9/3/20

Care for Client with

Oxygenation Problem
By Mark B. Samson

Outcomes
KNOWLEDGE
• Identify organs involve in the process of breathing.
• Describe each organ’s contribution in breathing.
• Define & familiarize with different terms associated with the
concept of respiration.

KNOWLEDGE
• Distinguish common complaints of clients with respiratory
disorders
• Review and describe process of physical assessment of the
respiratory system.
• List different diagnostic procedures utilized in assessing
respiratory abnormalities.
• Enumerate important nursing responsibilities before, while
and after carrying out the procedure.

I. Review of Lung Anatomy and Functions

• Respiratory System
• The respiratory system consists of two main parts:
A. Upper Respiratory System
1. Nose/Sinuses/Nasal Passages
2. Pharynx/Tonsils and Adenoids
3. Larynx
4. Trachea
B. Lower Respiratory System
1. Bronchus
2. Bronchioles
3. Respiratory Units

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The Upper Airways

The Nasal Cavity
-serves a passage way for air
-lined with mucous membrane to produce mucus and filter*
-highly vascular to warm*
-receives draining mucus from sinuses
-lined with olfactory nerves*
Functions:
1. Filter air
2. Humidify/Warms air
3. Aid in phonation
4. Olfaction

The Sinuses
-Four paired bony cavities, lined with mucous membrane and
ciliated pseudostratified columnar epithelium
-Named after their location
Frontal
Ethmoidal
Sphenoidal
Maxillary
Function:
1. Lightens the skull
2. Resonate speech
3. Trap/Drain debris

The Pharynx
-a funnel-shaped musculo-membranous tube that is
composed of:
nasopharynx*
oropharynx*
laryngopharynx*
Lymphoid Tissues
1. Adenoids
2. Tonsils

Functions:
1. Passageway for food/air
2. Protects lower airways

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The Larynx
-Composed of cartilage and membranes, connecting pharynx
to the trachea
-Contains vocal cord
Functions:
1. Protects lower airway
2. Vocalization
3. Facilitates coughing

The Trachea
-a cartilaginous tube of 12-15cm
-composed of 16-20 C-shaped rings of cartilages
-lined with mucus and cilia*
-located anteriorly to the esophagus
Functions:
Passageway between the larynx and bronchi

The Bronchial Tree

Bronchus
Function: Air Passage
Primary Bronchus
Right Bronchus Left Bronchus
Shorter Narrower
Wider Longer
More vertical* More horizontal

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The Bronchioles
-main bronchi subdivide into secondary (lobar) bronchi
-right middle lobe bronchus are smaller in diameter and
length
-bronchi further subdivide in tertiary (segmental)bronchi
then to smaller and smaller terminal bronchioles (last part of
the conducting airway)
-smallest parts are at risk of collapsing due to absence of
cartilage

The Respiratory Acinus

-the functional unit of the
lungs
-it consists of
Respiratory bronchioles
Alveolar ducts
Alveolar sac
Functions: Gas Exchange
through respiratory
membrane

Respiratory membrane is composed of two epithelial cells:

1. Type 1 pneumocyte –most of abundant, thin and flat,
where gas exchange occur
2. Type 2 pneumocyte –secretes lung surfactant*
3. Type 3 pneumocyte -macrophages

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Accessory Structures
Thoracic Cavity/Cage and Respiratory Muscles
-Composed of sternum, the rib cage, intercostal muscles
-the cavity is separated by the diaphragm
-Inspiratory muscles (diaphragm and intercostal muscles)

Pleura
-double layered serous membrane that covers the lungs and
the inside of the thoracic cage
-visceral and parietal pleurae
-has slightly negative pressure in the pleural space*
-pleural space contains serous fluid that lubricates*

Ventilation and Respiration

Pulmonary Ventilation –the act of breathing, the exchange of
air between lungs and the environment
Inspiration*
Expiration*

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Airway Resistance, Lung Compliance and

Elasticity

-Respiratory Passageway Resistance –affected by friction

created by constriction of the airway, presence of mucus or
infections material, and by tumor

-Lung Compliance –depends on the elasticity of the lung

tissue and flexibility of the rib cage

-Lung Elasticity –the ability of the lung tissue to distend and

recoil

Alveolar Surface Tension

-a liquid film of mostly water covers the alveolar walls
-the liquid film creates a state of tension due to the strong
affinity of liquid molecule to each other
-this tension aids in alveolar recoil
-Surfactant is a lipoprotein that reduces surface tension

Respiratory Volume and Capacity

Lung Volume
1. Tidal Volume (TV)
2. Inspiratory Reserve Volume (IRV) –amount of air that can
be inhaled forcibly (3,000 ml)
3. Expiratory Reserve Volume (ERV) –amount of air that can
be forced out (1,100 ml)
4. Residual Volume (RV) –volume of air that remains in the
lungs after a forced expiration (1,200 ml)
Lung Capacity
1. Vital Capacity (VC) –sum of TV+IRV+ERV
2. Inspiratory Capacity (IC) –sum of TV+IRV
3. Functional Residual Capacity (FRC) –sum ERV+RV
4. Total Lung Capacity (TLC) –sum TV+IRV+ERV+RV

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Respiration
External Respiration*

Internal Respiration*

Neurologic Control of the Respiratory

System
-Respiratory Centers in the Medulla Oblongata and Pons
-Chemoreceptors in medulla, carotid and aortic bodies
Example
Increased CO2 Concentration

Chemoreceptors Control center

Increased Respiratory Rate

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Respiratory Assessment
History Taking
Consider the Following:
1. Reason for Seeking Care
üChief complaints
üCough
üSputum production
üHemoptysis
üWheezing
üStridor
üChest pain
2. Present illness (History of Present Illness)

3. Previous illness (Past Medical History)

üChildhood/infectious diseases
üRespiratory immunizations
üMajor illnesses/hospitalization
üMedication
üAllergies
4. Family History
5. Social History*
üOccupational or environmental exposure
üGeographic location
üPersonal habits
(Years of Smoking x packs/day = pack years)

Physical Examination
Consider the Following:
1. Skin/Lip/Mucous Membrane Color
2. Nail Clubbing
3. Cough and Sputum Production
4. Inspection-Palpation-Percussion-Auscultation of the
Thorax (Activity 2)

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Common Diagnostic Test and Procedure

•Sputum Examination:
• To assess for gross appearance of the sputum
• Sputum C/S
• AFB
• Cytologic Examination
• Nursing Responsibilities:
• Best done in the morning just after awakening.
• Teaching coughing exercises.
• Increase fluid intake the night prior to procedure.
• Provide mouth care after the procedure

•Arterial Blood Gas:

• To assess ventilation and acid-base balance
• Normal Values:
• pH:
• PaO2:
• PaCO2:
• HCO3:
• Nursing Responsibilities:
• Specimen should be collected in heparinized needle and
syringe.
• Place sample in ice and should be taken immediately to
the lab.
• Indicate in client is receiving oxygen supplementation.
• Apply pressure to puncture site for 2-5 minutes.
• Do not collect specimen on the same arm for IV infusion,

•Pulse Oximetry:
• To assess oxygen saturation in blood
• Normal Values:
• Nursing Responsibilities:
• Assess for factors that may alter findings.
•Chest X-ray:
• To identify abnormalities in chest structure and lung
tissue
• Nursing Responsibilities:
• No special procedure in needed.
• Clothes and metallic objects on person must be remove
so as not to alter result.

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• Computed Tomography (CT Scan):

• Use when x-ray do not show some areas well
• Helps to differentiate pathologic conditions
• Nursing Responsibilities:
• No special preparation
• Positron Emission Tomography (PET Scan):
• Use to identify lung nodules
• Has 25% lower radiation as compared to CT
• Nursing Responsibilities:
• No alcohol, coffee, or tobacco is allowed for 24 hours
prior to test. Encouraged increase fluid intake post-test to
eliminate the radioactive material.

• Magnetic Resonance Imaging:

• Use when CT do not show tissue alterations well
• Nursing Responsibilities:
• Assess for any metallic implants.
• Test will not be performed in the presence of such,
• Pulmonary Angiography:
• Done to identify tumors, pulmonary emboli, aneurysm
and vascular changes and pulmonary circulation
• A catheter is inserted in the brachial and or femoral artery
into the pulmonary artery, dye is injected
• ECG leads are applied to the chest for cardiac monitoring.
Images of the lungs are taken
• Nursing Responsibilities:
• Monitor injection site and pulses distal to the side after
the test.

• Pulmonary Ventilation/Perfusion Scan (V/Q Scan):

• Done through two nuclear scans (ventilation and perfusion)
• Perfusion –done by injecting radioactive albumin into a vein
and scanning the lungs.
• Ventilation –done by inhaling radioactive gas
• Nursing Responsibilities:
• No special preparation is needed.
• Encouraged client to increase fluids after the procedure,
• Bronchoscopy:
• Direct visualization of the larynx, trachea, and bronchi with
bronchoscope.
• Nursing Responsibilities:
• Routine preoperative care
• Provide mouth care
• Have resuscitation and suction equipment at bedside
• Monitor V/S during procedure
• NPO for 2 hours or until fully awake
• Provide emesis basin for secretion and saliva (note color and
characteristics)
• Collect post bronchoscopy sputum for cytology

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• Lung Biopsy:
• Done to obtain tissue to differentiate tumors of the lungs
• Nursing Responsibilities:
• Same as Bronchoscopy
• Thoracentesis:
• Aspiration of fluid or air in the pleural space
• Nursing Responsibilities:
Before and During:
• Administer cough suppressant.
• Position client upright, leaning forward with arms and
head supported on an anchored overbed table.
• A sensation of pressure may be felt even if anesthesia use.
After:
• Monitor pulse, color, O2 sat and other signs.
• Apply a dressing on puncture site and position on the
unaffected site for 1 hour.

Therapeutic Management and Procedure

Coughing Exercises
üAfter using a bronchodilator treatment (if prescribed),
inhale deeply and hold your breath for a few seconds
üCough twice. The first cough loosens the mucus; the
second expels secretion
üFor huff coughing, lean forward and exhale sharply with a
“huff” sound. This technique helps keep your airways
open while moving secretions up and out of the lungs
üInhale by taking rapid short breaths in succession (sniffing
to prevent mucus from moving back into smaller airways
üRest

Deep Breathing Exercises

üPlace client in comfortable position
üAsk the client to flex knees to relax
abdominal muscles
üAsk the client to place one hand or both
hands on abdomen
üInstruct the client to breathe in deeply
through the nose keeping mouth closed*
üAsk the client to purse lips and breathe out
slowly, making a “whooshing” sound
without puffing cheeks*

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Peak Flow Meter

-as simple method of measuring the degree of airway obstruction
and helps to detect and monitor moderate to severe respiratory
disease*
üWash and dry hands
üAssemble equipment
üExplain the procedure
üSet the pointer to zero
üAsk the client to obtain a comfortable position
üAsk the patient to take a deep breath
üHolding PEF meter horizontally, ask the client to place their lips
and teeth around the mouthpiece, ensuring a good seal
üAsk the patient to breath out hard and fast
üNote the reading and then return pointer to zero
üAsk the client to repeat procedure twice

Adjust pointer to zero

Inhale deeply

Create a good seal and do a “fast

blast”

Chest Physiotherapy
üPercussion
üVibration
üPostural Drainage
üNursing Care
• Check doctor’s order
• Consider positioning through initial auscultation
• Do CPT of upper lobes before the lower lobes
• 10-15min in each position for a total of 30min per session
• Change position gradually to prevent postural
hypotension
• Best done 60 to 90min before meal or upon waking up or
before bed time
• Provide good oral hygiene

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Incentive Spirometer
-done to enhance deep inhalation. As the client inhales
indicators (balls/light) goes up which signifies good lung
expansion.
üWash and dry hands
üAssemble equipment
üExplain the procedure
üSet the pointer to zero
üAsk the client to obtain a comfortable position
üInstruct the client to place his lip around the mouth piece
and inhale deeply
üEncourage the client to go higher than the set point
üEncourage to repeat procedure few times in a day
üHealth teach about proper care of device

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Oxygen Administration
üAssess for signs and symptoms of hypoxemia
üVerify doctor’s order
üEnsure room safety*
üPosition client*
üOpen source of O2 and check for device functionality
üHumidify air by filling up the humidifier
üPlace administration device properly
üCoach normal breathing
üOronasal hygiene/lubrication of nares
üAsses effectiveness*
üMake relevant documentation

Suctioning
üClient should be in semi- or high-Fowler’s position
üObserve sterile technique by using sterile gloves and suction
tip
üHyperventilate with 100% oxygen before and after
suctioning*
üInsert catheter with gloved hand*
üApply suction during withdrawal of catheter
üRotate catheter during withdrawal while applying
intermittent suction
üSuctioning should be done within 5-10sec (maximum of 15)*
üEvaluate

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Closed Chest Drainage (Thoracotomy Tube)

-to remove air and/or fluids from the pleural space
-to reestablish negative pressure and re-expand the lungs

Type of Closed Chest Drainage

• One Bottle System
• Two Bottle System
• Three Bottle System

One Bottle System

üThe bottle serves as drainage and water seal
üImmerse tip of drainage tube in 2-3 cm of sterile water to
create water seal
üBottle should be kept lower that the body about 2-3 feet
üNever raise the bottler higher than the chest*
üAssess for patency of device
üObserve for fluctuation of fluid along the tube
üObserve for intermittent bubbling of fluid*
üIn the absence of fluctuation
üSuspect obstruction of the device
üIf without obstruction consider lung re-expansion to be
validated by x ray
üAir vent should be open for air

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Two Bottle System

-Without suction apparatus
üFirst bottle is drainage; the second is water seal
üObserve for fluctuation of fluid along the tube (water seal
bottle) and intermittent bubbling with each respiration
-With suction apparatus
üFirst bottle is drainage and water seal bottle; the second
bottle is suction control bottle
üImmerse tip of the tube in the first bottle in 2-3cm of sterile
NSS; immerse the the tube of the suction control bottler in
10-20cm of sterile NSS to stabilize the normal negative
pressure in the lungs. This protects the pleura from trauma if
the suction pressure is inadvertently increased.
üExpect continuous bubbling in the suction control bottler;
intermittent bubbling and fluctuation in water seal

Three Bottle System

üFirst bottle is drainage bottle; second bottle is water seal; third
bottle is suction control bottler
üObserve for intermittent bubbling and fluctuation with
respiration in water seal bottle; continuous bubbling in the
suction control bottle

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Nursing Care:
üEncourage to do following to promote drainage
1. Deep breathing and coughing exercises
2. Turn to sides at regular basis
3. Ambulate
üROM exercises of arms
üMark the amount of drainage at regular intervals
üAvoid milking and clamping of tube to prevent tension
pneumothorax
üRemoval of test tube –done by doctors
• Prepare:
1. Petroleum gauze
2. Suture removal kit
3. Sterile gauze
4. Adhesive tape

üPlace client in semi-Fowler’s position

üInstruct client to exhale deeply and to strain (Valsalva
maneuver) as the chest tube is removed
üChest x-ray may be done after the tube removal
üObserve for complications

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Arterial Blood Gas

üTo assess ventilation and acid-base balance
üRadial artery is the common site for withdrawal of blood
specimen.
üPerform Allen’s test before procedure
üUse 10ml pre-heparinized syringe
üPlace the specimen in a container with ice
üInterpretation*
üDetermine if the disorder is acidosis or alkalosis in nature
üDetermine if the disorder is respiratory or metabolic in
origin
üIdentify if there is compensation
üDetermine if compensation is full or partial

Imbalance pH PCO 2 HCO 3 PO 2 Compensaton

Respiratory Kidneys conserve HCO3

Acidosis Eliminate H+ to épH
Uncompensated ê é N N
Compensated N é é é
Respiratory Kidneys eliminate HCO3
Alkalosis Conserve H+ to êpH
Uncompensated é ê N N
Compensated N ê ê ê
Metabolic Acidosis Hyperventilation to ê CO2
Uncompensated ê N ê ê
And conserve HCO3

Compensated N ê ê ê
Metabolic Alkalosis Hypoventilation to é CO2
Uncompensated é N é é
Kidneys keep H+ and excrete
HCO3
Copensated N é é é

Let’s try it:

pH: 7.29
PaCO2: 33
HCO3: 20

One more:
pH: 7.32
PaCO2: 48
HCO3: 26

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ABG Results samples: • pH= 7.33

• PaCO2= 25
• ABG results are:
• pH= 7.44 • HCO3=12
• PaO2= 89
• PaCO2= 28
• HCO3= 24
• PaO2= 54
• ABG results are:
• pH= 7.48
• PaCO2= 28
• HCO3= 22
• PaO2= 85

• ABG results are:

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