Stressors that Affect Oxygen Needs

1. Stressors that AffectOxygen Needs NUR101 FALL 2008 K. BURGER, MSEd, MSN, RN, CNE LECTURE #19 PPP by Sharon Niggemeier RN, MSN Revised October 2005 by K. Burger

2. Oxygenation • Ventilation- air moves in & out of lungs • External respiration-exchange of O2 & CO2 between alveoli and blood • Gas Transport- blood transports O2 & CO2 to body cells • Internal respiration- exchange of O2 & CO2 between blood and cells.

3. Checkpoint • T / F The pulmonary artery carries oxygenated blood away from the lungs. FALSE

4. Factors Affecting Respiration • Integrity of the airway system (ventilation) • Functioning cardiovascular system (perfusion) • Functioning alveoli (diffusion) • Functioning medulla & chemoreceptors

5. Pulmonary Ventilation • Inspiration- air flows into lungs • Expiration-gases flow out of lungsAccording to pressure gradiant – Boyle • Intrapulmonic or intra-alveolar pressure- pressure within alveoli(fluctuates: Inspiration 759mm Hg Expiration 761mm Hg) • Intrapleural pressure-pressure within the intrapleural space (always negative)(756 mm Hg) • Note: Atmospheric Pressure = 760 mm Hg

6. Factors Affecting Ventilation • Lung elasticity / compliance(ability to stretch and recoil) • Airway obstruction • Musculature condition • Neurological controls

7. Checkpoint What is the name of the nerve that supplies the diaphragm? PHRENIC NERVE

8. Alveoli Gas Exchange • Air reaches alveoli • Oxygen from alveoli space moves into pulmonary capillary (oxygen uptake) via diffusion • Oxygen diffuses across alveoli membranes moving from high concentration (alveoli) to lower concentration (pulmonary capillary)

9. Alveoli Gas Exchange • Surfactant- secreted by alveoli cells, keeps surfaces moist and prevents atelectasis • Atelectasis- incomplete lung expansion or collapse of alveoli • Lung Compliance- elasticity of lung tissue and flexibility of rib cage • Lung recoil- ability of lungs to recoil

10. Other Factors Affecting Gas Exchange • Surface area • Thickness of tissue Fick’s Law of Diffusion:Rate of a diffusion of gas is dependent on surface area and thickness of the membrane

11. Perfusion • Transport of O2 & CO2 via blood to tissue • Volume of blood flowing through lungs affects amount of oxygen and gases exchanged • Adequate blood supply and cardiovascular functioning are needed • Oxyhemoglobin HbO2 (or SaO2)

12. Checkpoint The majority of CARBON DIOXIDE molecules are transported in the blood as: ??? BICARBONATE HCO3

13. Perfusion • Rate of O2 transport depends on: • Cardiac output • Activity level • CO2 transport

14. Neurologic/ChemicalControls of Respiration • Peripheral Chemoreceptors • Central Chemoreceptors • Medullary respiratory center • Spinal cord • Phrenic nerve • Diaphragm

15. Environment Emotions Exercise Health Age Life style Medications Respiratory History Factors Affecting Oxygenation

16. Checkpoint What is the normal respiratory rate of a newborn? 30-60 breaths/min

17. Assessing Respiratory Functioning • Difficulty breathing? • SOB? • Chest pain? • Coughing?Sputum production? • Nocturnal diaphoresis • Fatigue • Sleep with 2 or more pillows?

18. Respiratory Hx includes: Allergies Medications Medical Hx Smoking Lifestyle / Activity Level Stressors Recent exposures Developmental level Assessing Respiratory Functioning

19. Assessing Respiratory Functioning • Patient states difficulty breathing: you can assess by using PQRST • P- provokes • Q- quality • R- region/radiation • S- severity scale • T- timing

20. Assessing Respiratory Functioning • Respiratory Rate: • Tachypnea R>24 • Bradypnea R<10 • Apnea • Respiratory Depth: • Deep - diaphragmatic • Shallow

21. Assessing Respiratory Functioning • Respiratory Rhythm: • Regular – “even and symmetrical” • Cheyne-Stokes • Kussmauls • Biot’s (ataxic – without rhythm) • Apneustic breathing (gasping)

22. Assessing Respiratory Functioning • Respiratory Quality: • No difficulty- Eupneic/ Unlabored • Dyspnea • Orthopnea • Retractions • Use of accessory muscles • Auscultation: • Vesicular • Bronchial • Bronchovesicular

23. Cough: Nonproductive Productive Sputum Hemoptysis Adventitious Sounds: Crackles: fine,medium,coarse Wheeze: sibilant,sonorous Stridor Stertor Pleural friction rub Assessing Respiratory Functioning Breath sounds

24. Respiratory Assessment Review • Oxygen delivery method correctly applied • Obtain a pulse oximetry reading (norm is >95%) • Check Vital Signs ?T ?P ?R • Auscultate the pt’s lungs • Note changes in skin and mucosa color • Assess capillary refill

25. Checkpoint • What are some other elements of a respiratory assessment not yet mentioned? Neurological state Color Nail clubbing AP vs Transverse Diameter Barrel Chest?

26. Assessing Respiratory Functioning • Diagnostic tests: • Sputum • Nose/throat cultures • CBC (complete blood count) • ABG (arterial blood gases) • CXR (chest x ray) • PFT (pulmonary function tests) • Pulse Oximetry http://www.oximeter.org/pulseox/principles.htm • Other: Scopes, CT, MRI, PET

27. Hypoxia Hypoxemia Hyperventilation Hypercapnia Obstructed airway Foreign body obstruction (FBO) Alterations:Respiratory Functioning

28. Nursing InterventionsIndependent • Airway maintenance • Positioning • Deep breathing & coughing • Pursed-lip breathing • Abdominal/diaphragmatic breathing • Hydration • Teaching of health habits

29. Nursing InterventionsCollaborative/Dependent • Incentive spirometry • Percussion/postural drainage • Suctioning • Oxygen therapy • Medications

30. Nursing InterventionsCollaborative/Dependent • Oxygen Therapy • Indications • Sources- wall outlet or portable tank • Monitor pulse oximetry • Methods- cannula, mask, venturi mask, tent/isolette,BiPAP, CPAP

31. Administering Oxygen Therapy • Flow rate • Humidification • Hydration • Positioning • Safety precautions • Document • MD order required

32. Oxygen Safety Precautions • Signs: “No smoking. Oxygen in use.” •  Remove matches, lighters and cigarettes. •  Remove and store electrical equipment to avoid sparks. Ground electrical equipment. •  Avoid materials that generate static electricity •  Avoid use of volatile, flammable materials, such as alcohol. • Know location & use of fire extinguishers & alarms.

33. Nursing Interventions • Medications • Nebulizer Tx • Cough suppressants • Mucolytic: expectorants • Bronchodilators • Corticosteroids

34. Date Time LOC Rate Depth Rhythm Breath sounds (auscultated) Quality Color DocumentationRoutine Nurses Note

35. Nursing Diagnosis • Ineffective airway clearance • Risk for aspiration • Ineffective breathing pattern • Impaired gas exchange • Risk for suffocation • Ineffective tissue perfusion; cardiopulmonary • Impaired spontaneous ventilation • Dysfunctional ventilatory weaning response

36. Checkpoint Select a priority nursing diagnosis for the following scenario: 88 y.o. female with pneumonia who has a non-productive cough, R= 24, course crackles upon auscultation. She is weak, undernourished and fatigued. Ineffective airway clearance

37. Checkpoint Select a priority nursing diagnosis for the following scenario: A patient with hx of emphysema with decreased PO2, increased CO2 levels who is dyspneic and restless. Impaired Gas Exchange

38. Checkpoint Select a priority nursing diagnosis for the following scenario: A patient admitted to the ER post MVA with notable blood loss, BP= 80/50, P=120, R=22 Ineffective Tissue Perfusion; Cardiopulmonary

39. Summary: Oxygenation • Oxygenation based on ventilation/perfusion/diffusion of oxygen • Various factors effect oxygenation • Assessment includes respiratory Hx, clinical exam, diagnostic tests • Interventions include airway maintenance /proper breathing/ oxygen therapy/meds