Module K Potter and Perry Chapter 41

Module K Potter and Perry Chapter 41 ATI Chapter 53 Define terms associated with oxygenation Explain the physiology of oxygenation Explain the process of oxygen administration Explain the process of nasopharyngeal suctioning Explain the process for specimen collection Objectives Identify diagnostic values related to oxygenation Explain pulse oximetry Explain the process of connecting a pulse oximeter Identify emergency techniques for restoring oxygenation Explain the process of using various emergency techniques for restoring oxygenation Explain the process of applying the nursing process to maintaining oxygenation Vocabulary • Afterload • Humidification • • • • Angina BiPAP bradycardia Cardiac Output • • • • Incentive Spirometry Myocardial ischemia Modifiable risk factors Non-modifiable risk factors • • • • Chest physiotherapy (CPT) COPD CPAP Diffusion • • • • Orthopnea Preload Pursed-lip breathing Stroke volume • • • • Electrocardiogram (ECG) Furosemide Hemoptysis Hypoxemia • Subcutaneous emphysema • Ventilation • Hypoxia WHEN REGULAR OXYGEN O CHRISTMAS TREE THIS IS OUR MOST PORTABLE TANK... UNFORTUNATELY IT ONLY LASTS 3 MINUTES. JUST ISN'T ENOUGH YOU GET OXYGEN! AROL CA YOU GET OXYGEN! YOU GET OXYGEN! EVERYONE GETS OXYGEN! imgflip.com O CHRISTMAS TREE... The Structure and Function of the Lung • The right lung is made up of three lobes. • The left lung is made up of two lobes. • The lungs are responsible for bronchodilation (expansion of the airway in the lungs) and bronchoconstriction (restriction of the airway in the lungs). • The lungs are also linked with the nervous system by both the parasympathetic and sympathetic systems. Hypoxemia is when there is a limited amount of oxygen in the blood. Retractions are when the muscles are pulled inward and occur between the ribs when inspiration occurs. Intercostal retractions are a sign that the airway is blocked. Hypoxia is a lack of oxygen at the cellular or tissue level. Occurs with a decreased amount of oxygen in the blood and can lead to hypoxia Hypoxemia Manifestations of hypoxemia and hypoxia include • Confusion • Irritability • Restlessness • Dyspnea • Tachypnea • Tachycardia or bradycardia • cyanosis Hypoxemia - may be due to anemia, pneumonia, COPD, asthma, ARDS, pneumothorax, pulmonary embolism, or pulmonary edema. Gas Exchange: Respiration Conditions Affecting Chest Wall Movement Any condition that reduces chest wall movement will decrease ventilation. If the diaphragm is unable to fully descend with breathing, then the volume of inspired air decreases, delivering less 0 2 to the alveoli and subsequently the tissues. Musculoskeletal abnormalities - kyphosis Nervous system disease – Myasthenia gravis, GBS Trauma – flail chest or trauma to the spinal cord Trauma above C3-C5...phrenic nerve that innervates the diaphragm Pain management - incisional pain leads to more shallow respirations Chronic Disease – COPD, emphysema Gas Exchange and Oxygenation The Respiratory System is comprised of the: nose, oropharynx, larynx, trachea, bronchi, bronchioles, and lungs. The Structure and Function of the Lung • The upper airway consists of the nasopharynx or nose, oropharynx or mouth, and the larynx. • The lower airway includes the trachea, bronchi, bronchioles and alveoli of the lungs. The Physiology of Ventilation and Perfusion • Ventilation is the flow of air inside or outside of the alveoli. • Oxygen is transported into the alveoli and carbon dioxide is taken out. • Perfusion is the flow of blood by the cardiopulmonary system into the alveolar capillaries. • Oxygenated blood is directed into the capillaries and deoxygenated blood is returned to the lungs. Oxygenation of the Lungs • When a person inhales, the diaphragm and intercostal muscles contract, creating a negative pressure inside the lungs, and the thorax increases in size for inhalation. • When a person exhales, the diaphragm relaxes, the intercostal muscles contract, and exhalation occurs. • Surfactant, a lubricant made in the lungs, keeps the alveoli from collapsing. • Lung compliance is the point to which a lung can expand in response to increased pressure within the alveoli (interalveolar). • Airway resistance is the pressure that exists when the diameter of the airway is narrowed. • Lung compliance and airway resistance increase the work of breathing which results in accessory muscle use. Accessory muscles use is an indication of respiratory distress. Pulmonary Circulation Deoxygenated blood leaves the right ventricle routed to the pulmonary artery is then routed to the pulmonary valve to the pulmonary trunk within the pulmonary artery. Blood then flows to the pulmonary semilunar valve into the right and left pulmonary arteries into and through the lungs. Carbon dioxide is eliminated. The alveoli contain capillaries where oxygenation takes place. Oxygenated blood then flows from the pulmonary venules to the pulmonary veins. Pulmonary Circulation (cont.) Blood is then returned to the left atrium of the heart by the pulmonary vein. The oxygenated blood then leaves the lungs through pulmonary veins, which return it to the left heart, completing the pulmonary cycle. Blood then moves from the left atrium to the mitral valve into the left ventricle. Blood then flows to the aorta via the aortic valve into systemic circulation and later returns to the lungs to be circulated. This blood then enters the left atrium, which pumps it through the bicuspid valve into the left ventricle. The blood then passes through the aortic valve to the aorta and is distributed via systemic circulation before again returning to the pulmonary circulation. The pulmonary vein returns oxygenated blood to the left atrium of the heart. Factors Affecting Oxygenation Physiological factors Hypovolemia Decreased inspired oxygen concentration Increased metabolic rate • Decreased oxygen carrying capacity • Anemia, Carbon monoxide poisoning • Dehydration and Hemorrhage • High altitudes, Decreased administration of O2 • Fever, Pregnancy, Wound Healing, Exercise Incentive Spirometer Acapella • Used to help patients' clear mucus from airways. • Provides positive expiratory pressure and vibrations to help clear mucus. Pursed Lip Breathing Oxygen Concentrations Room air is 21% Oxygen Every increase by 1 LPM equates to a 4% increase in FiO2, starting from 24 Need humidification for 4L/min and above % Oxygen Flow Rate and FiO2 Table Nasal Cannula Flow Rate(L/min) 1L 2L 3L 4L 5L 6L %O2Delivered 24% 28% 32% 36% 40% 44% Oxygen Delivery pg 1013 Table 41.7 Nasal cannula - works best for stable patients who need lowflow oxygen at low to medium concentrations High-flow nasal cannulasimple to use, more expensive than low flow nasal cannula, requires specialized flowmeter Humidification and High-flow Nasal Cannula Oxygen Delivery Simple face mask - A simple face mask delivers oxygen concentrations of 4060% at 5-8/10 liters per minute. The face mask is well-suited for patients who are prone to nasal irritation and/or nosebleeds. Simple face masks are also used for patients who breathe strictly through their mouths Partial and Nonrebreather masksbag must always remain partially inflated, must have a good seal. Oxygen Delivery Continued Venturi mask - A Venturi face mask mixes oxygen with room air, creating high-flow, enriched oxygen with pre-set concentrations. Venturi masks deliver oxygen at concentrations of 4-10 L or 24-40 percent. Health care providers may opt for a Venturi mask if they’re concerned about a patient retaining carbon dioxide (CO2) Non-rebreather mask - ideal for patients who are critically ill and require higher concentrations of oxygen. This type of mask delivers high-flow oxygen at concentrations of 10-15 L or 40-90 percent. Its major drawback: the NRB mask must be tightly sealed against the face, which can be uncomfortable. It’s also associated with a higher risk of CO2 retention. Delivery Methods of Oxygen The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse? A. Obtain an arterial blood gas to check for carbon dioxide retention. B. Increase the patient’s oxygen until the pulse oximetry is greater than 98%. C. Lower the head of the patient’s bed and insert a nasal airway. D. Administer a mild sedative and reorient the patient as needed. Answer: A • Confusion and disorientation in a patient with severe COPD may likely be due to carbon dioxide retention. An arterial blood gas should be drawn to determine if this is the case. COPD patients should be kept on low oxygen flow rates whenever possible to avoid impeding the drive to breathe. Lowering the head of the bed will increase the difficulty of breathing as the abdominal contents press on the diaphragm. A sedative will cause respiratory depression and should be avoided. Oxygen Safety Never smoke Have signs posted Keep upright Heat sources should be 5 feet away Flammable liquids should be kept away Aerosol sprays - never use Bedding 100% cotton Have fire extinguishers and smoke alarms Notify fire department and electrical companies • NON-INVASIVE POSITIVE PRESSURE VENTILATION (NIPPV) CPAP vs BiPAP • Continuous positive airway pressure (CPAP) – CPAP is a noninvasive breathing machine that’s used to treat a common sleep disorder known as obstructive sleep apnea (OSA). CPAP delivers a mixture of oxygen and/or room air from a machine through a plastic tube that’s connected to a face or nasal mask. It’s mostly used at night when oxygen levels in the blood tend to drop more frequently but can also be used during the day. CPAP helps people with OSA and/or COPD keep their breathing passages open by providing a continuous flow of air into their airways. • Bi-level positive airway pressure (BiPAP) – Similar to CPAP, BiPAP is a non-invasive breathing machine that can be used as an alternative in patients who find it difficult to breathe against the continuous pressure of the CPAP machine. Because BiPAP provides a higher pressure when breathing in and a lower pressure when breathing out, it’s easier for some people with COPD and other breathing disorders to tolerate. CPAP vs BiPAР BIPAP CPAP Continuous Positive Airway Pressure Positive Airway BiLevel Two Delivers air set pressure at level that stays during Not as single consistent sleep Pressure different pressure settings for inhale vs exhale - allows for lower pressure during exhalation good for Used for accommodating breathing changes more complex breathing problems such central sleep apnea as (CSA), & heart/lung/neurological Generally recommended for obstructive sleep apnea Typically Inhale & less Exhale: (OSA) expensive constant pressure set disorders that require additional airway support during sleep (CHF, COPD, Parkinson's, ALS) Inhale: constant set pressure Exhale: (lower) constant set pressure archerreview.com Different types of CPAP machines and one alternative therapy Chest X-Ray Arterial Blood Gases (ABGs) Diagnostic Tests • pH expected range 7.35 – 7.45 • PaCO2 expected range 35 – 45 mmHg • HCO3 expected range 22 – 26 mEq/L • PaO2 expected range 80 – 100 mmHg • SaO2 expected range 95 – 100% Pulse Oximetry (SPO2) expected range 95 – 100% unless • COPD 88 – 92% Pulmonary Function Test (PFT) to diagnose asthma and COPD Bronchoscopy – allows for visualization of airway and specimen collection Thoracentesis - insertion of a needle into the patient's posterior chest to remove fluid or air from the pleural space. Pulse Oximetry is a painless, noninvasive method of measuring the saturation of oxygen in a person’s blood. The device emits light that passes through the fingernail, skin, tissue, and blood. On the other side of the finger, a sensor detects and measures the amount of light that passes through the finger without getting absorbed by the tissue and blood. Using that measurement, the device calculates the oxygen saturation of the blood. The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation? • A. • B. • C. • D. Insert an oral airway Lower the head of the bed Turn the patient’s head to the side Monitor the patient’s pulse oximetry Answer: A • An oral airway will prevent the patient’s tongue from falling back and occluding the airway. Lowering the head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient’s head to the side will not clear the back of the patient’s tongue from the airway. Monitoring the patient’s pulse oximetry will not improve oxygenation or clear the airway. Acute Care of Dyspnea Dyspnea Management Medications, oxygen therapy, physical techniques and psychosocial techniques • Bronchodilators • Steroids • Mucolytics • Antianxiety agents Mobilization of Pulmonary Secretions COPD patient Hydration Pursed-lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, instruct the patient to take a deep breath and exhale slowly through pursed lips as if blowing through a straw. Have him or her blow through a straw into a glass of water to learn the technique. Humidification Nebulization COPD Patients Normal findings Clinical History: • Chronic cough, often productive • Dyspnea (shortness of breath), especially with exertion • Wheezing • Chest tightness • History of smoking or exposure to environmental pollutants Physical Examination: • Barrel chest • Prolonged expiration • Wheezing or rhonchi (coarse, rattling sounds) • Decreased breath sounds • Use of accessory muscles of respiration (e.g., neck muscles) • Cyanosis (blueish tint to the skin) in severe cases Teach them: Pursed lip breathing Clubbing of the fingernails The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? Select all that apply. A. The patient is unable to count out loud past 15 after a deep breath B. The patient’s nails are noticeably clubbed C. The patient’s sputum has turned from yellow to greenishbrown D. The patient has stridor with wheezes heard in all lung fields E. The patient’s forced vital capacity has increased from 2.8 to 3.4 L F. The patient has become confused and mildly disoriented Answer: A, C, D, F A patient who is unable to count out loud past 15 after a deep breath is indicative of poor airflow through the airways, which must be addressed promptly. Greenish-brown sputum may indicate pneumonia requiring antibiotic treatment. Stridor and wheezes is indicative of an acute asthma attack. Confusion and disorientation in a patient with COPD may indicate retention of carbon dioxide. The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority? A. Activity intolerance r/t generalized weakness and hypoxemia B. Imbalanced nutrition r/t poor appetite and increased metabolic needs C. Ineffective airway clearance r/t thick secretions in trachea and bronchi D. Knowledge deficit r/t use of nebulizer and inhaled bronchodilators Answer: C. • Airway maintenance and patency is the highest priority for all patients, especially patients with respiratory disorders. Oxygenation is the most important human need. The other diagnoses can apply once the patient’s airway is kept patent. Endotracheal Tube • Artificial airways • Oral airway • Endotracheal and tracheal airways 45 Suctioning – do not suction more than 10 seconds • Oropharyngeal – Saliva or oral secretions – Not Sterile • Use Yankeur Suctioning techniques that are Sterile: • Nasopharyngeal – nasal drainage OR unable to use oral route • https://nursessity.wordpress.com/2015/03/19/nasalpharyngeal-suctioning/ • Endotracheal – sputum in ET tube; need to elicit a cough • Tracheal – Secretions in trach, unable to cough Assessment When Suctioning • Pre-procedure: • Assess for S/S of Hypoxia & Risk Factors for Airway Obstruction • Is client exhibiting signs of restlessness, increased B/P, tachypnea w/shallow depth, tachycardia, SpO2 < 90%, adventitious breath sounds, visual secretions, or have an absence of a spontaneous cough? • Is the client exhibiting accessory muscle use or have a pale skin color? • Has the client had any nasal bleeding, prior neck or nose surgeries or injuries, a bleeding disorder, or deviated septum? • Does the client have COPD, Dysphagia, decreased gag or cough reflex, impaired mobility, or pulmonary infection. • Post-Procedure • Compare Assessments Before and After Suctioning • Is the client still restless? Has skin color improved? Are accessory muscles still being used? Has B/P decreased? Is RR and depth WNL? Is pulse WNL? Has SpO2 increased? Are breath sounds clear? Is client able to cough up secretions? Safety Guidelines • Know the patient’s baseline range of vital signs. • Limit the introduction of the catheter to 2 times with each suctioning procedure. • Perform tracheal suctioning before pharyngeal suctioning whenever possible. • Use caution when suctioning patients with a head injury. • The use of normal saline instillation into the airway before suctioning is not recommended. • Review institutional policy before stripping or milking chest tubes. • The most serious tracheostomy complication is airway obstruction. • Patients with COPD who are breathing spontaneously should cautiously receive high levels of oxygen therapy. 48 Image result for blood flow through the heart Blood Flow Through the Heart Heart Valves Memory Tool ASS TOILET (Tricuspid) (Aortic Valve) MY (Mitral) PAPER (Pulmonic) Just Remember... T-oilet P-aper M-y A-ss Regulation of Blood Flow • Cardiac output, cardiac index, stroke volume, preload, afterload, myocardial contractility • Stroke volume: amount of blood ejected from one ventricle with each beat • Cardiac output: amount of blood that one ventricle can pump each minute Preload and Afterload • Preload: Degree of myocardial fiber stretch at the end of diastole, just before heart contracts (how full is the Left Ventricle?) • Afterload: Amount of pressure or resistance that the left ventricle must overcome to eject blood through the semi-lunar valves to the peripheral blood vessels Checking B/P assess • Contractility: Ability of the heart to squeeze blood from the ventricles and prepare for the next contraction Cardiac Output Electrical Conduction of the Heart 1. Sinoatrial node (SA): “The Pacemaker.” Located in the wall of the right atrium near the opening of the superior vena cava. 2. Travels along Intra atrial pathways to the AV node 3. Atrioventricular node (AV): located in the right atrium along the lower part of the interatrial septum 4. AV bundle (bundle of His): located in the septum of the ventricle 5. Purkinje Fibers: located in the walls of the ventricles, responsible for ventricular contraction Electrocardiogram (EKG or ECG) - PQRST EXPLAINED NURSE IN THE MAKING ATRIAL CONTRACTION P DEpolarization think DEcompressing PR Movement of electrical activity from atria to ventricles R VENTRICLE CONTRACTION Q DEpolarization think DEcompressing S T VENTRICLE RELAXING REpolarization think RElaxing & REfilling with blood Other Cardiac Tests Cardiac Enzymes – especially Troponin Cardiac Catheterization Echocardiogram – Ejection Fraction MI Patients Troponin Chest pain Assess Your Patient - This must come first! Is the patient’s skin warm and dry, or is it damp and clammy? How is their color? Are they having chest pain? Can you palpate peripheral pulses? Is your patient talking to you or are they struggling to catch their breath? What is their capillary refill? Do they have underlying heart conditions? What is their baseline physical activity? Have they ever had an EKG before? Have they ever been diagnosed with a heart condition? The nurse is caring for a patient who has presented to the ER with chest pain. Which diagnostic test will best indicate if there is significant blockage of certain important blood vessels that provide oxygen to the heart muscle? A. Cardiac catheterization B. Echocardiogram C. Chest X-ray D. Electrocardiogram Answer: A • Cardiac catheterization includes the use of contrast dye to visualize the coronary arteries and determine blood flow to cardiac muscle. The other tests will not allow the physician to determine which (if any) coronary arteries are occluded. Alterations in Cardiac Functioning Lifestyle factors on heart and lung health Nutrition Hydration Exercise Cigarette smoking Substance abuse Anxiety and stress Environmental factors Risk Factors Modifiable Factors • Exercise • Smoking • Diet Non-modifiable Factors • Age • Sex • Family History Left sided vs Right sided heart failure 66 NURSE IN THE MAKING Medical Terms for Breathing Suffix: -pnea ‫وو‬ LEFT-SIDED VS. RIGHT-SIDED HF HF MEMORY TRICK (breathing, respiration) EUPNEA BRADYPNEA TACHYPNEA APNEA HYPOPNEA HYPERPNEA DYSPNEA ORTHOPNEA eft Side think Lungs D Dyspnea normal breathing slow breathing fast breathing no R breathing Rales (crackles) W Weakness/fatigue Nocturnal paroxysmal dyspnea N Nagging cough deep breathing G Gaining weight rdifficulty this may be is in breathing seen when person lying flat (frothy, blood tinged sputum) (2-3 lbs a Right of the W Weight = the Rest body day) gain EEdema (pitting) L Large neck veins (JVD) LLethargy/fatigue Increased HR shallow breathing difficulty breathing TRICK S Swelling ofthe legs & hands Orthopnea N MEMORY Irregular heart rate N Nocturia G Girth (ascites) The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient’s pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse? 1 A. Administer the ordered diuretic 2 B. Prepare for insertion of a chest tube 3 C. Suction secretions from the patient’s respiratory tract 4 D. Have the patient use the ordered incentive spirometer Answer: 1 • The patient’s respiratory distress is due to pulmonary edema and fluid overload from leftsided congestive heart failure. A diuretic will pull the excess fluid out of the body through the urine and relieve the patient’s distress. A chest tube is not needed as the fluid is within the alveoli rather than between the lung and chest wall. Suctioning and use of an incentive spirometer will not address fluid overload or improve the patient’s symptoms. The nurse is caring for a patient who has just had a massive myocardial infarction. Which is the priority nursing diagnosis for this patient? A. Impaired comfort r/t noisy ICU environment and need for frequent monitoring B. Interrupted family processes r/t hospitalization of primary wage earner C. Readiness for enhanced knowledge r/t cardiac rehabilitation options D. Decreased cardiac output r/t weakened cardiac muscle and irregular heartbeat Answer: D • Circulation and perfusion of body systems is the highest priority for patients who have suffered myocardial infarction. Decreased cardiac output can lead to poor oxygenation of tissues and organs. The other diagnoses may be addressed once cardiac output has increased and stabilized. Some topics to Review • Normal Vital Signs and Abnormal • Right Sided Heart Failure • Cardiac Output • COPD (Chronic Obstructive Pulmonary Disease) • Electrical conductivity of the heart • Modifiable and Nonmodifiable Risk factors • Diuretics – lose fluid and electrolytes • Left Sided Heart Failure • Myocardial Infarction • Early vs Late signs of hypoxia: • Early – restlessness and irritability • Late – dysrhythmias, cyanosis, apnea Ineffective Airway Clearance Ineffective Breathing Pattern Activity Intolerance Nursing Diagnoses Fluid Volume Overload Ineffective Peripheral Perfusion Imbalanced Nutrition: Less than body requirements Impaired mobility