Chapter 41 Oxygenation Copyright 2017 Elsevier Inc All

Chapter 41 Oxygenation Copyright © 2017, Elsevier Inc. All Rights Reserved.

Scientific Knowledge Base Oxygen is needed to sustain life. Blood is oxygenated through the mechanisms of ventilation, perfusion, and transport of respiratory gases. Neural and chemical regulators control the rate and depth of respiration in response to changing tissue oxygen demands. The cardiovascular system provides the transport mechanisms to distribute oxygen to cells and tissues of the body. Copyright © 2017, Elsevier Inc. All Rights Reserved. 2

Case Study Mr. King, a 62 -year-old man, entered the ED with a 6 -day history of chest pain, shortness of breath, cough, and generalized malaise. His wife and son are with him. Mr. King works in sales and lives with his wife. He has a history of chronic obstructive pulmonary disease and alcohol abuse, but at present is not drinking. Mr. and Mrs. King have been heavy smokers for more than 40 years. Mr. King used to help out with the housework and loves to tinker in the garden; however, lately he has been unable to participate in any of the activities. His wife states, “All he seems able to do is sit in his chair and watch TV. ” Copyright © 2017, Elsevier Inc. All Rights Reserved. 3

Respiratory Physiology The exchange of respiratory gases occurs between the environment and the blood. Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism. The airways of the lung transfer oxygen from the atmosphere to the alveoli, where the oxygen is exchanged for carbon dioxide. Through the alveolar capillary membrane, oxygen transfers to the blood, and carbon dioxide transfers from the blood to the alveoli. Copyright © 2017, Elsevier Inc. All Rights Reserved. 4

Structure and Function Gases move into and out of the lungs through pressure changes. The diaphragm and external intercostal muscles contract to create a negative pleural pressure and increase the size of the thorax for inspiration. Copyright © 2017, Elsevier Inc. All Rights Reserved. 5

Structure and Function (Cont. ) Ventilation Perfusion Diffusion The process of moving gases into and out of the lungs The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs Exchange of respiratory gases in the alveoli and capillaries Copyright © 2017, Elsevier Inc. All Rights Reserved. 6

Case Study (Cont. ) John Smith is the nursing student assigned to his first hospital-based clinical experience. He has some experience in health assessment and patient teaching related to health promotion activities from a recent rotation at a clinic. In the previous experience, patients were encouraged to adjust their at-risk health behaviors, such as smoking or poor diet. John feels confident when he arrives in the clinical area this morning because Mr. King has similar health needs to the clinical experiences he has had. Copyright © 2017, Elsevier Inc. All Rights Reserved. 7

Structure and Function (Cont. ) Work of breathing The effort required to expand contract the lungs. Ø Inspiration and expiration Ø Surfactant Ø Atelectasis Ø Compliance and airway resistance Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 8

Structure and Function (Cont. ) Lung volumes Tidal Ø Residual Ø Forced vital capacity Ø Pulmonary circulation Ø Moves blood to and from the alveolar capillary membrane for gas exchange Copyright © 2017, Elsevier Inc. All Rights Reserved. 9

Structure and Function (Cont. ) Respiratory gas exchange Ø Diffusion is the process for the exchange of respiratory gases in the alveoli of the lungs and the capillaries of the body tissues Copyright © 2017, Elsevier Inc. All Rights Reserved. 10

Structure and Function (Cont. ) Oxygen transport Ø The oxygen transport system consists of the lungs and cardiovascular system Carbon dioxide transport Carbon dioxide, a product of cellular metabolism, diffuses into red blood cells and is rapidly hydrated into carbonic acid (H 2 CO 3) Ø The carbonic acid then dissociates into hydrogen (H) and bicarbonate (HCO 3 -) ions Ø Hemoglobin buffers the hydrogen ion, the (HCO 3 -) diffuses into the plasma Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 11

Case Study (Cont. ) When John goes to meet Mr. King and performs his morning assessment, he finds that Mr. King is overwhelmed. This patient is in a great deal of respiratory distress. It seems that every breath is a struggle for him. Everything that John planned to do for Mr. King seems less important. The patient is extremely anxious. His wife is at his side, anticipating John’s every move and demanding some action. Copyright © 2017, Elsevier Inc. All Rights Reserved. 12

Regulation of Respiration Neural regulation Central nervous system controls the respiratory rate, depth, and rhythm. Ø Cerebral cortex regulates the voluntary control of respiration. Ø Chemical regulation Maintains the rate and depth of respirations based on changes in the blood concentrations of CO 2 and O 2, and in hydrogen ion concentration (p. H). Ø Chemoreceptors sense changes in the chemical content and stimulate neural regulators to adjust. Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 13

Case Study (Cont. ) John’s knowledge of the physiology of pulmonary conditions will assist him in caring for Mr. King’s history reveals risk factors in addition to the 40 -year history of smoking 2 packs per day. Also, he continues to smoke. John knows that shortness of breath shows that the infection is obstructing his alveolar capillary membrane, preventing oxygenation of blood in some parts of his lung. He also is aware of the preexisting COPD. With John’s experience working with patients who are addicted to inhaled nicotine, he recognizes the difficulty of quitting. John knows that the most effective time to encourage patients to stop smoking is when they are in an acute care setting with an illness exacerbated by smoking. Copyright © 2017, Elsevier Inc. All Rights Reserved. 14

Cardiovascular Physiology Cardiopulmonary physiology involves delivery of deoxygenated blood (blood high in carbon dioxide and low in oxygen) to the right side of the heart and then to the lungs, where it is oxygenated. Oxygenated blood (blood high in oxygen and low in carbon dioxide) then travels from the lungs to the left side of the heart and the tissues. Copyright © 2017, Elsevier Inc. All Rights Reserved. 15

Cardiovascular Physiology (Cont. ) Structure and function Right ventricle pumps deoxygenated blood through systemic circulation. Ø As blood passes through the circulatory system, there is an exchange of respiratory gases, nutrients, and waste products between the blood and the tissues. Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 16

Case Study (Cont. ) John’s attitude about his nursing care reflects his respect for the patient’s autonomy and balances this with continually educating Mr. King about the risk factors of smoking. John knows the impact of support systems in assisting patients coping with chronic illness. He uses creativity and independent thinking to incorporate community and family resources into the plan of care for Mr. King. John will need to inquire about his social supports and the availability in his community of programs to help him quit smoking. Copyright © 2017, Elsevier Inc. All Rights Reserved. 17

Cardiovascular Physiology (Cont. ) Myocardial pump Myocardial blood flow Two atria and two ventricles As the myocardium stretches, the strength of the subsequent contraction increases (Starling’s law). Unidirectional through four valves Coronary artery circulation Systemic circulation Coronary arteries supply the myocardium with nutrients and remove wastes. Arteries and veins deliver nutrients and oxygen and remove waste products. S 1: mitral and tricuspid close S 2: aortic and pulmonic close Copyright © 2017, Elsevier Inc. All Rights Reserved. 18

Blood Flow Regulation Cardiac output Amount of blood ejected from the left ventricle each minute Stroke volume Amount of blood ejected from the left ventricle with each contraction Cardiac output (CO) = Stroke volume (SV) × Heart rate (HR) Preload End-diastolic pressure Afterload Resistance to left ventricular ejection Copyright © 2017, Elsevier Inc. All Rights Reserved. 19

Conduction System Transmits electrical impulses Generates impulses needed to initiate the electrical chain of events for a normal heartbeat Copyright © 2017, Elsevier Inc. All Rights Reserved. 20

Conduction System (Cont. ) Normal sinus rhythm (NSR) Originates at the SA node, follows normal sequence through conduction system Ø P wave Ø PR interval Ø QRS complex Ø QT interval Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 21

Factors Affecting Oxygenation Physiological factors Decreased oxygen-carrying capacity Ø Hypovolemia Ø Decreased inspired oxygen concentration Ø Increased metabolic rate Ø Conditions affecting chest wall movement Ø Pregnancy, obesity, neuromuscular disease, musculoskeletal abnormalities, trauma, neuromuscular disease, CNS alterations Influences of chronic diseases Copyright © 2017, Elsevier Inc. All Rights Reserved. 22

Case Study (Cont. ) John reviews the standards set by the American Cancer Society to identify that tobacco use accounts for at least 30% of ALL cancer deaths and 87% of lung cancer deaths. In 2011, ~221, 130 new cases of lung cancer and ~156, 940 deaths from lung cancer were reported in the United States. He uses this information and the resources at www. cancer. org to assist in educating Mr. King and his wife about cancer statistics and methods to quit smoking. Copyright © 2017, Elsevier Inc. All Rights Reserved. 23

Alterations in Respiratory Functioning Hypoventilation Hyperventilation Alveolar ventilation inadequate to Ventilation in excess of that meet the body’s oxygen demand required to eliminate carbon or to eliminate sufficient carbon dioxide produced by cellular dioxide metabolism Hypoxia Cyanosis Inadequate tissue oxygenation at the cellular level Blue discoloration of the skin and mucous membranes Copyright © 2017, Elsevier Inc. All Rights Reserved. 24

Alterations in Cardiac Functioning Disturbances in conduction Electrical impulses that do not originate from the SA node cause conduction disturbances Ø Dysrhythmias Ø Atrial fibrillation Ø Paroxysmal supraventricular tachycardia Ø Ventricular dysrhythmias Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 25

Alterations in Cardiac Functioning (Cont. ) Altered cardiac output Left-sided heart failure Ø Right-sided heart failure Ø Impaired valvular function Myocardial ischemia Angina Ø Myocardial infarction Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 26

Nursing Knowledge Base Factors influencing oxygenation: Developmental Ø Lifestyle Ø Environmental Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 27

Critical Thinking Use professional standards: Agency for Healthcare Research and Quality (AHRQ) Ø American Cancer Society (ACS) Ø American Heart Association (AHA) Ø American Lung Association (ALA) Ø American Thoracic Society (ATS) Ø American Nurses Association (ANA) Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 28

Assessment In-depth history of a patient’s normal and present cardiopulmonary function Past impairments in circulatory or respiratory functioning Methods that a patient uses to optimize oxygenation Review of drug, food, and other allergies Physical examination Laboratory and diagnostic tests Copyright © 2017, Elsevier Inc. All Rights Reserved. 29

Case Study (Cont. ) John Smith begins his morning care for Mr. King. He finds Mr. King restless and anxious. John notices that as the day progresses, Mr. King’s coughs are weaker, less sputum is produced, and Mr. King is becoming more fatigued. Copyright © 2017, Elsevier Inc. All Rights Reserved. 30

Assessment (Cont. ) Through the patient’s eyes Ask about patient’s priorities and expectations Ø Establish realistic, short-term outcomes that build to a larger goal Ø Educate the patient on the opportunities for individual, group, or telephone counseling and identifying a social support system Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 31

Assessment: Nursing History Pain Fatigue Dyspnea Cough Wheezing Smoking Respiratory infection Allergies Health risks Medications Copyright © 2017, Elsevier Inc. All Rights Reserved. 32

Case Study (Cont. ) Ask Mr. King how long he has been short of breath. “I have been short of breath for 1 week, and it has gotten worse. ” Take Mr. King’s vital signs. Pulse rate is 120 beats/min Temperature is 102° F Respiratory rate is 36 breaths/min Blood pressure is 110/45 mm Hg Arterial oxygen saturation (Sp. O 2 ) is 82%; Mr. King is dyspneic Ask Mr. King how long he has had his cough and whether it is a productive cough. “I usually cough when I wake up in the morning. Three days ago, I noticed that I was coughing up thick mucus that has not stopped. ” Auscultate Mr. King’s lung fields. Expiratory wheezes, crackles, and diminished breath sounds over the right lower lobe are audible. Ask Mr. King to produce Sputum is thick and discolored (yellow-green). a sputum sample. Copyright © 2017, Elsevier Inc. All Rights Reserved. 33

Physical Examination Inspection Palpation Skin and mucous membrane color, level of consciousness (LOC), breathing patterns, chest wall movement, general appearance, circulation Chest, feet, legs, pulses Percussion Auscultation Presence of abnormal fluid or air; diaphragmatic excursion Normal and abnormal heart and lung sounds Copyright © 2017, Elsevier Inc. All Rights Reserved. 34

Quick Quiz! 1. A patient complains of chest pain. When assessing the pain, you decide that its origin is cardiac—rather than respiratory or gastrointestinal—when it: A. does not occur with respiratory variations. B. is peripheral and may radiate to the scapular region. C. is aggravated by inspiratory movements. D. is nonradiating and occurs during inspiration. Copyright © 2017, Elsevier Inc. All Rights Reserved. 35

Diagnostic Tests Many tests used for cardiopulmonary functioning Blood specimens Ø X-rays Ø TB skin testing Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 36

Nursing Diagnosis Activity intolerance Impaired gas exchange Risk for aspiration Decreased cardiac Fatigue output Impaired verbal Ineffective airway communication clearance Ineffective breathing pattern Copyright © 2017, Elsevier Inc. All Rights Reserved. Ineffective health maintenance 37

Planning During planning, use critical thinking skills to synthesize information from multiple sources Goals and outcomes Ø Realistic expectations, goals, and measurable outcomes Setting priorities Teamwork and collaboration Copyright © 2017, Elsevier Inc. All Rights Reserved. 38

Case Study (Cont. ) Nursing diagnosis: Ineffective airway clearance related to pulmonary secretions Goals: Pulmonary secretions will return to baseline levels within 24 to 36 hours. Ø Mr. King’s oxygenation status will improve in 36 hours Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 39

Case Study (Cont. ) Respiratory status: gas exchange Mr. King’s sputum will be clear, white, and thinner in consistency within 36 hours. Ø Mr. King’s lung sounds will be at baseline within 36 hours. Ø Mr. King’s respiratory rate will be between 16 and 24 breaths per minute within 24 hours. Ø Mr. King will be able to clear airway secretions by coughing in 24 hours. Ø Mr. King’s Sp. O 2 will be >85% within 24 hours. Ø Mr. King’s perceptions of dyspnea will improve. Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 40

Implementation: Health Promotion Vaccinations Ø Healthy lifestyle Ø Influenza, pneumococcal Eliminating risk factors, eating right, regular exercise Environmental pollutants Ø Secondhand smoke, work chemicals, and pollutants Copyright © 2017, Elsevier Inc. All Rights Reserved. 41

Implementation: Acute Care Dyspnea management Hydration Airway maintenance Mobilization of pulmonary secretions Humidification Nebulization Coughing and deep-breathing techniques Copyright © 2017, Elsevier Inc. All Rights Reserved. 42

Implementation: Acute Care (Cont. ) Chest percussion Copyright © 2017, Elsevier Inc. All Rights Reserved. 43

Case Study (Cont. ) Airway management: Have Mr. King deep breathe and cough every 2 hours while awake. Ø Have Mr. King change position frequently if on bed rest. If able, have him ambulate 10 to 15 minutes every 8 hours, and encourage him to sit up in a chair as often as he is able to tolerate. Ø Encourage Mr. King to increase his fluid intake to 2800 m. L/24 hours if his cardiac condition does not contraindicate it, and to avoid caffeinated beverages and alcohol; recommend water. Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 44

Implementation: Suctioning Techniques Oropharyngeal and nasopharyngeal Ø Orotracheal and nasotracheal Ø Used when the patient can cough effectively but is not able to clear secretions Used when the patient is unable to manage secretions by coughing and does not have an artificial airway Tracheal Ø Used with an artificial airway Copyright © 2017, Elsevier Inc. All Rights Reserved. 45

Tracheal Care Suctioning methods Open Ø Closed Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 46

Artificial Airways Oral airway Ø Prevents obstruction of the trachea by displacement of the tongue into the oropharynx Copyright © 2017, Elsevier Inc. All Rights Reserved. 47

Artificial Airways (Cont. ) Endotracheal and tracheal airways Ø Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions Tracheostomy Ø Long-term assistance, surgical incision made into trachea Copyright © 2017, Elsevier Inc. All Rights Reserved. 48

Maintenance and Promotion of Lung Expansion Ambulation Positioning Ø Reduces pulmonary stasis, maintains ventilation and oxygenation Incentive spirometry Ø Encourages voluntary deep breathing Copyright © 2017, Elsevier Inc. All Rights Reserved. 49

Maintenance and Promotion of Lung Expansion (Cont. ) Invasive mechanical ventilation Life-saving technique used with artificial airways (ET or tracheostomy) Ø Physiological indications Ø Clinical indications Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 50

Maintenance and Promotion of Lung Expansion (Cont. ) Noninvasive ventilation Purpose is to maintain a positive airway pressure and improve alveolar ventilation Ø Continuous positive airway pressure (CPAP) Ø Bilevel positive airway pressure (Bi. PAP) Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 51

Case Study (Cont. ) Two days later, when John auscultates Mr. King’s lungs, he finds that the lung sounds are clear. Copyright © 2017, Elsevier Inc. All Rights Reserved. 52

Quick Quiz! 2. A patient with a tracheostomy has thick tenacious secretions. To maintain the airway, the most appropriate action for the nurse includes: A. tracheal suctioning. B. oropharyngeal suctioning. C. nasotracheal suctioning. D. orotracheal suctioning. Copyright © 2017, Elsevier Inc. All Rights Reserved. 53

Case Study (Cont. ) John asks Mr. King to keep track of his fluid intake. John asks Mr. King to ambulate for 10 minutes every 4 hours. John asks Mr. King to keep track of deep breathing every 2 hours while awake. Copyright © 2017, Elsevier Inc. All Rights Reserved. 54

Maintenance and Promotion of Lung Expansion (Cont. ) Chest tube Pneumothorax Ø Hemothorax Ø Special considerations Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 55

Case Study (Cont. ) Mr. King has kept track of his fluid intake, and he has averaged 2800 m. L/24 hours. He is coughing thin secretions. Mr. King ambulates once every 8 hours. Mr. King’s diary documented deep breathing every 2 hours while awake 85% of the time. Copyright © 2017, Elsevier Inc. All Rights Reserved. 56

Maintenance and Promotion of Oxygenation Oxygen therapy Ø Safety precautions Supply of oxygen Ø To prevent or relieve hypoxia Tanks or wall-piped system Methods of oxygen delivery Nasal cannula Ø Oxygen mask Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 57

Oxygen Masks Simple face mask Ø Plastic face mask with reservoir bag Ø Used for short-term therapy Used for higher concentrations of oxygen Venturi mask Copyright © 2017, Elsevier Inc. All Rights Reserved. 58

Home Oxygen Therapy Indications Arterial partial pressure (Pa. O 2) of 55 mm Hg or less –or– Ø Arterial oxygen saturation (Sa. O 2) of 88% or less on room air at rest, on exertion, or with exercise Ø Administered via nasal cannula or face mask T tube or tracheostomy collar used if patient has a permanent tracheostomy Beneficial effects for patients with chronic cardiopulmonary disease Copyright © 2017, Elsevier Inc. All Rights Reserved. 59

Quick Quiz! 3. When evaluating a postthoracotomy patient with a chest tube, the best method to properly maintain the chest tube would be to: A. strip the chest tube every hour to maintain drainage. B. place the device below the patient’s chest. C. double clamp the tube except during assessment. D. remove the tubing from the drainage device to check for proper suctioning. Copyright © 2017, Elsevier Inc. All Rights Reserved. 60

Restoration of Cardiopulmonary Functioning Cardiopulmonary resuscitation (CPR) 1. Circulation Ø 2. Airway Ø 3. Breathing Ø Defibrillation (automatic external defibrillator [AED]) Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 61

Case Study (Cont. ) Both Mr. and Mrs. King are interested in preventing future hospitalizations and in learning what they can do to maintain their health. John reviewed teaching strategies with them, with the goal of Mr. and Mrs. King verbalizing the steps they need to take to improve their health and reduce the risk for future hospitalizations. John established evaluation strategies to measure the success of patient teaching. Copyright © 2017, Elsevier Inc. All Rights Reserved. 62

Restorative and Continuing Care Cardiopulmonary rehabilitation Ø Controlled physical exercise; nutrition counseling; relaxation and stress management; medications; oxygen; compliance; systemic hydration Respiratory muscle training Breathing exercises Pursed-lip breathing Ø Diaphragmatic breathing Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 63

Case Study (Cont. ) John cares for Mr. King throughout his hospital stay. Mr. King is afebrile, his white blood cells are within normal limits, and his sputum cultures are negative on the day of discharge. He does not require supplemental oxygen. He is able to describe ways to prevent respiratory infections because they aggravate airways and precipitate an episode of acute respiratory failure. Because he now practices pursed-lip breathing, his breathing is more controlled, relieving his subsequent anxiety. Copyright © 2017, Elsevier Inc. All Rights Reserved. 64

Evaluation Through the patient’s eyes Ø Focus on evaluating how the disease is affecting dayto-day activities and how the patient believes he or she is responding to treatment Patient outcomes Ø Compare the patient’s actual progress to the goals and expected outcomes of the nursing care plan to determine his or health status Copyright © 2017, Elsevier Inc. All Rights Reserved. 65

Case Study (Cont. ) While John is observing Mr. King preparing for discharge, it is evident that Mr. King is using the various breathing techniques that they have worked on together. Mr. King is able to go home with improved activities of daily living. His wife appears even less anxious and states that she feels as though for the first time they have taken a step (even though small) toward improving the quality of their lives. Copyright © 2017, Elsevier Inc. All Rights Reserved. 66

Safety Guidelines Patients with sudden changes in their vital signs, level of consciousness, or behavior are possibly experiencing profound hypoxia. Perform tracheal suctioning before pharyngeal suctioning whenever possible. Use caution when suctioning patients with a head injury. The routine use of normal saline instillation into the airway before ET and tracheostomy suctioning is not recommended. Check your institutional policy before stripping or milking chest tubes. The most serious tracheostomy complication is airway obstruction, which can result in cardiac arrest. Patients with COPD who are breathing spontaneously should never receive high levels of oxygen therapy. Copyright © 2017, Elsevier Inc. All Rights Reserved. 67