20. Oxygenation

8/2/2019 20. Oxygenation

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OXYGENATION

Oxygenation is a basic human need. The Respiratory System replenishes thebodys oxygen supply and eliminates waste from the blood in the form of carbondioxide.

Terms and Definitions

a. Respiration - breathing and exchange of oxygen and carbon dioxide withinthe body tissues

b. Inspiration - inhaling, breathing in or drawing air into the lungs (active

phase)c. Expiration - exhaling, breathing out or expelling air from the lungs (passive

phase)

d. Ventilation - it is the process by which gases are moved into and out of thelungs. It can be normal breathing or with mechanical assistance.e. Diffusion of gases - it is a natural process essential to respiration in which

molecules of a gas pass from an area of greater concentration to one of lesserconcentration (example: oxygen moving from inhaled air through capillariesinto deoxygenated blood).

f. Thorax - it is the chest or the upper part of the trunk between the neck and

the abdomen.

g. Mediastinum - the space between the lungs where the heart, great vessels(aorta and vena cava), esophagus, trachea, and major bronchi lieh. Anoxia - an abnormal condition characterized by a lack of oxygeni. Apnea - absence of spontaneous respiration

j. Aspiration - taking foreign matter into the lungs during inhalation (e.g.,vomitus)

k. Bradypnea - an abnormally slow rate of breathingl. Cheyne-Stokes respiration - an abnormal pattern of respiration,

characterized by alternating periods of apnea (10-20 sec) and deep, rapidbreathing

m. Dyspnea - shortness of breath or difficulty in breathingn. Hyperpnea - deep, rapid, or labored respiration


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o. Hyperventilation - a ventilation rate that is greater than that metabolicallynecessary for the exchange of respiratory gases

p. Hypoventilation - an abnormal condition of the respiratory system that is

characterized by a reduced rate and depth of breathing

q. Hypoxia - inadequate supply of oxygen to body tissue and cellsr. Kussmaul breathing - abnormally deep and very rapid respiration

characteristic of diabetic acidosiss. Respiratory arrest - cessation of breathingt. Respiratory failure - the inability of the cardiac and pulmonary systems to

maintain an adequate exchange of oxygen and carbon dioxide in the lungs

u. Suffocation - a condition characterized by inadequate oxygen and excessivecarbon dioxide in the bloodv. Tachypnea - an abnormally rapid rate of breathingw. Adventitious sounds - abnormal lung sounds heard with auscultationx. Rhonchi - abnormal lung sound heard on auscultation of the lungs. When the

patients airways are obstructed with thick secretions. Can usually be clearedwith coughing (snoring)

y.Rales (crackles)

- abnormal lung sound heard on auscultation characterizedby fine bubbling sounds during inspiration.

z. Wheezes (wheezing) - abnormal lung sounds caused by severely narrowedbronchus. Can be both inspiratory and expiratory. Common lung soundassociated with asthma.

Anatomy and PhysiologyRespiration- the process of gaseous exchange between the individual and theenvironment.

1. The Airwaysa. Upper Airways

Nasal Cavity

Pharynx

LarynxFunctions of the upper airways:

Transport of gases to the lower airways

Protection of the lower airway from foreign matter


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Warming, Filtration and humidification ofinspired air

b. Lower Airways

Trachea

Right and Left mainsteam bronchi Segmental bronchi

Sub segmental bronchi

Terminal bronchiFunction of the lower airways:

Clearance mechanism-cough-mucocilliary system-macrophages-lymphatic

Immunologic responses

-cell-mediated immunity in the alveoli Pulmonary protection in injury

- respiratory epithelium

- mucocilliary system

2. The Pleura1. The pleurae are serous membranes that enclose the lungs.

2. The visceral pleura directly covers the lungs. (purple)3. The parietal pleura lines the cavity of each hemithorax. (blue)4. The pleural space is a potential space between the two pleurae. Only few ml ofserous fluid is found in the pleural space, to serve as lubricant.


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3. The Lungs1. The right lung has three lobes, while the left lung has two lobes.2. The two lungs are separated by a space called mediastinum.

3. There are approximately three hundred million alveoli in the lungs.4. The right lung is broader, but shorter due to the presence of liver on the rightside of the abdomen.

Lung Volumes and Capacities Tidal Volume (TV) volume of one breath. Minute Ventilation (MV) the total volume of air inhaled and exhaled

each minute = the respiratory rate multiplied by Tidal Volume.(RRxTv=MV)

Alveolar Ventilation Rate is the volume of air per minute that reachesthe alveoli and other respiratory portions. (Ex. 350mL per breath x 12

breaths/minute = 4200mL/minute) Inspiratory Reserve Volume refers to additional inhaled air when

taking a very deep breath. Expiratory Reserve Volume refers to amount of air forcibly exhaled

after normal inhalation. Forced Expiratory Volume- volume of air that can be exhaled from the

lungs in 1 second with maximal effort following a maximal inhalation. Residual Volume- remaining amount of air in the lungs after forced

exhalation. Minimal Volume- air remaining if the thoracic cavity is opened, and the

intrapleural pressure rises to equal the atmospheric pressure and forces

out some of the residual volume. Inspiratory Capacity- sum of the tidal volume and the inspiratory reserve

volume Functional Residual Capacity- sum of residual volume and expiratory

reserve volume Vital Capacity- sum of inspiratory reserve volume, tidal volume and

expiratory reserve volume.


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4. The Thorax and the Diaphragm The thorax provides protection for the lungs, heart and greatvessels. The diaphragm is the main respiratory muscle for inspiration. The following are the accessory muscles for inspiration:

sternocleidomastoid, scalene, parasternal, trapezius and pectoralismuscles. They are used during increased work of breathing.

5. Respiratory Control

a. Central Nervous System Control Medulla oblongata (central chemoreceptors) Pons (apneustic center, pneumatoxic center)

b. Reflex Control Cough reflex

c. Peripheral Control Carotid and aortic bodies

Measures that promote adequate respiratory function:1. Adequate oxygen supply from the environment.2. Deep breathing and coughing exercises.3. Positioning.4. Patent airway.

Causes of Airway Obstruction Tongue (among unconscious clients, the tongue tends to fall back)

Mucous secretions Edema of airways (rhinitis, laryngitis, bronchitis) Spasm of airways (laryngospasm, bronchospasm) Foreign bodies (aspirated foods, fluids)

5. Adequate hydration6. Avoid environmental pollutants, alcohol and smoking7. Chest Physiotherapy (CPT)8.Bronchial Hygiene measuresa. Steam InhalationPurposes:

To liquefy mucous secretions.

To warm and humidify inspired air.

To relieve edema of airways.

To soothe irritated airways.

To administer medications.

b. Aerosol inhalation- done among pediatric clients to administer bronchodilators or mucolytic-expectorants.


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c. Medimist inhalation- done among adult clients to administer bronchodilators or mucolytic-expectorants.

9. SuctioningPurpose: to clear airways from mucous secretions

Oropharyngeal and nasopharyngeal suctioningIndications:

Audible secretions during respiration Adventitious breath sound (auscultated)

Position: Conscious: Semi- Fowlers position Unconscious: Lateral position

Pressure of suction equipment:1. Wall Unit:a. Adult: 100-120 mmHgb. Child: 95- 110 mmHgc. Infant: 50- 95 mmHg2. Portable Unit:a. Adult: 10-15 mmHgb. Child: 5- 10 mmHgc. Infant: 2-5 mmHg

Appropriate size of sterile suction cathetera. Adult: Fr. 12- 18b. Child: Fr. 8- 10c. Infant: Fr. 5- 8

10. Incentive Spirometry- done to enhance deep inspiration


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11. Intermittent Positive Pressure Breathing- done to administer oxygen at pressures higher than the atmospheric pressure.

12. Administration of supplemental oxygenOxygen therapy the administration of oxygen to the client by any route

to prevent or relieve hypoxia.The provision of oxygen to the client with higher concentration than that found inthe air.Hypoxia decrease oxygen in the cellsHypoxemia decrease oxygen in the blood

Indication: hypoxemiaSigns of hypoxemia:

restlessness (initial sign)

Increased pulse rate

Rapid, shallow respiration and dyspnea

Light- headedness

Flaring of nares

Substernal or intercostals retraction

Cyanosis (Late sign)


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The oxygenation status of the patient can be determined at bedside byperforming focused assessment, monitoring the ABG (Arterial Blood Gas) levelsand pulse oximeter.

Five signs of inadequate oxygenation:

1. Restlessness2. Rapid breathing3. Rapid heart rate4. Sitting up to breathe5. Using accessory muscles.

Nurses can improve a patients oxygenation status by elevating the patientshead and chest and by instructing patient to perform breathing exercises.Oxygen Systems1. Low flow administration devices

1. Nasal Cannula (24- 25% at 2- 6 LPM)

May be used in clients with COPD at 2-3 LPM if venturi mask is not available

Nasal Cannula/prongs- a simple, comfortable low-flow (24% - 25%)

device inserted in the nostrils to deliver oxygen at a rate to five -6liters/min.

It consists of a rubber or plastic tubing that extends around the facewith to inch prongs that fit into the nostrils.

Delivers low concentration of oxygen when only minimal support isrequired

Allows uninterrupted delivery of oxygen when the client ingestsfoods or fluids.

Permits some freedom and movement and comfort to the client.

Nasal catheter a plastic or rubber tubing of different sizes that canbe inserted into the nose to the nasopharynx to administer oxygen-Provide an efficient means of administering high concentrationoxygen.

2. Simple Face Mask (40- 60% at 5-8 LPM)- a device that covers theclients nose and mouth for oxygen inhalation. They are made of a clear,pliable plastic or rubber that can be molded to fit the face. Held to theclients face with elastic bands, some have a metal clip that can be bent of


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the bridge of the nose for a snug fit. There ARE Several holes on the sidesof the mask (exhalation port) to allow escape of carbon dioxide

To provide moderate oxygen support and a higher concentrationof oxygen or humidity than is provided by the nasal cannula.

3. Partial Rebreathing Mask (60- 90% at 6- 10 LPM) consist of a maskwith a reservoir bag that provides an oxygen concentration of 70% - 90%,with flow rates of 6 15 L/min

4. Non- Rebreathing Mask (95- 100% at 6- 15 LPM) most frequently usedin clients with deteriorating respiratory system who might require intubations.

The nonrebreather most has a one-way valve between themask and the reservoir and two flaps over the exhalation ports.

The valve allows the client to draw the entire quantity of oxygenin the reservoir bag.


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5. Croupette

6. Oxygen tent

7. Aerosol mask used for clients requiring high humidity after extubation orupper airway surgery, or for clients with thick secretions.


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2. High flow administration devices

1. Venturi mask- Low- concentration venture- type mask is preferredfor clients with COPD (chronic obstructive pulmonarydisease) because it provides accurate amount of oxygen. They require2-3 LPM or 28% oxygen.

-An adapter is located between the bottom of the mask and the oxygensource, the adapter contains holes of different sizes that allow only specificamounts of air to mix with oxygen.

2. Face Mask- fits over the clients chin with the top extending halfway across theface.

-Oxygen concentration varies but the face tent is useful instead of atight fitting mask for the client who has facial trauma or burns.


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3. Oxygen hood- Can be used for low and high flow concentration.Incubator/ Isolette. Can be used for low and high flow concentration

Note:Oxygen is colorless, odorless, tasteless and dry gas that supports

combustion.

Nursing Implications:1. Since oxygen is colorless, odorless, tasteless gas, leakage cannot bedetected.2. Since oxygen is dry gas, it can irritate mucous membrane of the airways.3. Since oxygen supports combustion, it can cause fire.When giving oxygen therapy caution must be made to avoid highly flammablematerials/ substances:

1. Prominently display NO SMOKING sign on the door, at the foot ofthe bed, head of bed, or on the oxygen equipment.

2. Remove matches, cigarettes, and lighters from the bedside whenoxygen is in use.

3. Inspect all electrical equipment in the immediate vicinity.4. Avoid using wool blankets.5. Do not give electric or friction toys to children in oxygen therapy.

Remove alcohols, cosmetics, and lubricants which are oil-based from thebedside


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Abdominal (diaphragmatic) and Pursed Lip Breathing and Coughing1. Assume a comfortable semi-sitting position on bed or chair or a lying

position on bed with one pillow.2. Flex your knees to relax the muscles of your abdomen.3. Place one or both hands or your abdomen, just below the ribs.

4. Breathe in deeply through the nose keeping the mouth closed.5. Concentrate on feeling your abdomen rise as far as possible. Stay relaxedand avoid arching your back. If you have difficulty rising your abdomen,take a quick, forceful breath through the nose.

6. Then purse your lips as if about to whistle, and breathe out slowly andgently, making a slow whooshing sound without puffing out the cheeks.The pursed lip breathing creates a resistance to air coming out of thelungs, increases pressure within the bronchi, and minimizes collapsed ofsmaller airways, a common problem of patients with chronic obstructivepulmonary disease (COPD).

7. Concentrated on feeling the abdomen fall or sink and tighten (contract) he

abdominal muscles when breathing out to enhance effective exhalation.Count to seven during exhalation.8. If indicated cough two or more times during exhalation.9. Use this exercise whenever feeling short of breath, and increase gradually

to 5-10 minutes 4 times a day.

Alterations in Respiratory Function

1. Hypoxia insufficient oxygenation of tissues

Clinical Signs of Hypoxia

Early Signs Late Signs

Tachycardia Increased rate and depth of

respiration Slight increase in Systolic BP

Bradycardia Dyspnea Decreased systolic BP Cough

Hemoptysis expectoration ofblood

Other Clinical Signs of Acute Hypoxia nausea and vomiting 6. irritability oliguria, anuria 7. memory loss headache apathy dizziness


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Other Clinical Signs of Chronic Hypoxia1. fatigue, lethargy2. pulmonary ventilation increases3. RBC count increases

4. Hgb concentration increases5. clubbing of fingers

2. Altered Breathing Patternsa. Rate

Tachypnea- rapid respiratory rate Bradypnea- slow respiratory rate Apnea- cessation of breathing

b. Volume1. Hyperventilation

excessive amount of air in the lungs it results from deep, rapid respirations

2. Hypoventilation

decreased rate and depth of respiration

it causes retention of carbon dioxide

c. Rhythm1. Cheyne- stokes. Marked rhythmic waxing and waning of respirationsfrom very deep to very shallow breathing and temporary apnea


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3. Kussmauls (Hyperventilation). Increased rate and depth ofrespiration, seen in metabolic acidosis and renal failure.

3. Apneustic. Prolonged gasping inspiration followed by a very short,usually inefficient expiration.

4. Biots. Shallow breaths interrupted by apnea.

d. Ease of effort.1. Dyspnea. Difficult or labored breathing2. Orthopnea. Inability to breath except in upright or sitting position


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20. Oxygenation

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