oxygenation and oxygenation interventions

oxygenation

oxygenation

• you HAVE functioning lungs/ they can open close, u have airway

  • they work just not effective so need oxygenation

ventilation

• movement if air in and out of lungs

• occurs through pressure changes (diaphragm)

• CO2 triggers brain to do things

work of breathing (WOB)

effort required to expand and contract lungs

• amount of energy expended depends on

  • rate

  • depth of breathing

  • compliance (ease in which lungs can be expanded in response to inc. alveolar pressure )

    • dec. in diseases like pulmonary edema, interstitial and pleural fibrosis, structural abnormalities (khyphosis, rib fracture)

  • airway resistance

    • inc. in pressure as diameter of airways gets smaller from mouth/nose to alveoli

    • bronchoconstriction excess mucous, asthma, tracheal edema, COPD inc resistance

not everyone can tolerate wob

• tripod position in COPD

  • accessory muscle used to inc. volume but this = fatigue

• can finish sentence

normal/healthy = quiet, minimal effort

oxygen transport/delivery

consists of : lungs, CV system

diffusion, oxygen carring capacity

depends on:

• amount of O2 in lungs and plasma (ventilation)

• amount if hemoglobin (CARRIES O2 AND CO2) (perfusion)

  • not enough = not enough perfusion = no matter how much O2 u give wont help bc not enough to carry them

• rate of of diffusion

• tendency and hemoglobin to bind with O2

• oxygen carrying capacity

chemical regulators

• maintains RR and depth based on changes in CO2, O2, H concentration (pH)

  • controls chemoreceptoes in medulla, aortic body, carotid body → stimulates nueral receptors → adjust RR and depth → maintain normal ABG values

• if chem or neural regulators don’t work CANT BREATHE

neural regulation of ventilation

• ensures enough o2 intake and CO2 elimination to meet demands of body

• CNS control pf RR, depth, rhythm

• cerebral cortex = voluntary control

  • deliver impulse to resp motor neurons in SC

• based on changes on CO2, O2, H+, pH in blood

planning and outcomes

INDIVIDUALIZED PLAN OF CARE

• meet actual/potential oxygenation needs

• outcomes examples:

  • patient coughs productively

  • patient maintains or imroves pulse oximetry

  • teamwork & collaboration

    • family, colleauges, resp. therapist, physical therapits

dyspnea management acute interventions

• acute care setting = hospital

• treat underlying cause not enough to just given oxygen forever

• pharmacological measures:

  • bronchodilators

  • inhaled steroids

  • mucolytics

  • low-dose antianxiety meds (lowers resp., keeps out of hypervent)

• oxygen therapy

  • reduces dyspnea associated with exercise and hypoxemia

• physical techniques

  • cardiopulmonary reconditioning (build up body’s ability)

    • exercise

    • breathing

    • cough control

• psychosocial techniques

  • relaxation

  • biofeedback

  • meditation

airway maintenance interventions: acute care

• adequate hydration

  • fluid intake 1500-2500mL/day

    • want secretions thin to easily cough out

    • clear anything blocking O2 transport

  • contraindicated with pt. cardiac or renal patients

    • could overload w fluids heart or kidney

• adequate humidification

  • air/O2 with high relative humidity keep airway moist, loosens & mobilizes secretions

    • might become a reservoir, humidity at right time

  • for pt. receiving O2 therapy >4L/min

  • good for kids because since they have small airways, get obstructed easy, this helps clear

• proper coughing and breathing techniques

  • direct coughing

  • cascade cough

  • huff cough

  • quad cough

  • deep breathing

  • diaphragmatic breathing

airways maintence chest physiotherapy and neubilizer therapy

acute interventions

chest physiotherapy

• manipulation of secretions w external force

• often used with postural drainage to mobilize secretions

• chest percussion and drainage

• used for pt. who cant cough out secretions

  • cystic fibrosis stay with these vests on

nebulizer therapy

• add moisture/meds (bronchodialators and mucolytics) to inspired air

  • give bronchodialator first

• mixes particles of varying sizes with air, aerosolization suspends in air

• enhances mucociliary clearance → improves clearance of pulmonary secretions

oxygen safety

• COMBUSTIBLE

• O2 is prescribed, need order

  • nurse can give O2 then ask for order in case of emergency

  • pt. low in O2 = raise head of bed and give oxygen!!!!

• “oxygen in use” signs

• keep O2 delivery systems 10 ft from open flames

• electrical equipment → proper grounding

  • tech children not to play w electric or friction toys

  • don’t use radios or electrical equipment

• O2 cylinders: secure and store appropiately (broad base, chained)

  • keep upright

• check O2 level of portable tanks prior to transporting patients

oxygen delivery

• oxygen wall outlet has

  • detachable flowmeter

  • “christmas tree”

    • allows tubing to connect to oxygen

  • humidification

    • have to take tree off to inout humidification

    • humidity air w sterile water

humidification

• necessary when high flow rate → O2 flow rate >4L/min

• Sterile water

  • so doesn’t become reservoir

  • not sterile process, just connect container to deliver

• may form condensation in tubing: remove and throw away tubing, reservoir

• DO NOT drain fluid back into container → infection

• achieved through bubbling oxygen through sterile water for nasal cannula or face mask

• applied to all oxygen devices regardless of flow rate for peds

oxygen delivery systems

• low flow systems

  • part of tidal vol. is supplied by inspiring room air

  • nasal cannula - doesn’t block inhaling room air - mix

  • simple face mask

  • partial rebreather mask

  • non-rebreather mask

  • advantage = ease of use and pt. comfort

• high flow systems

  • usually over 6-15L per min

  • venturi mask

  • aerosol mask

  • face tent

  • tracheostomy collar

  • T-piece

know RECCOMENDATIONS of use

• is not a only, never, always

• only know what u should use by looking at pt. = highly individual

• learn table 41-7

nasal cannula

• FR: 1-6L/min

• FiO2: 24%-44%

• indications

  • chronic lung disease

  • long-term

• equipment

  • nasal prongs in nares

  • fit tubing over ears and secure under chin

• skin irritation

  • over ears and nostrils

simple face mask

• open holes on side of mask oxygen passively delivered over mouth and nose

• good if they have small blockage of nose

• for ppl in labor , w anxirty ect bc dont have to place perfectly or inhale air perfectly to get O2

• short term

• FR: 6-12 L/min

• C/I

  • CO2 retention (worsens_

• fit mask snugly over mouth. and nose w strap

• skin irritation under mask w long term use

face tent

• can be used w humidifaction

• cover nose and mouth does NOT create seal around

non-rebreather mask

looking at change in acuity

• on fast track to ICU, severe change to resp status

• clinically ill w deteriorating resp. mask

venturi mask

• most controlled mask for controlling how much FiO2 is being delivered to pt.

• non-invasive long term resp. options

high flow oxygen delivery

• good alternative to being intubated

• person is neurally intact

• still have to be able to maintain their own airway, and breathe in and out

• NOT TESTED ON HOW WORK

CPAP/ BiPAP

non-invaive positive pressure ventilation

CPAP- continuous positive airway pressure

• maintain positivr airwy pressire to improve alveolar pressire

• keeps airway open

• used for sleep apnea bc keeps airway from collapsing

• usual pressure between 5-20 cm of water

BiPAP bilevel

• assistance during inspiration and keeps airway from closing during expiration

• inc. air in lungs at end of expiration and reduced airway closure, improved oxygenation

deep breathing

airway maintenance

• effective when spontaneous coughing is inadequate

• removes secretions from upper and lower airways

• deep inhalation, closure of glottis, axtive contraction of expiratory muscles, glottis opening

• contraction allows high intrathoracic pressure to develop

  • glottis opens = large airflow expelled at high speed → mucus moves to upper airway to spit or swallow

huff cough

• helps move secretions to upper airways

• inhale deep, and holds breath 2-3 seconds, while forcefully exhaling say huff

• eventually can turn into a cascade cough

  • takes slow deep breathes, holds 1-2 seconds, then opens mouth and performs series of coughs throughout exhalation

quad cough

• for pt. without abdominal muscle control like w spinal cord injuries

• while pt breathes out w/ max effort nurse pushes in and up in muscles towards diaphragm causing cough

diaphragmatic breathing

• encourages deep nasal inspiration

• to inc. airflow to lower lungs

• belly out when breathing in and belly in when breathing out

• pt. w COPD helps inc. tidal vol., oxygen saturation. reduces dyspnea, improves exchange of resp. gases

nasal cannula

FiO2

24-28% = 1-2L flow rate

32-36% = 3-4L flow rate

40-44% = 5-6L flow rate

exact concentration depends on flow rate, clients rate/pattern of breathing and depth of RR

used for client in noncritical w/ minor breathing problems, clients who will not or cant wear mask

simple face mask

40-60% FiO2 = 5-8L

dont use less than 6L

requires fairly high rate to prevent rebreathing of CO2

accurate FiO2 difficult to estimate bc most air breathed in through side holes

fro those who need moderate flow rate for short time

nonrebreather face mask

FiO2 almost 100%

maintain reservior bag 2/3 full

usually not than 6L/min

valve closes during expiration so exhaled air doesn’t go in bag and is rebreatheed

valves on side open for expiration but close for inspiration so pt. doesn’t inhale room air

80-95% = 10-15L

partial rebreather masks = 60-75% = 6-11L/min

• no inspiratory valve

venturi mask

24-50% FiO2 = 4-10L

uses different sized adapters to deliver fixed predicted FiO2

amnt delivered depends on port

for COPD when needs accurate FiO2 delivered and CO2 buildup should be kept to a minimum

humidifiers not usually used

interferes w talking and eating so may need nasal cannula for eating

face tent

24-100% FiO2 = at least 10L

soft aerosol mask fit loose around face and neck

concentration cant rlly be controlled good for clients who are claustraphobic

• depends a lot on rate and depth of pt. respirations

often used after nasal and oral surgery

oxygen tent and hood

FiO2 approx. 50% = 10-15L flow rate

oxygen tent concetrations up to 30%???

hood = 28-85%

usually for peds that have airway inflammation, croup, or other resp. infection

disposable vinyl box fits over childs head

provides warm humidified oxygen at specific temp

ensure enough space btwen curve of hood and neck so CO2 can escape

manual resuscitation bag

to provide high levels of O2 to client before a procedure (suctioning or intubating)

and during resp or cardiac arrest

flow usually at 10-15 when doing manual resuscitation

tracheostomy mask

• mask that fits over tracheostomy site

• flow rate usually 10L/min with nebulizer set at appropiate oxygen concentration

• require humidification bc by passes nasal and oral humidification

• T-tube connects oxygen source to artificial pathway

the two types of noninvasive ventilation are

continuous positive pressure ventilation CPAP) and

Bilevel positive airway pressure (BiPAP)

compressed oxygen system

used in home settings

in gas cylinders and non liquid gas

stored inder high pressure psi

inexpensive and don’t require electrical source

bulky and heavy have to know how read regulator

up to 15L/mmin

to prep need:

• regulator

• pressure gage

• flow meter

• cylinder key

• oxygen delivery device

bulk liquid oxygen

used in hospital setting

up to 6/min

expensive, evaporation if not in use and in warm weather

stored outside of building at a precise and safe temp and is delivered as a gas through wall outlets in clients rooms

oxygen systems should be kept ___ ft away from flames

10 ft

if client not improving w therapy

• check if equipment functioning properly, correct device, and correct flow rate

• if everything is right might have to get prescription for new flow rate

• perform resp. assess w full vital signs

  • skin color

  • LOC

  • signs of hypoxia

• perform skin assess where device contacts skin

  • consider padding areas, move bands frequently

• keep skin clean and dry to reduce irritation

use home oxygen use when

• if client cant maintain sat. over 88%

• COPD, emphysema, advanced cardiac disease might require

• hospice for dyspnea

• improves exercise tolerance and not tiring easily

• nasal cannula and face masks most used

• alarm sounds when can is almost empty

oxygen concentrator

• takes nitrogen, water vapor, and hydrocarbons from room air and deliver oxygen that is concentrated from room air

• least expensive and good for home

• but concentration dec as flow inc

• 4-5L/min

oxygen therapy system in home should be in area thats

• well ventilated

• free of clutter

• 10 ft away from heat

respiration

• exchange of O2 and CO2 during cellular metabolism

ventilation

movement of gases into and out of lungs

occurs through pressure changes (diaphragms role)

perfusion

ability if CV system to pump oxygenated blood to tissues and return deoxygenated blood

inspiraton

active process

stimulated by chemoreceptors

• monitor pH, PaCO2, PaO2

expiration

passive process depends on the elasric recoil proerties of the lungs requiring little or no muscle work

patients w COPD lose this recoil → WOB inc.

pt. with diseases that make less surfactant develop atelectasis → collapse of alveoli

decreased preload effect on oxygenation

dec preload (venous return) → dec CO → dec O2 delivery tissues and lungs

increased preload affect on oxygenation

inc. preload → inc CO → inc O2 delivery to tissues

decreased afterload effect on oxygenation

dec. afterload (resistance) → inc CO → inc O2 delivery to tissues and lungs

inc afterload effect on oxygenation

inc afterload (resistance) = dec, CO = dec O2 delivery to tissues

dec myocardial contraction effect on oxygenation

dec. contraction = dec CO = dec O2 delivery tissues

increased myocardial contractions effect on oxygenation

inc contraction = increased CO = increased O2 delivery to tissues

Normal Values ABG

affected by hypoventilation, hyperventilation, and hypoxia

PaCO2 = 35-45mmHg

PaO2 = 80-100mmHg

SpO2 = 95%

hypoventilation

= PERFUSION

looking at efficiency of GAS EXCHANGE - inefficient

occurs when alveolar function is inadequate to meet O2 need and CO2 elimination (small amnt of air is being moved in and out of lungs)

ex: atelectstasis

rate or shallow breathing

ex: COPD

• administering O2 higher than 24-28% or 1-3L/min can result in hypoventilation

  • have adpted to high CO2, so receptors dont function properly

  • stimulus to breathe is a dec. arterial oxygen → giving O2 prevents O2 from falling to a level tha stimulates = no stimulus to breathe

  • leads to resp acidosis and arrest

• symptoms

  • altered mental, dysarhythmias, potential cardiac arrest

  • untreated = convulsions, unconsciousness, death

hyperventilation

high rate and depth of breathing - large amnt of air moved

remove CO2 faster than is produced by body “blown off”

can be induced by anxiety, infection, drugs, acid base imbal.

mild hyperventilaton:

• hypoxemia

• ventilation

• O2 in lungs

severe ventilation

• caused by: medications (ASA poisoning, amphetamines), CNS abnormalities (don’t control rate/rhythm well), diabetic ketoacidosis (ketones take up space in blood where O2 would be), high altitude, exercise, heat(fever), fear, anxiety

signs

• rapid respirations, sighing breaths, numbness and tingling of hands/feet (bc vasculature is constricting in order to circulate → less blood flow), light headedness and loss of conciousness bc of little bf to brain

hypoxia

more severe

inadequate oxygenation at cellular level (organs and tissues)

causes:

• dec. hemoglobin level and lowered O2 carrying capacity

• diminished concentration at inspiration like at altitudes

• inability of tissues to extract oxygen from blood, like in cyanide poisoning

• dec diffusion of O2 from alveoli into blood like in pneumonia, pulmonary edema

• poor perfusion w oxygenated blood (shock)

• impaired ventilation (rib fractures, chest trauma)

signs and symptoms

• apprehension

• restlessness (early sign)

• cant concentrate

• dec LOC

• dizziness

• behavior changes

• unable to lay flat and will be fatigued and agitated

• inc pulse, heart rate and blood pressure (bp declines as worsens)

• cyanosis (late sign)

hypoxemia

• decreased arterial blood O2 levels

• caused by

  • poor oxygen diffusion (w/o tissue damage) across alveoli-capillary membrane (ineffective external respiration)

  • pulse oximeter <95% SpO2

  • if phrenic nerve is damaged and the diaphragm cant contract properly → reducing inspiratory volumes

• symptoms

  • Central cyanosis- in tongue, soft palate, conjunctiva of eye where blood flow is high

  • clubbing of nails = chronic

hypercarbia / hypercapnia

• elevated PaCo2 levels

• seen in patients w COPD

• cause:

  • hypoventilation

  • airway obstruction

  • drug OD

• S/S

  • CNS depressant - coma, death (CO2 narcosis)

hypocarbia/hypocapnia

• dec CO2 in blood (O2 normal)

• cause

  • hyperventilation

• S/S

  • CNS stimulant

    • muscle twitching or spasm (hands/feet)

    • numbness/ tingling (face/lips)

physiological factors affecting oxygenation

• any condition affecting cardiopulmonary functioning directly affects oxygen demands

• Respiratory disorders

  • hyperventilation, hypoventilation, hypoxia

• Cardiac disorders

  • disturbances in conduction

  • impaired valvular function

  • myocardial hypoxia

  • cardiomyopathy conditions

  • peripheral tissue hypoxia

• O2 carrying capacity

  • anemia

• hypovolemia

  • dec circulating blood causes hypoxia in tissues

• decreased fraction of inspired oxygen FiO2

• metabolic rate

  • inc rate = inc in demand (pregnancy, healing, fever, exercise)

• alterations affecting chest wall movement

  • decreases ventilation

  • can be musculoskeletal or neuromuscular alterations

  • pregnancy obesity

lifestyle factors

• difficult to modify bc are often an enjoyable habit

  • smoking, junk food

• nutrition supports normal metabolic functions

  • poor nutriton → resp muscle weakness

  • moderate carbs = prevent inc in co2 prod

  • obesity = dec in lung expansion & inc in demand

• exercise

  • inc MR and demand

  • ppl who exercise regularly → lower pulse, bo, dec cholesterol, inc bf, greater oxygen extraction

• smoking

  • associated w heart disease COPD and lung cancer

  • causes v. constriction of peripheral and coronary blood vessels inc bp and dec blood flow to vessels

  • birth control + smoking = pulmonary emboli and thrombophlebitis

  • children exposed to smoke = asthma, pneumonia, ear infections

• substance abuse

environmental factors

• rural populations more COPD issues

  • more people smoke and have less access to cessation programs

• occupation pollutants

  • asbestos, talcum, dust, airborne fibers

• increased pulmonary disease is smoggy urban areas

chronic lung disease

• COPD and cystic fibrosis

• emphysema

  • changes in anterioposterior diameter of wall (barrel chest) occur bc of overuse of accessory muscles + air trapping

• results in hypoxemia and hypercapnia

• pursed lip breathing

• need more calories and smaller meals bc gets tired

conditions that affect chest wall movement

• DIAPHRAGM MOVEMENT = WALL MOVEMENT

• pregnancy

  • enlarged uterus pushes abdomical contents against diaphragm

  • last trimester = inspiratory capacity declines results in dyspnea on exertion and inc fatigue

• obesity

  • heavy lower thorax and abdomen = red lung volumes

  • reduction of compliance, inc WOB

  • suseptible to pneumonia bc lower lungs cant fully expand

• musculoskeletal abnormalitoes

  • structual

    • affect rib cage - pectus excabatu,

    • vertebral column - kyphosis, lordosis, scoliosis

  • trauma

    • rib fracture/bruising = reduce ventilation

    • flail chest = multiple rub frcatures cause chest wall instability

      • results in hypoxia

    • opiods for pain depress resp and dec wall expansion

  • neuromuscular disease

    • dec. ability to expand and contract chest wall

    • ventilation impaired = atelectstasis, hypercapnia, hypoxemia

    • ex: myasthnia gravis and guillian-barre syndrome

infant and toddlers

• inc. risk for upper resp infection

  • exposure to other children

  • immature immune system

  • exposure to second hand smoke

• teething

  • nasal congestion → bacterial growth → resp. infection

• airway obstructions from toys

school age children and adolescents

• exposed to resp. infections and resp risk factors

  • second hand smoke

  • experiment w smoking and inhalants

  • school age children’s posses other risk factors

    • obesity

    • inactive lifestyle

    • in heathy diets

    • excess use of caffeinated drinks

young & middle age adults

• unhealthy diet

• lack of exercise

• stress

• OTC and prescription drugs not being used as intended

• illegal substances

• smoking

• time when lifelong habits are formed so pt. education if important

  • inc. cost, state smoke free air policies, laws that band public space smoking, access to cessation programs and medications to help stop

older adults

• respiratory changes

  • associated w calcification of heart valves, vascular stiffening, and inc left ventricular wall thickness, impaired SA node function, costal cartilage stiffening atherosclerotic plates

  • osteoporosis → trachea and bronchi enlarged from calcification → alveoli enlarged → dec surface area for gas exchange → # of cilia is reduced → causes dec in effectiness of cough mechanism → inc. risk of resp infections

manifestations altered oxygenations

• 41.2 BOX TABLE 41-4

• SUBJECTIVE DATA

  • description of problems (chest pain, heart rate, specific time of day, during exercise, al the time?

  • risk factors (family history of lung cancer or cardiovascular disease, exposure to infectious organisms, enviornmental factors)

  • past respiratory problems

  • medication use

• OBJECTIVE DATA

  • assessment of cardiopulmonary system

  • look at effects on aging

    • dec alveolar surface area

    • dec carbon dioxide diffusion capacity

    • dec number of cilia

    • dec tone of upper airway muscles

physical examination

• table 41-2

• INSPECTION

  • color of skin and mucous membrane

  • nails clubbing

  • LOC, breathing pattern

  • chest wall movement

  • adequacy of systemic circulation

• PALPATION

  • pulses

  • thoracic excursion

  • tenderness

  • edema

• PERCUSSION

  • abnormal fluid/air in lungs

  • diaphragmatic excursion

• AUSCULTATION

  • normal and adventitious breath sounds

    • high pitched vibrations = good

    • dull thuds = bad

  • heart sounds

• DIAGNOSTIC TEST

  • CXR

  • TB skin test

  • sputum

  • pulmonary function tests

  • thoracentesis