Oxygenation
Chapter 41: Oxygenation
Scientific Knowledge Base (1 of 3)
Respiratory physiology
Structure and function
Work of breathing
Lung volumes
Pulmonary circulation
Scientific Knowledge Base (2 of 3)
Respiratory gas exchange
Oxygen transport
Carbon dioxide transport
Regulation of ventilation
Scientific Knowledge Base (3 of 3)
Cardiovascular physiology
Structure and function
Myocardial pump
Myocardial blood flow
Coronary artery circulation
Systemic circulation
Blood flow regulation
Conduction system
Case Study
Case Study (1 of 17)
Patient Profile:
Mr. King, a 62-year-old male, presents to the ED.
History of chest pain, shortness of breath, cough, and generalized malaise lasting 6 days.
Work history: Sales; lives with his wife.
Medical history: Chronic obstructive pulmonary disease (COPD) and alcohol abuse but currently not drinking.
Smoking history: Mr. and Mrs. King have smoked heavily for over 40 years.
Functional decline: Mr. King previously engaged in household chores and gardening; currently, he spends most of his time watching television.
Case Study (2 of 17)
Nursing Student Background:
John Smith, a nursing student, is assigned to clinical practice in ED.
Previous rotation focused on health promotion: Adjusting unhealthy behaviors like smoking and poor diet.
Feels confident in applying knowledge to Mr. King’s case due to similarities in health needs.
Case Study (3 of 17)
Patient Condition:
Mr. King is in significant respiratory distress; is anxious and overwhelmed.
His wife is present, expressing concern and urgency for action.
Case Study (4 of 17)
Physiology Knowledge Application:
John understands Mr. King's respiratory challenges:
Shortness of breath indicates infection obstructing alveolar-capillary membrane affecting oxygenation.
Pre-existing COPD complicates Mr. King’s condition.
Recognizes the challenge of smoking cessation in patients with nicotine addiction, especially when presenting with acute illness.
Case Study (5 of 17)
Patient Autonomy and Education:
John's care reflects respect for autonomy, prioritizing education about smoking risks and health impacts.
Awareness of support systems available to assist Mr. King in managing chronic illness and quitting smoking.
Plans to gather information on community resources for smoking cessation.
Factors Affecting Oxygenation
Physiological Factors:
Decreased oxygen-carrying capacity: Reduced hemoglobin or compromised blood oxygen levels.
Hypovolemia: Decreased blood volume affecting circulation and oxygen delivery.
Decreased inspired oxygen concentration: Impacted by environmental factors, altitude, or ventilation issues.
Increased metabolic rate: Raises oxygen demand during physical exertion or fever.
Conditions Affecting Chest Wall Movement
Influencing Conditions:
Pregnancy: Physical changes affect lung capacity and comfort.
Obesity: Extra weight can limit lung expansion and function.
Musculoskeletal abnormalities: Impact on chest wall structure can limit breathing efficacy.
Trauma: Injuries can impair respiratory mechanics.
Neuromuscular diseases: Affect the ability to control respiratory muscles.
Central nervous system alterations: Can disrupt normal respiratory drive.
Alterations in Respiratory Functioning
Hypoventilation:
Defined as inadequate alveolar ventilation, which leads to insufficient oxygen intake or inadequate removal of carbon dioxide.
Hyperventilation:
Occurs when ventilation exceeds the rate of carbon dioxide production, resulting in low CO2 levels in the blood.
Hypoxia:
Signifies inadequate oxygenation at the tissue level, which can lead to cellular dysfunction.
Case Study (6 of 17)
Lung Cancer Statistics:
John reviews information: Lung cancer is the second most frequent cancer among both genders, comprising about 13% of all new cancer cases.
Uses statistics to educate Mr. King and his wife about lung cancer risks associated with smoking.
Alterations in Cardiac Functioning
Disturbances in conduction:
Can lead to irregular heart rhythms, affecting overall cardiovascular efficiency.
Altered cardiac output:
Left-sided heart failure: Results in pulmonary congestion and reduced oxygenation.
Right-sided heart failure: Causes systemic fluid retention and can lead to congestion in the abdomen or legs.
Impaired valvular function:
Compromises efficient heart pumping and can lead to congestive heart failure.
Myocardial ischemia:
Is characterized by reduced blood flow to heart muscles, which can result in angina or myocardial infarction (heart attack).
Nursing Knowledge Base
Factors Influencing Oxygenation:
Developmental factors: Age and growth stages impact respiratory efficiency.
Lifestyle factors:
Nutrition: Role of vitamins and minerals in lung health.
Hydration: Adequate fluids are necessary for respiratory secretions.
Exercise: Physical activity improves lung function.
Smoking: Directly detrimental to respiratory health.
Substance abuse: Can lead to acute and chronic respiratory issues.
Stress: Physiologically affects breathing patterns and lung function.
Environmental factors:
Exposure to pollutants, allergens, and poor air quality can worsen respiratory conditions.
Critical Thinking
Use of Professional Standards:
Agencies and Associations:
Agency for Healthcare Research and Quality (AHRQ)
American Cancer Society (ACS)
American Heart Association (AHA)
American Lung Association (ALA)
American Thoracic Society (ATS)
American Nurses Association (ANA)
Nursing Process: Assessment
Assessment (1 of 3)
View Through Patient's Eyes:
Perform a nursing history focusing on:
Health risks
Pain assessment
Levels of fatigue
Dyspnea (difficulty breathing)
Cough characteristics
Assessment (2 of 3)
Nursing history Continued:
Investigate:
Environmental exposures
Smoking history
History of respiratory infections
Allergies
Medications taken
Assessment (3 of 3)
Physical Examination:
Techniques utilized include:
Inspection
Palpation
Percussion
Auscultation
Diagnostic tests: Further evaluations (like blood tests or imaging) may be required depending on findings.
Case Study (7 of 17)
Continuous Monitoring:
John notes Mr. King’s increasing restlessness and anxiety as symptoms progress.
Weakening cough and decreased sputum production are also observed.
Case Study (8 of 17)
Patient Assessment - Symptoms:
Duration of shortness of breath: 1 week, worsening.
Vital Signs:
Pulse: 120 beats/min,
Temperature: 102°F,
Respiratory rate: 36 breaths/min,
Blood pressure: 110/45 mm Hg,
Arterial oxygen saturation: 82%, dyspneic.
Duration of cough: Noticed three days ago with thick discolored mucus (yellow-green).
Lung Auscultation reveals wheezes, crackles, and diminished sounds in the right lower lobe.
Quick Quiz 1 (1 of 2)
Question: Assessing Chest Pain: When assessing chest pain, it is considered cardiac in origin when it:
A. Does not occur with respiratory variations.
B. Is peripheral and may radiate to the scapular region.
C. Is aggravated by inspiratory movements.
D. Is non-radiating and occurs during inspiration.
Quick Quiz 1 (2 of 2)
Answer: A. Does not occur with respiratory variations.
Nursing Diagnosis
Examples of Nursing Diagnoses for Oxygenation Issues:
Impaired Cardiac Output
Acute Pain
Activity Intolerance
Risk for Activity Intolerance
Impaired Airway Clearance
Planning
Nursing Care:
Use critical thinking to compile information from multiple sources to form a cohesive care plan.
Goals and Outcomes: Establish realistic expectations and measurable outcomes.
Setting Priorities: Prioritize care based on urgency and risk assessments.
Teamwork and Collaboration: Engage with interdisciplinary teams for optimal patient outcomes.
Case Study (9 of 17)
Nursing Diagnosis: Ineffective airway clearance related to pulmonary secretions
Goals:
Return pulmonary secretions to baseline levels within 24 to 36 hours.
Improve Mr. King's oxygenation status within 36 hours.
Case Study (10 of 17)
Respiratory Status Goals:
Sputum should be clear, thinner consistency within 36 hours.
Lung sounds should return to baseline within 36 hours.
Respiratory rate goal: 16 to 24 breaths per minute within 24 hours.
Mr. King to effectively clear secretions by coughing within 24 hours.
SpO2 goal: >85% within 24 hours.
Improvement in perceptions of dyspnea.
Implementation: Health Promotion
Preventative Measures:
Vaccinations: Influenza and pneumococcal vaccines to prevent infections.
Healthy lifestyle changes: Eliminate risk factors, promote nutritious diet, encourage regular exercise.
Awareness of environmental pollutants: Avoid secondhand smoke, occupational chemicals, and other pollutants.
Implementation: Acute Care (1 of 6)
Dyspnea Management Techniques:
Maintain clear airway
Mobilization of pulmonary secretions
Ensure adequate hydration
Include humidification and nebulization to soothe airways
Utilize coughing and deep breathing techniques to enhance oxygenation.
Implementation: Acute Care (2 of 6)
Chest Physiotherapy Techniques:
Use external chest manipulation methods like
Percussion
Vibration
High-frequency chest wall compression (HFCWC)
Postural drainage: Optimize lung drainage based on specific pulmonary conditions.
Implementation: Acute Care (3 of 6)
Positive Expiratory Pressure (PEP) Therapy:
Applied to maintain and promote lung expansion.
Ambulation: Encourage movement as tolerated to enhance lung function.
Positioning: Utilize proper body posture, like upright positioning, to facilitate easy breathing.
Incentive Spirometry: Encourage use of spirometer to expand the lungs and improve tidal volume.
Case Study (11 of 17)
Airway Management Techniques for Mr. King:
Deep breathing and coughing every two hours while awake.
Frequent position changes if bed-bound; ambulate 10-15 minutes every 8 hours.
Encourage sitting up in a chair as tolerated.
Increase fluid intake to 2800 mL/24 hours, avoiding caffeinated beverages and alcohol, recommending water instead.
Implementation: Acute Care (4 of 6)
Suctioning Techniques:
Oropharyngeal and nasopharyngeal suctioning: Maintain airway clearances in non-intubated patients.
Orotracheal and nasotracheal suctioning: For managing secretions in intubated patients.
Tracheal suctioning: Specifically critical for patients with significant respiratory distress.
Implementation: Acute Care (5 of 6)
Artificial Airways Utilization:
Oral airway and endotracheal tubes for securing airway.
Invasive and non-invasive ventilation methods.
Chest tubes for managing pleural effusions or tension pneumothorax.
Special considerations: Tailor interventions based on patient-specific factors, including risk of obstruction.
Case Study (12 of 17)
Follow-up Assessment:
Two days later, lung auscultation reveals clearer sounds indicating improvement in Mr. King’s condition.
Quick Quiz 2 (1 of 2)
Question: In a patient with a tracheostomy and thick secretions, the best action includes:
A. Tracheal suctioning
B. Oropharyngeal suctioning
C. Nasotracheal suctioning
D. Orotracheal suctioning.
Quick Quiz 2 (2 of 2)
Answer: A. Tracheal suctioning.
Case Study (13 of 17)
Patient Monitoring:
John follows up on Mr. King's hydration, ambulation routine, and consistent deep breathing exercises as part of his recovery effort.
Case Study (14 of 17)
Patient Progress:
Mr. King averages 2800 mL/24 hours fluid intake, producing thin secretions.
Documents successful ambulation and adherence to deep breathing exercises.
Implementation: Acute Care (6 of 6)
Oxygenation Maintenance and Promotion:
Oxygen therapy: Precautions necessary to ensure safe delivery.
Methods of oxygen delivery:
Nasal cannula
High flow nasal cannula
Oxygen masks
Restoration of Cardiopulmonary Functioning: CPR and emergency procedures as needed.
Implementation: Restorative and Continuing Care
Techniques for Maintenance:
Respiratory Muscle Training: Exercises that strengthen respiratory muscles.
Breathing Exercises:
Pursed-lip breathing to improve ventilation and decrease anxiety.
Diaphragmatic breathing to enhance lung expansion.
Home Oxygen Therapy: Guidelines for continued therapy and monitoring.
Quick Quiz 3 (1 of 2)
Question: To maintain a chest tube for a postthoracotomy patient, the best method is to:
A. Strip the chest tube every hour.
B. Place the device below the patient’s chest.
C. Double clamp the tube except during assessment.
D. Remove the tubing from the drainage device.
Quick Quiz 3 (2 of 2)
Answer: B. Place the device below the patient’s chest.
Case Study (15 of 17)
Patient Engagement:
Mr. and Mrs. King express interest in preventative measures for future health maintenance.
John develops teaching methods to ensure both can articulate and understand steps to improve health and decrease hospitalization risk.
Case Study (16 of 17)
Patient Outcomes:
Mr. King demonstrates health stability, is afebrile, and maintains normal white blood cell counts.
Sputum cultures are negative upon discharge and no supplemental oxygen is required.
Mr. King uses breathing techniques to help control anxiety-related symptoms.
Evaluation
Patient Perspective:
Evaluation involves understanding impacts of disease on daily activities and treatment satisfaction.
Patient Outcomes Evaluation:
Compare actual patient progress with anticipated goals and outcomes outlined in care plans.
Case Study (17 of 17)
Final Observations:
As Mr. King prepares for discharge, he utilizes breathing techniques effectively, indicating progress in managing his condition.
Improvement noted in daily living activities and reduced anxiety observed in Mrs. King, indicating successful interventions.
Safety Guidelines
Patient Safety Guidelines:
Know baseline vital signs for each patient.
Limit catheter introduction to 2 times per suction procedure.
Prefer tracheal suctioning before pharyngeal suctioning, when possible.
Caution with suctioning patients with head injuries.
Do not instill normal saline into airways before suctioning.
Review institutional policy regarding chest tube management.
Watch for serious complications such as airway obstruction in tracheostomy cases.
In COPD patients, utilize high levels of oxygen therapy with caution to prevent respiratory depression.