Presentation on theme: "Stressors that Affect Oxygen Needs"— Presentation transcript:
1 Stressors that Affect Oxygen Needs NUR101 FALL 2008K. BURGER, MSEd, MSN, RN, CNELECTURE #19PPP by Sharon Niggemeier RN, MSNRevised October 2005 by K. Burger
2 Oxygenation Ventilation- air moves in & out of lungs External respiration-exchange of O2 & CO2 between alveoli and bloodGas Transport- blood transports O2 & CO2 to body cellsInternal respiration- exchange of O2 & CO2 between blood and cells.Internal- exchange of O2 and CO2
3 CheckpointT / F The pulmonary artery carries oxygenated blood away from the lungs.The pulmonary ARTERY carries un-oxygenated blood from the heart(R Ventricle) to the lungsThe pulmonary VEIN carries oxygenated blood away from the lungsWHERE does it go????L Atrium and L Ventricle and then AORTA to bodyFALSE
4 Factors Affecting Respiration Integrity of the airway system (ventilation)Functioning cardiovascular system (perfusion)Functioning alveoli (diffusion)Functioning medulla & chemoreceptorsVentilation- Physical movement of gases into and out of lungsPerfusion- passage of blood through the pulmonary circulation. Amount of blood flowing thru lungs effects amount of O2 & CO2 exchanged.Diffusion- passage of gases thru the resp. membrane from the alveolar sac to the capillaries and back.Medulla- brain stem: stimulated by Inc. CO2 will cause an inc. ht. Rate to blow off CO2 and this inc. O2 levelsChemoreceptors- sensitive to inc. CO2 in arterial blood gas level activates medulla.
5 Pulmonary Ventilation Inspiration- air flows into lungsExpiration-gases flow out of lungs According to pressure gradiant – BoyleIntrapulmonic or intra-alveolar pressure- pressure within alveoli (fluctuates: Inspiration 759mm Hg Expiration 761mm Hg)Intrapleural pressure-pressure within the intrapleural space (always negative) (756 mm Hg)Note: Atmospheric Pressure = 760 mm HgRespiration depends on volume changes within the thoracic cavity.A change in the volume of air leads to a change in the air pressure, since gases always flow along a pressure gradient , a change in pressure results gases flowing into or out of lungs to equalize pressure.BOYLES LAW – volume of gas at a constant temperature varies inversely with the pressure FLOW from higher pressure to lower pressureINSPIRATION – diaphragm (aided by accessory external intercostal muscles) contracts, pulling downward ABOUT 3-5 CM lengthening thoracic cavity – creates negative intra-alveolar pressureEXPIRATION – diaphragm relaxes, decreasing thoracic volume- creates positive intra-alveolar pressure ( greater than atmospheric air 760 mm Hg)INTRAPULMONIC OR INTRA ALVEOLAR PRESSURE – fluctuates with respiration Inspiration = 759 mm Hg, Expiration = 761 mm HgINTRAPLEURAL PRESSURE – pressure in the space between 2 pleural linings. ALWAYS negative 756 mm HgExerts pulling pressure on alveoli to keep them inflated. TERMED a transmural pressure gradientPLEURISY = inflammation of pleural linings causes friction and pain. Fluid accumulation can decrease pressure resulting in reduced alveoli expansion
6 Factors Affecting Ventilation Lung elasticity / compliance (ability to stretch and recoil)Airway obstructionMusculature conditionNeurological controlsELASTICITY – TWO ELEMENTS: Elastic Recoil- ability of lungs to return to normal after stretchingCompliance – how difficult it is to stretch the lungsDecreased RECOIL = Especially in EMPHYSEMA; difficulty fully expiring airDecreased COMPLIANCE = normal aging and/or pulmonary fibrosisOBSTRUCTION – narrowing of airways NOTE: chronic obstruction ADDS to decreased recoilCOPD Chronic Brochitis/ long-term inflammation leads to edematous linings and excessive mucous productionAsthma/ thickening of airways and/or constriction of airways from histamine induced edemaEmphysema / collapse of smaller airways and alveoli d/t destructive trypsin enzymes released bymacrophages as defense mechanism in response to chronic inhaled cigarette smokeMUSCULATURE CONDITIONRespiration controlled by medulla with messages sent to diaphragm.When respiratory center is depressed – decreased messages to diaphragm to contractIf diaphragm or supplying nerve network is damaged – no contractionIf overall condition of patient is extremely debilitated – decrease accessory muscle use
7 Checkpoint What is the name of the nerve that supplies the diaphragm? PHRENIC NERVE
8 Alveoli Gas Exchange Air reaches alveoli Oxygen from alveoli space moves into pulmonary capillary (oxygen uptake) via diffusionOxygen diffuses across alveoli membranes moving from high concentration (alveoli) to lower concentration (pulmonary capillary)Partial Pressure GradiantsPartial pressure = individual pressure exerted by a particular gas in a mixture of gasesAtmospheric Air 760 mm Hg02 = 160 mm Hg ….. 21%N2 Nitrogen = 600 mm Hg….79%Arterial Blood PO2 = 100 mm Hg PCO2 = 40 mm HgRepresented by Pgas Ex: PO2
9 Alveoli Gas ExchangeSurfactant- secreted by alveoli cells, keeps surfaces moist and prevents atelectasisAtelectasis- incomplete lung expansion or collapse of alveoliLung Compliance- elasticity of lung tissue and flexibility of rib cageLung recoil- ability of lungs to recoilSurfactant – A mixture of lipids and proteins secreted by Type II alveolar cellsInterspersed among the water molecules in the liquid film that surrounds each alveoliWater molecules great greater surface tension – keeps alveoli stretched and maintains recoilSurfactant creates reduced surface tension:increases pulmonary compliance – reducing the work of inflationreduces the lungs tendency to recoil – alveoli do not collapse as readilyNewborn respiratory distress syndrome – premature birth, not enough surfactant, greater effort to inspireAlso adjacent alveoli exert outward pressure on each other – aiding the maintenance of inflationLung compliance – normally very compliant and it takes less than 3% of our total energy expenditure to maintain quiet breathingIn lung disease energy may be as high as 30%Recoil- lungs recoil after being stretched. In COPD there is decreased lung recoil leading to impaired respirations.
10 Other Factors Affecting Gas Exchange Surface areaThickness of tissueFick’s Law of Diffusion: Rate of a diffusion of gas is dependent on surface area and thickness of the membraneFICKS Laws of diffusionRate of a gas through a sheet of tissue depends on surface area and thickness of the membraneDuring heavy exercise and increased cardiac output many previously closed pulmonary capillaries are forced open.This increases the surface area of blood available for exchangeIncreased thickness can occur with pulmonary edema – buildup of excess interstitial fluidpneumonia – buildup of excess mucous and fluid
11 Perfusion Transport of O2 & CO2 via blood to tissue Volume of blood flowing through lungs affects amount of oxygen and gases exchangedAdequate blood supply and cardiovascular functioning are neededOxyhemoglobin HbO2 (or SaO2)Need the circulatory system to assist respiratory processesPerfusion is dependent on having enough blood and functioning circulatory system to do the exchangeOxygen is poorly soluble in body fluids so it must be bound to hemoglobin for transport.The PO2 of the blood is not a measure of the total content of oxygen in the blood but only the dissolved portionOnly 1.5% of oxygen is dissolved in bloodRemaining 98.5 % carried on hemoglobin as Oxyhemoglobin HbO2 or SaO2Inversely proportionalANEMIC HYPOXIA – reduced O2 carrying capacityCIRCULATORY HYPOXIA – blockage or shockHYPOXIC HYPOXIA – reduced atmospheric O2 ( high altitudes, suffocation)HISTOTOXIC HYPOXIA – HbO2 is OK but cells cannot use the oxygen supplied to them (cyanide poisoning)
12 CheckpointThe majority of CARBON DIOXIDE molecules are transported in the blood as:???BICARBONATEHCO360% = HCO330% on hemoglobin10% dissolved in blood
13 Perfusion Rate of O2 transport depends on: Cardiac output Activity levelCO2 transportCardiac output- Stroke volume x heart rate= 5L/min of blood needed to circulateFACTORS THAT PROMOTE THE UNLOADING OF O2 FROM HEMOGLOBIN during increased cardiac outputExercise ( increased cardiac output) produces:Heat - metabolizing cell gives off heat and enhances O2 release from HbIncreased CO2 in the blood ( attaches to hemoglobin and decreases O2 affinity) aids unloading of O2Increased acid in blood does same thing as CO2
14 Neurologic/Chemical Controls of Respiration Peripheral ChemoreceptorsCentral ChemoreceptorsMedullary respiratory centerSpinal cordPhrenic nerveDiaphragmPeripheral chemoreceptors located in CAROTIDs and AORTIC ARCHSense the PCO2 levels in bloodHYPERCAPNIA = increased CO2 levels in bloodCentral chemoreceptors located in medulla close to the respiratory centerIncreased CO2 in the blood cause release of HThe central chemoreceptors then….Sense the H concentration in brain extracellular fluid (NOT the CO2 level) to trigger respiration
15 Factors Affecting Oxygenation EnvironmentEmotionsExerciseHealthAgeLife styleMedicationsRespiratory HistoryEnvironment- work place, air pollution, smoke, clean chimneys, Sandblasting, Toxic fumesEmotions- upset trigger attack asthma/ stress cause dyspnea which increases stress…Exercise uses more O2, if resp. system not functioning to capacity increased exercise will cause inability to get enough O2Health- Fluid overload ( renal and cardiac patients), severe and chronic illness-muscle wasting, anemia,skeletal abnormalities ( kyphosis, pectus carinatum, pectus excavatum, scoliosis ) and of course Respiratory DisordersLifestyle- smokers/ second hand smoke.Medications- Depressant effect of narcotics FYI O2 is considered a medication – need MD orderAge – premature infant ( lack of surfactant) VERSUS elderly ( loss of lung tissue elasticity, decreased muscle tone)
16 Checkpoint What is the normal respiratory rate of a newborn? 30-60 breaths/minVital Signs lecture notes SAY 40-60Average adult = 16-20They go down as we age
17 Assessing Respiratory Functioning Difficulty breathing?SOB?Chest pain?Coughing? Sputum production?Nocturnal diaphoresisFatigueSleep with 2 or more pillows?
18 Assessing Respiratory Functioning Respiratory Hx includes:AllergiesMedicationsMedical HxSmokingLifestyle / Activity LevelStressorsRecent exposuresDevelopmental levelAllergies to cats/ dogs/ meds/food environmentMeds- take to tx resp problems…inhalers/ cough suppressant/ decongestantHx- asthma, TB, bronchitis, lung Ca COPD Cardio vascular disorders/ chronic illnessesSmoking PPD?Lifestyle-active, couch potatoes, can climb stairs without being SOB?Stress –what brings on stress….effects breathing…Take a deep breath….i.e. at the dentist “breathe”Exposure post 9/11 air particles/ Iraq sand/dustFireplace foe 2 weeks at the ski lodgeDev.- infants prone to specific resp problems differ from elderly COPD
19 Assessing Respiratory Functioning Patient states difficulty breathing: you can assess by using PQRSTP- provokesQ- qualityR- region/radiationS- severity scaleT- timingP- when I’m near the catQ- I get SOB and wheezeR-Tightness in my upper chestS-7-8 on scale of 1-10 (worse)T- it lasts till I take my inhaler
20 Assessing Respiratory Functioning Respiratory Rate:Tachypnea R>24Bradypnea R<10ApneaRespiratory Depth:Deep - diaphragmaticShallownormal easy respirations 12-20Tachy = respirations greater than 24/min rapid and shallowFYI: Hyperventilation = increase in both rate and depth ( extreme exertion or anxiety )_ Brady = respirations of 10 or less/min decreased but regularFYI: Hypoventilation = decrease in both rate and depth ( shallower than brady ) = overdose of narcoticsApnea – no respirations
21 Assessing Respiratory Functioning Respiratory Rhythm:Regular – “even and symmetrical”Cheyne-StokesKussmaulsBiot’s (ataxic – without rhythm)Apneustic breathing (gasping)Normal even and unlaboredC/S= shallow then increases then decrease and stop then shallow… related to decreased neuro response to CO2K- deep rapid – metabolic AcidosisB – like Cheyne stokes except regular rhythm interspersed with periods of apnea Also called ATAXICA- sustained inspiration effort with strained expiration – gasping
22 Assessing Respiratory Functioning Respiratory Quality:No difficulty- Eupneic/ UnlaboredDyspneaOrthopneaRetractionsUse of accessory musclesAuscultation:VesicularBronchialBronchovesicularD- difficultyO- leaning forward support by overbed table, tripod positionR intercostals muscles between ribs pull inAccessory muscles = abdominal, scalene, sternocleidomastoid, trapezius, pectoralisVesicular- heard over most of lung field I>EBronchial- heard over trachea and larynx I<EBroncovesicular Bronchi I=E
23 Assessing Respiratory Functioning Adventitious Sounds:Crackles: fine,medium,coarseWheeze: sibilant,sonorousStridorStertorPleural friction rubCough:NonproductiveProductiveSputumHemoptysisADVENTITIOUS SOUNDS AUDIBLE VS AUSCULATATEDSputumYellow/Green = bacterial infection may also be blood streakedMucoid = viral infectionSlight but persistant blood streaking = carcinomaLarger amts of blood and purulence = TBFine crackles (hairs between fingers)- end of inspiration/ not cleared by coughingMedium crackles – lower and moister sounding midstage of inspiration/ not cleared by coughingCourse crackles – loud and bubbly, during inspiration/ not cleared by coughingWheeze Sibilant = squeaky on inspiration and expiration/ louder on expirationSonorous ( Rhonchi) = snore like on inspiration and expiration / may clear with coughStridor- high pitched sound croup = acute airway obstructionStertor- snoring noisePleural Friction Rub = dry, grating/ inflammation of pleura/ inspiration and/or expiration/ heard laterallyBreath sounds
24 Respiratory Assessment Review Oxygen delivery method correctly appliedObtain a pulse oximetry reading (norm is >95%)Check Vital Signs ?T ?P ?RAuscultate the pt’s lungsNote changes in skin and mucosa colorAssess capillary refill
25 CheckpointWhat are some other elements of a respiratory assessment not yet mentioned?Neurological stateColor+ tactile fremitusVoice soundsDecreased diaphragmatic excursionNail clubbingAP vs Transverse DiameterBarrel Chest?
26 Assessing Respiratory Functioning Diagnostic tests:SputumNose/throat culturesCBC (complete blood count)ABG (arterial blood gases)CXR (chest x ray)PFT (pulmonary function tests)Pulse OximetryOther: Scopes, CT, MRI, PETSPUTUM- cells expelled from the lungs tested for: Cytology OR CultureBest obtained in AM, no saliva, Sterile cup with cytology liquid ( 50% alcohol)Nose/Throat Cultures- determine if pathogen is present & antimicrobial that it is sensitive to to destroy it: Strep/MRSACBC- determines RBC/ Hbg etc effects oxygenationABG: provide physiological functioning of respirations…PaO2-partial pressure of O2 in arterial blood. Decreased levels indicate insufficient Norm = 100mmHg PaCO2 partial pressure of CO2 Norm = 40 mm HgCxR- lungs examined via x-rayPFT- measures volume of air in lungs used to Dx and Tx & monitor resp system/ inspiratory and expiratory volumesPulse Ox- light waves measure noninvasive . SaO2 % or Sp02 = saturated O2 on Hgb in arterial blood % Less than 85 severe hypoxiaBased on the red and infrared light absorption characteristics of oxygenated and deoxygenated hemoglobin. Oxygenated hemoglobin absorbs more infrared light and allows more red light to pass through.Deoxygenated (or reduced) hemoglobin absorbs more red light and allows more infrared light to pass through.Caution with anemic patient – lo Hgb but all saturated CLICK ON WEBSITEBronchoscopy- scope used to visualize inside the lungs. Direct visualizationCT/MRI/PET –scans imaging used to Dx resp. disorders/pathology Indirect visualization
28 Nursing Interventions Independent Airway maintenancePositioningDeep breathing & coughingPursed-lip breathingAbdominal/diaphragmatic breathingHydrationTeaching of health habitsABC’s always maintain open airway to promote oxygenation… Hyperextension of neck ( unless otherwise contraindicated)Artificial airway if necessary:Oropharangeal keeps tongue from obstructing airway – post opNasopharangeal- used for frequent suctioning without nares traumaEndotracheal-inserted via nose or mouth into tracheaTracheostomy- surgical procedure to open airway via tracheaPositioning- allow for increased expansion of thoracic cavity…high fowlers/ orthopneicDB&C raises sputum to maintain airway ..take deep breath thru the nose ( warms /filters air) and cough with force…may have to splint abd…. DB done alone to increase more efficient respirationsPursed-lip- slowly inhale thru the nose exhale thru lips close together. This maintains positive pressure in lungs, prevents atelectasis and promotes fuller exhalation phaseA/D breathing- helps decrease resp. rate and increase volume. Place hands on abd/diaphragm, inhale slowly thru nose , inflating abd. As much as possible, exhale thru pursed lips while hands press on abd.Hydration- need fluids to thin secretions so they are more easily expelled.Habits- Teaching life style changes, no smoking, control asthma, monitor environment.etc..
29 Nursing Interventions Collaborative/Dependent Incentive spirometryPercussion/postural drainageSuctioningOxygen therapyMedicationsI/S-allows for sustained maximum inspiration. More air in greater the oxygenation. Exhale, insert mouthpiece, inhale deeply to make ball rise in chamber, remove mouth piece exhale thru pursed lips.Perc/PD- promotes drainage of secretions, Perc.- cupped hands beat firmly on chest. PD –Place client in various positions to promote lung drainage ( also known as chest physiotherapy.) Most often performed by Resp TherapySuctioning- clears secretions from airway. Using a device secretions are removed . Catheter placed in mouth, nose or lungs and secretions are sucked out.PLEASE REVIEW THE PROCEDURAL OUTLINE ( OROPHARYNGEAL/NASOPHARYNGEAL SUCTIONING, ADMINISTERING OXYGEN) IN YOUR TEXTBOOKS PRIOR TO LAB SESSIONOT –provides supplemental oxygen (will discuss further)Meds- various meds can assist pt. To breath easier thereby increasing their oxygenation (will discuss further)IE: bronchodilators, antihistamines, mucolytics, corticosteroids
30 Nursing Interventions Collaborative/Dependent Oxygen TherapyIndicationsSources- wall outlet or portable tankMonitor pulse oximetryMethods- cannula, mask, venturi mask, tent/isolette,BiPAP, CPAPWill discuss in lab.Sources- wall outlet, or portable tank.O2 is released under pressure and a regulator is needed to achieve the desired amount of O2Measured in L/min or % depending upon the type of delivery system. Often attached to humidificationMethods-LOW FLOW – provides only part of the patients total inspired airNasal Cannula- convenient/pt can talk and eat/causes nares to dry ( 2-3L )Simple Mask – short time period ( 12 hrs or less ) / higher delivery ( must be 5L or more to avoid CO2 retention)Re-breathers– collects some of expired air increasing overall O2 deliveryHIGH FLOW- provides total inspired air and consistent oxygen deliveryVenturi – Large tube narrows as it enters the mask creating air to be sucked into side ports ( keep unobstructed). Delivers a more precise volume of O2Mask problems: claustrophobic, moist air and skin breakdownTent- plastic tent / w/ children doesn’t provide accurate concentration.CAUTION IN COPD PATIENTS!! Normally the stimulus to breathe is excessive CO2 levels in blood but in COPD the chemoreceptors become de-sensitized to the excess CO2 and these patients respond to HYPOXIA ( low O2 levels ) for stimulus to breathe. If O2 therapy is administered too high this stimulus is removed and pt may stop breathing. Usually no more than 2L
31 Administering Oxygen Therapy Flow rateHumidificationHydrationPositioningSafety precautionsDocumentMD order requiredO2 is a drug must be prescribedFlow rate- prescribed by MD L/min or % ( % = the Fraction Inspired Oxygen or FiO2)Humidification- keeps mucus membranes moistHydration is important because O2 is very drying to the mucus membranes, nares is using N/C, mouth masksPositioning, using semi to high fowlersSafety precautions discuss next.Document in nurses note or flow sheet, pt. Respiratory status, amount O2/min , how administered, any problems,
32 Oxygen Safety Precautions Signs: “No smoking. Oxygen in use.” Remove matches, lighters and cigarettes. Remove and store electrical equipment to avoid sparks. Ground electrical equipment. Avoid materials that generate static electricity Avoid use of volatile, flammable materials, such as alcohol.Know location & use of fire extinguishers & alarms.
33 Nursing Interventions MedicationsNebulizer TxCough suppressantsMucolytic: expectorantsBronchodilatorsCorticosteroidsTx- apparatus produces fines spray/mist of medications administered directly into the lungs bronchodilators open the airway to provide better oxygenationCough suppressants- stops coughs can be liquids/ lozenges/drops/ etc. Coughing can prevent pt. From sleeping, can cause further respiratory distressExpectorants- thin secretions making it easier to expelBronchodilators- open narrow passage waysCorticosteroids – reduce inflammation
34 Documentation Routine Nurses Note DateTimeLOCRateDepthRhythmBreath sounds (auscultated)QualityColor1/5/05 10:23pm A & O x 3 Respirations 14 deep,even & unlabored, vesicular breath sounds clear, bilaterally, no cyanosis.
35 Nursing Diagnosis Ineffective airway clearance Risk for aspiration Ineffective breathing patternImpaired gas exchangeRisk for suffocationIneffective tissue perfusion; cardiopulmonaryImpaired spontaneous ventilationDysfunctional ventilatory weaning response
36 Ineffective airway clearance CheckpointSelect a priority nursing diagnosis for the following scenario:88 y.o. female with pneumonia who has a non-productive cough, R= 24, course crackles upon auscultation. She is weak, undernourished and fatigued.Ineffective airway clearance
37 CheckpointSelect a priority nursing diagnosis for the following scenario:A patient with hx of emphysema with decreased PO2, increased CO2 levels who is dyspneic and restless.Impaired Gas Exchange
38 Ineffective Tissue Perfusion; Cardiopulmonary CheckpointSelect a priority nursing diagnosis for the following scenario:A patient admitted to the ER post MVA with notable blood loss, BP= 80/50, P=120, R=22Ineffective Tissue Perfusion; Cardiopulmonary
39 Summary: OxygenationOxygenation based on ventilation/perfusion/diffusion of oxygenVarious factors effect oxygenationAssessment includes respiratory Hx, clinical exam, diagnostic testsInterventions include airway maintenance /proper breathing/ oxygen therapy/meds