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Chapter 40: Oxygenation

SCIENTIFIC KNOWLEDGE BASE


1. Factors Affecting Oxygenation
a. Physiological Factors anything affecting the cardiopulmonary functioning
i. Decreased oxygen-carrying capacity: Anemia and toxic substances alter the proper functioning of hemoglobin.
Oxygenation decreases as a secondary effect with anemia. Bodys response to increase RBC count(polycythemia) so
then more o2 is available to the tissues
ii. Hypovolemia: body compensates by peripheral constriction and increasing HR, increasing CO
iii. Decreased Inspired Oxygen Concentration: caused by upper or lower airway obstrxn
iv. Increased Metabolic Rate: increases o2 need
b. Conditions Affecting Chest Wall Movement
i. Pregnancy
ii. Obesity
iii. Musculoskeletal Abnormalities- those in the thoracic region affect the strxs for oxygenation like diaphragm
iv. Trauma: the unstable chest wall allows the lung underlying the injured area to contract on inspiration and bulge on
expiration, resulting in hypoxia.
v. Neuromuscular Diseases: decreases patients ability to expand/contract the chest wall; ex. Myasthenia gravis,
GuillanBarre, Poliomyelitis
vi. CNS Alterations: probs with medulla oblongata, trauma to C3 to C5(phrenic nerve)
c. Influences of Chronic Disease: COPD
2. Alterations in Respiratory Functioning (regular CO2 35-45mmHg; regular O2 80-100mmHg)
a. Hypoventilation: s/s mental status changes, dysrrthymias, potential cardiac arrest, convulsion, unconsciousness, death
b. Hyperventilation: occurs with fevers, DKA, taking too much of certain meds(aspirin); s/s rapid respirations, sighing breaths,
numbness and tingling, light-headedness, loss of consciousness
c. Hypoxia (inadequate tissue oxygenation at the cellular level): cx decreased hemoglobin level and lowered oxygen-carrying
capacity of the blood, diminished concentration of inspired oxygen, inability of tissues to extract o2 from blood(cyanide
poisoning), decreased diffusion of o2, poor tissue perfusion with o2blood(shock), impaired ventilation (chest trauma); s/s
apprehension, inability to concentrate, altered LOC, behavioral changes; unable to lie flat, fatigued, agitated, increased PR,
increased depth of respiration
3. Alterations in Cardiac Functioning
a. Disturbances in Conduction(dysrhythmias): classified by cardiac response and site of impulse origin;
brady/tachydysrhythmias lower CO and BP; Afib=irregularly irregular rhythm(most commonly seen in older adults); Vtach/Vfib
ae life threatening (Vtach can lead to decreased CO and Vfib)
b. Altered Cardiac Output
i. Left Sided Heart Fail: s/s of tissue hypoxia, crackles(P.edema), SOB on exertion, cough, paroxysmal nocturnal edema
ii. Right Sided Heart Fail: cx: pulm disease or extended Lheart fail; s/s: weight gain, JVD, hepato/splenomegaly,
peripheral edema
c. Impaired Valvular Function: mitral/tricuspid/aortic stenosis/regurgitation
d. Myocardial Ischemia(decreased supply of blood to heart muscle thru coronary arteries)
i. Angina aching, sharp, tingling, or burning feeling; 3-5 minutes long
ii. Myocardial Infarction(Acute Coronary Syndrome)
NURSING KNOWLEDGE BASE
1. Factors Influencing Oxygenation
a. Developmental Factors
i. Infants and toddlers high risk for upper respiratory tract infxn bc of frequent exposure to other children, immature
immune system, exposure to SHS
ii.
iii. School age and Adolescents cigarette smoking, SHS
iv. Young and Middle Age Adults- smoking cessation teachings
v. Older Adults- increased risk for resp infx bc of decrease in fxnal cilia(for cough); heart valves, SA nodes, costal
cartilages calcify
b. Lifestyle Factors
i. Nutrition
ii. Exercise-fully conditioned people increase o2 consumption by 10-20% bc of increased CO and increased efficiency of
myocardial muscle
iii. Smoking
iv. Substance Abuse - impairs tissue oxygenation in 2 ways
1. Poor nutritional intake
2. Depresses the resp center, reducing the rate and depth of respiration and the amount of inhaled o2
v. Stress
c. Environmental Factors
CRITICAL THINKING
NURSING PROCESS
1. Assessment
a. Through the Patients Eyes a combo of counseling and meds is more effective than either one alone; knowing your patients
mindsets and respecting their wishes goes a long way in helping them make significant beneficial lifestyle changes

b.

c.

2.

3.

4.

Nursing History
i. Pain presence of chest pain requires immediate evaluation including location, duration, radiation, and frequency;
pericardial pain is bc of itis; pleuritic chest pain is peripheral and radiates to scapular regions (knifelike pain)
ii. Fatigue with cardio, it means WORSENING
iii. Dyspnea- clinical sign of hypoxia; use the Visual Analogue Scale(VAS)-> have patients rate their dyspnea from 1-10
on this vertical scale; check for orthopnea and try diff interventions (pillows, sitting up straight)
iv. Cough productive cough has sputum(contains mucus, cellular debris, microbes, sometimes pus or blood); assess for
COCA; hemoptysis(bloody sputum) is associated with coughing and bleeding from the upper resp tract, sinus drainage,
or the GI tract(hematemesis)
v. Wheezing- high pitched musical sound caused by high velocity movement of air through a narrowed airway
vi. Environmental or Geographical Exposures
vii. Smoking pack*year history (2 pack per day for 20 years = 40 pack year history)
viii. Respiratory Infections
ix. Allergies
x. Health Risks
xi. Medications
Physical Examination
i. Inspection Kussmauls Respiration(acidic pH stimulates an increase in rate and depth of respirations to compensate
by decreasing CO2 levels) ; Cheyne-Stokes (caused by decreased blood flow to the brainstem); barrel chestemphysema
Abnormality
Cause
Xanthelasma(yellow lipid lesions on eyelids) Hyperlipidemia
Corneal arcus(whitish opaque ring around
Hyperlipidemia
junction of cornea and sclera)
Pale conjunctivae
Anemia
Cyanotic conjunctivae
Hypoxemia
Petechiae on conjunctivae
Fat embolus or bacterial endocarditis
Distension of neck veins
R. side heart fail
Flaring nares
Air hunger, dyspnea
Retractions of chest
Increased WOB
Periorbital edema
Kidney disease
Splinter hemorrhages of nail
Bacterial endocarditis

ii. Palpation-of chest, neck, and extremities for pulses, edema, tenderness
iii. Percussion detects abnormal fluid/air in lungs; determines diaphragmatic excursion
iv. Auscultation identify the location, radiation, intensity, pitch, and quality of murmur and lung sounds
d. Diagnostic Tests
i. Cardiopulmonary Diagnostic blood Studies : CBC, Cardiac Enzymes, Cardiac Troponins, Myoglobin, Serum
Electrolytes, Cholesterol
ii. Cardiac Function Diagnostic Tests : Holter monitor(portable ECG worn by patient), ECG exercise stress test, Thallium
stress test, electrophysiological study(EPS)(Invasive measure of intracardiac electrical pathways), ECG, Scintigraphy;
Cardiac cath and angio
Diagnosis
a. Possible diagnosis activity intolerance; decreased cardiac output, fatigue, impaired gas exchange, impaired spontaneous
ventilation, impaired verbal communication, ineffective airway clearance, ineffective breathing pattern, ineffective health
maintenance, risk for aspiration, risk for imbalanced fluid volume, risk for infxn, risk for suffocation
Planning
a. Goals and Outcomes
b. Setting Priorities
c. Teamwork and Collaboration
Implementation
a. Health Promotion
i. Vaccinations
ii. Healthy Lifestyle
iii. Environmental Pollutants
b. Acute Care
i. Dyspnea Management
ii. Airway Maintenance
iii. Mobilization of Pulmonary Secretions The ability of the patient to mobilize pulmonary secretions makes the
difference between shot term illness and a long recovery involving complications
iv. Hydration
v. Humidification - is necessary for patients receiving oxygen therapy at greater than 4L/min
vi. Nebulization (adds moisture or medication to inspired air by mixing particles of varying sizes with the air) vii. T/C/DB every two hours

5.

viii. Chest Physiotherapy (a group of therapies for mobilizing pulmonary secretions)- ex. Postural drainage, chest
percussion, vibration; used for those who have a decreased ability to cough
ix. Suctioning Techniques used for when patients are unable to clear resp secretions from the airways by coughing o
less invasive procedures; sterile technique bc oropharynx and trachea are considered sterile
1. Oropharyngeal and Nasopharyngeal Suctioning used for when patient is able to cough effectively but
unable to clear secretions by expectorating
2. Orotracheal and Nasotracheal Suctioning cannot manage the secretions by coughing and does not have an
artificial airway present; catheter can go through mouth or nose; it is not in the body for more than 15 secs
3. Tracheal Suctioning use for an artificial catheter; two types open and closed
x. Artificial Airways used with a with decreased LOC or airway obstxn
1. Oral Airway extends from the teeth to the oropharynx, maintaining the tongue in the normal position
2. Endotracheal and Tracheal Airway ET tube is a short term artificial airway to administer mechanical
ventilation, relieve upper airway obstrxn, protect against aspiration, or clear secretions; only a physician or a
skilled clinician can insert a ET tube.
xi. Maintenance and Promotion of Lung Expansion
1. Ambulation
2. Positioning The 45 degree semi fowlers is the most effective position to promote lung expansion and reduce
pressure from the abdomen on the diaphragm. In the presence of pulm abscess or hemorrhage, position the pt
with the affected lung down to prevent drainage toward the healthy lung
3. Incentive Spirometry encourages voluntary deep breathing by providing visual feedback to pt about
inspiratory volume. Promotes deep breathing and prevents or treats atelectasis in the postop patient
4. Noninvasive Ventilation (Noninvasive positive-pressure ventilation = NPPV)- the purpose of NPPV is to
maintain a positive airway pressure and improve alveolar ventilation. This prevents or treats atelectasis by
inflating the alveoli, reducing pulm edema by forcing fluid out of the lungs back into circulation and
improving oxygenation. Ventilatory support is achieved using a variety of modes, including continuous
positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP).
5. Chest tubes a catheter inserted to remove air and fluids from the pleural space or to reestablish normal
intrapleural and intrapulmonic pressures
6. Special Considerations
xii. Maintenance and Promotion of Oxygenation
1. Oxygen Therapy goal is to prevent or relieve hypoxia by delivering o2 at concentrations greater than
ambient air(21%); 6 rights of meds apply to administering o2
2. Safety Precautions
xiii. Supply of Oxygen
1. Nasal Cannula (1-6 L/minute)
2.
24-45% concentration of oxygen
3. Simple Face Mask (5-8 L/minute)
4.
30-60% concentration of oxygen
5. Nonrebreather Mask (6-10 L/minute)
6.
60-95% concentration of oxygen
7. Highest concentration of oxygen
8. Venturi Mask (4-12 L/minute)
9. 24-60% concentration of oxygen
xiv. Methods of Oxygen Delivery
1. Nasal Cannula
2. Oxygen Masks
xv. Home Oxygen Therapy
xvi. Restoration of Cardiopulmonary Functioning
1. Cardiopulmonary Resuscitation
c. Restorative and Continuing Care
i. Respiratory Muscle Training
ii. Breathing Exercises
1. Pursed Lip Breathing-deep inspiration and prolonged expiration thru pursed lips to prevent alveolar collapse
2. Diaphragmatic Breathing- improves efficiency of breathing by decreasing air trapping and WOB
Evaluation
a. Through the Patients Eyes
b. Patient Outcomes

Chapter 45: Urinary Elimination


SCIENTIFIC KNOWLEDGE BASE
1. Kidneys Erythropoietin(hormone) functions within the bone marrow to stimulate RBC production and maturation and prolongs the life
of mature RBCs
2. Ureters
3. Bladder
4. Urethra

5.

Act of urination reflex incontinence is caused by damage to the spinal cord above the sacral region; causes loss of voluntary control of
urination. Overflow incontinence occurs when a bladder is overly full and bladder pressure exceeds sphincter pressure, resulting in
involuntary leakage of urine.
a. Factors influencing urination
i. Disease conditions
ii. Sociocultural factors - privacy
iii. Psychosocial factors privacy and adequate time are imp to ppl
iv. Fluid balance nocturia(awakening to void one or more times at night), polyuria (excessive output of urine), oliguria
(decreased urine output), anuria (no urine is produced), diuresis (increased urine formation); Fever causes an increase
in body metabolism and accumulation of body wastes. Although urine volume is reduced, it is highly concentrated.
v. Surgical procedures
vi. Medications Patients with impaired kidney function require dosage adjustments in meds excreted by the kidneys
vii. Diagnostic Examination
b. Alterations in Urinary Elimination
i. Urinary retention
ii. UTI
iii. Incontinence urge incontinence is more common in younger women and may be caused by local irritating factors
such as UTIs. Individuals sense the urge to urinate but cannot keep from urinating long enough to reach a toilet. Stress
incontinence occurs more often in older women when intraabdominal pressure exceeds urethral resistance. Muscles
around the urethra become weak; thus even a small amount of urine may leak spontaneously.
iv. Urinary diversions The surgical formation of a urinary diversion temporarily or permanently bypasses the bladder
and urethra as the exit routes for urine
NURSING KNOWLEDGE BASE
1. Infection Control and Hygiene
2. Factors influencing urination
a. Growth and development
b. Muscle Tone
CRITICAL THINKING
NURSING PROCESS
1. Assessment
a. Through the Patients Eyes
b. Identifying Urinary Alterations
c. Nursing History
i. Pattern of Urination
ii. Symptoms of Urinary Alterations
iii. Table 45-1
d.

2.
3.

Physical Assessment
i. Skin and Mucosal Membranes
ii. Kidneys
iii. Bladder
iv. Urethral Meatus
e. Assessment of Urine
i. Intake and Output
ii. Characteristics of Urine
1. Color
2. Clarity
3. Odor
iii. Urine Testing
1. Specimen collection The nurse collects
random, clean-voided or midstream, sterile, and
timed specimens. The method of collection
varies based on a patients developmental level
the type of specimen ordered
2. Urine collection in children
iv. Common Urine Tests
1. Urinalysis
2. Specific gravity- weight or degree of
concentration of a substance compared with an equal volume of water
3. Urine Culture
f. Diagnostic Examinations
Diagnosis
a. Social isolation; Disturbed body image; urinary incontinence; pain; risk for infection; toileting, self-care deficit; impaired skin
integrity; impaired urinary elimination; constipation; urinary retention
Planning
a. Goals and Outcomes

4.

5.

b. Setting Priorities
c. Teamwork and Collaboration
Implementation
a. Health Promotion
i. Patient Education
ii. Promoting Normal Micturition
1. Stimulating Micturition Reflex
iii. Maintaining Elimination habits
iv. Maintaining Adequate Fluid Intake
v. Promoting Complete Bladder Emptying
vi. Preventing Infection
b. Acute Care
i. Maintaining Elimination habits
ii. Medications
iii. Catheterization
iv. Catheter Irrigations and Instillations
v. Alternatives to urethral Catheterization
1. Suprapubic Catheterization
2. Condom Catheterization
c. Restorative Care
i. Strengthening Pelvic Floor muscles Kegel exercises improve the strength of pelvic floor muscles and consist of
repetitive contractions of muscle groups. These exercises have demonstrated effectiveness in treating stress
incontinence, OAB, and mixed cause of urinary incontinence; noninvasive; low risk of adverse effects
ii. Bladder Retraining goal is to reduce the voiding frequency and perhaps the bladder capacity
iii. Habit training
iv. Self-Catheterization generally the goal is to have patients perform self-cath 4-6 times a day with volumes of 400500ml
v. Maintenance of Skin Integrity
vi. Promotion of comfort
Evaluation be sensitive to any changes in self-concept and sexuality. Self-concept, which includes body image, self-esteem, roles, and
identity, develops over a life span

Chapter 48: Skin Integrity and Wound Care


Skin risk assessment (look over Braden scale & be able to apply it)
a. The Braden Scale (Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear; higher the number, lower the
risk)
2. What are some risk factors for pressure ulcers?
a. Impaired Sensory Perception; Impaired Mobility; Alteration in LOC; Shear(sliding mvmt of skin and subQ tissue while the
underlying muscle and bone are stationary);friction(the force of two surfaces moving across one another); moisture
3. Why do we debride wounds?
4. Review wound stages (Stage I, II, III, & IV) - define each and how to care for stages
a. Stage One-Nonblanchable Redness of Intact Skinb. Stage Two- Partial Thickness Skin Loss or Blister shallow open ulcer with red-pink wound bed without slough
c. Stage Three- Full Thickness Skin Loss (fat visible)- subQ visible, may include undermining and tunneling, depends on
location to know the severity of the ulcer
d. Stage Four- Full Thickness Tissue Loss (muscle, bone visible)- exposed bone, tendon, or muscle; slough or eschar may be
present; often includes undermining and tunneling
e. Unstageable- a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough or eschar
5. What does granulating mean?
a. Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward
healing
6. Why would we use a hydrogel dressing? To provide a moist environment while adding a dressing for stage 2 ulcer The advantages are:
are soothing and can reduce wound pain, provides a moist environment, debrides necrotic tissue, and does not adhere to the wound base
and is easy to remove. Used for partial thicken and full thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and
radiation damaged wounds
7. How do you care for skin?
8. Define primary and secondary intention wounds.
a. The surgical incision heals by primary intention. The skin edges are approximated, or closed, and the risk of infection is low.
Healing occurs quickly, with minimal scar formation, as long as infection and secondary breakdown are prevented.
b. A wound involving loss of tissue such as a burn, pressure ulcer, or severe laceration heals by secondary intention. The wound
is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of
infection is greater. If scarring from secondary intention is sever, loss of tissue function is often permanent.
9. How do you assess tunneling?
10. Types of wound drainage
a. Serous (clear watery plasma); Purulent (thick, yellow, green, tan, or brown); Serosanguinous (pale, pink watery; mixture of clear
and red fluid); Sanguineous (bright red, indicates active bleeding)
1.

11. Dehiscence and Evisceration


a. Dehiscence- partial or total separation of wound layers; a patient
who is at risk for poor wound healing (poor nutrition, infection,
obesity); usually for an abdominal wound
b. Evisceration with total separation of wound layers, there is a
protrusion of visceral organs through a wound opening; place sterile

12.
13.
14.
15.

towels soaked in sterile saline over


extruding tissues to reduce chances of
bacterial invasion and drying of tissues;
surgical emergency
Nutrition and Protein
Position changes
Incontinent patients
Review wound healing