Promoting Oxygenation

Level of health Considerations That Can Affect Oxygenation

- Acute and chronic illnesses - any disorders that affects that cardiovascular system affects oxygenation

Developmental Considerations That Can Affect Oxygenation

- Age related changes - Older adult: respiratory tract tissues and airways become less elastic - Power of respiratory and abdominal muscles is reduced - Diaphragm moves less efficiently - Blood vessels and valves become less efficient

Oxygenation of body tissues is dependent on...

- Airway System - Alveolar System - Cardiovascular System

Promoting Optimal Functioning: Avoid Pollution

- Dust & vacuum at home - avoid exposure to industrial or occupational hazards - wear a mask when exposure unavoidable - avoid cigarette smoke

Cough Medications

- Expectorants - Suppressants - Lozenges

Oxygenation Physical Assessment

- Inspection - Palpation - Percussion - Auscultation

Factors Affects Cardiopulmonary Functioning & Oxygenation

- Level of health - Medication considerations - lifestyle considerations - environmental considerations - psychological health considerations

Promoting Comfort

- Positioning - Adequate fluid intake - providing humidifcation

Examples of acute and chronic illnesses

- Renal disease - cardiac disorders - muscle wasting/ poor muscle tone - anemia - obesity

Lifestyle Considerations That Can Affect Oxygenation

- Sedentary activity patterns - People who exercise - Cultural influences - Cigarette smoking

Promoting Proper Breathing

- deep breathing exercises - incentive spirometry - pursed-lip breathing

Oxygenation

- essential to life - demand for oxygen is met by cardiopulmonary system

Promoting Optimal Functioning: Maintain Good Nutrition

- foods low in saturated fats, cholesterol, and sugar - Diet rich in fruits, vegetables, low-fat diary, and nuts

Promoting Optimal Functioning

- health lifestyle - vaccination - avoid pollution - reduce anxiety - maintain good nutrition

Medication Considerations That Can Affect Oxygenation

- medication that can decrease rate & depth of respirations - other medication decrease heart rate can alter the flow the blood tissues

Positive Airway Pressure (PAP)

- uses mild airway pressure to keep airways open - Helps maintain CO2 & O2 levels

3 Processes of the Respiratory System

- ventilation - respiration - perfusion

Abnormal hemoglobin level...

90% or less

Normal hemoglobin level...

95-100%

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: a. "He is using his chest muscles to help him breathe." b. "His infection is causing him to breathe harder." c. "His lung muscles are swollen so he is using abdominal muscles." d. "He will require additional testing to determine the cause."

A

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? a. Pulse oximetry b. Thoracentesis c. Spirometry d. Peak expiratory flow rate

A

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response? a. "Have you tried nasal strips?" b. "There is very little that can be done for snoring." c. "Pursed-lip breathing can reduce your amount of snoring." d. "Let me teach you about incentive spirometry."

A

A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client: a. "The air is thicker or more viscous with humidity, thus it is harder for you to breathe." b. "You should use your inhaler as often as necessary during this time to help your breathing." c. "Have you had a stress test to determine if your airway is obstructed?" d. "The airway becomes occluded during periods of rain."

A

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery? a. educating the client on the use of incentive spirometry b. administration of inhaled corticosteroids c. oropharyngeal suctioning twice daily d. educating the client on pursed-lip breathing techniques

A

A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently? a. Encourage the client to take deep breaths. b. Instruct the client in the use of pursed-lip breathing technique. c. Inform the client about nasal strips. d. Teach the client diaphragmatic breathing.

A

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. a. True b. False

A

Oxygen and carbon dioxide move between the alveoli and the blood by: a. diffusion b. negative pressure c. hyperosmolar pressure d. osmosis.

A

The nurse is listening to the client's lungs and hears them fill with air and then return to a resting position. How will the nurse document this assessment data? a. inspiration and expiration b. ventilation and respiration c. respiration and inspiration d. expiration and ventilation

A

Coughing

A means of helping to keep the airways clear of secretions & debris

Cough Medication: Lozenges

Act on sensory and motor nerves to help control cough

Environmental Considerations That Can Affect Oxygenation

Air pollution, environmental or occupational exposure to pollutants/chemicals/carcinogens

Promoting Comfort by Positioning

Allow free movement of the diaphragm and expansion of chest wall

Pulmonary Function Studies

Assesses respiratory function by measuring lung volumes & capacities

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response? a. "Pursed-lip breathing can reduce your amount of snoring." b. "Have you tried nasal strips?" c. "Let me teach you about incentive spirometry." d. "There is very little that can be done for snoring."

B

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? a. Contact the healthcare provider to report the client's current status b. Ask the client what factors contribute to nonadherence. c. Explain the use of a BiPAP mask instead of a CPAP mask. d. Document outcomes of modifications in care.

B

A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client: a. "The airway becomes occluded during periods of rain." b. "The air is thicker or more viscous with humidity, thus it is harder for you to breathe." c. "You should use your inhaler as often as necessary during this time to help your breathing." d. "Have you had a stress test to determine if your airway is obstructed?"

B

A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips? a. "The nasal diameter is decreased by nasal strips." b. "Nasal strips may reduce or eliminate snoring." c. "You will need a prescription for nasal strips." d. "Those do not work for snoring."

B

A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function? a. Tachypnea b. Pleural effusion c. Wheezes d. Pneumonia

B

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations? a. Hyperventilation b. Hypoxia c. Perfusion d. Atelectasis

B

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a. They are loud, high-pitched sounds heard primarily over the trachea and larynx. b. They are low-pitched, soft sounds heard over peripheral lung fields. c. They are medium-pitched blowing sounds heard over the major bronchi. d. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

B

The nurse is caring for a client who was had a percutaneous tracheostomy (PCT) following a motor vehicle accident, and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? a. simple mask b. tracheostomy collar c. nasal cannula d. face tent

B

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? a. heart rate 110 beats/minute b. SpO2 92% c. respirations 26 breaths/minute d. clubbing of fingers

B

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? a. Inhale the medication rapidly. b. Be sure to shake the canister before using it. c. Inhale through the nose instead of the mouth. d. Inhale two sprays with one breath for faster action.

B

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a. Snack on high-carbohydrate foods frequently. b. Eat smaller meals that are high in protein. c. Contact the physician for nutrition shake. d. Eat one large meal at noon.

B

Cardiovascular System

Blood supply to carry nutrients and wastes to and from body cells

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: a. high cardiac output b. heart failure c. adequate tissue perfusion d. diminished stroke volume

C

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a. They are loud, high-pitched sounds heard primarily over the trachea and larynx. b. They are medium-pitched blowing sounds heard over the major bronchi. c. They are low-pitched, soft sounds heard over peripheral lung fields. d. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

C

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include the humidifier? a. "The humidifier prescribes the concentration of oxygen." b. "This is a gauge used to regulate the amount of oxygen that a client receives." c. "Small water droplets come from this, thus preventing dry mucous membranes." d. "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

C

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a. Contact the physician for nutrition shake b. Snack on high-carbohydrate foods frequently c. Eat smaller meals that are high in protein. d. Eat one large meal at noon.

C

The nurse assessing a patient with COPD suspects chronic hypoxia due to which of the following assessment findings? a. cyanosis b. edema c. clubbing of toes d. constipation

C and D

Bi-level PAP (BiPAP)

Changes the air pressure while the patient breathes in & out

Promoting Optimal Functioning: Reduce Anxiety

Create an environment that decreases anxiety

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from: a. pulmonary embolism. b. myocardial infarction. c. lung cancer. d. congestive heart failure.

D

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? a. "An occasional cigarette will not hurt you." b. "I understand; I used to be a smoker also." c. "Oxygen is a flammable gas." d. "You should never smoke when oxygen is in use."

D

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? a. "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." b. "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." c. "Take in a small amount of air very quickly and then exhale as quickly as possible." d. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

D

When caring for a client with a tracheostomy, the nurse would perform which recommended action? a. Clean the wound around the tube and inner cannula at least every 24 hours. b. Assess a newly inserted tracheostomy every 3 to 4 hours. c. Use gauze dressings over the tracheostomy that are filled with cotton. d. Suction the tracheostomy tube using sterile technique.

D

While reading a physician's progress notes, a student notes that an assigned client is having hypoxia. What abnormal assessments would the student expect to find? a. hypotension, reddened skin, edema b. diarrhea, flatulence, decreased skin turgor c. abdominal pain, hyperthermia, dry skin d. dyspnea, tachycardia, cyanosis

D

Cough Medication: Suppressants

Depress the cough reflex

Hypoxia Symtoms

Dyspnea, increased BP, increased pulse, pallor, cyanosis, anxiety, restlessness, confusion, and drowsiness

Promoting Proper Breathing: Incentive Spirometry

Encourages maximizing lung inflation & preventing/reducing atelectasis

When should oxygen saturation be checked?

Every couple of hours

Alveolar System

Exchange oxygen and carbon dioxide

Cough Medication: Expectorants

Facilitate removal of secretions by reducing viscosity

Respiration

Gas exchange between alveoli and blood

Promoting Optimal Functioning: Health Lifestyle

Good health-related behaviors decreases risk for disease

Chest Physiotherapy

Helps loosen & mobilize secretions - Helpful for increased secretions or ineffective cough - Percussion & Vibration - Postural drainage

Suctioning the Airway

Helps remove saliva, pulmonary secretions, blood, vomitus, or foreign material from pharynx - Oropharynx or nasopharynx - Tracheal

Patterns of respiration Medications Health history Recent changes Lifestyle & environment Cough Sputum Pain Dyspnea Fever Fatigue

How would you describe your breathing? Do you take any meds for your breathing ? Do you have any heart, lung, or breathing conditions? Have you noticed any changes in your breathing? Do you smoke or live with a smoker? How much & how often do you cough? Do you ever cough up & spit out mucous? Do you have any chest pain or pain with breathing? Can you sleep lying flat? Have you had pneumonia recently? Do you feel more tired recently?

Psychological Health Considerations That Can Affect Oxygenation

In response to stress and anxiety: - hyperventilation- decrease co2 levels - bronchospasms- asthma attack - Hypoxia- lead to anxiety

Hypoxia

Inadequate amount of O2 is available to cells

Promoting Optimal Functioning: Vaccination

Influenza and Pneumococcal

Nasal cannula can cause...

Irritation on back of ear so if they are more immune to skin break

Inhaled Medication: Mucolytic agents

Liquefy or loosen thick secretions

Promoting Proper Breathing: Deep Breathing Exercises

Make each breath deep enough to move the bottom ribs

Electrocardiography

Measures heart's electrical activity & is recorded on an electrocardiogram (ECG)

Capnography

Measures the amount of CO2 exhaled with each breath

Pulse Oximetry

Measures the arterial oxyhemoglobin saturation

Peak Expiratory Flow Rate

Measures the point of highest flow during forced expiration

Spirometry

Measures volume of air exhaled or inhaled

Ventilation

Movement of air into and out of the lungs

Inhaled Medication: Bronchodilators

Open narrowed airways

What does flow rate depend on?

Patient and route of administration

Thoracentesis

Procedure of puncturing the chest wall & aspirating pleural fluid

Promoting Proper Breathing: Pursed-Lip Breathing

Prolongs expiration resulting in improved gas exchange and decreased dsypnea

Inhaled Medication:Corticosteroids

Reduce inflammation in the airway

Involuntary Cough

Reflex stimulus of cough sensitive area - medication can help

Perfusion

The process by which oxygenated capillary blood passes through body tissues

Promoting Comfort by Providing Humidification

To protect against irritation and infection

Airway System

Transports air to and from lungs

Is O2 combustible?

Yes, bc/ patients smoke while using oxygen

Voluntary Cough

important pre-op & post-op - more effective when combines with deep breathing

Dry Cough

non-productive

Cough that produces respiratory secretions =

productive cough

Promoting Comfort by Adequate fluid intake

to keep secretions thin