Download Complex Respiratory Management

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B248: THE SCIENCE AND
TECHNOLOGY OF NURSING
Gas Exchange
Vema Sweitzer, MN, RN
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Gas exchange/Oxygenation
• Oxygenation can be defined as the mechanisms
that facilitate or impair the body’s ability to supply
oxygen to all cells of the body. 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.
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Pulmonary System
Ventilation
The process of
moving gases
into and out of
the lungs
Perfusion
The ability of the
cardiovascular
system to pump
oxygenated
blood to the
tissues and
return
deoxygenated
blood to the
lungs
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Pulmonary System
• Diffusion: Exchange of
respiratory gases in the
alveoli and capillaries.
• The thickness of the
alveolar capillary
membrane affects the
rate of diffusion.
• Oxygen transport = Lungs +
cardiovascular (CV) system
• Hemoglobin carries O2 and
CO2
• Carbon dioxide transport
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Pulmonary System
Cardiovascular Physiology (cont’d)
Cardiovascular Physiology
• Cardiopulmonary physiology involves delivery of
deoxygenated blood (blood high in carbon dioxide and
low in oxygen) to the right side of the heart and then to
the lungs, where it is oxygenated.
• Oxygenated blood (blood high in oxygen and low in
carbon dioxide) then travels from the lungs to the left
side of the heart and the tissues.
Cardiovascular Physiology
Myocardial pump
Myocardial blood flow
Two atria and two ventricles
As the myocardium stretches,
the strength of the subsequent
contraction increases
(Starling’s law).
Unidirectional through four
valves
Coronary artery
circulation
Coronary arteries supply the
myocardium with nutrients and
remove wastes.
S1: mitral and tricuspid close
S2: aortic and pulmonic close
Systemic circulation
Arteries and veins deliver
nutrients and oxygen and
remove waste products.
Blood Flow Regulation
Cardiac output
Stroke volume
Amount of blood ejected Amount of blood ejected
from the left ventricle
from the left ventricle with
each minute
each contraction
Cardiac output (CO) =
Stroke volume (SV) × Heart rate (HR)
Preload
End-diastolic pressure
Afterload
Resistance to left
ventricular ejection
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Collaborative Learning
In your learning group, develop a list
and discuss the physiological factors
affecting Oxygenation/Gas Exchange.
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Collaborative Learning
In your learning group, discuss the
meaning of the alterations in respiratory
functioning below.
Hypoventilation
Hyperventilation
Hypoxia
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Hypoventilation
• Causes
• Signs and Symptoms
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Hyperventilation
• Causes
• Signs and symptoms
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Hypoxia
• Causes
• Signs and Symptoms
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Case Study: Mr. William Smith
• Mr. Smith is a 65-year-old man who developed
shortness of breath while on a family vacation in the
mountains. When he returned home from vacation he
presented to the emergency department alert and
feeling ill with an elevated temperature of 101.5 F
and chills.
• Mr. Smith has a 1-pack per week history of smoking
and no history of alcohol or illicit drug abuse. Recent
history includes dry hacking cough, low-grade fever,
fatigue, loss of appetite, and feeling terrible.
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Case Study: Mr. William Smith
• Ben Adams is the nursing student assigned to his first
hospital-based clinical experience. He has some experience in
health assessment and patient teaching related to health
promotion activities from a recent rotation at a clinic. In the
previous experience, patients were encouraged to adjust their
at-risk health behaviors, such as smoking or poor diet.
• Ben feels confident when he arrives in the clinical area this
morning because Mr. Smith has similar health needs to the
clinical experiences he has had.
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Nursing Process: Assessment
Collaborative Learning
In your learning group, discuss what
questions Ben would have asked Mr. Smith
if he had been at the hospital when Mr.
Smith was being admitted.
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Questions
• Ask Mr Smith how long he has been short of breath.
• Ask Mr. Smith how long he has had his cough and
whether it is a productive cough.
• Ask Mr. Smith to produce a sputum sample.
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While Ben is completing his morning physical assessment,
what observations would he focus on to determine if Mr.
Smith’s oxygen needs were being met?
• Presents of:
• Inspection
• Palpation
• Percussion
• Auscultation
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Diagnostic Tests
• Diagnostic Tests
• CBC
• WBC: 5-10, 000
• RBC: Male: 4-6,000,000 Female 4-5,000,000
• Hgb: Male: 14-18 g/dL Female 12-16 g/dL
• Hct: Male 42%-52% Female 37%- 47%
• Chest x-ray
• Sputum specimens for C & S
• Pulse oximetry
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Case Study
• Ben’s morning assessment included the
following findings:
• BP 110/70 mm Hg
• HR 102 beats/min
• Temp 101.5
• RR 36 breaths/min
• Breath sounds: Expiratory wheezing, crackles and
diminished breath sounds over the right lower lobe are
audible.
• O2 Sats at 82% with O2 per NC at 2L/NC
• Sputum is thick and discolored (yellow-green).
• Wt 190 lbs
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Case Study: William Smith
• Ben reviewed the recent HCP’s orders and results.
• Admitting Diagnosis: Pneumonia
• Chest x-ray: revealed upper and middle lobe opacities on the right
side and some atelectasis in the lower lobe
• WBC 12.9
• Blood Cultures pending
• IV fluids: D5 .45 normal saline at 100 ml/hr
• Cefepime 1 g every 8 hours over 30 min. Mix in 50 ml of NS
• O2/NC at 2 L. Call if O2 sats are below 94%
• Encourage rest for 24 hours then up ad lib
• Incentive spirometer 10 time/hour while awake
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Pneumonia
• Pneumonia is an acute
inflammation of the
lung that is most
frequently caused by a
microorganism.
• Fluid and exudate in
the alveoli.
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Nursing Diagnosis
• Impaired gas exchange r/t fluid and exudate accumulation
in the alveoli AEB wheezing.
Outcome
• Patient will have a O2 sat of 94-100%, clear breath
sounds and temperature between 97.0-98.8.
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Plan of Care (POC)
• Assessments or what do we see
• Interventions or what we do
• Teaching or what do we teach
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Impaired gas exchange r/t fluid and exudate accumulation in
the alveoli AEB wheezing.
Outcome
Patient will have a O2 sat of 94-100%, clear breath sounds and
temperature between 97.0-98.8.
• In your learning group, develop the
care plan for Mr. Smith.
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Interventions
• Positioning: HOB up semi Fowlers
• Helps to drain secretions from specific segments of the
lungs and bronchi into the trachea
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Intervention
Nasal cannula
• Delivers flow rate up to 6 L/min
(24% to 40% oxygen)
(Skill 40-4)
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Intervention
• Order:
• 10 times/hr while awake
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Interventions
Deep breathing and coughing
Encourage fluids
• Diaphragmatic
• Hydration
breathing/belly breathing
• Cascade cough
• Huff cough
• Humidification
• Nebulization
• Oral and IV
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Case Study
• At the end of his 8 hours shift, Ben reported off to his
primary nurse. He reported:
• Mr. Smith:
• Used his IS 10 time every hour while awake. He had a productive
cough at the beginning of the morning, but by mid afternoon, he no
longer had a productive cough.
• Received his antibiotic per order
• Remained on bed rest per order. He did go to the BR and Ben
noticed Mr. Smith was SOB when he returned to bed. Mr. Smith did
have his HOB up at all time. After the change of O2 to 3 liter (per
order change) his O2 sats stayed at 95%.
• IV fluids are infusing with difficulty and he is taking oral fluids
independently (800 ml)
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Methods of Oxygen Delivery
• Used for short-term oxygen therapy.
Delivers 35%-50% FIO2
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Methods of Oxygen Delivery
• 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 40% to 70% with a flow rate
of 6-10 L/min
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Methods of Oxygen Delivery
• Venturi mask delivers higher oxygen concentrations of
24% to 60% with oxygen flow rates of 4 to 12 L/min,
depending on the flow-control meter selected.
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Oxygenation Safety
• 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.
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Oxygenation Safety
• Secure oxygen cylinders so they do not fall over. Store
them upright and either chained or secured in appropriate
holders.
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Tracheostomy equipment
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Suctioning
• Suctioning is necessary when patients are unable to clear
respiratory secretions from the airways by coughing or
other less invasive procedures.
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How to Suction a Tracheostomy
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How to Suction a Tracheostomy
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Emergency
Patient is having Acute Dyspnea
• Acute dyspnea for patient with tracheostomy is most commonly caused by
partial or complete blockage of the tracheostomy tube retained secretions. To
unblock the tracheostomy tube:
• 1. ASK THE PATIENT TO COUGH: A strong cough may be all that is needed
to expectorate secretions.
• 2. REMOVE THE INNER CANNULA: If there are secretions stuck in the tube,
they will automatically be removed when you take out the inner cannula. The
outer tube – which does not have secretions in it – will allow the patient to
breath freely. Clean and replace the inner cannula.
• 3. SUCTION: If coughing or removing the inner cannula do not work, it may
be that secretions are lower down the patients airway. Use the suction
machine to remove secretions.
• 4. If these measures fail – commence low concentration oxygen therapy via a
tracheostomy mask, and call for medical assistance.
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Suctioning (Skill 40-1)
• Key points:
• Use sterile procedure
• Suction set on continuous suction of 120-150 mm Hg
• Insert catheter, suction intermittently 10-15 seconds and slowly
rotate and withdraw
• Monitor patient:
• Risk for hypoxia
• Hypotension
• Arrhythmias
• Trauma
• Irritation
• Nursing Diagnosis: Ineffective airway clearance
r/t retention of secretions and poor cough effort.
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Oxygenation: Chest Tubes
Chest tubes
• A catheter placed through the thorax to remove air and fluids from
the pleural space
Purpose
• To remove air and fluids from the pleural space
• To prevent air or fluid from reentering the pleural space
• To re-establish normal intra-pleural and intra- pulmonary pressures
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Case Study: Mr. Scott
• Mr. Scott a 73-year-old man fell from a ladder while
cleaning his gutters. He presented to the emergency
department with c/o sudden onset of acute chest pain on
the right side and labored breathing and dyspnea.
• Assessment
• BP 170/88, HR 110, RR 40, O2 Sat 80%
• Uneven chest wall movement
• Very anxious
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Case Study: Mr. Scott
• Doctor’s Orders:
• chest x-rays
• CT scan (head, chest, abdomen, pelvis, and cervical spine),
• MRI (lumbar, thoracic, and cervical spine).
• He was diagnosed with having a right-sided
pneumothorax.
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Case Study: Mr. Scott
• Pneumothorax occurs
when air accumulates
in the pleural space
and causes complete
or partial collapse of a
lung.
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Case Study: Mr. Scott
• Chest tubes are inserted to
drain blood, fluid, or air
and allow full expansion of
the lungs. The tube is
placed in the pleural
space. The chest tube is
inserted between the ribs
into the chest and is
connected to a closed
water or dry seal. Suction
is attached to the system
to encourage drainage. A
stitch (suture) and
adhesive tape is used to
keep the tube in place.
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Impaired gas exchange r/t decreased functional lung tissue and ineffective
breathing pattern secondary to pain
Outcome
Patient will have a O2 sat of 94-100%, clear breath sounds in all lobes and lung
expanded per x-ray.
• In your learning group, complete this care plan.
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Case Study: Mr. Scott
Day 5
• Patient received a
chest x-ray to monitor
the status of the chest
tube placement and
pneumothorax. Results
showed that the right
lung remained fully
expanded.
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Gas Exchange and Interrelated Concepts
Anxiety
Nutrition
Perfusion
Gas
Exchange
Fatigue
Mobility