OXYGENATION

I. Structure and function of the

respiratory system
A. STRUCTURE:
 upper respiratory tract ( upper airway)
 nose and nasal cavity
 pharynx: oropharynx; nasopharynx;
laryngopharynx
 lower respiratory tract (lower airway)
 larynx or voice box
 trachea
 bronchi (left and right)
 bronchioles (terminal and respiratory)
 alveoli or air sacs
I. Structure and function of the
respiratory system
B. FUNCTION:
 Pulmonary ventilation
 is accomplished through the act of breathing
 cycle: inhalation or inspiration and exhalation or
expiration
 Factors affecting adequate ventilation:
 Clear airways
 Cough reflex
 Ciliary action
 Edema/ inflammation and spasms of airway
 Intact CNS and respiratory center
 Medulla and brainstem
 Altered with trauma, opiates or drugs
I. Structure and function of the
respiratory system
 Intact thoracic cavity- in response to changes
in pressure
 Intrapleural pressure: pressure in the
pleural cavity surrounding the lungs
 Intrapulomonary pressure: pressure within
the lungs
 Intactness of the diaphragm and use of
accessory muscles for respiration
 Adequate pulmonary compliance and recoil
 Lung compliance: the expansibility or
stretchability of lung tissue
 Decreases with aging
 Atelectasis: lung collapse
 Lung recoil: the continual tendency of the
lungs to collapse away from the chest wall
 Surfactant: increases lung surface tension
Structure and function of the
respiratory system
 Alveolar gas exchange
 Diffusion: transfer of solute particles from
area of higher to lower concentration
 Transport of oxygen and carbon dioxide
 97% combines with HEMOGLOBIN=
OXYHEMOGLOBIN
 remaining: dissolved in plasma and cells
 Factors affecting the rate of transport
(from lungs to cells):
 Cardiac output
 RBC count and hematocrit
 Exercise
I. Structure and function of the
respiratory system
 Carbon dioxide
 65% is carried by RBC as BICARBONATE (HCO3)
 30% combines with hemoglobin=
CARBHEMOGLOBIN or CABAMINOHEMOGLOBIN
 5% is transported in plasma and as carbonic acid
 Regulation of respirations
 Neural control and chemical control to maintain correct
concentrations of O2 and CO2 in blood
 Respiratory centers: Medulla and pons
 Chemoreceptors
 Central (Medulla): highly sensitive to increases in
CO2 in blood--- strongest stimulus
 (carotid and aortic): sensitive to decreases in O2 in
blood
II. Factors affecting
respirations
 Age
- Newborns: draining of fluids in lungs- increase in PCO2- first
breath
 Full inflation by 2 weeks
- Elderly: changes of aging that affect the respiratory function:
 Chest wall and airway becomes rigid and less elastic
 Amount of exchanged air is decreased
 Cough reflex and ciliary action decrease
 Decrease in muscle strength and endurance
 Decrease in efficiency of immune system- more prone to
infections
 GERD is more common= aspiration
 Environment
- Altitude: higher altitude=lesser oxygen=increase respiratory
rate and depth
- Heat and cold
- Air pollution
II. Factors affecting
respirations
 Lifestyle
- Physical exercise and activity increases
respirations
- Sedentary= lesser alveolar expansion and deep
breathing patterns
 Health Status
- Healthy=sufficient oxygen delivery and supply
 Medications
- Decreases rate and depth of respirations:
depressants, narcotics, anti-anxiety drugs
 Stress
- May cause hyperventilation
- Release of Epinephrine= bronchodilation
III. Alterations in respiratory
function
 Respirations can be altered by conditions that affect:
 Movement of air in and out of lungs
 Diffusion of oxygen and carbon dioxide between lungs and
blood
 Transport of oxygen and carbon dioxide via blood to and
from the cells
A. HYPOXIA
-Condition of insufficient oxygen in the body
- Adequate O2 is needed for brain function
-3-5minutes of hypoxia can be tolerated before permanent
brain damage occurs
Hypercarbia/ hypercapnia: accumulation of CO2 in blood
Hypoxemia: decreased O2 in cells
Cyanosis: bluish discoloration of skin, nail beds and
mucous membranes
III. Alterations in respiratory
function
 Clinical manifestations:
 Rapid pulse
 Rapid, shallow respirations and dyspnea
 Increased restlessness or lightheadedness
 Flaring of nares
 Substernal or intercostals retractions
 Cyanosis
 Conditions that can lead to hypoxia:
 Hypoventilation
 Decrease diffusion of O2 and CO2 as in pulmonary edema
 Problems with delivery of oxygen such as anemia, heart
failure, embolism
III. Alterations in respiratory
function
B. ALTERED BREATHING PATTERNS
 - refer to rate, volume, rhythm and
relative ease and effort in respirations
 Eupnea: normal; quiet, rhythmic and
effortless
 Tachypnea: increased rate
 Bradypnea: decreased rate
 Apnea: absence or cessation of
respirations
 Hyperventilation: increase rate and
depth
III. Alterations in respiratory
function
 Hypoventilation: decreased rate and depth
 Cheyne-Stokes respirations: marked rhythmic
waxing and waning from very deep to very
shallow to temporary apnea
 Biot’s respirations: shallow breaths interrupted
by apnea
 Kussmaul’s respirations: fast and deep breaths
like sighs with no expiratory phase
 Orthopnea: inability to breath except in upright
position
 Dyspnea: difficulty of breathing
III. Alterations in respiratory
function
C. OBSTRUCTED AIRWAYS
 Complete: complete obstruction of any
part of airway
 Heimlich maneuver (if client is
conscious); chest or abdominal thrust
(unconscious patient); chest thrust and
back blows (infants)
 Partial: partial obstruction of any part of
airway; assist the client to cough
IV. Assessment of respiratory
function
A. DIAGNOSTIC STUDIES
 Pulse Oximetry
 measures oxygen saturation of hemoglobin
 90-100%
 Arterial Blood Gas Analysis
 measures concentrations of blood gases
and identifies acid base balance of the
body
 use of arterial blood
IV. Assessment of respiratory
function
 Pulmonary Function Test
 Measures lung volumes and capacity
 Done by respiratory therapists; painless;
client will breath into a machine
 Tidal volume (VT)- volume of inhaled and
exhaled during normal and quiet
breathing
 Inspiratory reserve volume (IRV)-
maximum amount of air that can be
inhaled over and above the normal
breath
 Expiratory reserve volume maximum
amount of air that can be exhaled
following a normal exhalation
IV. Assessment of respiratory
function
 Residual volume (RV)- amount of air remaining in
the lungs after maximal exhalation
 Total lung capacity (TLC)- total volume of lungs at
maximum inflation; VT + IRV + ERV + RV
 Vital capacity (VC)- total amount of air that can be
exhaled after a maximal inspiration; VT+ IRV + ERV
 Inspiratory capacity- total amount of air that can be
inhaled following normal quiet respiration; VT + IRV
 Functional residual capacity (FRC)- volume left in
the lungs after normal exhalation; ERV +RV
 Minute volume (MV)- total amount of air breathed in
one minute
IV. Assessment of respiratory
function
 B. COMMON SIGNS AND SYMPTOMS:
 Cough
 Most common sign of respiratory disease
 Caused by irritation of mucous membranes
 Chief protection against accumulation of secretions and
foreign body
 Chest pain: may indicate hypoxia or damage to lungs
 Cyanosis and Clubbing of fingers: indicates hypoxia
 Hemoptysis: blood expectorated from the respiratory
tract; caused by trauma or break in the continuity of
respiratory tract
 Effort in breathing: Dyspnea or Orthopnea
 Sputum production
 Reaction of lungs to constantly recurring irritation
IV. Assessment of respiratory
function
 Thoracic sounds
 Crackles: loud, low pitched bubbling sound; results from
air passing through fluid
 Wheezes: musical sound; caused by air passing through
narrowed airways
 Stridor: loud, high pitched crowing sound
 Friction rub: grating, loud harsh sound
 Ronchi: sounds likes snores or moans
 Chest Configuration- AP: L= 1:2
 Barrel chest- increase in AP diameter
 Pigeon chest- increase in AP diameter; results from sternal
displacement
 Funnel chest- depression of lower portion of sternum
IV. Assessment of respiratory
function
C. HISTORY:
1. Current respiratory problems:
 Changes in breathing pattern
 Activities that may cause symptoms
 How many pillows used at night
2. History of respiratory disease
 Any respiratory diseases or infections
 Frequency of occurrence
 Exposure to pollutants
IV. Assessment of respiratory
function
3. Lifestyle
 Smoking history
 Exposure to smoke and other respiratory irritants
 Alcohol use
 Exercise pattern
4. Presence of cough
 How often
 When does it occur
 Productive or dry
5. Description of sputum
 When it is produced
 Amount, color, thickness, odor
 Presence of blood
IV. Assessment of respiratory
function
6. Presence of chest pain
 Location
 Description
 Does it occur with inspiration or expiration
 How long does it affect breathing
 Aggravating and alleviating factors
7. Presence of risk factors
 History of respiratory diseases in the family
8. Medication History
 OTC prescriptions for breathing e.g.
bronchodilators
V. Promoting Effective
respiratory function:
 PROMOTING OXYGENATION
 DEEP BREATHING AND COUGHING
 HYDRATION
 MEDICATIONS
 INCENTIVE SPIROMETRY
 CHEST PHYSIOTHERAPY
 OXYGEN THERAPY
PROMOTING OXYGENATION
 Positioning the client to allow
maximum chest expansion (Semi or
High Fowler’s position and Orthopneic
position)
 Encouraging or providing frequent
changes in position
 Encouraging ambulation
 Implementing measures that promote
comfort such as giving pain
medications
DEEP BREATHING AND
COUGHING
 To remove secretions from the airways
 Frequently indicated for clients with
restricted chest expansion
a. Breathing
 Abdominal or Diaphragmatic Breathing
-permits deep full breaths with little effort
 Pursed Lip Breathing
-helps client develop control over breathing
DEEP BREATHING AND
COUGHING
 Instructions:
 assume a comfortable position
 flex knees to relax abdominal muscles
 place both hands on abdomen
 breath deeply through the nose
 exhale through pursed lips counting to seven
b. Coughing: Controlled and Huff coughing
 After using bronchodilator, inhale deeply and hold
breath for a few seconds
 Cough twice (first: loosens secretions; Second:
expels them)
 Rest
HYDRATION
 Maintains moisture of respiratory
membranes
 Inadequate hydration can cause
the secretions to be thick and
more difficult to expel
 Humidifiers: add vapor to inspired
air
 Nebulizations: carries humidity
and medications
MEDICATIONS
 Bronchodilators: Salbutamol
 Anti-inflammatory drugs:
Prednisone
 Expectorants: Guaifenasin
 Mucolytics: Carboscistine
 Cough suppressants (Anti-
tussive) : Codeine Sulfate
INCENTIVE SPIROMETRY
 Sustained Maximal Inspiration Devices
 Measure the flow of air inhaled through a
mouthpiece
 Uses:
 Improve pulmonary ventilation
 Counteract the effects of anesthesia or
hypoventilation
 Loosen respiratory secretions
 Facilitate respiratory gas exchange
 Expand collapsed alveoli
CHEST PHYSIOTHERAPY: Percussion,
Vibration and Postural Drainage
 Dependent functions
 To remove secretions
 Sequence: positioning, percussion,,
vibration, removal of secretions by
coughing or suction
 Important Nursing Considerations:
>auscultate lungs before and after the
procedure
>administer bronchodilators before procedure
>document color, amount and character of
expectorated sputum
CHEST PHYSIOTHERAPY: Percussion,
Vibration and Postural Drainage
 Best time: before breakfast, before lunch, in
the late afternoon and before bedtime (can
be tiring and can induce vomiting)
 Nursing considerations:
 Assess stability of vital signs (PR and RR)-
to ensure tolerance of the patient
 Note for signs of intolerance such as
pallor, diaphoresis, dyspnea, nausea
 Make appropriate adjustments to the
positions as necessary
CHEST PHYSIOTHERAPY:
Percussion or Clapping
 Forceful striking of the skin with cupped hands
 Can mechanically dislodge tenacious
secretions
 Steps:
 Cover the area with a towel or gown to reduce
discomfort
 Ask the client to breathe slowly and deeply to
promote relaxation
 Alternately flex and extend the wrists rapidly to
slap the chest
 Percuss each affected lung segment for 1-2
minutes
CHEST PHYSIOTHERAPY:
Vibration
 Series of vigorous quiverings produced
by hands that are placed against the
client’s chest wall
 Used after percussion to increase the
turbulence of the exhaled air
 Done alternately with percussion
 Steps:
 Place hands, palms down, on the chest
area to be drained, one hand over the
other with the fingers together and
extended
CHEST PHYSIOTHERAPY:
Vibration
 Ask the client to inhale deeply and exhale
slowly through the nose and pursed lips
 During exhalation, tense all the hand and
arm muscles, and using mostly the heel
of the hand, vibrate the hands, moving
them downward. Stop when client inhales
 Vibrate during five exhalations over one
affected lung
 After each vibration, encourage client to
cough and expectorate secretions
CHEST PHYSIOTHERAPY:
Postural Drainage
 The drainage by gravity secretions
from various lung segments
 Bronchodilators or nebulization
therapy may be given before
postural drainage
 Scheduled 2 or 3 times a day
depending on degree of lung
congestion
 Each position is usually assumed
for 10-15 minutes
OXYGEN THERAPY
 Prescribed by the physician; but can be
given without order in emergency cases
 Physician specifies method of delivery, liter
flow per minute (LPM) and concentration of
oxygen (Fi02: fraction of inspired oxygen)
 Indications:
 Difficulty ventilating all areas of the lungs
 Impaired gas exchange
 Heart failure (MI)
 Hypoxia/ hypoxemia
 Hazards or complications:
 Ventilatory depression
 Oxygen toxicity (Retrolental Fibroplasia: O2 toxicity
in newborns) this can occur if the Fi02 given is >50%
in a 24hour duration
 Bacterial contamination- contaminated humidification
system
 Skin irritation from device material
 Drying effect on the mucous membranes of
respiratory tract-use humidifiers
 Oxygen supply:
 Wall outlets
 Tanks and cylinders
 Portable oxygen cylinders
OXYGEN THERAPY:
Types of O2 delivery systems
 Low flow systems: will not meet the entire flow demand of the
patient
 NASAL CANNULA/ NASAL PRONGS AND NASAL CATHETER
 O2 concentration: 24-45% at flow rates 2-6L per minute
 Advantages:
 most common and inexpensive device
 easy to apply
 does not interfere with the client’s ability to talk or eat
 comfortable and allows freedom of movement
 Disadvantages:
 inability to deliver higher concentrations of O2
 drying and irritating to mucous membranes
 can be easily dislodged
 SIMPLE FACE MASK
 covers the client’s nose and mouth
 -40-60% concentration at 5-8L per minute
OXYGEN THERAPY:
Types of O2 delivery systems
 NASAL CANNULA  SIMPLE FACE
MASK
OXYGEN THERAPY:
Types of O2 delivery systems
 Partial rebreather mask
 same as non-rebreather mask but without
valves
 allows the client to rebreathe about the first
third of the exhaled air (the reservoir bag)
 increases the FiO2 by recycling oxygen
 O2 concentration of 60-90% at 6-10L per
minute flow
 nurse should not let bag be totally deflated; if
this occurs increase the flow rate
OXYGEN THERAPY:
Types of O2 delivery systems
 Non-rebreather mask
 delivers highest O2 concentration as possible
 contains one-way valves which prevents the air
room and client’s expired air from entering the
reservoir bag
 only oxygen in the bag is inspired again
 should not be totally deflated during inspiration
to prevent CO2 build up; if it occurs increase
flow rate
 95-100% concentration at 10-15L per minute
flow
OXYGEN THERAPY:
Types of O2 delivery systems
 High flow systems: will meet the entire flow
need of the patients
 Venturi mask
 has wide bore tubing and color coded jet
adapters
 delivers 24-40% or 50% at 4-10L pr minute
flow
 color coded adapters:
Blue- 24% Green- 35%
Yellow- 28% Peach- 40%
White-31% Orange- 50%
OXYGEN THERAPY:
Types of O2 delivery systems
 VENTURI MASK  YELLOW ADAPTER
ADAPTERS ATTACHED TO
35%
28% 31% MASK

50% 40% 24%

OXYGEN THERAPY:
Nursing considerations:
 Humidifiers as needed. Do not give at
liter flows of less than 2
 Fire safety- oxygen is highly combustible
 Place “No Smoking” sign on patient’s
room
 Do not place near any electric devices
 Strap cylinders securely and handle
them with precaution
OXYGEN THERAPY:
Parts of the O2 delivery system:
 Oxygen outlet (wall or cylinders)
 Flow meter
 Humidifier bottle
 Tubing
 Delivery device (cannula, mask or
tent)
OXYGEN THERAPY:
Steps in using an oxygen outlet:
 Attach the flow meter to the outlet, flow
meter should be in the off position
 Fill the humidifier bottle with distilled or tap
water
 Attach humidifier bottle to base of flow
meter
 Attach prescribed O2 tubing and delivery
device to the humidifier
 Regulate flow
ARTIFICIAL AIRWAYS
 Oropharyngeal and
nasopharyngeal airways
 Endotracheal tubes
 Tracheostomy tubes
Oropharyngeal and
nasopharyngeal airways
 Used to keep the upper air passages open when
they may become obstructed by secretions or
the tongue
 Easy to insert and have less risk for
complications
 Oropharyngeal stimulate gag reflex and are
used only for unconscious clients
 To insert:
 Place patient in supine or semi-fowlers
 Put clean gloves
 Hold lubricated airway by the outer flange
 open the mouth and insert along the top of
the tongue
Endotracheal tubes
 Most commonly inserted for clients who have
general anesthesia or mechanical ventilators
 Inserted by the physician or respiratory therapist
 Inserted through the mouth and guided by a
laryngoscope
 The tube terminates just superior the bifurcation
of the bronchi
 Patient is unable to speak
 Nursing interventions for patient with ET:
 Assess client’s respiratory status at least
every 2hours or more if indicated
Endotracheal tubes
 Frequently assess nasal and oral mucosa for redness and
irritation andf report any abnormal findings to the
physician
 Secure the ET rube with tape or a commercially prepared
tracheostomy holder to prevent movement of the tube
farther into or out of the trachea. Assess position
frequently. Notify physician if tube is displaced
 Unless contraindicated, place the patient in a semi-prone
position to prevent aspiration of secretions
 Using sterile technique, suction ET tube as needed
 Closely monitor cuff pressure and maintain at 20-25mmHg
 Provide oral and nasal care every 2-4 hours
 Move the ET tubes to other side of mouth every 8 hours
 Provide humidified oxygen because ET tube bypasses
upper airways
 Communicate with client frequently, provide notepad as
needed
Tracheostomy
 An opening into the trachea
through the neck
 Two techniques:
 Traditional open surgical
method: done in OR
 Percutaneous insertion: can be
done at bed side
Tracheostomy tubes
 May be plastic or metal
 Components:
 outer cannula: inserted into the trachea
 flange: rests against the neck and allows the tube
to be secured in place with tape or ties
 inner cannula:
 obturator: kept at the client’s bedside in case the
tube becomes dislodged and needs to be reinserted
 inflatable cuff: produces an airtight seal to prevent
aspiration of oropharyngeal secretions and air
leakage between tube and trachea
 low pressure cuff: used to distribute a low, even
pressure against the trachea thus decreasing risk
for necrosis of tissue
Tracheostomy care:
Purposes
 Maintain airway patency
 Maintain cleanliness and prevent infectrion
at the tracheostomy site
 Facilitate healing and prevent skin
excoriation around the incision
 Promote comfort
 Assessment:
 Secretions: amount and character
 Drainage
 Appearance
 Signs of infection
Tracheostomy care:
Equipment
 Sterile tracheostomy kit
 Towel or drape to protect linens
 Sterile suction catheter kit
 Sterile NSS
 Sterile gloves 2 pairs
 Clean gloves
 Moisture proof bag
 Gauze: 4x4
 Cotton will ties
 Scissors
Tracheostomy care:
Procedure:
 Hand hygiene
 Prepare equipment
 Suction the tube as needed
 Clean the inner cannula
 Remove inner cannula from soaking
solution
 Clean lumen and entire cannula using
brush or pipe cleaners
 Rinse
 Replace the cannula and secure It in place
Tracheostomy care:
Procedure:
 Clean the incision site and tube flange
 Using sterile applicators or gauze dressing
moistened in NSS
 One stroke one applicator
 Apply sterile dressing
 Fold dressing
 Place dressing under flange
 Support tube while placing dressing
 Change tracheostomy ties
 Tape and pad tie and knot
 Check tightness
 Document