Chapter 41 Oxygenation

Scientific Knowledge Base Cardiovascular Physiology Decreased O2 carrying

Respiratory Physiology Deoxygenated blood-> right capacity cont.
Ventilation atrium-> right ventricle-> -Hemoglobin carries
-moving gas into and out of lungs where it becomes oxygen to tissues
the lungs, with air flowing oxygenated-> oxygenated Example using anemia->
into the lungs during blood enters left atrium-> Anemic people have a
inhalation and out of the left ventricle-> aorta-> body reduced amount of
lungs during exhalation tissues hemoglobin which results
Perfusion Structure and Function in a decrease in O2
-the ability of the CV system Myocardial pump Hypovolemia
to pump oxygenated blood to -4 chambers of the heart -blood loss
tissues and return -ventricles fill during diastole -factors such as shock and
deoxygenated blood to the (relaxation) dehydration cause
lungs -ventricles empty during extracellular loss and
Diffusion systole (contract) reduced circulating blood
-moving respiratory gasses -stroke volume is the volume volume
from one area to another by of blood ejected from the -What is hypoxia?
concentration gradient ventricles during ventricular -decreased circulating
What is a major inspiratory diastole blood volume
muscle? Coronary artery circulation -the body compensates by
DIAPHRAGM -coronary arteries fill during increasing the cardic
ventricular diastole output (the heart needs
Structure and function Systemic circulation to pump harder now to
Work of breathing Blood Flow Regulation get blood to the tissues)
-effort required to expand -normal output 4-8L/min for Decreased Inspired O2
and contract the lungs a healthy adult at rest Concentration
-lungs and diaphragm are -cardiac output is the -decline of inspired oxygen
used for breathing (EX> amount of blood ejected from concentration, the
paraplegics need something the left ventricle each min oxygen carrying capacity
to help them breath) Conduction System of the blood will decrease
Lung volumes -transmission of electrical -could be caused by upper
-determined by age, gender impulses or lower air way
and height -SA node is the pacemaker!! obstructions- this limits
Pulmonary Circulation the delivery of O2 to
-primary function is to move Factors Affecting alveoli
blood to and from the Oxygenation Increased Metabolic Rate
alevolar capillary membrane -Physiological -an increase in metabolic
for gas exchange -Developmental activity increases our O2
Respiratory Gas Exchange -Lifestyle demand
-diffusion -Environmental -tachypnea occurs before
Oxygen Transport hyperventalation
Carbon Dioxide Transport Physiological Factors
-deoxygenated blood comes Affecting Oxygenation
from the right superior vena Decreased O2 carrying
cava capacity
Regulation of Ventilation Ex. Anemia, Obesity, COPD
-ensures sufficent O2 intake
and CO2 elimination
Pertinent History for Lung Neuromuscular Disease Alterations in Cardic
Assessment -affects tissue oxygenation Functioning
-SUPER IMPORTANT!! by decreasing the pt ability Disturbances in Conduction
-Any chronic conditions? to expand and contract the -eletrical impulses that do
-Asthma, COPD, HF chest wall not originate from the SA
(during HF the heart has -ventilation is impaired node cause disturbances in
to work harder to keep resulting in atelectasis, conduction
up), DM hypercapnia (Co2 retention) -dysrhythmias
-Exposure to new and hypoxemia (low level of -deviation from normal
medication? O2 in the bloos sinus heart rhythm
-narcotics cause -ex. ALS-> neurons in your -tachycardia
respiratory depression! brain stop firing and telling -greater than 100 bpm
-Antidepressants can your body want to do -bradycardia
cause respiratory CNS Alterations -less than 60 bpm
depression bc the body -disease or trauma to -premature early beat
relaxes medulla oblongata or spinal -blocked (absent/delayed)
-Recent change in diet cord can result in impaired beat
-EX. Someone with a high ventilation -Atrial fibrillation
cholestrol diet is more at Influences of Chronic Lung -afib is the electrical
risk for blood clots Disease impulse in the atria is
-Substance abuse/ OD -oxygenation decreases as a chotic and originates
-hypoventilation direct consequence to CLD from multiple sites
-Prior DVT, pulmonary -AP diameter changes (COPD) Altered Cardiac Output
embolism (PE) or venous Heart failure
thromotic embolism (VTE) Alterations in Respiratory -failure of the myocardium
-clots can go to your Functioning to eject sufficent volume to
heart, brain or lungs! Hypoventiliation the systemic and
-Recent trauma to chest -too much CO2! pulmonary circulations
-not enough O2! occur in heart failure
Conditions Affecting -Atelectasis= lack of normal -Left sided HF
movement of the Chest Wall exchange of O2 and CO2= -oxygenated blood isnt
Pregnancy more alveoli collapse= less coming in!
-the fetus grows the the of lung get ventilated= -Right sided HF
enlarged uterus pushes up hypoventilation -deoxygenated blood
against the diaphragm Hyperventilation -impaired functioning of
Obestiy -too much O2! the right ventricle
-leads to reduced lung -lungs are removing CO2 -most common cause of
volumes from leavy lower faster than it is produced right sided HF is left
thorax and abdomen -what can cause this? sided HF
MSK abnormalities -anxiety, drugs, Impaired valvuar function
-reduce oxygenation infection -congential or acquired dz
-ex. Fractured ribs, scoliosis -use rebreathing! (Ex. of cardiac valve
Trauma Breathing into a paper bag) Stenosis- hardening,
-can reduce ventilation Hypoxia obstructs BF
-fractured ribs or brusing -inadequate tissue Regurgitation- impaired
can cause pain oxygenation at a cellular closure causing back flow
-flail chest- multiple rib level -Murmurs!
fractures can cause chest -ex. If the pt is anemic->
wall instability decreased hemoglobin->
lower oxygen carrying
Myocardial Ischemia Older adults -Smoking
-blood of myocardium -arteries harder-> -do they have a cough,
from coronary arteries blood cant flow as is the cough wet or dry,
is insufficent to meet well-> can lead to what is the color of
myocardial oxygen hypertension! their mucus, how many
demands Lifestyle factors packs, how many years
-Angina -Nutrition -Respiratory Infections
-chest pain! -Hydration -Allergies
-imbalance bet ween -can moisten -Medications
myocardial oxygen secretions in your -prescribed, OTC,
supply and demand throat herbal, home remedies
-lasts 3-5 mins -Exercise PHYSICAL EXAMINATION
-relieved with rest -expands alveoli-> Inspection
and nitroglycerin helps you breathe! -not the shape of the
(coronary -Smoking chest and the way it
vasodilator) -clogs lungs/alveoli moves! (SO IMPORTANT)
-Myocardial Infarction -Substance abuse -can be done during a
-heart attack!!! -depresses respiratory bed bath
-complete blockage center-> leads to -deformorites or
-cellular death occurs hypoxia asymmetry
after 20 mins of -Stress -AP diameter (anterior
myocardial ischemia -tachycardia often posterior)-> can tell us
-left sided chest pain leads to tachypnea if a pt has COPD (barrel
and radiates to back, Environmental Factors chest!)
left arm and neck -rural population -abnormal retractions
-signs and symptoms -workplace into the sternal space of
differ for men and -occupation pollutants the interspaces during
women Critical Thinking! respiration
-knowledge of the CV and -grunting
Scientific Knowledge Base respiratory physiology, O2 -using accessory
Factors Influencing supply and demand muscles too much
Oxygenation provides a scientific basis -lower interspaces,
-Developmental Stages for how to approach supraclavicular in acute
-Infant and toddlers assessment for pt asthma exacerbation
-air way obstruction -Ex. History, basic vitals -impaired respiratory
risk (pulse ox!), listening to movement
-when they cry, lungs -flail chest and
sometimes they stop paradoxical movement
breathing Nursing Process with rib fractures
-School-aged children and Assessment -assessment of normal
adolescents -History for cardiac breathing patterns
-exposed to cigarette assessment -normal adult: 12-20
smoke and secondhand -health risks, pain, -depth
smoking fatigue, dyspnea, -shallow? (COPD)
-Young and middle aged cough -deep (retractions)
adults -Environmental and -effort
-unhealthy diet, lack Occupation factors -unlabored (normal!)
of exercise -smog, mold, dander, -labored (tachypnea)
-as we get older, we gas, carbon monoxide -retractions (any use of
get decreased lung accessory muscles
capacity
Ap diameter Percussion Inspiration
-anterior posterior -you want to hear -air moving into smaller
-pts with COPD have barrel resonance! air ways and hitting walls
chest becase there is too -identify is underlying -MORE turbulence->
much air tissues are air filled, fluid increased sound
filled or solid Expiration
-percuss symmetrically on -air moving toward larger
chest wall air ways
-percuss side to side, -LESS turbulence-> decrease
avoiding bone sounds
-dullness replaces *Normal breath sounds are
resonance when fluid or loudest in inspiration and
Assess client color solid tissue replaces air in softest during expiration
-cyanosis! Lack of O2- the lungs
look at face/ -pleural effusions- the Breath Sounds
extremeties buildup of excess fluid Normal
Palpation bet ween layers of the Bronchial
-use fingertips pleura outside your -over trachea
-identify tender areas lungs -high pitched
-observe for -hemothorax- blood in -expiration> inspiration
appropriate chest wall the lungs Bronchovesicular (middle)
exapnsion (chest -tumor- dull sound -over major bronchi
excursion) -unilateral hyperresonance -bet ween scapula
Chest Excursion could indicate a -around sternum
pneumothorax( air leaking -medium pitched
out of the lungs) -inspiration= expiration
-generalized Vesicular
hyperresonance -over lung periphery
-COPD -soft pitched
-inspiration> expiration
Auscultation
Tactile fremitus -always look at diagnosis
symmetrically -10 posterior
-use ulnar side of -8 lateral
hand -8 anterior
-palpable vibrations -listen symmetrically!!!
transmitted to the -someone with COPD may
chest wall not be able to do 26 breath
-say “ninety- nine” sounds- you should listen to
-worry if you cannot at least 6 locations
feel-> could indicate a anterior and posterior
mass or fluid -listen to inhale and exhale
-decreased with COPD
and pleural effusions
 Stridor *PRIORITY* Planning and outcomes
Abnormal
-inspiratory muscial -set priorites
-absent
wheezing -teamwork and
-decreased
-loudest over trachea collaboration
-bronchial (if heard in
-obstruction
other locations of the lung)
-MEDICAL EMERGENCY Implementation
Causes?
Pleural Friction Rub Health promotion
-asthma- narrowing of
-dry grating, rubbing -vaccines
air way
sound -healthy lifestyle
-COPD- air way decrease
-inspiration or -environmental pollutants
or absent
expiration Acute care
-pleural effusion- fluid
-pleural surfaces are -Dyspnea management
in pleural space
inflammed and rub -pharmacological, O2
-pneumothorax-air
together therapy
leaking into pleural
-PE, pneumonia, TB, rib fx -Air way maintenance
space
-ARDS- usually see in a -adequate hydration
Symptoms of Hypoxia -Mobilization of pulmonary
bacterial infection
(lack of O2) secretions
-atelectasis-collapse of
Early -reposition and
alveoli. Prevention:
Restlessness suctioning
breathing exercises
Anxiety- due to lack -Hydration
(incentive spirometer)
of O2 -Humidification
Tachycardia or -keeps air ways moist
Adventitious (LISTEN ON
Tachypnea -Nebulization
PPT)
Late -adds moisture to
Crackles (rales)
Bradycardia- inspired air
-fluid in lungs
over worked/lack of -Coughing and Deep
-pneumonia
O2 breathing techniques!
-sounds like with you add
Extreme restlessness -Chest physiotherapy
milk to rice crispies
(they cant breathe) -external chest wall
-hear more with
Dyspnea (SOB) manipulation using
inspiration
In pediatrics percussion, vibration or
-air moving through
Feeding difficulty high frequency
secretion (fluid) and
Inspiratory stridor -Positive expiratory
collapse alveoli
Nares flaring pressure
-brief, intermitent
Expiratory grunting -acapella device- when
-fine/coarse
Sternal retractions you breathe out, it
Wheezing
(use of accessory vibrates
-upper air way narrowing
muscles) -Maintenance and
-continuous, high pitch,
musical sound promotion of lung
Analysis and Diagnosis expansion
-greater with expiration
-use ABCs! -Ambulation- decreases
-asthma, COPD, CHF, lung
Examples immobility risks
cancer
-impaired CO -Positioning- high
Rhonchi
-acute pain fowlers- opens lungs
-most often in lower lungs
-activity intolerance -Incentive Spirometry-
-loud, low pitched, snoring
-fatigue give pts visual feedback-
-obstruction of larger
-Impaired air way hold breath for 5-10
air ways by secretions
clearance (priority!) seconds-> helps expand
-bronchitis, obstruction,
COPD, pneumonia lungs
- up to 10X an hour!
Artifical Air ways Interventions Assessment methods
-for a pt with decreased Incentive Spirometry Peak flow meter
LOC or air way obstruction -encourages voluntary deep -green is good!
-oral air way breathing by providing -tests if pt is going to
-endotracheal and visual feedback o patients have an asthm attack
tracheal air ways about inspiratory volume -handheld device that
Tracheostromy tubes -5-10 breaths per session measures how well air
Air way Sunctioning every hour while pt is awak moves out of your lungs
-Open vs closed Acapella device Pulse oximetry
Sunctioning Techniques -vibrates chest wall -measure O2
-Oropharyngeal and -8-10 times per session -on infants, place on
nasotracheal suctioning -help people who have toes
-Tracheal sunctioning difficulty clearing phlegm -must be a warm
-Invasive mechanical from their lungs extremity
ventilation Pursed Lip breathing -95 or above is good
-Noninvasive ventilation -deep inspiration and Sputum collection
-Chest tubes prolonged expiration -best to collect in AM
Maintenance and through pursed lips (secretions build as they
promotion of oxygenation -prevents alveolar collapse lay flat)
-O2 therapy -breath in for 3 seconds and -sterile container
-safety precaution- O2 is out for 6 seconds -cough deep and
highly combustible Coughing and deep breathing expectorate into a
-supply of O2 -coughing is effective for container
Methods of oxygen maintaining pt air way
delivery -deep breathing with Positioning
-nasal cannula coughing is an air way -high fowlers
-high flow nasal cannula clearance tactic that is
-oxygen masks effective when Oxygen Administration
Restoration of spontaneous coughing is Room Air
cardiopulmonary inadequate -21% O2
functioning Chest PT manual and with -contains a variety of
-CPR vest elements and
-external chest wall substances other than
Restorative and continuing manipulation using oxygen
care percussion, vibration, high Nasal Cannula (need
Respiratory Muscle frequency chest wall order)
training compression -delivery is 1-6 L/min
Breathing Exercises (24%-44% O2)
-pursed lip breathing Pulmonary function testing -always assess for skin
-diaphragmatic (PFT) breakdown
breathing -group of tests that -flow rater greater than
Home oxygen therapy measure how well lungs 4L/min can hav drying
take in and release air and effect and may need
how well they move gasses humification
such as O2 from the High flow nasal cannula
atmosphere into the bodys -heated humified oxygen
circulation with a flow rate as high
as 60L/min
-used to tx respiratory
failure
Face Masks
Simple mask Safety Guidelines
-6-12L/min -Know your patients
-contraindicated in pts baseline range of VS!
with CO2 retention bc this -limit the introduction of
can worsen retention the catheter to 2 times
leading to decreased LOC with each suctioning
Partial rebreather and procedure
non-rebreather -perform tracheal
-10-15 L/min (60%-90% sunctioning before
oxygen pharyngeal sunctioning
-used if pt was in a fire- you whenever it is possible
would want to deliver the -use caution when
most amount of O2 suctioning pt with a head
Venturi mask injury
-4-10L/min (24%-60%) -use of normal saline
-the most precise airflow instillation into the
concentration air way before suction is
-specific NOT recommended
-COPD pts -review institutional
policy before stripping or
Sunctioning milking chest tubes
-oral/nasal- suction -the mos serious
intermittently only up to 2 tracheostomy
times complication= air way
-suction catheter- may obstruction
need to suction secretions -Pts with COPD who are
from trach breathing spontaneously
-sunction via nose or mouth should be cautious with
receiving high levels of
oxygen therapy