WK 1: oxygenation and trachs Flashcards
Factors that affect oxygenation
(and examples of each)
-decreased oxygen-carrying capacity
(Hemoglobin level, carbon monoxide)
-hypovolemia
-decreased inspired O2 concentration
(Increased altitude)
-chest wall movement
(pregnancy, obesity, trauma)
thorough respiratory assessment consists of what
-RR
-pattern, depth and rhythm
Hypoventilation
-def
-S/Sx
not enough oxygenation
inadequate alveolar ventilation
causes: medications, lung Dz
S/Sx: AMS, dysrhythmias, somnolent
can lead to: cardiac arrest, Sz, LOC, death
atelectasis
-def
collapsed alveoli which prevents nml gas exchange
VERY preventable by nurse
Conditions associated: immobility, obesity, sleep apnea, chronic Lung Dz
Can lead to: lung collapse, PNA, Resp failure
Chronic hypoxia
Chronic: assoc. with chronic lung Dz
common assessment findings: cyanotic nail beds, slow cap refill, clubbing, barrel chest
We do not treat for chronic hypoxia, while acute hypoxia is requires immediate intervention
hypoxia
-def
-S/Sx (rat/bed)
inadequate tissue oxygenation at cellular level, can be related to hypovolemia
Causes: low hemoglobin, low O2 concentration, pH imbalance, decreased diffusion, poor perfusion, impaired ventilation from traumas
S/Sx:
Early: RAT (restlessness, anxiety, tachycardia/tachypnea)
Late: BED (bradycardia, extreme restlessness, dyspnea)
Why do we encourage coughing?
helps maintain airway patency
most effective way to move secretions through airway
components of dyspnea
-associated with hypoxia
-SUBJECTIVE, difficult breathing, related to SOB
-S/Sx: accessory muscles, nasal flaring, increased RR and depth
Nursing interventions to improve oxygenation
(Include long/shirt term measures)
Long-term: vaccinations, healthy lifestyle, environmental and occupational exposures
Short-term: coughing, deep breathing, supplemental O2 (has to be ordered)
Ventilation
-what is it
-the goal of it
movement of gas in and out of lungs
Goal: nml arterial CO2 and O2 tension
ventilation = respirations
Diffusion
oxygen and CO2 exchange in alveoli and red blood cells
perfusion
distribution of newly oxygenated red blood cells to tissues in the body
When CO2 increases (hypercarbia) the body knows to increase __1__ and ___2__ of breathing
rate
depth
Why? to remove CO2 quicker
Tidal volume
What is it? What is it impacted by?
amount of air exhaled following normal inspiration
Tidal volume impacted by: health status, activity, pregnancy, exercise, obesity, lung Dz
What is the function of alveoli?
to promote gas exchange
What are three expected and normal breath sounds? where are they heard?
what do they sound like?
- bronchial: heard over tracheal area
-high pitched/loud - Bronchovesicular: heard over mainstream bronchi
-medium pitch - vesicular: heard laterally
-soft/low pitch/sounds like snoring
Crackles/rales
COARSE bubbly sounds, low pitched
associated with air passing through fluids
Course vs. fine?
Wheezing
high pitched whistling
narrow airways
asthma/inflammatory response
Rhonchi
low pitched rumbling
fluid/mucus in airway
can resolve with coughing
stridor
choking/ gasping sound
something is obstructing upper airway
pleural friction rub
inflamed pleural space
low pitched, harsh/grating sound with I/E
Bradypnea
abnormally slow respirations (< 12 breathes/min)
Tachypnea
abnormally rapid respirations ( > 20 breathes/min)
Apnea
respirations stop for several seconds
-if this happens persistently then respiratory arrest could occur
Hyperventilation
Rate and depth of respirations increases. Hypocarbia sometimes occurs
Hypoventilation
RR abnormally low and depth of ventilation is depressed. hypocarbia sometimes occurs
Oxygen Saturation
-measures diffusion and perfusion
-Peripheral oxygenation
-normal: 95-100%
-goal is: 95-98%
-Chronic lung Dz: 88% is nml, why wouldn’t you apply O2?
-SPO2 is measured with light transmission, impaired with: jaundice, nail polish, intravascular dyes, PVD, hypothermia, excessive edema
Compliance of lungs
ability of lungs to distend and expand, relies on inter-thoracic pressure changes
-lungs loose compliance -> unable to open/ close effectively
Work of breathing
effort to expand and contract lungs
determined by rate and depth
What is the purpose of an ABG? (arterial blood gas)
arterial blood is taken instead of peripheral blood b/c it will tell us how oxygenated the blood is
End tidal CO2
how much CO2 is present is at the end of exhalation
Hyperventilation
removing CO2 faster than it is produced by cellular metabolism
Causes: anxiety attack, fever, drugs, pH imbalance, asprin poisoning
S/Sx: high RR, sighing breathing (panting), numb/tinging, LH, LOC
Increased WOB
Primary problems/ nursing diagnoses related to oxygenation
ineffective airway clearance
risk for aspiration
impaired gas exchange
activity intolerance
Coughing techniques (need to know three)
- Huff cough: deep inhale, hold 2-3 seconds, forceful exhale, open glottis by saying “huff”
- Cascade cough: slow deep breath, hold 1-2 sec, then open mouth and perform series of coughs while exhaling
- Quad cough: manually assisted, for pt w/o abd muscle control, nurse pushes in/up on abd while pt exhales
Chest physiotherapy
includes: postural drainage, chest percussion, chest vibration
dependent nursing intervention for Pt with thick secretions w/ goal to mobilize secretions
Postural Drainage
EX: there is an infiltration seen in the Rt lower lobe, what position do you use?
laying on unaffected side to promote drainage of one particular lobe
lay on Lt side in trendelenburg
How to use an Incentive spirometer
sit up
deep breath
lips over mouthpiece
breathe in slowly, keeping range indicator at target zone
hold breath 3 seconds
repeat as Rx, usually 10 breathes every hour
cough and deep breathes after
Can a nurse delegate applying supplemental O2 to a CNA?
Yes
BUT the nurse must do a respiratory assessment along with assessment of pt response, setup, and adjustment responses
NC (nasal cannula)
1-6 liters
22-44%
use humidification if >4 liters or used over 24 Hrs
usually safe and well tolerated
Simple Face Mask
6-12 Liters
33-55%
best for short periods/ transportation
assess for fit, watch for aspiration risk/ claustrophobia
Partial Rebreather Mask
6-11 Liters
60-75%
used for short periods of dyspnea
keep reservoir partially inflated
HOURLY assessment
Non-Rebreather Mask
10-15 Liters
80-95%
best for critical needs, prior to intubation
HOURLY assessment
Pt is not rebreathing exhaled air d/t flaps covering ports on side of mask
Venturi Mask
High flow O2
4-12 Liters
24-50%
delivers PRECISE O2 concentration w/ humidity
NOT for long periods of time
Complications of O2 therapy
drying of mucus membranes
oxygen toxicity
skin breakdown
Pharyngeal airways
short term use
NPA & OPA’s
Pt still has respiratory drive
used for Pt with decreased LOC or who need frequent suctioning
Tracheal airways
longterm patency issues
for people who need mechanical ventilation
Endotracheal airways Vs. Percutaneous airways
ETT is always on a vent
Percutaneous trach is through the skin, bypasses upper airway structure, Pt can breathe independently or through vent
Indications for a tracheostomy
acute airway obstruction
airway protection
facilitate removal or secretions
prolonged intubation ( > 1 wk)
less damage to airway
more comfortable
allowed to eat
improved mobility
Shiley Vs. Jackson Trachs
Shiley: disposable inner cannula, plastic, cuff, obturator
Jackson: Reusable inner cannula, no cuff, obturator, metal
*with jackson you ALWAYS use a trach care kit for cleaning, but it should be used for shiley too
What is an obturator
device used to insert a trach, like a guidewire
- what is the purpose of a cuff on a trachea?
- dangers of prolonged inflation
- To help create a snug fit for the trachea, precent aspiration, and help ventilator give strong breaths
- increased mucosal pressure, causing ischemia, softening cartilage, mucosal erosion
-inflation of cuff has to be ordered by the physician
Passy-Muir
-speaking valve
-cuff deflated while being used
-cant use if Pt has respiratory distress
Nursing problems for a patient with a trach
-ineffective airway clearance
-impaired verbal communication
-risk for infection
-impaired swelling
-body image disturbance
-anxiety
how often is trach care done?
every 12 hours
usually patient dependent
