FUNDAMENTALS OF NURSING

Week 11: Oxygenation, Circulation, Loss, Grieving and Death

Oxygenation
I. Process of Oxygenation
A. Ventilation of the lungs - achieved by inspiration and expiration
B. Diffusion of oxygen from the alveoli and into the pulmonary blood vessels
C. Transport of oxygen from the lungs to the tissues
D. Diffusion of oxygen between the capillaries and tissues at the alveolar-capillary
level
II. Factors Affecting Respiratory Function
A. Age
B. Environment
C. Lifestyle
D. Health status
E. Medications
F. Stress
III. Alterations in Respiratory Function
A. Conditions affecting the airway
1. Obstruction -> stridor, adventitious breath sounds
B. Conditions affecting movement of air
1. Fever, pain -> tachypnea
2. Drug intake/overdose, anesthesia -> bradypnea
3. Diseases of respiratory muscles -> Hypoventilation
4. Metabolic acidosis -> Kussmaul’s breathing
5. Chronic diseases, increased intracranial pressure - Cheyne-Stokes, Biot’s
respirations
C. Conditions affecting diffusion
1. Pulmonary edema, atelectasis -> hypoxemia
D. Conditions affecting transport
1. Congestive heart failure, hypovolemia -> decreased cardiac output
IV. Promoting Oxygenation
A. Positioning the client to allow for maximum chest expansion
B. Encouraging or providing frequent changes in position
C. Encouraging deep breathing and coughing
D. Encouraging ambulation
E. Implementing measures that promote comfort, such as giving pain medications.
V. Deep Breathing and Coughing
A. The client is taught to breathe in normally through the nose and exhale through
pursed lips as if about to whistle, and blow slowly and purposefully, tightening the
abdominal muscles to assist with exhalation
B. Normal forceful coughing involves the client inhaling deeply and then coughing
twice while exhaling
VI. Hydration
 A. Adequate hydration maintains the moisture of the respiratory mucous
membranes
B. Humidifiers are devices that add water vapor to inspired air
VII. Percussion, Vibration and Postural Drainage
A. Percussion, sometimes called clapping, is forceful striking of the skin with cupped
hands
1. Cover the area with a towel or gown to reduce discomfort.
2. Ask the client to breathe slowly and deeply to promote relaxation.
3. Alternately flex and extend the wrists rapidly to slap the chest
4. Percuss each affected lung segment for 1 to 2 minutes
B. Vibration is a series of vigorous quiverings produced by hands that are placed flat
against the client’s chest wall
1. Place hands, palms down, on the chest area to be drained, one hand over
the other with the fingers together and extended. Alternatively, the hands
may be placed side by side.
2. Ask the client to inhale deeply and exhale slowly through the nose or
pursed lips.
3. During the exhalation, tense all the hand and arm muscles, and using
mostly the heel of the hand, vibrate (shake) the hands, mov ing them
downward. Stop the vibrating when the client inhales.
4. Vibrate during five exhalations over one affected lung segment.
5. After each vibration, encourage the client to cough and expectorate
secretions into the sputum container.
C. Postural drainage is the drainage by gravity of secretions from various lung
segments
VIII. Oxygen Therapy
A. Supplemental oxygen is indicated for clients who have hypoxemia due to the
reduced ability for diffusion of oxygen through the respiratory membrane,
hyperventilation, or substantial loss of lung tissue due to tumors or surgery
B. Oxygen is supplied in two ways in health care facilities: by portable systems
(cylinders or tanks) and from wall outlets
C. Clients who require oxygen therapy in the home may use small cylinders of
oxygen, oxygen in liquid form, or an oxygen concentrator
D. Oxygen Delivery Systems:
1. Cannula - the most common and inexpensive device used to administer
oxygen; It delivers a relatively low concentration of oxygen (24% to 45%)
at flow rates of 2 to 6 L/min
2. Face mask - cover the client’s nose and mouth may be used for oxygen
inhalation;
a) The simple face mask delivers oxygen concentrations from 40% to
60% at liter flows of 5 to 8 L/min
b) The partial rebreather mask delivers oxygen concentrations of
40% to 60% at liter flows of 6 to 10 L/min
c) The nonrebreather mask delivers the highest oxygen
 concentration possible—95% to 100%—by means other than
intubation or mechanical ventilation, at liter flows of 10 to 15 L/min
d) The Venturi mask delivers oxygen concentrations varying from
24% to 40% or 50% at liter flows of 4 to 10 L/min
3. Face tent - can replace oxygen masks when masks are poorly tolerated by
clients; provide varying concentrations of oxygen, for example, 30% to
50% concentration of oxygen at 4 to 8 L/min
4. Transtracheal catheter - transtracheal catheter is placed through a
surgically created tract in the lower neck directly into the trachea; high
flow rates, as much as 15 to 20 L/min, can be administered
5. Noninvasive Positive Pressure Ventilation (NPPV) - delivery of air or
oxygen under pressure without the need for an invasive tube such as an
endotracheal tube or tracheostomy tube
IX. Artificial Airways
A. Oropharyngeal and Nasopharyngeal Airways
B. Endotracheal Tubes
C. Tracheostomy
X. Suctioning
A. Position a conscious person who has a functional gag reflex in the semi-Fowler’s
position with the head turned to one side for oral suctioning or with the neck
hyperextended for nasal suctioning.
B. Position an unconscious client in the lateral position, facing you.
C. Place the towel or moisture-resistant pad over the pillow or under the chin. D.
Turn the suction device on and set to appropriate negative pressure on the suction
gauge. The amount of negative pressure should be high enough to clear secretions
but not too high.
E. For oral and oropharyngeal suction:
1. Moisten the tip of the Yankauer or suction catheter with sterile water or
saline.
2. Pull the tongue forward, if necessary, using gauze.
3. Do not apply suction (that is, leave your finger off the port) during
insertion.
4. Advance the catheter about 10 to 15 cm (4 to 6 in.) along one side of the
mouth into the oropharynx.
5. It may be necessary during oropharyngeal suctioning to apply suction to
secretions that collect in the mouth and beneath the tongue.
F. For nasopharyngeal and nasotracheal suction:
1. Open the sterile suction package.
2. Set up the cup or container, touching only the outside.
3. Pour sterile water or saline into the container.
4. Apply the sterile gloves, or apply an unsterile glove on the nondominant
hand and then a sterile glove on the dominant hand.
5. With your sterile gloved hand, pick up the catheter and attach it to the
suction unit.
 6. Lubricate the catheter tip with sterile water, saline, or water-soluble
lubricant.
7. Without applying suction, insert the catheter into either naris and advance
it along the floor of the nasal cavity.
G. Apply your finger to the suction control port to start suction, and gently rotate the
catheter.
H. Apply suction for 5 to 10 seconds while slowly withdrawing the catheter, then
remove your finger from the control and remove the catheter.
I. A suction attempt should last only 10 to 15 seconds. During this time, the
catheter is inserted, the suction applied and discontinued, and the catheter
removed.
J. Rinse the catheter and repeat suctioning as above if necessary.

Circulation
I. Coronary Circulation
A. The heart muscle moves blood to the lungs and peripheral tissues but does not
receive oxygen or nourishment from the blood within its chambers
B. It is supplied by a network of vessels known as coronary circulation or more
commonly as the coronary arteries
II. Arterial Circulation
A. Blood flow from the heart to the tissues determined by pressure differences and
resistance
III. Venous Return
A. Blood flow from the peripheral tissues to the heart
IV. Blood
A. Blood serves as the transport medium within the cardiovascular system B.
Transporting oxygen, nutrients, and hormones to the cells, and metabolic wastes
from the cells for elimination
C. Regulating body temperature, pH, and fluid volume
D. Preventing infection and blood loss
V. Factors Affecting Cardiovascular Function
A. Nonmodifiable Risk Factors
1. Heredity
2. Age
3. Gender
B. Modifiable Risk Factors
1. Elevated serum lipid level
2. Hypertension
3. Cigarette smoking
4. Diabetes
5. Obesity
6. Sedentary lifestyle
VI. Alterations in Cardiovascular Function
A. Decreased Cardiac Output
 1. Myocardial infarction
2. Heart failure
B. Impaired Tissue Perfusion
1. Ischemia
C. Blood alterations
1. Anemia
2. Hypovolemia
VII. Promoting Circulation
A. Vascular
1. Position with the legs elevated to promote venous return to the heart. 2.
Avoid pillows under the knees or more than 15 degrees of knee flexion to
improve blood flow to the lower extremities and reduce venous
stagnation.
3. Encourage leg exercises (such as flexion and extension of the feet, active
contraction and relaxation of calf muscles) for a client on bed rest, and
promote ambulation as soon as possible.
4. Encourage or provide frequent position changes.
B. Cardiac
1. Position the client in a high-Fowler’s position to decrease preload and
reduce pulmonary congestion.
2. Monitor intake and output. Fluid restriction is usually not required for
clients with mild to moderate cardiac dysfunction. With severe heart
failure, a fluid restriction may be ordered
C. Client Teaching: Promoting a Healthy Heart
1. Exercise regularly, participating in at least 30 minutes of moderate
intensity aerobic exercise five times a week.
2. Do not smoke.
3. Maintain your ideal weight.
4. Eat a diet low in total fat, saturated fats, and cholesterol.
5. Drink alcohol in moderation, if at all, consuming no more than 1 cocktail or
1 to 1 1/2 glasses of wine or beer daily.
6. Reduce stress and manage anger.
7. Effectively manage diabetes and hypertension, maintaining blood glucose
and blood pressure levels within normal limits.
8. If female, discuss with your health care provider the advantages and risks
of hormone replacement therapy after menopause (or after a total
hysterectomy).
9. Consult your primary care provider about the advisability of low-dose
aspirin therapy to further reduce the risk of CVD.
VIII. Preventing Venous Stasis
A. Applying Sequential Compression Devices
1. Place the client in a dorsal recumbent or semi-Fowler’s position.
2. Measure the client’s legs as recommended by the manufacturer if a
thigh-length sleeve is required.
 3. Place a sleeve under each leg with the opening at the knee.
4. Wrap the sleeve securely around the leg, securing the Velcro tabs.
IX. Cardiopulmonary Resuscitation
A. A combination of oral resuscitation (mouth-to-mouth breathing or use of a mask),
which supplies oxygen to the lungs, and external cardiac massage (chest
compression), which is intended to reestablish cardiac function and blood
circulation
B. The AHA issues revised standards for CPR every five years
C. It covers all aspects of emergency cardiac care and simplifies CPR procedures so
more health care professionals and lay rescuers might learn them and perform
them correctly.
D. A cardiac arrest is the cessation of cardiac function; the heart stops beating. 1.
Within 20 to 40 seconds of a cardiac arrest, the victim is clinically dead 2. After 4
to 6 minutes, the lack of oxygen supply to the brain causes
permanent and extensive damage
3. The three cardinal signs of a cardiac arrest are apnea, absence of a
carotid or femoral pulse, and dilated pupils
E. A respiratory arrest (pulmonary arrest) is the cessation of breathing.
1. It often occurs because of a blocked airway, but it can occur following a
cardiac arrest and for other reasons
F. It is vital that all nurses be trained to perform CPR so resuscitation measures can
be initiated immediately when a cardiac or respiratory arrest occurs

Loss, Grieving and Death

I. Loss - an actual or potential situation in which something that is valued is changed or no
longer available
A. Types of Losses
1. Actual Loss - can be recognized by others
2. Perceived Loss - experienced by one person but cannot be verified by
others
3. Anticipatory Loss - experienced before the loss actually occurs
B. Sources of Loss
1. Aspect of self
2. External objects
3. Familiar objects
4. Loved ones
II. Grief - the total response to the emotional experience related to loss A.
Types of Grief Responses
1. Abbreviated grief - brief but genuinely felt
2. Anticipatory grief - experienced in advance of the event
3. Disenfranchised grief - when a person is unable to acknowledge the loss
to other people
4. Complicated grief - the strategies to cope with the loss are maladaptive
and out of proportion or inconsistent with cultural, religious, or
 age-appropriate norms
a) Unresolved or chronic grief - grief is extended in length and
severity
b) Inhibited grief - many of the normal symptoms of grief are
suppressed and other effects, including somatic, are experienced
instead
c) Delayed grief - feelings are purposely or subconsciously
suppressed until a much later time
d) Exaggerated grief - using dangerous activities as a method to
lessen the pain of grieving
B. Stages of Grieving (Kübler-Ross)
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
C. Manifestations of Grief
1. Verbalization of the loss,
2. Crying
3. Sleep disturbance
4. Loss of appetite
5. Difficulty concentrating
D. Factors Influencing the Loss and Grief Responses
1. Age
2. Significance of loss
3. Culture
4. Spiritual beliefs
5. Gender
6. Socioeconomic status
7. Socioeconomic status
8. Support system
9. Cause of loss or death
E. Facilitating Grief Work
1. Explore and respect the client’s and family’s ethnic, cultural, religious, and
personal values in their expressions of grief.
2. Teach the client or family what to expect in the grief process, such as that
certain thoughts and feelings are normal (acceptable) and that labile
emotions, feelings of sadness, guilt, anger, fear, and loneliness will
stabilize or lessen over time.
3. Encourage the client to express and share grief with support people.
4. Teach family members to encourage the client’s expression of grief, not to
push the client to move on or enforce his or her own expectations of
appropriate reactions.
5. Encourage the client to resume normal activities on a schedule that
 promotes physical and psychological health.
F. Providing Emotional Support
1. Use silence and personal presence along with techniques of therapeutic
communication.
2. Acknowledge the grief of the client’s family and significant others.
3. Family support persons are part of the grieving client’s world.
4. Offer choices that promote client autonomy.
5. Provide information regarding how to access community resources:
clergy, support groups, and counseling services.
6. Suggest additional sources of information and help.
III. Dying and Death
A. Definitions of Death
1. Heart-Lung Death - traditional clinical signs of death were cessation of the
apical pulse, respirations, and blood pressure
2. Cerebral Death - occurs when the higher brain center, the cerebral cortex,
is irreversibly destroyed
B. Signs of Impending Clinical Death
1. Loss of muscle tone
a) Relaxation of the facial muscles
b) Difficulty speaking
c) Difficulty swallowing and gradual loss of the gag reflex
d) Decreased activity of the gastrointestinal tract,
e) Possible urinary and rectal incontinence due to decreased
sphincter control
f) Diminished body movement
2. Slowing of circulation
a) Diminished sensation
b) Mottling and cyanosis of the extremities
c) Cold skin, first in the feet and later in the hands, ears, and nose
d) Slower and weaker pulse
e) Decreased blood pressure
3. Changes in respirations
a) Rapid, shallow, irregular, or abnormally slow respirations
b) Noisy breathing, referred to as the death rattle, due to collecting
of mucus in the throat
c) Mouth breathing, dry oral mucous membranes
4. Sensory impairment
a) Blurred vision
b) Impaired senses of taste and smell
C. Hospice and Palliative Care
1. provides relief from pain and other distressing symptoms;
2. affirms life and regards dying as a normal process;
3. intends neither to hasten nor postpone death;
4. integrates the psychological and spiritual aspects of client care; 5.
 offers a support system to help clients live as actively as possible until
death;
6. offers a support system to help the family cope during the
7. client’s illness and in their own bereavement;
8. uses a team approach to address the needs of clients and their families,
including bereavement counseling, if indicated;
9. will enhance quality of life, and may also positively influence the course of
illness;
10. is applicable early in the course of illness, in conjunction with
other therapies that are intended to prolong life
D. Meeting the Physiological Needs of the Dying Client
1. Airway clearance
2. Air hunger
3. Bathing/hygiene
4. Physical mobility
5. Nutrition
6. Constipation
7. Urinary elimination
8. Sensory/perceptual changes
E. Postmortem Care
1. All equipment, soiled linen, and supplies should be removed from the
bedside
2. Normally the body is placed in a supine position with the arms either at
the sides, palms down, or across the abdomen
3. One pillow - is placed under the head and shoulders to prevent blood
from discoloring the face by settling in it
4. The eyelids are closed and held in place for a few seconds so they
remain closed
5. Dentures are usually inserted to help give the face a natural appearance.
The mouth is then closed.
6. Soiled areas of the body are washed; however, a complete bath is not
necessary
7. Absorbent pads are placed under the buttocks to take up any feces and
urine released because of relaxation of the sphincter muscles
8. A clean gown is placed on the client, and the hair is arranged 9. All
jewelry is removed, except a wedding band in some instances, which is
taped to the finger
10. The top bed linens are adjusted neatly to cover the client to the shoulders
11. The deceased’s wrist identification tag is left on and additional
identification tags are applied
12. The body is wrapped in a shroud, a large piece of plastic or cotton
material used to enclose a body after death. Identification is then applied
to the outside of the shroud.
13. The body is taken to the morgue if arrangements have not been made to
have a mortician pick it up from the client’s room.