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Stressors that Affect Oxygen Needs NUR101 FALL 2008 K. BURGER, MSEd, MSN, RN, CNE LECTURE #19 PPP by Sharon Niggemeier RN, MSN Revised October 2005 by K. Burger 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. Checkpoint 1) T / F The pulmonary artery carries oxygenated blood away from the lungs. FALSE Factors Affecting Respiration • Integrity of the airway system (ventilation) • Functioning cardiovascular system (perfusion) • Functioning alveoli (diffusion) • Functioning medulla & chemoreceptors Pulmonary Ventilation • Inspiration- air flows into lungs • Expiration-gases flow out of lungs According to pressure gradiant – Boyle • Intrapulmonic or intra-alveolar pressurepressure 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 Factors Affecting Ventilation • Lung elasticity / compliance (ability to stretch and recoil) • Airway obstruction • Musculature condition • Neurological controls Checkpoint What is the name of the nerve that supplies the diaphragm? PHRENIC NERVE 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) 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 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 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) Checkpoint The majority of CARBON DIOXIDE molecules are transported in the blood as: ??? BICARBONATE HCO3 Perfusion • • • • Rate of O2 transport depends on: Cardiac output Activity level CO2 transport Neurologic/Chemical Controls of Respiration • • • • • • Peripheral Chemoreceptors Central Chemoreceptors Medullary respiratory center Spinal cord Phrenic nerve Diaphragm Factors Affecting Oxygenation • • • • • Environment Emotions Exercise Health Age • Life style • Medications • Respiratory History Checkpoint What is the normal respiratory rate of a newborn? 30-60 breaths/min Assessing Respiratory Functioning • • • • • • • Difficulty breathing? SOB? Chest pain? Coughing? Sputum production? Nocturnal diaphoresis Fatigue Sleep with 2 or more pillows? Assessing Respiratory Functioning Respiratory Hx includes: • Allergies • Medications • Medical Hx • Smoking • Lifestyle / Activity Level • Stressors • Recent exposures • Developmental level 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 Assessing Respiratory Functioning • • • • • • • Respiratory Rate: Tachypnea R>24 Bradypnea R<10 Apnea Respiratory Depth: Deep - diaphragmatic Shallow Assessing Respiratory Functioning • • • • • • Respiratory Rhythm: Regular – “even and symmetrical” Cheyne-Stokes Kussmauls Biot’s (ataxic – without rhythm) Apneustic breathing (gasping) Assessing Respiratory Functioning • Respiratory Quality: • • • • • No difficulty- Eupneic/ Unlabored Dyspnea Orthopnea Retractions Use of accessory muscles • Auscultation: • Vesicular • Bronchial • Bronchovesicular Assessing Respiratory Functioning Cough: • Nonproductive • Productive • Sputum • Hemoptysis Breath sounds Adventitious Sounds: • Crackles: fine,medium,coarse • Wheeze: sibilant,sonorous • Stridor • Stertor • Pleural friction rub 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 Checkpoint • What are some other elements of a respiratory assessment not yet mentioned? Neurological state Color Nail clubbing AP vs Transverse Diameter Barrel Chest? 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 Alterations:Respiratory Functioning • • • • Hypoxia Hypoxemia Hyperventilation Hypercapnia • Obstructed airway • Foreign body obstruction (FBO) • • • • • • • Nursing Interventions Independent Airway maintenance Positioning Deep breathing & coughing Pursed-lip breathing Abdominal/diaphragmatic breathing Hydration Teaching of health habits Nursing Interventions Collaborative/Dependent • • • • • Incentive spirometry Percussion/postural drainage Suctioning Oxygen therapy Medications Nursing Interventions Collaborative/Dependent • • • • • Oxygen Therapy Indications Sources- wall outlet or portable tank Monitor pulse oximetry Methods- cannula, mask, venturi mask, tent/isolette,BiPAP, CPAP Administering Oxygen Therapy • • • • • • • Flow rate Humidification Hydration Positioning Safety precautions Document MD order required 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. Nursing Interventions • • • • • • Medications Nebulizer Tx Cough suppressants Mucolytic: expectorants Bronchodilators Corticosteroids Documentation Routine Nurses Note • • • • • Date Time LOC Rate Depth • Rhythm • Breath sounds (auscultated) • Quality • Color 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 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 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 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 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