MedSurg Ch 7 O2 Management

Ventilation

Is the movement of air in and out of the lungs

Perfusion

Is the gas exchange of oxygen and CO2 at the alveoli-capillary membrane

Oxygenation

Is the process of oxygen passively diffusing from the alveoli to the blood where the oxygen attaches to the hemoglobin or dissolves in the plasma.

Respiration

The process of the transport of oxygen from the inhaled air to the cells in the transport of CO2 in the opposite direction

Tracheotomy

Needed in some patients who are unable to maintain a normal airway. Is a surgical opening of the trachea

Tracheostomy

An opening/stoma directly into the trachea. Indicated when mechanical ventilation is needed for more than 7-14 days

Surfactant

A phospholipid and protein substance that covers the alveoli to prevent the alveoli from collapsing by reducing surface tension in the alveoli, allowing for gas exchange to take place.

Compliance

Ease of expansion of the lungs

oxygen is carried to the tissue in two ways

97% of the oxygen is attached to hemoglobin

3% of the oxygen is dissolved in plasma

Hypoxia

Occurs secondary to insufficient oxygen to meet the metabolic demands of the cells, tissues, and organs. Develops when there are low levels of oxygen in the arterial blood.

Hypoxia is indicated when what values are low?

PaO2 <60 mmHg

SaO2 < <90%

Hypoxemia

manifested when the PAO2 level in the blood becomes less than 60 mmHg or the Sa02 level becomes less than 90% when breathing on room air

Oxygen contraindicated in

hypercapnia, hypercarbia

1-2L NC appropriate for

COPD patients and patients with hypercapnia/hypercarbia

Use low flow O2

Indications for supplemental oxygen

PaO2 less than 60

SaO2 Less than 90%

An increased need for oxygen because of fever, infection, anxiety, anemia

COPD patients need lower O2 to avoid

suppressing their respiratory drive, which can lead to increased levels of carbon dioxide in the blood (hypercapnia/hypercarbia)

These patients are more sensitive to oxygen levels. Too much oxygen can lead to hypoventilation and hypercapnia/hypercarbia

COPD patients

PaO2

a measurement of the amount of oxygen dissolved in the body. It's a key indicator of how well your lungs are transferring oxygen into the bloodstream

low values mean the oxygen is not going where it’s supposed to (hypoxia)

PaO2 normal values

80-100

Trauma, acute myocardial infarction, and surgery or examples of acute care situations in which what may develop?

Hypoxemia

Early signs of hypoxia

Change in mental status, anxiety, restlessness, and or confusion because the cells in the brain or not receiving an adequate supply of oxygen. Increased respiratory and heart rates as well as dyspnea (difficulty breathing)

Hypercapnia/Hypercarbia

Increased PaCO2 levels in the body. Is often observed in patients with COPD

In patients with COPD

oxygen therapy should be started with caution because delivering too much oxygen may interfere with the hypoxic drive for breathing, leading to decreased respiratory effort and ultimately rate

Normal SpO2

95-99%

pH blood normal range

7.35-7.45

PaCO2 normal range

35-45

HCO3 normal range

22-26

Nasal cannula

delivers oxygen through tubing that has two soft prongs on one end that are placed into the patient’s nares; the other end of the tubing is connected to an oxygen source. This is the most commonly used delivery system because it is more comfortable, mobile, easy to use, and less expensive than other delivery systems. Delivers 24-44% oxygen

1L-6L/min

Simple face mask

used when the patient needs a moderate amount of oxygen to maintain an adequate PaO2 level. This device uses oxygen flow rates between 5 and 10 L/min and can deliver oxygen concentrations from 40% to 60%. The amount of oxygen that the patient receives depends on the patient’s respiratory pattern and proper fitting of the mask. The higher flow rate (5–10 L/min) assists the patient in preventing rebreathing of exhaled CO2 that can be retained in the mask, thus delivering more oxygen

Partial rebreather mask

a simple mask with a reservoir bag attached. The patient breathes in the oxygen from the reservoir bag; on exhalation, the bag refills with oxygen, and the exhaled gases exit through small holes on both sides of the mask. This allows for a greater concentration of oxygen to be delivered to the patient than with the simple face mask. Oxygen flow must be maintained to keep the reservoir bag one-third to one-half full on inspiration. Maintaining a flow rate of 8 to 10 L/min to this device can provide 50% to 75% oxygen to the patient. This device is useful for short-term oxygen therapy

Nonrebreather mask

similar to the partial rebreather mask except this mask has one-way valves. There is a one-way valve between the bag and the mask that prevents the exhaled air from entering the bag, thus ensuring a higher/more accurate oxygen concentration in the reservoir. This device also has one-way valves on both sides of the mask to prevent room air from entering the mask on inhalation. The reservoir bag must be kept inflated at one-third to one-half full on inspiration so that the patient receives the optimal amount of oxygen, and there should be a minimal flow rate of 10 L/min to maintain bag inflation. The nonrebreather mask can provide up to 90% oxygen to the patient

Venturi mask

This device can deliver oxygen concentrations of 24% to 60% by using different adapters and by adjusting the oxygen flow from 2 to 15 L/min. The adapter indicates the flow rate of oxygen that should be maintained to provide the prescribed percentage of oxygen to the patient

Aerosol mask

Indicated for high-humidity oxygen concentration post extubation, post upper airway surgery, or for thick secretions.

Can relieve bronchospasms

Tracheostomy collar

is used for patients with a tracheostomy. This device allows humidified oxygen to be delivered to the patient via the tracheostomy collar because the air is inhaled directly through the tracheostomy and bypasses the usual humidification and filtration processes provided by the nose and mouth

T-piece adapter

Used to wean patient off a ventilator. Can be used with endotracheal, nasotracheal, or tracheostomy tube. Used for spontaneous breathing trial

Spontaneous breathing trial

Requires the patient to maintain spontaneous breathing through the T-piece adaptor before a patient is extubated

Face tents

used for patients who have facial trauma, have burns, or have had upper airway surgery. The device fits under the chin and extends just above the ears. This device allows the delivery of oxygen mixed with a mist

High flow nasal cannula

uses an air-oxygen blender (blends O2 with compressed air), active humidifier, single heated tube, and nasal cannula to deliver heated and humidified medical gas up to 60 L/min

Tracheostomy suctioning

Assess the patient to determine if suctioning is necessary. Some patients require suctioning every 1 to 2 hours, and other patients may require less suctioning. Assess breath sounds for wheezes, crackles, and/or rhonchi; these sounds may indicate a need for suctioning. Other indications may include coughing, audible secretions, an increase in pulse or respirations, or restlessness

If at any time during the suctioning procedure, the patient’s oxygen saturation decreases or the heart rate drops, suctioning should be

stopped and 100% oxygen administered

Tracheostomy care

Suctioning

Replace inner cannula

Clean stoma site

Maintain sterile tracheostomy dressing

Replace Velcro tracheostomy holder if soiled

post tracheostomy complications

Accidental decannulation, pneumothorax, subcutaneous emphysema, infection, tracheal stenosis, tracheoesophageal fistula

Dyspnea

Difficulty breathing

Low PaCO2 indicates it is

alkalotic

High PaCO2 indicates it is

acidotic

High HCO3 indicates it is

alkalotic

Low HCO3 indicates it is

acidotic

How many L/min do nasal cannulas deliver?

1-6L/min

How many L/min do simple face masks deliver

5-10L/min

How many L/min do partial rebreather masks deliver

8-10L/min

How many L/min do nonrebreathers deliver

10L/min

Trauma patients are cared for by which oxygen mask?

nonrebreathers

How many L/min do venturi masks deliver

2-15L/min

Aerosol masks are used for

post intubation, post upper airway surgery, and thick secretions (like pneumonia patients)

What high flow delivery method must be humidified?

tracheostomy collar

Spontaneous breathing trial

when the tube is still in the patient but they are off the ventilator breathing on their own

T-piece adapter delivers _ and can _

humidified oxygen

be used pre-extubation

Long term oxygen therapy can be used for patients with

COPD, heart failure, cystic fibrosis, or patients with exercise intolerance

Oxygen concentrator

makes oxygen from the air around the patient but it is heavy and not very portable

Oxygen tank care

Store tanks upright, do not stack, prevent bottles from rolling around or the high pressure in the tube to explode, keep away from flames and stoves

Oxygen toxicity

when oxygen is greater than 50 delivered over 24-48 hours, damages alveoli capillary membranes and damages surfactant production

Humidify oxygen to prevent

mucous membrane dryness

Humidifiers can cause

infection due to the water inside of it, keep it clean and change per policy

Education for preventing oxygen infection

maintain asepsis and teach family to wash hands, replace equipment that has come into contact with the floor or soiled items

Endotracheal tube

artificial airway passed through the nares or through the mouth into the trachea

What is it called when an endotracheal tube is inserted?

Intubation. An inflated cuff at the end of it keeps it in place just above the carina (the point where the trachea divides into the left and right bronchi)

usually inserted by a doctor or nurse anesthetist, managed by respiratory therapists and nurses

Extubation

When the endotracheal tube is removed

Complications of endotracheal tubes

unplanned extubations (patients pulling it out)

aspiration

infection

Glasgow Coma Scale less than 8 means

to intubate because they cannot protect their airway

Endotracheal patient safety

monitor breath sounds and ensure they have bilateral breath sounds with no air passage at their belly

monitor ET tube placement (monitor depth markers to indicate location at the teeth) and get chest x-ray

provide oral care and suctioning

monitor O2 and vital signs

reassure and educate patient and family

Can a patient talk with an endotracheal tube?

No.

Endotracheal patient care

suction as needed for secretions

provide oral care

keep their head up

Things to monitor for an Endotracheal tube

ensure the patient has a symmetrical rise and fall of the chest, bilateral breath sounds, report lack of breath sounds or abnormal breath sounds

validate chest x-ray

check chest tube placement and make sure the bulb is inflated

Coughing or increased ventilation pressures may indicate

a mucous plug - which can cause respiratory distress

What should the nurse do when they are suctioning a patient and the patient’s pulse oximeter decreases or the patient’s heart rate decreases?

Stop suctioning immediately and give 100% oxygen

Endotracheal tubes increase the risk of aspiration because

it passes through the epiglottis and the patient loses protection of the epiglottis to prevent aspiration (such as gastric secretion aspiration)

Tracheostomy pros

prevents laryngeal damage unlike the endotracheal tube

improved patient comfort, improved oral care

decreased work of breathing, decreased airway resistance

most patients can eat

Can you feed your patient if they have an endotracheal tube?

NO ABSOLUTELY NOT

When to suction a patient with a tracheostomy

when wheezes, crackles, and/or rhonchi can be heard. Coughing, audible, secretions, and increase in pulse or respirations, or restlessness

What position should you place the patients placed in to suction their tracheostomy?

Semi-Fowlers

Caring for a tracheostomy

suction for no more than 10 seconds

assess for skin breakdown

clean stoma site and remove secretions around it to decrease infection

maintain sterile tracheostomy dressing

replace tracheostomy tube holder if soiled

When replacing the Velcro tracheostomy holder

always have two people present and use a sterile technique and clean technique

have someone hold the trash in so if the patient coughs, the trach will not fall out

Low pitch breath sounds continuous throughout inspiration may indicate

a blocked airway and they are called rhonchi

can sound like snoring

Wheezing

high pitched squeak noise from narrow passages caused by secretions, edema, inflammation, or bronchospasms

PPE when suctioning a tracheostomy is needed because

patients are able to cough the secretions up and at you

Accidental decannulation of a tracheostomy post-op is

a medical emergency because of the swelling and the stoma has not healed. And with reinsertion, there is a risk for reinfection. If it is removed, the patient is left without an airway

should only change trach holders hours after surgery

Pneumothorax

a collection of air in the pleural cavity. Can occur as a post op complication of a tracheostomy. It is a medical emergency

Signs of a pneumothorax

absent breath sounds on the affected side

subcutaneous emphysema (trach has a hole in it and air will move into the surrounding tissues like the face, neck, chest. Will feel like rice crispies)

Subcutaneous emphysema

A complication of a tracheostomy. The trach has a hole in it and air will move into the surrounding tissues like the face, neck, chest. Will feel like rice crispies

Notify doctor immediately

Tracheoesophageal fistula

opening between the trach and the esophagus because there is too much pressure in the trach

Incentive spirometry

patient inhales slowly and deeply, a ball goes up and encourages lung expansion and prevents atelectasis

patient should suck in and not blow into it

Chest physiotherapy

Ordered when the patient requires assistance in removing pulmonary secretions. Consists of percussion, vibration, postural drainage, and bronchodilators

Make sure to complete chest physiotherapy _ and _

1 hour before meals

3 hours after meals

Nebulizer treatments

Uses bronchodilators, corticosteroids, and/or mucolytic agents to reduce bronchospasm, edema, or inflammation, and thin secretions

Intermittent Positive Pressure Breathing

Indicated for patients with pulmonary atelectasis when other therapies have been unsuccessful. Delivers aerosol medications or assists the patient with ventilation

Incenitive spirometry patient teaching

use it 5-10 times an hour while awake

teach them that it improves their chest expansion

promotes airway clearance

inhale while using, do not blow into the device

When we breathe faster we blow off

CO2. Can cause respiratory alkalosis

While on mechanical ventilation the “assist control” method

can increase the respiratory rate, which means the patient is blowing off carbon dioxide and will put them in respiratory alkalosis

Vital signs that could make a patient breathe faster

an elevated temperature

pulse ox 88% on room air (she’s not getting enough oxygen so she breathes faster)

Low oxygen and acidosis can cause

ECG changes