53 a focus 8 oxygenation pdf

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53 a focus 8 oxygenation pdf

  1. 1. 10/6/2010 NURSING FUNDAMENTALS STAGGERING STATISTICS FOCUS VI OXYGENATION • Cardiovascular Diseases – # 1 killer • HTN – 65 million • Artheriosclerosis • Arteriosclerosis • Stroke • Hypercholesterolemia • 107 million - a risk factor for CVD • AMI – 7.5 Million per year, 460,000 die • Americans will pay 393.5 billion in 2005 for CVD related medical costs OBJECTIVES RESPIRATORY SYSTEM• List and discuss the major body structures.• Discuss functions responsible for proper oxygenation• Describe factors that may alter ones O2 balance.• Identify the behaviors indicating negative O2 balance.• Review the common diagnostic tests medically prescribed in order to determine the clients oxygenation status.• Explain the major purpose of the tests and the related nursing responsibilities. STAGGERING STATISTICS PROCESS OF BREATHING• Pulmonary Diseases • Lung CA - •Inspiration •Air flows into lungs • TB – •Expiration • Pneumonia – •Air flows out of lungs • Chronic Airflow Limitation (formerly COPD) – 1
  2. 2. 10/6/2010 NORMAL OXYGENATION PROCESS INSPIRATION• Cardiovascular: • Diaphragm and intercostals contact • Thoracic cavity size increases • Volume of lungs increases • Intrapulmonary pressure decreases • Air rushes into the lungs to equalize pressure NORMAL OXYGENATION PROCESS EXPIRATION• Systemic: • Diaphragm and intercostals relax • Volume of the lungs decreases • Intrapulmonary pressure rises • Air is expelledNORMAL OXYGENATIONS PROCESS GAS EXCHANGE • Occurs after the alveoli are ventilated • Pressure differences on each side of the respiratory membranes affect diffusion • Diffusion of oxygen from the alveoli into the pulmonary blood vessels • Diffusion of carbon dioxide from pulmonary blood vessels into alveoli 2
  3. 3. 10/6/2010 ADEQUATE O2 BALANCE CARBON DIOXIDE TRANSPORT• Maintenance of adequate O2 balance Gas Exchange • Must be transported from the tissues to the lungs • Continually produced in the process of cell metabolism • 65% is carried inside the red blood cells as bicarbonate • 30% combines with hemoglobin as carbhemoglobin • 5% transported in solution in plasma and as carbonic acid FACTORS THAT INFLUENCE OXYGEN TRANSPORT RESPIRATORY FUNCTION• Transported from the lungs to the •Age tissues• 97% of oxygen combines with •Environment hemoglobin in red blood cells and •Lifestyle carried to tissues as oxyhemoglobin •Health status• Remaining oxygen is dissolved and transported in plasma and cells •Medications •Stress COMMON MANIFESTATIONS OFNORMAL OXYGENATION PROCESS IMPAIRED RESPIRATORY FUNCTION• Cell environment/ O2 carrying capacity: •Hypoxia• O2 Carrying capacity of blood is expressed by: •Altered breathing • Red blood cells • Hematocrit patterns • Hemoglobin •Obstructed or partially obstructed airway 3
  4. 4. 10/6/2010 OBSTRUCTED OR PARTIALLY HYPOXIA OBSTRUCTED AIRWAY• Condition of insufficient oxygen anywhere in the body •Partial obstruction• Rapid pulse •low-pitched snoring during• Rapid, shallow respirations and dyspnea inhalation• Increased restlessness or lightheadedness• Flaring of nares •Complete obstruction• Substernal or intercostal retractions •extreme inspiratory effort with• Cyanosis no chest movementABNORMAL RESPIRATORY PATTERNS ADEQUATE O2 BALANCE• Tachypnea (rapid rate) • Example of Obstructive Disease Asthma• Bradypnea (abnormally slow rate)• Apnea (cessation of breathing)• Kussmaul’s breathing• Cheyne-Stokes respirations• Biot’s respirations ALTERATIONS IN EASE OF BREATHING ADEQUATE O2 BALANCE • Example of Restrictive Disease Hemothorax•Orthopnea•Dyspnea 4
  5. 5. 10/6/2010 NURSING MEASURES TO PROMOTE INADEQUATE O2 BALANCE RESPIRATORY FUNCTION • Behaviors of Negative O2 balance •Ensure a patent airway • Hypoventilation or hyperventilation • Stridor, audible sounds with respiration, wheezing, coughing •Positioning • Hypoxia • Change in mental status •Encourage deep breathing, • Change vital signs • Cyanosis coughing • Decrease in GI motility • Change in renal function •Ensure adequate hydration • Hypercapnia NURSING RESPONSIBILITIES NURSING RESPONSIBILITIES • Physical Assessment: • •• Determine adequacy of cardiopulmonary function: • Lung auscultation and breathing pattern • Nursing assessment • Abdominal assessment • HEART • Urine output • Respiratory assessment • Skin and mucous membranes • PMH • Heart sounds • LIFESTYLE • Circulation • Edema • DVT LUNG SOUNDS HEART PROBLEMS • Diminished or absent • Crackles course and fine • discontinuous course bubbling • fine crackling sound at the middle or end of inspiration • Rhonchi • a continuous sonorous sound • Wheezes • high pitch musical sounds Artheroscleosis = Coronary Artery Disease (CAD) • Pleural friction rub • grating rubbing, sound 5
  6. 6. 10/6/2010 COMMON TESTS AND NURSING RESPONSIBILITIES CHEST XRAY •• Measure adequacy of ventilation and gas exchange • Complete Blood Count (CBC) phlebotomy • Arterial Blood Gases (ABG) arterial puncture • Pulmonary Function Tests preparation by teaching Adenocarcinoma COMMON TESTS AND NURSING COMMON TESTS AND NURSING RESPONSIBILITIES RESPONSIBILITIES Thorancentesis• •Tests to determine abnormal cell growth or • Thoracentesis: infection in respiratory system: • Sputum culture • growing microorganisms from sputum • Throat culture • growth of microorganisms from throat material COMMON TESTS AND NURSING RESPONSIBILITIES NURSING RESPONSIBILITIES• •Tests to visualize structures of respiratory system: • Medications • Incentive spirometry • Bronchoscopy • Chest PT • Chest radiographs • Postural drainage • Oxygen therapy • Artificial airways • Airway suctioning • Chest tubes 6
  7. 7. 10/6/2010 BASIC NURSING INTERVENTIONS BASIC NURSING INTERVENTIONS • Improving Activity Tolerance:• Airway Maintenance: • Determine etiology • Facilitate effective coughing • Assess appropriateness of activity level • Suctioning airways • When appropriate gradually increase activity • Liquefying and mobilizing sputum • Ensure the client changes position slowly • Observe for symptoms of intolerance • Syncope with activity • refer to MD • Perform ROM exercises with activity intolerance or is immobile BASIC NURSING INTERVENTIONS BASIC NURSING INTERVENTIONS• Maintenance and promotion of proper lung • Mobilization of Pulmonary Secretions expansion:Re-expanding collapsed lungs • Auscultate breath sounds, monitor respiratory- Closed Chest Tube Drainage patterns, monitor ABG’s • Position client to optimize respiration • Pulmonary toileting • Incentive spirometry • Suctioning CHEST TUBES INCENTIVE SPIROMETRY 7
  8. 8. 10/6/2010 BASIC NURSING INTERVENTIONS • Effective Breathing Techniques • Position for maximal respiratory function • Pursed lip breathing • Diaphragmatic or abdominal breathing BASIC NURSING INTERVENTIONS BASIC NURSING INTERVENTIONS• Mobilization of Pulmonary Secretions Stress and anxiety reduction: • Encourage activity and ambulation as tolerated • Remove pertinent cause of anxiety at that moment - help client gain control over respiration • Encourage increased fluid intake - reassure client not in immediate danger • Chest physiotherapy • O2 • Chronic clients • exacerbations and remissions • Medications as ordered • goal is to reduce general level of anxiety • learn to control episodes of anxiety to improve quality of life • desensitization program • guided mastery BASIC NURSING INTERVENTIONS ADMINISTRATION OF PRESCRIBED MEDICATIONS• O2 Therapy: • Expectorants • Vasoconstrictors • Low flow • Mucolytics • High flow • Bronchodilators • Humidification • Cough suppressants • Nasal cannula • Corticosteroids • Simple mask • Antihistamines • Nonrebreathing mask • Antibiotics • Partial rebreathing 8
  9. 9. 10/6/2010 BASIC NURSING INTERVENTIONS COMMON TESTS AND NURSING RESPONSIBILITIES• Physical Exercise health teaching Activity and rest -- a priority! Tests to determine adequacy of cardiovascular function: • Activity stimulates respiratory function Rest conserves energy and reduces metabolic demand • CBC • MD’s treatment plan • guidelines for activity • Lipid profile • may simply call for activity as tolerate. • prioritize activities • Coagulation studies • arrange need items conveniently • Provide emotional support and encouragement • EKG/ECG • gradually increase activity • Simplify daily life • Angiography • Work at a steady state • Conserve energy • Doppler blood flow studies ADEQUATE O2 BALANCE BASIC NURSING INTERVENTIONS • Behaviors of Negative O2 balance Cardiovascular • Diet • Modify risk factors • Exercise Cardio Vascular Disease • Co morbidities • Preventing vasoconstriction • Arterial • Venous: • Positioning • Impaired tissue perfusion • Cold temperatures • Nicotine ADEQUATE O2 BALANCE BASIC NURSING INTERVENTIONS • Cardiovascular •Risk DVT •Position changes • Behaviors of Negative O2 balance CV - Prevent complications •Early ambulation •Obstruction removal • Restlessness, dizziness, syncope, bradycardia, •Bypass surgery decreased urine • Promoting rest • cold and clammy skin, cyanosis, slow capillary refill •Schedule rest periods • Decreased cardiac output •Assistance with ADL’s •Monitor Vitals with activity •Place items, i.e. call light, water pitcher, strategically •Quiet environment, decrease stimuli 9
  10. 10. 10/6/2010 ADMINISTRATION OF PRESCRIBEDBASIC NURSING INTERVENTIONS MEDICATIONS - Position semi to highCardiovascular fowlers-> decrease venous • Anti coagulants• Positioning to improve return and preload, decease preload-> decreases risk of CO heart congestion • Vasodilator Medications -• Avoiding Valsalva • Teach client to avoid • Inotropic Medications valsalva maneuver maneuver - Hold breath while turning or moving in bed-> assist • Anti Dysrhythmics - Bearing down during BM-> stool softeners and diet • Anti hypertensives BASIC NURSINGBASIC NURSING INTERVENTIONS INTERVENTIONSCardiovascular •Avoid appetite suppressants, cold• Avoid stimulants meds, coffee, tea, chocolate • Dietary control • Assess nutritional status• Maintaining fluid balance •Assess fluid status, monitor I&O, assess breath sounds, JVD, pitting edema in dependent areas, fluid • Consider a dietician referral to assess and NA+ restriction, daily Wgt with nutritional needs related to clients diuretic therapy, electrolyte monitoring-> MD • Chronicity of CAL and CAD and nutritionBASIC NURSING INTERVENTIONS BASIC NURSING INTERVENTIONSCardiovascular • Administer O2 • Weight control • Educate client• Increase O2 supply NO SMOKING! • Evaluate the client’s physiological status in relation to condition • Position to facilitate breathing • More than body requirements • Less than body requirements 10

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