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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chapter 28
Respiratory Care
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen
 Highest need on Maslow’s Hierarchy.
 Essential to life.
 Every cell in the body uses O2 to metabolize
nutrients and produce energy.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Normal Oxygenation
Airway –Refers to the normal path that air
takes as it enters and exits the lungs
Nostrils
pharynx
Trachea
Right or left bronchus
Bronchioles
Alveoli
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Regulation of Respiration
 The Respiratory Center of the brain is the
“Medulla”. The medulla is located in the
Brainstem.
 This brain function automatically controls
inhalation by sending impulses to the phrenic
nerve, which causes
the contraction of the
diaphram and the
intercostal muscles.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Inhalation
 The diaphragm contracts in response to
stimulus from phrenic nerves and moves
downward
 Intercostal muscles contract, moving ribs up
and out, increasing chest cavity size
 The lungs expand and a vacuum is created
 Air is pulled into the lungs to equalize pressure
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Exhalation
 As the muscles relax in response to nerve
stimulus, chest cavity size decreases
 The ribs come inward, diaphragm rises
upward, and lungs are compressed
 Air is forced out of the lungs
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Muscles Related to Breathing
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respiration
 External respiration takes place between the
alveolar and the capillary membranes.
 Internal respiration occurs at the cellular level
by means of hemoglobin and body cells.
 Hemoglobin carries O2 and CO2 to and from
the cells.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Effects of Chronic Lung Disease
on Respirations
 Air is trapped in the alveoli for long periods of time
 This raises blood’s level of carbon dioxide and lowers
oxygen level
 Body gradually acclimates to higher carbon dioxide
level
 High carbon dioxide level no longer stimulates
respirations
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Impaired Oxygenation
 If a blockage occurs in the airway or oxygen
can not pass into the blood through the
alveoli to capillaries, the patient will not have
effective oxygenation to the lungs or to the
rest of the body cells and tissue.
 When levels of oxygen drop in the blood this is
referred to as Hypoxemia and leads to
hypoxia.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
•S/S of Inadequate Oxygenation
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Decreased energy
Restlessness
Rapid, shallow breathing
Rapid heart rate
Sitting up to breathe
Nasal flaring
Use of accessory muscles
Hypertension
Sleeplessness, confusion, stupor & coma
Cyanosis of skin See additional on chart 28-1 pg 614
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Possible Causes of Hypoxia
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Airway obstruction
Anemia
Atelectasis Partial collapse of the lung
Decreased cardiac output
High altitude
Hypoventilation due to sedatives or anesthesia
Poor peripheral circulation
Pulmonary embolus
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respiratory Conditions
 Atelectasis: partial or total collapse of a lung
 Crepitus: air in the subcutaneous tissue
 Cyanosis: decrease in oxygen levels in the
tissues; lips take on bluish color
 Dyspnea: difficulty moving air in and out of
the lungs
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assessing Respiratory Status
Inspection
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Color of skin and mucous membranes
Respiratory effort
Cough
Chest appearance
Oxygenation status
Oxygen saturation
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Possible Respiratory Findings
Related to Palpation
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Airway obstruction
Pneumothorax
Pleural effusion
Crepitus
Fundamentals of Nursing Care: Concepts, Connections, & Skills
True/False Question
People who have severe chronic lung disease
gradually develop a different stimulus to
breathe.
A. True
B. False
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Answer
A. True
Rationale: People who have severe chronic
lung disease gradually develop a different
stimulus to breathe due to the high levels of
carbon dioxide in their lungs.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Possible Respiratory Findings
Related to Auscultation
 Rate, character, and quality of respirations
 Patterns of respirations
 Tachypnea, bradypnea, eupnea, Kussmaul,
Cheyne-Stokes, apnea
 Adventitious breath sounds
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygenation Status Pulse Oximetry
 Noninvasive technique
for periodically or
continuously
monitoring the O2
saturation of blood.
 Composed of a sensor
and microprocessor.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Oximetry
 SpO2-abbreviation
 Normal 95-100%
 Below 70%- life-threatening
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Oximetry
 Factors that interfere with accurate readings:
1. Movement of the sensor.
2. Poor circulation.
3. Barrier to light-nail polish, thick toenails, acrylic
nails.
4. Direct sunlight.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diagnostic Tests
 ABG’s
 Lab test that uses arterial blood to assess
oxygenation, ventilation and acid-base
balance.
 Depending on hospital policy ABG’s can be
drawn by lab technician, nurse, or respiratory
therapist.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Arterial Blood Gases
Values for ABG’s:
 PaO2-partial pressure O2 dissolved in plasma
(normal is 80-100mm Hg).
Ex. <40 indicates severe hypoxia
 SaO2-% of hemoglobin saturated with O2
(normal is 95-100)
Ex. Below 95% can indicates anemia
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diagnostic Tests
 Sputum specimens
See how to collect page 631.
 May help diagnose infection, TB, bleeding,
and fluids in the lungs.
 Throat cultures Specimens
 Generally ordered to detect streptococcus
infection (Strep Throat).
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diagnostic Tests
 Pulmonary function test.
Rationale: Pulmonary function tests are used
to diagnose obstructive or restrictive lung
disease such as COPD or asthma. Peak flow
determines dosages for medications.
 Chest x-ray determines lung filling, cardiac
silhouette, tumors, infiltrates, pneumonia, and
effusions.
 TB skin test confirms past exposure to TB.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Promoting Oxygenation
Positioning:
 High Fowler’s Positionupright
1. Allows abdominal
organs to descent
away from the
diaphragm.
2. Allows the lungs to fill
with greater volume
of air.
3. Post OP’s splinting.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Interventions for Patients
With Impaired Oxygenation
 Turning
 Coughing
 Deep breathing
 Incentive spirometry
 Nebulizer treatments
 Supplemental oxygen
 Conservation of energy
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Orthopneic Position
 Patient is seated with
arms supported on
pillows or arm rests of
chair and leans forward
over the bedside table.
 Allows for maximum
vertical and lateral chest
expansion and provides
comfort while resting or
sleeping.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Delivery Safety Precautions
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Place No Smoking signs in room
Ensure there are no open flames in the room
Check electrical devices for frayed wires
Eliminate possibility of static electricity
Avoid using petroleum-based products
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Breathing Techniques
Deep Breathing:
 Provides maximum ventilation.
 Air fills alveoli to a greater capacity to
improve exchange.
 Use with patients who are shallow
breathers, esp. those in pain.
 Technique-have patient take in as much air
as possible, hold breath briefly, exhale
slowly.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Delivery Systems
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Piped-in oxygen
Oxygen tank
Oxygen E-cylinder
Oxygen concentrator
Liquid oxygen
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Teaching Patients to Conserve Energy
 Place a chair in the shower and use a terry
cloth robe to dry off
 Encourage patient to use Pulmocare to
increase protein and calories and eat more
frequent, smaller meals
 Encourage patient to rest after performing
activities of daily living
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Incentive Spirometry
 Deep breathing using a
calibrated device.
 Encourages patients to
reach a goal-directed
volume of inspired air.
Allows the nurse to
evaluate the patients
breathing efforts.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Use of Incentive Spirometer
 Nurse needs to instruct patient in proper
technique:
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Sit upright.
Identify the goal for inhalation.
Exhale normally.
Insert mouthpiece.
Hold breath for 3 to 6 seconds.
Remove mouthpiece and exhale normally.
Repeat 10 to 20 times an hour.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Breathing Techniques
Pursed-Lip Breathing
 Form of controlled ventilation
in which the client consciously
prolongs the expiration phase
of breathing.
 Helps eliminate more than
usual amounts of CO2.
 Used with patients with
chronic lung disease, and
patients with hypercarbia
(excessive levels of CO2 in the
blood).
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Breathing Techniques
Purses-Lip Breathing
Technique:
 Inhale slowly through nose
while counting to three.
 Purse the lips as though to
whistle.
 Contract the abdominal
muscles.
 Exhale through pursed lips
for a count of six or more.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Artificial Airways
 Pharyngeal
 Orpharyngeal
 Nasopharyngeal
 Endotracheal
 Endotracheal tube
 Tracheostomy
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assessment Parameters for
Respiratory Disorders
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Lung sounds
Existence of hypoxia
Cough
Color, amount, and consistency of sputum
Nutrition
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Breathing Techniques
 Diaphragmatic Breathing-breathing that
promotes the use of the diaphragm rather than
the upper chest muscles.
 Used to increase the volume of air exchanged
during inspiration and expiration.
 Reduces respiratory effort and relieves rapid,
ineffective breathing.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diaphragmatic Breathing Technique
Instruct Patient to:
 Lie down with knees
bent.
 One hand on abdomen,
one hand on chest.
 Inhale slowly and
deeply through nose
while letting abdomen
rise more than chest.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Breathing Techniques
Nasal Strips
 Used to reduce airflow
resistance by widening
breathing passageways of
the nose.
 Used for people with
ineffective breathing,
athletes to increase O2
during exercise, reduce
snoring.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Therapy
 Oxygen therapy-an intervention for
administering more oxygen than is present in the
atmosphere to prevent or relieve hypoxia
 May be necessary when breathing techniques are
inadequate to keep the blood adequately
saturated with oxygen.
 Must have a physician’s order to administer O2.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Therapy
Oxygen Sources:
 Wall outlet
 Portable tank
 Liquid oxygen unit
 Oxygen concentrator
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Therapy
Wall Outlet:
 Used in modern health
care facilities.
 Outlet is connected to a
large central reservoir
filled with O2 on a
routine basis.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Sources
 Used for transport.
 Resemble steel cylinders.
 Large tank holds 2,000
lbs. of pressure per
square inch.
 Delivered with a
protective cap to prevent
accidental force against
tank outlet.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Equipment
 Gauge used to regulate
the amount of oxygen
delivered to the client.
 Attached to an oxygen
source.
 O2 is measured in liters.
 Physician prescribes the
dose.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Equipment
 Device that produces
water droplets.
 Used during oxygen
administration because
O2 is drying to mucous
membranes.
 Bottle is filled with
distilled water and
attached to the
flowmeter.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Cleaning a Tracheostomy
 Remove the inner cannula and clean it in
hydrogen peroxide mixed half-strength with
saline
 Rinse it in saline, dry it, and reinsert it
 Perform this step every 8 hours using aseptic
technique
 Remove the inner cannula if disposable;
reinsert a new one rather than cleaning and
reinserting the used cannula
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Equipment
Nasal Cannula
 Hollow tube with ½ inch
prongs placed in nostrils.
 Tube wraps around ears
and fitted under chin.
 Used for low
concentration for O2.
 Used for patients with
COPD or other resp.
disorders.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Equipment
Nasal Cannula-2-6L/min
 Advantages
• Easy to apply and comfortable.
• Can eat and talk with it.
• Less likely to feel suffocation.
• Most inexpensive.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Equipment
Mask
 Simple mask fits over the nose and mouth.
 O2 delivered at 5-8L/min.
Advantage
 Higher concentration than cannula.
 Effective for mouth breathers or nasal
disorders.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Equipment
Disadvantage
 Dries nasal mucosa.
 May irritate cheeks and ears.
.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Equipment
Venturi Mask
Disadvantage
 Requires
humidification.
 Interferes with eating
and talking.
 Anxiety with
claustrophobic patient.
 Risk for rebreathing
CO2 retained in mask.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Equipment
Partial Rebreather Mask
 Patient inhales a
mixture of atmospheric
air, oxygen from its
source, and oxygen
contained within a
reservoir bag.
 Range of 6-10L/min
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Non-Rebreather Mask
 Oxygen delivery device
in which all the exhaled
air leaves the mask
rather than partially
entering the reservoir
bag.
 Delivers 90% -100% O2.
 Range of 6-10L/min.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Face Tent
 Provides O2 to the nose
and mouth without the
discomfort of a mask.
 Range of 8-12L/min.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Face Tent
Advantages
 Comfortable fit
 Used in patients with facial trauma and burns.
 Facilitates humidification.
Disadvantages
 Interferes with eating.
 Amount of O2 received may be inconsistent with
what is prescribed due to environmental losses.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Tracheostomy Collar
 Tracheotomy-surgical
opening between the
first and second
cartilage ring.
 Range 4-10L/min
 Delivers 24%-100% O2.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Endotrachial Intubation
 A flexible plastic tube is
inserted into the
trachea to maintain an
open airway.
 Usually done on
critically ill patients or
surgical patients.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Hazards
Safety Precautions
 Control all possible sources of open flames or
underground electricity.
(Oxygen does not burn, but supports combustion)
 Potential for O2 toxicity. (Lung damage that may
develop when O2 concentrations of more than 50%
are administered for longer than 48 to 72 hours)
 Best prevention is to administer the lowest possible
amount for the shortest time.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
S/S of Oxygen Toxicity
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Non-productive cough
Substernal chest pain
Nasal stuffiness
Nausea and vomiting
Fatigue
Headache
Sore throat
Hypoventilation
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Safe Oxygen Administration
 Post “Oxygen in Use” signs wherever O2 is
stored or in use.
 No Smoking.
 Remove equipment requiring electricity or use
three-pronged plugs.
 Remove matches and lighters.
 Avoid flammable materials-oils, greases.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Safety
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chest Tubes
 If negative pressure in the pleural cavity is
disrupted, the lungs can no longer fully
expand.
As a result:
 Dyspnea
 Chest pain
 Hypoxia
 Respiratory Distress
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pneumothorax
 When air enters the pleural space, it rises to
the top of the cavity
 A chest tube is inserted into the pleural space
through an incision in the anterior surfaces of
the chest in the 2nd to 4th intercostal space to
release the air.
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Hemothorax
Collection of Fluid
When a Chest Tube is inserted to
drain blood, or fluid It is inserted in
the anterior chest wall, between the
8th and 9th intercostal space.
When air and fluid are in the pleural
cavity one is placed higher and one
lower
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chest Tube Indications