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B.8 Situation – Care of client with problems in oxygenation
Fundamentals – Ch 40: Oxygenation/Gas Exchange
 Oxygenation – mechanisms that facilitate or impair the body’s ability
to supply oxygen to all cells of the body.
o The function of the respiratory system is to obtain oxygen
from atmospheric air, to transport this air through the
respiratory tract into the alveoli, and ultimately to diffuse
oxygen into the body that carries oxygen to all the cells of
the body
Pulmonary System
 Process of oxygenation
o Ventilation
 Process of moving gases into and out of the lungs
o Perfusion
 Ability of the cardiovascular system to pump
oxygenated blood to the tissues and return
deoxygenated blood to the lungs
o Diffusion
 Exchange of respiratory gases in the alveoli and
capillaries of the body tissues
 The thickness of the alveolar capillary membrane
affects the rate of diffusion
 Diffusion of respiratory gases occurs at the
alveolar capillary membrane
 Patients with pulmonary edema, pulmonary
infiltrates, or pulmonary effusion have a thickened
membrane
 Resulting in slow diffusion, slow exchange
of respiratory gases, and decreased
delivery of oxygen to tissues
 Chronic diseases (emphysema), acute diseases
(pneumothorax), and surgical processe (lobectomy)
often alter the amount of alveolar capillary
membrane surface area
 Oxygen transport = lungs + cardiovascular (CV) system
 Hemoglobin carries O2 and CO2
 The oxygen transport system consists of the lungs and
cardiovascular system
o Delivery depends on the amount of oxygen entering the
lungs (ventilation), blood flow to the lungs and tissues
(perfusion), the rate of diffusion, and the oxygen-carrying
capacity.
o The airways of the lung transfer oxygen from the
atmosphere to the alveoli, where the oxygen is exchanged
for CO2
 Three things influence the capacity of the blood to carry oxygen:
o Amount of dissolved oxygen in the plasma
o Amount of hemoglobin
o Tendency of hemoglobin to bind with oxygen
 Hemoglobin – carrier for oxygen and carbon dioxide, transports
most (97%) oxygen
o Decreased hemoglobin levels alter the patient’s ability to
transport oxygen
 Conditions and diseases that changed the structure and function of
the pulmonary system alter respiration
 Gases move into and out of the lungs through pressure changes.
o Intrapleural pressure is negative, or less than atmospheric
pressure, which is 760 mm Hg at sea level.
o For air to flow into the lungs, intrapleural pressure becomes
more negative, setting up a pressure gradient between the
atmosphere and the alveoli.
o The diaphragm and external intercostal muscles contract to
create a negative pleural pressure and increase the size of
the thorax for inspiration. Relaxation of the diaphragm and
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B.8 Situation – Care of client with problems in oxygenation
contraction of the internal intercostal muscles allow air to o The volume of blood ejected from the ventricles during
escape from the lungs. systole is the stroke volume. Hemorrhage and dehydration
cause a decrease in circulating blood volume and a decrease
Cardiovascular physiology in stroke volume.
 Cardiopulmonary physiology involves delivery of deoxygenated  The amount of blood in the left ventricle at the end
blood (blood high in carbon dioxide and low in oxygen) to the right of diastole (preload), resistance to left ventricular
side of the heart and then to the lungs, where it is oxygenated. ejection (afterload), and myocardial contractility all
 Oxygenated blood (blood high in oxygen and low in carbon dioxide) affect stroke volume.
then travels from the lungs to the left side of the heart and the o Heart rate affects blood flow because of the relationship
tissues. between rate and diastolic filling time.
o The cardiac system delivers oxygen, nutrients, and other
substances to the tissues and facilitates the removal of Factors affecting oxygenation
cellular metabolism waste products by way of blood flow  Physiological factors
through other body systems such as respiratory, digestive, o Decreased oxygen-carrying capacity
and renal.  Anemia
o The primary functions of the heart are to deliver o Hypovolemia
deoxygenated blood to the lungs for oxygenation, and  Dehydration and hemorrhage
oxygen and nutrients to the tissues. o Decreased inspired oxygen concentration
 Systemic circulation  High altitudes
o Arteries and veins deliver nutrients and oxygen and remove o Increased metabolic rate
waste products  Fever
 Blood flow regulation o Any condition that affects cardiopulmonary functioning
o directly affects the body’s ability to meet oxygen demands
o When patients take opioids, their respiratory center is
depressed
 Factors affecting chest wall movement
o Pregnancy
o Obesity
o Musculoskeletal abnormalities
 Kyphosis, pectus excavatum
o Normal cardiac output is 4-6 L/min in the healthy adult at o Trauma
rest  Flail chest is a condition in which multiple rib
fractures cause instability in part of the chest wall.
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B.8 Situation – Care of client with problems in oxygenation
o Neuromuscular disease
 myasthenia gravis, Guillain-Barre syndrome, and
poliomyelitis.
o CNS alterations
 Cervical trauma at C3 to C5 usually results in
paralysis of the phrenic nerve.
o Chronic disease
 COPD
 Alterations in respiratory functioning
o Hypoventilation: alveolar ventilation inadequate to meet
the body’s oxygen demand; respiratory rate and depth is
low
 Caused by atelectasis and collapsed alveoli
 Signs and symptoms:
 Mental status changes, cardiac
dysrhythmias, convulsions, dizziness,
headache upon awakening, lethargy,
electrolyte imbalances, coma, and cardiac
arrest
o Hyperventilation: ventilation in excess of that required;
rate and depth of respirations increase
 Can be caused by anxiety, infection, drugs, acid-
base imbalance, fever, aspirin poisoning, or
amphetamine use.
 Signs and symptoms:
 Rapid respirations, sighing breaths,
numbness and tingling of hands/feet, light-
headedness, loss of consciousness
o Hypoxia: Inadequate tissue oxygenation at the cellular level,
late sign cyanosis
 Causes may include: anemia, carbon monoxide
poisoning, septic shock, cyanide poisoning,
pneumonia atelectasis, cardiomyopathy, spinal cord
injury, and head trauma
 Decrease in hemoglobin and lowered O2
carrying-capacity of blood, diminished
inspired O2, a decrease in diffusion of O2
from the alveoli to the blood, impaired
ventilation
 Signs and symptoms:
 Apprehensive, restlessness, inability to
concentrate, decreased LOC, dizziness,
behavioral changes, agitated, increased RR
and HR
 What is a late sign of hypoxia?
o Cyanosis, and lowered RR and HR
 Lifestyle factors
o Nutrition
 Cardioprotective nutrition = diets rich in fiber,
whole grains, fresh fruits and vegetables, nuts,
antioxidants, lean meats, and omega-3 fatty acids
 Severe obesity decreases lung expansion,
and increased body weight increases tissue
oxygen demands.
 Patients who are morbidly obese and/or
malnourished are at risk for anemia.
 Diets high in carbohydrates play a role in
increasing the carbon dioxide load for
patients with carbon dioxide retention.
o Exercise
 people who exercise 30-60 mins daily have a lower
pulse rate and BP, cholesterol level, increased blood
flow, and greater oxygen extraction be working
muscles
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B.8 Situation – Care of client with problems in oxygenation
o Smoking
 Associated with heart disease, COPD, and lung
cancer
 The risk of lung cancer is 10 times greater for a
person who smokes than for a nonsmoker.
 Cigarette smoking and secondhand smoke
are associated with a number of diseases,
including heart disease, COPD, and lung
cancer. Cigarette smoking worsens
peripheral vascular and coronary artery
diseases.
 Women who take birth control pills and
smoke cigarettes are at increased risk for
thrombophlebitis and pulmonary emboli.
 Exposure to secondhand smoke is also
dangerous.
o Substance abuse
 Excessive use of alcohol and other drugs impairs
tissue oxygenation.
o Stress
 A continuous state of stress or severe anxiety
Pneumonia
increases the metabolic rate and oxygen demand of
the body.
 The body responds to anxiety and other
stresses with an increased rate and depth of
respiration. Most people adapt, but some,
particularly those with chronic illnesses or
acute life-threatening illnesses such as an
MI, cannot tolerate the oxygen demands
associated with anxiety.
 Environmental factors
o The incidence of pulmonary disease is higher in smoggy,
urban areas than in rural areas.
o A patient’s workplace sometimes increases the risk for
pulmonary disease.
 Asbestosis
 Asbestosis is an occupational lung disease
that develops after exposure to asbestos.
The lung with asbestosis often has diffuse
interstitial fibrosis, creating a restrictive
lung disease. Patients exposed to asbestos
are at risk for developing lung cancer, and
this risk increases with exposure to tobacco
smoke.
 Others include: talcum powder, dust, and airborne
fibers.
 For example, farm workers in dry regions of the
southwestern United States are at risk for
coccidioidomycosis, a fungal disease caused by
inhalation of spores of the airborne bacterium
Coccidioides immitis.
 Acute inflammation of the lung that is most frequently caused by a
microorganism
 Fluid and exudate in the alveoli
o Streptococcus pneumoniae
 Interventions:
o Positioning HOB up – semi fowlers
 Helps to drain secretions from specific segments of
the lungs and bronchi into the trachea
o Nasal cannula
 Delivers flow rate up to 6 L/min
 24% to 44% oxygen
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B.8 Situation – Care of client with problems in oxygenation
 Starting at 1 L/min, increasing the oxygen flow by 1
L/min will increase the inspired oxygen
concentration about four percentage points:
 1 L/min = 24%
 2 L/min = 28%
 3 L/min = 32%
 4 L/min = 36%
 5 L/min = 40%
 6 L/min = 44%
o Incentive spirometry
o Deep breathing and coughing
 Diaphragmatic breathing/belly breathing
 Technique used that increases airflow to
the lower lungs. It also opens the pores of
Kohn between alveoli to allow sharing of
oxygen between alveoli which is especially
important since this pt has a lot of mucus
 Cascade and cascade cough
o Methods of coughing that will keep the throat open longer
in order to help move the mucous from the lungs more
effectively.
o Encourage fluids
 Hydration, humidification, nebulization, oral and IV
Oxygen Safety
 Hydration keeps mucociliary clearance normal. With
adequate hydration, pulmonary secretions are
thinner, whiter, and more watery thus making it
easier to expel.
 Methods of Oxygen Delivery
o Simple face mask
 Delivers 35%-50% at liter flows of 6-12 L/min
 Minimum of 6 L/min is required
o A plastic face mask with a reservoir bag is capable of
delivering higher concentrations of oxygen. A partial
rebreather mask is a simple mask with a reservoir bag that
should be at least one third to one half full on inspiration
and delivers from 60% to 90% with a flow rate of 10-15
L/min
 Non-Rebreather Mask
 Oxygen 60% to 90% 10-15 L/min flows into
reservoir bag and mask. Valve prevents
expired air from flowing back into bag.
 Partial Rebreather Mask
 Reservoir bag conserves oxygen
concentrations of 40-60% at 6-10 L/min
only difference is valve between mask and
bag is removed. The oxygen reservoir bag is
attached allows the client to rebreathe
about the first third of the exhaled air in
conjunction with oxygen
 Venturi mask delivers higher oxygen concentrations
of 24%-50% with oxygen flow rates of 4 to 12 L/min,
depending on the flow-control meter selected
 Minimum of 4 L/min
 Oxygen must be prescribed and adjusted only with a HCP’s order.
 Determine that all electrical equipment in the room is functioning
correctly and properly grounded. An electrical spark in the presence
of oxygen can result in a serious fire.
 Check the oxygen level of portable tanks before transporting a
patient to ensure there is enough oxygen in the tank.
 Secure oxygen cylinders so they do not fall over; store them upright
and either chained or secured in appropriate holders
 Parts of a tracheostomy tube.
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B.8 Situation – Care of client with problems in oxygenation
o Tracheostomy tube inserted in airway with inflated cuff. o Review the skill in the book for specific steps
o Fenestrated tracheostomy tube with cuff, inner cannula,  Changing a tracheostomy tube
decannulation plug, and pilot balloon. o A - A slit is cut about 1 inch (2.5 cm) from the end. The slit
o Tracheostomy tube with foam cuff and obturator (one cuff end is put into the opening of the cannula.
is deflated on tracheostomy tube). o B - A loop is made with the other end of the tape.
 Suctioning o C - the tapes are tied together with a double knot on the
o Necessary when patients are unable to clear respiratory side of the neck.
secretions from the airways by coughing or other less o D - A tracheostomy tube holder can be used in place of twill
invasive procedures ties to make tracheostomy tube stabilization more secure.
o Contraindications to nasotracheal suctioning o A two-person technique, one to stabilize the tracheostomy
 Occluded nasal  Coagulopathy or bleeding and one to change the ties, is best to assure that the
passages disorder tracheostomy does not become accidentally dislodged
 Nasal bleeding  Irritable airway during the procedure.
 Epiglottitis  Laryngospasm or  Patient is having Acute Dyspnea
 Croup bronchospasm
o Acute dyspnea for patient with tracheostomy is most
 Acute head, facial, or  Gastric surgery with high
anastomosis commonly caused by partial or complete blockage of the
neck injury or surgery
 Myocardial infarction tracheostomy tube retained secretions. To unblock the
o Key points: tracheostomy tube
 Use sterile procedure  Suction set on continuous suction 1. ASK THE PATIENT TO COUGH: A strong cough may be
 Insert catheter, suction up to 120 mm Hg for open all that is needed to expectorate secretions.
intermittently 10 suctioning 2. REMOVE THE INNER CANNULA: If there are secretions
seconds and slowly  Suction set on continuous suction stuck in the tube, they will automatically be removed
rotate and withdraw up to 160 mm Hg for closed when you take out the inner cannula. The outer tube –
 Allow 20-30 seconds suctioning.
which does not have secretions in it – will allow the
between passes
patient to breath freely. Clean and replace the inner
o Monitor patient: cannula.
 Risk for hypoxia  Trauma 3. SUCTION: If coughing or removing the inner cannula do
 Hypotension  Irritation not work, it may be that secretions are lower down the
 Arrhythmias patients airway. Use the suction machine to remove
secretions.
o Vagal stimulation 4. If these measures fail – commence low concentration
 Potentially hazardous complication from suctioning, oxygen therapy via a tracheostomy mask, and call for
can lead to bradycardia medical assistance.
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B.8 Situation – Care of client with problems in oxygenation
 Passy-Muir speaking tracheostomy valve MedSurg – Ch 24: Management of Patients With Chronic
o The valve is placed over the hub of the tracheostomy tube Pulmonary Disease
after the cuff is deflated. Multiple options are available and Chronic Obstructive Pulmonary Disease (COPD)
can be used for ventilated and nonventilated patients. The  COPD is a slowly progressive respiratory disease of airflow
valve contains a one-way valve that allows air to enter the obstruction
lungs during inspiration and redirects air upward over the o Emphysema, chronic bronchitis
vocal cords into the mouth during expiration. o Preventable and treatable but not fully reversible
o Other: Cystic fibrosis, bronchiectasis, asthma
Oxygenation: chest tubes
 Inflammation and fibrosis of the bronchial wall
 Chest tubes
 Hypertrophied mucous glands → excess mucus
o A catheter placed through the thorax to remove air and
o Obstructed airflow
fluids from the pleural space
 Loss of alveolar tissue
 Purpose
o Decreased surface area for gas exchange
o To remove air and fluids from the pleural space
 Loss of elastic lung fibers
o To prevent air or fluid from reentering the pleural space
o Airway collapse, obstructed exhalation, air trapping
o To re-establish normal intra-pleural and intra- pulmonary
 Decreased ability to exhale
pressures
 Chest tube interventions COPD: Clinical Manifestation
o Maintain secure, airtight dressing  Three primary symptoms
o Maintain underwater seal o Chronic cough
o Monitor and secure all connections o Sputum production
o Observe for bubbling o Dyspnea
o Monitor tubing for patency  Weight loss due to dyspnea
o Record output (quantity, characteristics)  “Barrel chest”
o Monitor patient
o Dressing changes per agency Chronic Bronchitis
 Pathophysiology: Chronic irritation of airways
Summary of interrelated concepts with Gas Exchange o Increased number of mucous cells
 Anxiety o Mucus hypersecretion
 Perfusion o Cough and sputum production for at least 3 months in each
 Fatigue of 2 consecutive years
 Nutrition o Ciliary function is reduced, bronchial walls thicken,
 Mobility bronchial airways narrow, and mucous may plug airways
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B.8 Situation – Care of client with problems in oxygenation
Alveoli become damaged, fibrosed, and alveolar Complications
macrophage function diminishes → more susceptible to  Assessment and Diagnosis of COPD
respiratory infections o Health history
o Increased pulmonary artery pressure may cause right-sided o Risk factors
heart failure (Cor pulmonale)  tobacco smoke, secondhand smoke,
dust/chemicals, air pollution, increased age
Emphysema
o Pulmonary function tests
 Pathophysiology: impaired oxygen and carbon dioxide exchange
o Spirometry
results from destruction of the walls of overdistended alveoli.
o Arterial blood gas, pulse oximetry
o Abnormal distention of air spaces beyond the terminal
o Chest x-ray
bronchioles with destruction of the walls of the alveoli
 Complications of COPD
o Decreased alveolar surface area increases in “dead space,”
o Respiratory insufficiency and failure
impaired oxygen diffusion
o Pneumonia
o Hypoxemia results → respiratory acidosis
o Chronic atelectasis
o (May potentially increase the risk of Cor pulmonale)
o Pneumothorax
 Blue bloaters (usually bronchitis)
o Cor pulmonale (right-sided heart failure)
o Cannot increase respiration enough to maintain oxygen
levels COPD: Management
o Cyanosis and polycythemia  Medical management
o Cor pulmonale o Risk reduction
 Pink puffers (usually emphysema)  Smoking cessation
o Increase respiration to maintain oxygen levels o Pharmacologic therapy
o Dyspnea; increased ventilatory effort  Bronchodilators
o Use accessory muscles; pursed-lip breathing  Corticosteroids
 Vaccine (Influenza, Pneumococcal)
 Antibiotics, Mucolytics
o Management of exacerbations
o Oxygen therapy
 Keep at least 90% oxygen saturation
Assessment  Keep at least 60 mmHg arterial oxygen
and Diagnosis  Long-term oxygen therapy
of COPD/
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B.8 Situation – Care of client with problems in oxygenation
 Do not provide too much oxygen (leads retaining of  Medical management: promote bronchial drainage and prevent
CO2) infection
o Surgical management o Postural drainage
 Bullectomy o Chest physiotherapy
 Lung volume reduction o Smoking cessation
 Lung transplant o Antibiotics
o Pulmonary rehabilitation o Bronchodilators and mucolytics
 Nursing management o Hydration
o Assessment  Nursing management: alleviating symptoms and clearing
o Airway clearance pulmonary secretions
o Improving breath patterns (slow expiration) o Breathing exercises
 Diaphragmatic breathing o Postural drainage
 Purse-lip breathing o Patient teaching
o Improving activity tolerance  Smoking cessation
o Monitoring/managing potential complications  Postural drainage
o Promoting home community-based and transitional care  Early signs and symptoms of respiratory infections
 Avoid contact with people with URI
Bronchiectasis
 Pathophysiology: a chronic, irreversible dilation of the bronchi and Asthma
bronchioles  Pathophysiology: Chronic inflammatory disease of the airways that
o Causes by inflammatory process associated with pulmonary causes hyper responsiveness, mucosal edema, and mucus
infections damage production
o These damaged air passages allow bacteria and mucus to o Inflammation leads to cough, chest tightness, wheezing, and
build up and pool in lungs. This results in frequent infections dyspnea
and blockages of the air way o Asthma is largely reversible; spontaneously or with
 Clinical Manifestations treatment
o Chronic cough o Allergy is the strongest predisposing factor
o Purulent sputum in copious amounts  Clinical Manifestations
o Clubbing of the fingers o Cough, dyspnea, wheezing
o Repeated pulmonary infection o Exacerbations (asthma attack)
 Cough, productive or not
Bronchiectasis: Management
 Generalized wheezing
 Chest tightness and dyspnea
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B.8 Situation – Care of client with problems in oxygenation
 Diaphoresis o Respiratory alkalosis (low PaCO2) due to hyperventilation
 Tachycardia  Medical management
 Hypoxemia and central cyanosis o A short-acting Beta2-adrenergic agonists and a short course
of corticosteroids
Asthma: Management o Oxygen
 Prevention: avoid the causative agents, standard asthma o IV fluid for hydration
medications  Nursing management
 Medical management o Monitor patient conditions and VS
o Pharmacological therapy o Administer IV fluid as prescribed
 Quick-relief medications
 Beta2-adrenergic agonists (bronchodilators) Cystic Fibrosis
 Anticholinergics  Pathophysiology: Most common autosomal recessive disease
o Long-acting medications among the Caucasian population
 Corticosteroids o Genetic mutation changes chloride transport which leads to
 Long-acting beta2-adrenergic agonists thick, viscous secretions in the lungs, pancreas, liver,
 Leukotriene modifiers intestines, and reproductive tract
o Management of exacerbations o Respiratory infections are the leading cause of morbidity
o Peak flow mentoring and mortality
 Nursing management: patient education  Clinical manifestations
o How to identify and avoid triggers o Cough, wheezing
o Proper inhalation techniques o Impaired mucus clearance
o How to perform peak flow monitoring o Hyperinflation of the lung fields (Chest X-ray)
o How to implement an action plan o Non-pulmonary manifestations
o When and how to seek assistance  Gastrointestinal problems (e.g., pancreatic
insufficiency, biliary cirrhosis, etc.)
Status Asthmaticus
 Pathophysiology: rapid, sever, and persistent asthma that does not Cystic Fibrosis: Management
respond to conventional therapy.  Medical management
o Severe bronchospasm with mucus plugging leading hypoxia o Chronic: control of infections; antibiotics
 Clinical manifestations o Acute: aggressive therapy involves airway clearance and
o The same with sever asthma; when obstruction worsens, antibiotics based on results of sputum cultures
wheezing may disappear → signs of respiratory failure (life o Anti-inflammatory agents
threatening condition) o Corticosteroids; inhaled, oral, IV during exacerbations
NLOA SFE
B.8 Situation – Care of client with problems in oxygenation
o Inhaled bronchodilators
o Oral pancreatic enzyme supplementation with meals
o Cystic fibrosis transmembrane conductance regulator
(CFTR) modulators are a new class of drugs and help to
improve function of the defective CFTR protein
o Postural drainage, chest physiotherapy, high-frequency
chest wall oscillation
 Nursing management
o Help patients manage pulmonary symptoms and prevent
complications
o Strategies that promote removal of pulmonary secretions
 Chest PT and breathing exercises
o Educate patient to reduce risk factors for respiratory
infection
o Adequate fluid and electrolyte intake
o Palliative care
o Discuss end-of-life issues and concerns