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NR 224


Oxygen Clear, odorless gas that constitutes approximately 21% of the air we breathe. Oxygen is necessary to sustain life. Oxygen is a drug with the potential for toxic effects.
Goal of Oxygen Therapy The goal is to provide optimal O2 saturation with the lowest, most effective dose. Should be 95% or greater.
3 Basic Steps in Oxygenation/Respiration 1. Ventilation 2. Diffusion 3. Transport of Respiratory Gases
Ventilation Is the movement of air between the atmosphere and the alveoli of the lungs as we inhale and exhale. Use of diaphragm muscle. Intercostal muscles are accessory.
Diffusion Gas exchange which involves diffusion of oxygen and CO2 between the alveoli and the pulmonary capillaries. If the pulmonary capillaries thicken, can't diffuse O2 effectively.
Transport of Respiratory Gases Oxygen: from lungs to tissues Carbon Dioxide: from tissues to lungs Most of the oxygen (97%) combines with hemoglobin. Function of respiratory system is gas exchange. O2 transport consists of the lungs and CV system.
Pulmonary Circulation Moves blood to and from the alveolar capillary membranes for gas exchange.
Inspiration/Expiration Inspiration is an active process. Expiration is a passive process.
Control of Respiration Respiratory center is medula and pons. Neural and chemical regulators(CO2, pH)control the rate and depth of respiration. Strongest stimulus for breathing is CO2.
Factors Affecting Respiratory Conditions Fatigue Decreased Activity Dyspnea Pallor Tachycardia
Hyperventilation Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism. *NEVER DISMISS PT. WITH HYPERVENTILATION
Hypoxia Inadequate tissue oxygenation at the cellular level.
Hypoventilation Ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide. Usually seen in drug overdoses.
Cyanosis Blue discoloration of the skin and mucous membranes. Warning sign. Bad & Late.
Peripheral Cyanosis Fingers, toes, nails -Vasoconstriction, cold environment
Central Cyanosis Lips, tongue, conjunctiva -High blood flow areas
Definition of Hypoxia Insufficient O2 available to meet the metabolic needs of tissue and cells. Results from hypoxemia which is a deficiency of arterial blood oxygen. Causes: Low hemoglobin, decreased O2 carrying capacity
Clinical S/S of Hypoxia Early onset: Unexplained apprehension, restlessness or irritability. Early or late: Confusion, poor concentration, lethargy. Late Onset: Combativeness and Coma
Respiratory S/S Early onset: Tachypnea, dyspnea on exertion Late onset: Dyspnea at rest, use of accessory muscles, retractions on inspiration, pause for breath between words and sentences.
CV S/S Early onset: Tachycardia, mild elevated BP Early or late: Dyshythmias Late onset: Cyanosis and cool, clammy skin
Other S/S Early or Late: Diaphoresis, decreased urine output, unexplained fatigue.
Presence of clinical signs of Hypercarbia(hypercapnia) Elevated CO2 levels in blood Restlessness Hypertension Headache Lethargy Temor
Lifestyle Risk Factors Nutrition (Obesity-Anemia; Iron) Exercise Smoking cessation Substance abuse Stress reduction Environmental- Asthma, Pollution
Assessment: Nursing History Pain, Dyspnea, Wheezing, Resp. infections, Health Risks, Smoking, Cough, Environmental/Geographic exposure, Allergies, Medications
Physical Examination Look at Patient: Inspection, Percussion, Palpation, Auscultation Behavior, facial expression, position
Common Respiratory Assessment Abnormalities Pursed-lip breathing (keeps airways open) Tripod position Accessory muscle use Increased AP Chest diameter Tachypnea Kussmaul Respirations (Acidosis) Cyanosis Clubbing of fingers (Pulmonary, Congenital Heart Disease) Abnormal breath sounds
Ventilation and Oxygenation Diagnostic Studies Arterial Blood gas (Invasive) Pulmonary function studies Peak expiratory flow rate Thoracentesis Bronchoscopy Lung Scan Sputum specimens; C&S, Acid-fast,Bacillus,Cytology
Tuberculosis Skin Testing Whether a person is infected with Mycobacterium tuberculosis. TB Vaccine (+) Raised, need chest x-rays Check within 48-72 hours. If not read in that time period, re-do test.
Pulse Oximetry (SpO2) Indirect measurement of Arterial O2 saturation, it is non-invasive Normal is greater than 95% Reliable when saturation is over 70% Earlobe probes have greater accuracy at lower saturations.
Pulse Oximetry Cntd. Factors affecting: Motion, low perfusion, anemia, cold extremities, bright fluroscent light, nail polish, acrylic nails, dark skin tone. Proper alignment is essential for accurate measurement. Make sure alarms are on Inspect location of probe q2-4h
Red Flag/Oximetry Notify health care provider of +/- 4% change from baseline or decrease to 90% or below 95%
Implementation: Health Promotion Vaccines: Influenza (6mnth or older), Pneumococcal(65 and older) Healthy Lifestyle: Eliminate risk factors, eat right, regular exercise Environmental Pollutants: ETS, work chemicals, pollutants
Nursing Interventions to Promote Oxygentation Position client up right to allow for maximal chest expansion. Assist client with position changes q2h. Deep breathing and coughing. Ambulation. Spriometer (10x every hour while awake) Comfort
Dyspnea Management Medications: Bronchodilators (1st to open airway), inhaled steroids, mucolytics Oxygen Therapy Physical Therapy Relaxation Techniques
Airway Maintenance Adequate hydration Proper cough Suctioning Chest PT Nebulizer treatment
Suctioning Techniques Oropharyngeal and Nasopharyngeal: Cough effectively but is not able to clear secretions by expectorating. Orotracheal and Nasotracheal: Unable to manage secretions by coughing. Tracheal: Artifical airway, ET tube or tracheostomy
S/S Indicating Need for Suction *Based on clinical need, not schedule. Signs of resp. distress, unable to cough up and expectorate secretions. Dyspnea, bubbling or rattling breath sounds. Poor skin color/cyanosis. Decrease in O2 saturation.
Yankauer Device for Oral Suctioning May be delegated, but UAP must be trained. Moisten tip with sterile water/saline. Do not apply suction during insertion. Advance along the side of mouth (prevent gagging). May need to suction under tongue.
Critical Elements of Suctioning It removes oxygen from client's airway Avoid excessive suctioning Do not suction more than 10-15seconds, rest between passes and replace O2 in rest Apply suction only when cath is being removed.
Critical Elements cntd. 12-18 for adults 8-10 for children 5-8 for infants Usual pressure settings for adults is 80-120mmHg
Oral Airway Prevents obstruction of trachea by displacement of tongue into oropharynx. *Critical to use correct size. (Measure corner or mouth to angle of jaw just below ear)
Endotracheal Airway Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions.
Tracheostomy Long term assistance Surgical incision made into trachea and a tracheostomy tube is inserted.
Maintenance and Promotion of Lung Expansion Fowlers is most effective positon. Elevating HOB and supporting with pillows. Client with unilateral disease positioned with the good lung down. Client with abscess or hemorrhage, affected lung down.
Ambulation An effective, noninvasive and inexpensive method of stimulating respiration Need to always assess client's tolerance
Oxygen Therapy Goals 1. Prevent and relieve hypoxia 2. Reduce work of breathing 3. Reduce myocardial workload 4. Provide optimal O2 saturation with the lowest, most effective dose.
Oxygen Toxicity Prolonged exposure can lead to damage of lungs. S/S: Substernal pain, cough, sore throat, dyspnea, pulmonary edema *Levels above 50% for over 24 hours potential for toxicity
Oxygen Therapy Oxygen is a medication, it must be administered as prescribed. Humidification is necessary for clients receiving O2 therapy >4L/min. If client is transported = make sure portable tank has enough oxygen.
Oxygen Therapy Delegation Initiating the administration of oxygen is not delegated to UAP. However, UAP may reapply the oxygen delivery device.
Oxygen Safety/Red Flag Oxygen in high concentrations has a great combustion potential and readily fuels fires.
Nasal Cannula Most commonly used oxygen device because of convenience and comfort. (low flow) Nasal passages must be patent for client to receive O2. Can cause skin breakdown over ears and in the nares.
Nasal Cannula Cntd. Oxygen capability: 24-48% at 1-6L/min "Rule of Four" 1L=24% 2L=28% 3L=32% 4L=36% 5L=40% 6L=44% *Room O2=21%
Face Mask Covers the client's nose and mouth. To avoid rebreathing CO2, a minimum of 5L/min oxygen flow rate is required. Exhalation ports on side of mask allow exhaled CO2 to escape. Limitations: Hard to achieve proper fit and poor tolerance.
Simple Face Mask 40-60% when operated at 5-10L. Most common midrange O2 delivery device. Minimum of 5L/min O2 required to prevent inhaled CO2.
Simple Face Mask Cntd. 5-6L=40% 6-7L=50% 7-8L=60% 8L=60% *Face mask is contraindicated for clients with CO2 retention because it can worsen.
Face Masks with Reservoir Bags Provide a higher oxygen concentration. Portion of client's expired air is directed into bag. Oxygen concentration remains the same as the inspired air.
Partial Nonrebreather w/ Reservoir Bag Deliver 40-70% oxygen at 6-10L/min. Do not allow bag to deflate during inspiration to avoid CO2 buildup.
Nonrebreather Face Mask w/ Reservoir Bag *Delivers the highest oxygen concentration possible with 60-80% at liters of 10L/min. Prevent room air and client's exhaled air from entering the bag so only O2 in bag is inspired. Must not deflate. Used for critically ill patients.
Venturi Mask Provides precise and consistent O2 concentration. O2 will decrease if mask does not fit properly. Delivers between 24-60% oxygen. 4L=24-48% 8L=35=40% 12L=50-60% Hot and confining
Face Tent Used when masks are not tolerated. Provide 30-50% concentrations of O2 at 4-8L Keep skin dry.
Restorative and Continuing Care Hydration 1500-2000ml/day. Coughing techniques: DB&C q2h while awake, if lg amount of sputum qh Cascade cough (clear secretions),Huff Cough and Quad cough(open airways) Breathing exercises: Pursed-lip breathing and diaphragmatic breathing
Controlled and Huff Coughing Inhale deeply and hold breath for a few seconds. Cough twice. The first loosens the mucus and the second expels it. Huff Cough: lean forward and exhale sharply with a "huff", keeps airways open while moving secretions.
Created by: MeganZajac