Transcript Oxygenation

Oxygenation
Dr. Belal Hijji, RN, PhD
March 3 & 4, 2012
Learning Outcomes
At the end of this lecture, students will be able to:
• Describe the anatomic and physiologic overview of the
respiratory system
• Identify the factors that influence the respiratory function
• Recognise common alterations in respiratory function
• Describe the nursing management of client with oxygenation
problems
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Anatomic and Physiologic Overview of the Respiratory
System
• The RS (next slide) is composed of the upper and lower
respiratory tracts which are responsible for ventilation
(movement of air in and out of the airways).
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The Respiratory System
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Upper Respiratory Tract
• Nose: Warming, humidification, and filtering of air takes place
here. The sneeze reflex is initiated by irritants in nasal
passages.
• Pharynx: Is a shared pathway for food and air. Its lymphoid
tissue traps and destroys pathogens entering with air.
• Larynx: Can be identified as the Adam’s apple. It is important
for speech, it maintains airway patency, and protects the lower
airways from swallowed material.
• Trachea: The trachea serves as the passage between the larynx
and the bronchi.
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Lower Respiratory Tract
• Lungs: Primary bronchi divide repeatedly into smaller and
smaller bronchi, ending with terminal bronchioles. Trapping of
pathogens and microscopic particulate matter takes place in
the trachea and bronchi. Foreign particles are moved upward
toward the larynx and throat. The cough reflex is triggered by
irritants in the larynx, trachea, or bronchi. Each lung is made
up of 300 million alveoli (this is where oxygen and carbon
dioxide exchange takes).
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Factors Affecting Respiratory Function
• Age: At birth, the fluid-filled lungs drain [deplete], the PCO2
rises, an the neonate takes the first breath. Full lung expansion
is achieved by the age of 2 weeks. Changes of aging that affect
the RS of elders become important if the system is
compromised by infection, physical or emotional stress,
surgery, or anaesthesia.
• Environment: Altitude and air pollution affect oxygenation.
• Lifestyle: Physical exercise or activity increase the rate and
depth of respiration and hence the supply of oxygen in the
body.
• Health status: Diseases of the RS such as chronic obstructive
pulmonary disease can adversely affect the oxygenation of
blood.
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Factors Affecting Respiratory Function (Cont..)
• Medications: Some medications can decrease the rate and
depth of respiration. For example valium (diazepam),
morphine, and demerol (meperidine hydrochloride).
• Stress: Physiologic and psychologic responses to stress can
affect oxygenation. Some people hyperventilate; arterial PO2
rises and PCO2 falls.
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Alteration in Respiratory Function
• Hypoxia: Insufficient oxygen anywhere in the body, from the
inspired gas to the tissues.
– Hypoventilation: inadequate alveolar ventilation leading to
hypoxia. It may occur due to diseases of the respiratory muscles,
drugs, and anaesthesia. CO2 often accumulates in the blood.
– Hypoxemia: Reduced oxygen in the blood. It is characterised by
low PO2 in arterial blood or a low haemoglobin saturation.
– Cyanosis: Bluish discoloration of the skin, nailbeds, and mucous
membranes due to reduced haemoglobin-oxygen saturation.
• Altered breathing patterns: Breathing pattern refers to rate,
volume, rhythm, and relative ease of respiration. Normal
respiration is quiet, rhythmic, and effortless. Tachypnea (rapid
rate), bradypnea (slow rate), apnea (cessation of breathing).
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• Obstructed airway
– Complete or partial obstruction: Can occur anywhere along the
upper or lower RS.
– Immediate action by nurses to maintain an open airway is a
nursing responsibility.
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Nursing Management of Oxygenation Problems
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Assessment
• Health history: Explore the presenting problem (cough,
sputum, shortness of breath, pain) including how long it has
been present and whether it has recently gotten worse.
• Physical exam: Inspect the client for efforts at ventilation,
flaring of nostrils, and position preferences. Count the
respiratory rate and note the rhythm of the breathing for
regularity or irregularity. Observe for cyanosis and clubbing of
fingers (next slide). Auscultate the lungs for crackles or
wheezes.
• Diagnostic and laboratory data: Assist the physician in
obtaining a blood sample for ABG measurement. Assist the
patient in collecting a sputum specimen for analysis/ culture.
Document the color of the sputum (see next slide for the
interpretation of different sputum colors.
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Clubbing of the fingers as a result of chronic hypoxia. Note the
flattened angle of the nailbed and a rounding of the fingertips
Pathologies Associated with Different Colors of Sputum
Sputum Color Pathology
Yellow or green
Rust or blood-tinged
Black
Pink
Bacterial infection
Pneumonia, tuberculosis
Black lung disease
Pulmonary edema
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Nursing Diagnoses
• Ineffective airway clearance related to obstruction (by tongue,
secretions, edema, or foreign body).
• Ineffective breathing pattern related to immobility: Inspiration
and/ or expiration that do(es) not provide adequate ventilation.
• Impaired gas exchange: Excess or deficit in oxygenation and/
or carbon dioxide elimination.
• Decreased cardiac output related to decreased circulating
blood volume.
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Planning
•
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•
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Promote airway clearance
Improve breathing pattern
Improve oxygen uptake and delivery
Increase cardiac output and tissue perfusion
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Implementation
• Promote airway clearance: This is achieved through:
– Teaching effective coughing: Prior to actual coughing, teach the
patient to take slow, deep breaths. The intent is to raise the
sputum to the level where it can then be coughed out. In a
postoperative patient, ask him/ her to splint the incision by
holding a pillow firmly against it will reduce the pain caused by
coughing. In most cases, assisting the client to a sitting position
will increase the effectiveness of the cough.
– Monitoring hydration: Providing adequate fluid intake is
important in thinning the pulmonary secretions for easy
expectoration. This may help in cases of pneumonia, bronchitis,
and asthma. Patients experiencing congestive heart failure may
require limitation of fluid intake to reduce pulmonary congestion
due to fluid volume overload.
continued on next slide
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– Medications administration: Expectorants/ mucolytics
(Mucomyst [acetylcysteine]) and bronchodilators
(Aminophylline) assist with airway clearance. Nurses must
teach patient the name of the medications, its purpose, dose, and
route. Nurses should also inform the patient about the most
significant side effects.
– Environmental and lifestyle modification: Identifying and
removing allergens that the patient is sensitive to may
dramatically improve asthma. Certain allergens such as animal
dander [minute scales from hair or skin] may be relatively easy
to eliminate. However, house dust and pollen may be impossible
to eliminate but can be reduced by using air filters.
– Airway suctioning: Suctioning of the airway may be necessary to
clear secretions the client cannot remove by coughing.
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Implementation (continued…)
• Improve breathing pattern: This could be achieved through:
– Proper patient positioning: If the client finds that breathing is
easier in an upright position, that position should be maintained.
Nurses should support the patient with elevation of the head of
bed.
– Controlled breathing exercises: Teach the patient the pursed-lip
breathing technique, which involves forced exhalation against
pursed (partially closed) lips, to maintain positive pressure in the
lungs during the expiratory phase and prevents collapse of the
smaller airways. Another intervention is deep-breathing
exercises by encouraging the patient to take slow, deep breaths
instead of the rapid, shallow breathing . Finally, abdominal
breathing involves the use of the abdominal muscles to pull the
diaphragm downward. Placing your hand on the client’s
abdomen and instructing the client to watch it rise give a visual
aid to teaching the technique.
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Implementation (continued…)
• Improve oxygen uptake and delivery: This could be achieved
through:
– Oxygen administration: Oxygen uptake in the pulmonary
capillary beds can be improved by increasing the concentration
of oxygen in the alveolar air. Administer oxygen as prescribed.
The physician’s order should indicate the concentration, method
of delivery, and liter flow per minute.
– Blood transfusion: Blood component administration (e.g., red
blood cells) is indicated when the client’s oxygenation is
impaired because of decreased circulating blood volume as in
anemia or hemorrhage.
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Implementation (continued..)
• Increase cardiac output and tissue perfusion: This could be
achieved through:
– Maintaining fluid balance: Management of fluid balance is a
cornerstone in the care of the client with reduced cardiac output.
If congestive heart failure is present, fluid and sodium intake
may be restricted to prevent edema and circulatory overload.
Diuretics may also be given to increase fluid excretion by the
kidneys. The nurse needs to maintain accurate fluid intake and
output and record the patient’s weight daily.
– Positioning patient properly: Proper positioning of a patient is
done to decrease the fluid load to the heart and to decrease the
development of pulmonary edema. Therefore, the nurse should
keep the patient’s head and upper body elevated and the legs are
in a dependent position. Supine position may be detrimental for
the patient with congestive heart failure, as evidenced by
worsening dyspnea, tachycardia and tachypnea, and decreased
arterial oxygen saturation.
Continued on next slide
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– Administering medications: Medications to improve cardiac
output and perfusion include diuretics (lasix), cardiac glycosides
(digoxin), and inotropic agents (dopamine). Lasix increases
excretion of water and some electrolytes; lowers blood pressure
and cardiac workload. Digoxin increases force of cardiac
contraction and slows heart rate. Dopamine increases the force
of cardiac contraction.
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Evaluation
• Using the goals identified in the planning stage of the nursing
process, the nurse collects data to evaluate the effectiveness of
interventions.
• If goals are not achieved, all concerned need to explore the
reasons before modifying the care plan.
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