis
- Lung disease
- Heat disease
- Anemia
- Hypertension
- Medications—sedatives, narcotics, stimulants, alcohol
nursing history – subjective: symptoms of hypoxia
- Restlessness & Apprehension –> Altered
Level of Consciousness- do you know where you are? do you know your name? do you know the situation?
- hypoxia = not getting adequate amt of oxygen
symptoms of oxygenation problems
- Cough
- How often? When? What precipitates?
- Productive or nonproductive?
- Color, consistency?
- Dyspnea
- Orthopnea = difficulty breathing, lying flat
nursing history – subjective
- Symptoms
- Fatigue
- Fluid Retention: fluid buildup in their extremities
- Dependent areas
- Pain
- Intermittent (comes and goes) claudication–Aching in Calves
- Chest pain
more nursing history subjective
- Personal Habits
- Smoking—pack year history
- # of packs/day X # of years smoking
- Smoking—pack year history
- Allergy
- Exposure to pollutants,
respiratory disease- home, workplace
- Exercise
- Diet
- Current drug therapy
- History of chronic diseases
physical exam – objective
- Skin
- Cyanosis (seen on lips, toes, extremities. blue on fingertips)
- Edema (pooling of fluid in extremities)
- Nailbeds
- Capillary filling time (<3 seconds)
- Clubbing (fingernails are rounded)
- Neck veins (bulging is bad)
- Chest wall movement
Physical exam – breathing pattern
- Check rate rhythm and depth
- Normal rate for adult 12-20, average 16
physical exam – pulses
- Check rate and rhythm
- Normal rate for adult 60-100, average 80
physical exam – lungs
- Normal—Clear to auscultation (CTA)
- Abnormal
- Crackles: fluid in the lungs
- Rhonchi
- Wheezes
- if you don’t hear a clear blowing sound, then it’s abnormal
physical exam – BP
- Systolic—pressure in arteries with contraction
of ventricles- “top” number—should be < 120
- Diastolic—pressure in arteries during resting
phase of heart- “bottom” number—should be < 80
- Pulse pressure
- Difference between systolic and diastolic
- Orthostatic hypotension: shift position and BP drops. lying to sitting –> BP drops and heart rate increases
diagnostics
- Hemoglobin & hematocrit (H&H)
- Hemoglobin (carries oxygen throughout the body)
- Men 14-18
- Women 12-16
- Hemoglobin (carries oxygen throughout the body)
- Hematocrit (solid part of the blood)
- Men 40-45
- Women 38-43
- Arterial Blood Gases: measure oxygen status in the pts blood
- Electrocardiogram (EKG)
- Should be Normal sinus
rhythm (NSR)
- Should be Normal sinus
- Chest X-ray (CXR)
- Should be clear
pulse oximetry
- Normal >95%
- False elevated with CO
exposure - False low oxygen
saturation with poor
circulation- if fingers are cold, they can be falsely low
nursing diagnostic category: ineffective airway clearance
- Difficulty keeping airway passages clear of secretions
or obstructions (Gulanick & Meyer p. 11-14) - may have secretions in chest but doesn’t have a cough to cough it up
- Ineffective or absent cough***
- Inability to remove airway secretions***
- Abnormal breath sounds: if you have secretions, lungs will sound crackly
- Abnormal respiratory rate, rhythm, depth
nursing diagnostic category: activity intolerance
- Inability to perform physical activity without experiencing symptoms such as shortness of breath or fatigue. (Gulanick & Meyer p.8)
- bc I have an issue w/ my lungs it makes it hard for me to do activities
- Defining characteristics (supportive data) are about altered physiologic response to activity
- VS should return to normal within 3 minutes of activity
nursing diagnostic category: impaired breathing
- Difficulty passing air
through airway passages during inhalation and/or exhalation (Gulanick & Meyer p. 25) - pt is not able to breath properly
- pt with asthma
- pt who is hyperventilating
- air can’t flow freely back and forth
- not enough oxygenation
nursing diagnostic category: impaired gas exchange
- A change in the ability to adequately exchange oxygen and carbon dioxide in the lungs which may alter the body’s acid-base balance (Gulanick & Meyer p. 58)
- Not enough O2 or too much CO2 in blood
- Blood gases or pulse oximetry
interventions/implementation TCDB q2 hours
- turn, cough, deep breathing
interventions/implementation deep breathing
- Incentive Spirometry: helps open up alveoli and then you’ll be able to cough and do some deep breathing than can help excel those situations
- Treats atelectasis
- Usually done 5-6x q 1-2h
interventions/implementation chest physiotherapy
- requires MD order in many situations
interventions/implementation hydration
- loosen secretions to get it out
- for adult, at least 1500-2500 ml/day
interventions/implementation humidified O2
- caution as O2 supports combustion
interventions/implementation early mobilization
- Gradually increase activity
- Involve IP team (OT: ADL; PT: ambulation, muscle strengthening)
- Monitor VS, dizziness, dyspnea after activity
interventions/implementation suctioning – only if necessary
not good for lungs when done too frequently
interventions/implementation administer meds
- Physician order
- Nebulized medication
interventions/implementation NIC
- Cough enhancement
- Respiratory monitoring
- Oxygen therapy
Which of the following areas of the body provides the best site to determine cyanosis in a person with dark skin?
A. The earlobes
B. The beds of the fingernails
C. Mucous membranes of the mouth (CORRECT)
D. Whites of the eyes
Which of the following observations by the nurse may indicate an alteration in the oxygenation status of the client?
A. Neck veins are flat
B. Chest expansion is symmetrical
C. Needing to sit up to breathe (CORRECT)(orthapnea)
D. Even unlabored respirations
Which of the following is the most correctly stated outcome for the Nursing DX:
Ineffective airway clearance r/t thick mucus secretions?
A. Airway clearance will be effective –> goal
B. Will turn, cough, deep breathe q 2 hours –> intervention
C. Intake of 2500 ml of fluid per day –> intervention
D. Lungs CTA (how will ik. when i listen to them lungs will be clear. CORRECT)
Which of the following are appropriate interventions to increase airway clearance?
Select all that apply.
A. Perform Chest PT as ordered (CORRECT)
B. Teach patient controlled coughing (CORRECT)
C. Encourage the client to stay in bed until her strength returns. (NO. ambulate)
D. Increase fluid intake to 2500 ml/ day (CORRECT)
E. Encourage patient to use incentive spirometer once a day (maybe?)
All of the following are oxygen delivery methods. Place in order from that which can deliver the highest oxygen concentration to the method that provides the lowest O2 concentration
A. Face mask. 3
B. Nasal canula. 4 lowest
C. Non-rebreather mask. 1 highest
D. Partial rebreather mask. 2
The patient has a pulse oximetry reading of 88% on room air. Based on this
information alone you would hypothesize that the most likely nursing diagnosis for this patient is
A. Activity intolerance
B. Impaired gas exchange (CORRECT)
C. Ineffective airway clearance
D. Ineffective breathing patterns
