UNIVERSITY OF THE CORDILLERAS

College of Nursing
FUNDAMENTALS OF NURSING
MIDTERMS

OXYGENATION

Introduction
Oxygenation is a basic human need. Breathing is synonymous with life.
The respiratory system replenishes the body's oxygen supply and eliminates waste from thi blood in the form of
carbon dioxide. Nurses are responsible for promoting normal respiratory function regardless of practice area. School
nurses conduct classes about the hazards of smoking. Community nurses screen for and teach about prevention of
respiratory disorders like tuberculosis, SARS, (Severe Acute Respiratory Syndrome) and others.
Nurses also help to improve breathing in clients with altered respiratory function. Most important, nurses apply the
nursing process to promote normal respiratory function, and therefore, adequate oxygenation.

Anatomy and Physiology of the Respiratory System

Respiration - The process of gaseous exchange between the individual and the
environment.
1. The Airways
a. Upper Airways
 Nasal Cavity
 Pharynx
 Larynx
b. Lower Airways (Tracheobronchial Tree)
 Trachea
 Right and left mainstem bronchi
 Segmental bronchi
 Subsegmental bronchi
 Terminal bronchi
c. Functions of the Upper Airways:
 Transport of gases to the lower airways.
 Protection of the lower airway from foreign matter.
 Warming, filtration and humidification of inspired air.

d. Functions of the Lower Airways

 Warming, filtration and humiditication of inspired air.
 Clearance Mechanism
 Cough
 Mucociliary system
 macrophages
 lymphatics
 Immunologic Responses
 Cell - mediated immunity in the alveoli.
 Pulmonary protection in Injury.
 Respiratory epithelium.
 Mucociliary system.
 The openings of the nose on the face area are called nostrils or nares.
 Each nostril leads to a cavity called vestibule.
 The hair that lines the vestibule are called the vibrissae. The vibrissae filter foreign objects.

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Rambo Laguiwed Ebbes, RN
Instructor NCM 103 (Theory)
  The paranasal sinuses are open areas within the skull, lined with mucous membrane. They help in
phonation. The different sinuses are as follows: frontal, maxillary, ethmoid and sphenoid.
 The pharynx is a funnel-shaped tube that extends from the nose to res the larynx. It is a common opening
between the digestive and
respiratory system.
 The three sections of the pharynx are as follows;
nasopharynx, oropharynx and laryngopharynx.
 From the middle ear, the eustachean tubes open into the nasopharynx.
 The larynx is the voice box.
 The epiglottis covers the larynx. When eating, the epiglottis closes, when speaking it opens.
 The trachea (windpipe) is 12 cm (4-5 in.) long. The point at which it divides is called carina.
 The trachea and bronchi are lined with cilia and goblet cells.
 The cilia are microscopic hair-like projections which have rapid, coordinated, unidirectional upward
motion.
 The cilia sweep out debris and excessive mucous from the lungs. no: • The goblet cells secrete 120 ml of
mucous per day. The mucous allerod secretions entrap debris in the respiratory tract.
 The right mainstem bronchus is shorter, broader and more vertical than the left.

2. The Pleura
1) The pleurae are serous membranes that enclose the lungs.
2) The visceral pleura directly covers the lungs.
3) The parietal pleura lines the cavity of each hemithorax.
4) 4. The pleural space is a potential space between the two pleurae. Only few mi of serous fluid is found in
the pleural space, to serve as lubricant.
3. The Lungs
 The right lung has three lobes, while the left lung has two lobes.
 The two lungs are separated by a space called mediastinum.
 There are approximately three hundred million alveoli in the lungs.
 The right lung is broader but shorter due to the presence of the liver on the right side of the abdomen.
 Residual volume is the amount of air that remains in the lungs after forceful expiration. It prevents collapse
of the lungs during expiration. (1200 ml.)
 Tidal volume is the amount of air that moves in and out of the lungs with each normal breath (500 ml.)
 Inspiratory reserve volume is the amount of extra air that can be exhaled, beyond the tidal volume.
 Expiratory reserve volume is the amount of extra air that can be exhaled after a normal breath.
 Total lung capacity is the total of all four volumes (residual, tidal, inspiratory reserve volume and
expiratory reserve volumes).
 Functional residual capacity is the amount.of air that remains in the lungs after normal exhalation.
 Pneumocytes. The type I pneumocytes line the alveoli, whereas the type Il pneumocytes produce surfactant.

4. The Thorax and the Diaphragm

o The thorax provides protection for the lungs, heart and great vessels.
o The thorax is made up of 12 pairs of ribs, bounded anteriorly by the 57 sternum and posteriorly by the
thoracic vertebrae.
o The diaphragm is the main respiratory muscle for inspiration. It is supplied by the phrenic nerve.
o The following are the accessory muscles for inspiration: sternocleidomastoid, scalene, parasternal,
trapezius and pectoralis muscles. They are used during increased work of breathing.

5. Respiratory Control
a. Central Nervous System Control
 medulla oblongata (central chemoreceptors)
b. Reflex Control

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Rambo Laguiwed Ebbes, RN
Instructor NCM 103 (Theory)
  pons (apneustic center, pneumotaxic center)
 cough reflex
 Peripheral control
 Carotoid and aortic bodies

PLANNING
Measures That Promote Adequate Respiratory Function
1. Adequate oxygen supply from the environment. Man requires 21 % of oxygen from the environment in
order to survive. The higher the altitude, the lower is the oxygen concentration.
2. Deep breathing and coughing exercises. To promote maximum lung expansion and to loosen mucous
secretions. Inhale deeply through the nose, then exhale passively through the mouth.
3. Positioning. The semi-fowler's or high fowler's position promotes maximum lung expansion. By gravity,
the diaphragm moves down, and abdominal organs do not compress the diaphragm.
4. Patent airway. To promote gaseous exchange between the person and the environment.

Causes of Airway Obstruction

 tongue (among unconscious clients, the tongue tends to fall back).
 mucous secretions.
 edema of airways (rhinitis, laryngitis, bronchitis).
 spasm of airways (laryngospasm, bronchospasm)
 foreign bodies (aspirated foods, fluids)
* Airway obstruction is characterized by noisy breathing.

5. Adequate hydration. To maintain moisture of the mucous membrane lining and respiratory tract. This is
necessary to prevent irritation and infection. Fluids also liquefy mucus secretions. Fluid intake should
ideally be 6 go 8 glasses of fluid, preferably water, everyday.
6. Avoid environmental pollutants, alcohol and smoking. These factors inhibit mucociliary function.
7. Chest physiotherapy (CPT)
• Percussion, Vibration and Postural Drainage (PVD)
These procedures are dependent nursing functions.
 Percussion (clapping) is forceful striking of the skin with cupped hands. It can mechanically dislodge
tenacious secretions from bronchial walls.
 Vibration is a series of vigorous quivering produced by hands that are placed flat against the client's chest
wall. It is done to loosen mucous secretions.
 Postural Drainage is expulsion of secretions from various lung segments by gravity. This involves placing
the client in different positions so that the area of lung congestion will be in vertical position with the
bronchus. This facilitates drainage by gravity.
 Each position during postural drainage will be assumed by the client for 10-15 minutes.
 The entire treatment should last only for 30 minutes
 Gradual change position should be observed to prevent exhaustion and postural hypotension.
 Before postural drainage, bronchodilator medication or nebulization therapy is given to loosen mucous
secretions, as ordered.
 The best time to do postural drainage treatment is before meals, in the morning upon awakening and at
bedtime.
 Do not perform postural drainage immediately after meals because it may cause vomiting, thereby
aspiration.
 Provide good oral hygiene after the procedure. To remove unpalatable taste of the mucus secretions from
the mouth.

8. Bronchial Hygiene measures.

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Rambo Laguiwed Ebbes, RN
Instructor NCM 103 (Theory)
a. Steam Inhalation
The purposes of steam inhalation are as follows:
1) To liquefy mucous secretions.
2) To warm and humidify inspired air.
3) To relieve edema of airways.
4) To soothe irritated airways.
5) To administer medications.

 It is dependent nursing function. Heat application requires physician order

 Inform the client and explain the purpose of the procedure. To allay anxiety.
 Place the client in semi-fowler's position. For maximum inhalation of steam
 Cover the client's eyes with wash cloth to prevent irritation.
 Check the electrical device before use to prevent injury.
 Place the steam inhalator in a flat, stable surface. To prevent scalding from the hot water.
 Place the spout 12-18 inches away from the client's nose or adjust the distance as necessary.

CAUTION: Avoid burns. Cover the chest with towel to prevent burns due to dripping of condensate from the
steam. Assess for redness on the side of the face which indicates first degree burns.

 To be effective, render steam inhalation therapy for 15-20 minutes

 Instruct the client to perform deep breathing and coughing exercises after the procedure to facilitate
expectoration of mucous secretions.
 Provide good oral hygiene after the procedure. To remove unpalatable taste of sputum from the mouth.
 Do after-care of equipment.
 Make relevant documentation.
B. Aerosol Inhalation
 Done among pediatric clients to administer bronchodilators or mucolytic-expectorant
c. Medimist Inhalation
 Done among adult clients to administer bronchodilators or mucolytic-expectorants.

9. Suctioning: Oropharyngeal and Nasopharyngeal

 To clear airways from mucus secretions.

Oropharyngeal and Nasopharyngeal suctioning

1. Assess indications for suctioning:
 audible secretions during respiration
 adventitious breath sounds (auscultated)
2. Position:
 Conscious: Semi-Fowler's position
 Unconscious: Lateral position
3. Pressure of suction equipment, to prevent trauma to mucous membrane of airways.
 Wall Unit:
 Adult: 100-120mmHg
 Child: 95-110 mmHg
 Infant: 50-95 mmHg
 Portable Unit:
 Adult: 10-15 mmHg
 Child: 5-10 mm Hg
 Infant: 2-5 mm Hg
4. Appropriate size of sterile suction catheter, to prevent trauma to mucous membrane of airways.
 Adult: Fr. 12-18
 Child: Fr. 8-10
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Rambo Laguiwed Ebbes, RN
Instructor NCM 103 (Theory)
  Infant: Fr. 5-8
5.Don sterile gloves. Sterile technique prevents introduction of microorganisms into the respiratory tract.
6.Length of catheter:
 Measure from the tip of the client's nose to the earlobe or about 13 cm (5 in) for an adult
7. Lubricate catheter, to reduce friction.
 Nasopharyngeal suction tip-water soluble lubricant
 Oropharyngeal suction tip- sterile water or NSS
8. Apply suction during withdrawal of the suction catheter (never during insertion) to prevent trauma to the mucous
membrane.
9. Apply suction for 5-10 seconds (maximum 15 seconds)
Oversuctioning causes hypoxia and vagal stimulation
10.Hyperventilate client with 100% oxygen before and after suctioning to prevent hypoxia.
11. Allow 20-30 second interval between each suction to bring up mucous secretions into the upper airways, and
prevent hypoxia.
12. Provide oral and nasal hygiene.
13.Dispose contaminated equipment/articles safely. To prevent
contamination of the environment.
 Use one sterile suction catheter for each episode of suctioning.
14. Assess effectiveness of suctioning.
 Auscultate chest for clear breath sounds.
15. Document relevant data

10. Incentive Spirometry

 Done to enhance deep inspiration.
11. Intermittent Positive Pressure Breathing (IPPB)
 Done to administer oxygen at pressures higher than the atmospheric pressure.
12. Administration of Supplemental Oxygen
 Indication: hypoxemia.
 Signs of Hypoxemia
 Restlessness (initial sign)
 Increased pulse rate
 Rapid, shallow respiration and dyspnea
 Light - headedness
 Flaring of nares
 Substernal or intercostals retractions
 Cyanosis (late sign)

Oxygen Systems
1. Low flow administration devices
• Nasal Cannula (24-45 % at 2-6 LPM)
 May be used in clients with COPD at 2 - 3 L/min if venturi mask is not available.
• Simple Face Mask (40-60% at 5-8 LPM)
 Partial Rebreathing Mask (60-90% at 6-10 LPM)
 Non-Rebreathing Mask (95-100% at 6-15 LPM)
 Croupette
 Oxygen Tent
2. High flow administration devices
 Venturi mask - low-concentration venture- type mask is preferred for clients with COPD because it
provides accurate amount of oxygen. They require 2-3 L/min or 28% oxygen.
 Face mask
 Incubator/Isolette – can be used for low and high flow concentration
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Rambo Laguiwed Ebbes, RN
Instructor NCM 103 (Theory)
Nursing Implications:
 Since oxygen is colorless, odorless, tasteless and dry gas that supports combustion.
 Since oxygen is dry gas, it can irritate mucous membrane of the airway’s.
 Since oxygen supports combustion, it can cause fire

Nursing Planning, Interventions and Evaluation in the Administration of Oxygen therapy

1. Assess signs and symptoms of hypoxemia
2. Check the doctor’s order
3. Position patient, preferably semi-fowler’s. To enhance lung expansion.
4. Open source of oxygen before insertion of oxygen device. This is to check for malfunctioning of the
device
5. Regulate oxygen flow accurately. Excessive administration of oxygen can cause oxygen narcosis
(respiratory alkalosis).
6. Place “NO SMOKING” sign at the bedside.
 Strictly enforce this warning
 Oxygen greatly accelerates combustion and could cause a fire from small spark
7. Avoid use of oil, greases, alcohol and eater near the client receiving oxygen. These may further
support combustion.
8. Check the electrical appliances before use. Small spark may cause a fire from a small spark
9. Avoid materials that generate static electricity, such as woolen blankets and synthetic fabrics
10. Humidify oxygen
11. Provide good oronasal hygiene. To prevent dryness and irritation of the mucous membrane.
12. Lubricate nares with water-soluble lubricant to soothe the mucous membrane. Do not use oil. Oil
ignites when exposed to compressed
13. Assess effectiveness of oxygen therapy. Check VS, especially RR; note quality of respiration; evaluate
arterial blood gas results (ABG analysis).
14. . Make relevant documentation.

Alterations in Respiratory Function

Hypoxia.
 Insufficient oxygenation of tissues.

Clinical signs of Hypoxia

Early Signs
 Tachycardia
 Increased rate and depth of respiration
 Slight increase in systolic BP
Late Signs
 Bradycardia
 Dyspnea
 Decreased systolic BP
 Cough
 Hemoptysis

Other Clinical Signs of Acute Hypoxia

1. nausea and vomiting
2. oliguria, anuria
3. headache
4. apathy
5. dizziness
6. irritability
7. memory loss

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Rambo Laguiwed Ebbes, RN
Instructor NCM 103 (Theory)
 Other Clinical Signs of Chronic Hypoxia
1. fatigue, lethargy
2. pulmonary ventilation increases
3. RBC count increases
4. Hgb concentration increases
5. clubbing of fingers

2. Altered Breathing Patterns

a. Rate
Tachypnea - Rapid respiratory rate
Bradypnea - Slow respiratory rate
Apnea - Cessation of breathing

b. Volume
 Hyperventilation
 Excessive amount of air in the lungs.
 Hypoventilation
 It results from deep rapid respirations
 Decreased rate and depth of respiration
 It causes retention of carbon dioxide.
c. Rhythm
 Cheyne-stokes. Marked rhythmic waxing and waning of respirations from very deep to very shallow
breathing and temporary apnea
 Kussmaul's (Hyperventilation). Increased rate and depth of respiration, seen in metabolic acidosis and renal
failure.
 Apneustic. Prolonged gasping inspiration followed by a very short, usually inefficient expiration.
 Biot's. Shallow breaths interrupted by apnea.
d. Ease of Effort
 Dyspnea. Difficult or labored breathing
 Orthopnea. Inability to breath except in upright or sitting position.

Nursing Diagnosis
Client's with Oxygenation Problems
1. Ineffective airway clearance related to:
 tracheobronchial infection, obstruction, secretions
 decreased energy and fatigue
 trauma
 dehydration
2. Ineffective breathing pattern related to:
 neuromuscular/musculoskeletal impairment
 pain
 anxiety
 decreased energy and fatigue inflammatory process decreased lung expansion
 tracheobronchial obstruction alteration of normal 02/CO2 ratio
3. Decreased cardiac output related to:
 structural alterations
 electrical alterations in rate, rhythm and conduction

 mechanical alteration in preload, afterload and inotropic changes in

the heart
4. Impaired gas exchange related to:
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Rambo Laguiwed Ebbes, RN
Instructor NCM 103 (Theory)
  altered oxygen supply
 alveolar-capillary membrane changes
 altered oxygen-carrying capacity of the blood
 altered blood flow
5. Activity intolerance related to:
 imbalance between oxygen supply and demand
 sedentary lifestyle
6. Anxiety related to:
 ineffective airway clearance
 ineffective breathing pattern
7. Ineffective individual coping related to:
 activity intolerance associated with ineffective airway clearance
8.Fear related to feeling of suffocation associated with ineffective airway
clearance
 Powerlessness related to:
 impaired verbal communication associated with endotracheal tube
 self care deficit and decreased cardiac output
10. Sleep pattern disturbance related to:
 ineffective breathing pattern (orthopnea)
 anxiety associated with ineffective airway clearance

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Rambo Laguiwed Ebbes, RN
Instructor NCM 103 (Theory)