Unit 3

Oxygenation

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Normal Lung

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Emphysema Lung

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Emphysema

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Anaplastic Carcinoma

• Oat Cell

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Lung Damaged from Smoking

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Squamous Cell Carcinoma

• Most common lung cancer

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Roles and Responsibilities

• Discuss the role and responsibilities of the PN

in managing care of clients

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Inadequate ventilation

• Hypoxemia
• Hypoxia
• Anxiety
• Restlessness or confusion
• Use of accessory muscles for breathing
• Change in cognition

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 Common Respiratory Disorders

Restrictive Obstructive

1.Atelectasis-collapsed lung 1.Pneumonia-inflammation

2.Pleural effusion-fluid 2.Asthma-narrow bronchi

3.Hemothorax-blood in pleural 3.Emphysema-air trapped in lung

due to loss of elasticity
space

4.Tuberculosis-chronic lung
4.Pneumothorax-air in pleural inflammation
space

5.Lung Cancer-malignant growth

5.Pneumoconsiosis-fibrotic lung
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 Respiratory Disorders

• Pneumothorax -air enters pleural space.

• The loss of intrapleural pressure causes the

lung to collapse; may be caused by chest
trauma or spontaneously.

• S & S: pain as atmospheric air irritates the

pleura, dyspnea (breathlessness) is common
and worsens as the size of the pneumothorax
increases.

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 Respiratory Disorders

Tension Pneumothorax - Chest wall is intact

• Air enters the pleural space from the lung or
airway, and it has no way to leave
• There is no vent to the atmosphere as there is
in an open pneumothorax
• Most dangerous when patient is receiving
positive pressure ventilation in which air is
forced into the chest under pressure
• Can Kill
 Respiratory Disorders

• Hemothorax - occurs after thoracic surgery

and many traumatic injuries
• As with pneumothorax, the negative pressure
between the pleurae is disrupted, and the lung
will collapse to some degree, depending on the
amount of blood
• The risk of mediastinal shift is insignificant, as
the amount of blood needed to cause the shift
would result in a life-threatening intravascular
loss
Factors Affecting Respiration

• Lifestyle Factors
• Environmental Factors
• Developmental Factors
• Physiological Factors

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 Assessing Respiratory Status

• Health History
• Pain – presence of chest pain
• Fatigue – early sign of chronic condition
• Smoking – exposure to 2nd hand as well
• Dyspnea – breathlessness
• Cough & lung sounds
• Environmental exposures
• History of allergies & respiratory
infections
• Medications 15
 Assessing Respiratory Status

• Physical Examination
• Orientation, level of consciousness,
behavior
• Vital signs
• Inspection - Skin and mucous
membranes, clubbing of nails
• Breathing patterns
• Lung auscultation
• Abdominal assessment 16
Abnormal Breath Sounds

• Diminished or Absent
• Fine Crackles
• Coarse Crackles
• Wheezes
• Pleural Friction Rub
• Rhonchi

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 Recognizing Hypoxia

• Caused by Hypoxemia: low oxygen

levels in the blood
• Signs and Symptoms
• Changes in mental status — decreased
LOC, restlessness, confusion, agitated
• Changes in vital signs — respiratory
rate increases initially, then drops
• Changes in the skin — cyanosis

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Common Diagnostic Tests

• CBC
• Pulmonary Function Test
• Arterial Blood Gases
• Pulse Oximetry
• Sputum Culture
• Imaging Studies (x-ray, CT, lung scan)
• Endoscopy (Bronchoscopy, Thoracoscopy)
• Thoracentesis
• Biopsy
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Sputum Abnormalities

• Normal is clear / white

• Profuse amount of purulent sputum
(thick and yellow, green, or rust-
coloured) probably indicates a
bacterial infection
• Thin, mucoid sputum may indicate
viral bronchitis
• Gradual increase of sputum over time
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may indicate chronic bronchitis
Sputum Abnormalities

• Pink-tinged mucoid sputum may

indicate a lung tumour
• Profuse, frothy, pink material may
indicate pulmonary edema
• Foul smelling sputum may be caused
by an infection

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Nursing Diagnosis Related to Respiration

• Ineffective Breathing Pattern

• Ineffective Airway Clearance

• Impaired Gas Exchange

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Nursing Diagnosis Related to
Respiration

• Activity intolerance
• Decreased cardiac output
• Pain
• Anxiety
• Hopelessness
• Ineffective health maintenance
• Unbalanced nutrition
• Fatigue 24
Nursing Measures for Alteration in
Oxygenation

• Chest/Respiratory assessments
• Oxygenation saturation
• Vital signs
• Choice of mask
• Positioning in bed
• Comfort
• Pain relief
***Oxygen is a medication and needs to be prescribed by a Dr, except
in emergency situations***

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Nursing Measures for Alterations in Oxygenation

• Chest physiotherapy
• Nasopharyngeal suctioning
• Oxygen therapy via mask
• Artificial airways
• Oral Airway
• Endotracheal Tube
• Tracheostomy

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Interventions for Alterations in Oxygenation

• Positioning
• Giving O2
• Opening Airways
• Improving Efficiency - Chest physiotherapy -
suction
• Reduce Anxiety

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Interventions to Clear the
Airways

• Assisting the Client to Cough

• Suctioning the Airways
• Liquefying and Mobilizing Sputum
• Reducing Sputum Production

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Suction Catheters

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Indications for Suctioning

• What are signs and symptoms

indicating need for suctioning?
• Increased resp rate
• Wet lung sounds
• Increased oral and nasal secretions
• Drooling

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Indications for Suctioning

• Visual assessment: Rapid, shallow breathing or difficult,

labored breathing
• Auditory assessment: Moist, noisy, or gurgling sounds
associated with breathing
• Tactile assessment: Placing a hand flat over the client’s
chest wall detects vibrations of loose secretions
• Auscultation assessment: Coarse crackles, a loose,
continuous, low-pitched rattling sound that disappears after
suctioning or coughing
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 Suctioning

• Wet cough, crackles, rhonchi, cyanosis, desaturation

• Irritates bronchus and stimulates coughing reflex-normal
• Explain procedure
• Position
• Sterile gloves/suction tubing/saline
• Suction 5-10 seconds, 3 minutes between suctions
• Use intermittent suction to remove secretions; no suction when inserting
catheter
• Rinse suction catheter
• Provide oral care 32
 Chest Physiotherapy

• Chest percussion
• Vibration
• Different postural drainage
systems (Page 906 in Potter &
Perry)

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Oxygen Therapy

• Normal ABG PaO2 80-100mmHg;

SaO2 95-100%
• Flow rates are in L/min
• Why would you want to add
humidity to O2 therapy?
• What are the O2 requirements for
COPD clients?
• Teach pursed lip breathing technique
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for these pateints.
Oxygen Delivery Systems

• Low-Flow Systems
• Nasal cannula 1-6L/min (24-44%)
• Simple oxygen mask 6-8L/min (40-60%)
• Oxygen mask with reservoir bag
• Non-rebreather 12-15 L/min (80-100%)
• High-Flow System – noisy, can receive 100%
oxygen

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 Oxygen Delivery Systems

• CPAP (continuous positive airway pressure)

• Used for sleep apnea, positive pressure keeps
airway & trachea open
• BIPAP (bilevel positive airway pressure)
• Each inspiration can be initiated by client or
programmed back up rate
• Provides inspiratory & expiratory support
• Used for clients who require ventilatory assistance
at night
 Oxygen Delivery Systems

Mechanical Ventilation
• Type – volume or pressure cycle
• Mode - Controlled or assist-control
• Problems – bucking the ventilator (breathing
against the machine)
 Chest Tube Draining Systems

• Pleural chest tubes-inserted into

plural cavity to drain fluid
• Serous, sanguinous, purulent
drainage

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 Heimlich Valve
• Used to evacuate air from the
pleural space
• Has rubber flutter, one way
valve, within a rigid plastic tube
• Attached to the external end of
the chest tube
• Valve opens when pressure is
greater than atmospheric
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pressure
 Drainage Wet & Dry

• Wet-
• 3 chambers: Collection chamber, water
seal chamber, and wet suction control
chamber

• Dry Suction with or without water seal

• One way valve to allow air to leave chest
by setting the suction control valve

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Assessment of Chest tubes

• Tidaling in water seal noted with

breathing (fluid will rise and fall)
• No tidaling-Lungs expanded or tubing
kinked
• Intermittent bubbling is ok
• Should not be excessive bubbling –
indicates a leak
• May need to refill water seal chamber
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 Monitoring Chest Tube/Output

• Mark q shift and hourly if necessary

• Intake and output form
• Notify Dr. if greater than 100ml/h
• Never clamp the tubing
• If going for tests, may discontinue
suction but leave suction vent open

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 Artificial Airways
• Endotracheal airway

• Tracheostomy tube

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 Airway

• Endotracheal-catheter passed through

nose or mouth into the trachea
• Tracheostomy tube-tube inserted
through an opening in the trachea – to
bypass upper airway obstruction
• Opening is made in 2-3rd tracheal ring
cuffed tube inserted and inflated.

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 Tracheostomy
• Artificial opening made into trachea
through which a curved tube
(tracheostomy tube) is inside
• Replaces endotracheal tube
• Method for mechanical ventilation
• To bypass an upper airway obstruction
• To remove tracheobronchial secretions

• Outer cannula-remains in place

• Inner cannula-removed for cleaning or
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replaced
 Tracheostomy

• Cuffed
• Seals opening around tube against air leakage
• Prevents aspirations
• Permits mechanical ventilation
• As a general rule, the cuff should be inflated

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Tracheostomy

• Uncuffed
• Usually established stoma
• Low risk for aspiration
• Can eat/talk

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Tracheostomy Care

• Sterile procedure
• Pre-oxygenation prior to suctioning if doing deep
suctioning
• Suctioning-no more than 10 sec
• Cleaning inner cannula/or replace
• Unlock and remove inner cannula to soak/clean
• Using solution that Doctor has ordered and dry,
check hospital policy for cleaning solutions
• Prevent accumulation of secretions
• Clean outer cannula with separate applicator 49
Tracheostomy Care T

• Change dressings and ties

• Have assistance to hold tube in place to prevent
dislodgement/decannulation of tube
• Do not use ties that fray
• Do not cut gauze, use pre-cut non-ravelling dressing, flaps
pointing up, to prevent fibres from entering the trach tube
• Tie knot to side of neck
• Clean skin around tracheostomy to prevent build up of
dried secretions and skin breakdown
• Assess and clean stoma under face plate
• Document 50
Tracheostomy Assessments

• Ineffective airway clearance as the tube is a foreign

object in airway and increases production of mucus
• Client is unable to cough to clear airway
• Frequent respiratory assessment and suctioning required
• secretions around cannula and dressing
• excessive coughing or expectorations
• respiratory status-breath sounds, RR, use of accessory
muscles, air entry bilateral, SpO2
• signs of respiratory distress-tachypnea, anxiety, flared
nostrils, tachycardia, accessory muscles
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Documentation

• What is pertinent information to report and

document?
• Problem – SOB, asthmatic episode

• Complete assessment e.g.: accessory muscle use,

respiratory distress, colour, positioning etc.

• Flow rate of O2, mask used or nasal prongs

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Client Teachings to include:

• Purpose of O2/Hazards of O2
• Deep breathing and coughing
• Using a metered dose inhaler
• Using an incentive spirometer
• Diaphragmatic breathing
• Pursed-Lip breathing

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Critical Thinking: Integration Theory
and Practice

• Nursing Metaparadigm
• Nursing Concepts
• Art and Science of Nursing
• Determinants of Health to Patient Outcomes In this unit