Oxygenation Flashcards
Passive process of breathing
Regulated by O2, CO2, and pH of blood
When CO2 increases [hypercarbia], body knows to increase rate and depth of breathing
Ventilation
movement gas in and out of lungs
Diffusion
oxygen and carbon dioxide exchange (alveoli & red blood cells)
Perfusion
distribution of red blood cells
Increased rate depth
increased ventilator effort, removes co2, (hypercarbia)
Chronic lung diseases
respond to hypoxemia instead of hypercarbia (receptors in carotid arteries and margarita
Purpose of lungs/alveoli is to promote
GAS EXCHANGE
GAS EXCHANGE
Occurs at the alveolar capillary membrane
capillary membrane
membrane thickness affects pulmonary edema, exudate, infiltrates effusions –> slow diffusion
Lung volumes
age gender and height
Tidal volume
amount of air exhaled following normal inspiration
Health status, activity, pregnancy, exercise, obesity, obstructive/restrictive lung diseases all impact TV
Alveoli function
expand during inhalation, taking in oxygen, and shrink during exhalation, expelling carbon dioxide
Ventilation = Respirations
12-20 breaths per minute
Rate/depth/rhythm
RR above 27 linked with increased risk of cardiac arrest
Age- kids, babies breathe much faster
Males & children use more abdominal muscles. Women thoracic muscles
Pain- shallow, increased, may split chest wall
Anxiety- shallow increased
Medications- narcotics, anxiolytics, amphetamines, cocaine
Illnesses
Hemoglobin function– less hemoglobin, altitudes lowers amount, abnormal cell function (think sickle cell), anemia– loss RBCS to carry
Exercise
Breath Sounds -
Expected (Normal) - Bronchial, Bronchovesicular, Vesicular
Adventitious (Abnormal) - Crackles/rales- fine to coarse bubbly sounds, associated with air passing through fluid or collapsed small airways
Wheezes- high pitched whistling, narrow obstructed airways
Rhonchi- loud low pitched rumbling, fluid or mucus in airways, can resolve with coughing
Stridor- choking, children
Pleural friction rub
Hyperpnea
Respirations are labored, increased in depth, and increased in rate (greater than 20 breaths/min) (occurs normally during exercise).
Hyperventilation
Rate and depth of respirations increase. Hypocarbia sometimes occurs.
Hypoventilation
Respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercarbia sometimes occurs.
Diffusion/perfusion
oxygen saturation
SpO2
95% to 100%
Interference with light transmission –> patient motion, jaundice, intravascular dyes, dark nail polish
Interference with arterial pulsations –> PVD, hypothermia, pharmacologic vasoconstrictors, decreased cardiac output, edema, tight probes
Also affected by the things that affect respirations
When patient shallow and tachypnea, pulse ox can decrease
Inspiration and expiration
Expiration passive process
To be done well- need elastic recoil of lung tissue, surfactant helps keep surface tension of alveoli and keep them open
Compliance- ability of lungs to distend/expand, relies on intrathoracic pressure changes
Airway resistance- bronchoconstriction
factors affecting oxygenation
Decreased oxygen-carrying capacity
Hemoglobin levels, carbon monoxide
Hypovolemia
Decreased inspired oxygen concentration
Altitude, hypoventilation increased metabolic demand
Chest wall movement
Pregnancy, obesity, musculoskeletal diseases, trauma, neuromuscular diseases, central nervous system (CNS) alterations
factors affecting oxygenation
Morbidly obese- reduced lung volumes, heavy lower throax abdomen cant lay down flat or in recumbent postion
Spinal abnormalities
Flail chest– rib fractures= instability; abdominal surgeries!, or any surgery
Guillain barre, myasthenia gravis, ALS
C3-C5 results in paralysis of phrenic nerve= phrenic nerve control diaphragm, below C5– watch out for intercostal nerve damage which doesn’t allow for accessory muscle help and prevents anterposterior chest expansion
Damage to medulla oblongata neural regulation of respiration, abnormal breathing patterns develop
Alterations is respiratory functions
Goal of ventilation= normal arterial carbon dioxide tension and normal arterial oxygenation tension
Labs:
PaO2= 80-100
PaCO2= 35-45
Oxygenation saturation (SpO2) = greater than 95%
EtCo2= 35-45
Hypoventilation
Inadequate alveolar ventilation to meet demand
Not enough oxygen, and/or too much carbon dioxide
Causes:
Medications, alveolar collapse=atelectasis (lung diseases)
S/S:
Mental status changes, dysrhythmias
Can lead to cardiac arrest, convulsions, unconsciousness, death
Hyperventilation
Removing CO2 faster than it is produced by cellular metabolism
Causes:
Anxiety attacks (severe), infection/fever, drugs, acid-base imbalance (pH), aspirin poisoning, amphetamine use
Signs/Symptoms:
Rapid respirations, sighing breaths, numbness/tingling of hands feet, light-headedness, loss of consciousness
Think increased WOB
Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates increase in the patient’s rate and depth of respiration, causing hyperventilation.
Atelectasis
Collapsed alveoli
Prevents normal respiratory gas exchange
Conditions associated:
IMMOBILITY
Obesity
Sleep apnea
Chronic lung conditions
Can lead to lung collapse respiratory distress syndromes/pneumonias/respiratory failure
It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid.
Risk factors:
Older age
Any condition that makes it difficult to swallow
Confinement to bed with infrequent changes of position
Lung disease, such as asthma, COPD, bronchiectasis or cystic fibrosis
Recent abdominal or chest surgery
Recent general anesthesia
Weak breathing (respiratory) muscles due to muscular dystrophy, spinal cord injury or another neuromuscular condition
Medications that may cause shallow breathing
Pain or injury that may make it painful to cough or cause shallow breathing, including stomach pain or rib fracture
Smoking
Hypoxia
Inadequate TISSUE OXYGENATION
At the cellular level, not enough oxygen to meet needs
Can be related to a delivery problem
Untreated can lead to cardiac dysrhythmias, why?
Cardiac cells need oxygen to work
Causes:
Decreased hemoglobin levels/low oxygen-carrying capability
Diminished oxygen concentration of inspired oxygen (think altitude)
Inability of tissues to get oxygen from blood (cyanide poisoning)
Decreased diffusion of oxygen from alveoli to blood- infections/pneumonia
Poor perfusion with oxygenated blood– shock
Impaired ventilation from traumas– rib fractures Signs/symptoms:
Apprehension, restless, inability to concentrate, decreased level of consciousness, dizziness, behavioral changes
Difficulty staying still, lying flat
Fatigued, yet agitated
Causes increased pulse, increased respirations (rate and depth)
Initially increased blood pressure, then leads to shock/low BP
Cyanosis: blue discoloration skin/mucous membranes, late sign of hypoxia
Not a reliable measure of oxygen status
Central cyanosis tongue, soft palate, conjunctiva of the eye = hypoxemia
Peripheral cyanosis extremities, nail beds, earlobes = vasoconstriction not oxygenation problem
Chronic Hypoxia
Associated with chronic lung conditions
COPD most common
Common assessment findings:
Cyanotic nailbeds
Sluggish capillary refill
Clubbing
Barrel chest AP diameter 1:1 (normal 2:1)
Young- middle aged adults: focus is on avoidance of oxygenation problem risk factors
Smoking, unhealthy lifestyle, environmental considerations
Older-adults:
Mental status changes typically first sign of any issue
More susceptible to respiratory infections and compromise
Low reserve once compromised can deteriorate quickly
Lifestyle and oxygenation
Smoking
Secondhand exposure
Obesity
Air pollution/quality
Malnourished
Muscle weakness, weak cough
Exercise protective increases metabolic activity, helps promote increased oxygen consumption
Substance Use
Occupational exposure
Kids second hand exposure– asthma, pneumonia, ear infections
Babies- higher risk of SIDS
Substances– inhaled substances permanent lung damage
Environmental: Occupational pollutants include asbestos, talcum powder, dust, and airborne fibers. Asbestos.
Firefighters increased risk of lung damage
Radon
Cough
Protective reflex to clear trachea, bronchi and lungs of irritants and secretions
How often is cough? (frequency)
Productive/nonproductive?
Sputum- what is coughed up
What does it look like? Bloody, mucus? Thin/thick? Odorous?
Bloody= hemoptysis
Chronic versus acute
Adequate hydration and coughing helps patient maintain airway patency
Encourage coughing– most effective way to move secretions through the airways
More efficient than artificial suctioning
Pain
Specimen collection
Sputum collection:
To analyze for pathogens (usually pneumonia, cytology)
Best to collect in early morning
Wait 1-2 hours after patient eats
Sterile specimen container– teach patient not to touch the inside of container or lid
Tell patients to cough into the container and get as much expectorate sputum as possible
If patient too weak or cannot get expectorate into container, may require suctioning
Diagnostic tests related to oxygenation
Sputum Specimens - Nasal aspirate/swabs for respiratory syncytial virus, influenza
Sputum culture and sensitivity - Obtained to identify a specific microorganism or organism growing in sputumIdentifies drug resistance and sensitivities to determine appropriate antibiotic therapy
Sputum for acid-fast bacillus (AFB) - Screens for presence of AFB for detection of tuberculosis by early-morning specimens on 3 consecutive days
Sputum for cytology - Obtained to identify lung cancerDifferentiates type of cancer cells (small cell, oat cell, large cell)
Pulmonary Function Tests
Basic ventilation studies
Peak Expiratory Flow Rate (PEFR)
The point of highest flow during maximal expiration (Normal in adults is based on age and body weight.)
Long-Term, Preventative Measures
Vaccinations
Flu vaccine, pneumonia vaccine (over 65, immunocompromised)
Healthy lifestyle
Nutrition, exercise
Environmental and occupational exposures
STOP SMOKING
May need to change jobs if reaction to exposure
Dyspnea management
Difficult to treat
Treat underlying condition (Asthma, pneumonia, heart failure, etc.)
Oxygen therapy
Pharmacologic treatment
Bronchodilators, inhaled steroids, mucolytic, anti-anxiety medication
Cough and deep breath
Coughing helps keep airways clear and expectorate (get rid of) sputum, mucous
Nursing intervention can be to ENCOURAGE COUGHING
Typically encourage patients to initiate coughing every 2 hours when experiencing lung conditions/upper respiratory problems
Deep breathing– increases air to the lower lobes of the lungs
Opens small pores between alveoli which help promote gas exchange
What are some considerations nurses make take into account when teaching about these techniques?
With thecascade coughthe patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then he or she 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.
Thehuff coughstimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the wordhuff.With practice he or she inhales more air and is able to progress to the cascade cough.
Thequad coughtechnique 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.
Cover mouth, wash hands, if a patient is too compromised or in an anxious state, coughing would not be appropriate, deep breathing may be appropriate
Chest physiotherapy
Goal: mobilize pulmonary secretions
Include multiple activities
Postural drainage
Chest percussion
Chest vibration
Follow these activities with coughing and deep breathing
Indications: patients with thick secretions
Contraindications: pregnant, rib/chest injuries, increased intracranial pressure, recent abdominal/thoracic surgery, bleeding disorders, osteoporosis
Percussion- cupped hands to clap rhythmically on chest to break up secretions
Vibrations0 use of shaking movements during exhalation to help remove secretion
Postural drainage- use of various positions to allow secretions to drain by gravity
– Lay on unaffected side to promote drainage of one particular lobe
Example: Infiltration seen on RIGHT lower lobe
Lay on left side, in Trendelenburg
Other considerations: 1 hour before eating, 2 hours after eating, doing before bedtime helps (but can cause coughing so not RIGHT before)
Bronchodilators, and nebulizers 30 minutes before postural drainiage
Spend 10-15 minutes in each position
If client reports dizziness, faint stop
Older clients decreased res muscle strength, and chest wall compliance risk for aspiration
Suctioning
Indicated when patients cannot clear secretions on their own through coughing or CPT
Sterile procedure in hospital
Orotracheal and Nasotracheal (NT) common
Sterile catheter passed through nose (NT most common) into pharynx
Extremely uncomfortable, often stimulate patient into extreme coughing
Should be less than 10 seconds total
Will be discussed more in lab
Incentive spirometer
Promotes lung expansion through deep breathing
Prevents or treats atelectasis
Most often used in the post-operative patient
Oxygen therapy basics
Despite other interventions, such as coughing and deep breathing, many patients require oxygen therapy
Goal: prevent or relieve hypoxia
% of O² in inspired air is referred to as fraction of inspired O² or “FiO²”; Room air = FiO² of 21%
Gives oxygen at higher concentration than our ambient air (21%)
MUST HAVE A HEALTHCARE ORDER TO ADMINISTER OXYGEN THERAPY
Outside of an emergency situation
Must follow the six rights of medication administration
