Funds recorded lecture 8/12 Respiratory, Oxygen, Surgery, and Sleep Physiology

Respiratory Interventions and Oxygen Delivery Systems

• Incentive Spirometer Usage

  • The incentive spirometer is a critical tool for promoting lung expansion.
  • Proper technique involves having the patient blow out (exhale) first to empty the lungs.
  • The patient then pulls air back in (inhales) slowly and deeply until they reach a predetermined target level on the device.
  • Patients are generally instructed to perform this maneuver $10$ times every hour while they are awake.

• Oxygen Delivery Devices and Flow Rates

  • Nasal Cannula: Delivers oxygen at a flow rate of $1 \times 60 \, L/min$ (note: commonly $1-6 \, L/min$, but documentation reflects range up to high flow limits).
  • Simple Mask: Delivers oxygen at a flow rate of $5-10 \, L/min$.
  • Non-rebreather Mask: Delivers oxygen at a flow rate of $10-15 \, L/min$. This mask includes a reservoir bag at the bottom that fluctuates rapidly to show the patient is receiving a high concentration of oxygen.

• Oxygen Safety and Nursing Considerations

  • Flow meters must be checked regularly against the physician's orders to ensure the patient is receiving the correct level of oxygen.
  • Only water-soluble lubricants should be used around the nasal area when a patient is on oxygen.
  • Petroleum jelly (e.g., Vaseline) must be avoided because it is combustible and poses a significant fire risk in the presence of oxygen.
  • Signs of respiratory distress (dyspnea) include intercostal muscle retractions, nasal flaring, and difficulty breathing. Nurses can check pulse oximetry and initiate oxygen as needed in emergency situations.

• Tracheostomy Care and Suctioning

  • Standard protocol for suctioning involves suctioning $3$ times and hyperoxygenating the patient $4$ times.
  • Nurses must know how to clean the internal cannula and perform overall tracheostomy care.

Cardiovascular Support and Clinical Prioritization

• Sequential Compression Devices (SCDs)

  • SCD devices are used on a patient's legs to prevent the formation of blood clots (Deep Vein Thrombosis).
  • These devices increase circulation in the lower extremities, which is especially critical for patients mandated to bed rest.

• Cardiac Auscultation

  • When assessing a patient after a mitral valve repair, the stethoscope should be placed at the apex of the heart.
  • The apex is located at the mitral valve area, often described as the middle of the fifth intercostal space at the midclavicular line.

• Principles of Prioritization

  • Prioritization often follows the ABCs (Airway, Breathing, and Circulation).
  • While breathing is a priority, active bleeding is an immediate life threat that must be addressed to prevent death. If a patient is bleeding, the priority is to stop the bleeding.

Perioperative Care and Surgical Procedures

• Surgical Classifications

  • Surgeries are generally classified by urgency, risk level, and purpose.

• Roles in Informed Consent

  • The physician/surgeon is responsible for explaining the procedure and why it is necessary.
  • The nurse's role is to ensure the patient understands what was explained and that they know why they are having the surgery.

• Urinary Elimination and Catheterization

  • Catheter insertion is a sterile procedure. If any part of the sterile field or equipment is contaminated, the nurse must stop and obtain a completely new kit.
  • Following the removal of an indwelling catheter, the patient must void within $6 \, hours$. If the patient has not voided in that time, the doctor must be notified, which may result in an order for a straight catheterization.
  • During straight catheterization, it is important not to drain more than $1000 \, mL$ of urine at one time.

The Physiology and Stages of Sleep

• Stages of Non-Rapid Eye Movement (NREM) Sleep

  • Stage 1: Occupies approximately $5\%$ of total sleep.
  • Stage 2: Occupies $50-55\%$ of sleep. The patient is still relatively easy to arouse during this stage.
  • Stage 3: This is the most restorative stage of sleep where arousal is difficult. Physiological changes include relaxed muscles, slowed metabolism, and decreased vital signs.

• Rapid Eye Movement (REM) Sleep

  • The eyes move back and forth quickly.
  • Small muscle twitches may occur, but large muscles experience immobility (paralysis).
  • Metabolism and body temperature increase.
  • Respirations and pulse become irregular, and periods of apnea may occur.

• Hormonal Regulation and Sleep Deprivation

  • Sleep deprivation increases cortisol levels.
  • Leptin: A hormone that tells the brain to stop eating. Levels decrease during sleep deprivation.
  • Ghrelin: A hormone that promotes continued eating. Levels increase during sleep deprivation.
  • Physiological effects of poor sleep include GI symptoms (nausea, diarrhea, abdominal pain), decreased emotional regulation, and a reaction time similar to a person intoxicated with alcohol.

Sleep Disorders and Hygiene

• Common Sleep Disorders

  • Insomnia: Characterized by difficulty falling asleep, intermittent sleep, or frequent waking with trouble returning to sleep. Often aggravated by chronic conditions like depression, heart failure, or diabetes.
  • Obstructive Sleep Apnea (OSA): Characterized by loud snoring and apnea (cessation of breathing) or hypopnea (diminished breathing effort). CPAP (Continuous Positive Airway Pressure) is a common treatment.
  • Narcolepsy: Excessive daytime sleepiness and involuntary loss of skeletal muscle tone (cataplexy) lasting seconds or minutes. Treatments include antidepressants and behavioral changes like scheduled naps.

• Parasomnias (Episodic Sleep Behaviors)

  • Somnambulism: Sleepwalking; safety and injury prevention are essential.
  • Sleep Terrors: Most common in children; involves waking up screaming with intense fear and increased heart rate/sweating, typically occurring during the deepest stage of NREM sleep.
  • Nightmares: Vividly frightening dreams that are often remembered upon waking.
  • Sleep Enuresis: Bedwetting; considered primary if the person has never stayed dry for a period of $6 \, months$.
  • Sleep-Related Eating Disorders: Eating or drinking during sleep with no memory of the event the next morning.

• Sleep Hygiene Protocols

  • Establish a consistent ritual, going to bed and waking up at the same time.
  • Avoid eating large meals late at night.
  • Avoid stimulants like caffeine and sugar close to bedtime.
  • Exercise promotes both REM and NREM sleep but should not be performed within $3 \, hours$ of bedtime, as it can interfere with falling asleep.

Clinical Assessment and Nursing Roles

• Sleep History and Diaries

  • Assessments should include when sleep problems started, how often they happen, and the impact of stressors or drugs (antidepressants, diuretics).
  • A sleep diary should track retirement time, time to fall asleep, number of awakenings, stressors, food/drink intake, and energy levels.

• Collaborative Care

  • Respiratory Therapists (RT) typically perform scheduled breathing treatments.
  • Nurses are responsible for checking the Medication Administration Record (MAR), notifying the RT when treatments are due, and ensuring the treatments are completed.

Questions & Discussion

• Question: Regarding skin cancer prevention, there were two correct answers: SPF 30 sunscreen and avoiding tanning beds. How do I differentiate which is better?

• Response: The key is the wording. One option might suggest "limiting" use, but the correct clinical rationale is to avoid tanning beds altogether.

• Question: What is the nurse's role in surgery?

• Response: The nurse must make sure the patient understands why they are getting the surgery, even though the doctor is the one who explains the procedure for consent.

• Question: How many stages of sleep are there?

• Response: There are three stages (NREM) followed by REM.