Chapter 41 Oxygenation Copyright © 2017, Elsevier Inc. All Rights Reserved.

Scientific Knowledge Base
Oxygen is needed to sustain life. Blood is oxygenated through the mechanisms of ventilation, perfusion, and transport of respiratory gases. Neural and chemical regulators control the rate and depth of respiration in response to changing tissue oxygen demands. The cardiovascular system provides the transport mechanisms to distribute oxygen to cells and tissues of the body. [Ask students to recall the anatomy and physiology of the respiratory and cardiovascular systems learned in their prerequisite coursework.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study Mr. King, a 62-year-old man, entered the ED with a 6-day history of chest pain, shortness of breath, cough, and generalized malaise. His wife and son are with him. Mr. King works in sales and lives with his wife. He has a history of chronic obstructive pulmonary disease and alcohol abuse, but at present is not drinking. Mr. and Mrs. King have been heavy smokers for more than 40 years. Mr. King used to help out with the housework and loves to tinker in the garden; however, lately he has been unable to participate in any of the activities. His wife states, “All he seems able to do is sit in his chair and watch TV.” [Ask students: What barriers to health can you identify? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Respiratory Physiology
The exchange of respiratory gases occurs between the environment and the blood. Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism. The airways of the lung transfer oxygen from the atmosphere to the alveoli, where the oxygen is exchanged for carbon dioxide. Through the alveolar capillary membrane, oxygen transfers to the blood, and carbon dioxide transfers from the blood to the alveoli. There are three steps in the process of oxygenation: ventilation, perfusion, and diffusion. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Structure and Function
Gases move into and out of the lungs through pressure changes. The diaphragm and external intercostal muscles contract to create a negative pleural pressure and increase the size of the thorax for inspiration. Conditions or diseases that change the structure and function of the pulmonary system alter respiration. The respiratory muscles, pleural space, lungs, and alveoli are essential for ventilation, perfusion, and exchange of respiratory gases. Intrapleural pressure is negative, or less than atmospheric pressure, which is 760 mm Hg at sea level. For air to flow into the lungs, intrapleural pressure becomes more negative, setting up a pressure gradient between the atmosphere and the alveoli. Relaxation of the diaphragm and contraction of the internal intercostal muscles allow air to escape from the lungs. [Shown is Figure 41-1: Structures of pulmonary system.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Structure and Function (Cont.)
Ventilation The process of moving gases into and out of the lungs Perfusion The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs Diffusion Exchange of respiratory gases in the alveoli and capillaries Three steps are involved in the process of oxygenation: ventilation, perfusion, and diffusion. Ventilation requires coordination of the muscular and elastic properties of the lung and thorax. The major inspiratory muscle of respiration is the diaphragm. It is innervated by the phrenic nerve, which exits the spinal cord at the fourth cervical vertebra. Perfusion relates to the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs. Diffusion is responsible for moving the respiratory gases from one area to another by concentration gradients. For the exchange of respiratory gases to occur, the organs, nerves, and muscles of respiration need to be intact; and the central nervous system needs to be able to regulate the respiratory cycle. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) John Smith is the nursing student assigned to his first hospital-based clinical experience. He has some experience in health assessment and patient teaching related to health promotion activities from a recent rotation at a clinic. In the previous experience, patients were encouraged to adjust their at-risk health behaviors, such as smoking or poor diet. John feels confident when he arrives in the clinical area this morning because Mr. King has similar health needs to the clinical experiences he has had. [Ask students: How do you think John’s experience will affect his interaction with Mr. King? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Work of breathing The effort required to expand and contract the lungs. Inspiration and expiration Surfactant Atelectasis Compliance and airway resistance The amount of energy expended on breathing depends on the rate and depth of breathing, the ease with which the lungs can be expanded (compliance), and airway resistance. Inspiration is an active process, stimulated by chemical receptors in the aorta. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. Patients with advanced chronic obstructive pulmonary disease (COPD) lose the elastic recoil of the lungs and thorax. As a result, the patient’s work of breathing increases. Patients with certain pulmonary diseases have decreased surfactant production and sometimes develop atelectasis. Atelectasis is a collapse of the alveoli that prevents normal exchange of oxygen and carbon dioxide. Accessory muscles of respiration can increase lung volume during inspiration. Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue. During assessment observe for elevation of the patient’s clavicles during inspiration, which can indicate ventilatory fatigue, air hunger, or decreased lung expansion. Compliance is the ability of the lungs to distend or expand in response to increased intraalveolar pressure. Compliance decreases in diseases such as pulmonary edema, interstitial and pleural fibrosis, and congenital or traumatic structural abnormalities such as kyphosis or fractured ribs. Airway resistance is the increase in pressure that occurs as the diameter of the airways decreases from mouth/nose to alveoli. Any further decrease in airway diameter by bronchoconstriction can increase airway resistance. Diseases causing airway obstruction such as asthma and tracheal edema increase airway resistance. When airway resistance increases, the amount of oxygen delivered to the alveoli decreases. Decreased lung compliance, increased airway resistance, and the increased use of accessory muscles increase the work of breathing (WOB), resulting in increased energy expenditure. Therefore the body increases its metabolic rate and the need for more oxygen. The need for elimination of carbon dioxide also increases. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Lung volumes Tidal Residual Forced vital capacity Pulmonary circulation Moves blood to and from the alveolar capillary membrane for gas exchange The normal lung values are determined by age, gender, and height. Tidal volume is the amount of air exhaled following a normal inspiration. Residual volume is the amount of air left in the alveoli after a full expiration. Forced vital capacity is the maximum amount of air that can be removed from the lungs during forced expiration. Variations in tidal volume and other lung volumes are associated with alterations in patients’ health status or activity, such as pregnancy, exercise, obesity, or obstructive and restrictive conditions of the lungs. Pulmonary circulation begins at the pulmonary artery, which receives poorly oxygenated mixed venous blood from the right ventricle. Blood flow through this system depends on the pumping ability of the right ventricle. The flow continues from the pulmonary artery through the pulmonary arterioles to the pulmonary capillaries, where blood comes in contact with the alveolar capillary membrane and the exchange of respiratory gases occurs. The oxygen-rich blood then circulates through the pulmonary venules and pulmonary veins, returning to the left atrium. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Respiratory gas exchange Diffusion is the process for the exchange of respiratory gases in the alveoli of the lungs and the capillaries of the body tissues Diffusion of respiratory gases occurs at the alveolar capillary membrane. The thickness of the membrane affects the rate of diffusion. Increased thickness of the membrane impedes diffusion because gases take longer to transfer across the membrane. Patients with pulmonary edema, pulmonary infiltrates, or pulmonary effusion have a thickened membrane; resulting in slow diffusion, slow exchange of respiratory gases, and decreased delivery of oxygen to tissues. Chronic diseases (e.g., emphysema), acute diseases (e.g., pneumothorax), and surgical processes (e.g., lobectomy) often alter the amount of alveolar capillary membrane surface area. [Shown is Figure 41-2: Alveoli at terminal end of lower airway.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Oxygen transport The oxygen transport system consists of the lungs and cardiovascular system Carbon dioxide transport Carbon dioxide, a product of cellular metabolism, diffuses into red blood cells and is rapidly hydrated into carbonic acid (H2CO3) The carbonic acid then dissociates into hydrogen (H) and bicarbonate (HCO3-) ions Hemoglobin buffers the hydrogen ion, the (HCO3-) diffuses into the plasma Delivery depends on the amount of oxygen entering the lungs (ventilation), blood flow to the lungs and tissues (perfusion), rate of diffusion, and oxygen-carrying capacity. Three things influence the capacity of the blood to carry oxygen: the amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the ability of hemoglobin to bind with oxygen. Hemoglobin, which is a carrier for oxygen and carbon dioxide, transports most oxygen (approximately 97%). The hemoglobin molecule combines with oxygen to form oxyhemoglobin. The formation of oxyhemoglobin is easily reversible, allowing hemoglobin and oxygen to dissociate (deoxyhemoglobin), which frees oxygen to enter tissues. Reduced hemoglobin (deoxyhemoglobin) combines with carbon dioxide, and the venous blood transports the majority of carbon dioxide back to the lungs to be exhaled. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) When John goes to meet Mr. King and performs his morning assessment, he finds that Mr. King is overwhelmed. This patient is in a great deal of respiratory distress. It seems that every breath is a struggle for him. Everything that John planned to do for Mr. King seems less important. The patient is extremely anxious. His wife is at his side, anticipating John’s every move and demanding some action. [Ask students: What could John do next? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Regulation of Respiration
Neural regulation Central nervous system controls the respiratory rate, depth, and rhythm. Cerebral cortex regulates the voluntary control of respiration. Chemical regulation Maintains the rate and depth of respirations based on changes in the blood concentrations of CO2 and O2, and in hydrogen ion concentration (pH). Chemoreceptors sense changes in the chemical content and stimulate neural regulators to adjust. Regulation of respiration is necessary to ensure sufficient oxygen intake and carbon dioxide elimination to meet the demands of the body (e.g., during exercise, infection, or pregnancy). Neural and chemical regulators control the process of respiration. Neural regulation includes central nervous system control of respiratory rate, depth, and rhythm. The cerebral cortex regulates the voluntary control of respiration by delivering impulses to the respiratory motor neurons by way of the spinal cord. Chemical regulation maintains the appropriate rate and depth of respirations based on changes in carbon dioxide (CO2), oxygen (O2), and hydrogen ion (H+) concentrations (pH) in the blood. Changes in levels of O2, CO2, and H (pH) stimulate chemoreceptors located in the medulla, aortic body, and carotid body, which in turn stimulate neural regulators to adjust the rate and depth of ventilation to maintain normal arterial blood gas levels. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) John’s knowledge of the physiology of pulmonary conditions will assist him in caring for Mr. King. Mr. King’s history reveals risk factors in addition to the 40-year history of smoking 2 packs per day. Also, he continues to smoke. John knows that shortness of breath shows that the infection is obstructing his alveolar capillary membrane, preventing oxygenation of blood in some parts of his lung. He also is aware of the preexisting COPD. With John’s experience working with patients who are addicted to inhaled nicotine, he recognizes the difficulty of quitting. John knows that the most effective time to encourage patients to stop smoking is when they are in an acute care setting with an illness exacerbated by smoking. [Ask students: How can John open the subject of quitting smoking with Mr. King? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Cardiovascular Physiology
Cardiopulmonary physiology involves delivery of deoxygenated blood (blood high in carbon dioxide and low in oxygen) to the right side of the heart and then to the lungs, where it is oxygenated. Oxygenated blood (blood high in oxygen and low in carbon dioxide) then travels from the lungs to the left side of the heart and the tissues. The cardiac system delivers oxygen, nutrients, and other substances to the tissues and facilitates the removal of cellular metabolism waste products by way of blood flow through other body systems such as respiratory, digestive, and renal. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Cardiovascular Physiology (Cont.)
Structure and function Right ventricle pumps deoxygenated blood through systemic circulation. As blood passes through the circulatory system, there is an exchange of respiratory gases, nutrients, and waste products between the blood and the tissues. [Shown is Figure 41-3: Schematic representation of blood flow through the heart.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) John’s attitude about his nursing care reflects his respect for the patient’s autonomy and balances this with continually educating Mr. King about the risk factors of smoking. John knows the impact of support systems in assisting patients coping with chronic illness. He uses creativity and independent thinking to incorporate community and family resources into the plan of care for Mr. King. John will need to inquire about his social supports and the availability in his community of programs to help him quit smoking. [Ask students: Where could John go to get standards set by an authoritative body? What organization would have information that may help Mr. King understand the seriousness of continued smoking? Discuss: The American Cancer Society and the American Lung Association.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Cardiovascular Physiology (Cont.)
Myocardial pump Two atria and two ventricles As the myocardium stretches, the strength of the subsequent contraction increases (Starling’s law). Myocardial blood flow Unidirectional through four valves S1: mitral and tricuspid close S2: aortic and pulmonic close Coronary artery circulation Coronary arteries supply the myocardium with nutrients and remove wastes. Systemic circulation Arteries and veins deliver nutrients and oxygen and remove waste products. The pumping action of the heart is essential for oxygen delivery. The ventricles fill with blood during diastole and empty during systole. The volume of blood ejected from the ventricles during systole is the stroke volume. Hemorrhage and dehydration cause a decrease in circulating blood volume and a decrease in stroke volume. Myocardial fibers have contractile properties that allow them to stretch during filling. As the myocardium stretches, the strength of the subsequent contraction increases; this is known as the Frank-Starling (Starling’s) law of the heart. In the diseased heart (cardiomyopathy or myocardial infarction [MI]), Starling’s law does not apply because the increased stretch of the myocardium is beyond the physiological limits of the heart. The subsequent contractile response results in insufficient stroke volume, and blood begins to “back up” in the pulmonary (left heart failure) or systemic (right heart failure) circulation. To maintain adequate blood flow to the pulmonary and systemic circulation, myocardial blood flow must supply sufficient oxygen and nutrients to the myocardium itself. Blood flow through the heart is unidirectional. The four heart valves ensure this forward blood flow. During ventricular diastole, the atrioventricular (mitral and tricuspid) valves open, and blood flows from the higher-pressure atria into the relaxed ventricles. As systole begins, ventricular pressure rises and closes the mitral and tricuspid valves. Valve closure causes the first heart sound (S1). During the systolic phase, the semilunar (aortic and pulmonic) valves open, and blood flows from the ventricles into the aorta and pulmonary artery. The mitral and tricuspid valves stay closed during systole, so all of the blood is moved forward into the pulmonary artery and aorta. As the ventricles empty, ventricular pressures decrease, allowing closure of the aortic and pulmonic valves; this causes the second heart sound (S2). Some patients with valvular disease have backflow or regurgitation of blood through the incompetent valve, causing a murmur that you can hear on auscultation. The coronary circulation is the branch of the systemic circulation that supplies the myocardium with oxygen and nutrients and removes waste. The coronary arteries fill during ventricular diastole. The left coronary artery has the most abundant blood supply and feeds the more muscular left ventricular myocardium, which does most of the work of the heart. [Ask students to trace blood from when it leaves the heart to the systemic circulation, to when it returns to the heart.] The arteries of the systemic circulation deliver nutrients and oxygen to tissues, and the veins remove waste from tissues. Oxygenated blood flows from the left ventricle through the aorta and into large systemic arteries. These arteries branch into smaller arteries, then arterioles, and finally the smallest vessels, the capillaries. Exchange of respiratory gases occurs at the capillary level, where the tissues are oxygenated. Waste products exit the capillary network through venules that join to form veins. These veins become larger and form the vena cava, which carries deoxygenated blood to the right side of the heart, from which it then returns to the pulmonary circulation. Copyright © 2017, Elsevier Inc. All Rights Reserved. 18

Blood Flow Regulation Cardiac output (CO) =
Amount of blood ejected from the left ventricle each minute Stroke volume Amount of blood ejected from the left ventricle with each contraction Cardiac output (CO) = Stroke volume (SV) × Heart rate (HR) Preload End-diastolic pressure Afterload Resistance to left ventricular ejection Normal cardiac output is 4 to 6 L/min in the healthy adult at rest. The circulating volume of blood changes according to the oxygen and metabolic needs of the body. Stroke volume is affected by preload, afterload, and myocardial contractility all affect stroke volume. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. The ventricles stretch when filling with blood. The more stretch on the ventricular muscle, the greater the contraction and the greater the stroke volume (Starling’s law). In certain clinical situations, medical treatment alters preload and subsequent stroke volumes by changing the amount of circulating blood volume. If volume is not replaced, preload, stroke volume and the subsequent cardiac output decreases. Afterload is the resistance to left ventricular ejection. The heart works harder to overcome the resistance so blood can be fully ejected from the left ventricle. The diastolic aortic pressure is a good clinical measure of afterload. In hypertension the afterload increases, making cardiac workload also increase. Myocardial contractility also affects stroke volume and cardiac output. Poor ventricular contraction decreases the amount of blood ejected. Injury to the myocardial muscle such as an acute MI causes a decrease in myocardial contractility. The myocardium of the older adult is stiffer with a slower ventricular filling rate and prolonged contraction time. Heart rate affects blood flow because of the relationship between rate and diastolic filling time. With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume and cardiac output. The heart rate of the older adult is slow to increase under stress, but studies have found that this may be caused more by lack of conditioning than age. Exercise is beneficial in maintaining function at any age. Copyright © 2017, Elsevier Inc. All Rights Reserved. 19

Conduction System Transmits electrical impulses
Generates impulses needed to initiate the electrical chain of events for a normal heartbeat The rhythmic relaxation and contraction of the atria and ventricles depend on continuous, organized transmission of electrical impulses. The cardiac conduction system generates and transmits these impulses. The autonomic nervous system influences the rate of impulse generation and the speed of transmission through the conductive pathway and the strength of atrial and ventricular contractions. Sympathetic and parasympathetic nerve fibers innervate all parts of the atria and ventricles and the sinoatrial (SA) and atrioventricular (AV) nodes. Sympathetic fibers increase the rate of impulse generation and speed of transmission. The parasympathetic fibers originating from the vagus nerve decrease the rate. The conduction system originates with the SA node, the “pacemaker” of the heart. The SA node is in the right atrium next to the entrance of the superior vena cava. Impulses are initiated at the SA node at an intrinsic rate of 60 to 100 cardiac action potentials per minute in an adult at rest. The electrical impulses are transmitted through the atria along intraatrial pathways to the AV node. The AV node mediates impulses between the atria and the ventricles. It assists atrial emptying by delaying the impulse before transmitting it through the bundle of His and the ventricular Purkinje network. [Shown is Figure 41-4: Conduction system of the heart. AV, Atrioventricular; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; SA, sinoatrial.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Conduction System (Cont.)
Normal sinus rhythm (NSR) Originates at the SA node, follows normal sequence through conduction system P wave PR interval QRS complex QT interval An electrocardiogram (ECG) reflects the electrical activity of the conduction system. An ECG monitors the regularity and path of the electrical impulse through the conduction system; however, it does not reflect the muscular work of the heart. The normal sequence on the ECG is called the normal sinus rhythm (NSR). NSR implies that the impulse originates at the SA node and follows the normal sequence through the conduction system. The P wave represents the electrical conduction through both atria. Atrial contraction follows the P wave. The PR interval represents the impulse travel time from the SA node through the AV node, through the bundle of His, and to the Purkinje fibers. The normal length for the PR interval is 0.12 to 0.2 second. An increase in the time greater than 0.2 second indicates a block in the impulse transmission through the AV node; whereas a decrease, less than 0.12 second, indicates the initiation of the electrical impulse from a source other than the SA node. The QRS complex indicates that the electrical impulse traveled through the ventricles. Normal QRS duration is 0.06 to 0.1 second. An increase in QRS duration indicates a delay in conduction time through the ventricles. Ventricular contraction usually follows the QRS complex. The QT interval represents the time needed for ventricular depolarization and repolarization. The normal QT interval is 0.12 to 0.42 second. This interval varies inversely with changes in heart rate. Changes in electrolyte values such as hypocalcemia or therapy with drugs such as disopyramide (Norpace) or amiodarone (Cordarone) increase the QT interval. Shortening of the QT interval occurs with digitalis therapy, hyperkalemia, and hypercalcemia. [Shown is Figure 41-5: Normal electrocardiogram waveform.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Factors Affecting Oxygenation
Physiological factors Decreased oxygen-carrying capacity Hypovolemia Decreased inspired oxygen concentration Increased metabolic rate Conditions affecting chest wall movement Pregnancy, obesity, neuromuscular disease, musculoskeletal abnormalities, trauma, neuromuscular disease, CNS alterations Influences of chronic diseases Any condition that affects cardiopulmonary functioning directly affects the body’s ability to meet oxygen demands. Hemoglobin carries the majority of oxygen to tissues. Anemia and inhalation of toxic substances decrease the oxygen-carrying capacity of blood by reducing the amount of available hemoglobin to transport oxygen. Anemia (e.g., a lower-than-normal hemoglobin level) is a result of decreased hemoglobin production, increased red blood cell destruction, and/or blood loss. Oxygenation decreases as a secondary effect with anemia. The physiological response to chronic hypoxemia is the development of increased red blood cells (polycythemia). This is the adaptive response of the body to increase the amount of hemoglobin and the available oxygen-binding sites. Carbon monoxide (CO) is the most common toxic inhalant decreasing the oxygen-carrying capacity of blood. In CO toxicity hemoglobin strongly binds with CO, creating a functional anemia. Because of the strength of the bond, CO does not easily dissociate from hemoglobin, making hemoglobin unavailable for oxygen transport. [Ask students if they can remember cardiac anatomy and physiology and to name some condition that would affect oxygenation. Answers may include conduction defects, valvular dysfunction, myocardial ischemia, cardiac myopathy, tissue hypoxemia on the cardiac side and hyperventilation on the respiratory side, hypoventilation, hypoxia, and others.] [Ask students why hypovolemia affects gas exchange. Any condition that reduces chest wall movement will result in decreased ventilation. If the diaphragm is unable to descend fully with breathing, the volume of inspired air decreases, delivering less oxygen to the alveoli and all tissues.] Conditions such as shock and severe dehydration cause extracellular fluid loss and reduced circulating blood volume, or hypovolemia. Decreased circulating blood volume results in hypoxia to body tissues. With significant fluid loss, the body tries to adapt by peripheral vasoconstriction and increasing the heart rate to increase the volume of blood returned to the heart, thus increasing the cardiac output. With the decline of the concentration of inspired oxygen, the oxygen-carrying capacity of the blood decreases. Decreases in the fraction of inspired oxygen concentration (FiO2) are caused by upper or lower airway obstruction, which limits delivery of inspired oxygen to alveoli; decreased environmental oxygen (at high altitudes); or hypoventilation (occurs in drug overdoses). Increased metabolic activity increases oxygen demand. The level of oxygenation declines when body systems are unable to meet this demand. When fever persists, the metabolic rate remains high, and the body begins to break down protein stores. This causes muscle wasting and decreased muscle mass, including respiratory muscles such as the diaphragm and intercostal muscles. The body attempts to adapt to the increased carbon dioxide levels by increasing the rate and depth of respiration. The patient’s WOB increases, and the patient eventually displays signs and symptoms of hypoxemia. Patients with pulmonary diseases are at greater risk for hypoxemia. Oxygenation decreases as a direct consequence of chronic lung disease. Changes in the anteroposterior diameter of the chest wall (barrel chest) occur because of overuse of accessory muscles and air trapping in emphysema. The diaphragm is flattened, and the lung fields are over distended, resulting in varying degrees of hypoxemia and/or hypercapnia. [Ask students if they can name some nervous system diseases that may affect breathing. Answers may include myasthenia gravis, Guillain-Barré, and polio.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) John reviews the standards set by the American Cancer Society to identify that tobacco use accounts for at least 30% of ALL cancer deaths and 87% of lung cancer deaths. In 2011, ~221,130 new cases of lung cancer and ~156,940 deaths from lung cancer were reported in the United States. He uses this information and the resources at to assist in educating Mr. King and his wife about cancer statistics and methods to quit smoking. [Ask students: What type of cancer is the greatest killer? Discuss: Lung cancer is the leading cause of cancer death in the United States for both men and women.] In the United States, tobacco use is responsible for nearly 1 in 5 deaths. (Source: Cancer Facts & Figures 2011; Copyright © 2017, Elsevier Inc. All Rights Reserved.

Alterations in Respiratory Functioning
Hypoventilation Alveolar ventilation inadequate to meet the body’s oxygen demand or to eliminate sufficient carbon dioxide Hyperventilation Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism Hypoxia Inadequate tissue oxygenation at the cellular level Cyanosis Blue discoloration of the skin and mucous membranes Illnesses or conditions that affect ventilation or oxygen transport cause alterations in respiratory functioning. The goal of ventilation is to produce a normal arterial carbon dioxide tension (PaCO2) between 35 and 45 mm Hg and a normal arterial oxygen tension (PaO2) between 80 and 100 mm Hg. Hypoventilation and hyperventilation are often determined by arterial blood gas analysis. Hypoxemia refers to a decrease in the amount of arterial oxygen. Nurses monitor arterial oxygen saturation (SpO2) using a noninvasive oxygen saturation monitor pulse oximeter. Normally SpO2 is greater than or equal to 95%. Hypoventilation occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide. As alveolar ventilation decreases, the body retains carbon dioxide. Their peripheral chemoreceptors of the aortic arch and carotid bodies are primarily sensitive to lower oxygen levels, causing increased ventilation. Because the stimulus to breathe is a decreased arterial oxygen (PaO2) level, administration of oxygen greater than 24% to 28% (1 to 3 L/min) prevents the PaO2 from falling to a level (60 mm Hg) that stimulates the peripheral receptors, thus destroying the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide, which can lead to respiratory acidosis and respiratory arrest. Signs and symptoms of hypoventilation include mental status changes, dysrhythmias, and potential cardiac arrest. If untreated, the patient’s status rapidly declines, leading to convulsions, unconsciousness, and death. [Ask students to identify signs and symptoms. Answers may include dizziness, headache upon awakening, lethargy, cardiac dysrhythmias, electrolyte imbalances, convulsions, coma, and cardiac arrest.] Severe anxiety, infection, drugs, or an acid-base imbalance induces hyperventilation. Hyperventilation is sometimes chemically induced. It also occurs as the body tries to compensate for metabolic acidosis. Signs and symptoms of hyperventilation include rapid respirations, sighing breaths, numbness and tingling of hands/feet, light-headedness, and loss of consciousness. [Ask students: Why? Answers may include that an increase in respiratory rate causes excessive amounts of carbon dioxide elimination.] Causes of hypoxia include (1) a decreased hemoglobin level and lowered oxygen-carrying capacity of the blood; (2) a diminished concentration of inspired oxygen, which occurs at high altitudes; (3) the inability of the tissues to extract oxygen from the blood, as with cyanide poisoning; (4) decreased diffusion of oxygen from the alveoli to the blood, as in pneumonia; (5) poor tissue perfusion with oxygenated blood, as with shock; and (6) impaired ventilation, as with multiple rib fractures or chest trauma. The clinical signs and symptoms of hypoxia include apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes. The patient with hypoxia is unable to lie flat and appears both fatigued and agitated. Vital sign changes include an increased pulse rate and rate and depth of respiration. During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock. As the hypoxia worsens, the respiratory rate declines as a result of respiratory muscle fatigue. Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. The presence or absence of cyanosis is not a reliable measure of oxygen status. Central cyanosis, observed in the tongue, soft palate, and conjunctiva of the eye where blood flow is high, indicates hypoxemia. Peripheral cyanosis, seen in the extremities, nail beds, and earlobes, is often a result of vasoconstriction and stagnant blood flow. Copyright © 2017, Elsevier Inc. All Rights Reserved. 24

Alterations in Cardiac Functioning
Disturbances in conduction Electrical impulses that do not originate from the SA node cause conduction disturbances Dysrhythmias Atrial fibrillation Paroxysmal supraventricular tachycardia Ventricular dysrhythmias [Review Table 41-2, Inspection of Cardiopulmonary Status, with students.] Illnesses and conditions that affect cardiac rate and rhythm, strength of contraction, and blood flow through the chamber and peripheral circulation will cause altered cardiac functioning. Older adults experience alterations in cardiac function as a result of calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis, and a decrease in the number of pacemaker cells in the SA node. Rhythm disturbances are called dysrhythmias, meaning a deviation from the normal sinus heart rhythm. Dysrhythmias occur as a primary conduction disturbance such as in response to ischemia; valvular abnormality; anxiety; drug toxicity; caffeine, alcohol, or tobacco use; or as a complication of acid-base or electrolyte imbalance. Dysrhythmias are classified by cardiac response and site of impulse origin. Cardiac response is tachycardia (greater than 100 beats/min), bradycardia (less than 60 beats/min), a premature (early) beat, or a blocked (delayed or absent) beat. Tachydysrhythmias and bradydysrhythmias lower cardiac output and blood pressure. Tachydysrhythmias reduce cardiac output by decreasing diastolic filling time. Bradydysrhythmias lower cardiac output because of the decreased heart rate. Atrial fibrillation is a common dysrhythmia in older adults. Abnormal impulses originating above the ventricles are supraventricular dysrhythmias. The abnormality on the waveform is the configuration and placement of the P wave. Ventricular conduction usually remains normal, and there is a normal QRS complex. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously. Sometimes excitement, fatigue, caffeine, smoking, or alcohol use precipitates paroxysmal supraventricular tachycardia. Ventricular dysrhythmias represent an ectopic site of impulse formation within the ventricles. It is ectopic in that the impulse originates in the ventricle, not the SA node. The configuration of the QRS complex is usually widened and bizarre. P waves are not always present; often they are buried in the QRS complex. Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Alterations in Cardiac Functioning (Cont.)
Altered cardiac output Left-sided heart failure Right-sided heart failure Impaired valvular function Myocardial ischemia Angina Myocardial infarction Failure of the myocardium to eject sufficient volume to the systemic and pulmonary circulations occurs in heart failure. Left-sided heart failure is an abnormal condition characterized by decreased functioning of the left ventricle. If left ventricular failure is significant, the amount of blood ejected from the left ventricle drops greatly, resulting in decreased cardiac output. Signs and symptoms include fatigue, breathlessness, dizziness, and confusion as a result of tissue hypoxia from the diminished cardiac output. As the left ventricle continues to fail, blood begins to pool in the pulmonary circulation, causing pulmonary congestion. Clinical findings include crackles in the bases of the lungs on auscultation, hypoxia, shortness of breath on exertion, cough, and paroxysmal nocturnal dyspnea. Right-sided heart failure results from impaired functioning of the right ventricle. It more commonly results from pulmonary disease or as a result of long-term left-sided failure. The primary pathological factor in right-sided failure is elevated pulmonary vascular resistance (PVR). As the PVR continues to rise, the right ventricle works harder, and the oxygen demand of the heart increases. As the failure continues, the amount of blood ejected from the right ventricle declines, and blood begins to “back up” in the systemic circulation. Clinically the patient has weight gain, distended neck veins, hepatomegaly and splenomegaly, and dependent peripheral edema. Valvular heart disease is an acquired or congenital disorder of a cardiac valve that causes either hardening (stenosis) or impaired closure (regurgitation) of the valves. When stenosis occurs, the flow of blood through the valves is obstructed. When the ventricles contract, blood escapes back into the atria, causing a murmur, or “whooshing” sound. Myocardial ischemia results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands. Angina pectoris is a transient imbalance between myocardial oxygen supply and demand. The condition results in chest pain that is aching, sharp, tingling, or burning or that feels like pressure. Typically chest pain is left sided or substernal and often radiates to the left or both arms, the jaw, neck, and back. It is usually relieved with rest and coronary vasodilators, the most common being a nitroglycerin preparation. Myocardial infarction (MI) or acute coronary syndrome (ACS) results from sudden decreases in coronary blood flow or an increase in myocardial oxygen demand without adequate coronary perfusion. Infarction occurs because ischemia is not reversed. Cellular death occurs after 20 minutes of myocardial ischemia. Chest pain associated with MI in men is usually described as crushing, squeezing, or stabbing. The pain is often in the left chest and sternal area; may be felt in the back; and radiates down the left arm to the neck, jaws, teeth, epigastric area, and back. It occurs at rest or exertion and lasts more than 20 minutes. Rest, position change, or sublingual nitroglycerin administration does not relieve the pain. There is a significant difference between men and women in relation to coronary artery disease. Women’s symptoms differ from those of men. The most common initial symptom in women is angina, but they also present with atypical symptoms such as fatigue, indigestion, shortness of breath, and back or jaw pain. Women have twice the risk of dying within the first year after a heart attack than men. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Knowledge Base
Factors influencing oxygenation: Developmental Lifestyle Environmental In addition to physiological factors, multiple developmental, lifestyle, and environmental factors affect patients’ oxygenation status. It is important to recognize these as possible risks or factors that impact health care goals. Infants and toddlers are at risk for upper respiratory tract infections as a result of frequent exposure to other children, an immature immune system, and exposure to secondhand smoke. School-age children and adolescents are exposed to respiratory infections and respiratory risk factors such as cigarette smoking or secondhand smoke. Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. The cardiac and respiratory systems undergo changes throughout the aging process. The changes are associated with calcification of the heart valves, SA node, and costal cartilages. The arterial system develops atherosclerotic plaques. Osteoporosis leads to changes in the size and shape of the thorax. The trachea and large bronchi become enlarged from calcification of the airways. The alveoli enlarge, decreasing the surface area available for gas exchange. The number of functional cilia is reduced, causing a decrease in the effectiveness of the cough mechanism, putting the older adult at increased risk for respiratory infections [Review Box 41-1, Focus on Older Adults: Cardiopulmonary Implication in Older Adults, with students.] Lifestyle modifications are difficult for patients because they often have to change an enjoyable habit such as cigarette smoking or eating certain foods. Nutrition: Severe obesity decreases lung expansion, and increased body weight increases tissue oxygen demands. The malnourished patient experiences respiratory muscle wasting, resulting in decreased muscle strength and respiratory excursion. Dietary practices also influence the prevalence of cardiovascular diseases. Exercise increases the metabolic activity and oxygen demand of the body. The rate and depth of respiration increase, enabling the person to inhale more oxygen and exhale excess carbon dioxide. Cigarette smoking and secondhand smoke are associated with a number of diseases, including heart disease, COPD, and lung cancer. Excessive use of alcohol and other drugs impairs tissue oxygenation in two ways. First, the person who chronically abuses substances often has a poor nutritional intake. With the resultant decrease in intake of iron-rich foods, hemoglobin production declines. Second, excessive use of alcohol and certain other drugs depresses the respiratory center, reducing the rate and depth of respiration and the amount of inhaled oxygen. The body responds to anxiety and other stresses with an increased rate and depth of respiration. The environment influences oxygenation. The incidence of pulmonary disease is higher in smoggy, urban areas than in rural areas. Occupational pollutants include asbestos, talcum powder, dust, and airborne fibers. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Critical Thinking Use professional standards:
Agency for Healthcare Research and Quality (AHRQ) American Cancer Society (ACS) American Heart Association (AHA) American Lung Association (ALA) American Thoracic Society (ATS) American Nurses Association (ANA) To understand how alterations in oxygenation affect patients and the interventions necessary, you need to integrate knowledge from nursing and other disciplines and information gathered from patients. Critical thinking attitudes ensure that you approach patient care in a methodical and logical way. Professional standards such as those developed by the Agency for Healthcare Research and Quality (AHRQ), the American Cancer Society (ACS), the American Heart Association (AHA), the American Lung Association (ALA), the American Thoracic Society (ATS), and the American Nurses Association (ANA) provide valuable guidelines for care and management of patients. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Assessment In-depth history of a patient’s normal and present cardiopulmonary function Past impairments in circulatory or respiratory functioning Methods that a patient uses to optimize oxygenation Review of drug, food, and other allergies Physical examination Laboratory and diagnostic tests Nursing assessment of cardiopulmonary functioning includes an in-depth history of a patient’s normal and present cardiopulmonary function, past impairments in circulatory or respiratory functioning, and methods that a patient uses to optimize oxygenation. The nursing history includes a review of drug, food, and other allergies. Physical examination of a patient’s cardiopulmonary status reveals the extent of existing signs and symptoms. Utilizing assessment values of pulse oximetry and capnography aide in the assessment of patients with spontaneous breathing, intubated patients, and those patients requiring oxygen therapy or mechanical ventilation. Pulse oximetry provides an instant feedback about the patient’s level of oxygenation. Capnography, also known as end title CO2 monitoring, provides instant information about the patient’s ventilation (how effectively CO2 is being eliminated by the pulmonary system), perfusion (how effectively CO2 is being transport through the vascular system), as well as how effectively CO2 is produced by cellular metabolism. Capnography is measured near the end of exhalation. Finally, a review of laboratory and diagnostic test results provides valuable assessment data. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) John Smith begins his morning care for Mr. King. He finds Mr. King restless and anxious. John notices that as the day progresses, Mr. King’s coughs are weaker, less sputum is produced, and Mr. King is becoming more fatigued. [Ask students: What are five assessment steps John could take? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Assessment (Cont.) Through the patient’s eyes
Ask about patient’s priorities and expectations Establish realistic, short-term outcomes that build to a larger goal Educate the patient on the opportunities for individual, group, or telephone counseling and identifying a social support system Identifying their expectations involves patients in the decision-making process and helps them participate in their care. Educating the patient on the opportunities for individual, group, or telephone counseling and identifying a social support system give more individual choices when developing the cessation plan. After this is determined, the various nicotine and nonnicotine medications for treatment of tobacco dependence can be discussed to find one that may fit the patient’s lifestyle. A combination of counseling and medication is more effective than either alone. Remember that your goals and expectations do not always coincide with those of your patient. By addressing a patient’s concerns and expectations, you establish a relationship that addresses other health care goals and expected outcomes. Knowing your patients’ mindsets and respecting their wishes goes a long way in helping them make significant beneficial lifestyle changes. [Review Figure 41-6, Critical thinking model for oxygenation assessment, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Assessment: Nursing History
Pain Fatigue Dyspnea Cough Wheezing Smoking Respiratory infection Allergies Health risks Medications The nursing history focuses on the patient’s ability to meet oxygen demands. The nursing history for respiratory function includes the presence of a cough, shortness of breath, dyspnea, wheezing, pain, environmental exposures, frequency of respiratory tract infections, pulmonary risk factors, past respiratory problems, current medication use, and smoking history or secondhand smoke exposure. The nursing history for cardiac function includes pain and characteristics of pain, fatigue, peripheral circulation, cardiac risk factors, and the presence of past or concurrent cardiac conditions. Ask specific questions related to cardiopulmonary disease. [Review Box 41-2, Nursing Assessment Questions, with students.] The presence of chest pain requires an immediate thorough evaluation, including assessment of location, duration, radiation, and frequency. Note any other symptoms associated with chest pain, such as nausea, diaphoresis, extreme fatigue or weakness. Pleuritic chest pain results from inflammation of the pleural space of the lungs, the pain is peripheral and radiates to the scapular regions. Musculoskeletal pain is often present following exercise, rib trauma, and prolonged coughing episodes. Fatigue in the patient with cardiopulmonary alterations is often an early sign of worsening of the chronic underlying process. Dyspnea is a clinical sign of hypoxia. It is the subjective sensation of difficult or uncomfortable breathing. Dyspnea is associated with exaggerated respiratory effort, use of the accessory muscles of respiration, nasal flaring, and marked increases in the rate and depth of respirations. The use of a visual analogue scale (VAS) helps patients objectively assess their dyspnea. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated. Patients with a chronic cough tend to deny, underestimate, or minimize their coughing. Often, because they are so accustomed to it, they are unaware of how frequently it occurs. Patients with chronic sinusitis usually cough only in the early morning or immediately after rising from sleep. If hemoptysis (bloody sputum) is present, determine whether it is associated with coughing and bleeding from the upper respiratory tract, sinus drainage, or the gastrointestinal tract (hematemesis). Wheezing is a high-pitched musical sound caused by high-velocity movement of air through a narrowed airway. It is associated with asthma, acute bronchitis, and pneumonia. Environmental exposure to inhaled substances is closely linked with respiratory disease. With CO poisoning, the patient will have vague complaints of general malaise, flulike symptoms, and excessive sleepiness. Radon gas is a radioactive substance from the breakdown of uranium in soil, rock, and water that enters homes through the ground or well water. It is important to determine patients’ direct and secondary exposure to tobacco. Ask about any history of smoking; include the number of years smoked and the number of packs smoked per day. This is recorded as pack-year history. Obtain information about the patient’s frequency and duration of respiratory tract infections. Ask about any known exposure to tuberculosis (TB) and the date and results of the last tuberculin skin test. Determine the patient’s risk for human immunodeficiency virus (HIV) infection. Patients with a history of intravenous (IV) drug use and multiple unprotected sexual partners are at risk of developing HIV infection. When obtaining information about allergies, ask specific questions about the types of allergens, responses to these allergens, and successful and unsuccessful relief measures. Determine familial risk factors such as a family history of lung cancer or cardiovascular disease. Documentation includes blood relatives who had cardiopulmonary disease and their present level of health or age at time of death. Other family risk factors include the presence of infectious diseases, particularly TB. Medications include prescribed medications, over-the-counter medications, folk medicines, herbal medicines, alternative therapies, and illicit drugs (such as opioids, marijuana, cocaine) and substances. It is important to determine if a patient uses illicit drugs. Assess the patient’s knowledge and ability to self-administer medications correctly. Copyright © 2017, Elsevier Inc. All Rights Reserved. 32

Case Study (Cont.) Ask Mr. King how long he has been short of breath.
“I have been short of breath for 1 week, and it has gotten worse.” Take Mr. King’s vital signs. Pulse rate is 120 beats/min Temperature is 102° F Respiratory rate is 36 breaths/min Blood pressure is 110/45 mm Hg Arterial oxygen saturation (SpO2 ) is 82%; Mr. King is dyspneic Ask Mr. King how long he has had his cough and whether it is a productive cough. “I usually cough when I wake up in the morning. Three days ago, I noticed that I was coughing up thick mucus that has not stopped.” Auscultate Mr. King’s lung fields. Expiratory wheezes, crackles, and diminished breath sounds over the right lower lobe are audible. Ask Mr. King to produce a sputum sample. Sputum is thick and discolored (yellow-green). The assessment steps John took are in the left column. The results and Mr. King’s responses are in the right column. [Ask students: What nursing diagnosis should John use for Mr. King? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Physical Examination Inspection Palpation Percussion Auscultation
Skin and mucous membrane color, level of consciousness (LOC), breathing patterns, chest wall movement, general appearance, circulation Palpation Chest, feet, legs, pulses Percussion Presence of abnormal fluid or air; diaphragmatic excursion Auscultation Normal and abnormal heart and lung sounds The physical examination includes assessment of the cardiopulmonary system. When assessing an older adult patient, give special consideration to changes that occur with the aging process. These changes affect the patient’s activity tolerance and level of fatigue or cause transient changes in vital signs and are not always associated with a specific cardiopulmonary disease. [Review Table 41-1, Effects of Aging on Assessment Findings of the Cardiopulmonary System, with students.] Inspection: skin and mucous membranes for color, appearance, level of consciousness, adequacy of systemic circulation, breathing patterns, and chest wall movement. Inspection includes observations of the nails for clubbing. At rest the normal adult rate is 12 to 20 regular breaths/min. Bradypnea is less than 12 breaths/min, and tachypnea is greater than 20 breaths/min. In some conditions, such as metabolic acidosis, the acidic pH stimulates an increase in rate, usually greater than 35 breaths/min, and depth of respirations (Kussmaul respiration) to compensate by decreasing carbon dioxide levels. Apnea is the absence of respirations for lasting for 15 seconds or longer. Cheyne-Stokes respiration occurs when there is decreased blood flow or injury to the brainstem. Conditions such as emphysema, advancing age, and COPD cause the chest to assume a rounded “barrel” shape. Palpation: Palpation of the chest provides assessment data in several areas. It documents the type and amount of thoracic excursion; elicits any areas of tenderness; and helps to identify tactile fremitus, thrills, heaves, and the cardiac point of maximal impulse (PMI). Palpation of the extremities provides data about the peripheral circulation (e.g., the presence and quality of peripheral pulses, skin temperature, color, and capillary refill) (see Chapter 31). Palpation of the feet and legs determines the presence or absence of peripheral edema. Patients with alterations in cardiac function, such as those with heart failure or hypertension, often have pedal or lower-extremity edema. Edema is graded from 1+ to 4+ depending on the depth of visible indentation after firm finger pressure. Palpate the pulses in the neck and extremities to assess arterial blood flow (see Chapter 31). Use a scale of 0 (absent pulse) to 4 (full, bounding pulse) to describe what you feel. The normal pulse is 2; and a weak, thready pulse is 1. Percussion: detects the presence of abnormal fluid or air in the lungs. It also determines diaphragmatic excursion. Auscultation: identification of normal and abnormal heart and lung sounds. Auscultation of the cardiovascular system includes assessment for normal S1 and S2 sounds and the presence of abnormal S3 and S4 sounds (gallops), murmurs, or rubs. Identify the location, radiation, intensity, pitch, and quality of a murmur. Auscultation also identifies any bruit over the carotid, abdominal aorta, and femoral arteries. Auscultation of lung sounds involves listening for movement of air throughout all lung fields: anterior, posterior, and lateral. Adventitious, or abnormal, breath sounds occur with collapse of a lung segment, fluid in a lung segment, or narrowing or obstruction of an airway. Copyright © 2017, Elsevier Inc. All Rights Reserved. 34

Quick Quiz! 1. A patient complains of chest pain. When assessing the pain, you decide that its origin is cardiac—rather than respiratory or gastrointestinal—when it: A. does not occur with respiratory variations. B. is peripheral and may radiate to the scapular region. C. is aggravated by inspiratory movements. D. is nonradiating and occurs during inspiration. Answer: A Copyright © 2017, Elsevier Inc. All Rights Reserved.

Diagnostic Tests Many tests used for cardiopulmonary functioning
Blood specimens X-rays TB skin testing [Discuss possible findings in altered oxygenation for each test.] TB skin test is a simple test and is required for health care workers; restaurant employees; students on entry to school, teachers, and other school employees; prisoners and correctional facility employees; and residents of long-term care facilities. [Review Box 41-3, Tuberculosis Skin Testing, with students.] [Review Table 41-3, Cardiopulmonary Diagnostic Blood Studies, Table 41-4, Cardiac Function Diagnostic Tests, and Table 41-5, Ventilation and Oxygenation Diagnostic Studies, with students.] When reviewing results of pulmonary function studies, be aware of expected variations in patients from different cultures. These changes are caused by structural variations in chest wall size. [Review Box 41-4, Cultural Aspects of Care: Cultural Impact on Pulmonary Diseases, with students.] Invasive diagnostic tests such as a thoracentesis are painful. Reduce the patient’s anxiety by explaining the thoracentesis procedure and telling the patient what to expect. Be sure that the patient understands the importance of following instructions such as taking a deep breath and holding it when requested and not coughing during the procedure. Provide appropriate pain management before the procedure to reduce the perception of pain. After any procedure, monitor the patient for signs of changes in cardiopulmonary functioning, such as sudden shortness of breath, pain, oxygen desaturation, and anxiety. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nursing Diagnosis Activity intolerance Decreased cardiac output
Fatigue Impaired gas exchange Impaired verbal communication Ineffective airway clearance Risk for aspiration Ineffective breathing pattern Ineffective health maintenance Based upon your assessment, you develop nursing diagnoses for patients with oxygenation alterations by clustering specific defining characteristics and identifying the related etiology. [Review Box 41-5, Nursing Diagnostic Process: Impaired Gas Exchange Related to Decreased Lung Expansion, with students.] The defining characteristics for diagnoses related to oxygenation can be similar. A closer review of assessment findings as well as an analysis of the patient’s history will help you clarify and select the correct diagnosis. The clustered defining characteristics and related factor must support the nursing diagnosis. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Planning During planning, use critical thinking skills to synthesize information from multiple sources Goals and outcomes Realistic expectations, goals, and measurable outcomes Setting priorities Teamwork and collaboration Critical thinking ensures that your plan of care integrates individualized patient needs. Professional standards are especially important to consider when developing a plan of care. These standards often establish scientifically proven guidelines for selecting effective nursing interventions. Patients with impaired oxygenation require a nursing care plan directed toward meeting actual or potential oxygenation needs. Allow patients to collaborate in setting relevant goals of care. Develop individual outcomes based on patient-centered goals. Often a patient with cardiopulmonary disease has multiple nursing diagnoses. In this case, identify when goals or outcomes apply to more than one diagnosis. The presence of multiple diagnoses also makes priority setting a critical activity. A patient’s level of health, age, lifestyle, and environmental risks affect the level of tissue oxygenation. Patients with severe impairments in oxygenation frequently require nursing interventions in multiple areas. Consider which goal is the most important to achieve while the patient is in the hospital or primary care setting. Both you and the patient need to focus on the same goal and expected outcomes. Be sure to respect the patient’s preferences for his or her degree of active engagement in the care process. The time spent with a patient in any setting is limited. Therefore collaborate with family members, colleagues, and other specialists to achieve the established goals and expected outcomes. Communicating among everyone on the patient’s health care team and recognizing everyone’s contributions in achieving the health care goals for the patient are imperative. [Review Figure 41-7, Critical thinking model for oxygenation planning, with students.] [Review Figure 41-8, Concept map for Mr. Edwards, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Nursing diagnosis: Ineffective airway clearance related to pulmonary secretions Goals: Pulmonary secretions will return to baseline levels within 24 to 36 hours. Mr. King’s oxygenation status will improve in 36 hours [Ask students: What expected outcomes would accompany these goals? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Respiratory status: gas exchange
Mr. King’s sputum will be clear, white, and thinner in consistency within 36 hours. Mr. King’s lung sounds will be at baseline within 36 hours. Mr. King’s respiratory rate will be between 16 and 24 breaths per minute within 24 hours. Mr. King will be able to clear airway secretions by coughing in 24 hours. Mr. King’s SpO2 will be >85% within 24 hours. Mr. King’s perceptions of dyspnea will improve. [Ask students: What possible interventions will help Mr. King achieve these outcomes? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation: Health Promotion
Vaccinations Influenza, pneumococcal Healthy lifestyle Eliminating risk factors, eating right, regular exercise Environmental pollutants Secondhand smoke, work chemicals, and pollutants Health promotion includes vaccinations against flu and pneumonia, exercise programs, nutrition support, smoking cessation, and environmental assessment for pollutants and air quality. Maintaining the patient’s optimal level of health is important in reducing the number and/or severity of respiratory symptoms. Prevention of respiratory infections is foremost in maintaining optimal health. Providing cardiopulmonary-related health information is an important nursing responsibility. [Review Box 41-6, Patient Teaching: Prevention of Recurrent Respiratory Infections, with students.] Flu shot is recommended for children 6 months and older, and for those with chronic illnesses. It is also recommended for those who are in contact with high-risk groups (health care providers) and for immunosuppressed and human immunodeficiency virus (HIV)-positive individuals. Pneumococcal vaccine is recommended for those older than 65 years of age, those at risk for pneumonia, and those with chronic illnesses or immunosuppression (such as acquired immunodeficiency syndrome [AIDS] or HIV). Encourage patients to eat a healthy low-fat, high-fiber diet; monitor their cholesterol, triglyceride, high-density lipoprotein (HDL), and low-density lipoprotein (LDL) levels; reduce stress; exercise; and maintain a body weight in proportion to their height. Eliminating cigarettes and other tobacco, reducing pollutants, monitoring air quality, and adequately hydrating are additional healthy behaviors. Exercise is a key factor in promoting and maintaining a healthy heart and lungs. Patients with known cardiac disease and those with multiple risk factors are cautioned to avoid exertion in cold weather. Avoiding exposure to secondhand smoke is essential to maintaining optimal cardiopulmonary function. People who work as farmers, painters, or carpenters might benefit from the use of particulate filter masks to reduce inhalation of particles. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation: Acute Care
Dyspnea management Airway maintenance Mobilization of pulmonary secretions Hydration Humidification Nebulization Coughing and deep-breathing techniques Dyspnea is difficult to measure and treat. Treatments are individualized, and more than one therapy can be implemented. Oxygen therapy reduces dyspnea associated with exercise and hypoxemia. Airway maintenance requires adequate hydration to prevent thick, tenacious secretions. Proper coughing techniques remove secretions and keep the airway open. A variety of interventions, such as suctioning, chest physiotherapy, and nebulizer therapy, assist patients in managing alterations in airway clearance. Nursing interventions promoting removal of pulmonary secretions assist in achieving and maintaining a clear airway and help to promote lung expansion and gas exchange. Maintenance of adequate systemic hydration keeps mucociliary clearance normal. Humidification is the process of adding water to gas. Humidification is necessary for patients receiving oxygen therapy at greater than 4 L/min (check agency protocol). It might be necessary to add humidification at lower oxygen concentrations if the environment is dry and arid. Bubbling oxygen through water adds humidity to the oxygen delivered to the upper airways. [Review Skill 41-4, Using Home Oxygen Equipment, with students.] Nebulization adds moisture or medications to inspired air by mixing particles of varying sizes with the air. Coughing is effective for maintaining a patent airway. Directed coughing is a deliberate maneuver that is effective when spontaneous coughing is not adequate. With the cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then the patient opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. With practice the patient inhales more air and is able to progress to the cascade cough. The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough. Diaphragmatic breathing/belly breathing is a technique that encourages deep breathing to increase air to the lower lungs. Chest physiotherapy is a group of therapies used to mobilize pulmonary secretions. These include postural drainage, chest percussion, and vibration. You will want to work collaboratively with respiratory therapists when using these techniques. [Review Box 41-7, Guidelines for Chest Physiotherapy, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation: Acute Care (Cont.)
Chest percussion Postural drainage is a component of pulmonary hygiene; it consists of drainage, positioning, and turning and is sometimes accompanied by chest percussion and vibration. It improves secretion clearance and oxygenation. Positioning includes most lung segments and helps to drain secretions from specific segments of the lungs and bronchi into the trachea. [Review Table 41-6, Positions for Postural Drainage, with students.] Chest percussion involves rhythmically clapping on the chest wall over the area being drained to force secretions into larger airways for expectoration. Position the hand so the fingers and thumb touch and the hands are cupped. The cupping makes the hand conform to the chest wall while trapping a cushion of air to soften the intensity of the clapping. The procedure should produce a hollow sound and should not be painful. Perform chest percussion by vigorously striking the chest wall alternately with cupped hands. Percussion is contraindicated in patients with bleeding disorders, osteoporosis, or fractured ribs. Vibration is a gentle, shaking pressure applied to the chest wall to shake secretions into larger airways. Place a flattened hand or two hands (pressing top and bottom hand into each other to vibrate) firmly on the chest wall over the appropriate segment and tense the muscles of the arm to provide a shaking motion. Have the patient exhale as slowly as possible during the vibration. This technique increases the velocity and turbulence of exhaled air, facilitating secretion removal. Vibration increases the exhalation of trapped air, shakes mucus loose, and induces a cough. [Shown is Figure 41-9: Chest wall percussion, alternating hand clapping against patient’s chest wall.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Airway management:
Have Mr. King deep breathe and cough every 2 hours while awake. Have Mr. King change position frequently if on bed rest. If able, have him ambulate 10 to 15 minutes every 8 hours, and encourage him to sit up in a chair as often as he is able to tolerate. Encourage Mr. King to increase his fluid intake to 2800 mL/24 hours if his cardiac condition does not contraindicate it, and to avoid caffeinated beverages and alcohol; recommend water. [Ask students: What are the rationales for these interventions for Mr. King? Discuss: A major complication of reduced mobility is retention of pulmonary secretions, which predisposes the patient to atelectasis and pneumonia. Ambulation, sitting upright, and frequent position changes are consistent with normal activities, and promote normal lung function and mucociliary clearance. Fluid intake of 2800 mL/24 hours will help liquefy secretions for easier removal. Caffeinated and alcoholic beverages promote diuresis and dehydration. Water is an effective expectorant; it is easily available and cost-effective.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Implementation: Suctioning Techniques
Oropharyngeal and nasopharyngeal Used when the patient can cough effectively but is not able to clear secretions Orotracheal and nasotracheal Used when the patient is unable to manage secretions by coughing and does not have an artificial airway Tracheal Used with an artificial airway Suctioning is necessary when patients are unable to clear respiratory secretions from the airways by coughing or other less invasive procedures. Suctioning techniques include oropharyngeal and nasopharyngeal suctioning, orotracheal and nasotracheal suctioning, and suctioning of an artificial airway (discussed on a later slide). Each type of suctioning requires the use of a round-tipped, flexible catheter with holes on the sides and end of the catheter. When suctioning, you apply negative pressures (not greater than 150 mm Hg) during withdrawal of the catheter, never on insertion. Oropharyngeal and Nasopharyngeal Suctioning Apply suction after a patient has coughed. Once the pulmonary secretions decrease and a patient is less fatigued, he or she is then able to expectorate or swallow the mucus, and suctioning is no longer necessary. Orotracheal and Nasotracheal Suctioning You pass a sterile catheter through the mouth or nose into the trachea. The nose is the preferred route because stimulation of the gag reflex is minimal. The entire procedure from catheter passage to its removal is done quickly, lasting no longer than 10 seconds. Tracheal Suctioning The size of a catheter should be as small as possible but large enough to remove secretions. Recommendation is about half the internal diameter of the endotracheal (ET) tube (AARC, 2010a). Never apply suction pressure while inserting the catheter to avoid traumatizing the lung mucosa. Once you insert a catheter the necessary distance, maintain suction pressure between 120 and 150 mm Hg (AARC, 2010a) as you withdraw. Apply suction intermittently only while withdrawing the catheter. Rotating the catheter enhances removal of secretions that have adhered to the sides of the ET tube. You will learn various suctioning techniques in the nursing skills lab. You will differentiate between when to use sterile and when to use clean techniques. If you suction the patient too much, he or she can be at risk for hypoxemia, hypotension, dysrhythmias, and trauma to the mucosa of the lungs. [Review Skill 41-1, Suctioning, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Tracheal Care Suctioning methods Open Closed
The two current methods of suctioning are the open and closed methods. Open suctioning involves using a new sterile catheter for each suction session (AARC, 2010a). Wear sterile gloves and follow Standard Precautions during the suction procedure. Closed suctioning involves using a reusable sterile suction catheter that is encased in a plastic sheath to protect it between suction sessions. Closed suctioning is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the risk of oxygen desaturation. Although sterile gloves are not used in this procedure, nonsterile gloves are recommended to prevent contact with splashes from body fluids. [Shown is Figure 41-10: Ballard tracheal care, closed suction catheter.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Artificial Airways Oral airway
Prevents obstruction of the trachea by displacement of the tongue into the oropharynx Airway maintenance may require use of artificial airways and suctioning. An artificial airway is used for a patient with a decreased level of consciousness or an airway obstruction and aids in removal of tracheobronchial secretions. The presence of an artificial airway places a patient at high risk for infection and airway injury. Use clean technique for oral airways, but use sterile technique in caring for and maintaining endotracheal and tracheal airways to prevent health care–associated infections (HAIs). Artificial airways need to stay in the correct position to prevent airway damage. [Review Skill 41-2, Care of an Artificial Airway, with students.] The oral airway, the simplest type of artificial airway, prevents obstruction of the trachea by displacement of the tongue into the oropharynx. The oral airway extends from the teeth to the oropharynx, maintaining the tongue in the normal position. Use the correct-size airway. Determine the proper oral airway size by measuring the distance from the corner of the mouth to the angle of the jaw just below the ear. The length is equal to the distance from the flange of the airway to the tip. If the airway is too small, the tongue does not stay in the anterior portion of the mouth; if the airway is too large, it forces the tongue toward the epiglottis and obstructs the airway. Insert the airway by turning the curve of the airway toward the cheek and placing it over the tongue. When the airway is in the oropharynx, turn it so the opening points downward. Correctly placed, the airway moves the tongue forward away from the oropharynx, and the flange (e.g., the flat portion of the airway) rests against the patient’s teeth. Incorrect insertion merely forces the tongue back into the oropharynx. [Shown is Figure 41-11: Artificial oral airways.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Artificial Airways (Cont.)
Endotracheal and tracheal airways Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions Tracheostomy Long-term assistance, surgical incision made into trachea A physician or specially trained clinician inserts the ET tube. The tube is passed through the patient’s mouth, past the pharynx, and into the trachea. It is generally removed within 14 days; however, it is sometimes used for a longer period of time if the patient is still showing progress toward weaning from invasive mechanical ventilation and extubation. If a patient requires long-term assistance from an artificial airway, a tracheostomy is considered. A surgical incision is made into the trachea, and a short artificial airway (a tracheostomy tube) is inserted. Most tracheostomies have a small plastic inner tube that fits inside a larger one (the inner cannula). The most common complication of a tracheostomy tube is partial or total airway obstruction caused by buildup of respiratory secretions. If this occurs, the inner tube can be removed and cleaned or replaced with a temporary spare inner tube that should be kept at the patient’s bedside. Keep tracheal dilators at the bedside to have available for emergency tube replacement or reinsertion. Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. Tracheostomy suctioning should be done as often as necessary to clear secretions. [Shown is Figure 41-12: Endotracheal tube inserted into trachea. Cuff inflated to maintain position. (Copyright © 2015 Medtronic. All rights reserved. Used with the permission of Medtronic.)] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Maintenance and Promotion of Lung Expansion
Ambulation Positioning Reduces pulmonary stasis, maintains ventilation and oxygenation Incentive spirometry Encourages voluntary deep breathing Immobility is a major factor in developing atelectasis, ventilator-associated pneumonia (VAP), and functional limitations. Progressive mobilization from dangling the legs to standing and then walking is safe for intubated patients. Frequent changes of position are simple and cost-effective methods for reducing stasis of pulmonary secretions and decreased chest wall expansion, both of which increase the risk of pneumonia. Research shows that turning critically ill patients every 2 hours is not often enough to prevent pneumonia. The 45-degree semi-Fowler’s is the most effective position for promoting lung expansion and reducing pressure from the abdomen on the diaphragm. In the presence of pulmonary abscess or hemorrhage, position the patient with the affected lung down to prevent drainage toward the healthy lung. For bilateral lung disease, the best position depends on the severity of the disease. Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It promotes deep breathing and prevents or treats atelectasis in the postoperative patient. There is solid evidence to support the use of lung expansion with incentive spirometry in preventing postoperative pulmonary complications following surgery. Incentive spirometry encourages patients to use visual feedback to maximally inflate their lungs and sustain that inflation. [Shown is Figure 41-13: Volume-oriented incentive spirometer.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Maintenance and Promotion of Lung Expansion (Cont.)
Invasive mechanical ventilation Life-saving technique used with artificial airways (ET or tracheostomy) Physiological indications Clinical indications Physiological indications for invasive mechanical ventilation include supporting cardiopulmonary gas exchange (alveolar ventilation and arterial oxygenation) increasing lung volume, and reducing the work of breathing. Clinical indications for invasive mechanical ventilation include reversing hypoxia and acute respiratory acidosis, relieving respiratory distress, preventing or reversing atelectasis and respiratory muscle fatigue, allowing for sedation and/or other neuromuscular blockade, decreasing oxygen consumption, reducing intracranial pressure and stabilizing the chest wall. It can be used to either fully or partially replace spontaneous breathing depending on the need of the patient. Ventilatory support is achieved using a variety of modes; the choice is dependent upon the patient’s situation and goals of treatment. The most commonly used modes: assist-control (AC), synchronized intermittent mandatory ventilation (SIMV) and pressure support ventilation (PSV). Assist Control delivers a set tidal volume (VT) with each breath, regardless if the breath was triggered by the patient or the ventilator. Synchronized intermittent mandatory ventilation like AC, delivers a minimum number of fully assisted breaths per minute that are synchronized with the patient’s respiratory effort. Any breaths taken between volume-cycled breaths are not assisted; the volume of these breaths are determined by the patient’s strength, effort, and lung mechanics. Pressure Support mode is often combined with SIMV mode, inspiratory pressure is added to spontaneous breaths to overcome the resistance of the endotracheal tube or to help increase the volume of the patient’s spontaneous breaths. Physiological complications associated with invasive mechanical ventilation include: volutrauma, cardiovascular compromise, gastrointestinal disturbances, and ventilator-associate pneumonia. Volutrauma occurs as a result of alveolar overdistention secondary to the mechanical ventilation. Ventilator-associated pneumonia (VAP) is a significant potential complication because the artificial airway tube bypasses many of the lung’s normal defense mechanisms. [Review Box 41-8, Evidence-Based Practice: Adherence to a Ventilator Care Bundle on Reducing Ventilator-Associated Pneumonia, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Noninvasive ventilation Purpose is to maintain a positive airway pressure and improve alveolar ventilation Continuous positive airway pressure (CPAP) Bilevel positive airway pressure (BiPAP) Noninvasive positive-pressure ventilation (NPPV) is used to prevent using invasive artificial airways (ET tube or tracheostomy) in patients with acute respiratory failure, cardiogenic pulmonary edema, or exacerbation of COPD. It has also been used following extubation of an ET tube. Continuous positive airway pressure (CPAP) treats patients with obstructive sleep apnea, patients with heart failure, and preterm infants with underdeveloped lungs. Equipment includes a mask that fits over the nose or both nose and mouth and a CPAP machine that delivers air to the mask The smallest mask with the proper fit is the most effective. Because straps hold the mask in place, it is important to assess for excess pressure on the patient’s face or nose that could cause skin breakdown or necrosis. The mask should have enough slack to allow one to two fingers between the straps and the face. The most common mode of support is bilevel positive airway pressure (BiPAP) that provides both inspiratory positive airway pressure (IPAP) and expiratory airway pressure (EPAP), also known as positive end-expiratory pressure (PEEP). The difference between these two pressures indicates the amount of pressure support a patient needs. During inhalation the positive pressure increases the patient’s tidal volume and alveolar ventilation. The pressure support decreases when the patient exhales, allowing for easier exhalation. Complications of noninvasive ventilation include facial and nasal injury and skin breakdown, dry mucous membranes and thick secretions, and aspiration of gastric contents if vomiting occurs during ventilation. Complications avoided by noninvasive ventilation are VAP, sinusitis, and effects of large-dose sedative agents. Use of noninvasive ventilation results in shorter intensive care unit (ICU) and hospital stays (Soo Hoo, 2014). Perform good oral hygiene every few hours while a patient is on BiPAP to relieve dryness. [Shown is Figure 41-14: CPAP mask.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Two days later, when John auscultates Mr. King’s lungs, he finds that the lung sounds are clear. [Ask students: What three other steps could John take as nursing actions of evaluation? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 2. A patient with a tracheostomy has thick tenacious secretions. To maintain the airway, the most appropriate action for the nurse includes: A. tracheal suctioning. B. oropharyngeal suctioning. C. nasotracheal suctioning. D. orotracheal suctioning. Answer: A Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) John asks Mr. King to keep track of his fluid intake. John asks Mr. King to ambulate for 10 minutes every 4 hours. John asks Mr. King to keep track of deep breathing every 2 hours while awake. Notice how John has empowered Mr. King in resolving his health crisis. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Chest tube Pneumothorax Hemothorax Special considerations A catheter inserted through the thorax to remove air and fluids from the pleural space, to prevent air or fluid from reentering the pleural space, or to reestablish normal intrapleural and intrapulmonic pressures. Chest tubes are common after chest surgery and chest trauma and are used for treatment of pneumothorax or hemothorax to promote lung reexpansion. [Review Skill 41-3, Care of Patients with Chest Tubes, with students.] A pneumothorax is a collection of air in the pleural space. The loss of negative intrapleural pressure causes the lung to collapse. There are a variety of causes for a pneumothorax. A secondary pneumothorax can occur as a result of chest trauma. Spontaneous (primary) pneumothorax is a genetic condition that occurs unexpectedly in healthy individuals who develop blisterlike formations (blebs) on the visceral pleura, usually on the apex of the lungs. The blebs can rupture during sleep or exercise. A hemothorax is an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleura, usually as a result of trauma. It produces a counter pressure and prevents the lung from full expansion. A rupture of small blood vessels from inflammatory processes such as pneumonia or TB can cause a hemothorax. In addition to pain and dyspnea, signs and symptoms of shock develop if blood loss is severe. A variety of chest tubes are available to drain air or excess fluid from the pleural space to relieve respiratory distress. A small-bore chest tube (12 to 20 Fr) is used to remove a small amount of air, and a larger-bore chest tube is used to remove large amounts of fluid or blood and large amounts of air. After a chest tube is inserted, it is attached to a drainage system. A traditional chest drainage unit (CDU) has three chambers for collection, water seal, and suction control. This unit can drain a large amount of both fluid and air. The simplest closed drainage system is the single chamber unit. The chamber serves as a fluid collector and a water seal. The use of two chambers permits any fluid to flow into the collection chamber as air flows into the water-seal chamber. Fluctuations in the water-seal tube are still anticipated. Two chambers allow for more accurate measurement of chest drainage and are used when larger amounts of drainage are expected. When a volume of air or fluid needs to be evacuated with controlled suction, all three chambers are used. Mark the suction control with centimeter readings to adjust the amount of suction. Usually 15 to 20 cm of water is used for adults (Carroll, 2015). This means that the chamber is filled with sterile water to the 15- or 20-cm water level. Keep a chest tube system closed and below the chest. The tube should be secured to the chest wall. Watch for slow, steady bubbling in the suction-control chamber and keep it filled with sterile water at the prescribed level. Make sure that the water-seal chamber is filled to the manufacturer-specified level and watch for fluctuation (tidaling) of the fluid level to ensure that the chest tube and system are working. A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately. Report any unexpected cloudy or bloody drainage. Do not let the tubing kink or loop, and ideally it should lie horizontally across the bed or chair before dropping vertically into the drainage device. Make sure that he or she is frequently repositioned and ambulated if not contraindicated. Routinely assess respiratory rate, breath sounds, SpO2 levels, and the insertion site for subcutaneous emphysema. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Chest tubes are not routinely stripped or milked to move clots or increase chest tube drainage. Handle the chest drainage unit carefully and maintain the drainage device below the patient’s chest. Removal of chest tubes requires patient preparation. The most frequent sensations reported by patients during chest tube removal include burning, pain, and a pulling sensation. [Shown is Figure 41-15: Chest tube placement.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Mr. King has kept track of his fluid intake, and he has averaged 2800 mL/24 hours. He is coughing thin secretions. Mr. King ambulates once every 8 hours. Mr. King’s diary documented deep breathing every 2 hours while awake 85% of the time. [Ask students: Which outcomes have been met? How would you document them? Discuss: Good daily fluid intake. Secretions are thin, white, and watery. Outcome met. Mr. King ambulates for about 5 minutes. Outcome is not completely achieved. Secretions are thin, the lung is clear, and no evidence of infection is noted. Outcome met.] [Ask students: What teaching strategies could John use with Mr. King? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Maintenance and Promotion of Oxygenation
Oxygen therapy To prevent or relieve hypoxia Safety precautions Supply of oxygen Tanks or wall-piped system Methods of oxygen delivery Nasal cannula Oxygen mask Promotion of lung expansion, mobilization of secretions, and maintenance of a patent airway assist patients in meeting their oxygenation needs. The goal of oxygen therapy is to prevent or relieve hypoxia by delivering oxygen at concentrations greater than ambient air (21%). Oxygen has dangerous side effects such as oxygen toxicity. The dosage or concentration of oxygen is monitored continuously. Routinely check the health care provider’s orders to verify that the patient is receiving the prescribed oxygen concentration. The six rights of medication administration also pertain to oxygen administration. Supplemental oxygen therapy offers many benefits to patients with chronic cardiopulmonary diseases. This therapy reduces mortality, improved self-reported sleep quality and general comfort, increased exercise tolerance, and reduced polycythemia and pulmonary hypertension. [Review Box 41-9, Procedural Guidelines: Applying a Nasal Cannula or Oxygen Mask, with students.] Oxygen is a highly combustible gas. Although it does not burn spontaneously or cause an explosion, it can easily cause a fire in a patient’s room if it contacts a spark from an open flame or electrical equipment. Promote oxygen safety by the following measures: Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider’s order. Distribution must be in accordance with federal, state, and local regulations (AARC, 2007). Place an “Oxygen in Use” sign on the patient’s door and in the patient’s room. If using oxygen at home, place a sign on the door of the house. No smoking should be allowed on the premises. Keep oxygen-delivery systems 10 feet from any open flames. Determine that all electrical equipment in the room is functioning correctly and properly grounded (see Chapter 27). An electrical spark in the presence of oxygen can result in a serious fire. When using oxygen cylinders, secure them so they do not fall over. Store them upright and either chained or secured in appropriate holders. Check the oxygen level of portable tanks before transporting a patient to ensure that there is enough oxygen in the tank. Ensure that patients have adequate oxygen tubing to safely move around their home environment. Tubing up to 98 feet (30 m) will deliver the prescribed oxygen flow rate. Oxygen is supplied to a patient’s bedside either by oxygen tanks or through a permanent wall-piped system. In the hospital or home, oxygen tanks are delivered with the regulator in place. The nasal cannula and oxygen masks are the most common devices to deliver oxygen to patients. A nasal cannula is a simple, comfortable device used for precise oxygen delivery. The two nasal prongs are slightly curved and inserted in a patient’s nostrils. An oxygen mask is a plastic device that fits snugly over the mouth and nose and is secured in place with a strap. It delivers oxygen as the patient breathes through either the mouth or nose by way of a plastic tubing at the base of the mask that is attached to an oxygen source. [Review Table 41-7, Oxygen Delivery Systems, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Oxygen Masks Simple face mask Plastic face mask with reservoir bag
Used for short-term therapy Plastic face mask with reservoir bag Used for higher concentrations of oxygen Venturi mask The simple face mask (Fig ) is used for short-term oxygen therapy. It fits loosely and delivers oxygen concentrations from 6 to 12 L/min (35% to 50% oxygen). The mask is contraindicated for patients with carbon dioxide retention because retention can be worsened. Flow rates should be 5 L or more to avoid rebreathing exhaled carbon dioxide retained in the mask. Be alert to skin breakdown under the mask with long-term use. A plastic face mask with a reservoir bag is capable of delivering higher concentrations of oxygen. A partial rebreather or nonrebreather mask is a simple mask with a reservoir bag that should be at least one-third to one-half full on inspiration and delivers a flow rate of 10 to 15 L/minute (60-90% oxygen). Frequently inspect the reservoir bag to make sure that it is inflated. If it is deflated, the patient is breathing large amounts of exhaled carbon dioxide. High-flow oxygen systems should be humidified. The Venturi mask delivers higher oxygen concentrations of 24% to 60% and usually requires oxygen flow rates of 4 to 12 L/min, depending on the flow-control meter selected. [Shown is Figure 41-16: Simple face mask.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Home Oxygen Therapy Indications
Arterial partial pressure (PaO2) of 55 mm Hg or less –or– Arterial oxygen saturation (SaO2) of 88% or less on room air at rest, on exertion, or with exercise Administered via nasal cannula or face mask T tube or tracheostomy collar used if patient has a permanent tracheostomy Beneficial effects for patients with chronic cardiopulmonary disease Home oxygen therapy improves patients’ exercise tolerance and fatigue levels and in some situations assists in the management of dyspnea. [Review Skill 41-4, Using Home Oxygen Equipment, with students.] Three types of oxygen delivery systems are used: compressed gas cylinders, liquid oxygen, and oxygen concentrators. Before placing a certain delivery system in a home, assess the advantages and disadvantages of each type, along with the patient’s needs and community resources. [Review Table 41-8, Home Oxygen Systems, with students.] In the home, the major consideration is the oxygen delivery source. Patients and their family caregivers need extensive teaching to be able to manage oxygen therapy efficiently and safely. Teach the patient and family about home oxygen delivery (i.e., oxygen safety, regulation of the amount of oxygen, and how to use the prescribed home oxygen delivery system) to ensure their ability to maintain the oxygen delivery system. The home health nurse coordinates the efforts of the patient and family, home respiratory therapist, and home oxygen equipment vendor. The social worker usually assists initially with arranging for the home care nurse and oxygen vendor. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Quick Quiz! 3. When evaluating a postthoracotomy patient with a chest tube, the best method to properly maintain the chest tube would be to: A. strip the chest tube every hour to maintain drainage. B. place the device below the patient’s chest. C. double clamp the tube except during assessment. D. remove the tubing from the drainage device to check for proper suctioning. Answer: B Copyright © 2017, Elsevier Inc. All Rights Reserved.

Restoration of Cardiopulmonary Functioning
Cardiopulmonary resuscitation (CPR) 1. Circulation 2. Airway 3. Breathing Defibrillation (automatic external defibrillator [AED]) If a patient’s hypoxia is severe and prolonged, cardiac arrest results. A cardiac arrest is a sudden cessation of cardiac output and circulation. When this occurs, oxygen is not delivered to tissues, carbon dioxide is not transported from tissues, tissue metabolism becomes anaerobic, and metabolic and respiratory acidosis occurs. Permanent heart, brain, and other tissue damage occur within 4 to 6 minutes. The previous ABC (establish an Airway, initiate Breathing, and maintain Circulation) of cardiopulmonary resuscitation (CPR) is changed to CAB (Chest compression, Airway, Breathing) for adults and pediatric patients (excluding newborns). In adults (the majority of cardiac arrests) the critical initial elements found to be essential for survival were chest compressions and early defibrillation. Ventilation is done after the first cycle of 30 chest compressions. In addition, the American Heart Association (AHA) (2014) has set a goal for hospitals to deliver the first electrical shock to patients in ventricular fibrillation in less than 2 minutes. Defibrillation by automatic external defibrillator (AED) is needed to stop an abnormal heart rhythm, and AEDs are now available in public places such as schools, airports, and workplaces. [Review Box 41-10, Automated External Defibrillator, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) Both Mr. and Mrs. King are interested in preventing future hospitalizations and in learning what they can do to maintain their health. John reviewed teaching strategies with them, with the goal of Mr. and Mrs. King verbalizing the steps they need to take to improve their health and reduce the risk for future hospitalizations. John established evaluation strategies to measure the success of patient teaching. [Ask students: What do you suggest for teaching strategies? Discuss: Establish rapport with the Kings, and maintain eye contact during the teaching session. Use words the Kings will understand; avoid medical jargon when possible. Set goals in partnership with the Kings, so that they are realistic, meaningful, and achievable. With each significant point, ask the Kings to repeat back the information you have given them. Provide an overview of chronic obstructive pulmonary disease and pneumonia, signs and symptoms of exacerbation, medications, and follow-up appointments. Encourage Mr. King to balance activity and rest. Report any changes in activity tolerance to his primary health care provider. Provide a written copy of the material taught for reinforcement and reference. Allow time for questions, and answer honestly. Summarize the material.] [Ask students: What do you suggest for evaluation strategies? Discuss: Ask Mr. and Mrs. King to verbalize what they have learned. Ask Mr. King to describe in simple terms what community-acquired pneumonia and chronic obstructive pulmonary disease are, and to list signs and symptoms of exacerbation. Ask the Kings to verbalize understanding of each medication Mr. King will be taking. Ask Mr. and Mrs. King if they have any questions or need any additional information.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Restorative and Continuing Care
Cardiopulmonary rehabilitation Controlled physical exercise; nutrition counseling; relaxation and stress management; medications; oxygen; compliance; systemic hydration Respiratory muscle training Breathing exercises Pursed-lip breathing Diaphragmatic breathing Cardiopulmonary rehabilitation helps patients achieve and maintain an optimal level of health through controlled physical exercise, nutrition counseling, relaxation and stress-management techniques, and prescribed medications and oxygen. As physical reconditioning occurs, a patient’s complaints of dyspnea, chest pain, fatigue, and activity intolerance decrease. In addition, the patient’s anxiety, depression, or somatic concerns often decrease. The patient and the rehabilitation team define the goals of rehabilitation. Respiratory muscle training improves muscle strength and endurance, resulting in improved activity tolerance. Respiratory muscle training prevents respiratory failure in patients with COPD. One method for respiratory muscle training is the incentive spirometer resistive breathing device (ISRBD). Patients achieve resistive breathing by placing a resistive breathing device into a volume-dependent incentive spirometer. Patients achieve muscle training when they use the ISRBD on a scheduled routine. Breathing exercises include techniques to improve ventilation and oxygenation. The three basic techniques are deep-breathing and coughing exercises, pursed-lip breathing, and diaphragmatic breathing. Deep-breathing and coughing exercises, previously discussed, are routine interventions used by postoperative patients. Pursed-lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, instruct the patient to take a deep breath and exhale slowly through pursed lips as if blowing through a straw. Have him or her blow through a straw into a glass of water to learn the technique. Diaphragmatic breathing is useful for patients with pulmonary disease, postoperative patients, and women in labor to promote relaxation and provide pain control. The exercise improves efficiency of breathing by decreasing air trapping and reducing the WOB. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) John cares for Mr. King throughout his hospital stay. Mr. King is afebrile, his white blood cells are within normal limits, and his sputum cultures are negative on the day of discharge. He does not require supplemental oxygen. He is able to describe ways to prevent respiratory infections because they aggravate airways and precipitate an episode of acute respiratory failure. Because he now practices pursed-lip breathing, his breathing is more controlled, relieving his subsequent anxiety. [Ask students: What other measures could John use to verify Mr. King’s improvement? Discuss.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Evaluation Through the patient’s eyes Patient outcomes
Focus on evaluating how the disease is affecting day-to-day activities and how the patient believes he or she is responding to treatment Patient outcomes Compare the patient’s actual progress to the goals and expected outcomes of the nursing care plan to determine his or her health status Evaluate nursing interventions and therapies by comparing the patient’s progress with the goals and expected outcomes of the nursing care plan. Patient expectations evaluate the care from the patient’s perspective. Patients who have chronic lung problems often must be motivated to participate in necessary therapies. Evaluate the patient’s motivation and emotional readiness to adhere to treatments provided. Be aware of the need to change a treatment plan to be culturally sensitive to improve adherence to it. Determine if the patient or family/caregiver feels more in control of the health situation after you have provided instruction. Consider the use of survey tools such as COPD Self Efficacy Scale, Chronic Respiratory Disease Questionnaire, and Pulmonary-Specific Quality of Life for COPD Scale (AARC, 2010b) to evaluate a patient’s perception of his or her quality of life. If the nursing measures used are not successful in improving oxygenation, modify the care plan and reevaluate. Continuous evaluation helps to determine whether new or revised therapies are required and if new nursing diagnoses have developed and require a new plan of care. Do not hesitate to notify the health care provider about a patient’s deteriorating oxygenation status. Prompt notification helps avoid an emergency situation or even the need for CPR. Ask the patient about his or her degree of breathlessness. Observe respiratory rate before, during, and after any activity or procedure. Ask the patient if the distance ambulated without fatigue has increased. Ask the patient to rate breathlessness on a scale of 0 to 10, with 0 being no shortness of breath and 10 being severe shortness of breath. Ask the patient which interventions help reduce dyspnea. Ask the patient about frequency of cough and sputum production and assess any sputum produced. Auscultate lung sounds for improvement in adventitious sounds. Evaluate pulse oximetry changes to decreases in oxygen delivery. Monitor arterial blood gas levels, pulmonary function tests, chest x-ray films, ECG tracings, and physical assessment data to provide objective measurement of the success of therapies and treatments. [Review Figure 41-17, Critical thinking model for oxygenation evaluation, with students.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Case Study (Cont.) While John is observing Mr. King preparing for discharge, it is evident that Mr. King is using the various breathing techniques that they have worked on together. Mr. King is able to go home with improved activities of daily living. His wife appears even less anxious and states that she feels as though for the first time they have taken a step (even though small) toward improving the quality of their lives. Measuring improvement in terms of activities of daily living (ADLs) and interviewing family members are other steps John could take. [Ask students: What would you write in your documentation note if you were John? Discuss: Suggestions include: Mr. King discharged to home. Able to state the purpose of breathing exercises and each medication, able to list causes and symptoms of respiratory tract infection. Has an appointment in 1 week with a community-based rehabilitation program. Scheduled to see his health care provider in 2 weeks. Prescriptions explained and given to patient. Accompanied to the exit. Left with wife and son.] Copyright © 2017, Elsevier Inc. All Rights Reserved.

Safety Guidelines Patients with sudden changes in their vital signs, level of consciousness, or behavior are possibly experiencing profound hypoxia. Perform tracheal suctioning before pharyngeal suctioning whenever possible. Use caution when suctioning patients with a head injury. The routine use of normal saline instillation into the airway before ET and tracheostomy suctioning is not recommended. Check your institutional policy before stripping or milking chest tubes. The most serious tracheostomy complication is airway obstruction, which can result in cardiac arrest. Patients with COPD who are breathing spontaneously should never receive high levels of oxygen therapy. Note that the most serious tracheostomy complication is airway obstruction, which can result in cardiac arrest. Patients with COPD who are breathing spontaneously should never receive high levels of oxygen therapy because this may result in a decreased stimulus to breathe. Do not administer oxygen at more than 2 L/min unless a health care provider’s order is obtained. Copyright © 2017, Elsevier Inc. All Rights Reserved.

Chapter 41 Oxygenation Copyright © 2017, Elsevier Inc. All Rights Reserved.

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