Nursing Fundamentals Focus VIII Oxygenation

Staggering statistics
• Pulmonary Diseases
•Lung CA -
•TB – •Pneumonia –
•Chronic Airflow Limitation (formerly COPD) –
Staggering statistics
•Cardiovascular Diseases – # 1 killer
•HTN – 65 million Normal Oxygenation Process
•Artheriosclerosis Inspiration
•Arteriosclerosis • Diaphragm and intercostal muscles contract
•Stroke • Thoracic cavity size increases
•Hypercholesterolemia • Volume of lungs increases
• 107 million - a risk factor for CVD • Intrapulmonary pressure decreases
•AMI – 7.5 Million per year, 460,000 die • Air rushes into the lungs to equalize
pressure
• Americans paid 393.5 billion in 2005 for
CVD related medical costs Expiration
•Diaphragm and intercostal muscles relax
•Lung volume decreases
•Intrapulmonary pressure rises
•Air is expelled
Gas Exchange
• Occurs after the alveoli are ventilated
• Pressure differences (gradient) on each
side of the respiratory membranes affect diffusion
• Alveoli:
Respiratory System
• PO2 100mmHg
Process of Breathing
• PCO2 40mmHg • Venous blood:
•Inspiration
• PO2 60mmHg
•Air flows into lungs
• PCO2 45mmHg
•Expiration
• O2 diffusion from alveoli pulmonary blood
•Air flows out of lungs
vessels
Normal Oxygenation Process
• CO2 diffusion from pulmonary blood vessels
• Cardiovascular:  alveoli
Adequate O2 Balance

Normal

Oxygenation Process
• Systemic:
• Maintenance of adequate O2 balance Gas • Flaring of nares
Exchange
• Substernal or intercostal retractions
Oxygen Transport
• Cyanosis
• Transported from the lungs to the tissues
Abnormal Respiratory Patterns
• 97% of O2 combines with RBC Hgb
•Tachypnea (rapid rate)
 oxyhemoglobin carried to tissues
•Bradypnea (abnormally slow rate)
• Remaining O2 is dissolved and transported
•Apnea (cessation of breathing)
in plasma and cells (PO2)
•Kussmaul’s breathing
Normal Oxygenation Process
•Cheyne-Stokes respirations
• Cell environment / O2 carrying capacity:
•Biot’s respirations
• O2 Carrying capacity of blood is expressed
by:

- Red blood cells (#)

- Hematocrit - % of blood that is RBCs
Men 40-54%
Women 37-50%
- Hemoglobin

Carbon Dioxide Transport

• Must be transported from tissues  lungs
• Continually produced in the process of cell
metabolism
• 65% – carried inside RBCs as bicarbonate Alterations in Ease of Breathing
(HCO3-) •Orthopnea
• 30% – combines with Hgb  •Dyspnea
carbhemoglobin
Obstructed or Partially
• 5% – transported in plasma as carbonic
acid (H2CO3) Obstructed Airway
Factors that Influence Respiratory Function •Partial obstruction
•Age •low-pitched snoring during inhalation
•Environment •Complete obstruction
•Lifestyle •extreme inspiratory effort with no chest movement
•Health status
•Medications
•Stress
Common Manifestations of Impaired
Respiratory Function
•Hypoxia
•
•Altered breathing patterns
•Obstructed or partially obstructed airway
Hypoxia
• Condition of insufficient oxygen anywhere in
the body Adequate O2 Balance
• Rapid pulse Example of Obstructive Disease: Asthma
• Rapid, shallow respirations and dyspnea Example of Restrictive Disease: Hemothorax
• Increased restlessness or lightheadedness
Inadequate O2 Balance
• Behaviors of Negative O2 balance
• Hypoventilation or hyperventilation
• Stridor, audible sounds with respiration,
wheezing, coughing
• Hypoxia
• Change in mental status
• Change vital signs
• Cyanosis
• Decrease in GI motility
• Change in renal function
• Hypercapnia
6 Ps of Dyspnea
1. Pulmonary Bronchial Constriction
2. Possible Foreign Body
3. Pulmonary Embolus
4. Pneumothorax- collapsed lung, air leaks
into the space between your lung and chest wall.
5. Pump Failure
6. Pneumonia – tubig sa baga
 • Physical Assessment:
• Lung auscultation and breathing pattern
• Abdominal assessment
• Urine output
• Skin and mucous membranes
• Heart sounds
• Circulation
• Edema
• DVT
Lung sounds
• Diminished or absent
• Crackles course and fine
• discontinuous course bubbling

Nursing Responsibilities • fine crackling sound at the middle or end of

inspiration
• Determine adequacy of cardiopulmonary
function: • Rhonchi

• Nursing assessment • a continuous sonorous sound

• HEART • Wheezes

• Respiratory assessment • high pitch musical sounds

• PMH • Pleural friction rub

• LIFESTYLE • grating rubbing, sound

HEART •Measure adequacy of ventilation and gas

•Have client describe
• specific location, onset and duration of the
problem
•Explore associated signs and symptoms
•Ask - activities that worsen or ease the problem
•Rate the severity of discomfort or incapacity
•Talk - treatments or interventions used to alleviate
the problem and their effectiveness
Heart Problems
Artheroscleosis = Coronary Artery Disease (CAD)
Nursing Measures to Promote Respiratory
Function
exchange
• Complete Blood Count (CBC)  phlebotomy
• Arterial Blood Gases (ABG) arterial
puncture
• Pulmonary Function Tests preparation by
teaching
•Tests to determine abnormal cell growth or
infection in respiratory system:
• Sputum culture
• growing microorganisms from sputum
• Throat culture
• growth of microorganisms from throat
material

•Ensure a patent airway • Tests to visualize structures of respiratory

system: Bronchoscopy and Chest Radiograph.
•Positioning
Common Tests and Nursing Responsibilities
•Encourage deep breathing, coughing
a. Chest Xray
•Ensure adequate hydration b. Thoracentesis
Nursing Responsibilities
Nursing Responsibilities Incentive spirometry
• Medications
• Incentive spirometry
• Chest PT
• Postural drainage Basic Nursing Interventions
• Oxygen therapy • Mobilization of Pulmonary Secretions
• Artificial airways • Encourage activity and ambulation as
tolerated
• Airway suctioning
• Encourage increased fluid intake
• Chest tubes
• Chest physiotherapy
Basic Nursing Interventions
• O2
• Airway Maintenance:
• Medications as ordered
• Facilitate effective coughing
Basic Nursing Interventions
• Suctioning airways
• O2 Therapy:
• Liquefying and mobilizing sputum
• Low flow
Basic Nursing Interventions
• High flow
• Maintenance and promotion of proper lung
expansion: • Humidification
Re-expanding collapsed lungs • Nasal cannula
- Closed Chest Tube Drainage • Simple mask
Chest Tubes • Nonrebreathing mask
Basic Nursing Interventions • Partial rebreathing
•Improving Activity Tolerance: Basic Nursing Interventions
• Determine etiology • Effective Breathing Techniques
• Assess appropriateness of activity level • Position for maximal respiratory function
• When appropriate gradually increase • Pursed lip breathing
activity
• Diaphragmatic or abdominal breathing
• Ensure the client changes position slowly
Basic Nursing Interventions
• Observe for symptoms of intolerance
Stress and anxiety reduction:
• Syncope with activity
• Remove pertinent cause of anxiety at that
• refer to MD moment
• Perform ROM exercises with activity - help client gain control over respiration
intolerance if is immobile
- reassure client not in immediate danger
Basic Nursing Interventions
• Chronic clients
•Mobilization of Pulmonary Secretions
• exacerbations and remissions
• Auscultate breath sounds, monitor
• goal is to reduce general level of anxiety
respiratory patterns, monitor ABG’s
• learn to control episodes of anxiety to
• Position client to optimize respiration
improve quality of life
• Pulmonary toileting
• desensitization program
• Incentive spirometry
• guided mastery
• Suctioning
Administration of Prescribed
Medications • Lipid profile
• Expectorants • Vasoconstrictors • Coagulation studies
• Mucolytics • EKG/ECG
• Bronchodilators • Angiography
• Cough suppressants • Doppler blood flow studies
• Corticosteroids Basic Nursing Interventions
• Antihistamines Cardiovascular •Diet
• Antibiotics • Modify risk factors •Exercise
Basic Nursing Interventions •Co morbidities
• Physical Exercise health teaching • Preventing vasoconstriction
Activity and rest -- a priority! •Positioning
Activity stimulates respiratory function •Cold temperatures
Rest conserves energy and reduces metabolic •Nicotine
demand
Basic Nursing Interventions
• MD’s treatment plan
•Cardiovascular
• guidelines for activity
- Prevent complications
• may simply call for activity as tolerate.
• Promoting rest
• prioritize activities
•Risk DVT
• arrange need items conveniently
•Position changes
• Provide emotional support and
•Early ambulation
encouragement
•Obstruction removal
• gradually increase activity
•Bypass surgery
• Simplify daily life
•Schedule rest periods
• Work at a steady state
•Assistance with ADL’s
• Conserve energy
•Monitor Vitals with activity •Place items, i.e. call
Adequate O2 Balance
light, water pitcher, strategically •Quiet
• Behaviors of Negative O2 balance  Cardio environment, decrease stimuli
Vascular Disease
Basic Nursing Interventions
• Arterial
Cardiovascular
• Venous:
• Positioning to improve CO
• Impaired tissue perfusion
Adequate O2 Balance
• Avoiding Valsalva maneuver
• Behaviors of Negative O2 balance  CV
- Position semi to high fowlers-> decrease
• Restlessness, dizziness, syncope, venous return and preload, decease preload->
bradycardia, decreased urine decreases risk of heart congestion
• cold and clammy skin, cyanosis, slow - Teach client to avoid valsalva maneuver
capillary refill
- Hold breath while turning or moving in
• Decreased cardiac output bed-> assist - Bearing down during BM->
stool softeners and diet
Common Tests and Nursing Responsibilities
Tests to determine • adequacy of cardiovascular
function: Basic Nursing Interventions
• CBC Cardiovascular
• Avoid stimulants
• Maintaining fluid balance •Avoid
appetite suppressants, cold meds, coffee, tea,
chocolate
•Assess fluid status, monitor I&O, assess breath
sounds, JVD, pitting edema in dependent areas,
fluid and NA+ restriction, daily Wgt with diuretic
therapy, electrolyte
monitoring-> MD

Basic Nursing Interventions

Cardiovascular • Administer O2 • Increase O2
supply • Educate client NO SMOKING!
• Position to facilitate breathing
Administration of Prescribed Medications
• Anti coagulants
• Vasodilator
Medications
• Inotropic Medications
• Anti Dysrhythmics
• Anti hypertensives
Basic Nursing Interventions
•Dietary control
• Assess nutritional status
• Consider a dietician referral to assess
nutritional needs related to clients
• Chronicity of CAL and CAD and nutrition
Basic Nursing Interventions
•Weight control
• Evaluate the client’s physiological status in
relation to condition
• More than body requirements
• Less than body requirements

COPD (chronic obstruct pulmonary diseases)
- Pulmonary Diseases that causes chronic
obstruction of airflow from lungs.
• Limited Airflow – Inflamed bronchioles…
deform and narrow w/ excessive mucous
production
• Inability to fully exhale – loss of elasticity in
air sacs and air pockets develop.
• Irreversible (no cure) -.. cases vary from
from mild – severe
• Managed w/ lifestyle and medications
Causes
1. Environmental – from harmful irritants that
are inhaled into lungs. Ex. SMOKING
• Happens gradually… most ppl start to
notice s/sx in middle ages.
 Dyspnea w/ activity, chronic cough,
recurrent lung infection and etc
TYPES:
COPD used now “catch all” term for diseases that
limit airflow
 Chronic Bronchitis (blue bloaters) – tend to
have cyanosis due to low of oxygen and tend to
edema.
- Hyperinflation/ became inflames/ produce
mucus/narrowing of the air sacs
- Abnormal diaphragm (flattens)
- Low amount of oxygen (cyanotic) ->
increasing the amount of RBCs (causes the blood
to become to thick) -> increase pressure in
pulmonary artery (pulmonary hypertension) back-
flowing to the right side of heart -> affect the
liver(incongestion) leads to left side failure and
bloating comes.
 Emphysema (Pink puffers) – hyperventilate
for compensation (lack of oxygen ) and maintain
pink complexion. No cyanosis, Barrel chest from
accessory muscle usage)
- (lack of oxygen, increases of CO2 retention)
- Alveoli sac lose elasticity due to inflames;
response in body-> air gets trapped in the sacs
- Hyperinflation (diaphragm to flatten) due to
retaining air volume
- Diaphragm plays a huge role in making
breathing easier but it doesn’t work when
compensate and use of accessory
muscles/hyperventilate leads to barre chest
increased in anteroposterior diameter 
hyperventilation causing in increased of RR  have
less hypoxemia than chronic bronchitis … hence
pink puffer
Signs and Symptoms of COPD
L – lack of energy
U – unable to tolerate activity
N – nutrition poor (Weight loss esp. emphysema)
G – Gases abnormal (PCO2>45 and PO2 <90..
respacidosis
D – dry or productive cough esp. chronic bronchitis
A – accessory muscle usage for breathing
(emphysema); Abnormal lung sound
M – Modification of skin color (pink to cyanosis)
A – Anteroposterior diameter increased (barrel
chest)
G – gets in tripod position to breathe (stand leaning
forward while supporting hands on object
E – Extreme Dyspnea
Complications in COPD
1. Heart diseases: heart failure
2. Pneumothorax: spontaneous air sacs
3. Lung Infection : PNA
4. Increased risk of lung cancer
DIAGNOSED
1. Spirometry – a test where a patient
breathes into a tube which measures:
 How much colume the lungs can hold
during inhalation
 How much and how fast air volume is
exhaled
 Measuring FVC (Forced Vital Capacity)- low
reading -> restrict breathing -> largest amount of air
exhaled after breathing in deeply in one second
 Measuring Forced Expiratory – volume: how
much air a person can exhale w/in 1 second low
reading shows severity

NURSING INTERVENTIONS
1. Monitor Respiratory System
- Listening to lung sounds (may need suction)
- Monitor sputum production (collect if
ordered( @risk for PNA
- Keep O2 Sat 88-93% (pt w/ copd are
stimulated to breathe due to low oxygen level rather
than high carbon dioxide levels.. but if give them
too much O2, the breathing will stop ->
hypoventilate and CO2 will become toxic
*used bronchodilator 1st (dilate airways)then
corticosteroid inhaler and RINSE mouth after use
cortico… due to developing thrush
Phosphodiestrace – 4inhibiters: “Roflumilast” (used
for ppl w/ chronic bronchitis and helps decreased
copd exarcebation… (not bronchodilator)
Sideffect: cause suicide ideation, weight loss
Methylxanthines: “Theophylline” (given orally many
times).. type of bronchodilator, used long term w/
pts w/ severe copd
*narrow therapeutic range : 10-20 mcg/mL :
increased Digoxin toxicity and low effects of
Lithiumt Dilantin

- Administer O2 as prescribe 1-2L Short-acting bronchodilators:relacxes smooth

muscles of bronchial tubes.. emergency situation
2. Monitor Effort of breathing – teach about and quick relief (used in emergency situation)
pursed-lip diaphragmetic breathing
- Beta2 Agonist: Albuterol
- Pursed lip: used for dyspneic episodes to
increased oxygen level.. encourage to breathe out - Anticholinergic : Atrovent
longer (remember to retain air) .. like blowing out a
Long-acting bronchodilator: same action as short
bday candle
but effects last longer… used over perion of time..
- Diaphragmatic : used abdominal muscles scheduled.
rather than accessory muscles – helps strengthen
- Beta2 Agonist: Salmeterol/ SF ( increased
diagphrams, slows down breathing rate to makes it
urinary retention
easier, decreased energy used to breath.
- Antechollinergic : Spirivia / SF(dry mouth
3. Administer breathing Tx: (RT herbs)
and blurred vision)
shortacting (albuterol, Atrovant) nurse inhalers
know long vs short, cortosteroids etc. *used before inhaled corticosteroid
4. NURSING EDUCATION *airway breathing and circulation (primary )
- Nutrition needs: eat high calorie and protein *promote blood flow – encourage to walk
meas, small frequent and start hydrated 2-3L per (circulation); elevate the foot.
day
- Avoid sick ppl, irritants, hot humid
(smothering days) or extreme cold
- Stop smoking and avoid 2nd hand smoke
- Vaccinations up-to-date: annual flu shot and
pneumonia every 5 years

MEDICATIONS: REGIME
“Chronic Pulmonary Medications Save Lungs!”
Corticosteroids : decreased inflammation and
mucous production.. oral or IV, or inhaled.. it used
many times w/ bronchodilators
- Prednisone
- Solumedrol
- Pulmicort
- Symbicort : steroid and long acting
bronchodilator
Side Effects: easy bruising, hyperglycemia and
increased risk infection(long-term use- boneloss)