Week 12 Content/Alterations in Oxygenation

What is the upper respiratory good for

humidifying and filtering

What is the lower respiratory good for

gas exchange

Respiratory assessment: inspection

inspecting respiratory rate and pattern.

Decreased respiratory rate and depth can cause

hypoxemia (low oxygen levels in the blood) and hypercapnia (high carbon dioxide levels in the blood)

Increased respiratory rate and depth can cause

decreased levels of carbon dioxide in the blood which can cause dizziness and ultimately exhaustion

Respiratory assessment inspection: respiratory effort

work of breathing / Is the client using neck and shoulder muscles to breathe? Is the client leaning forward, to enlarge the chest cavity, to breathe? Is the infant client flaring their nostrils or retracting their ribcage to breathe? Is the client pale around the lips/under the tongue or near the eyelids indicating cyanosis? Are the tips of the fingers and/or toes rounded and enlarged, indicating clubbing? Clubbing is usually a long-term sign of hypoxia, sometimes seen in clients with pulmonary fibrosis or COPD

Respiratory assessment auscultation: breath sounds

Are there areas of the lungs that you cannot auscultate air movement? Are breath sounds equal on both sides of the chest? Are there abnormal breath sounds like crackles, rhonchi, wheezes or stridor? (refer to Craven Table 30-2)

What does crackles in lungs indicate

fluid in alveoli (pneumonia, HF, interstitial fibrosis, atelectasis, pulmonary edema)

What does rhonchi in lungs indicate (low pitched, gurgling noises)

mucus secretions in large airways, indicates bronchitis, pneumonia, cystic fibrosis, thick secretions. Helps to clear with coughing

What does wheezes in lungs indicate

narrow airways (bronchoconstriction), asthma, COPD, airway obstruction, allergic reaction

What does stridor in lungs indicate

severe upper airway obstruction. Croup (inflammation of the larynx and trachea in children), epiglottitis, foreign body obstruction, severe allergic reaction. Think airway compromise.

Respiratory assessment mental status

Is the client confused? Confusion could indicate low oxygen and/or high carbon dioxide

Ventilation

Physical process of moving air in and out of the lungs so that gas exchange can take place

Inspiration (active process)

Diaphragm and intercostal muscles contract, Intrathoracic pressure decreases, Chest wall expands pulling lungs outward, Air rushes into the lungs

Exhalation (Passive process)

Diaphragm and intercostal, muscles relax and the thorax returns to its normal size, pressure in the chest increases allowing air to flow out of the lungs. Because it's passive, the PT doesn't need to be actively engaged to do this (it happens automatically).

We measure ventilation by

respiratory rate and effort, capnography (looking at carbon dioxide levels with EtCo2, and arterial CO2.

Ventilation is much more involved with carbon dioxide than

oxygen

We treat ventilation acutely with

bag-valve mask ventilation, treating the original cause of the ventilation and using CPAP, BIPAP and mechanical ventilation (just know these last 3 are ventilation associated).

Oxygenation is the process of

obtaining oxygen from the air and making it available to the organs and tissues of the body

Oxygen is carried through the blood through

hemoglobin

In oxygenation, O2 and CO2 move back and forth across the alveolar-capillary membrane by

diffusion

We measure oxygenation by

color (skin and mucous membranes), pulse oximetry (95-100), arterial O2 (obtained by drawing blood through radial artery and analyzing it through a machine)

Treat oxygenation with supplemental oxygen (short term) and treating the cause of hypoxia (long term)

Upper respiratory includes what issues

tracheal abnormalities, bronchospasm (allergic reactions), anaphylaxis, obstructive sleep apnea (OSA)

Lower respiratory includes what issues

bronchitis, asthma, COPD, pneumonia, atelectasis (partial or complete collapse of the lung)

Signs and symptoms of respiratory distress

think about oxygenation issues. Things we can often reverse using interventions associated with oxygenation (signs: airway open without support, tachypnea, increased effort, clear sounds, tachycardia, agitated, pale). Typically clear breath sounds.

Signs and symptoms of ventilation distress

think about ventilation issues. Signs: airway possibly obstructed, slow breathing, no effort, abnormal sounds, bradycardia, fails to respond, cyanotic

Managing oxygenation problems: improving air flow

bronchodilation (aerosolized medications (nebulizer) ), dry powder inhalers, metered dose inhalers and removing obstructions (thorugh coughing and deep breathing, chest PT and postural drainage).

Managing oxygenation problems: repositioning

consider the client's position - oxygenation can improve just by sitting the client upright in high fowlers (unless contraindicated)

Managing oxygenation problems: supplemental O2

Supplied via wall O2, tank O2, oxygen concentrator. Nasal cannula (1-6 L/min), Simple face mask (FiO2 40-60% when operated at 6-10 l/min), Venturi mask (FiO2 24-50% when operated at 3-8 l/min), Non rebreather mask (FiO2 up to 90% when operated at 12-15 l/min)

How is oxygen supplied?

Oxygen tanks, wall oxygen, oxygen concentrator

Two dangers of keeping oxygen in storage

it is flammable and a dry gas - it will dry skin and oral/nasal mucosa without addition of humidity

Oxygen tanks

Various sizes, Inpatient, outpatient and home use

Wall oxygen

Supplied through pipes in the wall, inpatient

Oxygen concentrator

Takes atmospheric air, delivers oxygen and sends the rest of the components back into the atmosphere, home use

How is oxygen measured

Flowmeters determine the flow from either the wall or a tank. Oxygen concentrators often have built in flowmeters. Turn the dial clockwise to increase flow and watch the metal ball rise. The metal ball should sit half above and half below the desired flow. Green=Oxygen. Yellow=Medical Air (just pressurized air, no oxygen)

Nasal cannula oxygen

Least invasive oxygen delivery method

how does nasal cannula oxygen work? what should you look out for?

Nasal prongs are inserted into the nostrils with the curvature pointing downward toward the mouth and then the tubing is placed over the ears and tightened at the chin. Does not impact eating, drinking or ability to take oral temperatures. Set flowmeter to 1-6 liters/minute of Oxygen, based upon provider order. Can cause nosebleeds (oxygen drying the nasal mucosa)—using humidity can help decrease this side effect. Watch the skin below the nose and behind the ear for pressure injury

Simple face mask

Mask covers the mouth and nose. The metal piece can be formed around the nose. The elastic strap can be tightened. Can impact eating, drinking and oral temperature route. Set flowmeter to 6-10 liters/minute of oxygen based upon provider order. Can cause nosebleeds and skin dryness from oxygen—using humidity can help decrease this side effect. Watch the skin on the face for pressure injury. If the skin is pink when the mask is removed but clears quickly, it is not too tight. If the skin is broken or the skin is reddened and does not disappear quickly, it is too tight

Venturi face mask

Mask fits the same as the simple mask, but oxygen rate is set differently. This mask allows for lower flow of oxygen while delivering higher rates of oxygen Uses either a dial system or color coded interchangeable system that allows for different oxygen rates. Measured in FiO2 (fraction of inspired oxygen) from 24-60%. Oxygen flowmeter is set based upon the dial or colored piece. For example: for the dial to the left, setting the oxygen flowmeter at 3l/min and the arrow at 24% will deliver oxygen at 24%

Non-rebreather mask

Mask covers the mouth and nose. The metal piece can be formed around the nose. The elastic strap can be tightened. Can impact eating, drinking and oral temperature route. Used for acute respiratory distress. The flowmeter is set to 12-15 liters/minute—too little flow can cause rebreathing of carbon dioxide and not allow oxygen flow, so this is an all-or-nothing device. The reservoir bag below must fill with oxygen and inflate

Aerosolized medications

Nebulized medications use pressurized gas to change a liquid medication into a smoke-like mist. A home machine can be used with pressured room air OR high flow oxygen or medical air can be used in a healthcare setting. The medication can be misted into the airway through a mask or a mouthpiece. The client should sit upright and inhale and exhale normally until all of the liquid medication/mist is gone

Atelectasis

a condition in which the alveoli in the lung collapse. Think of alveoli as balloon-like structures that require inspiratory pressure to stay open. This reduces the amount of space available for gas exchange. Typically, but not always, not associated with increased mucous secretions (dry process). If not improved with treatment, will allow for secretion pooling in the lungs and progress to pneumonia

Certain conditions and diseases stiffen the lungs or prevent alveoli from fully expanding, including

COPD, bronchiectasis, recent surgery especially chest and abdominal, recent anesthesia, being bedbound, pain, smoking, medications that depress respirations, use of abdominal or chest binders

Signs and symptoms of atelectasis

Shortness of breath. Increased HR, Dry cough, Decreased SPO2, Decreased lung sounds

Incentive spirometer

Designed to mimic natural sighing or yawning by encouraging patient to take a deep, slow breath. Take slow deep breath, hold breath and then slowly exhale. Encourage the client to perform Sets of 10 breaths every hour. Used for the prevention of atelectasis (alveolar collapse), helps to mobilize secretions. Can be used preventatively to prevent atelectasis or to treat atelectasis; usually doesn't require a provider order.

Pneumonia

inflammatory process in which alveoli air sacs fill with pus and may become solid and cause obstruction of air flow. Can affect one or both lungs or parts/lobes of lungs. Requires treatment to include antibiotics, antifungals, antipyretics, anti-inflammatories.

PNA can be caused by

viruses, bacteria and fungi. Examples include RSV, COVID (SARS CoV-2), Strep, influenza

Signs and symptoms of PNA

Shortness of breath, Increased RR, Increased HR, Productive (wet) cough, Rhonchi, crackles and or wheezing breath sounds, Decreased SPO2, Fatigue, May include fever, Chest X-ray confirmation

Oscillating positive expiratory pressure (PEP) device

help people with lung diseases like COPD or Cystic Fibrosis loosen and cough up mucus by vibrating airways and creating resistance during exhalation. Use to •to break up secretions/mucous through pressure and vibrations. •Replacement for chest physiotherapy (Chest PT). •Provides positive airway pressure. •Encourage 10 breaths/hour while awake, •Encourage coughing afterward to expectorate secretions.

High frequency chest wall oscillation device

Also known as Chest Vest - Used for Cystic Fibrosis, Replacement for Chest PT, and can be combined with postural drainage

Restrictive lung disease

•Lung diseases that make it difficult to fully expand the lungs. Example: pulmonary fibrosis

Obstructive lung disease

Lung diseases that make it hard to exhale all of the air in the lungs, Example: COPD, asthma

Goals of restrictive and obstructive lung disease

Manage inflammation (if present), Use MDI, Use DPI, Use aerosolized medications

Respiratory health promotion

smoking cessation, reduced exposure to allergens/pathogens, careful use of opioids, sedatives and CNS depressants, immune system building (nutrition, rest, ect), weight management, mobility

Describe the anatomy of the respiratory system and respiratory assessment

The respiratory system is divided into the upper and lower tracts. The upper respiratory tract (nose, mouth, pharynx, larynx) is responsible for humidifying, warming, and filtering incoming air. The lower respiratory tract (trachea, bronchi, bronchioles, alveoli) performs gas exchange, moving oxygen into the blood and removing carbon dioxide. A respiratory assessment includes inspecting the patient’s rate, pattern, and work of breathing, looking for accessory muscle use, nasal flaring, retractions, cyanosis, clubbing, and changes in mental status. Auscultation determines whether breath sounds are equal and present and identifies abnormal sounds such as crackles (fluid in alveoli), rhonchi (mucus in large airways), wheezes (narrowed airways), and stridor (severe upper airway obstruction).

Differentiate between alterations in oxygenation and ventilation

Oxygenation and ventilation differ significantly. Ventilation refers to the physical movement of air in and out of the lungs, with a primary focus on carbon dioxide regulation. Poor ventilation causes hypercapnia, while excessive ventilation can lower CO₂ and cause dizziness. Oxygenation refers to getting oxygen into the blood and delivering it to tissues, carried by hemoglobin. It is assessed by skin color, SpO₂, and arterial oxygen levels. Ventilation is measured by respiratory rate, effort, and CO₂ levels (EtCO₂).

State signs and symptoms of respiratory distress and respiratory failure

Respiratory distress is usually an oxygenation problem. These clients are often tachypneic with increased work of breathing, tachycardia, pallor, agitation, and generally clear breath sounds. They maintain their airway but have reduced oxygen saturation. Respiratory failure is a ventilation problem where clients may have slow or minimal respiratory effort, airway obstruction, abnormal or absent breath sounds, bradycardia, cyanosis, and altered mental status. These clients are no longer able to breathe effectively or remove CO₂.

Identify nursing interventions used to manage problems with oxygenation to include supplemental oxygen, incentive spirometry and PEP devices

Nursing interventions for oxygenation problems include supplemental oxygen via nasal cannula, simple mask, Venturi mask, or non-rebreather mask depending on severity. Nurses also promote oxygenation by improving airflow with bronchodilators (MDI, DPI, nebulizers), encouraging coughing and deep breathing, performing chest physiotherapy or using PEP devices, and repositioning patients—usually in high Fowler’s—to maximize lung expansion. Incentive spirometry is used to prevent or treat atelectasis by encouraging slow, deep breaths that reopen alveoli, while PEP devices help loosen mucus through positive pressure and vibration.

Differentiate between atelectasis and pneumonia to include assessment and interventions

Atelectasis involves the collapse of alveoli, often after surgery, prolonged bedrest, pain, or sedation. It presents with shortness of breath, increased heart rate, dry cough, decreased SpO₂, and reduced or absent breath sounds. It is usually a dry process unless secretions later accumulate. Interventions include incentive spirometry, mobility, deep breathing, and repositioning. Pneumonia, on the other hand, is an infection causing alveoli to fill with pus, leading to inflammation and impaired airflow. It presents with fever, fatigue, tachypnea, productive cough, rhonchi, crackles or wheezes, and decreased oxygenation. Treatment includes antibiotics or antivirals, oxygen therapy, hydration, chest PT, PEP or oscillation devices, and airway-clearing interventions.

The nurse's assessment findings are below. Which of the following best describes this patient's condition? The patient has unexplained restlessness Respiratory rate 28 The patient gets short of breath when walking to the bathroom HR 100

Early onset of inadequate oxygenation

Anxiety

Late onset of inadequate oxygenation

A diagnosis of pneumonia

Early onset of inadequate oxygenation

The patient's oxygen saturation is 87% on room air. The provider ordered supplemental oxygen via nonrebreather mask. Based upon this method of oxygen delivery, which statement is correct? Select all that apply.

The oxygen flowmeter should be set at 12-15 LPM

There nurse should expect the oxygen reservoir bag to inflate

The patient should expect oxygen tubing to be placed in the nares/nostrils

The nurse should add humidity to the oxygen

The oxygen flowmeter should be set at 12-15 LPM

There nurse should expect the oxygen reservoir bag to inflate

When using an incentive spirometer, which of the following statements are correct? Select all that apply.

The nurse should instruct the patient to breathe out deeply and quickly

The patient should do sets of 10 every hour

Incentive spirometry is used to prevent atelectasis

Holding the breath for at least 2-3 seconds at full inspiration is important

The patient should do sets of 10 every hour

Incentive spirometry is used to prevent atelectasis

Holding the breath for at least 2-3 seconds at full inspiration is important

The patient with pneumonia is ordered to use a flutter valve/device. Which of the following statements is correct regarding this therapy? Select all that apply.

It produces positive expiratory pressure and oscillation of the airways

The patient should inhale deeply and slowly

The patient should be instructed to cough after use

It is used for atelectasis to open alveoli

It produces positive expiratory pressure and oscillation of the airways

The patient should be instructed to cough after use

Smoking is the most important lifestyle choice affecting respiration. Which of the following are more likely in smokers than non-smokers? Select all that apply.

Airway blockage created by the inhibition to remove mucous

Bacterial colonization and infection

Increased respiratory rate

Diagnosis of emphysema, chronic bronchitis, lung cancer, oral cancer and cardiovascular diseases

Airway blockage created by the inhibition to remove mucous

Bacterial colonization and infection

Increased respiratory rate

Diagnosis of emphysema, chronic bronchitis, lung cancer, oral cancer and cardiovascular diseases