Oxygenation - Med Surg II

respiration vs. ventilation

* respiration = act of breathing in and out (exchange of gases)
* ventilation = the **movement of air** in and out of alveoli

which 2 diseases affects gas exchange?

• COPD!!

• pulmonary embolism

diseases that affect ventilation

* asthma
* cystic fibrosis
* anaphylaxis
* pneumothorax
* pneumonia

which disease specifically affects RESPIRATION (gas exchange)?

* PULMONARY EMBOLISM!!

how does COPD affect lung compliance?

* in COPD, the lungs will keep getting more expanded, but not fully squeeze back to normal :((

normal VQ scan results

* ventilation 4L air/minute
* perfusion 5L blood/minute
* REMEMBER THAT PERFUSION is higher than ventilation

VQ scan - usually done to verify what? what other test can be done?

* VQ scans are used to verify a suspected PE
* a CT with contrast can also be done to check this

CT with contrast - CONTRAINDICATIONS!!

* severe contrast allergy
* unable to get a 20 G IV
* pregnancy
* renal disease with low GFR and NOT on hemodialysis (unable to get rid of contrast!!)

PaO2 - normal range? Is it possible to have a PaO2 higher than 100? How does this happen?

* normal range = 80-100
* you can get a PaO2 over 100 if the patient receives too much oxygen → INVESTIGATE WHY IT IS LOWER !!!

normal SaO2 for COPD? if on oxygen, when should you start to wean them off? why?

* normal SaO2 = 88-90 for COPD
* if on oxygen and they get to 96%, you start to wean them off because they can become RELIANT on it (NO BUENO)

O2 + hemoglobin = ?

oxyhemoglobin

what is PaO2?

the volume of O2 dissolved in the plasma

diagnostic procedures for respiratory disorders

* PFTs
* ABGs
* pulse ox
* cultures
* sputum studies
* chest x-ray
* CT scan
* MRI
* pulmonary angiography
* VQ scan
* bronchoscopy
* thoroscopy
* thoracentesis

hypoxemia - symptoms

* dizziness
* anxiety/SOB
* decreased LOC/mental status (LATER ON)
* cyanosis (blue lips/fingernails)
* headache
* clubbing nails

Do you need an order for oxygen? What amount is a nurse legally allowed to give WITHOUT an order?

* oxygen is a medication, NEED AN ORDER
* WITHOUT an order, a nurse may administer 2 L of O2

why is the amount of oxygen given to COPD patients VERY important to note?

COPD patients hold on to CO2 so their drive to breathe is a low pO2 (88-92 is THEIR normal); therefore if pt gets too much O2, the drive to breathe is knocked out, causing their CO2 to rise even higher causing acidosis (NO BUENO!!)

COPD (what is meant by “less is more”)

keeping them on LESS oxygen is MORE beneficial in the long run (maintains their drive to breathe)

what is the max amount of O2 one can administer via nasal cannula? what happens if you go over?

* 6L is the max you can give; going over will NOT increase the amount of oxygen going in (POINTLESS AF)

venti mask - why is it very beneficial?

VERY specific with the amount of oxygen being given, ensuring one doesn’t over/underdo it

non-rebreather - why is it very beneficial?

ESSENTIALLY BREATHING PURE OXYGEN (does not allow you to breathe anything but oxygen)

* this is the step just below intubation

ABCs - what is meant by this? what should you NOT do?

* PRIORITIES - airway, breathing, circulation
* do NOT add to the question by making up airway issues (ex: airway for COPD vs. airway for hip fracture (no relationship whatsoever))

OSA - risk factors

* LARGE NECK CIRCUMFERENCE!!
* genetics

OSA - patient presentation (hint: 3 S’s)

* sleepy during the day
* snoring
* significant other sent them to get checked out (OMG LMAO SO FUNNY)

OSA - diagnostic

SLEEP STUDY!!

OSA - medical management (2)

* CPAP (continuous positive air pressure (into pt; patient still breathes on their own)
* BiPAP (blows air and forcefully has them expel a breath too (REALLY good for COPD patients!!)

OSA - surgical intervention? when is this usually done?

* removal of the tonsils
* usually only done in pediatrics (not for adults)

OSA - nursing education

* ENFORCE LUNG COMPLIANCE!! (to encourage lung expansion)

cancer of the larynx - patient presentation

* hoarse voice
* FEELS like swollen lymph nodes (but no pain)
* Air way is being blocked!!!

cancer of the larynx - 2 diagnostics

* CT to show mass
* biopsy to confirm cancer

cancer of the larynx - surgical intervention?

TOTAL LARYNGECTOMY!! (removal of the upper airway)

cancer of the larynx - #1 cause

SMOKING!!

tracheostomy vs. laryngectomy

* tracheostomy = surgical opening to access the tracheal lumen WITH the entire larynx remaining intact
* laryngectomy = surgery where ENTIRE larynx is removed and the trachea is brought to the skin as a stoma, which no longer has any anatomical connection with the oropharyngeal cavity and digestive tract

laryngectomy - communication?

* work with speech therapist!! (esophageal speech / artificial electric larynx)

pleural effusion - risk factors

* fluid overload
* laying down/not moving (for long periods of time)

pleural effusion - lung sounds?

* DIMINISHED!!!! (NOT crackles)

pleural effusion - diagnostic?

CHEST X-RAY!!!

pleural effusion - nursing management

* INCENTIVE SPIROMETER!!
* ambulation!!
* promote lung expansion

pleural effusion - 3 draining techniques

* chest tube (if severe)
* thoracentesis
* pleur-x catheter (LONG TERM!! patient is able to drain fluid by themselves)

pleural effusion - pleur-x catheter (nursing considerations)

* MAINTAIN STERILITY!!
* provide patient education!
* AT HOME? - patient will always have a home care nurse to monitor them and provide education

empyema - what is it?

pleural effusion that has become infected (due to lack of sterility, bacteria build, or patient has pneumonia, etc)

empyema - patient presentation

* infection (fever; elevated WBC; tachycardia; low BP; lung symptoms such low SaO2)

empyema - medical management

* antibiotics
* fluid drainage (think about the pleural effusion drainage techniques!)

pneumothorax - what is it?

air in the thoracic cavity, collapsing the lung

pneumothorax - 4 types

* simple/spontaneous (usually occuring in tall skinny males)
* traumatic (gunshot, stabbing, etc)
* hemothorax (blood in thoracic cavity)
* surgery (open heart surgery (EXPECTED); bilateral chest tubes are placed after surgery to fix lungs)

what is a good indication that a pneumothorax has occurred?

chest x-ray indicates heart and trachea migration (on x-ray, BLACK indicates air, white is structures)

what is used to temporarily fix a pneumothorax prior to inserting a chest tube?

a catheter needle (to expel air)

chest tubes - assessment

1. make sure chest tube is SECURE!! (they move excessively and are uncomfy); make it a priority keep it secure with FOAM TAPE!!


1. assess tubing to ensure there’s no kinks/clots
2. drainage system = UPRIGHT at all times!!
3. drainage system = BELOW level of chest
4. assess for crepitus (RICE CRISPIES!!); caused usually by an air leak
5. suction? - need an order
6. CHECK FOR AIR LEAKS (look for bubbles)

chest tube emergency management (3 bedside supplies)

1. foam dressing/tape (at insertion site to prevent air from leaking)
2. hemostats (to clamp off chest tube; if tubing disconnects from chamber system, air can easily get into the chest cavity)
3. Vaseline gauze with a covering (XEROFORM)


1. prevents air from leaking in AT the insertion site

pulmonary embolism (risk factors)

• DVT (clot breaks off and goes to lungs)

• orthopedic surgeries (anesthesia, decreased mobility, laying down)

• cerebral palsy

• clotting disorders

• smoking

• birth control users/pregnant women

  • INCREASED ESTROGEN LEVELS, which increases clotting factors

• obesity

pulmonary embolism - symptoms

* SOB (air flow is good, but NO GAS EXCHANGE!!!)
* diminished lung sounds / cyanosis
* increased HR and BP
* impending doom (I feel like I am going to die)

saddle PE? what is it

a VERY large blood clot that prevents blood flow to BOTH lungs (very unlikely to live from it)

d-dimer - what is it?

a test that indicates if there is a blood clot in the body (NOT specific)

pulmonary embolism - what test will look normal ?

CHEST x-ray (shows structures, not vessels) - NOT RELIABLE :(

pulmonary embolism - diagnostics

* d-dimer (indicates blood clot SOMEWHERE in body)
* __**CT chest with contrast (check kidney function to ensure pt can get rid of contrast; start on heparin drip if clot is confirmed!!)**__
* VQ scan (HIGH ventilation, low perfusion)
* ABG (shows respiratory alkalosis (hyperventilation))
* ECG (sinus or tachycardia; right sided heart failure symptoms also start occurring)

 PE (d-dimer, CXR, VQ scan, respirations, heart rate, pulse ox, and temp results) - CHART

pulmonary embolism - prevention

* ambulation / mobility
* SCDs
* subq heparin / lovenox (to prevent); heparin drip (clot detected, prevents it from getting BIGGER/adhere to wall preventing migration)

atelectasis - what is it

(alveoli collapse due to BLOCKED AIR PASSAGE)

atelectasis - #1 risk factor

SURGERY

atelectasis - nursing education/prevention?

use incentive spirometry!!!!

atelectasis - symptoms

chest pain, SOB, shallow respirations

atelectasis - complication

CAN BECOME PNEUMONIA (increased mucus in collapsed lung leads to infection)

what is the #1 cause of death from an infectious disease?

PNEUMONIA!!

pneumonia - diagnostic test?

SPUTUM CULTURE!!

pneumonia - 4 types

1. CAP
2. HAP


1. VAP
3. Aspiration

CAP - when does it usually develop?

usually after a recent illness (PREDICTABLE!!)

what is the most commonly acquired pneumonia?

CAP

2 most common organisms that cause CAP

1. strep-pneumo
2. H-flu

HAP - what is it

pt. admitted in hospital for AT LEAST 48 hours, and then pneumonia develops

HAP - are they caused by the same organisms involved in CAP?

NOOOO, which is why sputum cultures are SOOO important

VAP - what is it?

a pneumonia the forms due to lack of hand hygiene/sterility on a ventilated patient, who has been on the ventilator for AT LEAST 48 hours

aspiration pneumonia - 2 populations at risk?

1. stroke (swallow reflex is weakened; CONFIRM GOOD SWALLOW EVAL before giving anything PO)
2. parkinson’s

aspiration pneumonia - what is it?

* food you eat goes into the lungs, preventing gas exchange; as well, vomiting while laying down can cause it too

CAP/HAP/VAP/aspiration pneumonia (risk factors) - CHART

CAP/HAP/VAP/aspiration pneumonia (symptoms) - CHART

pneumonia - nursing considerations (WITHOUT an order)

* Oxygenation monitor​
* Adequate fluid intake (help with dehydration / loosen secretions)​
* Elevate head of bed​
* Incentive spirometry​
* Ambulation (to promote lung expansion​
* Encourage coughing / deep breathing / suctioning

pneumonia - anticipated provider orders

* Antibiotics!!!​
* IV fluids​
* Chest x-ray​
* Sputum culture (need an order to send it, but can collect it without an order) (NEEDS TO BE COLLECTED BEOFRE ANTIBIOTIC ADMINISTRATION, as it can alter results)​
* Antipyretic to lower the fever!!!

COVID-19 - what specific PPE must be worn ?

N95 mask!!!

COVID-19 - specific finding to confirm diagnosis?

* ground glass opacities (in a CT scan)

COVID-19 - risk factors

* older age
* obese
* immunocompromised
* underlying lung disease patients

COVID-19 - hypoxia management

* continuous cardiorespiratory monitoring (rapid decompensation is prevalent!!)
* encourage patient to self-prone as often as possible/tolerated
* supplemental oxygen (nasal cannula; non-rebreather; CPAP; and if still not enough, ET intubation)

pulmonary edema - what is it?

abnormal accumulation of fluid in the alveoli, lung tissue, or both; NO GAS EXCHANGE occurs

pulmonary edema - causes

* congestive heart failure (already fluid overloaded)
* damage to pulmonary lining (from trauma for example)

pulmonary edema - symptoms

* PINK FROTHY SPUTUM!!
* very crackly lung sounds
* low pulse ox

pulmonary edema (what will you see in a CXR)

LOTS OF WHITE (fluid)

what is the #1 cancer death in the US?

LUNG CANCER!!

lung cancer has a 5-year survival rate. what does this mean?

from the time of diagnosis to 5 years later, only 5% are still alive

* why? THEY DON’T STOP SMOKING

lung cancer - patient presentation

* chronic cough
* sputum
* pulse ox will STILL LOOK NORMAL if they don’t have COPD (same symptoms as COPD!!)

lung cancer - what is the good news for pt who are long term smokers?

CAT scans can be administered (insurance included) to catch lung cancer early (lose dose radiation/contrast)!!!

lung cancer - 2 diagnostic tests

1. biopsy (to prove cancer)
2. bronchoscopy (to verify place of cancer)

lung cancer - medical managment

SYMPTOM management :)

4 treatments for ALL cancers? how is the type of treatment decided?

4 treatments:

* surgery
* chemo
* radiation
* palliative
* patient / provider decide what treatment they want, depending on the stage of cancer they’re in

staging of all cancers (0-4)

* stage 0 = Precancer (found a polyp)
* stage 1 = on surface of organ (remove it and you’re good)
* stage 2 = invading deeper from the surface
* stage 3 = spread to the surrounding lymph nodes (feel for swelling); this is HOW cancer metastasizes
* stage 4 = more than one organ has cancer :(

bronchoscopy - 2 medications used? what are their purposes?

* lidocaine (to numb the gag reflex / prevent pain during procedure)
* atropine (to prevent hypotension (caused by hitting vagal nerve); keep the heart rate up; DRY SECRETIONS (preventing aspiration))

bronchoscopy - postop nursing considerations

* monitor O2 status
* monitor HR/BP
* AVOID FOOD AND FLUID UNTIL GAG REFLEX IS BACK
* monitor for lung collapse (tracheal deviation and other symptoms)
* monitor for any bleeding (minor hemoptysis is expected)

what is the third leading cause of death in the US?

COPD

COPD - what is it?

a disease state characterized by chronic airflow limitation that is irreversible (chronic bronchitis and emphysema)

COPD - why do patients have the barrel chest?

* patients are able to have lung expansion, but no ability to squeeze to exhale (lungs get BIGGER and BIGGER overtime)

emphysema - what happens?

alveolar walls are destroyed, resulting in impaired gas exchange; overtime this will ead to chronic hypoxemia and CO2 retention

emphysema - do they have a high or low CO2? why?

HIGH CO2, because their ability to exhale is impaired, causing them to retain more CO2

how to facilitate breathing for patients with emphysema?

position them into a tripod position