Care for Client with Oxygenation Problem

Flashcards about Oxygenation Problems

Pulmonary Ventilation

The process of breathing.

Nasal Cavity

Passageway for air; lined with mucous membrane to produce mucus and filter; highly vascular to warm; receives draining mucus from sinuses; lined with olfactory nerves.

Sinuses Function

Lightens the skull; resonate speech; trap/drain debris.

Pharynx Function

Passageway for food/air; protects lower airways.

Larynx Function

Protects lower airway; vocalization; facilitates coughing.

Trachea Function

Passageway between the larynx and bronchi.

Bronchus Function

Air Passage.

Respiratory Acinus Function

Gas Exchange through respiratory membrane.

Type 1 pneumocyte

Most of abundant, thin and flat, where gas exchange occur.

Type 2 pneumocyte

Secretes lung surfactant.

Pleura

Slightly negative pressure in the pleural space.

Pulmonary Ventilation

The act of breathing, the exchange of air between lungs and the environment.

Respiratory Passageway Resistance

Affected by friction created by constriction of the airway, presence of mucus or infections material, and by tumor.

Lung Compliance

Depends on the elasticity of the lung tissue and flexibility of the rib cage.

Lung Elasticity

The ability of the lung tissue to distend and recoil.

Surfactant

A lipoprotein that reduces surface tension.

Inspiratory Reserve Volume (IRV)

Amount of air that can be inhaled forcibly (3,000 ml)

Expiratory Reserve Volume (ERV)

Amount of air that can be forced out (1,100 ml)

Residual Volume (RV)

Volume of air that remains in the lungs after a forced expiration (1,200 ml)

Vital Capacity (VC)

Sum of TV+IRV+ERV

Inspiratory Capacity (IC)

Sum of TV+IRV

Functional Residual Capacity (FRC)

Sum ERV+RV

Total Lung Capacity (TLC)

Sum TV+IRV+ERV+RV

Neurologic Control of the Respiratory System

Increased CO2 Concentration-Chemoreceptors-Increased Respiratory Rate

Sputum Examination: Nursing Responsibilities

Best done in the morning just after awakening; teaching coughing exercises; increase fluid intake the night prior to procedure; provide mouth care after the procedure

Arterial Blood Gas: Nursing Responsibilities

Specimen should be collected in heparinized needle and syringe; place sample in ice and should be taken immediately to the lab; indicate in client is receiving oxygen supplementation; apply pressure to puncture site for 2-5 minutes; do not collect specimen on the same arm for IV infusion

Pulse Oximetry: Nursing Responsibilities

Assess for factors that may alter findings.

Chest X-ray: Nursing Responsibilities

No special procedure is needed; clothes and metallic objects on person must be remove so as not to alter result.

Computed Tomography (CT Scan): Nursing Responsibilities

No special preparation

Positron Emission Tomography (PET Scan): Nursing Responsibilities

No alcohol, coffee, or tobacco is allowed for 24 hours prior to test. Encouraged increase fluid intake post-test to eliminate the radioactive material.

Magnetic Resonance Imaging: Nursing Responsibilities

Assess for any metallic implants; test will not be performed in the presence of such

Pulmonary Angiography: Nursing Responsibilities

Monitor injection site and pulses distal to the side after the test.

Pulmonary Ventilation/Perfusion Scan (V/Q Scan): Nursing Responsibilities

No special preparation is needed. Encouraged client to increase fluids after the procedure,

Bronchoscopy: Nursing Responsibilities

Routine preoperative care; provide mouth care; have resuscitation and suction equipment at bedside; monitor V/S during procedure; NPO for 2 hours or until fully awake; provide emesis basin for secretion and saliva (note color and characteristics); collect post bronchoscopy sputum for cytology

Lung Biopsy: Nursing Responsibilities

Same as Bronchoscopy

Thoracentesis: Nursing Responsibilities

Administer cough suppressant; position client upright, leaning forward with arms and head supported on an anchored overbed table; a sensation of pressure may be felt even if anesthesia use; monitor pulse, color, O2 sat and other signs; apply a dressing on puncture site and position on the unaffected site for 1 hour.

Coughing Exercises

After using a bronchodilator treatment (if prescribed), inhale deeply and hold your breath for a few seconds; cough twice. The first cough loosens the mucus; the second expels secretion

Deep Breathing Exercises

Place client in comfortable position; ask the client to flex knees to relax abdominal muscles; ask the client to place one hand or both hands on abdomen

Peak Flow Meter

Wash and dry hands; assemble equipment; explain the procedure; set the pointer to zero

Chest Physiotherapy: Nursing Care

Check doctor’s order; consider positioning through initial auscultation; do CPT of upper lobes before the lower lobes

Incentive Spirometer

Wash and dry hands; assemble equipment; explain the procedure; set the pointer to zero

Oxygen Administration

Assess for signs and symptoms of hypoxemia; verify doctor’s order; ensure room safety

Suctioning

Client should be in semi- or high-Fowler’s position; observe sterile technique by using sterile gloves and suction tip; hyperventilate with 100% oxygen before and after suctioning

Closed Chest Drainage (Thoracotomy Tube)

To remove air and/or fluids from the pleural space; to reestablish negative pressure and re-expand the lungs

One Bottle System

The bottle serves as drainage and water seal immerse tip of drainage tube in 2-3 cm of sterile water to create water seal

Two Bottle System - Without suction apparatus

First bottle is drainage; the second is water seal observe for fluctuation of fluid along the tube (water seal bottle) and intermittent bubbling with each respiration.

Two Bottle System - With suction apparatus

First bottle is drainage and water seal bottle; the second bottle is suction control bottle

Three Bottle System

First bottle is drainage bottle; second bottle is water seal; third bottle is suction control bottler

Nursing Care:

Encourage to do following to promote drainage. 1. Deep breathing and coughing exercises 2. Turn to sides at regular basis 3. Ambulate

Arterial Blood Gas

To assess ventilation and acid-base balance

Arterial Blood Gas Procedures

Radial artery is the common site for withdrawal of blood specimen.