NR224 Fundamentals: Oxygenation

Respiratory Anatomy and Structures

• Upper Respiratory Tract

  • Nasopharynx

  • Oropharynx

  • Laryngopharynx

  • Nasal cavity (left and right)

  • Pharynx

  • Larynx

• Lower Respiratory Tract

  • Trachea

  • Primary bronchi (left and right)

  • Bronchioles

  • Alveolar duct

  • Alveoli

  • Alveolar sac

  • Capillary network surrounding the alveoli

Impaired Gas Exchange and Respiratory Definitions

• Hyperventilation

  • Defined as rapid, deep breathing that may be regular or irregular.

  • Results in increases in $CO_2$ levels (hypercapnia) or decreases in $O_2$ levels in the blood (hypoxemia).

• Hypoventilation

  • Defined as slow, deep breathing with a regular rhythm.

  • Consists of a decreased respiratory rate and depth of breathing.

  • Results in the increased retention of $CO_2$ in the body.

  • Common causes include Central Nervous System (CNS) depression.

• Hypoxemia

  • Low levels of $O_2$ in the blood.

  • Caused by diffusion impairment that prevents gas exchange, inadequate oxygen intake, or impaired lung function.

  • Hyperoxygenation is required before tracheostomy suctioning specifically to prevent hypoxemia.

• Hypoxia

  • Low levels of $O_2$ in the tissue.

  • Typically caused by hypoxemia, but can also occur due to poor blood circulation.

Alterations in Breathing Patterns

• Eupnea

  • Description: Normal breathing pattern.

  • Respiratory Rate ($RR$): $12-20\,\text{breaths/min}$.

• Bradypnea

  • Description: Slow respiratory rate with a regular pattern.

  • Respiratory Rate ($RR$): Less than $12\,\text{breaths/min}$.

  • Common causes: Medications such as sedatives or opioid use.

• Tachypnea

  • Description: Fast respiratory rate with a regular pattern.

  • Respiratory Rate ($RR$): Greater than $20\,\text{breaths/min}$.

  • Common causes: Anxiety, anemia, smoking, illness, or high altitude.

Comparisons of Hypoxemia and Hypoxia Manifestations

• 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).

• Mental Status and Other Symptoms

  • Confusion: Present in both; in hypoxia, it can range from mild confusion to coma.

  • Headache: May be present in both conditions.

  • Restlessness: May be present in both conditions.

Comprehensive Respiratory Assessment

• Inspection

  • Assess patient's respiratory rate ($RR$) and effort.

  • Observe for the use of accessory muscles.

  • Examine chest shape and symmetry.

  • Assess skin color and mental status.

• Palpation

  • Check for tracheal deviation.

  • Assess for chest wall tenderness.

  • Check for subcutaneous crepitus (trapped subcutaneous air).

  • Assess tactile fremitus (vibrations).

• Percussion

  • Note sounds: Flat vs. dull, Resonant vs. hyperresonant, or Tympanic.

• Auscultation

  • Assess for abnormal breath sounds: Coarse, Crackles, Wheezing, Stridor, or Absent sounds.

Nursing Diagnoses and Management

• Core Nursing Diagnoses

  • Impaired gas exchange: Associated with conditions like COPD, asthma, or low oxygenation saturation.

  • Ineffective breathing pattern: Associated with neurological disease/injury or asthma.

  • Ineffective airway clearance: Associated with pneumonia or cystic fibrosis.

• Actions to Improve Impaired Gas Exchange

  • Strategies to open the airway.

  • Oxygen delivery.

  • Ventilation assistance.

  • Note: While fluid administration and positioning are mentioned, supine positioning is generally avoided in favor of elevation.

• Independent Nursing Interventions

  • Elevate Head of Bed (HOB).

  • Monitor Vital Signs.

  • Repositioning (Turning) the patient.

  • Breathing exercises: Diaphragmic and purse-lip breathing.

  • Coughing and Deep Breathing.

  • Suctioning.

  • Ongoing Assessment.

• Dependent Nursing Interventions

  • Administering Oxygen.

  • Incentive Spirometer use.

  • Chest Physiotherapy (CPT).

  • Postural drainage.

Oxygen Delivery Devices and Flow Rates

• Nasal Cannula

  • FiO2 ($$): $24-44\,$.

  • Flow Rate: $1-6\,L/min$ on regulator.

• High Flow Nasal Cannula

  • FiO2 ($$): $60-90\,$.

  • Flow Rate: $1-15\,L/min$ (typically starting at $6\,L/min$).

• Simple Face Mask

  • FiO2 ($$): $35-50\,$.

  • Flow Rate: $6-12\,L/min$.

• Venturi Mask

  • FiO2 ($$): $24-50\,$ or $24-60\,$.

  • Flow Rate: Uses color-coded valves to deliver a precise amount of oxygen.

• Partial Rebreather

  • FiO2 ($$): $60-80\,$.

  • Flow Rate: $10-15\,L/min$.

• Nonrebreather Mask

  • FiO2 ($$): $100\,$.

  • Flow Rate: $15\,L/min$.

  • Delivers the highest $O_2$ concentration; indicated for patients who are dyspneic and cyanotic.

• Manual Resuscitation Bags (BVM)

  • FiO2 ($$): $100\,$.

  • Flow Rate: $10-15\,L/min$.

Advanced Airway Support

• CPAP (Continuous Positive Airway Pressure)

  • Maintains a high level of continuous pressure to make inhalation easier.

• BiPAP (Bilevel Positive Airway Pressure)

  • Utilizes two different levels of pressure for inhalation and exhalation.

Oxygen Safety Protocols

• Ensure all electrical equipment is properly grounded.

  • Strict "NO SMOKING" policy.

  • Use only water-based lubricants; never use oil-based products.

  • Patients should wear cotton clothing to avoid static electricity associated with wool or synthetic fabrics.

  • Oxygen flow rates must be checked regularly.

Supplemental Respiratory Therapy

• Incentive Spirometry

  • Purpose: A device that helps patients take slow deep breaths (Inspiration). It promotes lung expansion, increases oxygenation, and prevents atelectasis.

  • Indications: Post-operative care, pneumonia, COPD, and cystic fibrosis.

• Chest Physiotherapy (CPT) and Postural Drainage

  • Involves the use of percussion, vibration, and specific positioning.

  • Goal: To promote the mobilization and drainage of lung secretions.

Tracheostomy Management

• Overview

  • A surgical incision into the trachea to create a temporary or permanent airway.

  • Patient Independence: A client cannot be discharged home until they can care for the tracheostomy independently.

• Indications

  • Airway obstruction (foreign body or tumor mass).

  • Requirement for prolonged mechanical ventilation.

  • Requirement for frequent suctioning.

  • Severe facial trauma or facial burns.

• Bedside Safety Equipment

  • An extra tracheostomy tube of the same size.

  • An extra tracheostomy tube one size smaller.

  • Ambu bag (BVM).

  • In the event of accidental dislodgment (an emergency), reinsert the tube immediately.

• Suctioning Procedure

  1. Collect sterile equipment: suction catheter (size must be no larger than half the lumen of the tracheostomy tube), gloves, sterile water, cup, and drape.

  2. Perform hand hygiene and apply goggles.

  3. Use sterile technique to open the package and fill the cup with sterile water.

  4. Don sterile gloves and connect the catheter to the suction tubing.

  5. Designate one hand as "contaminated" for: (a) connecting/disconnecting suction tubing, (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 $30\,seconds$ to prevent hypoxemia.

  8. Gently insert the catheter without applying suction to minimize oxygen removal.

  9. Apply suction intermittently while withdrawing the catheter in a rotating manner.

  10. Limit the suctioning duration to a maximum of $10\,seconds$.

  11. Record the time, amount, and character of secretions, as well as the patient's response.

Questions & Discussion

• Nursing actions to improve impaired gas exchange:

  • Question: Which nursing actions can improve impaired gas exchange? Select all that apply.

  • Answer: Strategies to open the airway, Oxygen delivery, Ventilation assistance, Fluid administration.

• Emergency Oxygen Device Selection:

  • Question: You enter your patient’s room, and they are dyspneic and cyanotic. What oxygen delivery device will you use?

  • Answer: Non-rebreather mask.

• Tracheostomy Evaluation:

  • How do you know a patient needs their tracheostomy suctioned?

  • How do you evaluate the effectiveness of the suctioning?