OXYGENATION

What is oxygenation?

-How the oxygen we breathe in is distributed throughout the body
-Breathe in O2; Breathe out CO2
-Gas exchange occurs in lungs and alveoli
-Heart pumps oxygenated blood to tissues
-O2 disassociates from hemoglobin and goes into tissues
-Deoxygenated blood returns to heart
-Pumped into the lungs where gas exchange occurs again

What is ventilation?

-Mechanical process of getting the O2 into the lungs
-Inhalation and exhalation

What is perfusion and diffusion?

-Gas exchange and transfer of oxygenated blood to the tissues
-Dependent on the ability of cardiovascular system to pump blood

Disturbance in oxygenation leads to

-hypoxia and hypoxemia develop
-Ventilation problems: COPD, Asthma, decreased resp effort (drug overdose, sleep apnea), obstruction, lung collapse

What is hypoxemia

low oxygen in your blood
-Hypoxemia can cause hypoxia, when your blood doesn't carry enough oxygen to your tissues to meet your body's needs

What is hypoxia?

-low oxygen in your tissues
-Oxygen therapy is used to treat hypoxia (provider order required)

Intervention for ineffective gas exchange

Oxygen

What do you use ventilation for?

-COPD, asthma, decreased respiratory effort, obstruction
-With these you can use, incentive spirometer
-OR use of invasive or non-invasive positive pressure ventilation such as Ventilator or CPAP

What is hemoglobin?

-Carrier of oxygen (O2), and carbon dioxide (CO2)
-Carbon monoxide has a greater affinity for Hgb.

-Hemoglobin levels and acid-base status directly affect oxygenation
---Decrease in pH decreases affinity to Hgb

When would you have increased oxygen demands?

-Pain and anxiety
-Fever increases the body’s metabolic rate, increasing oxygen demand

When would you have decreased O2 carrying capacity?

-Anemia: Sickle cell
-Increased CO2: Chronic levels thicken alveolar membrane
-Carbon monoxide: CO binds to hemoglobin with much greater affinity than oxygen
-Cyanide poisoning: Inability of tissues to extract O2 from the blood

Physiological factors that affect oxygenation

-Hypovolemia
Blood loss
Severe dehydration

-Decreased circulating volume
Decreased inspired O2
Airway obstruction
Collapsed alveoli
High altitudes: Oxygen molecules in the air are further apart, reducing the oxygen content of each breath incrementally

-Increased metabolic rate
Increased O2 demand

What conditions affecting chest wall movement affect oxygenation?

-Pregnancy
-Obesity
-Musculoskeletal abnormalities: Scoliosis, Kyphosis
-Trauma: Impaired ventilation like rib fractures or tracheal obstruction
-CNS alterations
-Neuromuscular diseases: Guillain-Barré 

In what conditions would you have hypoventilation (and air trapping)

-Emphysema
-Cystic fibrosis:Thick mucous accumulation
-Bronchitis

In what conditions would you have hyperventilation?

-Asthma
-Anxiety /Panic Attacks
-Stress
-Emphysema

Cardiac alterations can also cause alterations in respiratory functioning? TRUE OR FALSE

TRUE

What two chronic diseases affect oxygenation?

COPD and emphysema

What occurs with COPD and emphysema?

-Barrel chest
-Air trapping
-Diaphragm flattens
-Normal respiration is driven mostly by the levels of carbon dioxide in the blood

-Hypoxic drive in COPD: If PaO2 is too high will decrease respiratory drive

-Chronic elevated CO2 levels alters alveolar membrane thickness…slows/impairs gas exchange

Children and respiratory infections

-Immature immune system puts them at higher risk of getting respiratory infections

Elderly and respiratory infections

-Physiological changes in the body
Posture like kyphosis
-Aging immune system which may be weaker
-Higher risk of getting respiratory infections

-Health promotion:
Pneumococcal vaccination
CDC recommendation

Lifestyle Factors Influencing Oxygenation

-Smoking: Second & third hand exposure, residual nicotine and other chemicals left on indoor surfaces by tobacco
-Smoking and BCP at increased risk of DVT/PE
-Nutrition: Diet impacting cardiac function, Anemia
-Exercise
-Substance abuse
-Stress: Panic/anxiety attacks

Environmental Factors Influencing Oxygenation

-Smog in urban areas
-Occupational pollution: Asbestos exposure, Talcum powder, Dust, Airborne fibers

Nursing ass for oxygenation

Pain
Fatigue
Dyspnea: Shortness of breath
Cough
Wheezing or any other adventitious breath sounds
Environmental exposures
Smoking exposure
History of respiratory infections
Allergies
Health risks
Medications

Nursing actions oxygenation -

Health promotion:
-Health education for an overall healthy lifestyle
-Vaccinations
Pneumococcal vaccination
CDC recommendation

Nursing interventions

directed toward:
-Halting the pathological process
-Shortening the duration and severity of the illness
-Preventing complications from the illness or treatments

Things for Maintenance & Promotion of Lung Expansion

-Ambulation
-Positioning
-Cough and deep breath
-Incentive Spirometry
-Invasive Mechanical Ventilation
-Non-Invasive Ventilation
-Chest Tubes

Pursed Lip breathing

-Prevents alveolar collapse
-Deep inspiration and prolonged expiration through pursed lips
-Breathe out twice as long as you breathe in
-Helps keep airways open longer to promote removal of air that is trapped in lungs by slowing down respiratory rate and relieving shortness of breath

Diaphragmatic breathing

-Decrease respiratory rate
-Actively pulling the diaphragm down with each inward breath
-Helps the lungs fill more efficiently
-Decreases air trapping
-Reduces the work of breathing: Asthma attack
-Helps relax

Mobilization of Pulmonary Secretions: cough

-Cough, turn, deep breathe every hour while awake and every 2 hours while sleeping
Cascade cough
Huff cough
Quad cough

Cascade cough

-Patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles
-As they exhale perform a series of coughs throughout exhalation
-Promotes airway clearance & a patent airway when patients have large amounts of sputum

Huff cough

-While exhaling, the patient opens the glottis by saying the word huff.
-With practice they will be able to inhale more air and can progress to the cascade cough
-This stimulates a natural cough reflex and effective in clearing central airways.

Quad cough

-While the patient breathes out with maximal effort
-The patient or nurse pushes inward and upwards on the abdominal muscles toward the diaphragm causing the cough.
-This if for patients without abdominal muscle control such as those with spinal cord injuries

What can help mobilize secretions?

-Hydration: At least 1500-2000 mL/day
-Humidification
-Nebulizers - can have bronchodilator meds-monitor HR
-Chest physiotherapy (CPT)
-Postural drainage
-Suctioning techniques

Humidification

-Process of adding sterile water to gas
-Necessary for O2 delivered > 4L/min
-If environment dry and arid --> add humidification
-Keeps airways moist and loosens secretions
-Dry air: bleeding and skin breakdown

What do nebulizers do?

- and loosens secretions
-Aerosolizes the medication so that it can be suspended and inhaled
-Enhances muco-ciliary clearance

Oxygen delivery

-Oxygen therapy: To prevent or relieve hypoxia
-Supply of oxygen
Tanks or wall-piped system
--Oxygen flowmeter
------Liters per minute

Oxygen satefy

-No smoking around oxygen AT ALL!!!
-Keep anything that can potentially cause a spark away from oxygen
---Fuel source=FIRE!
-Oxygen DOESN'T CAUSE FIRE, it supports and accelerates combustion
-If using an oxygen cylinder tank  secure so it does not fall
---Store upright (chained or in appropriate holder)
-Check oxygen tank level BEFORE transporting a patient
-Ensure enough oxygen tubing to safely move around
--Tubing up to 98’ will deliver the prescribed oxygen flow rate

Nasal cannula

-Up to 6L
-24-40% O2

Hi-flow nasal cannula

-Up to 10L
-35-45% O2
-Titrate to maintain desired oxygen saturation levels
-Humidified and heated oxygen (98.6)
-Prongs should not completely occlude nares
-Up to 60L: which is 100% O2
-accomplishes a reduction of nasopharyngeal airway resistance
-leads to improved ventilation and oxygenation through the application of a positive-pressure environment.
-delivers volumes of air over what a patient ventilates physiologically, which increases ventilation 

Evidence-Based Practice for heated-high flow nasal cannula?

-Prongs should not completely occlude the nares of the patient
-The temperature of the oxygen should be set at 37°C
-FiO2 is titrated to maintain the desired oxygen saturation levels
-Flow is titrated to maintain the desired respiratory rate, work of breathing, and oxygen saturation levels
-Heart rate, respiratory rate, and oxygen saturation levels should be continuously monitored

Simple face mask

-Short term O2 therapy
-6-12L or 35% to 50% O2
-Flow rates MUST be >5L or patient will be rebreathing exhaled CO2
-Assess for skin breakdown under mask

Face tent

-Good for patients who are claustrophobic
-8-12L or 28% to 100%
-Needs to be humidified
-O2 concentration can’t be controlled because it depends on the depth of breath

Partial rebreather mask

10-15L or 60% to 90% O2

Nonrebreather mask

-10-15L or 60% to 100% O2
-Ports on face mask: one-way valve which prevents breathing in room air
-Between bag and mask : one-way valve allowing to breathe in O2 from bag and O2 supply

Both rebreather and nonrebreather mask

-Simple masks with reservoir bags
-Must be humidified
-Bag must be inflated at least 1/3 to ½ full

Venturi mask

-Face mask with flow meter regulator
-4-12L or 24% to 60% O2
-More precise oxygen concentration

Delegation for oxygentation

-Certain agencies allow the skill of applying a nasal cannula or oxygen mask to be delegated to UAP
-The nurse directs the UAP by:

Informing how to safely adjust the device and clarifying its correct placement and positioning

Instructing to inform the nurse immediately about any changes in:
vital signs
pulse oximetry
level of consciousness
skin irritation from the cannula, mask, or straps
patient complaints of pain or breathlessness

Instructing personnel to provide extra skin care around patient’s ears and nose to prevent skin breakdown

Nurse responsibilities in oxygenation

-assessing patient’s respiratory system
-response to oxygen therapy
-setup of oxygen therapy
-adjustment of oxygen flow rate

OXYGENATION Unexpected outcomes and related interventions: Drying

-Patient experiences nasal and upper airway mucosa drying:
--If oxygen flow rate is greater than 4 L/min, use humidification.
--At rates greater than 5 L/min, nasal mucous membranes dry, and pain in frontal sinuses may develop
--Assess patient’s fluid status and increase fluids if appropriate.
--Provide frequent oral care

OXYGENATION Unexpected outcomes and related interventions: Breakdown/irritation

-Patient experiences skin irritation or breakdown, sinus pain, or epistaxis
--Increase humidification to oxygen---delivery system
--Provide appropriate skin/wound care. Do not use petroleum-based gel around oxygen because it is flammable

OXYGENATION Unexpected outcomes and related interventions: Hypoxia

-Patient experiences continued hypoxia
--Notify health care provider
--Obtain health care provider’s orders for follow-up SpO2 monitoring or ABG determinations: PRN orders for increasing oxygen delivery
--Consider measures to improve airway patency
--------Coughing techniques
--------Oropharyngeal or orotracheal suctioning

What is an incentive spirometer

-Helps a patient deep breathe
-----Breath IN
-Commonly used for patient recovery postoperatively
-Types: flow-oriented and volume-oriented

Delegation for spirometer

-The skill of helping a patient to use incentive spirometry can be delegated to AP.
-The nurse directs the AP:
-Informing about the patient’s target goal for incentive spirometry
Informing to immediately notify the nurse about any unexpected outcomes such as
----Chest pain
----Excessive sputum production: Foul smelling, color
----Fever

Nurse responsibilities for spirometers

The nurse is responsible fo:
-assessing and monitoring the patient
-evaluating the patient response,
-educating the patient about the proper use of the IS and evaluating that education

SPIROMETER: Unexpected outcomes and related interventions: not meeting target volume

-Patient is unable to achieve incentive spirometry target volume:
-Encourage patient to attempt incentive spirometry more frequently, followed by rest periods.
-Teach cough-control exercises.
-Teach patient how to splint and protect incision sites during deep breathing.
-Administer ordered analgesic if acute pain is inhibiting use of

SPIROMETER: Unexpected outcomes and related interventions: Lung expansion

-Patient has decreased lung expansion and/or abnormal breath sounds or decreased pulse oximetry readings:
-Teach patient cough-control exercises
-Provide help with suctioning if patient cannot cough up secretions effectively

-Patient develops hyperventilation
Encourage longer rest periods between breaths

SPIROMETER: Unexpected outcomes and related interventions: Hyperventilation

-Patient develops hyperventilation
Encourage longer rest periods between breaths

Peak Flowmeter

-Peak expiratory flow rate (PEFR) measurements
-Used for monitoring of Asthma
-Maximum flow that a patient forces out during one quick, forced expiration
-Measured in liters per minute
-Used as an objective indicator of a patient’s current status or the effectiveness of treatment

Delegation for peak flowmeter

-Initial assessment of the patient’s condition is a nursing responsibility and cannot be delegated.
-The skills of follow-up PEFR measurements in a stable patient can be delegated to AP.

-The nurse instructs the AP to:
-Report immediately to the nurse patient’s difficulty breathing or decrease in PEFR measurement

Non-invasive ventilation

-Purpose is to maintain positive airway pressure and improve alveolar ventilation
-Keeps alveoli open at end expiration
-Improves alveolar ventilation without the need for an artificial airway

-Types:
Continuous positive airway pressure (cpap)
Bi-level positive airway pressure (bipap)

Delegation for receiving Noninvasive Positive Pressure Ventilation

-The skill of caring for a patient receiving NIV cannot be delegated to AP.
-However, the skills of patient positioning, therapeutic coughing, and CPAP/BiPAP mask application can be delegated to AP

What can the nurse delegate:

-The nurse directs the AP by
-Informing about the need to immediately report to the nurse any changes in patient’s:
vital signs
oxygen saturation
mental status
skin color
skin changes around mask area

-Informing about the need to immediately report to the nurse any machine or patient alarms
-Instructing on how to modify care
-Informing about the prescribed settings on the NIPPV equipment and instructing personnel to immediately notify the nurse of any change in settings or patient comfort

Noninvasive Positive Pressure Ventilation: Unexpected outcomes and related interventions: skin breakdown

-Patient develops skin breakdown at mask sites or sites where mask straps are located such as bridge of nose, nasal septum, or ears:
-Notify health care provider
-Place protective synthetic coverings on nasal bridge or areas of irritation/possible irritation to protect skin
-Fit mask so it is tight enough to not cause air leak but loose enough to not cause skin breakdown
-Reassess patient

Noninvasive Positive Pressure Ventilation: Unexpected outcomes and related interventions: Claustrophobia

-Patient states sense of smothering or claustrophobia:
-Explain system to patient again
-Demonstrate use of quick-release straps
-Have patient demonstrate use of quick-release straps

Noninvasive Positive Pressure Ventilation: Unexpected outcomes and related interventions: lung condition

-Patient experiences hypoxia, hypercapnia, or other signs of worsening respiratory function or barotrauma (pneumothorax):
-Notify health care provider
-Reassess patient
-Determine correct settings and integrity of NIPPV. Consult with respiratory therapist

Invasive mechanical ventilation

-Endotracheal tubes: Short-term
-Nasotracheal tubes: Short-term
-Tracheostomy: Long-term after 7-10 days

Administering Oxygen Therapy to a Patient With an Artificial Airway

Patients with artificial airways:
-Require constant warmed humidification to the airway
-----Artificial airway bypasses the normal filtering and humidification process of the nose and mouth

What devices supply humidified gas to an artificial airway

Devices that supply humidified gas to an artificial airway
T- tube
Tracheostomy collar

Outer cannula

-Keeps stoma open
NEVER removed
Secure with trach ties

Inner cannula

-May be disposable
-May be removed for cleaning
-Suctioning

Cuff

Prevents secretions from entering lungs
-Check pressure in cuff b/c if pressure it too high, trachea can prevent good circulation to area leading to necrosis

Obturator

-Used to insert tracheostomy tube
-Always keep at the bedside

Fenestrated Trach Tube

-Allows air to flow up to vocal cords so the patient can talk
-Does not allow maximal O2 support
-May be difficult to suction

Metal Trach Tube

-Used long term
-Can be uncomfortable
-No MRIs or Metal detectors

Cuffed Trach Tube

-Prevents aspiration
-Must check cuff pressure regularly to avoid over inflation: Impaired circulation
-Cuff pressure should not exceed 20mmHg

Uncuffed Trach Tube

-For Infants and Children
-Mucosal injury
-Tissue Edema
-Growth of fibrous connective tissue

Temporary Trach Tube

-Prolonged mechanical ventilation
>7-10 days
-Secretions which cannot be cleared routinely

Permanent Trach Tube

-Disease that will permanently affect airway
-Trauma
-Laryngeal cancer

Trach Care

-Performed every 8 to 12 hours to remove secretion build up and provide skin care to stoma
-Prevent infection
-oral care every 2 hours to prevent hospital acquired pneumonia
-Clinical indications:
-Soiled/loose tracheostomy ties or tracheostomy dressing
-Unstable tracheostomy tube
-Excessive secretions

Unexpected Outcomes of Tracheostomy Care

* Trach ties are loose: Adjust them accordingly

* Inner cannula remains plugged:
-Remove it and clean or replace it
-Provide adequate hydration to thin secretions

*Inflammation of the tracheostomy stoma
-Increase frequency of trach care
-Apply hydrocolloid dressing beneath trach flange and around stoma
-Apply antibacterial ointment to peristomal area
-Consult wound care nurse

*Respiratory distress occurs
-Support the client (oxygen and ambu-bag if necessary)
-Stay with patient and call for assistance

*Pressure around tracheostomy tube
-Increase frequency of trach care
-Keep dressing under faceplate at all times
-Consider a double dressing or hydrocolloid dressing around the stoma

Emergency Management of Dislodgement

-Call for help
-Place head of bed at 45o
-Insert obturator into new trach (if available) or dislodged trach
-Lubricate with water soluble lubricant
-Insert tube at 45o angle to neck
-If unsuccessful, place suction catheter into stoma to allow for air entry
-If still unsuccessful, cover stoma with bag-valve-mask to ventilate

-ALWAYS keep obturator at the bedside
-ALWAYS keep a replacement trach tube at the bedside
-Bedside report

Delegation for artificial airway trach

-The skill of administering oxygen therapy to a patient with an artificial airway cannot be delegated to AP
-The nurse directs the AP about:

-Patient-specific variations for application or adjustment of the T tube or tracheostomy collar
-Immediately reporting to the nurse:
Increase in anxiety
Hypoxia
Changes in vital signs
Increase in airway secretions

Unexpected outcomes and related interventions for artificial airway

-Patient experiences tracheal stoma or lip irritation
-Thick, tenacious secretions
Increase frequency of suctioning and airway care
-Pressure areas on neck or near stoma site
-Patient experiences continued hypoxia
----Determine if cause of continued hypoxia is:
Functioning of oxygen-delivery device
Obstruction of airway
Oxygen flow rate
New clinical problem
-Notify health care provider of continued or worsening hypoxia

Mechanical ventilation

-Takes over the physical work of moving air into and out of the lungs
-Does not replace or alter the physiological function of the lung
-Types
Positive pressure
Negative pressure: ‘Iron’ lung
-Patients should remain on mechanical ventilation only as long as necessary
-causes thoracic expansion and a decrease in pleural and alveolar pressures, creating a pressure gradient for air to move from the airway opening into the alveoli.
-can cause trauma- tissue pneumothorax

Delegation of mechanical ventilator

-The skill of caring for a patient on a mechanical ventilator cannot be delegated to AP
-The nurse directs the AP about
-Reporting immediately to the nurse any change in the patient’s respiratory status, vital signs, or oxygen saturation and if patient indicates breathlessness
-Informing the nurse immediately if any of the ventilator alarms sound
-Helping in daily care such as bathing and repositioning the patient

Mechanical Ventilator: Unexpected outcomes and related interventions: ventilator associated event

Patient experiences Ventilator-associated event:
-Notify health care provider
-Remain with patient
-Conduct complete cardiac and pulmonary assessment
-Be prepared with:
-Antibiotic therapy
-Chest tube
-Re-intubation

Mechanical Ventilator: Unexpected outcomes and related interventions: pt worsens

-Patient experiences no improvement in or worsening of respiratory status:
-Notify health care provider
-Reassess patient
-Assess integrity of ventilator system
-Expect ventilator change

Mechanical Ventilator: Unexpected outcomes and related interventions: self exastubation

-Patient experiences self-extubation:
-Maintain patent airway by suctioning and inserting oral airway
-Provide oxygen
-Assess patient’s respiratory status and level of oxygenation and ventilation
-Notify health care provider or rapid response team immediately
-Patient may need sedation and/or use of restraints to prevent this complication from occurring in the future

Oropharyngeal & Nasopharyngeal
Suctioning

-Used when the patient can cough effectively but is not able to clear secretions
-Non-sterile
-Suction after client coughs
-Suction catheter or Yankauer suction
-Secretions removed from Posterior oral cavity
-Cough intact
-Oropharyngeal: device is Yankauer suction
-Nasopharyngeal: device is Size 5-12 Fr Tube

Orotracheal & Nasotracheal Suctioning

-Used when the patient is unable to manage secretions by coughing and does not have an artificial airway
-Nasotracheal the preferred route
-Sterile technique
-Secretions removed from nasotracheal lower airways
-Not cough intact
-Nasotracheal: device is size 5-12 Fr Tube
-Measurement: Nose>earlobe>sternal notch

To get a sterile specimen

Go through nasotracheal suction route

Tracheal Suctioning

-Used with an artificial airway (Endotracheal or Tracheostomy)
-Closed or open systems
-Sterile technique

Clinical Indications for the need to Suction

-Increased respiratory rate
-Increased pulse
-Increased blood pressure
-Dyspnea
-Decrease in SaO2
-Anxiety/apprehension
-Behavior change/irritability
-Pallor/cyanosis

-Assess secretions:
Nasal secretions
Drooling
Gastric secretions/vomitus in mouth
Auscultation
Adventitious breath sounds

-Routine q 1 to 2 hour suctioning not indicated

When suctioning the nurse should

-Hyperoxygenate them NOT hyperventilate them so turn it down after

Dangers of Suctioning

-Desaturation (lowering of oxygen)
---Hypoxia
---Hypoxemia
---SaO2

Oropharyngeal Suctioning

-Yankauer catheter – rigid tonsillar Tip
-Can be delegated
-Unexpected Outcomes
--Increase in respiratory distress
--Bloody secretions are noted

Nasopharyngeal and/or Nasotracheal Suctioning

-Cannot be delegated
-Contraindications
Facial trauma and/or surgery
Bleeding disorders
Nasal bleeding
Epiglottitis and/or croup
Laryngospasm
Irritable airway

Nasopharyngeal and/or Nasotracheal Suctioning Unexpected Outcomes

-Worsening respiratory status
-Return of bloody secretions
-Unable to pass suction catheter through nares on first attempt
-Paroxysms of coughing
-No secretions obtained

Nasotracheal Suctioning Complications

-Hypoxemia
-Cardiac dysrhythmia: Bradycardia caused by vagal stimulation
-Laryngeal and bronchospasm
-Nasal, pharyngeal, or tracheal trauma and bleeding induced by the suction catheter

Suctioning TIPS

-Catheter size should be small as possible but large enough to remove secretions
-Suction is only applied INTERMITTENTLY during WITHDRAWAL of the catheter over no more than 10 seconds
-Suction pressure needs to be 120-150 mmHg
-Rotating the catheter in a circular motion aids in secretion removal
-Do NOT instill saline into the airway
-Hyperoxygenate patient BEFORE suctioning for 30 – 60 sec
-No more than 3 total suction passes at a time
-Rinse catheter with sterile saline in between passes and hyperoxygenate
-Let patient rest at least 1 minute in between passes
-Suction when pulling it back not going in