Oxygenation Fundamentals and Skills

Determine oxygenation status by utilizing various clinical methods.
Provide supplemental oxygen utilizing nasal cannulas and face masks.
Clinical concepts with exemplars include:
- Gas Exchange
- Oxygen Devices
- Tracheostomy Care
- Tracheostomy Suctioning

Upper Respiratory Tract:
- Nasal cavity
- Pharynx (including Nasopharynx, Oropharynx, and Laryngopharynx)
- Larynx
Lower Respiratory Tract:
- Trachea
- Left and right primary bronchi
- Bronchioles
- Alveolar duct
- Alveoli
- Capillary
- Alveolar sac

Hyperventilation:
- Description: Rapid deep breathing, which may be regular or irregular.
- Effects: Causes increased $CO_2$ levels (hypercapnia) or decreased $O_2$ levels in the blood (hypoxemia).
Hypoventilation:
- Description: Slow deep breathing with a regular rhythm.
- Effects: Increases the retention of $CO_2$ in the body.
- Cause: Central Nervous System (CNS) depression.
Hypoxemia:
- Description: Low levels of $O_2$ in the blood.
- Cause: Diffusion impairment prevents gas exchange; Inadequate oxygen intake; Impaired lung function.
Hypoxia:
- Description: Low levels of $O_2$ in the tissue.
- Cause: Typically caused by hypoxemia, but can occur due to poor blood circulation.

Eupnea: Normal breathing pattern with a Respiratory Rate (RR) of $12-20$ breaths per minute.
Bradypnea: Slow RR less than $12$ with a regular pattern.
- Causes: Medications such as sedatives and opioid use.
Tachypnea: Fast RR greater than $20$ with a regular pattern.
- Causes: Anxiety, anemia, smoking, illness, or high altitude.
Hypoventilation: Characterized by decreased respiratory rate and depth of breathing.
Hyperventilation: Characterized by increased respiratory rate and depth of respirations.
Hyperoxygenation: Conducted before tracheostomy suctioning to prevent hypoxemia.

Respiratory Rate:
- Hypoxemia: May be normal, rapid, or shallow.
- Hypoxia: Rapid, shallow breathing (tachypnea).
Heart Rate:
- Hypoxemia: May be normal or increased (tachycardia).
- Hypoxia: Increased heart rate (tachycardia).
Blood Pressure:
- Hypoxemia: May be normal.
- Hypoxia: May be normal or low (hypotension).
Skin Color:
- Hypoxemia: May be normal or pale.
- Hypoxia: Blueish tint to the skin (cyanosis).
Neurological/Mental Status:
- Confusion: May be present in both; ranges from mild confusion to coma in hypoxia.
- Headache: May be present in both conditions.
- Restlessness: May be present in both conditions.

Inspection:
- Patient's respiratory rate and effort.
- Use of accessory muscles.
- Chest shape and symmetry.
- Skin color.
- Mental status.
Palpation:
- Tracheal deviation.
- Chest wall tenderness.
- Subcutaneous crepitus (trapped subcutaneous air).
- Tactile fremitus (vibration).
Percussion:
- Identification of flat vs. dull sounds.
- Identification of resonant vs. hyperresonant sounds.
- Identification of tympanic sounds.
Auscultation:
- Assessment for coarse lung sounds.
- Assessment for crackles.
- Assessment for wheezing.
- Assessment for stridor.
- Identification of absent lung sounds.

Nursing Diagnoses:
- Impaired gas exchange: Seen in COPD, asthma, or low oxygenation saturation.
- Ineffective breathing pattern: Seen in neurological disease/injury or asthma.
- Ineffective airway clearance: Seen in pneumonia or cystic fibrosis.
Nursing Actions to Improve Gas Exchange:
- Strategies to open the airway.
- Oxygen delivery.
- Ventilation assistance.
Independent Nursing Interventions:
- Elevate the Head of the Bed (HOB).
- Monitor Vital Signs.
- Repositioning (Turning the patient).
- Breathing exercises (Diaphragmatic and purse-lip breathing).
- Coughing and Deep Breathing.
- Suctioning.
- Ongoing Assessment.
Dependent Nursing Interventions:
- Oxygen administration.
- Incentive Spirometer use.
- Chest Physiotherapy (CPT).
- Postural drainage.

Nasal Cannula:
- $FiO_2$ : $24-44\%$
- Flow: $1-6\,L$
High Flow Nasal Cannula:
- $FiO_2$ : $60-90\%$
- Flow: $1-15\,L$ (Usually start at $6\,L$ )
Simple Face Mask:
- $FiO_2$ : $35-50\%$
- Flow: $6-12\,L$
Venturi Mask:
- $FiO_2$ : $24-50\%$
- Note: Uses color-coded valves to deliver a precise amount of oxygen.
Partial Rebreather Mask:
- $FiO_2$ : $60-80\%$
- Flow: $10-15\,L$
Nonrebreather Mask:
- $FiO_2$ : $100\%$
- Flow: $15\,L$
- Clinical Application: Used for patients who are dyspneic and cyanotic as it delivers the highest $O_2$ concentration.
Manual Resuscitation Bags (BVM):
- $FiO_2$ : $100\%$
- Flow: $10-15\,L$

Continuous Positive Airway Pressure (CPAP):
- Maintains a high level of continuous pressure to make inhalation easier.
Bilevel Positive Airway Pressure (BiPAP):
- Utilizes two distinct levels of pressure.
Oxygen Safety Protocols:
- Properly ground all electrical equipment.
- NO SMOKING in areas where oxygen is used.
- Use water-based lubricants only (Avoid oil-based products).
- Wear cotton clothing; avoid wool or materials that create static electricity.
- Regularly check oxygen flow rates.

Definition: A device used to help patients take slow deep breaths (inspiration).
Functions: Promotes lung expansion, increases oxygenation, and prevents atelectasis.
Indications for Use:
- Post-operative care.
- Pneumonia.
- COPD.
- Cystic fibrosis.

Types of Suctioning:
- Oropharyngeal
- Nasopharyngeal
- Artificial airway (tracheostomy)
Suctioning Procedure:
1. Collect sterile equipment: suction catheter (no larger than half the lumen of the tracheostomy tube), sterile gloves, sterile water, cup, and drape.
2. Wash hands and apply goggles.
3. Use sterile technique to open the package and fill the cup with sterile water.
4. Apply sterile gloves and connect the catheter to suction tubing.
5. Designate one hand as contaminated for: (a) connecting/disconnecting tubing at the suction catheter, (b) using the resuscitation bag, and (c) operating the suction control.
6. Test the system by suctioning sterile water through the catheter.
7. Hyper-oxygenate the patient for a minimum of $30\,\text{seconds}$ to prevent hypoxemia.
8. Gently insert the catheter without suction to minimize $O_2$ removal.
9. Apply intermittent suction while withdrawing the catheter in a rotating manner.
10. Limit the suctioning duration to $10\,\text{seconds}$ .
11. Record time, amount, and character of secretions and patient response.
Chest Physiotherapy (CPT) and Postural Drainage:
- Involves percussion, vibration, and specific positioning to promote mobilization and drainage of lung secretions.

Definition: A surgical incision into the trachea to create a temporary or permanent airway.
Discharge Requirement: A patient cannot go home until they can care for the tracheostomy independently.
Indications:
- Airway obstruction (e.g., tumor mass or foreign body).
- Requirement for prolonged mechanical ventilation.
- Requirement for frequent suctioning.
- Severe facial trauma or facial burns.
Emergency Bedside Equipment:
- An extra tracheostomy tube of the same size.
- An extra tracheostomy tube one size smaller.
- An Ambu bag.
Emergency Procedures:
- Tracheostomy dislodgment is an emergency.
- If dislodgment occurs, reinsert the tube immediately.