305 CHAPTER 40 OXYGENATION

The process of moving gases into and out of the lungs.

Phrenic nerve

Relates to the ability of the CV system to pump oxygenated blood to the tissues and retur nRESPIRATORY PHYSIOLOGY: (910): Structure and Function:
Ventilation?deoxygenated blood to the lung

Responsiblefor moving the respiratory gases from one area to another

The effort rerquires to expaid and contract the lungs

Accessory muscles of respiration can increase lung volume uring inspiration.
Emphysema - COPD client often use these muscles to increase lung volumes --> prolonged use of the accessory musle does not promote effective ventilation and causes fatigue

Ventilatory fatigue, air hunger or decreased lung expansion

The ability of the lungs to distend or to expand in response to increased intraaveolar pressure
Diseases such as pulmonary edeam, interstitial and pleural fibrosis, and congenital or traumatic structural abnormalities such as kyphosis or fractured ribs

The pressure difference between the mouth and the alveoli in relation to the rate of flow of inspired gas
Diseases such as airway obstruction, asthma and tracheal edema increase airway resistance

Decreased lung compliance, increased airway resitance and active expiration with the use of accessory muscles increases the work of breathing, resulting in increased energy expenditure. --> body increases its metabolic rate and the need for oxygen.

Aveolar capillary membrane

Thickness of capillary membrane affects the rate of diffusion --> thicker membrane --> impeded diffusion (gas takes long to cross the membrane
Pulmonay edema, pulmonary infiltrates or pulmonary effusion clients have thick membranes

the amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the tendency of hemoglobin to bind with oxygen

Carrier for oxygen and CO2 and transports most oxygen to form oxyhemoglobin

physiology
developmental
lifestyle
environmental

Aveolar capillary membrane

Thickness of capillary membrane affects the rate of diffusion --> thicker membrane --> impeded diffusion (gas takes long to cross the membrane
Pulmonay edema, pulmonary infiltrates or pulmonary effusion clients have thick membranes

the amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the tendency of hemoglobin to bind with oxygen

Carrier for oxygen and CO2 and transports most oxygen to form oxyhemoglobin

physiology
developmental
lifestyle
environmental
Health status
Psyhological Health
medication

Cardiac disorders: disturbances in conduction, impaired vavlular function, myocardio hypoxia, cardiomyopathic conditions, and peripheral tissue hypoxia
Others (important): alterations affecting the oxgyen carrying capacity of blood such as anemia; increases in the body's metabolic demands, such as pregnancy or fever and infection
Alterations affecting chest wall movement or the CNS

Decreased Oxygen-Carrying Capacity
Decreased Inspired Oxygen Conentration
Hypovolemia
Increased Metabolic Rate
Conditions affecting Chest Wall Movement (Pregnancy, Obesity, Musculoskeletal Abnormalities, Trauma, Neuromuscular Diseases, CNS alteraions, Influences of Chronic Disease
Alterations in Cardiac Functions (Disturbances in Conduction, Altered Cardiac Output (Left-Sided Heart Failure, Right Sided Heart Failure
Impaired Valvular Function
Myocardial Ischemia
Alterationss in Respiratory Functioning (Hyperventilation, Hypoventilation, Hypoxia)

A lower than normal hemoglobin level
Result of decreased Hgb production, increased RBCs destruction, and/or blood loss

Anemia and inhaltion of toxic substances desease oxygen carrying capacity of blood by reducing the amount of available Hgb to transport oxygen

CO is the most commone toxic inhalant decreasing the oxygen-carrying capacity of blood.
Hgb binds strongly to CO, creating functional anemia --> Hgb is unavailable for oxygen

Clients present with fatigue, increased breathlessness, pallor, and increased heart rate

a state of ventilation in exess of that required to eliminate the CO2 produced by cellular metabolism
Causes: infections, anxiety, drugs, or an acid-base imbalance, hypoxia associated with pulmonary embolus or shock
Sometimes is chemically induced such as aspirin poisoning causes excessive stimulation of the respiratory center as the body attempts of compensate for excess CO
Also occurs when the body try to compensate for metabolic acidosis by producing respiratory alkalosis
Excessive exhalation of CO2

Occurs when alveolar ventilation is inadequate to meet the body's oxygen demand or to eliminate sufficient CO2
Retention of CO2
Causes Atelectasis (collapse of the alveli --> prevents normal exchange of oxygen and CO2). As alveoli collapse, less of lung is ventilated and hypoventilation occur

The administration of excessive oxygen results in hypoventilation becauses COPD clients have adapted to a high CO2 level and their CO2 sensitive chemoreceptors are not functioning

S/S: Mental status changes, dysrhythmias, and potential cardiac arrest
Treatment: Improving tissue oxygenatoin, restoring ventilatory function, treating the underlying cause of the hypoventilation, and achieving acid-base balance
If untreated: Convulsions, unconsciousness and death

Inadequate tissue oxygenation at the cellular level resulting from a deficiency in oxygen delivery or oxygen utilization at the cellular level
Causes:
- A decreased Hgb level and lowered oxygen-carrying capacity of the blood
- A diminished concentration of inspired oxygen which occurs at high altitudes
- The inability of the tissues to extract oxygen from the blood (cyanide poisoning)
- Decreased diffusion of oxygen from the alveoli to the blood (as with pneumonia)
- Poor tissue perfusion with oxygenated blood (as with shock)
- Impaired ventilation (as with multiple rib fractures or chest trauma
Untreated:
- Cardiac dysrhythmias --> death
S/s:
- apprehension
- restlessness
- Inability to concentrate
- Declining level of consciouness
- Dizziness and behavioral changes
- Client unable to lie down, appears fatigued and agitated

Increase pulse rate, and Increase rate and depth of respiration initially, then respiratory decline as a result of respiratory muscle fatigue
During early stages of hypoxia, BP is elevated unless the condition is caused by shock

Dyspnea:
a. Subjective sensation of difficult breathing
b. Nasal flaring, exaggerated respiratory effort, increased respiratory rate and depth

Pain and characteristics of pain
Dyspnea
Fatigue
Peripheral ciruclation
Cardiac risk factors
The presence of past or concurrent cardiac conditions

Presence of a cough, SOB, wheezing, pain, environment exposures, frequency of respiratory tract infection, pulmonary risk factors, past respiratory problems, current medication use, and smoking history or second hand smoke exposure

Often the left side of the chest and radiates to the left arm in the men
In women: less definitive and is often a sensation of breathlessness, jaw or back pain, nausea and fatigue

Peripheral and radiates to the scapular regions
Coughing, yawning, and sighing worsen pleuritic chest pain
Causes: an inflammation or infection in the pleural space often causes this
S/s: knifelike, lasting from one minutes to hours, always associate with inspiration

Subjective sensation in which client reports a loss of endurance

Pain
Fatigue
Smoking
Dyspnea
Cough
Wheezing
Environmental or geographical exposures
Respiratory Infections
Allergies
Health risks
Medications

because any form of tobacco exposure increasesthe client's risk for cardiopulmonary diseases

Clinical sign of hypoxia
The subjective sensation of difficult or uncomfortable breathing
Associate with exercise or excitement
Also associated with pulmonary disease, cardiovascular disease, nueromuscular condition and anemia.
Pollution, cold air, and smoking can worsen dyspnea

0-100 with 0 no dyspnea and 100 is worst breathlessness

Clients with chronic sinusitis usually cough only in the early morning or immediately after rising from sleep
Clients with chronic bronchitis cough and produce sputum all day

Frequency
Productive or nonproductive
Productive cough often results in sputum production, materia coughed up from the lungs that the client swallows or expectorates
Collect data about the type and quantity of sputum
Inspect color, consistency, odor, and amount
If hemoptysis (bloody sputum) present, check to see if it is associated with coughig and bleeding from the upper respiratory tract, from sinus drainage or from GI (hematemesis)

Mucus, cellular debris, and microorganisms, sometimes pus or blood

Associated with asthma, acute bronchitis, pneumonia
Occur during inspiration and expiration or both

Investigate exposures in the client's home and workplace

Obtain information about client's frequency and duration of respiratory tract infections
Determine the client's risk for human immunodeficiency virus (HIV) infection...

Client's allergic response: coughing, sneezing, runny nose, cough or wheezing

Assess familial risk factors such as family hx of lung cancer or CV disease
Presence of infectious disease such as TB

Ask clients about all medication at home include OTC and herbal supplements

HISTORY:
- smoking
- use of oxygen
- cough/sputum
- chest pain
- dyspnea
- positioning
- environment
Physical exam:
- Inspect
- Auscultate
Pt with shortness of air

Nutrition
Exercise
Smoking
Substance abuse
Stress

Pulomonary Function Tests
Peak Expiratory Flow Rate (PEFR)
Bronchoscopy
Lung scan
Thoracentesis
Sputum Specimens

Elevated BP unless the condition is caused by shock

Determines the lungs ability to exchange oxygen and CO2
It is basic ventilation studies

Surgical perforation of the chest wall to obtain pleural fluid
- Usually indicative of either infection or neoplastic disease

Blue discoloration of the skin and mucous membranes caused the presence of desaturated Hgb in capillaries

No, it is not reliable

Check tongue, soft palate, and conjunctiva of the eye where blood flow is high, indicates hypoxemia

Extremities, nail beds, earlobes
Often the result of vasoconstriction and stagnant blood flow.

Person who abuses substances often has a poor nutritional intake --> decrease in intake of iron rich foods --> Hgb production declines
Excessive use of alcohol and certain drugs depresses the respiratory center --> reducing the rate and depth of respiration and the amount of inhaled oxygen

Stress and anxiety increase the body's metabolic rate and the oxygen demand
The body responde to anxiety and other stresses with an increased rate and depth of respiration

First, treat the underlying process causing dyspnea
Then, add additional therapies such as:
pharmacological measures: bronchodilators, inhaled steroids, muclytics, low-dose antianxiety medications
Oxygen theraly reduces dyspnea associated with exercise
Physical techniques: exercise, breathing techniques, and cough control
Others: Relaxation techniques, biofeedback, and meditation

Humidification - the process of adding water to gas
Necessary when oxygen is delivered at 4l/min or greater
Keeps airways moist and mobilizes secretions

Nebulization adds moisture or medication to inspired air by mixing particles of varing sizes with the air
Suspends water droplets and medication for inhalation

Group of therapies used to mobilize pulmonary secretions
Include Postural Drainage, chest percussion, and vibration
Used for patient with cytic fibrosis

Humidification through nebulization enhances mucociliary clearance, the body's natural mechanism for removing mucus and cellular debris from the respiratory tract.

Productive cough and suctioning of the client who has a decreased ability to cough

Clients who produce greater than 30mL of sputum per day or have evidence of atelectasis by chest Xray examination

Drainage, positioning, and turning

Clieths with bleeding disorders, osteoporosis or fractured ribs

This technique increases the velocity and turburlence of exhaled air, facilitate secretion removal

Striking the chest wall over the area being drained
Position the hand so that the fingers and thumb touch and cupped hands

Used when the client is unable to clear respiratory secretions from the airways

Oropharyngeal and nasopharyngeal suctioning
Orotracheal and nasotracheal suctioning
Suctioning an artificial airway

Sterile technique: oropharynx and tracheal suctioning
Clean technique: Mouth suctioning

Suctioning oral secretions after suctioning of the oropharynx and trachea.

At home setting, clean technique is used instead of sterile technique for tracheal suctioning because client is not exposed to pathogens common to health care setting

When you auscultate the secretions and other methods to remove airway secretion have failed

Increase client risk for development of hypoxemia, hypotension, arrhythmias and possible trauma to the musosa of the lungs

When the client able to cough effectively, but unable to clear secretion by expoectorating or swallowing.
Apply suction after the client has coughed.

Used when the client with pulmonary secretions is unable to manage secretion by coughing and does not have an artificial airway present
Last no longer than 15s

Because the stimulation of gag reflex is minimal

Never apply suction during insertion
Keep oxygen closed by to reduce suctioning induce hypoxemia

Occurs through an aritifical airway such as an endotraceal tube or trachostomy tube
Make sure the suction catheter is no greater than half the size of the internal diameter of the artificial airway

Unilateral lung disease client: Position in a manner to promote perfusion of the healthy lung and improve oxygenation --> good lung down
Pulmonary absces or hemorrhage client: position the client with the affected lung down to prevent drainage toward the healthy lung.

To encourage voluntary deep breathing by proving visual feedback to clients about inspiratory volume
Promotes deep breathing and prevents or treats atelactasis in the postoperative client.
Preventing postoperative pulmonary complications following abdominal surgery

Reduce risk for suction induced hypoxemia

Insert catheter during client inhalation, especially if inserting catheter into trachea because epiglottis is open.
Do not insert during swallowing or cather will mostlikely enter esophagus.
Never apply suction during insertion.
Client should cough
If client gags or becomes nauseated, catheter is most likely in esophagus and needs to be removed.

Turn client's head to right helps suction the left mainstem bronchus and turn head to left helps suction the right mainstem bronchus.

Catheter has probably hit carina, pull catheter back 1cm before applying suction

Note whether there is a change of 20 beats/min (increase or decrease) f if pulse ox below 90% or 5% from baseline

Do not perform more than two passes with catheter
Allow at least 1min between suction passes for ventilation and oxygenation

Evaluate client's fluid status, increase fluids as appropriate
Assess for signs of infection
Determine needs for ches physiotherapies
Assess adequate of humidification on oxygen delivery

Limit length of suctioning
Determine need for more frequent suctioning, possibly of shorter duration
Notify MD

Determine amount of suction pressure used. Decrease if necessary
Evaluate suctioning frequency
Provide more frequent oral hygiene

Cheap, widely available and used in a variety of setting
Goal is to relieve or prevent tissue hypoxia

Oxygen is a medication --> has side affects such as atelectasis or oxygen toxicity
Requires a physician’s order
Supports combustion, DO NOT explode

Most common are nasal cannula and oxygen mask

Simplest, most comfortable
Up to 6l/min
Needs humidification @ 4L/min, may promote comfort even for even lower rates

1L/min = 24% and for each additional liter, add 4 more % --> 6L/min = 44%

Simple face mask:
- Low concentrations of oxygen
- NOT appropriate for COPD, can worsen CO2 retention
Simple face mask with resevoir bag:
i. High concentration of oxygen
ii. When used with a reservoir bag, the bag must remain inflated with oxygen to prevent trapping of carbon dioxide

30% - 60%

60-95% with a flow rate of 6-10L/min

Delivery oxygen concentrations of 24%-60% with oxygen flow rates of 4-12L

Improve ventilation and oxygenation

i. Deep breathing and coughing
1. Take two slow, deep, deliberate breaths through the nose and exhale out the mouth. Inhale deeply the third breath, hold it for the count of three and cough fully 2-3 coughs

Deep breathing and coughing
Pursed-Lip breathing
Diaphragmatic breathing

Deep inspiration and prolonged expiration against pursed-lips
--> to prevent aveolar collaspe

1. Expanding the diaphragm during controlled inspiration
2. Reduces the work of breathing and decreases trapped air

Pulmonary disease clients
Postoperative clients
Women in labor to promote relaxtion and provide pain control

Pneumothorax

Tension Pneumothorax

Pneumothorax: Semi-Fowler to evacuate air
Hemothorax and effusion: High Fowler's position to drain fluid