asic Human Needs Chapter 1 Oxygenation Introduction Oxygenation is a basic human need. Breathing is synonymous with life, The respiratory system replenishes the body's oxygen supply and eliminates waste from the blood in the form of carbon dioxide. Nurses ate responsible for promating normal respiratory function Tegardiless of practice area. School nurses conduct classes about the hazards of smoking. Community nurses sereen for and teach about prevention of respiratory disorders like tuberculosis, SARS, {Severe Acute Respiratory Syndrome) and others. Nurses also help to improve breathing in clients with altered respiratory function: Most important, nurses apply the nursing process to promote normal respiratory function, and therefore, adequate oxygenation, Anatomy and Physiology of the Respiratory System. Respiration. The process of gaseous exchange between the individual and th environment. 1. The Airways 2. Upper Airways ° Nasal Cavity © Pharynx @ Larynx b, Lower Alrways (Tracheobronchial Tree) ° Trachea 9 Right and left mainstem bronchi ¢ Segmental bronchi ® Subsegmental bronchi ° Terminal bronchi c. Functions of the Upper Airways: © Transport of gases to the lower airways. * Protection of the lower airway from foreign matter. ¢ Warming, filtration and humidification of inspired air. Scanned with CamScanner! 1, Fun ctions of the Lower Ainways Clearance Mechanism = Cough + Mucociliary system 2 Macrophages 2 lymphatics 2 Immunologic Responses * Cell— mediated immunity in the alveoli. Pulmonary protection in Injury. # Respiratory epithelium. = Mucociliary system. The openings of the nose on the face area are called nostrils or ares. Each nostril leads to a cavity called vestibule. The hair that lines the vestibules are called the vibrissae. The vibrissae filter foreign objects. The paranasal sinuses are open areas within the skull, lined with mucous membrane. They help in phonation. The different sinuses are as follows: frontal, maxillary, ethmoid and sphenoid. The pharynx is a funnel-shaped tube that extends from the nose to the larynx. It is a common opening ‘between the digestive and respiratory system. The three seetions of the pharynx are as follows; nasopharynx, oropharynx and laryngopharynx, From -the middle ear, the eustachian tubes open into the nasopharynx. The larynx is the voice box. The epiglottis covers the larynx. Whén eating, the epiglotts closes, when speaking it opens> The trachea (windpipe} is 12 cm (4-5 in.) long. The point at which it divides is called carina, ‘The trachea and bronchi are lined with cilia and goblet cells. The cilia are microscopic hairlike projections which have rapid, coordinated, unidirectional upward motion. The cilia sweep out debris and excessive mucous from the lungs. The goblet cells secrete 120 ml of mucous per day. The mucous Secretions entrap debris in the respiratory tract. The right mainstem bronchus is shorter, broader and more vertical than the left. 335 Scanned with CamScannerSe 2, The Pleura” | 1. The pleurae are serous membranes that enclose the lungs, ! 2. The visceral pleura directly cover the lungs. 3. The parietal pleura line the cavity of each hemithorax, 4, The pleural space is a potential space between the two plaura, | Only few ml ef serous fuid is found in the pleural space, to sane as lubricant. ~ 4 3. The Lungs ~ © The right iung has three lobes, while the left lung has twolobes, J separated by a space calied mediastinuy ly three hundred million ziveoli > The two lungs 2 There are api © The righ thelungs, | 2 to the presence of the} * Residual volume is the emount of air that remains in the lungs after forceful expiration. It prevents collapse of the lungs during | expiration. (4200 mi.) @ Tidal volume is the amount of air that moves in“and out of the lungs with each normal breath, (500 ml.) | e° Inspiratory reserve volume is the amount of extra air that can be exhaled, beyond the tidal volume. © Expiratory reserve volume is the amount of extra air that canbe | exhaled after a normal breath. ‘e Total lung capacity is the total of all four volumes (residual, ida, inspiratory reserve volume and expiratory reserve volumes), e Functional residual capacity is the amount of air that remains in the lungs after normal exhalation. 2 Pneumocytes. The type | pneumocytes line the alveoli, whereas the type Il pneumocytes produce surfactant, 4, The Thorax and the Diaphragm . The thorax provides protection for the lungs, heart and great vessels. © The thorax is made up of 12 pairs of ribs, bounded anteriorly by the sternum and posteriorly by the thoracic vertebrae. © The diaphragm is the main respiratory muscle for inspiretion. It is supplied by the phrenic nerve. 7 @ The following are the accessory muscles for inspiration: sternocleidomastoid, scalene, parasternal, trapezius and pectoralis muscles. They are used during increased work of breathing. o 336 Scanned with CamScannereatary control torvous System Control « medulla oblongata (central chemoreceptors) neustic center, pneumotaxic center) «pons {i be Reflex Control = cough refiex ¢. Peripheral Control id and aortic bodies planning reg That Promote Adequate Respiratory Function 4. Adequate oxygen supply from the environment. Man requires 21 % of oxygen from the environment: in order to survive, The higher the altitude, the lower is the oxygen concentration. . Deep breathing and coughing exercises. To promote maximum lung expansion and to loosen mucous secretions. Inhale deeply through the nose, then exhale passively through the mouth, - positioning, The semifowler’s or high fowler's position promotes maximum lung expansion, By gravity, the diaphragm moves down, and abdominal argens do not compress the diaphragm. 4, Patent airway. To promote gaseous exchange between the person and the environment. Causes of Airway Obstruction ‘a Tongue (among unconscious clients, the tongue tends to fall back). Mucous secretions. : «Edema of airways (rhinitis, taryngitis, bronchitis). @ Spasin of airways (laryngospasm, bronchospasm) Foreign bodies {aspirated foods, fluids) Airway obstruction is characterized by noisy breathing. . Adequate hydration. To maintain moisture of the mucous membrane fining and respiratory tract. This is necessary to prevent irritation and infection, Fluids also liquefy mucus secretions. Fluid intake should ideally be 6 go 8 glasses of fluid, preferably water, everyday. ~ 6 Avoid environmental pollutants, alcohol. and smoking. These factors inhibit mucocillary function. 7. Chest physiotherapy (CPT) : © Percussion, Vibration and Postural Drainage (PVD) These procedures are dependent ‘nursing functions. «Percussion (clapping) is forceful striking of the skin with cupped hands. It can mechanically dislodge tenacious secretions from bronchial walls. 337 Scanned with CamScanner2 a series of vigorous quivering produced by hands that st the client’s chest wall. It Is done to loosen © Vibratic: are placed flat agaln mucous secretions. ' sons f ag i secretions from vari Postural Drainage is expulsion o| varus lung segments by gravity. This involves placing ae client in different positions so that the area of lung congestion will be in vertica) position with the bronchus. This facilitates rainage by gravity, Each position during postural drainage will be assumed by the client for 10-15 minutes. . The entire treatment should last only for 30 minutes, © Gradual change of position should be observed to prevent exhaustion and postural hypotension. Before postural drainage, bronchodilator medication or nebulization therapy is given to loosen mucous secretions, as ordered. «The best time to do postural drainage treatment is before meals, in the morning upon awakening and at bedtime. * Do not perform postural drainage immediately after meals because it may cause vomiting, thereby aspiration. Provide good oral hygiene after the procedure: To remove unpalatable taste of the mucus secretions from the mouth, Bronchial Hygicne measures. a. Steam Inhalation The purposes of steam inhalation are 2s follows: 1, To liquefy mucous secretions. 2. To warm and humidify inspired air. 3. Torelieve edema of airways. 4, To soothe irritated airways. 5. To administer medications. it is dependent nursing function. Heat application requires physician's order. Inform the client and explain the purpose of the procedure. To allay anxiety. © Place the client in semi-fowler’s position. For maximum inhalation of steam, 7 © Cover the client’s eyes with wash cloth to prevent irritation. © Check the electrical device before use. To prevent injury. * Place the steam inhalator in a flat, stable surface. To prevent scalding from the hot water. 338 Scanned with CamScannerigce the spout 12-18 inches away frorn the client’s nose or adjust Pl ort ce as necessary. * tpestan yrt0N: Avoid burns. Cover the chest with towel to prevent burns eto dripping of condensate from the steam. Assess for redness on je of the face which indicates first degree burns. thesis : ‘ be effective, render steam ion therapy for 15.29 2.10 minutes. instruct the dient to perform deep breathing and coughing exeicises after the procedure to facilitate expectoration of mucous secretions. provide good ofel hygiene after the procedure, To remove unpalatable taste of sputum from the mouth, 7 Do after-care of equipment. ‘Make relevant documentation. b,Aerosol Inhalation Done among pediatric clients to administer bronchodilators or mucclytic-expectorants, ¢.Medimist Inhalation . 2 Done amorig adult ciiénts to administer bronchodilators or mucolytic-expectorents. suctioning: Oropharyngeal and Nasopharyngeal ¢ To clear aitways from mucus secretions. oropharyngeal and Nasopharyngeal suctioning {L._Assess indications for suctioning: «Audible secretions during respiration « Adventitious breath sounds (auscultated) 2. Position: : © Conscious: Semi-Fowler’s position ‘® Unconscious: Lateral position 3, Pressure of suction equipment, to prevent trauma to mucous membrane of airways. © Wall Unit: = Adult: 100-120 mm Hg «= Child: 95-110 mm He © Infant: 50-95 mm Hg 339 Scanned with CamScannerPortable Unit: = Adult: 410-15 mm Hg = child: 5-10. mm Hg * Infant: 2-5mm He 4, Appropriate size of sterile suction catheter, to prevent trauma to mucous membrane of airways. © Adult: Fr, 12-18 © Child: Fr8-40 © Infant: 58 - 5. Don sterile gloves. Sterile technique prevents introduction of microorganisms into the respiratory tract. 6. Length of catheter: 2 Measure from the tip of the cllent’s nose to the earlobe or about 13 cm (5 in) for an adult 7. Lubricate catheter, to reduce friction, © Nasopharyngeal suction tip-water soluble lubricant ‘© Oropharyngeal suction tip- sterile water or NSS 8. Apply suction during withdrawal of the suction catheter (never during insertion) to prevent trauma to the mucous membrane. 9, Apply suction for 5-10 seconds (maximum 15 seconds) Oversuctioning causes hypoxia and vagal stimulation, 10.Hyperventtilate client with 100% oxygen before and after suctioning to prevent hypoxia. 11. Allow 20-20 second interval between each suction to bring up mucous secretions into the upper airways, and prevent hypoxia. . 12. Provide oral and nasal hygiene. 13. Dispose contaminated equipment/ articles safely. To prevent contamination of the environment, e Use one sterile suction catheter for each episode of suctioning. 14, Assess effectiveness of suctioning. © Auscultate chest for clear breath sounds. 15, Document relevant data w 10. Incentive Spirometry . © Done to enhance deep inspiration. 11. Intermittent Positive Pressure Breathing (PPS) * Done to administer oxygen at pressures higher than the -atmospheric pressure, e 340 Scanned with CamScanneren SpRETIS ; bad tow how administration devices a ie psolCannul (24-45 % at 2 LP) g = Maybe used in clients with COPD at 2-3 L/inins isnet available. 3 Vinin if venturi mag Simple Face Mask (40-60 % at 5-8 LPM) Partial Rebreathing Mask (50-90 % at 6-10 LPM} Non-Rebreathing Mask (95-100 % at 6-15 LPM) Croupette Cxygen Tent, h flow acministéation devices Venturi mask. Low - concentration venture - type mask is preferred for clients with COPD because it provides accurate amount of oxygen. They require 2~3 L/min. or 28% oxygen. « Face Mask « Oxygen hood. Can be used for low and high flow concentration. © Incubator/isolette. Cen be used for low and high flow concentration. Note: Oxygen is colctiess, odorless, tasteless and dry gas that supports combustion. Nursing implicatfons: # Since oxygen is colorless, odorless, tasteless,gas, leakage cannot be detected. © Since oxygen is a dry gas, it can irritate mucous membrane of the airways. Since oxygen supports combustion, it can cause fire. 341 Scanned with CamScannerNursing Planning, Intervent as and Evaluation In the Administration Oxygen Therapy: a i Assess signs and symptoms of hypoxemia. ' Check doctor's orders. Position patient, preferably semi-Fowler’s. To enhance ung expan Open source of oxygen before insertion of oxygen device, This mn, check for malfuncti of the device. ® to 5, Regulate oxygen flow accurately. Excessive administration of o, can cause ainygen narcosis (respiratory alkalosi) "yen 6. Place a “No Smoking” sign at the bedside. 2 Strictly enforce this warning. * Oxygen greatly accelerates combustion and could cause a fire from a small spark. 7. Avoid use of oil, greases, alcohol and ether near the client receiy oxygen. These may further support combustion. ing 8.0 | appliances before use. Smell spark may cause a fr there is leakage of oxygen. ‘Avoid materials that genérate static electricity, such as wog) blankets and synthetic fabrics. Use cotton blankets, ~ a 10, Humiify oxygen. Place sterile water into the oxygen humidifier, 7, prevent dryness and irr f mucous membrane in the ainwaye, 11, Provide good oronasal © prevent dryness and irritation of mucous membrane. 12. Lubricate nares ¥ ith water-soluble lubricant to, soothe the mucous ‘ang. Do not use cil. Oil ignites when exposed to compressaq oxygen. 13. Assess effet of oxygen therapy. Check VS, especially RR; note quality of respiration; evaluate arterial blood gas results (agg | pe N ven analy 14. elevant documentation. © Eupnea. Is normal breathing. It is effortless, noiseless breathing 342 Scanned with CamScanneria it a wy?" suffcien Alterations in Respiratory Function t oxygenation of tissues. jgns of Hypoxia * ines Ea 3 Tachycara increased rete and depth|» Dyspnea \ Age Decreased systolic ap | | | | . | Slight increase in systolic BP | © Cough 2 _Hemostysis \ LU = SS een 5 6. 7 wee other Clinical Signs of A Nausea and vorniti Oliguria, anuiria Headache Apathy . Dizziness Ircitability memory loss other Clinical Signs of Chronic Hypoxia Fatigue, lethargy Pulmonary ventilation increases Rbc count increases Hb concentration increases Clubbing of fingers Altered Breathing Pattems a, Rate e Tachypnea - Rapid respiratory rate e Bradypnea = - Slow respiratory rate e Apnea fo Cessation of breathing b. Volume 6 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. 343 Scanned with CamScanner= ee a c. Rhythm , 5 _ Marked rhythmic waxing and” waning © Cheyne-stokes. respirations from very temporary apnea ' - : e Kussmaul’s {Hyperventilation). Increased rate and depth fH respiration, seen in metabolic acidosis and renal feiture, © Apneustic. Prolonged gasping inspiration followed by a very short, usually inefficient expiration. Biot’, Shallow breaths interrupted by apnea, deep to very shallow breathing am d. Ease of Effort ; Dyspnea, Difficult or bored breathing 2 Orthopriea. inability to breath except in upright or sitting position. Nursing Diagnosis Client's with Oxygenation Preblems 1. Ineffective airway clearance related to: Tracheobronchial infection, obstruction, secretions © Decreased energy and fatigue ~ © Trauma © Dehydration 2. Ineffective breathing pattern related to: © Neuromuscular/muscuioskeletal impairment @ Pain © Anxiety @ Decreased energy and fatigue © Inflaramatory process © Decreased lung expansion @ Tracheobronchial obstruction «Alteration of normal 02/co2 ratio Decreased cardiac output related to: © Structural alterations © Electrical alterations in rate, rhythm and conduction © Mechanical alteration in preload, afterload and inotropic changes in the heart . Impaired gas exchange related to: © Altered oxygen supply © Alveolar-capillary membrane changes * Altered oxygen-carrying capacity of the blood * Altered blood flow Se 344 » = Scanned with CamScanner5, Activity intolerance related to: 2 imbalance between oxygen supply and demand e Sedentary lifestyle 6. Anxiety related to: e Ineffective airway clesrance o Ineffective breathing pattern 7. Ineffective individual coping related to: e Act / intolerance associated with ineffective airway clearance 8. Fear related to feeling of suffocation associated with ineffective tpaired verbal communication associated with endotracheal tube » Self care deficit and decreased cardiac cutout 10. Sigep pattern disturbance related to: 2 (neffective breathing pattern (orthopnea} s Anxiety associated with ineffective airway. clearance. Scanned with CamScanner