CHAPTER 50

NUR 107
2014

Oxygenation

O2 CO2

Copyright 2012
by Pearson
Education, Inc.

OXYGENATION
O2

is tasteless, colorless
Accounts 21% atmospheric air
Oxygen use: maintain adequate cellular
oxygenation.
For

Tx. of acute and chronic respiratory

problems

Hypoxemia

inadequate oxygen levels in

the blood
O2 flow rates vary attempt to maintain
SaO2 > 92%

HYPOXEMIA
Late signs

Early signs

Tachypnea
Tachycardia
Restlessness
Elevated BP
Skin Pallor
Respiratory distress

Nasal

flaring
Use of accessory muscles
Adventitious lung sounds

Cyanosis
Confusion & stupor
Bradypnea
Bradycardia
Hypotension
Cardiac dysrhythmias

OXYGENATION
Assess/monitor

resp. rate, rhythm, debth & effort

Monitor SaO2; ABG/s (95% - 100%)
SaO2 < 92% require nursing interventions
SaO2 < 86% - emergency
SaO2 < 80% - life threatening

OXYGEN TOXICITY
May

result from high concentrations of oxygen

Delivering > 50%
Long durations of oxygen therapy
More than 24 48 hrs.
Symptoms: non-productive cough, substernal
pain, nasal stuffiness, N/V, headache, sore
throat, hypoventilation.

OXYGEN TOXICITY
Intervention
Decrease oxygen as soon as condition permits
Use lowest oxygen necessary to maintain
adequate SaO2
Monitor ABGs
Use CPAP, BiPAP or PEEP while on a ventilator
Helps to decreases the amt. of oxygen
needed for an adequate low level without
compromising lung compliance

OXYGEN-INDUCED
HYPOVENTILATION
May

occur in COPD with chronic hypoxemia

and hypercarbia (elevated CO2)
COPD pts rely on low levels of arterial oxygen
as their primary drive for breathing
Supplemental oxygen at high levels can
decrease or eliminate the respiratory drive
Monitor for resp. depression
O2 supplement must be at 1-2L/min
Venturi mask if tolerated
Monitor LOC

STRUCTURES OF THE
UPPER
Nose
RESPIRATORY TRACT
passages
Pharynx
Tonsils and adenoids
Larynx: epiglottis,
glottis,
vocal cords

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Sinuses/nasal

Lobes of the lungs:

Left:

upper and
lower
Right: upper,
middle, and lower
Alveoli
Pleura membranes
Pul. capillary network

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STRUCTURES OF THE
LOWER
Trachea
RESPIRATORY SYSTEM
Bronchi / bronchioles

AVEOLI
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Where gas exchange takes place

Alveolar-capillary membrane
Surfactant lipoprotein
produced by alveolar cells
acts like a detergent
reducing alveolar surface
tension.
Without surfactant, lung expansion becomes
exceedingly difficult and the lungs collapse.

LUNG COMPLIANCE
Compliance

lung recoil
Ability of the lungs and thorax to expand
Necessary for normal inspiration &
expiration
Continual tendency of the lung to collapse
away from the chest wall
Decreased in diseases such as
pulmonary edema, congenital structural
abnormalities, fx ribs
Decreases with aging

VENTILATION
Inspiration

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- inhalation
Expiration - exhalation
Ventilation is dependent
upon:
Clear airway
Intact CNS
Intact respiratory center
Adequate pulmonary
compliance/recoil
Thoracic capacity to
contract/expand

INSPIRATION
Diaphragm

& intercostals muscle contraction

Thoracic cavity size increases
Volume of lungs increases
Intrapulmonary pressure decreases always
negative
Negative pressure in lungs creates suction that
holds the pleural membranes together as the
chest expands
Air rushes into the lungs to equalize pressure
Pulmonary recoil enhances negative pressure.

EXHALATION
Diaphragm

and intercostals relax

Volume of the lungs decreases
Intrapulmonary pressure rises
Air is expelled
Other Ventilation Factors:
Intrapulmonary pressure
Tital volume

GAS EXCHANGE
Occurs

vessels into alveoli

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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

ALVEOLAR DIFFUSION AND

PERFUSION
Diffusion - the process by which oxygen and
carbon dioxide are exchanged at the
alveolar-capillary membrane.

Perfusion - the blood flow through

the pulmonary circulation.

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OXYGEN TRANSPORT
Oxygen

is transported from the

lungs to the tissues
97% of O2 combines with Hgb in
RBCs and is carried to tissues as
oxyhemoglobin
Remaining oxygen is dissolved
and transported in plasma and
cells

CARBON DIOXIDE
TRANSPORT
Must

be transported from the tissues

to the lungs
CO2 is continually produced in cell
metabolism
65% is carried inside the RBC as
bicarbonate
30% combines with Hgb as
carbhemoglobin
5% transported in the plasma and as
carbonic acid

RESPIRATORY
REGULATION

Neural

regulation respiratory center is

controlled by the medulla oblongata and
pons of the brain
Chemical regulation
CO2 sensitive (medulla)
Hydrogen ion concentration
Decrease O2 concentration (carotic &
aortic bodies)
Decrease arterial O2 concentration
(chemoreceptors)
Emphysema- O2 concentration plays a role
in regulating respirations

TIDAL VOLUME
Degree

of chest expansion during

normal breathing is minimal, requiring
little energy expenditure.
500ml of air is inspired and expired
with each breath in the normal adult

CONTINUED
Inspiratory

reserve volume (IRV) - is the

amount of air that can be inhaled after a
normal or tidal inspiration
Expiratory reserve volume (ERV) - amount of
air that can be forcibly exhaled after normal or
tidal expiration
Residual Volume - the amount of air remaining
in the lungs after forced maximal expiration

CONTINUED
Vital

Capacity

The

VC is the maximal amount of air

that can be exhaled after maximal
inspiration.
The VC is the total of the tidal
volume, inspiratory reserve volume,
and expiratory reserve volume.

RESPIRATORY
ALTERATIONS

Hypoxia

Insufficient

02 anywhere in the body

Signs of Hypoxia
Rapid pulse
Rapid shallow respirations and
dyspnea/flaring of nares/cyanosis
Increased resltlessness or
lightheatedness/confusion

SIGNS/SYMPTOMS OF
HYPOXEMIA

Early
Tachycardia
Tachypnea
Restlessness
Skin pallor
Elevated BP
Sx resp. distress

Nasal flaring
Acsessory muscles
adv, Lung sounds

Late
Confusion, stupor
Cyanosis skin &
mucous membranes
Bradypnea
Bradycardia
Hypotension
Cardiac dyshythmias

HYPERCARBIA
Hypercarbia

Hypoventilation,

CO2 accumulation

Cyanosis
Bluish discoloration of the skin, nailbeds,
and mucous membranes, due to reduced
Hemoglobin conc.

CARDIOVASCULAR
ALTERATIONS
Conditions

that Affect:
The function of the heart as a pump
Blood flow to organs and tissues
Composition of the blood and its
ability to transport 02 and C02

CARDIOVASCULAR ALTERATIONS
Decreased

Cardiac Output
MI, Heart Failure, Pulmonary
Edema
Impaired Tissue Perfusion
Ischemia, TIA-stroke, Pulmonary
Emboli
Blood Alterations
Hypovolemia, Anemia

RESPIRATORY EFFORTS
Accessory

Muscles:
Increase lung volume during inspiration
Clients with COPD, especially emphesyma,
frequently use accessory muscles to increase
lung volume.
Nurse might observe clavicles being elevated
when breathing; retractions
Results in energy expenditure which increases
metabolic rate
Increase metabolic rates increase the need for
more O2 & the need to eliminate CO2

FACTORS INFLUENCING
RESPIRATORY FUNCTION
Age
Environment
Lifestyle,

Activity
Health status
Medications
Stress, Emotions
Body position
Body temp./ Environment temp

BREATHING PATTERNS
During

inspirations, the thoracic

cavity must have a lower
pressure than the atmosphere.
Eupenea normal
Bradycardia - < 10 breaths/min
Tachypnea > 24 breaths/ min
Hypoventilation shallow,
irregular breathing

Breathing Patterns

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SYMPTOMS OF IMPAIRED
RESPIRATORY FUNCTION
Hypoxia
Altered

breathing patterns
Obstructed or partially obstructed
airway

HYPOXIA
Condition

of insufficient oxygen
anywhere in the body
Rapid pulse
Rapid, shallow respirations and
dyspnea
Increased restlessness or
lightheadedness
Flaring of nares
Substernal or intercostal retractions
Cyanosis

ALTERED BREATHING
PATTERNS
Apnea cessation of breathing
Kussmauls

breathing deep rapid

breathing
hyperventilation r/t metabolic acidosis
Body attempts to blow off CO2
Cheyne-stokes waxing & waning
respirations
Biots respirations shallow clusters of
breaths that are interrupted by apnea
Orthopnea inability to breath except in an
upright position
Dyspnea diff. breathing (SOB)

OBSTRUCTED AIRWAY
Complete

or partial obstruction may occur

anywhere along the resp. tract
Aspiration of foreign object
Tongue falls back & occludes oropharynx
Secretions or mucus accumulation

ADVENTITOUS LUNG SOUNDS

Adventitious

abnormal
Partial obstruction
Low-pitch snoring sound during inhalation
Complete obstruction
No chest movement
Inability to cough or speak
Sternal & intercostal retractions
Stridor high-pitch sound during inspiration

ASSESSMENT
Health

Hx: physical & functional problem

dyspnea, pain, accumulation of mucus,
wheezing, hemoptysis, edema of the feet,
fatigue, weakness
S/Sx of dyspnea, orthopnea, cough
Major s/sx dyspnea, sputum production,
chest pain, wheezing, clubbing of fingers,
hemoptysis, cyanosis
Clubbing of nails, sign of lung disease found in
pts. with chronic hypoxic conditions

PHYSICAL ASSESSMENT
Breathing pattern to be assessed without clients
awareness.
Normal respiratory rate ranges 12-20bpm.
Rate greater than 20 (tachypnea) indicates
hypoxemia (low serum oxygen levels) hypercapnia
(high serum CO2 levels) or anxiety.

PHYSICAL ASSESSMENT
Health

Status- chronic illness can cause

muscle wasting including muscles of the
respiratory system
Renal/Cardiac- create fluid overload, affect
respiratory functioning
Chest Trauma-impairs ability to expand and
contract chest

PHYSICAL ASSESSMENT
Considerations

related to the clients normal

breathing patterns, position, health
problems, medications or therapies, and
cardiovascular function affecting
respirations should be made
Opioids- Depress respiratory center,
decreasing rate and depth of respirations

PHYSICAL ASSESSMENT
Environment-

Altitude,heat, cold, and air

pollution affect oxygenation.
Polluted air- Headache, dizziness, coughing,
choking, and stinging of eyes
Physical Growth and Development
Conditions such as scoliosis affect breathing
patterns and cause air trapping.
Obese people are often SOB, with activity
due to alveoli at the base of the lungs are not
stimulated to expand fully

ASSESS CHEST
CONFIGURATION
1.
2.
3.
4.

Barrel chest - occurs as a result of over

inflation of the lungs
Funnel chest occurs when there is
depression of the lower portion of the sternum
Pigeon chest displacement of the sternum
Kyphoscoliosis Abnormal curvature of the
spine
Scoliosis, Kyphosis, Lardosis

5.
x

Flail Chest (due to rib fractures)

ASSESSMENT
Cyanosis

a bluish coloring of the skin;

indicates hypoxia
Determined by amt. of deoxygenated
hemoglobin in the blood
Cyanosis appears when < 5g/dL of
unoxygenated hemoglobin
A person with a hemoglobin of 15g/dL will
not show cyanosis until 5g/dL of that
becomes unoxygenated
Anemic pts. rarely show cyanosis.

ASSESSMENT
Assess

lips, skin, and nail beds for signs of

peripheral cyanosis, such as blue-gray tinge
or clubbing of the nails.
Clubbing is a sign of long-term, impaired
oxygenation.

LISTEN TO BREATH
SOUNDS
Abnormal

breath sounds
Normal breath sounds vs. Adventious
Crackles, wheezes, friction rubs
Voice Sounds vocal resonance
Bronchophony intense & clear sound
Egophony distorted voice sounds
Whispered pectoriloquy a subtle
sound

SPUTUM
Lungs reaction to irritants or nasal
discharge
Bacterial infection - thick, yellow, green,
rust color sputum
Viral infection thin, mucoid sputum
Lung tumor pink-tinged sputum
Pulmonary edema profuse, frothy
sputum
Lung abcess, bronchietosis foul
smelling sputum c bad breath
x

COUGH
Timing;

frequency- does it get worse, what

agravates it?
Chronic, Acute, or Paroxysmal
Productive or nonproductive
Dry or moist
Barking, Hoarseness, Hacking

HEMOPTYSIS
Blood tinged sputum
Review CXR, chest angiography,
bronchospcopy, pt. history & physical.
Determine the source of blood (gums, throat
lungs, stomach)
From lungs bright red, frothy
From nose or throat preceded by
sniffling, blood possibly visible in nose
From stomach vomiting vs. coughing;
dark coffee grounds color

CLUBBING
Sign

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of lung disease found in pts. with

chronic hypoxic conditions, chronic
lung infections,
&
malignancies.
Sponginess of nail
beds with loss of
nail-bed angle

CLUBBING

ASSESS FOR CHEST PAIN

Pain Associated with pulmonary or cardiac
disease
May occur with pneumonia, Pulmondy
emboli, lung infarction, pleurisy, cancer
Relief measures: analgesic, regional
anesthetics

NURSING MEASURES TO
PROMOTE RESPIRATORY
FUNCTION
Ensure
a patent airway
Encouraging

deep
breathing, coughing
Ensuring adequate
hydration

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Positioning

SPUTUM: RELIEF MEASURES

Decrease

viscosity - increase hydration

Inhalation of aerosolized solutions
Stop smoking interferes with ciliary action,
increases bronchial secretions, causes
inflammation, reduces surfactant.
Nutrition considerations - may be
compromised due to the smell or taste of
sputum

THERAPEUTIC MEASURES TO
PROMOTE RESPIRATORY
FUNCTION

Medications
Incentive spirometry
Chest PT
Postural drainage
Oxygen therapy
Artificial airways
Airway suctioning
Chest tubes

ASSESSMENT OF COPD
Questions

regarding dyspnea, cough,

sputum production, recent colds
Nurse notes any postural changes in
respiratory rate
Respiratory rate may be increased and
expiration prolonged.

COPD
Chest

may have an increased anteriorposterior diameter (barrel chest) with the

decreased chest movement and increased
abdominal movement during breathing.
Several interventions done to diagnose
COPD
History and physical exam
Pulmonary function test
Chest x-ray, radiography
Lab tests

TREATMENT
Goal

is to alleviate acute symptoms and

prevent complications. Treatment includes:
Bronchodilators to improve airflow
Corticosteroids to decrease inflammation
Low flow O2 if PaO2 is less than 55 or
SaO2 less than 88%
Antibiotics

NURSING DIAGNOSES
Focus

on the impact of physiologic changes

on the patients functioning.
Chronic dyspnea can influence activity
tolerance and ability to care for the self
Coughing and SOB can disturb sleep and
contribute to fatigue and weakness
Extra work on breathing can increase
calorie requirements but eating and
swallowing may be limited to dyspnea.

NURSING INTERVENTIONS
Teach

effective breathing patterns

Improve airway clearance
Improve Gas Exchange
Take medications as ordered
Encourage adequate nutritional intake
Prevent Infections

NURSING INTERVENTIONS
Evaluate

Activity Intolerance
Teach family to assess patient orientation
Teach patient and family about COPD,
stress healthy behaviors, smoking
cessation, and signs of potential problems
Promote health sleep patterns
Decrease feelings of powerlessness

ASTHMA
Chronic Inflammation of airways leading to
intermittent obstruction
Progressive airway obstruction unresponsive to
treatment leads to emergency situation
Form of obstructive pulmonary disease

ETIOLOGY
Intrinsic etiologies-physical and psychological
stress, exercise induced
Extrinsic etiologies- air pollutants, allergic response,
cold and dry air, medications
Widespread spasms of bronchiole smooth muscle
with airway edema

ASSESSMENT
Severe dyspnea/wheezing with expiration
Cough/Feeling of chest tightness
Increased heart rate and blood pressure
Extreme restlessness, anxiety, agitation
Tachypnea and use of accessory muscles

PLANNING AND
IMPLEMENTATION
Assess

respiratory and oxygenation status

Administer supplemental O2
Administer bronchodilators
Identify/remove/avoid precipitating factors

EXPECTED OUTCOMES/EVAL
Absence of dyspnea, chest tightness, wheezing
Respiratory rate of 12 to 24
Bilaterally clear and equal lung sounds
Afebrile
Adequate air clearance of clear thin secretions

INCENTIVE SPIROMETRY

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B
A

CHEST PHYSIOTHERAPY

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OXYGEN THERAPY

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OXYGEN THERAPY
Nasal cannula
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Simple face mask

Partial rebreather
mask

OXYGEN THERAPY
Nonrebreather mask
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Venturi mask

OXYGEN HOOD

Oxygen Mask
OxygenTent

HUMIDIFIER VIDEO

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Click here to view a video on humidifiers.

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ARTIFICIAL AIRWAYS

Nasopharyngeal Airway

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Oropharyngeal Airway

ARTIFICIAL AIRWAYS

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TRACHEOSTOMY TUBE

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CHEST DRAINAGE SYSTEM

For

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pneumothorax or
hemothorax
Tubes are inserted into
the pleural cavity to drain
fluid/blood and restore
negative pressure
Closed system with a
suction control chamber &
water seal chamber

PNEUMOSTAT
For

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pneumothorax
with small amounts
of fluid drainage
One way valve
prevents back flow

HEIMLICH CHEST
DRAINAGE VALVE
Used

with ambulatory patients

Allows air to escape from the chest
cavity without air re-entering
Does not collect fluid

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DESIRED OUTCOMES
Maintain

a patent airway
Improve comfort and ease of breathing
Maintain or improve pulmonary
ventilation and oxygenation
Improve ability to participate in
physical activities
Prevent risks associated with
oxygenation problems

ARTERIAL BLOOD GASES

ABGS
Evaluates respiratory functioning in a patient and
determine the actual levels of CO2 and O2 in
arterial blood.
The other values derived from the ABG analysis are
Power of hydrogen (PH), HCO3
Arterial saturation of the hemoglobin

 pH

7.35 7.45
PaCO2
ABGS
35 45 mm Hg
PaO2
80 100 mm
Hg
ARTERIAL BLOOD
GASES
SaO2
92 98%
HCO3
22 26 mEq/L
Base excess (BE)
-2.0 to 2.0 mEq/L
CaO2
16-22 nL O2/dL

OXYGEN SAFETY
No

Smoking when in use

Know locations of closest fire extinguisher
Educate clients:
Hazards of smoking with oxygen
To wear cotton gowns, synthetics or wool
spark static electricity
Use of grounded electrical equipment
Assess clients whose main respiratory drive is
hypoxia for oxygen-induced hypoventilation

NANDA NURSING
DIAGNOSES
Anxiety
Fatigue

Activity

intolerance
Imbalanced nutrition: less than body
requirement

NURSING INTERVENTIONS
Respiratory

assessment
Appropriate application of oxygen delivery
systems

NASAL CANNULA
delivers O2 at concentrations of 24-40%
Flow rate 1-6 L/min
Safe and simple method, easy to apply
Flow rates may vary depending on depth of
clients breathing; dislodges easily
NC may cause nasal skin breakdown
Provide humidification for flow rates

SIMPLE MASK
Covers nose & mouth
Delivers 40% 60%
5 8 L/ min
For short-terms oxygen therapy
Minimum flow rate or 5 to ensure flushing of CO2 from
the mask
Mask may be poorly tolerated

NON-REBREATHER MASK
Also covers nose & mouth
One-way valve and two exhalation ports

Delivers 80%-95% O2
10 15 L/min
Reservoir bag to stay 2/3 full during inspiration
& expiration
Delivers highest concentration possible

VENTURI MASK
Also

covers nose & mouth

One-way valve and two exhalation ports
Delivers 24%-55% O2
2 10 L/min
Delivers the most precise oxygen
concentration with different size adaptors
Best suited for clients with chronic lung
disease
Expensive, & requires frequent
assessment

PARTIAL REBREATHER MASK

Also covers nose & mouth

Delivers 60%-75% O2
6 11 L/min
Reservoir bag with no valve, allows rebreathing
up to 1/3 of exhaled air mixed with room air
Complete deflation of reservoir bag during
inspiration causes CO2 build up

AEROSOL MASKS
Fits loosely over face or neck (tracheostomy
collars)
Delivers 24% - 100% O2
Best for clients who do not tolerate other masks;
facial trauma & burns
Deliver high humidity

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NURSING CARE
Assess O2 need
Monitor appropriateness of oxygen therapy
Document therapy response
Monitor O2 Sats, ABGs
Promote good oral hygiene
Rest, decrease environmental stimul
Support the anxious clieints

NURSING CARE IN
RESPIRATORY DISTRESS

Fowlers position
Complete a focus respiratory assessment
Promote adequate oxygenation: deep breathing &
supplemental oxygen
Promote airway clearance: coughing, suctioning
Stay with client
Decrease anxiety

QUESTION
You are caring for a client who had
abdominal surgery 24 hours ago. This
client has a 10yr old history of COPD.
What interventions are necessary to
maintain a patent airway????