Oxygenation

0 Oxygenation is a basic human need

0 Breathing is synonymous to life, thus, oxygen is

required to sustain life 0 2 body systems that supply the bodys oxygen demands
0 Cardiovascular system
0 Respiratory system

Respiratory System
0 The lung transfers O2 from the atmosphere into the

alveoli, where the O2 is exchanged for CO2 0 The alveoli transfers O2 and CO2 to and from the blood through the alveolar membrane

Pulse Oximetry
0 Noninvasive

0 Estimates arterial blood oxygen susturation (SpO2)

0 Normal SpO2 95-100% 0 < 70% - life threatening 0 Detects hypoxemia (low oxygen; more in blood)

before clinical 0 Sensor, photodetector, pulse oximeter unit

Pulse Oximetry
0 Factors that affect accuracy include 0 Hemoglobin level 0 Circulation 0 Activity 0 Carbon monoxide poisoning

Respiration
0 Processes 0 Ventilation 0 Diffusion 0 Perfusion

Ventilation
0 Factors influencing ventilation 0 Adequate atmosphere oxygen 0 Clear air passages 0 Adequate pulmonary compliance and recoil 0 Regulation of respiration

Diffusion
0 Factors influencing diffusion of gasses 0 Thickness of membrane 0 Surface area of the membrane 0 Diffusion coefficient of gasses 0 Pressure gradient on each side of the membrane

Perfusion
0 Factors affecting oxygen transport from lungs to the

tissues

0 Cardiac output 0 Number of erythrocytes 0 Exercise

0 Blood hematocrit

Factors Affecting Oxygenation

0 Environment (altitude, heat, cold, air pollution)

0 Exercise
0 Emotions (fear, anxiety, anger) 0 Lifestyles (smoking, occupations, sedentary life, etc) 0 Health status (anemia [low red blood cells]

respiratory) Narcotics (morphine, demorol, etc)

3 Major Alterations in Respiratory Functions

0 1. Hypoxia 0 Respiratory insufficiency 0 Acapnea (absence of CO2 in blood) 0 Hypocarbia
0 Depressed level of CO2 in the blood

0 Hyperpnea (rapid breathing)

0 Hypopnea (slow breathing)

Signs of Hypoxia
0 Early/ acute signs 0 Restlessness 0 Increased pulse rate 0 Increased rate and depth of respiration 0 Increase in systolic blood pressures

Signs of Hypoxia
0 Late/chronic signs 0 Decreased pulse rate 0 Decreased systolic blood pressure 0 Dyspnea 0 Fatigue and lethargy 0 Cough 0 Hemoptysis 0 Clubbing of fingers

3 Major Alterations in Respiratory Functions

0 2. Altered breathing patterns 0 Rate 0 Volume (hypo or hyper) 0 Rhythm (Cheyne Stokes, Kussmauls, Apneustic, and Biats) 0 Relative case of effort respiration (dyspnea and orropnea)

3 Major Alterations in Respiratory Functions

0 3. Obstructive or particularly obstructive airways 0 Upper airway, obstruction
0 nose, pharynx, larynx, trachea

NANDA Nursing Diagnosis Related to Oxygenation

0 1. Ineffective airway clearance 0 Refers to inability of the individual to clear secretions or obstruction from the respiratory tract to maintain airway patency
0 Tracheobrachial infections 0 Obstructions, secretions

NANDA Nursing Diagnosis Related to Oxygenation

0 2. Ineffective breathing pattern 0 Refers to and individuals inhalation or exhalation pattern that inhibits adequate ventilation
0 Neuromuscular 0 Pain, anxiety 0 Decreased energy and fatigue 0 Inflammatory process

NANDA Nursing Diagnosis Related to Oxygenation

0 3. Decreased cardiac output 0 State in which the blood pumped by the heart is sufficiently reduced that it is inadequate to meet the needs of the body 0 Structural alteration
0 Ventricular septal rupture, valvular disease

NANDA Nursing Diagnosis Related to Oxygenation

0 4. Impaired gas exchange 0 State in which there is an imbalance between O2 and CO2 elimination at the alveolar capillary membrane gas exchange area
0 Altered O2 supply 0 Altered blood

NANDA Nursing Diagnosis Related to Oxygenation

0 5. Altered tissue perfusion 0 State in which an individual experiences a decrease in nutrition and oxygenation at the cellular level because of a deficit in capillary blood supply
0 Interrupted venous or arterial flow 0 Hypo/hyper volemia

Measures That Promote Adequate Respiratory Function

0 1. Ensure a patent airway 0 To promote gaseous exchange between client and environment 0 Check for obstructions
0 Foreign objects, mucus

0 2. Positioning 0 To allow maximum chest expansion 0 Fowlers position 0 Encourage frequent changes

Measures That Promote Adequate Respiratory Function

0 3. Deep breathing and coughing exercises 0 To promote lung expansion and loosen secretions
0 E.g. abdominal breathing (diaphragmatic and pursed lip)

0 4. Adequate hydration 0 Maintain moisture of the respiratory mucus membrane 0 Use of humidifiers/ nebulizers
0 Steam/ aerosol/ medimist

Measures That Promote Adequate Respiratory Function

0 5. Chest physiotherapy 0 Percussion
0 Forceful striking of skin with cupped hands

0 Vibration 0 Serves of vigorous quivering produced by hands that are placed flat against clients chest wall; done during exhalation 0 Postural drainage 0 Drainage by gravity of secretions from various lung segments

Measures That Promote Adequate Respiratory Function

0 6. Proper suctioning 0 A catheter for 12-18 mmHg, tip of mouth to earlobe 5 meters suction 5-10 seconds, max is 15 seconds, wall suction 80-120 mmHg 0 7. Avoid environmental pollutants = smoking

Measures That Promote Adequate Respiratory Function

0 8. Using inflation devices 0 Incentive spirometry to enhance deep inspiration 0 Intermittent positive pressure breathing
0 To administer O2 at pressures higher than the atmospheric

pressure

0 9. Administration of supplemental O2 0 Nasal cannula

Nursing Implication
0 Since oxygen is colorless, odorless, and tasteless,

leakage cant be detected 0 Since oxygen is dry, gas mucus membrane invitation could happen

Nursing Planning, Intervention, and Evaluation in O2 Administration

0 Assess s and sx of hypoxemia

0 Check doctors orders

0 Open source before insertion of device 0 Regulated accurately 0 Place a No Smoking sign 0 Avoid use of oil, grease, and alcohol

Nursing Planning, Intervention, and Evaluation in O2 Administration

0 Check of electrical device malfunction

0 Avoid using materials that could generate static

electricity 0 Humidify O2 0 Provide good oro-nasal hygiene 0 Lubricate with water soluble stuff 0 Document