chapter 38 oxygenation perfusion

teaching about pollution free environments

A pollution-free environment is particularly important for people with cardiopulmonary problems. Teach the patient to assess the environment and make adjustments, whenever possible, to factors that impair respiratory functioning ("triggers"). The patient must actively plan to prevent exposure to pollutants and triggers. This might involve a job change, use of protective equipment, requesting enforcement of laws by government agencies, or subcontracting jobs. In order to minimize triggers in the home, dusting and vacuuming the office and home must be done at least twice per week. In some situations, the patient may be asked to wear a mask to prevent some symptoms of respiratory distress. Explain to the patient that exposure to industrial or occupational hazards (e.g., paint, varnish, gaseous fumes, asbestos) must also be restricted. In the United States, fine pollutants—including carbon monoxide, sulfur dioxide, total suspended particulates, ozone, and nitrogen dioxide—that pose a hazard to health are monitored closely. On days when pollutant levels are elevated significantly, morbidity and mortality rates among people with pre-existing pulmonary disease are increased greatly. Thus, on days when pollution alerts are announced, people with altered respiratory function should reduce their activities, stay indoors, and use an air conditioner, electronic air cleaner, or air filter. If pollen alters the patient's respiratory function, the same principles apply. Cigarette smoking is a major risk factor in cardiopulmonary diseases. The inhalation of cigarette smoke increases airway resistance, reduces ciliary action, increases mucus production, causes thickening of the alveolar-capillary membrane, and causes bronchial walls to thicken and lose their elasticity. Smoking is the most common cause of chronic obstructive pulmonary disease (COPD), and increases the risk for many types of cancer, including cancers of the oral cavity, esophagus, lung, urinary bladder, and kidneys. In addition, cigarette smoking causes reduced circulation by narrowing the blood vessels (arteries). Smoking causes coronary heart disease, the leading cause of death in the United States, and causes a much greater risk for stroke, peripheral vascular disease, and abdominal aortic aneurysm (abnormal dilation of blood vessels). These effects occur in both smokers and nonsmokers (children and adults) who live with smokers (CDC, 2010). Habitual smokers usually have great difficulty quitting or reducing their smoking and need much encouragement. The American Lung Association and the American Heart Association (AHA) offer many free educational materials to aid and support patients who are trying to stop smoking. Their addresses and phone numbers are listed in local telephone directories; both agencies offer extensive information online. As a nurse, it is important to play a key role in presenting accurate information about the effects of smoking. Encourage the decision to never start smoking or to stop smoking. Provide appropriate information, counseling, support, and resources to assist patients to be successful with smoking cessation.

lifestyle factors affecting oxygenation

Activity levels and habits can dramatically affect a person's cardiopulmonary status. For example, sedentary activity patterns do not encourage the expansion of alveoli and the development of pulmonary exercise patterns (deep breathing). People who exercise (e.g., aerobics, walking, swimming) three to six times per week can better respond to stressors to respiratory health. Regular physical activity provides many health benefits, including increased heart and lung fitness, improved muscle fitness, and reducing the risk of heart disease. Cultural influences can also play a role in a person's lifestyle, encouraging or discouraging healthy choices. Culture is a strong force in the determinants of health and behavior change. An understanding of a patient's cultural background is necessary to promote health and disease prevention in any population (Ritter & Hoffman, 2010). For example, consider the implications of the use of traditional methods for health restoration, such as cupping by patients of Chinese descent to treat lung congestion (Spector, 2009). An important part of care would be to assess the impact of this practice and belief on a patient's readiness to participate in the proposed plan of care related to the treatment of pneumonia. Cigarette smoking (active or passive) is a major contributor to lung disease and respiratory distress, heart disease, and lung cancer. Cigarette smoking is the most important risk factor for chronic COPD (Macnee, 2007). Smoking causes coronary heart disease, the leading cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2010). Nurses working with patients to initiate changes in health habits that affect oxygenation must also examine themselves as a factor in the success of the plan. Nurses who role model good health behaviors are more effective teachers. Use the display, Promoting Health 38-1: Oxygenation, for yourself before using it with others.

administering cpr and evaluating

Administering Cardiopulmonary Resuscitation Cardiopulmonary resuscitation (CPR) is the combination of chest compressions, which circulate blood, and mouth-to-mouth breathing, which supplies oxygen to the lungs. After checking the victim for a response, activate the emergency response system, get an automated external defibrillator (AED) or defibrillator, and begin CPR with the CAB sequence: Chest Compressions: Check the pulse. If the victim has no pulse, initiate chest compressions to provide artificial circulation. Airway: Tilt the head and lift the chin; check for breathing. The respiratory tract must be opened so that air can enter. Breathing: If the victim does not start to breathe spontaneously after the airway is opened, give two breaths lasting 1 second each. Defibrillation: Apply the AED as soon as it is available. Start CPR in any situation in which either breathing alone or breathing and a heartbeat are absent. The brain is sensitive to hypoxia and will sustain irreversible damage after 4 to 6 minutes of no oxygen. The faster CPR is initiated, the greater the chance of survival. During CPR, standard precautions are followed even though contact with a patient's blood or body fluids does not always occur. Occupational Safety and Health Administration (OSHA) standards require health care facilities to provide an ample supply of ventilation masks along with other protective barriers for staff to use during resuscitation efforts. The automated external defibrillator (AED) has also proved effective in reducing deaths attributed to cardiac arrest. This easy-to-use, computer-based device is designed to deliver a shock to the heart muscle quickly to interrupt ventricular fibrillation, the most common initial rhythm occurring in cardiac arrest. The AED has the ability to analyze the heart's rhythm, direct the operator to deliver a shock when appropriate or deliver one automatically, and then reanalyze the rhythm to determine whether it has returned to normal (Fig. 38-20). Using the AED is an integral part of resuscitation. Most professional organizations recommend and support widespread efforts to teach CPR to laypeople and all health professionals. Mannequins for practice can be obtained from the AHA, the American Red Cross, and health agencies. The nurse is professionally responsible for maintaining proficiency in CPR skills. This necessitates periodic practice with mannequins (adult and infant). CPR must be administered quickly and accurately, without hesitation, when cardiac or pulmonary arrest occurs. In 2008, the AHA instituted changes in their suggestions regarding emergency interventions outside of health care facilities. Learning conventional CPR is still recommended. However, the AHA alternately recommends that when a teen or adult suddenly collapses, people near the victim should call 911 (activate the emergency response system) and push hard and fast in the center of the victim's chest. Studies of real emergencies that have occurred in homes, at work, or in public locations show that these two steps, called Hands-Only CPR, can be as effective as conventional CPR. Providing Hands-Only CPR to an adult who has collapsed from a sudden cardiac arrest can more than double or triple that person's chance of survival (AHA, 2012). Evaluating Evaluation is the final step of the nursing process; the accompanying concept map illustrates the nursing process for the care of Tyrone Jacobs. Evaluation is an ongoing and deliberate part of the nursing process that involves the nurse, patient, family, and other health care team members. It compares the patient's health status with previously defined expected outcomes and examines the patient's projected progress in meeting those outcomes. Everyone involved in the evaluation process needs to identify effective interventions and reasons for any failures in achieving the expected outcomes. Adjustments in the nursing plan of care are made accordingly. See Nursing Plan of Care 38-1 for Joan McEntyre.

physical assessment (oxygenation)

Always proceed in a well-organized manner through a sequence of inspection, palpation, percussion, and auscultation. Note the patient's vital sign measurements, particularly the pulse and respiratory rate, as well as the blood pressure.

using artificial airways overview(implementing)

Artificial airways are used to preserve a functioning airway in patients who are unable to maintain a patent airway without assistance. Communicating effectively with patients with artificial airways, such as endotracheal tubes or tracheostomies, is essential. Patients with endotracheal tubes, and most tracheostomies, are unable to speak. The communication needs of these patients must be part of the nursing assessment. Identify appropriate alternate communication strategies to ensure that the patient's needs are conveyed. Consider the patient's impaired ability to communicate and keep communication tools (e.g., writing board, letters, vocabulary cards) close at hand, along with the call light or bell. To prevent anxiety, offer frequent reassurance and explanations and anticipate the patient's needs.

promoting propper breathing (implementing)

DEEP BREATHING When hypoventilation occurs, a decreased amount of air enters and leaves the lungs. However, deep-breathing exercises can be used to overcome hypoventilation. Instruct the patient to make each breath deep enough to move the bottom ribs. Unless the patient has a nasal condition that prohibits or prevents normal breathing, have the patient start slowly taking deep ventilations nasally and then expiring slowly through the mouth. Breathing through the nose warms, filters, and humidifies the air. The patient's respiratory status, motivation, and general clinical condition dictate the timing of this exercise, which should be done hourly while awake or four times daily. USING INCENTIVE SPIROMETRY Incentive spirometry provides visual reinforcement for deep breathing by the patient. An incentive spirometer assists the patient to breathe slowly and deeply and to sustain maximal inspiration. The gauge on the spirometer allows the patient to measure one's own progress, providing immediate positive reinforcement. It encourages the patient to maximize lung inflation and prevent or reduce atelectasis. Optimal gas exchange is supported and secretions can be cleared and expectorated. Before using incentive spirometry equipment, the patient needs instructions on using the equipment properly. Validate the patient's correct use of this equipment in both health care and home environments. See Guidelines for Nursing Care 38-1 for information regarding teaching patients to use this device. PURSED-LIP BREATHING Patients who experience dyspnea and feelings of panic can often reduce these symptoms by using pursed-lip breathing. Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration. Prolonged expiration is thought to result in decreased airway narrowing during expiration and prevent the collapse of small airways. This results in improved air exchange and decreased dyspnea. Pursed-lip breathing also helps the patient to control the rate and depth of respiration, helping to reduce feelings of dyspnea. It also encourages relaxation, which aids the patient to gain control of dyspnea and reduce feelings of panic. Encourage patients with COPD to try this breathing technique to help manage their daily activities (Corbridge, Wilken, Kapella, & Gronkiewicz, 2012; Hinkle & Cheever, 2014). While sitting upright, the patient inhales through the nose while counting to three, then exhales slowly and evenly against pursed lips while tightening the abdominal muscles. During exhalation, the patient counts to seven. To purse the lips, the patient should position the lips as though sucking through a straw or whistling. When walking and using pursed-lip breathing, the patient should inhale while taking two steps and then exhale through pursed lips while taking the next four steps, then repeat the cycle. DIAPHRAGMATIC BREATHING Many people with COPD breathe in a shallow, rapid, and exhausting pattern. Teach the patient with COPD to change this type of upper chest breathing to another form, diaphragmatic breathing. Diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration (Hinkle & Cheever, 2014). To do this, the patient places one hand on the stomach and the other on the middle of the chest. The patient breathes in slowly through the nose, letting the abdomen protrude as far as it will go, then breathes out through pursed lips while contracting the abdominal muscles, with one hand pressing inward and upward on the abdomen. The patient repeats these steps for 1 minute, followed by a rest for 2 minutes. Encourage the patient to practice this breathing pattern several times during the day, so that eventually it becomes automatic.

Levels of health (factors affecting oxygenation)

Acute and chronic illnesses can affect a person's cardiopulmonary function dramatically. For example, people with renal or cardiac disorders often have compromised respiratory functioning because of fluid overload and impaired tissue perfusion. People with chronic illnesses often have muscle wasting and poor muscle tone. These problems affect all the muscles, including those of the respiratory system. Alterations in muscle function contribute to inadequate pulmonary ventilation and respiration, as well as inadequate functioning of the heart. Anemia can result in impaired respiratory function. As discussed previously, anemia may lead to an inadequate supply of oxygen to the tissues of the body. Because hemoglobin also carries carbon dioxide to the lungs, anemia results in diminished carbon dioxide exchange. Myocardial infarction causes a lack of blood supply to the heart muscle. Damage to the heart muscle interferes with effective contractions of the heart muscle, leading to decreased perfusion of tissues and decreased gas exchange. Physical changes such as scoliosis (curvature of the spine) influence breathing patterns and may cause air trapping. Research reveals a statistically significant correlation between obesity and chronic bronchitis. Moreover, people who are obese are often short of breath during activity, ultimately leading to less participation in exercise. As a result, the alveoli at the base of the lungs are rarely stimulated to expand fully.

meeting oxygenation needs with medication(implementing)

Although treating patients with medications is a dependent nursing intervention, monitoring the patient's response and development of side effects to medications is an independent nursing action. Table 38-4 lists some common medications for improving respiratory functioning, their side effects, and nursing implications. Many of the drugs used to dilate bronchial airways interact with caffeine. Encourage patients to avoid caffeine, which may potentiate the side effects of bronchodilators.

common cardiopulmonary function studies

Arterial Blood Gas and pH Analysis These examine arterial blood to determine the pressure exerted by oxygen and carbon dioxide in the blood and blood pH. This test measures the adequacy of oxygenation, ventilation, and perfusion. Normal results are: pH, 7.35 to 7.45; PCO2, 35 to 45 mm Hg; PO2, 80 to100 mm Hg; HCO3, 22 to 26 mEq/L; and base excess or deficit, -2 to +2 mmol/L. Explain to the patient that this test requires an arterial puncture and collection of a blood specimen. The radial, brachial, or femoral arteries are usually the sites of choice. Perform Allen's test to ensure adequate ulnar blood flow when using the radial artery. Record supplemental oxygen or respirator settings on specimen information. The arterial specimen is immediately placed on ice and taken to the laboratory. Apply pressure for 5 to 10 minutes and watch for evidence of bleeding. If the patient is taking anticoagulants, pressure must be applied for a longer interval. Cardiac Biomarkers CK and isoenzymes are enzymes that are released as a result of injury to tissues, including the heart muscle. Troponin is a protein found in skeletal and cardiac muscle fibers and is also released after injury to the heart. These biomarkers are used to monitor cardiac injury and myocardial infarction. Measuring the levels of these enzymes can help determine the extent and timing of the damage. Review the procedure with the patient. Inform the patient that this test can assist in assessing for heart damage. Inform the patient that a series of samples will be required; based on facility protocol, samples could be taken three to four times, in 3- to 4-hour intervals. Inform the patient that specimen collection takes approximately 5 to 10 minutes. Address concerns about pain and explain that there may be some discomfort during the venipuncture (puncture of the vein). There are no food, fluid, or medication restrictions unless ordered by the primary health care provider. Recognize anxiety related to test results. Provide teaching and information regarding the implications of the test results. Reinforce information given by the patient's primary health care provider regarding further testing, treatment, or referral to another health care provider. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of illness. Evaluate test results in relation to the patient's symptoms, health care problems, and other tests performed. Complete Blood Count (CBC) Review the procedure with the patient. Inform the patient that this test can assist in evaluating the body's response to illness. Inform the patient that specimen collection takes approximately 5 to 10 minutes. Address concerns about pain and explain that there may be some discomfort during the venipuncture (puncture of the vein). There are no food, fluid, or medication restrictions unless ordered by the primary health care provider. Reinforce information given by the patient's primary health care provider regarding further testing, treatment, or referral to another health care provider. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of illness. Evaluate test results in relation to the patient's symptoms, health care problems, and other tests performed. Cytologic Study This involves a microscopic examination of sputum and the cells it contains. It is done primarily to detect cells that may be malignant, determine organisms causing infection, and identify blood or pus in the sputum. Collect the specimen, if possible, in the morning before breakfast. The test usually involves 3 successive days of sputum collection. About 1 teaspoon of sputum is needed for a specimen. The patient should take a deep breath, then expel the air with a deep cough. Expectorate the specimen into a sterile specimen container with the appropriate preservative, if indicated. Close the container with a tight-fitting lid. Advise the patient to inform the nurse when the specimen has been obtained. Label and package the specimen and send it to the laboratory as soon as possible.

teaching patients to use an incentive spirometer

Assist the patient to an upright or semi-Fowler's position if possible. Remove dentures if they fit poorly. Assess for pain. Administer pain medication, as prescribed, if needed. If the patient has recently undergone abdominal or chest surgery, place a pillow or folded blanket over a chest or abdominal incision for splinting. Demonstrate how to steady the device with one hand and hold the mouthpiece with the other hand. Instruct the patient to exhale normally and then place lips securely around the mouthpiece. Instruct the patient not to breathe through the nose. Use a nose clip if necessary. Instruct the patient to inhale slowly and as deeply as possible through the mouthpiece without using the nose (a nose clip may be used). Instruct the patient to remove the lips from the mouthpiece and exhale normally. If patient becomes light-headed during the process, tell him or her to stop and take a few normal breaths before resuming incentive spirometry. Encourage the patient to complete breathing exercises about 5 to 10 times every 1 to 2 hours, if possible. Rest in between breaths as necessary.

alterations in respiratory function

If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. Anxiety, restlessness, confusion, and drowsiness also are common signs of hypoxia. Hypoxia is often caused by hypoventilation (decreased rate or depth of air movement into the lungs). Hypoxia can also be a chronic condition. The effects of chronic hypoxia can be detected in all body systems and are manifested as altered thought processes, headaches, chest pain, enlarged heart, clubbing of the fingers and toes, anorexia, constipation, decreased urinary output, decreased libido, weakness of extremity muscles, and muscle pain. Additional information related to alterations in respiratory function is discussed in Chapter 24.

ascultation in assessment

Auscultation of the lungs assesses air flow through the respiratory passages and lungs. Listen for normal and abnormal lung sounds. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Auscultate as the patient breathes slowly through an open mouth. Breathing through the nose can produce falsely abnormal breath sounds. In addition to air flow, listen for adventitious sounds (extra, abnormal sounds of breathing), such as wheezing or crackles. Abnormal lung sounds can occur as a result of alterations in the respiratory and cardiovascular systems and lead to impaired oxygenation. Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. They are produced by fluid in the airways or alveoli and delayed reopening of collapsed alveoli. They occur due to inflammation or congestion and are associated with pneumonia, heart failure, bronchitis, and COPD. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. They are often heard in patients with asthma, tumors, or a buildup of secretions. Auscultation of the heart assesses function of the heart, heart valves, and blood flow. Listen for normal and abnormal heart sounds. Listen to the rhythm of the beat and the characteristic "lub-dub." The first sound, the lub, is followed by the second sound, the dub, with a pause before the next lub-dub. These sounds are made by the closure of valves in the heart during the cardiac cycle. The lub correlates with the beginning of systole, the contraction of the ventricles, and is called S1. The dub correlates with the end of systole and the beginning of diastole, the relaxation of the ventricles, and is called S2. In addition to S1 and S2, listen for extra and abnormal heart sounds. Abnormal heart sounds occur as a result of alterations in the cardiovascular system that may lead to impaired oxygenation. Refer to Chapter 25 for a detailed discussion of auscultation as part of the assessment of the respiratory and cardiovascular systems.

managing artificial airways part 1

OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAYS An oropharyngeal or nasopharyngeal airway is a semicircular tube of plastic or rubber inserted into the back of the pharynx through the mouth (oro) or nose (naso) in a patient who is breathing spontaneously. The oropharyngeal airway is used to keep the tongue clear of the airway. It is often used for postoperative patients until they regain consciousness. Once the patient regains consciousness, remove the oropharyngeal airway. Do not use tape to hold the airway in place because the patient should be able to expel the airway once he or she becomes alert. A nasopharyngeal airway is inserted through the nare and protrudes into the back of the pharynx. The nasal trumpet allows for frequent nasotracheal suctioning without trauma to the nasal passageway. This airway may be left in place, without much discomfort, in the patient who is alert and conscious. Techniques to use when inserting an artificial airway are outlined in Guidelines for Nursing Care 38-4. ENDOTRACHEAL TUBE An endotracheal tube is a polyvinylchloride airway that is inserted through the nose or mouth into the trachea, using a laryngoscope as a guide. It is used to administer oxygen by mechanical ventilator, to suction secretions easily, or to bypass upper airway obstructions (e.g., tongue or tracheal edema). Although uncomfortable and easy to manipulate with the tongue, orotracheal insertion is often the method of choice, especially in an emergency, because insertion is easier and a larger tube can be used, making ventilation easier. Placement of the tube through the nasotracheal route, although tolerated better by patients, is more difficult and requires the use of a narrower tube. Most commonly, a cuffed endotracheal tube is used (Fig. 38-15). This type of tube prevents air leakage and bronchial aspiration of foreign material while allowing more precise control of oxygen and mechanical ventilation. However, careful monitoring of cuff pressure is necessary to decrease the risk for tracheal necrosis. The smallest amount of air that results in an airtight seal between the trachea and the tube is desirable and less likely to result in complications. Patients with endotracheal tubes often require suctioning via the endotracheal tube to remove secretions from the airway. Refer to the discussion related to tracheal suctioning later in the chapter. Routine oral suctioning to aspirate secretions that accumulate above the cuff of the tube is also necessary to reduce the risk of pneumonia (Sole, Penoyer, Bennett, Bertrand, & Talbert, 2011).

providing supplemental oxygen part 3

OXYGEN DELIVERY SYSTEMS Oxygen can be administered by many different delivery systems: nasal cannula, nasopharyngeal catheter, transtracheal catheter, simple mask, partial rebreather mask, nonrebreather mask, Venturi mask, and tent. Table 38-5 compares several oxygen delivery systems. Administering Oxygen via Nasal Cannula Click to Show Nasal Cannula. A nasal cannula, also called nasal prongs, is the most commonly used oxygen delivery device. The cannula is a disposable plastic device with two protruding prongs that are inserted into the nostrils. The cannula is connected to an oxygen source with a flow meter and, many times, a humidifier. The cannula does not impede eating or speaking and is used easily in the home. Disadvantages of this system are that it can be dislodged easily and can cause dryness of the nasal mucosa. In addition, if a patient breathes through the mouth, it is difficult to determine the amount of oxygen the patient is actually receiving. Skill 38-3 describes oxygen administration by nasal cannula. Nasopharyngeal Catheter. A nasopharyngeal catheter is another efficient means for administering oxygen, but it is infrequently used because it is uncomfortable for the patient and may cause trauma to respiratory mucous membranes. It is inserted into the nose through one nostril, with the end of the catheter resting in the oropharynx. It is important to remove the catheter for cleaning and change it to the other nostril every 12 to 24 hours (Eastwood, Gardner, & O'Connell, 2007). Gastric distention often occurs because the gas flow can be misdirected into the stomach. Face masks. Disposable and reusable face masks are available. Fit the mask carefully to the patient's face to avoid leakage of oxygen. It should be comfortably snug but not tight against the face. The most commonly used types of masks are the simple face maskhe simple face mask is connected to oxygen tubing, a humidifier, and a flow meter, just like the nasal cannula. This mask has vents on its sides that allow room air to leak in at many places, thereby diluting the source oxygen. The vents also allow exhaled carbon dioxide to escape. Often a simple mask is used when an increased delivery of oxygen is needed for short periods (e.g., less than 12 hours). The mask should fit closely to the face to deliver this higher concentration of oxygen effectively. Patients may have difficulty keeping the mask in position over the nose and mouth, and because of this pressure and the presence of moisture, skin breakdown is a possibility. Eating or talking with the mask in place can be difficult. Because of the risk of retaining carbon dioxide, never apply the simple face mask with a delivery flow rate of less than 5 liters per minute. The partial rebreather mask is similar to a simple face mask, but is equipped with a reservoir bag for the collection of the first part of the patient's exhaled air. The remaining exhaled air exits through vents. The air in the reservoir is mixed with 100% oxygen for the next inhalation. Thus, the patient rebreathes about one-third of the expired air from the reservoir bag. This type of mask permits the conservation of oxygen. An additional advantage is that the patient can inhale room air through openings in the mask if the oxygen supply is briefly interrupted. The disadvantages are those of any mask: eating and talking are difficult, a tight seal is required, and there is the potential for skin breakdown. Monitor the reservoir bag carefully. It should deflate slightly with inspiration; if it deflates completely, the flow rate should be increased until only a slight deflation is noted. The nonrebreather mask delivers the highest concentration of oxygen via a mask to a spontaneously breathing patient. It is similar to the partial rebreather mask except that two one-way valves prevent the patient from rebreathing exhaled air. The reservoir bag is filled with oxygen that enters the mask on inspiration. Exhaled air escapes through side vents. A malfunction of the bag could cause carbon dioxide buildup and suffocation. This mask can also be used to administer other gases, such as heliox. Heliox is a mixture of helium and oxygen, used to reduce the work of breathing, deliver aerosols, and reduce fear and anxiety for patients in respiratory distress. Helium has a very low density that allows it to flow easily into narrow or twisty air passages, delivering nebulized medications into the lower airways. In addition, carbon dioxide diffuses through helium at four to five times the rate it diffuses through room air, thus it can exit the body faster and easier (Hess, MacIntyre, Mishoe, Galvin, & Adams, 2012; Pruitt, 2007a). The Venturi mask gets its name from the Venturi effect, which allows the mask to deliver the most precise concentrations of oxygen. This mask has a large tube with an oxygen inlet. As the tube narrows, the pressure drops, causing air to be pulled in through side ports. These ports are adjusted according to the prescription for oxygen concentration. Be sure that the ports are always open. If these are occluded by linens, clothing, or a patient rolling on the mask, the oxygen delivered might be at an unsafe (too high or too low) concentration., the partial rebreather mask, the nonrebreather mask, and the Venturi mask. Skill 38-4 describes the actions and rationales involved in using face masks. Oxygen Tent. Oxygen also can be administered by way of an oxygen tent. An oxygen tent is a light, portable structure made of clear plastic and attached to a motor-driven unit. The motor helps to circulate and cool the air in the tent. The cooling device functions like an electric refrigeration unit. A thermostat in the unit keeps the tent at the temperature considered most comfortable for the patient. The tent fits either over the top part of the bed so that the patient's head and thorax are inside, or over the entire bed. It has side openings through which nursing care can be administered. An oxygen tent is commonly used with children who need a cool and highly humidified airflow (e.g., children with pneumonia). Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, it is rarely used with other patients. In addition, it is difficult to maintain a consistent level of oxygen and to deliver oxygen at a rate higher than 30% to 50% (Kyle & Carman, 2013). The humidified airflow quickly creates moisture, leading to damp clothing and linens, and, possibly, hypothermia. Therefore, frequent assessment of the child's temperature, pajamas, and bedding is necessary.

respiration (physiology)

Respiration, gas exchange, occurs at the terminal alveolar capillary system. Gases are exchanged between the air and blood via the dense network of capillaries in the respiratory portion of the lungs and the thin alveolar walls (see Fig. 38-1, p. 1398 and Fig. 38-3). Gas exchange occurs via diffusion. Diffusion is the movement of gas or particles from areas of higher pressure or concentration to areas of lower pressure or concentration. In respiration, diffusion refers to the movement of oxygen and carbon dioxide between the air (in the alveoli) and the blood (in the capillaries). These gases move passively from an area of higher concentration to an area of lower concentration. The greater pressure of oxygen in the alveoli causes the oxygen to move from the alveoli into the capillaries containing the unoxygenated venous blood. Likewise, the carbon dioxide in the returning venous blood exerts a greater pressure than the carbon dioxide in the alveoli. Therefore, carbon dioxide diffuses across the capillary into the alveoli and ultimately is exhaled. Diffusion of gases in the lung is influenced by several factors, including changes in surface area available, thickening of alveolar-capillary membrane, and partial pressure. Any change in the surface area available for diffusion hinders diffusion. For example, removal of a lung or the presence of a disease that destroys lung tissue can decrease the surface area available, ultimately affecting gas exchange. Incomplete lung expansion or the collapse of alveoli, known as atelectasis, prevents pressure changes and the exchange of gas by diffusion in the lungs. Areas of the lung with atelectasis cannot fulfill the function of respiration. Examples of conditions that predispose a patient to atelectasis are obstructions of the airway by foreign bodies, mucus, airway constriction, external compression by tumors or enlarged blood vessels, and immobility. Any disease or condition that results in thickening of the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult. The partial pressure, or pressure resulting from any gas in a mixture depending on its concentration, can also affect diffusion. If environmental oxygen is reduced, such as when a person is at higher altitudes or in the presence of toxic fumes, less oxygen is available for diffusion. When oxygen is administered, an increased amount of oxygen is available, resulting in greater diffusion across capillary membranes.

maintaining good nutrition

Beneficial behaviors, such as a healthy diet, should be incorporated into a patient's daily activities. Encourage patients to eat a diet that includes foods low in saturated fat and cholesterol, low in sodium (salt), and high in fiber. This diet can help patients reduce their risk for chronic disease such as cardiopulmonary diseases, improve health, and reduce the prevalence of overweight and obesity (U.S. Department of Agriculture [USDA], 2012). Patients with cardiovascular diseases, such as hypertension, benefit from eating a diet rich in fruit, vegetables, low-fat dairy products, and nuts and legumes, with reduced amounts of fat, red meat, sweets, and beverages with sugar. This diet provides a high intake of potassium, magnesium, calcium, protein, and fiber, along with a low intake of saturated fat, sodium, cholesterol, total fat, and extra sugars. People who work hard at breathing often do not have much energy for eating. Many of the medications used for treatment can cause anorexia and nausea. However, maintaining an adequate nutritional intake is crucial. Interventions should focus on ensuring an adequate intake of proteins, vitamins, and minerals. Consider the use of six small meals distributed over the course of the day instead of the usual three larger meals. Provide frequent oral hygiene and rest periods before eating to help improve the patient's intake. Encourage patients to eat their meals 1 to 2 hours after breathing treatments and exercises. Patients who have COPD require a high-protein/high-calorie diet to counter malnutrition. Encourage obese patients to lose weight using a calorie-controlled diet. Diets should be 40% to 55% carbohydrates, 30% to 40% fat, and 12% to 20% protein. A diet rich in antioxidants, vitamins A and C, and the B vitamins is important. If supplemental oxygen is used, reinforce the importance of wearing the cannula during and after meals. Eating and digestion require energy, which causes the body to use more oxygen.

using cough medications (implementing)

Various medications can be used to promote coughing, aiding in the movement of mucus through the respiratory tract, and in controlling coughing to allow the patient to rest. Expectorants. Expectorants are drugs that facilitate the removal of respiratory tract secretions by reducing the viscosity of the secretions. Patients with extremely tenacious (thick) secretions may need the secretions liquefied for their cough to be effective. In that way, the nonproductive cough of a person with lung congestion can become productive. Use of an expectorant by a person without congestion is inappropriate. Guaifenesin is widely used as an expectorant in cold and cough medications (e.g., Robitussin). Some health care providers consider adequate fluid intake and air humidification as effective expectorants. Cough Suppressants. Suppressants are drugs that depress a body function—in this case, the cough reflex. Codeine, which is present in many cough preparations, is generally considered the preferred cough suppressant ingredient. However, codeine can be addictive, and because of possible abuse, most states require a prescription for its use. Drowsiness is a side effect, thus it may not be safe to use codeine when the person must remain alert, such as when driving a car. A suppressant that is not addictive is dextromethorphan, which can be found in many over-the-counter cold and cough remedies. An irritating, nonproductive cough in people without congestion may be treated appropriately with suppressants. Suppression of the productive cough is usually not recommended unless the patient is trying to sleep. If a productive cough is suppressed, secretions can be retained, leading to a pulmonary infection. Lozenges. Cough lozenges can often relieve mild, nonproductive coughs in people without congestion. A lozenge is a small, solid medication intended to be held in the mouth until it dissolves. Lozenges generally control coughs by the local anesthetic effect of benzocaine. The local anesthetic acts on sensory and motor nerves, controlling the primary irritation and inhibiting afferent and efferent impulses. Teaching about Cough Medications. Cough medications are readily available, and people who purchase them are usually eager for relief. Often, consumers take excessive amounts of more than one type. Teach about the appropriate choice of expectorants and suppressants and about misuse of cough mixtures. For example, cough syrups with a high sugar or alcohol content can disturb the metabolic balance of patients with diabetes mellitus or can trigger a relapse for recovering alcoholics. Preparations containing antihistamines have an anticholinergic action, which can cause serious problems for people with glaucoma or cause urinary retention in men with prostate enlargement. Other cough preparations can be detrimental to people with hypertension or thyroid or cardiac diseases. In addition, prolonged use of self-prescribed cough preparations can conceal more serious health problems. If a cough lasts more than 7 days, urge the person to contact the primary care provider. In addition, encourage the person to increase fluid intake if the secretions become too thick to expectorate.

Physiology of the Cardiovascular System

Blood is squeezed through the heart and out into the body by contractions starting in the atria, followed by contraction of the ventricles, with a subsequent resting of the heart. Deoxygenated blood (low in oxygen, high in carbon dioxide) is carried from the right side of the heart to the lungs, where oxygen is picked up and carbon dioxide is released, and then returned to the left side of the heart. This oxygenated blood (high in oxygen, low in carbon dioxide) is pumped out to all other parts of the body and back again (Fig. 38-6). The quantity of blood forced out of the left ventricle with each contraction is called the stroke volume (SV). The cardiac output (CO) is the amount of blood pumped per minute, which averages from 3.5 L/min to 8.0 L/min in a healthy adult (Grossman & Porth, 2014). This volume is determined by using the following formula: cardiac output = stroke volume × heart rate. Thus, the cardiac output of an adult with a stroke volume of 70 mL and a heart rate of 70 beats/min is 4.9 L/min. Cardiac output increases during physical activity and decreases during sleep; it also varies depending on body size and metabolic needs. Oxygen is carried via plasma and red blood cells. It is dissolved in plasma, but because oxygen is insoluble in liquids, little oxygen is carried in this way. The majority of oxygen is carried by the red blood cells. The hemoglobin in red blood cells has a strong affinity for oxygen. Therefore, most oxygen (97%) is carried in the body by red blood cells as part of hemoglobin in the form of oxyhemoglobin. Hemoglobin also carries carbon dioxide easily in the form of carboxyhemoglobin. Once the red blood cells reach the tissues, internal respiration must occur. Internal respiration is the exchange of oxygen and carbon dioxide between the circulating blood and the tissue cells. Any abnormality in the blood's components affects internal respiration. For example, hemorrhage or loss of blood can cause a decrease in cardiac output. A decrease in cardiac output causes a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Alternately, exercise can improve the transport of oxygen. Regular exercise contributes to more effective pumping of the heart muscle, and improved oxygen transport to cells.

capnography

Capnography is a method to monitor ventilation and, indirectly, blood flow through the lungs. Exhaled air passes through a sensor that measures the amount of carbon dioxide (CO2) exhaled with each breath. The reported results also provide information about the respiratory rate and depth, the presence of apnea, and efficiency of gas exchange. When carbon dioxide levels are abnormal, either high or low, adverse effects, including death, can occur. It is useful for confirming placement of advanced airways and nasogastric tubes, as well as identifying patients with low cardiac output and hypoventilation. Capnography can detect signs of hypoventilation earlier than pulse oximetry (Johnson, Schweitzer, & Ahrens, 2011). The use of capnography to verify nasogastric tube placement is discussed in Chapter 37.

performing chest physiotherapy (implementing)

Chest physiotherapy helps loosen and mobilize secretions, increasing mucous clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough. Chest physiotherapy includes percussion, vibration, and postural drainage. PERCUSSION Percussion of lung areas involves the use of a cupped palm to loosen pulmonary secretions so that they can be expectorated with greater ease. With the hand held in a rigid, dome-shaped position (Fig. 38-11), strike the area over the lung lobes to be drained in a rhythmic pattern. Position the patient in a lateral, supine, or prone position, based on the lobes to be treated. Proper hand and patient positioning will ensure that the patient does not experience any pain with this procedure. Percussion is never done on bare skin or performed over surgical incisions, below the ribs, or over the spine or breasts because of the danger of tissue damage. Typically, each area is percussed for 30 to 60 seconds several times a day. If the patient has tenacious secretions, the area may be percussed for up to 3 to 5 minutes several times per day. Patients may learn how to percuss the anterior surfaces of their own chest wall. In addition, it is a good idea to teach family members how to percuss posterior surfaces. Mechanical devices as well as manual handheld cupping devices also are available for percussion on the chest wall. VIBRATING Vibration uses manual compression and tremor on the patient's chest wall to help loosen respiratory secretions. Loosened secretions can be expectorated more easily. The practitioner uses rhythmic contraction and relaxation of arm and shoulder muscles while holding the hands flat on the patient's chest wall as the patient exhales. Vibration can be done for several minutes, several times a day. To avoid causing patient discomfort, vibration is never done over the patient's breasts, spine, sternum, and lower rib cage. Vibration (see Fig. 38-11) can also be taught to family members or accomplished using a mechanical device. FIGURE 38-11. (A) The cupping position and action of the hand on manual percussion of the lung area. (B) The position and action of the hands necessary to use vibration to loosen respiratory secretions in the lungs. (Photos by B. Proud.) PROVIDING POSTURAL DRAINAGE Postural drainage makes use of gravity to drain secretions from the lungs. Position the patient in a way that promotes the drainage of secretions from smaller pulmonary branches into larger ones, where they can be removed by coughing (Fig. 38-12). Vibration, percussion, or both often precede postural drainage. When implementing postural drainage, have tissues and an emesis basin close at hand for the patient to use when coughing and expectorating secretions. Place the patient in an appropriate position to promote drainage from the lobes of the lungs. Postural drainage should be done two to four times a day for 20 to 30 minutes. Discontinue the drainage if the patient begins to feel weak or faint. Delay postural drainage for 1 to 2 hours after meals to avoid provoking vomiting. Appropriate positioning to achieve postural drainage is as follows: Use high Fowler's position to drain the apical sections of the upper lobes of the lungs. Place the patient in a lying position, half on the abdomen and half on the side, right and left, to drain the posterior sections of the upper lobes of the lungs. Place the patient lying on the left side with a pillow under the chest wall to drain the right lobe of the lung. Place the patient in the Trendelenburg position to drain the lower lobes of the lungs.

promoting and controlling coughing overview(implementing)

A cough is a cleansing mechanism of the body. It is a means of helping to keep the airway clear of secretions and other debris. A cough that is dry is termed a nonproductive cough. A cough that produces respiratory secretions is termed a productive cough. The respiratory secretion expelled by coughing or clearing the throat is called sputum. When there are excessive fluids or secretions in an organ or body tissue, the patient is said to be congested. Thus, a person with secretions or fluid in the lungs is said to have congested lungs. If the cough is dry, the patient is said to be congested with a nonproductive cough. If the cough produces sputum, the patient is said to be congested with a productive cough. Thick respiratory secretions are sometimes called phlegm. A patient who is coughing and does not have any congestion or secretions produced is said to be noncongested with a nonproductive cough. A series of events produce a cough. The cough mechanism (Fig. 38-10) consists of an initial irritation; a deep inspiration; a quick, tight closure of the glottis together with a forceful contraction of the expiratory intercostal muscles; and an upward push of the diaphragm. This causes an explosive movement of air from the lower to the upper respiratory tract. To be effective, a cough should have enough muscle contraction to force air to be expelled and to propel a liquid or a solid on its way out of the respiratory tract. Coughing is most effective when the patient is sitting upright with feet flat on the floor. Coughing can be voluntary or involuntary.

thoracentisis assessment procedure

A thoracentesis is usually carried out with the patient sitting on a chair or the edge of the bed with the legs supported and the arms folded and resting on a pillow on the bedside table (Fig. 38-9). If unable to sit up, the patient may lie on the unaffected side with the hand of the affected side raised above the shoulder. The location where the needle is inserted depends on where the fluid is present and where the practitioner can best aspirate it. Once this spot is identified, the skin is cleansed with an antimicrobial agent. A local anesthetic is administered and then the needle is inserted between the ribs through the intercostal muscles and fascia and into the pleura. After the procedure, the needle or plastic catheter is removed and a small sterile dressing is placed over the entry site. During thoracentesis, fluid or air can be removed from the pleural cavity with a syringe. Another method for removing fluid is to drain the fluid into a bottle in which a partial vacuum has been created. With this technique, a small plastic catheter may be threaded through the needle, allowing the needle to be withdrawn. This catheter reduces the possibility of puncturing the lung. When this method is used, the tubing connecting the needle and the bottle must be sterile. Commonly, a calibrated bottle is used to collect the drainage, allowing the amount of fluid removed to be determined. The maximum amount of fluid removed is generally 1,000 mL. Nursing Responsibilities. The nurse is responsible for collecting baseline data before the procedure and for preparing the patient physically and emotionally for the procedure. Instruct the patient not to cough or breathe deeply during the procedure. Urge the patient to remain as still as possible to diminish the risk for accidental injury to the lung. Administer analgesics before the procedure as ordered. During the procedure, observe the patient's reactions. Monitor the patient's color, pulse, and respiratory rates, reporting immediately to the primary care provider any deviation from the patient's baseline. Fainting, nausea, and vomiting may occur. Ensure that specimens, if obtained, are taken to the laboratory immediately. After the procedure, assess the patient for changes in vital signs, particularly respirations. If a large amount of fluid was removed, respirations usually become easier. If the lung was punctured, respiratory distress becomes acute. If blood appears in the sputum or the patient has severe coughing, notify the primary care provider promptly. A chest radiograph is usually done after the procedure to verify the absence of complications.

administering and teaching about inhaled medications(implementing)

ADMINISTERING INHALED MEDICATIONS Inhaled medications may be administered to open narrowed airways ( bronchodilators), to liquefy or loosen thick secretions (mucolytic agents), or to reduce inflammation in airways (corticosteroids). These medications typically are administered via nebulizer, metered-dose inhaler, or dry powder inhaler. Refer to Guidelines for Nursing Care 28-8 for pictures of these devices. Nebulizers disperse fine particles of liquid medication into the deeper passages of the respiratory tract, where absorption occurs. The treatment continues until all the medication in the nebulizer cup has been inhaled. A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. Common mistakes that patients make when using MDIs include the following: Failing to shake the canister Holding the inhaler upside down Inhaling through the nose rather than the mouth Inhaling too rapidly Stopping the inhalation when the cold propellant is felt in the throat Failing to hold their breath after inhalation Inhaling two sprays with one breath To use an MDI, the patient must activate the device while continuing to inhale. For some patients, especially young children and older adults, a spacer or extender device may be necessary to aid delivery of medication by the inhalation route. The spacer acts as a reservoir. When the MDI is compressed, the medication is deposited in the reservoir, and the patient then inhales the medication from the spacer device. This makes administration less complicated, the dose more predictable, and enhances the delivery of medication to the lungs. Dry powder inhalers (DPI) are another type of delivery method for inhaled medications. DPIs are breath activated. A quick deep breath by the patient activates the flow of medication, eliminating the need to coordinate activating the inhaler (spraying the medicine) while inhaling the medicine at the same time. DPIs require less manual dexterity than do MDIs. DPIs are actuated by the patient's inspiration, so there is no need to coordinate the delivery of puffs with inhalation. Many types of DPIs are available with distinctive operating instructions. Some have to be loaded with a dose of medication each time they are used. Some hold a preloaded number of doses. It is important to understand the particular instructions for the medication being used. One disadvantage of DPIs is that the medication in DPIs will clump if exposed to humidity. TEACHING PATIENTS ABOUT INHALED MEDICATIONS Patients need repeated instruction on how to use inhalers and nebulizers effectively and safely. Overuse may result in serious side effects and eventual ineffectiveness of the medication. Nebulizers require cleaning after use, thus patients must understand how to do this correctly. Patients must understand that it is important to keep track of dosing with MDIs. A few MDIs have integrated dose counters, but most do not, and it can be difficult to know when the canister is empty. Patients must understand the importance of keeping track of dosing to ensure that they are not using an empty canister. Most DPIs have a dose counter, so patients have accurate information about when to refill the medication. Patients should not exhale into the DPI, as they risk blowing out the medication. Information about how to use MDIs, DPIs, and small-volume nebulizers properly, including patient teaching information, is provided in Chapter 28, Guidelines for Nursing Care 28-8. Package inserts with the medication also reinforce correct technique for using inhalers. To ensure correct administration when a spacer is used, slow, deep inspirations are necessary. To prevent inhaling too quickly, some spacers are equipped with a whistle device that sounds if inhalation is too rapid. A spacer is also recommended for patients using corticosteroid inhaled agents because it reduces the risk of acquiring an oral fungal infection.

perfusion (physiology)

Oxygenated capillary blood passes through the tissues of the body in the process called perfusion. The amount of blood flowing through the lungs is a factor in the amount of oxygen and other gases that are exchanged. The amount of blood present in any given area of lung tissue depends partially on whether the person is sitting, standing, or lying down. Perfusion is greater in dependent areas. The perfusion of lung tissue also depends on the person's activity level. Greater activity results in an increased need for cellular oxygen by the body's tissues and a subsequent increase in cardiac output and consequently in increased blood return to the lungs. In addition, perfusion to the body's tissues depends on an adequate blood supply and proper cardiovascular functioning to carry oxygen and carbon dioxide to and from the lungs (discussed later).

palpation assessment

Palpate the chest. Note skin temperature and color. Skin temperature in this area is typically the same as the rest of the body. Assess chest expansion (thoracic excursion), which should be symmetrical. Note the presence or absence of masses, edema, or tenderness on palpation. Palpate the point of maximal impulse (PMI). Note pulsations in any other area of the chest. Abnormal size or location of the PMI or the presence of vibrations can indicate heart failure, myocardial infarction, disease of the heart valves, or other cardiac diseases. Palpate the patient's extremities. Assess skin temperature and color, pulses, and capillary refill. Note the presence or absence of edema, or tenderness on palpation. The presence of decreased skin temperature, pallor, cyanosis, decreased pulses, and prolonged capillary refill can indicate less than optimal cardiac function and oxygenation. The presence of edema an also indicate alterations in cardiovascular function. Refer to Chapter 25 for a detailed discussion of palpation as part of the assessment of the respiratory and cardiovascular systems.

managing chest tubes

Patients with fluid ( pleural effusion), blood ( hemothorax), or air ( pneumothorax) in the pleural space require a chest tube to drain these substances and allow the compressed lung to re-expand. A chest tube is a firm plastic tube with drainage holes in the proximal end that is inserted in the pleural space. Once inserted, the tube is secured with a suture and tape, covered with an airtight dressing, and attached to a drainage system that may or may not be attached to suction. Other components of the system may include a closed water-seal drainage system that prevents air from re-entering the chest once it has escaped and a suction control chamber that prevents excess suction pressure from being applied to the pleural cavity. The suction chamber may be a water-filled or a dry chamber. A water-filled suction chamber is regulated by the amount of water in the chamber, whereas dry suction has a one-way mechanical valve system that allows air to leave the chest and prevents air from moving back into the chest and is automatically regulated to changes in the patient's pleural pressure. Most health care agencies use a molded plastic, three-compartment disposable chest drainage unit for management of chest tubes (Fig. 38-14). There are also portable drainage systems that utilize gravity for drainage. Table 38-6 compares different types of chest drainage systems. The type of drainage determines the placement of the chest tube. When air is to be drained, the tube is placed higher in the chest. If fluid needs to be drained, the tube is inserted lower in the lung because fluids settle at the base of the lung. Nursing responsibilities include assisting with insertion and removal of a chest tube. Once the tube is in place, monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system. Guidelines for monitoring a patient with a chest tube are shown in Guidelines for Nursing Care 38-3. FIGURE 38-14. A chest drainage system attached to a patient. (Photo by Rick Brady.) Removal of chest tubes can be a painful and stressful process for patients. Whenever possible, administer analgesics prior to the tube removal, at a sufficient interval to allow for the medication to take effect, based on the medication prescribed. The application of cold to the chest prior to removal has also been shown to decrease patient discomfort during chest tube removal. Refer to the accompanying Research in Nursing box. Nursing responsibilities related to chest tube removal also include providing emotional support for the patient, as well as monitoring the patient's status after removal. Monitor the patient's respiratory status, vital signs, pain, and site dressing.

percussion

Percussion is used to assess the position of the lungs, density of lung tissue, and identify changes in the tissue. This assessment skill is not used frequently. When used, it is usually included in examinations performed by advanced practice nurses and other advanced practice professionals. Refer to Chapter 25 for a detailed discussion of percussion as part of the assessment of the respiratory and cardiovascular systems.

positive airway pressure

Positive airway pressure (PAP) therapy uses mild air pressure to keep airways open. This treatment can help the body better maintain carbon dioxide and oxygen levels in the blood. PAP therapy may be used to treat many adult disorders, such as sleep apnea, obstructive sleep apnea, obesity hypoventilation syndrome, and heart failure. It also may be used to treat preterm infants whose lungs have not fully developed. Continuous positive airway pressure (CPAP) provides continuous mild air pressure to keep airways open. Bilevel positive airway pressure (BiPAP) changes the air pressure while the patient breathes in and out. Both therapies use a mask or other device that fits over the nose or nose and mouth. Straps keep the mask in place. A tube connects the mask to the machine's motor, which blows air into the tube (National Heart Blood and Lung Institute [NHLBI], 2011). Adjusting to the therapy and machine can take time. Patients report feeling strange wearing a mask on the face at night or feeling the flow of air. Some people feel confined by the mask. Nurses can assist patients by reinforcing accurate information about treatment; encourage patients to ease into use of the device. It may help for patients to start by practicing wearing just the mask for short periods of time while awake, for example, while watching TV. Then patients should try wearing the mask and hose with the air pressure on, still during the daytime, while awake. Once patients become accustomed to how the equipment feels, they should shift to using the device every time they sleep—at night and during naps. Inconsistently wearing the device may delay getting used to it. Provide support and encouragement so that the patient persists with the therapy; it may take several weeks or more to see if the mask and pressure settings will work for the patient. In addition, relaxation exercises help some people adjust to using these therapies (NHLBI, 2012a). If the device is used in the hospital or other facility, nursing responsibilities also may include monitoring the settings, ensuring correct use by the patient, and assessment of respiratory status. Careful assessment of the patient's skin on the face, in the areas the mask sits, is an important part of care. Pressure from the mask can cause alterations in skin integrity.

pulmonary function studies assessment

Pulmonary function studies encompass a group of tests used to assess respiratory function to assist in evaluating respiratory disorders. They provide an evaluation of lung dysfunction, diagnose disease, assess disease severity, assist in management of disease, and evaluate respiratory interventions. Most tests are administered by a respiratory therapist, technician, nurses with specialized training, or physicians. Several tests commonly encountered are described in the next section. More specialized tests and their purposes include: Diffusion capacity estimates the patient's ability to absorb alveolar gases and determine if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Exercise testing helps evaluate dyspnea during exertion.

pulmonary ventillation part 1

Pulmonary ventilation (breathing) is the movement of air into and out of the lungs. The process of ventilation has two phases: inspiration (inhalation) and expiration (exhalation). Inspiration, the active phase, involves movement of muscles and the thorax to bring air into the lungs. Expiration, the passive phase, is the movement of air out of the lungs. During inspiration, the following events occur: the diaphragm contracts and descends, lengthening the thoracic cavity; the external intercostal muscles contract, lifting the ribs upward and outward; and the sternum is pushed forward, enlarging the chest from front to back. This combination of an increased lung volume and decreased intrapulmonic pressure allows atmospheric air to move from an area of greater pressure (outside air) into an area of lesser pressure (within the lungs). The relaxation, or recoil, of these structures then results in expiration. The diaphragm relaxes and moves up, the ribs move down, and the sternum drops back into position. This causes a decreased volume in the lungs and an increase in intrapulmonic pressure. As a result, air in the lungs moves from an area of greater pressure to one of lesser pressure and is expired (Fig. 38-2). Other physical factors contribute to airflow in and out of the lungs. These factors include the condition of the musculature, compliance of lung tissue, and airway resistance. The condition of the body's musculature can affect the process of respiration. Weakening of the muscles involved in respiration can contribute to less effective inhalation and exhalation. The accessory muscles of the abdomen, neck, and back are used to maintain respiratory movements at times when breathing is difficult. These muscles are used to facilitate breathing; the movement is called retraction.

pulse oximetry assessment

Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. The reported result is a ratio, expressed as a percentage, between the actual oxygen content of the hemoglobin and the potential maximum oxygen-carrying capacity of the hemoglobin (Van Leeuwen, Poelhuis-Leth, & Bladh, 2011). Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and monitoring postoperative patients. Pulse oximetry does not replace arterial blood gas analysis. Desaturation (decreased level of SpO2) indicates gas exchange abnormalities. Oxygen desaturation is considered a late sign of respiratory compromise in patients with reduced rate and depth of breathing (Johnson, Schweitzer, & Ahrens, 2011). Be aware of the patient's hemoglobin level before evaluating oxygen saturation because the test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a patient with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the patient may not have enough oxygen to meet body needs. A range of 95% to 100% is considered normal SpO2; values ≤90% are abnormal, indicate that oxygenation to the tissues is inadequate, and should be investigated for potential hypoxia or technical error.

spirometry in pft (assessment)

Spirometry measures the volume of air in liters exhaled or inhaled by a patient over time. It evaluates lung function and airway obstruction through respiratory mechanics. Spirometry can be used to measure the degree of airway obstruction and evaluates response to inhaled medications. The patient inhales deeply and exhales forcefully into a spirometer, an instrument that measures lung volumes and airflow. Patients also use spirometers to promote deep breathing while recovering from surgery, and to monitor health status in management of chronic asthma. A discussion regarding the use of incentive spirometers can be found later in this chapter. Peak Expiratory Flow Rate. Peak expiratory flow rate (PEFR) refers to the point of highest flow during forced expiration. PEFR reflects changes in the size of pulmonary airways and is measured using a peak flow meter. It is routinely used for patients with moderate or severe asthma to measure the severity of the disease and degree of disease control. With the patient standing or sitting with the back positioned as straight as possible, the patient takes a deep breath and places the peak flow meter in the mouth, closing the lips tightly around the mouthpiece. The patient forcibly exhales into the peak flow meter, and an indicator on the meter rises to a number. The patient is asked to repeat this three times, and the highest number is recorded. This produces a measurement in liters indicating the maximum flow rate during a forced expiration. Normal values are established in regard to height, age, and gender, as well as individual baseline values for patients with disease. Patients with asthma commonly measure PEFR at home to monitor airflow. The results are used to track disease progression and regulate treatment by the patient and clinician.

suctioning the airway(implementing)

Suctioning of the pharynx is indicated to maintain a patent airway and to remove saliva, pulmonary secretions, blood, vomitus, or foreign material from the pharynx. Suctioning of the oropharynx or nasopharynx may be indicated if the patient is able to raise secretions from the airways but unable to clear from the mouth. Refer to Skill 38-2. The frequency of suctioning varies with the amount of secretions present but should be done often enough to keep ventilation effective and as effortless as possible. If the patient is unable to raise secretions from the airways, tracheal suctioning may be indicated. Tracheal suctioning is discussed later in the chapter. Suctioning irritates the mucosa and removes oxygen from the respiratory tract, possibly causing hypoxemia (insufficient oxygen in the blood). Thus, it is important to preoxygenate the patient before suctioning. This is accomplished by applying or increasing supplemental oxygen and having the patient take several deep breaths before inserting the catheter. When performed correctly, suctioning provides comfort by relieving respiratory distress. When performed incorrectly, it can increase anxiety and pain and cause respiratory arrest. At minimum, it is an uncomfortable procedure and it can be a very painful and/or distressing experience. Individualized pain management must be performed in response to the patient's needs (Arroyo-Novoa et al., 2008). Anticipate the administration of analgesic medication to a patient who has had surgery or other trauma before suctioning, because the cough reflex will be stimulated. Possible complications of suctioning include infection, cardiac arrhythmias, hypoxia, mucosal trauma, and death. Wear gloves on both hands, goggles, and a mask—and a gown, if necessary—for protection from microorganisms. Continuously monitor the patient's color and heart rate and the color, amount, and consistency of secretions. If cyanosis, an excessively slow or rapid heart rate, or suddenly bloody secretions are noted, stop suctioning immediately, administer oxygen, and notify the physician. Cyanosis and a change in heart rate can indicate hypoxemia. Blood can indicate damage to the mucosa.

managing artificial airway part 2

TRACHEOSTOMY A tracheostomy tube is inserted for a variety of reasons. It may be used to replace an endotracheal tube, to provide a method for mechanical ventilation of the patient, to bypass an upper airway obstruction, or to remove tracheobronchial secretions. The tube is made of semi-flexible plastic (polyurethane or silicone), rigid plastic, or metal and is available in different sizes with varied angles. The condition and needs of the patient determine the selection of either a metal or plastic tracheostomy tube. Although metal tubes are more cost-effective for long-term use, most do not have an adapter at the neck plate that permits connection to respiratory therapy equipment (e.g., an oxygen delivery system, Ambu bag, or mechanical ventilator). A tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. An obturator, which guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place (Fig. 38-16). Many tubes also have inner cannulas that may or may not be disposable. The outer cannula remains in place in the trachea, and the inner cannula is removed for cleaning or replaced with a new one. Periodic cleaning or replacement of the inner cannula prevents airway obstruction from secretions that have accumulated on the tube's inner surface. A tube with an inner cannula is necessary when patients have excessive secretions or have difficulty clearing their secretions. It also may be recommended for a patient who will be discharged with a tracheostomy tube in place. Tracheostomy tubes may be either cuffed or cuffless (see Fig. 38-16). The inflated cuff seals the opening around the tube to create a tight fit in the trachea. This prevents air leakage and aspiration, and permits mechanical ventilation. Newer tracheal cuffs are low pressure, do not require deflating for short intervals every few hours, and can be maintained at lower than tracheal capillary pressure. If a cuffed tube is used, always deflate it before oral feeding unless the patient is at high risk for aspiration. If left cuffed, the balloon can cause pressure that extends through the trachea and onto the esophagus, possibly impeding swallowing or causing erosion of the tissue. A fenestrated tracheostomy tube has one large or several small openings or windows on its outer curve, has an inner cannula, and can be cuffed or cuffless. When the patient is being mechanically ventilated, the inner cannula is in place, blocking the small openings. After the patient is no longer connected to the ventilator, the inner cannula can be removed, the cuff deflated, and the tube plugged, allowing the patient to speak. Because the tube has these openings, it is not recommended for use in patients with a history of aspiration. The tracheostomy tube is held in place by twill tapes or a Velcro strip fastened around the patient's neck. When the tracheostomy is new, a sterile, square gauze pad that has been precut by the manufacturer may be placed between the skin and outer wings of the tube. This tracheostomy dressing must be kept dry to prevent infection and skin irritation. Regularly check cuff pressure, although some tubes have a pressure-release valve that prevents pressure from increasing to damaging levels. Also, because the tracheostomy tube bypasses the natural humidifying and heating mechanisms in the nose and mouth, administer heated, humidified oxygen to prevent secretions from becoming dry. Keep the tracheostomy tube free from foreign objects and nonsterile materials, such as cotton balls, loose threads from dressings, needles, and other small objects, to reduce the risk of obstruction and infection. Artificial noses, small pieces that attach over the end of the tracheostomy tube, are available to filter and warm the air before it enters the trachea. Preparation for emergency situations is an important part of nursing care for these patients. The tracheostomy is the patient's only airway, and measures to maintain its patency need to be readily available. Standard bedside equipment for emergency use should include the obturator from the current tube, suction equipment, oxygen, a spare tracheostomy tube of the same size, and one a size smaller (Freeman, 2011; Roman, 2005). Patients with tracheostomies frequently have an ineffective cough mechanism and copious secretions, which necessitate tracheal suctioning to remove secretions. Refer to the discussion related to tracheal suctioning later in the chapter. Providing Tracheostomy Care. The nurse is responsible for replacing a disposable inner cannula or cleaning a nondisposable one. The inner cannula requires cleaning or replacement to prevent accumulation of secretions that can interfere with respiration and occlude the airway. Because soiled tracheostomy dressings place the patient at risk for the development of skin breakdown and infection, regularly change dressings and ties. Use gauze dressings that are not filled with cotton to prevent aspiration of foreign bodies (e.g., lint or cotton fibers) into the trachea. Clean the skin around a tracheostomy to prevent buildup of dried secretions and skin breakdown. Exercise care when changing the tracheostomy ties to prevent accidental decannulation or expulsion of the tube. Have an assistant hold the tube in place during the change or keep the soiled tie in place until a clean one is securely attached. Agency policy and patient condition determine specific procedures and schedules, but a newly inserted tracheostomy may require attention every 1 to 2 hours. Skill 38-5 outlines tracheostomy care.

anatomy of the respiratory system

The airway, which begins at the nose and ends at the terminal bronchioles, is a pathway for the transport and exchange of oxygen and carbon dioxide. The airway is divided into the upper and the lower airways. The upper airway is composed of the nose, pharynx, larynx, and epiglottis. Its main function is to warm, filter, and humidify inspired air. The lower airway, known as the tracheobronchial tree, includes the trachea, right and left main stem bronchi, segmental bronchi, and terminal bronchioles (Fig. 38-1). Its major functions are conduction of air, mucociliary clearance, and production of pulmonary surfactant. The airways are lined with mucus, which traps cells, particles, and infectious debris. This mucus covering also helps to protect the underlying tissues from irritation and infection. Cilia, which are microscopic hair-like projections, propel trapped material and accompanying mucus toward the upper airway so they can be removed by coughing. Removal is facilitated when mucus is watery in consistency. An adequate fluid intake is necessary for ciliary action and for the production of watery mucus normally present in the respiratory tract. The lungs, the main organs of respiration, are located within the thoracic cavity on the right and left sides (see Fig. 38-1). The lungs extend from the base at the level of the diaphragm to the apex (top), which is above the first rib. The heart lies between the right and left lung.

anatomy of the cardiovascular system

The cardiovascular system is composed of the heart and the blood vessels. The heart is the main organ of circulation, the continuous one-way circuit of blood through the blood vessels, with the heart as the pump (Taylor & Cohen, 2013). The heart lies in the thoracic cavity between the lungs, in the center and somewhat to the left of the body's midline (Fig. 38-4). The heart is a cone-shaped, muscular pump, divided into four hollow chambers. The upper chambers, the atria (singular, atrium), receive blood from the veins (the superior and inferior vena cava and the left and right pulmonary veins). The lower chambers, the ventricles, force blood out of the heart through the arteries (the left and right pulmonary arteries and the aorta). One-way valves that direct blood flow through the heart are located at the entrance (tricuspid and mitral valves) and exit (pulmonary and aortic valves) of each ventricle (Fig. 38-5). The blood vessels form a closed circuit of tubes that carry blood between the heart and the body cells. Arteries and arterioles conduct blood away from the ventricles to the capillaries and the venules and veins, and return blood from the capillaries to the atria. Capillaries function in the exchange of substances between the blood and the body cells.

blood flow in the cardiovascular system

The muscles of the heart have their own blood vessels that provide oxygen and nourishment and remove waste products. The main blood vessels that provide coronary circulation are the right and left coronary arteries, which branch off the aorta. They encircle the heart and branch out to all regions of the heart. The coronary arteries fill with blood during relaxation of the ventricles. The blood returns to the right atrium after passing through the heart muscle via the cardiac veins.

nursing history in assessment

The nursing history, an important clinical tool in the early steps of the nursing process, always includes a cardiopulmonary component. The information gained provides data about why the patient needs nursing care and what kind of care is required to maintain sufficient oxygenation of tissues. Interview questions help identify current or potential health deviations, actions performed by the patient for meeting cardiopulmonary needs, and the effects of such actions. They also help identify any contributing factors, the use of any aids to improve oxygenation, and effects of health problems on the patient's lifestyle and relationships with others. Before starting the interview, make certain that the patient is not in acute distress. If the patient is experiencing any respiratory distress, initiate appropriate actions immediately to help relieve symptoms. Enlist the aid of family members or others to help answer questions. Interview the patient at a later point, when the patient is able, to expand the initial database. If no emergency interventions are necessary for the patient's clinical condition, obtain a comprehensive history at this time. When a health deviation is noted during the data collection, collect as much descriptive information as possible, including whether the problem evolved suddenly or slowly. The accompanying Focused Assessment Guide 38-1 provides some appropriate questions for health history assessment related to oxygenation.

assessing (oxygenation)

The patient's health history is an essential component for assessing the patient's cardiopulmonary function and ability to maintain adequate oxygenation. This information can be obtained from either the patient or a family member. The nursing examination combined with laboratory findings can provide information to identify a patient's strengths; the nature of any problems; their course; related signs and symptoms; and onset, frequency, and effects on activities of daily living. The nurse decides, based on these findings, what problems can be treated independently by nursing. Other problems are referred to a physician and/or other collaborative professionals for decisions on treatment

regulation of the respiratory system

The respiratory center is located in the medulla in the brainstem, immediately above the spinal cord. It is stimulated by an increased concentration of carbon dioxide and hydrogen ions and, to a lesser degree, by the decreased amount of oxygen in the arterial blood. In addition, chemoreceptors in the aortic arch and carotid bodies are sensitive to the same arterial blood gas (measurement of blood pH, and arterial oxygen and carbon dioxide) levels and blood pressure, and can activate the medulla. Proprioceptors in the muscles and joints respond to body movements, such as exercise, and cause an increase in ventilation. Stimulation of the medulla increases the rate and depth of ventilation (both inspiration and expiration) to blow off carbon dioxide and hydrogen and increase oxygen levels (the patient is breathing faster and more deeply). The medulla sends an impulse down the spinal cord to the respiratory muscles to stimulate a contraction leading to inhalation. If a condition causes a chronic change in the oxygen and carbon dioxide levels, these chemoreceptors may become desensitized and not regulate ventilation adequately.

thoracentisis assessment

Thoracentesis is the procedure of puncturing the chest wall and aspirating pleural fluid. The pleural cavity is a potential cavity because it is normally not distended with fluid or air. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or it can be performed in the radiology department. The patient is required to sign a permit for this procedure. A thoracentesis may be performed to obtain a specimen for diagnostic purposes or to remove fluid that has accumulated in the pleural cavity and is causing respiratory difficulty and discomfort. Because the cavity being entered is sterile, surgical asepsis is required. Standard precautions also are used.

commonly measured values from pulmonary functions test

Tidal volume (TV): Total amount of air inhaled and exhaled with one breath Vital capacity (VC): Maximum amount of air exhaled after maximum inspiration Forced vital capacity (FVC): Maximum amount of air that can be forcefully exhaled after a full inspiration Forced expiratory volume (FEV): The amount of air exhaled in the first second after a full inspiration; can also be measured at 2 or 3 seconds Total lung capacity (TLC): The amount of air contained within the lungs at maximum inspiration Residual volume (RV): The amount of air left in the lungs at maximal expiration Peak expiratory flow rate (PEFR): The maximum flow attained during the FVC

voluntary and involuntary coughing (implementing)

VOLUNTARY COUGHING When a cough does not occur as a result of reflex stimulation of the cough-sensitive areas, it can be induced voluntarily. Teaching the patient to cough voluntarily is an important aspect of preoperative and postoperative care. Coughing is more effective when combined with deep breathing. Although teaching a patient to cough and deep breathe is relatively easy, experience has shown that it is difficult to motivate patients to follow through and perform coughing on their own. Refer to Guidelines for Nursing Care 29-2: Effective Coughing,, for detailed instructions for teaching this intervention. Frequently remind patients to perform effective coughing throughout the day. Develop a specific schedule for coughing on the patient's plan of care. Coughing early in the morning after rising removes secretions that have accumulated during the night. Coughing before meals improves the taste of food and oxygenation. At bedtime, coughing removes any buildup of secretions and improves sleep patterns. For a patient who is unable to cough voluntarily, manual stimulation over the trachea and prolonged exhalation can be helpful. If neither of these methods is successful, mechanical endotracheal suctioning with a catheter may be necessary. If the patient has a neuromuscular disorder and is unable to cough physically, an assisted cough may be used. For an assisted cough, firm pressure is placed on the abdomen below the diaphragm in rhythm with exhalation. This pressure is similar to the Heimlich maneuver, but with less force. This pressure is used to substitute for the weakened or paralyzed abdominal muscles. INVOLUNTARY COUGHING Involuntary coughing often accompanies respiratory tract infections and irritations. Many times respiratory infections lead to the production of respiratory secretions. These secretions can trigger the cough mechanism. When the cough is productive, it helps clear the airway. However, when the cough is nonproductive, it can be fatiguing and irritating. Medications may control involuntary coughing. Refer to the next section, Cough Suppressants. Observation of the patient's breathing and coughing characteristics is necessary to determine the appropriate type of medication.

tracheal suctioning(implementing)

When performed correctly, suctioning provides comfort by relieving respiratory distress. When performed incorrectly, it can increase anxiety and pain and cause respiratory arrest. Tracheal suctioning may be performed by passing a sterile catheter through a tracheostomy or endotracheal tube. Suctioning to remove secretions is performed using the sterile technique as described in Chapter 23. The frequency of suctioning varies with the amount of secretions present but should be done often enough to keep ventilation effective and as effortless as possible. The suction catheter should be small enough not to occlude the airway being suctioned but large enough to remove secretions. Several sizes of catheters are available. Wear gloves on both hands, goggles, and a mask—and a gown, if necessary—for protection from microorganisms. Tracheal suctioning is an uncomfortable procedure at minimum, and it can be a very painful and/or distressing experience. Therefore, anticipate assessing for the need for the administration of analgesic medication to a patient before suctioning (Arroyo-Novoa et al., 2008). However, only perform suctioning when clinically necessary because there are many potential risks. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. Sterile technique is used for tracheal suctioning, to reduce the risk of introduction of disease-causing organisms. In the home setting, clean technique is used, as the patient is not exposed to disease-causing organisms that may be found in health care settings, such as hospitals (American Association for Respiratory Care [AARC], 1999). Closely assess the patient before, during, and after the procedure to limit negative effects. In order to prevent hypoxia, hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80-150 mm Hg) will help prevent atelectasis related to the use of high negative pressure (Hess, et al., 2012). Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis (Hess et al., 2012; Pate, 2004). Skill 38-6 describes suctioning a tracheostomy with an open system. The procedure is similar for an endotracheal tube. A closed airway suction system can be used to keep the airway patent for a patient with an endotracheal or tracheostomy tube who is receiving continuous mechanical ventilation, and reduce the risk of hypoxemia or, possibly, infection (Fig. 38-17). The catheter, encased in a plastic sleeve, remains connected to the patient's airway or ventilator tubing for up to 24 hours. This closed system is cost-effective because only one catheter is used daily, and the caregiver has additional protection from exposure to the patient's secretions. Some systems have an access valve, a safety feature that completely closes off access between the suction catheter and the endotracheal tube.

other nursing process oxygenation

Diagnosing The data collected about the patient's cardiopulmonary status may lead to the development of one or more nursing diagnoses related to alterations in oxygenation. The etiology of the problem directs nursing interventions. Data collected during the nursing assessment may also lead to the identification of a collaborative problem. Alterations in Oxygenation as the Problem After the assessment is completed and the data are examined, the nurse concludes either that there is no problem at this time or that there is an actual or potential oxygenation problem that is amenable to independent or interdependent nursing actions. Examples of nursing diagnoses indicating alterations in oxygenation include: Ineffective Airway Clearance Decreased Cardiac Output Impaired Gas Exchange Examples of these diagnoses, etiologic factors, and defining characteristics appear in Examples of NANDA-I Nursing Diagnoses: Oxygenation. Alterations in Oxygenation as the Etiology An alteration in oxygenation may affect other areas of human functioning. Examples of nursing diagnoses for which problems with oxygenation are the etiology for other problems include: Activity Intolerance related to imbalance between oxygen supply and demand Anxiety related to feeling of suffocation Fatigue related to impaired oxygen transport system Imbalanced Nutrition: Less Than Body Requirements, related to difficulty breathing Disturbed Sleep Pattern related to orthopnea and bronchodilators Outcome Identification and Planning When caring for patients with an alteration in oxygenation, nursing measures support the following general expected outcomes. The patient will: Demonstrate improved gas exchange in the lungs by an absence of cyanosis or chest pain and a pulse oximetry reading more than 95% Relate the causative factors, if known, and demonstrate a method of coping with these factors Preserve cardiopulmonary function by maintaining an optimal level of activity Demonstrate self-care behaviors that provide relief from symptoms and prevent further cardiopulmonary problems When the patient's physical, psychosocial, and spiritual dimensions contribute to alterations in oxygenation, individualized expected outcomes are developed with the patient's input (e.g., "By March 15, the patient will be able to walk up one flight of steps at home without dyspnea.").

anatomy of the respiratory system part 2

Each lung is divided into lobes. The right lung has three lobes; the left has two. Each lobe is subdivided into segments or lobules. The main bronchus branches to each lung from the trachea. It immediately subdivides into secondary bronchi, one to each lobe. The bronchi subdivide again and again, becoming smaller and smaller as they branch through the lung. The smallest of these branches are the bronchioles, ending at the terminal bronchioles. The lungs are composed of elastic tissue that can stretch or recoil. At the end of the terminal bronchioles there are clusters of alveoli (singular, alveolus), small air sacs. The alveoli are the site of gas exchange. The wall of each alveolus is made of a single-cell layer of squamous epithelium (see Fig. 38-1). This thin wall allows for exchange of gases with the capillaries covering the alveoli. The average adult has more than 300 million alveoli. Surfactant, a detergent-like phospholipid, reduces the surface tension between the moist membranes of the alveoli, preventing their collapse. When surfactant production is reduced, the lung becomes stiff and the alveoli collapse. The lungs and thoracic cavity are lined with a serous membrane called the pleura. The visceral pleura covers the lungs, and the parietal pleura lines the thoracic cavity. These two membranes are continuous with each other and form a closed sac. The pleural space lies between the two layers. Pleural fluid between the membranes acts as a lubricant and as an adhesive agent to hold the lungs in an expanded position. A few milliliters of fluid between the pleural surfaces allows the lungs to move easily along the chest wall as they expand and contract. Without this fluid, filling and emptying of the lungs are difficult. Pressure within the pleural space (intrapleural pressure) is always subatmospheric (a negative pressure). This constant negative intrapleural pressure, along with the pleural fluid, holds the lungs in an expanded position.

regulation of the cardiovascular system

Electrical impulses produced in and carried over specialized tissue within the heart control contraction of the muscles of the heart. These tissues make up the heart's conduction system (Fig. 38-7). The sinoatrial (SA) node is a mass of tissue in the upper right atrium, just below the opening of the superior vena cava. This node initiates the transmission of electrical impulses, causing contraction of the heart at regular intervals. It is also referred to as the pacemaker. After initiation, the electrical impulse travels throughout the muscle of each atrium, causing contraction of the atrium. The impulse also travels at the same time to the atrioventricular (AV) node, located at the bottom of the right atrium. When the impulse reaches the AV node, it enters a group of fibers called the atrioventricular bundle, or bundle of His. This bundle divides into right and left branches. Smaller conduction myofibers (Purkinje fibers) branch off, traveling throughout the ventricles. The right branch extends to the walls of the right ventricle and the left branch travels through the left ventricle. The electrical impulse continues through the atrioventricular bundle and the Purkinje fibers, causing contraction of the ventricles. The contraction of the ventricles, which occurs just a moment after the atrial contractions, completes a cardiac cycle, or singe heartbeat. The heart rests a moment, and another cycle begins almost immediately. Many things can influence the function of the heart. A person's heart rate can be modified by the nervous system based on the needs of the body. Stimulation of the SA and AV nodes by the sympathetic nerves increases the heart rate and force of contraction in response to increased activity, and as part of the response to real or perceived threats. Parasympathetic stimulation of the SA and AV nodes by the vagus nerve decreases the heart rate. The balance between the parasympathetic and sympathetic effects on the heart is maintained with the help of input from the medulla in the brainstem. Hormones and other chemicals made by the body, as well as drugs, also affect heart action.

environmental and psychological considerations affecting oxygenation

Environmental Considerations Although it is impossible to pinpoint all the effects of air pollution, researchers have demonstrated a high correlation between air pollution and cancer and lung diseases. For example, a person with adequate respiratory functioning who is exposed to air pollution may experience stinging of eyes and nasal passages, coughing, choking, headache, and dizziness. Occupational exposure to asbestos, silica, or coal dust, as well as environmental pollution, can lead to chronic pulmonary disease. Chronic exposure to radon, radiation, asbestos, and arsenic can lead to lung cancer. Additionally, people who have experienced an alteration in respiratory functioning in the past often have difficulty continuing to perform self-care activities in a polluted environment. Psychological Health Considerations Many psychological factors and conditions can affect the respiratory system. People responding to stress may sigh excessively or exhibit hyperventilation (increased rate and depth of ventilation, above the body's normal metabolic requirements). Hyperventilation can lead to a lowered level of arterial carbon dioxide. Generalized anxiety has been shown to cause enough bronchospasm to produce an episode of bronchial asthma. In addition, patients with respiratory problems often develop some anxiety as a result of the hypoxia caused by the respiratory problem.

clearining an obstructed airway implementing

Foreign-body obstruction of the airway often occurs during eating. In adults, meat is the most common food-related cause. In children, any variety of foods or objects can obstruct the upper airway. A patient who is semiconscious or unconscious develops airway obstruction as the tongue falls back, covering the pharynx. In fact, the tongue is the most common cause of airway obstruction. Foreign bodies can cause a partial or complete airway obstruction. In partial airway obstruction with good air exchange, the patient can cough forcefully. Allow the person to cough, and encourage spontaneous breathing. Do not interfere with the patient's efforts to expel the object. With a partial airway obstruction, good air exchange can progress to poor air exchange. Poor air exchange may be indicated by a weak, ineffective cough, high-pitched noises while inhaling, increased breathing difficulties, and cyanosis. When this occurs, it is managed in the same way as complete airway obstruction. With a complete airway obstruction, the victim is unable to speak or cough and may demonstrate the universal distress signal (clutching the throat with both hands; Fig. 38-19). Immediate action is necessary, or the patient will become unconscious as the brain becomes hypoxic. After complete airway obstruction has been determined, perform the Heimlich maneuver (abdominal thrusts). Follow the American Heart Association (AHA) protocols for obstructed airways and cardiopulmonary resuscitation (see next section). These protocols are continually being developed and updated.

providing supplemental oxygen part 2 (implementing)

HUMIDIFICATION Most institutions do not require humidification with very-low-flow oxygen (2 L/min or less) delivered by nasal cannula (see oxygen delivery systems to follow) when administered to adults. However, because oxygen dries and dehydrates the respiratory mucous membranes, humidifying devices (supplying 20%-40% humidity) are commonly used when oxygen is delivered at higher flow rates. Distilled or sterile water is commonly used to humidify oxygen. When moving patients receiving humidified oxygen, make sure that water from the humidifier does not enter the tubing through which the oxygen is flowing. Additional suggestions for transporting a patient with a portable oxygen tank are given in Guidelines for Nursing Care 38-2. PRECAUTIONS FOR OXYGEN ADMINISTRATION Oxygen, which constitutes 21% of normal air, is a tasteless, odorless, and colorless gas. It supports combustion. To prevent fires and injuries, take the following precautions: Avoid open flames in the patient's room. Place "no smoking" signs in conspicuous places in the patient's home. Instruct the patient and visitors about the hazard of smoking when oxygen is in use. Check to see that electrical equipment used in the room, such as electric bell cords, razors, radios, and suctioning equipment, is in good working order and emits no sparks. Avoid wearing and using synthetic fabrics that build up static electricity. Avoid using oils in the area. Oil can ignite spontaneously in the presence of oxygen.

promoting optimal functioning (implementing)

Healthy lifestyle choices and behaviors are an important part of preventing and managing cardiopulmonary diseases, which can have an impact on level of health and oxygenation. Vaccination is an important part of preventing respiratory infections. Teaching patients with problems of oxygenation about pollution-free environments is an important part of respiratory management. Many people with altered oxygenation experience anxiety as a result of their symptoms and the actual or potential loss of independence. It is important to minimize anxiety in patients with alterations in oxygenation in order to promote optimal functioning. Promoting good nutrition is another vital part of promoting optimal cardiopulmonary functioning. Teach patients about their health conditions and provide information and support to improve patient health literacy. Refer to the accompanying Promoting Health Literacy box. HEALTHY LIFESTYLE Patients who practice good health-related behaviors can reduce their risk for many cardiopulmonary diseases. Explain that beneficial behaviors should be incorporated into their daily and weekly activities. Encourage patients to eat a healthy diet (see discussion later in the chapter). Encourage patients to maintain a healthy weight. Regular exercise should also be part of a patient's daily activities. Current recommendations suggest 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorous-intensity aerobic activity, or an equivalent mix of the two each week (CDC, 2011a). Teach patients to monitor their cholesterol, triglyceride, lipoprotein (HDL) and low-density lipoprotein levels, (LDL), as well as their blood pressure. Encourage patients to limit alcohol intake and stop smoking (see discussion later in the chapter). VACCINATION Influenza. Influenza (the flu) is a contagious respiratory illness that causes mild to severe illness, and even death. People at high risk for serious flu complications include young children; pregnant women; people with chronic health conditions like asthma, diabetes, or heart and lung disease; and people 65 years and older. The best way to prevent the flu is by getting vaccinated. All people 6 months of age and older should be vaccinated each year (CDC, 2012). Pneumococcal Disease. Pneumococcal disease is an infection caused by a type of bacteria called pneumococcus. There are different types of pneumococcal disease, such as pneumococcal pneumonia, meningitis, and otitis media. Pneumococcal disease can be fatal. In some cases, it can result in long-term problems, like brain damage, hearing loss, and limb loss. Pneumococcal vaccine is very good at preventing severe disease, hospitalization, and death. Pneumococcal vaccine is recommended for all children less than 59 months of age. Children aged more than 24 months who are at high risk for pneumococcal disease and adults with risk factors should receive this vaccine. Risk factors for children and adults include those with long-term health problems, with a disease or condition that lowers the body's resistance to infection, or who are taking a drug or undergoing a treatment that lowers the body's resistance to infection. All adults 65 years of age and older, any adult 19 through 64 years of age who is a smoker or has asthma, and residents of long-term care facilities should also receive this vaccine (CDC, 2011b).

inserting an artificial airway

INSERTING AN ARTIFICIAL AIRWAY Inserting an Oropharyngeal Airway Use an airway that is the correct size. Airway should reach from the opening of the mouth to the back angle of the jaw. Wash your hands and put on PPE, as indicated. Identify the patient. Explain what you are going to do and the reason for doing it, even though the patient does not appear to be alert. Put on gloves; put on mask and goggles or face shield as indicated. Check for loose teeth, dentures or other foreign material. Use caution to prevent aspiration of loose teeth or pushing of object to the throat during insertion. Remove dentures if present. Position the patient in the semi-Fowler's position. Open the patient's mouth by using your thumb and index finger to gently pry teeth apart. Insert the airway with the curved tip pointing up toward the roof of the mouth. Slide the airway across the tongue to the back of the mouth. Rotate the airway 180 degrees as it passes the uvula (a flashlight can confirm the position of the airway with the curve fitting over the tongue). Ensure adequate ventilation by auscultating breath sounds. Position the patient on his or her side when the airway is in place. Remove the airway for a brief period every 4 hours, or according to facility policy. Provide mouth care and a clean airway before reinserting it. Inserting a Nasopharyngeal Airway (Nasal Trumpet) Use an airway that is the correct size. Airway should reach from the tragus of the ear to the nostril plus 1 inch. The diameter should be slightly smaller than the diameter of the nostril. Wash your hands and put on PPE, as indicated. Identify the patient. Explain what you are going to do and the reason for doing it, even though the patient does not appear to be alert. Put on gloves; put on mask and goggles or face shield as indicated. If the patient is awake and alert, position in the semi-Fowler's position. If the patient is not conscious or alert, position in a side-lying position. Lubricate the airway with the water-soluble lubricant. Gently insert the airway into the naris, narrow end first, until the rim is touching the naris. If resistance is met, stop and try inserting in the other naris. Check placement by closing the patient's mouth and placing your fingers in front of the tube opening to check for air movement. Assess the pharynx to visualize the tip of the airway behind the uvula. Assess the nose for blanching or stretching of the skin. Remove the airway, clean it, and place it in the other naris at least every 8 hours, or according to facility policy. Assess for any evidence of skin breakdown. The airway may be used for suctioning to prevent trauma to the mucosa

alterations in cardiovascular system

If a problem exists in the cardiovascular system, alterations in function of the heart may occur, leading to impaired oxygenation. A dysrhythmia or arrhythmia is a disturbance of the rhythm of the heart. Dysrhythmias are caused by an abnormal rate of electrical impulse generation from the SA node, or from impulses originating from a site or sites other than the SA node. They can also be caused by the abnormal conduction of electrical impulses through the heart. They can occur with heart disease, hypertension, damage to the heart, in the presence of various drugs, with decreased oxygenation of the heart tissues, and with trauma. Dysrhythmias cause disturbances of the heart rate, heart rhythm, or both, and can affect the pumping action of the heart, interfering with circulation, leading to alterations in oxygenation. Symptoms vary, depending on the cause and type of dysrhythmia. Symptoms may include decreased blood pressure, dizziness, palpitations (awareness of throbbing heart beats), weakness, and fainting. Myocardial ischemia, decreased oxygen supply to the heart caused by insufficient blood supply, can lead to impaired oxygenation of tissues in the body. It is most commonly caused by atherosclerosis, the accumulation of fatty substances and fibrous tissue in the lining of arterial blood vessel walls, creating blockages and narrowing the vessels, reducing blood flow. Angina and myocardial infarction can result from myocardial ischemia. Stable angina is a temporary imbalance between the amount of oxygen needed by the heart and the amount delivered to the heart muscles. Myocardial infarction, one type of acute coronary syndrome characterized by the death of heart tissue due to lack of oxygen, is also known as a heart attack. Myocardial ischemia causes disturbances of the heart rate, heart rhythm, or both, and can affect the pumping action of the heart, interfering with circulation, leading to alterations in oxygenation. Symptoms vary, based on the problem, but include pain, anxiety, nausea, vomiting, indigestion, and shortness of breath. Heart failure occurs when the heart is unable to pump a sufficient blood supply, resulting in inadequate perfusion and oxygenation of tissues. It can be the result of many heart conditions, including chronic hypertension, coronary artery disease, and disease of the heart valves. Symptoms include shortness of breath, edema (swelling), and fatigue. Additional information related to alterations in cardiovascular function is discussed in Chapter 24.

developmental considerations (factors affecting oxygenation)

Infants The normal infant's chest is small, the airways are short, and aspiration is a potential problem. The respiratory rate is more rapid in infants than at any other age (see Table 38-1). As the alveoli increase in number and size, adequate oxygenation is accomplished at lower respiratory rates. Surfactant is formed in utero between 34 and 36 weeks. An infant born before 34 weeks may not have produced sufficient surfactant, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli. Infants are at risk for upper respiratory tract infections and asthma as a result of exposure to secondhand smoke. Respiratory activity is primarily abdominal in infants. The pulse rate is more rapid in infancy than in adulthood, limiting the infant's ability to increase cardiac output by increasing the heart rate (Kyle & Carman, 2013). Toddlers, Preschoolers, School-Aged Children, and Adolescents The preschool child's eustachian tubes, bronchi, and bronchioles are elongated and less angular. Thus, the average number of routine colds and infections decreases until the child enters daycare or school and is exposed more frequently to pathogens. Young children who are not placed in daycare usually have not had the opportunity to develop antibodies for the variety of viruses and bacteria they may encounter in a school setting. Encourage good hand hygiene and tissue etiquette. Most children at this age have colds or upper respiratory infections, but some have more serious problems of otitis media, bronchitis, and pneumonia. Children in this age group are also at risk for asthma as a result of exposure to secondhand smoke. By the end of late childhood and during adulthood, the immune system is prepared to protect the person from most infections. A child's blood vessels widen and increase in length over time. The blood pressure increases over time, reaching the adult level in adolescence. Older Adults Specific physical changes occur in older adults that are unrelated to any pathology. Refer to the Focus on the Older Adult Box . The tissues and airways of the respiratory tract (including the alveoli) become less elastic. The power of the respiratory and abdominal muscles is reduced, therefore the diaphragm moves less efficiently. The chest is unable to stretch as much, resulting in a decline in maximum inspiration and expiration. Airways collapse more easily. These alterations increase the risk for disease, especially pneumonia and other chest infections. The normal aging heart can maintain adequate cardiac output under ordinary circumstances, but may have a limited ability to respond to situations that cause physical or emotional stress (Hinkle & Cheever, 2014). Decreased physical activity, physical deconditioning, decreased elasticity of the blood vessels, and stiffening of the heart valves can lead to a decrease in the overall function of the heart.

promoting comfort(implementing)

Interventions to promote patient comfort are an important part of nursing care for patients with alterations in cardiopulmonary function. Promoting proper positioning, adequate fluid intake, humidification of inspired air, and appropriate breathing techniques are used to maximize the patient's sense of well-being. In addition, encourage the patient to pace physical activities and schedule frequent rest periods to conserve energy. POSITIONING Proper positioning is important to ease respirations. A proper position for breathing is a position that allows free movement of the diaphragm and expansion of the chest wall. Alternately, sitting in a slumped position permits the abdominal contents to push upward on the diaphragm, decreasing lung expansion during inspiration. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Research has demonstrated that, in patients with pulmonary disease who are acutely ill, turning to the prone position on a regular basis promotes oxygenation (Dirkes et al., 2012; Rickelmann, 2012). In this position, the posterior dependent sections of the lungs are better ventilated and perfused. MAINTAINING ADEQUATE FLUID INTAKE Patients can help keep their secretions thin by drinking 2 to 3 quarts (1.9-2.9 L) of clear fluids daily. Fluid intake should be increased to the maximum that the patient's health state can tolerate. Increased fluids are needed by patients who have an elevated temperature, who are breathing through the mouth, who are coughing, or who are losing excessive body fluids in other ways. However, encourage patients with heart failure and low sodium levels to limit their fluid intake to 1.5 L/day (Dudek, 2014). PROVIDING HUMIDIFIED AIR Inspiring dry air removes the normal moisture in the respiratory passages that protect against irritation and infection. This is especially troublesome for patients who cannot breathe through their nose. When air humidity is low, it may be necessary to humidify the air with room humidifiers or vaporizers. Electric vaporizers that produce steam or cool mist are also useful, but neither device has been demonstrated to have greater therapeutic value than the other. Although a cool-mist vaporizer reduces the danger of burns because it does not generate heat or hot water, it can be a medium for pathogen growth if it is not cleaned adequately. A steam vaporizer does not present this risk for infection because the heat kills most pathogens.

reducing anxiety

It is important to create an environment that is likely to reduce anxiety. Help institute measures to alleviate discomfort immediately. Use effective listening skills and accurate observation to display a caring attitude. Attempt to understand the patient's life experiences and habits without judging them. Patients with harmful health habits often fear they will be judged, which impedes the use of nursing interventions. Patients who believe nurses are genuinely concerned about them and their families are more willing to work toward achieving mutually desirable outcomes.

providing supplemental oxygen part 4

Liquid oxygen and oxygen concentrators, rather than cylinders, are used more commonly in the home setting. Liquid oxygen is kept inside a small thermal container that can be refilled from a larger storage tank kept in the home. An oxygen concentrator removes nitrogen from the room air and concentrates the oxygen left in the air. The oxygen concentrator needs a power source such as an electrical outlet or battery pack. Oxygen concentrators are portable, cost-effective, and easy to use but cannot deliver oxygen flow at greater than 5 L/min (fraction of inspired oxygen [FiO2] of about 40%; Stoller, 2011). Patients using continuous supplemental oxygen therapy in the home have another alternative: transtracheal oxygen delivery (Fig. 38-13). With this type of delivery system, a small catheter is inserted into the trachea under local anesthesia, then the catheter is attached to the oxygen source. A transtracheal catheter does not interfere with talking, eating, or drinking and delivers oxygen throughout the respiratory cycle rather than just at inspiration. The patient or family must assume responsibility for daily catheter care. Patients usually report improved mobility, comfort, and appearance, and lower cost with this delivery system. FIGURE 38-13. A transtracheal oxygen setup. Oxygen-conserving devices are also available for use outside the hospital setting. Reservoir cannulas have a reservoir space that stores oxygen during exhalation. On subsequent inhalation, the patient receives that stored oxygen, essentially adding a bolus volume to the continuous-flow oxygen delivery. The patient receives the same oxygen therapy at a lower continuous-oxygen flow rate, conserving oxygen use. Intermittent-flow devices operate by turning oxygen delivery on during some portion of inhalation and off for the balance of the breathing cycle. Patient-exhaled oxygen is conserved, allowing a supply of oxygen to last two to four times as long as if it was delivered continuously (Hess et al., 2012). Patients using oxygen at home need instruction regarding safety precautions. See Teaching Tips 38-1 for information regarding the use of oxygen in the home setting.

physiology of the respiratory system

Living cells require oxygen and the removal of carbon dioxide, a byproduct of oxidation. Gas exchange, the intake of oxygen and the release of carbon dioxide, is made possible by pulmonary ventilation, respiration, and perfusion. Pulmonary ventilation refers to the movement of air into and out of the lungs. Respiration involves gas exchange between the atmospheric air in the alveoli and blood in the capillaries. Perfusion is the process by which oxygenated capillary blood passes through body tissues.

pulmonary ventillation part 2

Lung compliance refers to the ease with which the lungs can be inflated. The compliance of lung tissue affects lung volume. The ability of the lungs to adequately fill with air during inhalation is achieved by the normal elasticity of lung tissue, aided by the presence of surfactant. The varying changes in lung pressure and resulting lung compliance can be compared to differences in blowing up a new, noncompliant balloon versus one that was inflated previously. A stiff, noncompliant lung (like a new balloon) requires a greater inspiratory effort to inflate it. Emphysema, a chronic lung condition, and the normal changes associated with aging are examples of conditions that result in decreased elasticity of lung tissue, which, in turn, decreases compliance. Airway resistance is the result of any impediment or obstruction that air meets as it moves through the airway. Any process that changes the bronchial diameter or width causes airway resistance. Obstruction in any part of the normal passageways impedes respiration. Obstruction can be caused by a foreign substance, such as a piece of food, a coin, or a toy, or by liquids, as in the case of a drowning victim. Obstruction can also result from secretions (e.g., excessive or thickened secretions) or tissues (e.g., tumors or edema of the respiratory tract). A decrease in the size of air passages resulting from constriction or poor neck positioning can also impede respiration. Bronchial constriction in asthma is an example of airway resistance related to a decrease in the size of air passages.

monitoring patients with chest tube

MONITORING A PATIENT WITH A CHEST TUBE Assess the patient's vital signs, respiratory status, oxygen saturation, and breath sounds. Assess for pain. Monitor for any indication of change in respiratory status. Observe the dressing around the chest tube insertion site and ensure that it is occlusive. Gently palpate around the insertion site, feeling for crepitus, a result of air or gas collecting under the skin (subcutaneous emphysema). Tape all connections securely. Check that the drainage tube has no dependent loops or kinks. Make sure the drainage collection device is positioned below the tube insertion site to facilitate drainage. Observe the water-seal chamber for fluctuations of the water level with the patient's inspiration and expiration (tidaling). If suction is used, temporarily disconnect the suction to observe for fluctuation. Assess for the presence of bubbling in the water-seal chamber. Add water, if necessary, to maintain the level at the 2-cm mark, or the mark recommended by the manufacturer. Assess the suction control chamber if suction is in use. If water suction is used, ensure that water is at the appropriate level; add water to ensure that suction is adequate. Gentle bubbling in the suction chamber indicates that suction is being applied to assist drainage. Keep the drainage collection device secure so that it does not tip over. Check that two padded Kelly clamps are available and secured at the bedside. If the drainage unit requires changing, position one clamp 1½ to 2½ inches from the insertion site; position the second clamp 1 inch down from the first one until the unit has been switched. Alternately, many systems have integrated clamps on the tubing. The chest tube may be clamped before its removal to observe the patient's tolerance when it is discontinued or the chest tube may be clamped to assess for an air leak. Keep a bottle of sterile saline or water at the bedside. If the chest tube disconnects from drainage unit, submerge the end in water. This is done instead of clamping to prevent another pneumothorax. Air is still allowed to escape. Never clamp the tube if the patient leaves the unit for a test or moves away from the bed. Disconnect the suction tubing from the drainage system, allowing the unit to continue to collect drainage by gravity. Avoid milking or stripping the tube to promote drainage. This creates excessive negative pressure that can damage delicate lung tissue. Measure drainage output at the end of each shift by marking the level on the container or placing a small piece of tape at the drainage level to indicate date and time. Drainage is never emptied from the collection chamber. Document the color and consistency of the drainage. Drainage that dramatically increases or becomes bright red indicates fresh bleeding. Notify the primary care provider immediately.

medication considerations (factors affecting oxygenation)

Many medications affect the function of the cardiopulmonary system. Patients receiving drugs that affect the central nervous system need to be monitored carefully for respiratory complications. For example, opioids are chemical agents that depress the medullary respiratory center. As a result, the rate and depth of respirations decrease. Be alert for the possibility of respiratory depression or arrest when administering any narcotic or sedative. Other medications decrease heart rate, with the potential to alter the flow of blood to body tissues.

promoting propper breathing implementing

Many people, both well and ill, have breathing habits that are not conducive to maximal respiratory functioning. Some people develop a pattern of shallow breathing or walk with a posture that makes the chest wall appear caved in, affecting chest expansion. Ill people may limit their respiratory efforts to compensate for disease symptoms or an illness. Breathing exercises are designed to help patients achieve more efficient and controlled ventilations, to decrease the work of breathing, and to correct respiratory deficits. The accompanying box, Examples of Nursing Intervention and Nursing Outcome Classifications (NIC/NOC), lists standardized nursing interventions and corresponding outcomes related to maximizing oxygen and carbon dioxide exchange in the lungs. Descriptions of specific techniques follow.

assissting ventilation (implementing)

Mechanical ventilators are used to assist or completely control ventilation. These machines are used with patients who have endotracheal or tracheostomy tubes in place. Mechanical ventilation can be performed in acute care facilities, in extended care settings, and in the home. Mechanical ventilation improves oxygenation and ventilation and supports the patient's breathing function during emergency or acute care episodes as well as long-term situations. Many types of ventilators are available. The nurse is responsible for addressing the physical and psychological concerns of the patient and family. In addition, key interventions include evaluating the patient's response to ventilation therapy, using safe practices and techniques, and monitoring the patient carefully for complications. (See clinical texts and literature that discuss the use of mechanical ventilators in greater detail.) Another mechanical device used to assist ventilation is intermittent positive-pressure breathing (IPPB). This is a method of providing a specific amount of air, oxygen, and aerosolized medication under increased pressure to the respiratory tract. The patient receiving IPPB inhales the aerosol therapy through a mouthpiece or face mask. IPPB forces deeper inspiration by positive-pressure inhalation and then permits passive exhalation. The amount of pressure varies with each patient. It is now recognized as an alternative therapy when the patient is unable or unwilling to make the effort to ventilate one's lungs. However, conservative methods must be attempted first, such as deep-breathing and coughing exercises, percussion, vibration, and postural drainage. In emergency situations, the manual resuscitation bag (or Ambu bag) can be used to assist ventilation in patients whose respirations have ceased (Fig. 38-18). With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (16-20 breaths/minute in adults). The one-way valve in the mask allows exhaled air to escape. Artificial ventilation can be sustained until spontaneous breathing starts, until other mechanical assistance is available, or until death is confirmed. The bag is self-inflating and may be attached to supplemental oxygen if needed.

inspection (oxygenation)

Observe the patient's general appearance. Does the patient appear to be in any distress? Is the patient restless or anxious? Note the patient's level of consciousness and orientation to person, place, and time. Alterations in oxygenation to body tissues can be a result of respiratory or cardiac distress and lead to altered mental status. Inspect the patient's skin, mucous membranes, and general circulation, which can be a general indicator of the patient's health status, as well as indicating problems with oxygenation. Pallor (lack of color) of skin and mucous membranes can indicate less than optimal oxygenation. Cyanosis (bluish discoloration) of these areas indicates decreased blood flow or poor blood oxygenation. Note any abnormalities in the structures of the chest. The adult chest contour is slightly convex, with no sternal depression. The anteroposterior diameter should be less than the transverse diameter. Kyphosis (curvature of the spine) contributes to the older person's appearance of leaning forward and can limit respiratory ventilation. Barrel chest deformity may be a result of aging or COPD (chronic obstructive pulmonary disease). Note the contour of the intercostal spaces, which should be flat or depressed, and the movement of the chest, which should be symmetrical. Observe the respiratory rate, rhythm, and depth. Normally, respirations are quiet and nonlabored, and occur at a rate of 12 to 20 times each minute in healthy adults. Note any flaring of the nostrils, muscular retractions, tachypnea (rapid breathing), or bradypnea (slow breathing), which are suggestive of a health deviation requiring further evaluation. Refer to Chapter 25 for a detailed discussion of inspection as part of the assessment of the respiratory and cardiovascular systems.

factors that affect oxygenation of the body

One is the integrity of the airway system to transport air to and from the lungs. A properly functioning alveolar system in the lungs to oxygenate venous blood and to remove carbon dioxide from the blood is also important. A properly functioning cardiovascular system and blood supply to carry nutrients and wastes to and from body cells is a necessary component of oxygenation.

electrocardiography (assessment)

One of the most valuable and frequently used diagnostic tools, electrocardiography, measures the heart's electrical activity. Impulses moving through the heart's conduction system create electric currents that can be monitored on the body's surface. Electrodes attached to the skin can detect these electric currents and transmit them to an instrument that produces a record—the electrocardiogram (ECG)—of cardiac activity. The data are graphed as waveforms. ECG can be used to identify myocardial ischemia and infarction, heart damage, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and drug toxicity. The standard 12-lead ECG uses a series of electrodes placed on the extremities and the chest wall to assess the heart from 12 different viewpoints (leads) by attaching ten cables with electrodes to the patient's limbs and chest; four limb electrodes and six chest electrodes. Each lead provides an electrographic snapshot of electrochemical activity of the myocardial cell membrane. The ECG device measures and averages the differences between the electrical potential of the electrode sites for each lead and graphs them over time, creating the standard ECG complex, called PQRST. These electrodes provide views of the heart from the frontal plane as well as the horizontal plane. It is essential that connection or placement of the ECG electrodes/leads is accurate to prevent misdiagnosis. The ECG tracing needs to be clear to enable accurate and reliable interpretation (Jevon, 2010). An ECG is typically accomplished using a multichannel method. All electrodes are attached to the patient at once and the machine prints a simultaneous view of all leads. It is important to reassure the patient that the leads just sense and record and do not transmit any electricity. The patient must be able to lie still and refrain from speaking to prevent body movement from creating artifacts in the ECG. Variations of standard ECG include exercise ECG (stress ECG) and ambulatory ECG (Holter monitoring). Refer to Table 38-3 for information regarding these tests.

cardiovascular system

Oxygen and carbon dioxide must move through the alveoli and be carried to and from body cells by the blood. Thus, an adequately functioning cardiovascular system is vital for exchange of gases.

respiratory system

Oxygen and carbon dioxide must move through the alveoli as part of the oxygenation process. Thus, an adequately functioning respiratory system is vital for the exchange of gases.

implementing oxygenation

Oxygen deficits, particularly in older people, impair all aspects of daily living. Going to get the mail or cleaning the house may become a monumental task for people with oxygen deficits. Nursing interventions related to oxygenation aim to promote optimal functioning of the cardiopulmonary systems, to promote comfort, and to promote and control coughing. Nurses may also need to intervene by performing chest physiotherapy, suctioning the airway, meeting respiratory needs with medications, providing supplemental oxygen, managing chest tubes, using artificial airways, clearing an obstructed airway, and administering CPR.

providing supplemental oxygen part 1

Oxygen therapy, which provides supplemental oxygen, can increase the amount of oxygen transported in the blood. Oxygen is considered a medication and must be ordered by a health care provider. However, in an emergency situation the absence of a prescription should not delay the administration of oxygen to the patient (Higginson, Jones, & Davies, 2010). Oxygen therapy can be intimidating or frightening for patients. Therefore, provide clear explanations about the procedures and purpose to help reduce anxiety. Encourage patients to discuss concerns. If oxygen is given in an emergency, explanations concurrent with administration are appropriate. SOURCES OF OXYGEN Therapeutic oxygen is supplied from a wall outlet or a portable cylinder or tank. A specially designed flow meter is attached to the wall outlet (see Skill 38-3, pp. 1449-1452, for an illustration of a flow meter). A valve regulates the oxygen flow in liters per minute. To release oxygen safely and at the desired rate from a cylinder or tank, a regulator is used. The regulator has two gauges. The one nearest the tank shows the pressure or amount of oxygen in the tank. The other gauge indicates the number of liters per minute of oxygen being released. In patients with chronic respiratory insufficiency who use oxygen on a daily basis at home, having to transport an oxygen canister can impede their functional exercise capacity. The portable canister's weight and increased respiratory and skeletal muscle load contributes an additional burden for these patients. A small walking aid may be suggested to reduce the patient's burden. Oxygen concentrators are another way to provide oxygen. This oxygen delivery system concentrates room air to provide the appropriate concentration of oxygen to the patient. They are used frequently in home situations. OXYGEN FLOW RATE The flow rate of oxygen, measured in liters per minute, determines the amount of oxygen delivered to the patient. The rate varies depending on the condition of the patient and the route of administration of the oxygen. The flow rate does not necessarily reflect the oxygen concentration actually inspired by the patient because there is leaking and mixing with atmospheric air. If more precise doses are necessary, they are usually prescribed in terms of percentage of inspired oxygen. To regulate the oxygen percentage concentration accurately, samples of the air mixture the patient is actually inhaling may be analyzed every 4 hours. Several types of commercial oxygen analyzers are available. The medical order prescribes the rate of oxygen administration. Closely monitor the flow rate to verify that the patient is receiving the prescribed concentration. Normally, excessive levels of carbon dioxide in the blood stimulate the patient to breathe. However, the chemoreceptors of some, but not all, patients with chronic lung disease, such as emphysema, become insensitive to carbon dioxide and respond to hypoxia to stimulate breathing (Hinkle & Cheever, 2014; McGlolin, 2008). If excessive oxygen is given, the stimulus to breathe is removed; as a result, the patient may stop breathing completely. Monitor respiratory rate and arterial blood gas results closely for changes. Many times, continuous pulse oximetry also is used to monitor the patient receiving oxygen.