Oxygenation

Dr. Belal Hijji, RN, PhD

March 3 & 4, 2012

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Learning Outcomes

At the end of this lecture, students will be able to:

• Describe the anatomic and physiologic overview of the respiratory system

• Identify the factors that influence the respiratory function

• Recognise common alterations in respiratory function

• Describe the nursing management of client with oxygenation problems

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Anatomic and Physiologic Overview of the Respiratory System

• The RS (next slide) is composed of the upper and lower respiratory tracts which are responsible for ventilation (movement of air in and out of the airways).

4The Respiratory System

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Upper Respiratory Tract

• Nose: Warming, humidification, and filtering of air takes place here. The sneeze reflex is initiated by irritants in nasal passages.

• Pharynx: Is a shared pathway for food and air. Its lymphoid tissue traps and destroys pathogens entering with air.

• Larynx: Can be identified as the Adam’s apple. It is important for speech, it maintains airway patency, and protects the lower airways from swallowed material.

• Trachea: The trachea serves as the passage between the larynx and the bronchi.

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Lower Respiratory Tract

• Lungs: Primary bronchi divide repeatedly into smaller and smaller bronchi, ending with terminal bronchioles. Trapping of pathogens and microscopic particulate matter takes place in the trachea and bronchi. Foreign particles are moved upward toward the larynx and throat. The cough reflex is triggered by irritants in the larynx, trachea, or bronchi. Each lung is made up of 300 million alveoli (this is where oxygen and carbon dioxide exchange takes).

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Factors Affecting Respiratory Function

• Age: At birth, the fluid-filled lungs drain [deplete], the PCO2 rises, an the neonate takes the first breath. Full lung expansion is achieved by the age of 2 weeks. Changes of aging that affect the RS of elders become important if the system is compromised by infection, physical or emotional stress, surgery, or anaesthesia.

• Environment: Altitude and air pollution affect oxygenation.

• Lifestyle: Physical exercise or activity increase the rate and depth of respiration and hence the supply of oxygen in the body.

• Health status: Diseases of the RS such as chronic obstructive pulmonary disease can adversely affect the oxygenation of blood.

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Factors Affecting Respiratory Function (Cont..)

• Medications: Some medications can decrease the rate and depth of respiration. For example valium (diazepam), morphine, and demerol (meperidine hydrochloride).

• Stress: Physiologic and psychologic responses to stress can affect oxygenation. Some people hyperventilate; arterial PO2 rises and PCO2 falls.

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Alteration in Respiratory Function

• Hypoxia: Insufficient oxygen anywhere in the body, from the inspired gas to the tissues.– Hypoventilation: inadequate alveolar ventilation leading to

hypoxia. It may occur due to diseases of the respiratory muscles, drugs, and anaesthesia. CO2 often accumulates in the blood.

– Hypoxemia: Reduced oxygen in the blood. It is characterised by low PO2 in arterial blood or a low haemoglobin saturation.

– Cyanosis: Bluish discoloration of the skin, nailbeds, and mucous membranes due to reduced haemoglobin-oxygen saturation.

• Altered breathing patterns: Breathing pattern refers to rate, volume, rhythm, and relative ease of respiration. Normal respiration is quiet, rhythmic, and effortless. Tachypnea (rapid rate), bradypnea (slow rate), apnea (cessation of breathing).

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• Obstructed airway– Complete or partial obstruction: Can occur anywhere along the

upper or lower RS.

– Immediate action by nurses to maintain an open airway is a nursing responsibility.

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Nursing Management of Oxygenation Problems

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Assessment

• Health history: Explore the presenting problem (cough, sputum, shortness of breath, pain) including how long it has been present and whether it has recently gotten worse.

• Physical exam: Inspect the client for efforts at ventilation, flaring of nostrils, and position preferences. Count the respiratory rate and note the rhythm of the breathing for regularity or irregularity. Observe for cyanosis and clubbing of fingers (next slide). Auscultate the lungs for crackles or wheezes.

• Diagnostic and laboratory data: Assist the physician in obtaining a blood sample for ABG measurement. Assist the patient in collecting a sputum specimen for analysis/ culture. Document the color of the sputum (see next slide for the interpretation of different sputum colors.

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Clubbing of the fingers as a result of chronic hypoxia. Note the flattened angle of the nailbed and a rounding of the fingertips

Pathologies Associated with Different Colors of SputumSputum Color Pathology

Yellow or green Bacterial infectionRust or blood-tinged Pneumonia, tuberculosisBlack Black lung diseasePink Pulmonary edema

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Nursing Diagnoses

• Ineffective airway clearance related to obstruction (by tongue, secretions, edema, or foreign body).

• Ineffective breathing pattern related to immobility: Inspiration and/ or expiration that do(es) not provide adequate ventilation.

• Impaired gas exchange: Excess or deficit in oxygenation and/ or carbon dioxide elimination.

• Decreased cardiac output related to decreased circulating blood volume.

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• Promote airway clearance• Improve breathing pattern• Improve oxygen uptake and delivery• Increase cardiac output and tissue perfusion

Planning

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• Promote airway clearance: This is achieved through:– Teaching effective coughing: Prior to actual coughing, teach the

patient to take slow, deep breaths. The intent is to raise the sputum to the level where it can then be coughed out. In a postoperative patient, ask him/ her to splint the incision by holding a pillow firmly against it will reduce the pain caused by coughing. In most cases, assisting the client to a sitting position will increase the effectiveness of the cough.

– Monitoring hydration: Providing adequate fluid intake is important in thinning the pulmonary secretions for easy expectoration. This may help in cases of pneumonia, bronchitis, and asthma. Patients experiencing congestive heart failure may require limitation of fluid intake to reduce pulmonary congestion due to fluid volume overload.

continued on next slide

Implementation

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– Medications administration: Expectorants/ mucolytics (Mucomyst [acetylcysteine]) and bronchodilators (Aminophylline) assist with airway clearance. Nurses must teach patient the name of the medications, its purpose, dose, and route. Nurses should also inform the patient about the most significant side effects.

– Environmental and lifestyle modification: Identifying and removing allergens that the patient is sensitive to may dramatically improve asthma. Certain allergens such as animal dander [minute scales from hair or skin] may be relatively easy to eliminate. However, house dust and pollen may be impossible to eliminate but can be reduced by using air filters.

– Airway suctioning: Suctioning of the airway may be necessary to clear secretions the client cannot remove by coughing.

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• Improve breathing pattern: This could be achieved through:– Proper patient positioning: If the client finds that breathing is

easier in an upright position, that position should be maintained. Nurses should support the patient with elevation of the head of bed.

– Controlled breathing exercises: Teach the patient the pursed-lip breathing technique, which involves forced exhalation against pursed (partially closed) lips, to maintain positive pressure in the lungs during the expiratory phase and prevents collapse of the smaller airways. Another intervention is deep-breathing exercises by encouraging the patient to take slow, deep breaths instead of the rapid, shallow breathing . Finally, abdominal breathing involves the use of the abdominal muscles to pull the diaphragm downward. Placing your hand on the client’s abdomen and instructing the client to watch it rise give a visual aid to teaching the technique.

Implementation (continued…)

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• Improve oxygen uptake and delivery: This could be achieved through:– Oxygen administration: Oxygen uptake in the pulmonary

capillary beds can be improved by increasing the concentration of oxygen in the alveolar air. Administer oxygen as prescribed. The physician’s order should indicate the concentration, method of delivery, and liter flow per minute.

– Blood transfusion: Blood component administration (e.g., red blood cells) is indicated when the client’s oxygenation is impaired because of decreased circulating blood volume as in anemia or hemorrhage.

Implementation (continued…)

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• Increase cardiac output and tissue perfusion: This could be achieved through:– Maintaining fluid balance: Management of fluid balance is a

cornerstone in the care of the client with reduced cardiac output. If congestive heart failure is present, fluid and sodium intake may be restricted to prevent edema and circulatory overload. Diuretics may also be given to increase fluid excretion by the kidneys. The nurse needs to maintain accurate fluid intake and output and record the patient’s weight daily.

– Positioning patient properly: Proper positioning of a patient is done to decrease the fluid load to the heart and to decrease the development of pulmonary edema. Therefore, the nurse should keep the patient’s head and upper body elevated and the legs are in a dependent position. Supine position may be detrimental for the patient with congestive heart failure, as evidenced by worsening dyspnea, tachycardia and tachypnea, and decreased arterial oxygen saturation. Continued on next slide

Implementation (continued..)

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– Administering medications: Medications to improve cardiac output and perfusion include diuretics (lasix), cardiac glycosides (digoxin), and inotropic agents (dopamine). Lasix increases excretion of water and some electrolytes; lowers blood pressure and cardiac workload. Digoxin increases force of cardiac contraction and slows heart rate. Dopamine increases the force of cardiac contraction.

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• Using the goals identified in the planning stage of the nursing process, the nurse collects data to evaluate the effectiveness of interventions.

• If goals are not achieved, all concerned need to explore the reasons before modifying the care plan.

Evaluation