Documente Academic
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Prepared by:
Shellah Marie Ostrea- Mamawag
Nursing Fundamentals Focus VIII
oxygenation
-is a basic human need
Breathing is synonymous to life, thus, oxygen is
required to sustain life
Factors affecting oxygen transport from lungs to the
tissues
Cardiac output
Number of erythrocytes
Exercise
Blood hematocrit
Factors Affecting Oxygenation
Environment (altitude, heat, cold, air pollution)
Exercise
Emotions (fear, anxiety, anger)
Lifestyles (smoking, occupations, sedentary life, etc)
Health status (anemia [low red blood
cells]respiratory)
Narcotics (morphine, demErol, etc)
3 Major Alterations in
Respiratory Functions
1. Hypoxia
Respiratory insufficiency
Acapnia (absence of CO2 in blood)
Hypocarbia -Depressed level of CO2 in the blood
Hyperpnea (deep ,rapid breathing)
Hypopnea (slow breathing)
Rapid pulse,
Signs of Hypoxia
Early/ acute signs
Restlessness
Increased pulse rate
Increased rate and depth of respiration
Increase in systolic blood pressures
Signs of Hypoxia
Late/chronic signs
Decreased pulse rate
Decreased systolic blood pressure
Dyspnea
Fatigue and lethargy
Cough
Hemoptysis
Clubbing of fingers
3 Major Alterations in
Respiratory Functions
2. Altered breathing patterns
- Rate
- Volume (hypo or hyper)
- Rhythm (Cheyne Stokes, Kussmaul’s, Apneustic,
and BiOt’s)
Relative case of effort respiration (dyspnea and
orthopnoea)
3 Major Alterations in
Respiratory Functions
3. Obstructive or particularly obstructive airways
Upper airway, obstruction in nose, pharynx, larynx,
trachea
Assessment of
Oxygenation
• Physical examination
–Inspection
–Palpation
–Percussion
–Auscultation
Assessment of Oxygenation (cont'd)
Diagnostic tests:
blood studies
–Complete blood count
–Cardiac enzymes
–Cardiac troponin I
–Serum electrolytes
–Cholesterol
Assessment of Oxygenation (cont'd)
Diagnostic tests:
cardiac function
–Electrocardiogram (ECG)
–Holter monitor
–Exercise stress test
–Thallium stress test
–Electrophysiological study (EPS)
–Echocardiography
–Scintigraphy
–Cardiac catheterization
Assessment of Oxygenation (cont'd)
Diagnostic tests:
ventilation studies
–Pulmonary function
–Peak expiratory flow rate (PEFR)
–Arterial blood gases
–Oximetry
–Chest x-ray
–Bronchoscopy
–Lung scan
Diagnostic tests:
ventilation studies (cont'd)
–Thoracentesis
–Throat cultures
–Sputum specimens
Planning
Goals and outcomes
–Client’s lungs are clear on auscultation
–Client coughs productively
• Setting priorities
• Continuity of care
Implementation: Health Promotion
Body weight
• Diet
• Exercise
• Stress reduction
• Occupational safety
• Smoke-free
• Regular physical examinations
Vaccinations/immunizations
–Influenza
–Pneumonia
Implementation: Acute Care
Dyspnea management
• Airway maintenance
–Mobilization of secretions
–Suctioning
–Artificial airways
Implementation: Acute Care (cont'd)
Maintenance and promotion of lung expansion
–Positioning
–Incentive spirometry
–Chest tubes
Implementation: Acute Care (cont'd)
Maintenance and promotion of oxygenation:
oxygen therapy
–Safety precautions
–Oxygen supply
–Methods of oxygen delivery
–Home oxygen therapy
Implementation: Acute Care (cont'd)
Restoration of cardiopulmonary functioning
—CPR
Implementation: Restorative Care
• Hydration
• Coughing techniques
• Respiratory muscle training
• Breathing exercises
Evaluation
Client care
• Client expectations
Nursing Diagnoses
• Ineffective airway clearance
• Ineffective breathing pattern
• Decreased cardiac output
• Impaired gas exchange
• Risk for infection
• Ineffective tissue perfusion
• Impaired spontaneous ventilation
NANDA Nursing Diagnosis
Related to Oxygenation
1. Ineffective airway clearance
Refers to inability of the individual to clear
secretions or obstruction from the respiratory tract to
maintain airway patency
Tracheobrachial infections
Obstructions, SECRETIONS
NANDA Nursing Diagnosis
Related to Oxygenation
2. Ineffective breathing pattern
Refers to and individual’s inhalation or exhalation
pattern that inhibits adequate ventilation
Neuromuscular
Pain, anxiety
Decreased energy and fatigue
Inflammatory process
NANDA Nursing Diagnosis
Related to Oxygenation
3. Decreased cardiac output
State in which the blood pumped by the heart is
sufficiently reduced that it is inadequate to meet the
needs of the body
Structural alteration
-Ventricular – septal rupture, valvular disease
NANDA Nursing Diagnosis
Related to Oxygenation
4. Impaired gas exchange
State in which there is an imbalance between O2
And CO2 elimination at the alveolar capillary
membrane gas exchange area
Altered O2 supply
Altered bloOD
NANDA Nursing Diagnosis
Related to Oxygenation
5. Altered tissue perfusion
>State in which an individual experiences a decrease
in nutrition and oxygenation at the cellular level
because of a deficit in capillary blood supply
>Interrupted venous or arterial flow
>Hypo/hypervolemia
Measures That Promote
Adequate Respiratory Function
1. Ensure a patent airway
> To promote gaseous exchange between client and
environment
> Check for obstructions
>Foreign objects, mucus
2. Positioning
> To allow maximum chest expansion
Fowler’s position
Encourage frequent changes
Measures That Promote
Adequate Respiratory Function
3. Deep breathing and coughing exercises
> To promote lung expansion and loosen secretions
E.g. abdominal breathing (diaphragmatic and
pursed lip)
4. Adequate hydration
> Maintain moisture of the respiratory mucus
membrane
> Use of humidifiers/ nebulizers
>Steam/ aerosol/ medimist
Measures That Promote
Adequate Respiratory Function
5. Chest physiotherapy
> Percussion
Forceful striking of skin with cupped hands
>Vibration
Serves of vigorous quivering produced by hands that
are placed flat against clients chest wall; done during
exhalation
> Postural drainage
Drainage by gravity of secretions from various lung
segments
Measures That Promote
Adequate Respiratory Function
6. Proper suctioning
> A catheter – for 12-18 mmHg, tip of mouth to
earlobe 5 meters suction 5-10 seconds, max is 15
seconds, wall suction 80-120 mmHg
7. Avoid environmental pollutants = smoking
Measures That Promote
Adequate Respiratory Function
8. Using inflation devices
> Incentive spirometry – to enhance deep inspiration
>Intermittent positive pressure breathing
-To administer O2 at pressures higher than the
atmospheric pressure
9. Administration of supplemental O2
> Nasal cannula
Nursing Implication
Since oxygen is colorless, odorless, and tasteless,
leakage can’t be detected
Since oxygen is dry, gas mucus membrane invitation
could happen
Nursing Planning, Intervention,
and Evaluation in O2
Administration
Assess Signs and Sx of hypoxemia
Check doctor’s orders
Open source before insertion of device
Regulate accurately
Place a “No Smoking” sign
Avoid use of oil, grease, and alcohol
Nursing Planning,
Intervention,
and Evaluation in O2
Administration
Check of electrical device malfunction
Avoid using materials that could generate static
electricity
Humidify O2
Provide good oro-nasal hygiene
Lubricate with water soluble stuff
Document
Situation 1
Patient Jim diagnosed
Of COPD exacerbation.
S/Sx:
-wheezing on bilateral
upper lobes during
expiration.
O2 sat. of 90%
RR: 26 b/min
Situation 2
Data:
“S/P Laparoscopic Cholecystectomy.
- Patient complaining of 8/10 acute aching pain to the
right upper quadrant of the abdomen
Situation 3
Patient has history of HTN and patient having multiple
blood pressure medication.
Medications are: Norvasc 5 mg daily, atenolol 25mg
BID, Clonidine 0.1 mg PO q 6 hours PRN for systolic BP
greater than 160 or diastolic BP greater than 90.
Vital signs: BP -130/70 mmhg
PR- 88 b/min
Situation 3
Mrs. Enad is a 41 years old, accounting staff who was
admitted to hospital with an elevated temperature,
fatigue,rapid loud respirations,and mild dehydration. The
nursing history reveals that Mrs. Has had a “ bad cold”
for several weeks that just wouldn’t go away. She has been
dieting for several months and skipping meals .Mrs enad
mention that in addition to her full time job as a secretary
she is attending college classes two evening a week. She
has smoked one package of cigarettes per day since she
was 20 years old. Chest X- ray confirms Pneumonia.
Physical Examination
Height: 5’6 Dx Data:
Weight: 54.4 kg
Temperature: 39.4
Chest X- Ray: Right
Pulse: 68 beats/min lobar infiltration
Respirations: 24/min WBC: 14,000
BP: 120/70 mmhg Ph: 7.49
Skin: Pale; cheeks flushed
Chills; use of accessory muscles
PaCO2: 33 mmhg
Inspiratory crackles with HCO3: 20 meq/L
diminished breath sounds right PaO2: 80 mmhg
base; expectorating thick,
yellow sputum O2 sat: 88%
We get up early and don’t have
time to drink coffee over
newspaper. We come home late
and are too tired to cook. We work
extra because we know there are
families who needs us. We dont
get excited over minor crisis
because we deal with issues all
day. We have seen the worse. We
dont want to talk when we come
home.we have talked all day. We
Scared we will let our patients and
dont want to move when we come families down. We have to deal
home. We have moved all day. It with angry families and all the
may seem, we have left all our while do our best to help them. We
caring, our heart and our love at dont tell you the trauma we see
work, then come home feeling affects us and how stressed we are
for the pain our families are going
empty. We probably are empty but
through. Im a nurse, and there are
we dont tell you that many times some days when its the hardest
at work we are scared work i have ever done