Week 1 Oxygenation Flashcards
Alveoli
Diffusion (exchange of respiratory gasses) occur in alveoli.
They’re at the terminal end of the lower airway.
Tidal volume
amount of air exhaled following normal inspiration
Adventitious breath sounds
Abnormal breath sounds
• 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
Bradypnea
Rate of breathing is regular but abnormally slow (less than 12 breaths/min).
Tachypnea
Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min).
Apnea
Respirations cease for several seconds. Persistent cessation results in respiratory arrest.
Hyperventilation vs Hypoventilation
HYPER: Rate and depth of respirations increase. Hypocarbia sometimes occurs. Increased WOB.
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
HYPO: Respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercarbia sometimes occurs.
Causes:
• Medications, alveolar collapse=atelectasis (lung diseases)
S/S:
• Mental status changes, dysrhythmias
• Can lead to cardiac arrest, convulsions
Compliance
ability to extend or expand, relies on pressure change
decreased compliance, increased airway resistance, and/or increased accessory muscle use increases WOB
Work of breathing
- Effort to expand and contract lungs
- Healthy person= quiet, minimal effort
- Determine by rate and depth
- Evaluate accessory muscle use
Hypercarbia vs. Hypocarbia
HYPER: Increased CO2
HYPO: Decreased CO2
Atelectasis
Collapse of alveoli in the lung
Prevents normal respiratory gas exchange
Conditions associated:
• IMMOBILITY
• Obesity
• Sleep apnea
• Chronic lung conditions
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
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
Cyanosis (central and peripheral)
• Central cyanosis –> tongue, soft palate, conjunctiva of the eye = hypoxemia
• Peripheral cyanosis –> extremities, nail beds, earlobes = vasoconstriction not
oxygenation problem
Barrel chest
AP diameter 1:1
Associated with chronic lung conditions
Clubbing
Associated with chronic hypoxia
Dyspnea
Abnormal or difficulty breathing
Associated with hypoxia
R/t SOB with exercise or diseases
Sputum
Nasal aspirate/swabs for respiratory syncytial virus, influenza
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
Cascade cough
When using a cascade cough, the patient takes a slow deep breath, holds it for 1 to 2 seconds, then opens the mouth and performs a series of coughs throughout exhalation. This technique is often used in patients with large amounts of sputum, such as those with cystic fibrosis.
huff cough
The huff cough stimulates a natural cough reflex and is generally used to help move secretions to the larger airways. The patient inhales deeply and then holds his or her breath for 2 to 3 seconds. While forcefully exhaling, the patient opens the glottis by saying the word huff.
quad cough
The quad cough, or manually assisted 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.
Chest physiotherapy
(percussion and postural drainage) is another method still used by respiratory therapists with the goal of keeping the airways clear. It helps the patient drain secretions from specific segments of the bronchi and lungs into the trachea so that he or she is able to cough and expel them.
- Indications: patients with thick secretions
- Contraindications: pregnant, rib/chest injuries, increased intracranial pressure, recent abdominal/thoracic surgery, bleeding disorders, osteoporosis
Postural drainage
it consists of drainage, positioning, and turning and is sometimes accompanied by chest percussion and vibration. It aids in improving secretion clearance and oxygenation. Positioning involves draining affected lung segments and helps to drain secretions from those segments of the lungs and bronchi into the trachea. Some patients do not require postural drainage of all lung segments, and clinical assessment is crucial in identifying specific lung segments requiring it.
For example, patients with left lower lobe atelectasis require postural drainage of only the affected region, whereas a child with CF often requires postural drainage of all lung segments.
Lecture example:
Lay on unaffected side to promote drainage of one particular lobe
–> Infiltration seen on RIGHT lower lobe. Lay on left side, in Trendelenburg.
FiO2
• % 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%)
Bubbler/ bubble humidifier
• Prevents drying out of mucous membranes
• ALWAYS when greater than 4L/M or greater than 24 hours of
supplemental oxygen
• Use with any supplemental oxygen
• Sterile water is used
Venturi Mask
High Flow Mask
FiO2: 4-12L/min; 24%-50%
Provides the ability to deliver PRECISE oxygen concentration with humidity
Not preferable for long periods of time
Used for pts who need highly regulated O2 concentrations (chronic lung dz)
Face tent (aerosol mask)
Fits loosely around face and neck, 24%-100% of oxygen
Provides relatively high humidity
See a lot in post-operative
High-flow nasal cannula
Nasal cannula with ETCO2 monitor
Non Rebreather vs Partial Rebreather
Non Rebreather
- Flap covers exhalation ports so that patient does not rebreathe exhaled air
- FiO2: 10-15L/min; 80%-95%
- Best for a patient in critical need of oxygen, steps before intubation
- Low flow
Partial Rebreather
- Partially filled reservoir bag
- FiO2: 6-11 L/min; 60-75%
- Used for short periods of dyspnea or other increased oxygen needs
- Patients’ rebreathe up to 1/3 of exhaled air, helps with humidification
- Low flow
Simple Face Mask
- 6-12 L/MIN: 33-55%
- Best for short periods, transportation
- Not great for claustrophobic patients, skin breakdown, higher risk of
aspiration - Low low mask
Nasal Cannula
- FiO2: 1-6L/min: 22-44%
- Safe and well tolerated
- FiO2 can vary, can lead to skin breakdown, tubing dislodges easily
- Use humidification if greater than 4L of flow
- Low flow
INCENTIVE SPIROMETER
- Promotes lung expansion through deep breathing
- Prevents or treats atelectasis
- Most often used in the post-operative patient
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
TCDB
Turn cough deep breathe
Best positioning for breathing
Upright, supported
Semi-Fowlers, High Fowlers
How can you manage pulmonary secretions?
mobilize, hydrate, humidification, medications
CAB
Circulation/compressions, airway, breathing
Dyspnea Management
Difficult to treat, treat underlying condition, O2 therapy, medications
Nursing Diagnoses related to oxygenation
ineffective airway clearance, risk for aspiration, impaired gas exchange, activity intolerance
Symptoms of Hypoxia
Early RAT R - Restlessness A - Anxiety T - Tachycardia/pnea
Late BED B - Bradycardia E - Extreme restlessness D - Dyspnea
Normal SpO2 range
95-100%; best is 98%
chronic lung disease – 88%
Hyperpnea
Not common term used
Respirations are labored, increased in depth, and increased in rate (greater than 20 breaths/min) (occurs normally during exercise)
Expected lung sounds
- Bronchial: high pitch, heard over trachea
- Bronchovesicular: medium pitch, heard over mainstream bronchi
- Vesicular: low pitch, heard over most of normal lung
RR normal range
12-20
Ventilation
movement of gas in and out of lungs
Diffusion
O2 and CO2 exchange between alveoli and RBC
Perfusion
Distribution of oxygenated RBC to all tissues in the body
The nurse is caring for a patient who came in with respiratory distress. When the nurse enters the room the patient is lying with the head of bed at 10%, has the nasal cannula laying beside them, is complaining they cannot catch their breath, and the O2 sat is reading 84%. What is the first thing the nurse should do?
Elevate the head of bed to greater than 45%
What instructions given by the nurse are appropriate for a patient who has intermittent episodes of cough accompanied by thick, yellow sputum, and coarse crackles in the lungs? Select all that apply.
A. Drink plenty of water
B. Walk around as much as you can
C. Place a warm compress on the chest
D. Try to spend time in the prone position
E. Perform deep breathing exercises every hour you are awake
A, B, E
A nurse tells you that her patient has chronic hypoxia. What cues would you recognize as consistent with this condition? Select all that apply.
A. Restlessness B. Nasal flaring C. Clubbed finger tips D. O2 sat 89% on 2L NC E. AP chest diameter 2:1 F. Cap refill >3 seconds G. Patient complains of dyspnea H. Cyanotic lips
C, D, F
Restlessness - acute
dyspnea - acute
AP 1:1
A nurse tells you that her patient has chronic hypoxia. What cues would you recognize as consistent with this condition? Select all that apply.
A. Restlessness B. Nasal flaring C. Clubbed finger tips D. O2 sat 89% on 2L NC E. AP chest diameter 2:1 F. Cap refill >3 seconds G. Patient complains of dyspnea H. Cyanotic lips
C, D, F
Restlessness - acute
dyspnea - acute
AP 1:1
A patient has been prescribed CPT twice daily. What is the PRIMARY purpose of this intervention?
Promote airway clearance
The nurse is assessing a patient and find the following:
A: Patient is restless
B: Patient has O2 sat of 93%
C: Patient is on 4L NC
D: Patient refuses to walk
What is the most concerning finding?
Patient is restless (hypoxia)
Box 41.2 Questions to Ask Associated With Breathing
• Describe the breathing problems you are having.
• How has your breathing pattern changed?
• Do you have a cough? Is the coughing increasing? Is it worse at a certain time
of day?
• Describe your cough. Is it dry or moist? Do you have sputum with coughing? Is
this different in color, volume, or thickness?
• On a scale of 0 to 10, with 10 being the most severe, rate your shortness of
breath. What helps your shortness of breath?
Box 41.3 Cultural Aspects of CareCultural Impact on Pulmonary Diseases
The cigarette smoking rate in the United States is highest in American Indian/Alaskan Natives (24.6%), Caucasians (15.3%), African-Americans (15.1%), Hispanics (9.9%), and Asians (7.0%).
Smoking rates are also highest in those who have less than a high school education (22%) than in those who have a baccalaureate degree or higher (5.8%).
Smoking increases the risk for a number of cancer types, chronic obstructive pulmonary disease (COPD), and heart disease
Box 41.5 Impaired gas exchange r/t decreased lung expansion
Ask patient or family about patient’s mood, attentiveness, memory, and activity level.
Observe patient’s respirations for rate, rhythm, depth.
Inspect skin and mucous membranes.
Auscultate chest.
Figure 41.6 Concept Map
Look at image on ipad
Table 41.5 Ventilation and Oxygenation Studies
Know terminology for different labs, tests.
Not tested on lab values
Box 41.7 Guidelines for Chest Physiotherapy
Nursing and respiratory therapy collaborate with the health care provider to determine whether chest physiotherapy (CPT) is best for a patient. The following guidelines help in physical assessment and subsequent decision making:
- Conduct a complete respiratory assessment to confirm need for CPT, including sputum production, effectiveness of cough, history of pulmonary problems successfully relieved with CPT, abnormal lung sounds, and documented conditions such as atelectasis, complicated pneumonia, vital signs, or changes in oxygenation status.
- Know the patient’s medications. Certain medications, particularly diuretics and antihypertensives, cause fluid and hemodynamic changes. These decrease a patient’s tolerance to positional changes and postural drainage. Long-term steroid use increases a patient’s risk of pathological rib fractures and often contraindicates vibration.
- Know the patient’s medical history. Certain conditions such as increased intracranial pressure, spinal cord injuries, and abdominal aneurysm resection contraindicate the positional changes of postural drainage. Thoracic trauma or surgery contraindicates percussion and vibration.
- Know the patient’s level of cognitive function. Participation in controlled coughing techniques requires him or her to follow instructions. Congenital or acquired cognitive limitations alter a patient’s ability to learn and participate in these techniques.
- Be aware of the patient’s exercise tolerance. CPT maneuvers are fatiguing.
Table 41.6 Positions for Postural Drainage
Ipad
