Oxygen

Oxygenation and Perfusion

Pulmonary System

  1. Upper Airway
  • Nose to Epiglottis (nose, pharynx, larynx, epiglottis)
  • Pulls in air and filter out dust and debris (warms, filters, humidifies)
  • NON-STERILE environment
  1. Lower Airway
  • Trachea to Alveoli (trachea, right and left bronchi, segmenting bronchi, terminal bronchioles)
  • Anything that goes into the lower airway must be STERILE!
  • Conduct air, clear mucous, produce surfactant.
  1. Ventilation – the act of air moving in and out of lungs (breathing).
  2. Respiration
  • Exchange of gases (oxygen and C02) between alveoli (air) and capillaries (blood.)
  • When gases exchanged inside of the alveoli leave.
  1. Perfusion
  • The process of oxygenated blood moving through the body’s tissues and organs (circulation).
  • Our bodies need this because that’s how it gets oxygenated.
  1. VENTILATION
  • Inspiration – Breathing in (INHALE).
  • Expiration – Breathing out (EXHALE).
  1. What affects ventilation?
  2. Weakened Respiratory Muscles - Difficult to breath in and out.
  3. Lung Compliance - How easy it is for lungs to inflate and deflate.
  4. Resistance to Airflow in Airways – Anything that is causing the airway to be blocked or restricted. (Ex. Choking, asthma, excessive secretions).
  5. RESPIRATION
  • Delivery of oxygen from the lungs to the bloodstream, and elimination of carbon dioxide from the bloodstream to the lungs and out the body.
  • When alveoli filled with thickened secretion the gas cannot exchange.
  • When alveoli collapses, they can’t have gas exchange (ATELECTASIS).
  • Ex. Abdominal Surgery – After abdominal surgery, people breathe shallowly, and overtime develop Atelectasis.
  • Atelectasis can lead to pneumonia or pulmonary edema.

Factors That Influence Pulmonary Function:

  • Level of Health – People with chronic medical conditions; anything that affects lung function; can have negative impact with lungs when they get other things.
  • Developmental Stage
  • Environment – Stress, allergies, asthma, pollution, altitude.
  • Lifestyle – Anything that you pull into your lungs can cause a problem (occupational hazards, smoking, nutrition).
  • Medications – Pain medicines, Respiratory depression, Respiratory arrest, Bronchodilators (improve respiratory).
  • Pathophysiological Conditions – Anything apart of the respiratory system. (Ex. Flu, upper respiratory infection, pneumonia, asthma).
  • Psychological Conditions – Causes problems with gas exchange. (Ex. Anxiety).

Assessment of Oxygenation Status

  • History – Any risk factors that can cause problems with a patient’s pulmonary function. (Ask if they want the FLU shot, do they smoke, offer smoking cessation if smoking [How many packs? Years?], talk to the provider about nicotine patches. The patient cannot smoke with nicotine patch on. DOCUMENT THIS!
  • Physical assessment – Inspect, Palpate, auscultate (Listen).
  1. Breathing patterns – Normal breathing (Eupnea) 12-20 breaths per minute.
  2. Respiratory effort – Should be effortless.
  3. Cough – Persistent? Productive? How much?

Abnormal Breathing Patterns

  • Tachypnea – Patient breathing too fast (greater than 20 breaths per minute).
  • Bradypnea – Breathing too slow (less than 12 breaths per minute).
  • Kussmaul’s – Breathing too fast and too deep but with regular rhythm. This is like hyperventilating. Mostly seen in diabetics.
  • Biot’s – Abnormal/irregular breathing that alternate patterns of shallow and then periods of not breathing (APNEA). Could mean that there is a brain injury or death.
  • Cheyne Stokes – Breathing too fast, then too slow, then stops completely. Also, could be a result of a brain injury or death.
  • Apnea – Absence of breathing. This is an EMERGENCY!

Breath Sounds - Sounds that you give to normal lung sounds such as Bronchial, Bronchovesicular, and Vesicular.

  1. Bronchial – loud, high-pitched.
  2. Bronchovesicular – Mid-pitched.
  3. Vesicular – Low-pitched and soft (Quieter because of very small air ways).

Adventitious Lung Sounds

  1. Wheezing – Partial obstruction of small airways; when vesicular are partially blocked it may be because they or constricted or getting smaller; musical sound like a whistle; hard to push air through. Ex. Asthma
  2. Stridor – Partial obstruction of the larger airways (larynx or trachea); Ex. Croup (harsh, barking cough); choking (edema of the throat); smoke inhalation.
  3. Crackles – Popping sound (like crinkling paper); what you hear when air passes through fluid; Ex. Pneumonia (fluid on the lungs).

Abnormal Respiratory Effort

  • Nasal Flaring (Nostrils flare out) – attempting to take in more air. (Ex. See this mostly in geriatric patients and babies).
  • Retractions – When a patient breathes in so deeply that you can see it.
  • Use of Accessory Muscles – Increased demand for oxygen
  • Requires certain body positioning. (Ex. Position bed in high fowlers for maximum breathing).
  • Paroxysmal Nocturnal Dyspnea – Shortage of breath during sleep cause awakening (Sleep Apnea).
  • Conversational Dyspnea – increased shortage of breath when speaking.
  • Dyspnea – Difficulty breathing.
  • Diminished or Absent Breath Sounds – Signs of worsening ventilation; In certain parts of the lungs, you won’t hear airflow. (Ex. Atelectasis or pneumonia).

Diagnostic Tests

  • Pulse Oximetry – If oxygen is abnormal (94% or lower), notify the provider.
  • Arterial Blood Gases (ABGs) – Direct way of measuring oxygen in blood (drawing blood from an artery because that is where oxygenated blood is to see how much oxygen is present in the blood).
  • If a patient looks good, but their numbers are low, recheck the numbers.
  • If a patient looks bad and numbers are bad, assess the patient.
  • If there are problems with pulse oximeter reading, check your patient FIRST!
  • Dark nail polish or cold hands/feet (poor circulation) can affect an oximeter reading.
  • Patient must be still to get accurate readings.

ALWAYS ASSESS PATIENT FIRST!

  • Cough
  • How is it? Dry/productive/hacking?
  • When does it occur?
  • What makes it better/worse?
  • How long has it been going on?
  • What have you taken to treat it? Did it work?
  1. Expectorant
      • Helps to cough up mucous.
      • The only exception is if a patient has a productive cough and needs rest, they can take a SUPPRESSANT at night.
  • Sputum
  1. Comes from the lungs.
  2. If a patient can’t voluntarily get it up, a deep suctioning is done (as far as the trachea) to get it out.
  3. REMEMBER…. ANYTHING THAT GOES INTO THE TRACHEA MUST BE STERILE!
  4. Other techniques that can be used are steam/humidifier.
  5. Encourage to drink more fluids/give IV fluids.
  6. The first thing in the morning is the best time to collect sputum.
  • Abnormal Sputum
  1. White/Clear – viral
  2. Yellow/Green – infection
  3. Black – smoke or soot inhalation
  4. Rust – Pneumonia or TB; May contain blood.
  5. Hemoptysis (EMERGENCY! Contact Provider) - Blood
  6. Pink and Frothy (EMERGENCY!) – Pulmonary Edema (excess fluid in the lungs).

Nursing Diagnosis

  • Ineffective Airway Clearance – Patient is unable to clear the airway; Trouble breathing (dyspnea.
  • Ineffective Breathing Pattern –AEB Abnormal breathing patterns (tachypnea, bradypnea, kussmaul’s, biots’s, Cheyne-stokes, and apnea); AEB hyper-/hypoventilation.
  • Impaired Gas Exchange – Balance of O2 and CO2 are altered.

Interventions for Optimal Respiratory Function

  • Prevention of Upper Respiratory infections by handwashing and using antibiotics only when prescribed by a doctor.
  • Prevention of the FLU and Pneumonia by offering the Pneumonia vaccine to geriatric patients 65 and older/ 64 and younger if they have chronic lung disease or is a smoker.
  • Giving this vaccine can help to have optimal respiratory function.
  • Offer them help to quit smoking.
  • Teach them about positioning themselves for optimal respiratory function.
  • Teach of use of incentive spirometer.
  • Teach deep breathing and coughing (take a deep breath and then a forceful cough). This is used especially for patients who have had surgery. It helps them to push out secretions.
  • Early and frequent ambulation after surgery (need patients to ambulate in distances to open the lungs as soon as they can ambulate).
  • Exercise and healthy weight
  • Maintain hydration with oral fluids or humidified air.

Tripod Position

  • More beneficial for COPD patients.
  • When sitting in a chair or on the side of the bed, place pillows on bedside table and lean over on them.
  • Patients get good lung expansion this way.
  • Mid to high fowlers (position) – Also help with good lung expansion.

IF PATIENT IS SHORT OF BREATH, STAY CALM TO KEEP THEM CALM!

Pursed Lip Breathing

  • Helps to reduce dyspnea and panic-breathing.
  • Sit upright in high fowlers.
  • This will help the airways to stay open to push out more CO2 to keep you from hyperventilating.
  • Count to 7.
  • Slows and prolongs expiration, allowing airways to remain open longer.

Chest Physiotherapy (CPT)

  • If a person can’t cough up secretions, we use chest physiotherapy (CPT).
  • CPT uses 3 methods to help break up the thick secretions and move them to larger airways so that they will be easily removed through coughing or suction:
  1. Postural Drainage – uses positioning to promote drainage. When the right lung is done, lay on the left side. If it’s the left lung, lay on the right side. If both, alternate sides so that they can properly drain.
  2. Percussion – Clapping of the chest wall using cupped hands (forceful). This helps to break down larger secretions using vibrations.
  3. Vibration – Vibration of the chest wall using the palms of the hands (lightly). This helps to break thick secretions up into smaller pieces.
  • Ex. Kids with CPF get secretions frequently.

Oxygen Therapy

  • Oxygen is considered as a medication and it requires a doctor’s order for the dosage a patient receives and the way they receive it (nasal cannula (NC), face mask, etc.).
  • If it is an EMERGENCY ONLY, I can put the patient on oxygen then call the doctor. AN EMERGENCY SITUATION IS THE ONLY EXCEPTION!!

Hypoxia

  • When someone doesn’t have enough oxygen in their body.
  • Anything that affects the lungs can cause Hypoxia (CHRONIC LUNG DISEASE).
  • Symptoms:
  1. Early (RAT)
  • Restlessness (brain not getting enough O2)
  • Anxiety (brain not getting enough O2)
  • Tachycardia/tachypnea (heart racing/breathing to fast)
  1. Late (BED)
  • Bradycardia (heart rate too slow)
  • Extreme restlessness (adds confusion)
  • Dyspnea (struggling to breath)
  • Apoxia – no oxygen at all.

When does my patient need oxygen therapy?

  • If O2 saturations (sats) are less than 95%, the patient needs oxygen (O2).
  • Early signs:
  • Anxiety/restlessness
  • Pallor (pale skin)
  • Tachycardia/Tachypnea (heart racing/beating too fast).
  • Complaints of not being able to breathe (“air hunger”).
  • Headache/dizziness
  • Late Signs:
  • Cyanosis - bluish color of the skin (nailbeds/lips)
  • Prolonged capillary refill (greater than 3 seconds)
  • Bradycardia (slow heartrate)
  • Extreme restlessness
  • Confusion

Ways to Promote Circulation:

  • Increase the flow of blood to the heart – elevate the extremities, avoid crossing of legs, early ambulation and ROM exercises, wear compression stockings when OOB (out of bed) and TED hose while in bed, use SCD (sequential compression devices) pumps, restrict/eliminate smoking, and exercise.
  • Prevent blood clots (impede – stop circulation of blood)
  • Blood cots can be prevented by:
  • Medications
  • Turning the patient frequently
  • Early ambulation/ROM exercises
  • Smoking cessation (careful monitoring women on oral contraceptives).
  • Adequate fluid intake

Delivery Systems

  1. Nasal Cannula – Make sure to check behind ears and to check the cheeks for breakdown while a patient is wearing this. Must be humidified if over 3 because the oxygen can dry the nares out.
  2. Simple Face Mask – Patients wear these to receive a higher flow of oxygen. Anything over the face mask needs to go to ICU.
  3. Non-rebreather – This is the only airflow system that will give your patient 100% oxygen. You can go all the way up the highest liter (L). The bag should always be inflated when on a patient.
  4. Partial rebreather – Bag is not 100% oxygen (O2), it is mixed with some CO2.
  5. Venturi – This is the only method of oxygen (O2) that can be ordered by the percentage. This is the only mode that is precise about how much O2 a patient is receiving. (Certain percentage means use VENTURI ONLY!)
  6. Face Tent – This is used when a patient needs just a little bit of oxygen, but not specifically. This is used for people who need O2 but don’t have to have their mouth and nose covered. (Ex. For people who received facial surgery).

Oxygen Hazards

  • Don’t smoke around it.
  • Do not put anything flammable near it. Keep it at least 3 feet away from any flame or heat source.
  • Do not allow grease to come into contact with oxygen.
  • Make sure any electrical equipment that is near oxygen is grounded properly.

When assessing a patient for circulation you must:

  • Palpate a patient’s pulses for quality and rate and their skin for temperature.
  • Inspect a patient’s skin color to watch out for pallor (pale skin) and check for delayed capillary refill (more than 3 seconds).
  • Auscultate a patient’s heart sounds to see if they are normal/abnormal (rate/rhythm). Bradycardia is less than 60 bpm and tachycardia is more than 100 bpm.
  • Check a patient’s blood pressure to assess for circulation.

To improve circulation, we want to improve VENUS RETURN. We can do this by doing anything for the patient that improves blood flow back to the heart.