Systolic—pressure in arteries with contraction of ventricles “top” number—should be BP drops and heart rate increases

oxygenation Flashcards by Kaitlin Buckle

overview of oxygenation

Respiration
- Upper respiratory tract
- Lungs
  - Ventilation
  - Diffusion of Oxygen
Circulation
- Heart
  - CO=HRxSV (increase one will increase cardiac output)
- Blood vessels
- Blood
  - Transports O2, nutrients, wastes
  - Regulation of body temperature, pH
  - Prevention of infection (white blood cells) & blood loss (platelets)

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factors that affect oxygenation - age

Infant
a. Premature infants incapable of making surfactant
b. Lungs fluid filled in utero, infant takes first breath
c. Lungs fully expand in 2 weeks
d. Airways small in diameter, likely to collapse
Child
a. Diaphragmatic breathing until age 5
b. Limited ability to increase stroke volume
Older adult
a. Lungs
i. Increased chest wall stiffness
ii. Decreased lung volume
iii. V/P mismatch
iv. increased risk of aspiration due to GE reflux
b. Circulation
i. Decrease in maximal HR, SV, RBC production
ii. Increased systolic BP

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factors that affect oxygenation - environment

Altitude, heat, cold can affect respiration & circulation
Air pollution
Carbon monoxide

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factors that affect oxygenation - lifestyle

Diet—obesity increases work of breathing, can lead to increased BP
Cigarette smoking, substance abuse
Exercise vs sedentary lifestyle

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factors that affect oxygenation - stress

Hyperventilation
Epinephrine, bronchiole dilatation, increased blood flow

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factors that affect oxygenation - health status

Conditions affecting chest wall movement—pregnancy, obesity
MS abnormalities—scoliosis, kyphosis
Trauma—upper abdominal incision, chest wall trauma
Disease of musculoskeletal system—muscular dystrophy
Disease of nervous system—SC injury, Myasthenia gravis
Lung disease
Heat disease
Anemia
Hypertension
Medications—sedatives, narcotics, stimulants, alcohol

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nursing history – subjective: symptoms of hypoxia

Restlessness & Apprehension –> Altered
Level of Consciousness
- do you know where you are? do you know your name? do you know the situation?
hypoxia = not getting adequate amt of oxygen

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symptoms of oxygenation problems

Cough
- How often? When? What precipitates?
- Productive or nonproductive?
- Color, consistency?
Dyspnea
- Orthopnea = difficulty breathing, lying flat

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nursing history – subjective

Symptoms
- Fatigue
- Fluid Retention: fluid buildup in their extremities
  - Dependent areas
Pain
- Intermittent (comes and goes) claudication–Aching in Calves
- Chest pain

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more nursing history subjective

Personal Habits
- Smoking—pack year history
  - # of packs/day X # of years smoking
Allergy
Exposure to pollutants,
respiratory disease
- home, workplace
Exercise
Diet
Current drug therapy
History of chronic diseases

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physical exam – objective

Skin
- Cyanosis (seen on lips, toes, extremities. blue on fingertips)
- Edema (pooling of fluid in extremities)
Nailbeds
- Capillary filling time (<3 seconds)
- Clubbing (fingernails are rounded)
Neck veins (bulging is bad)
Chest wall movement

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Physical exam – breathing pattern

Check rate rhythm and depth
Normal rate for adult 12-20, average 16

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physical exam – pulses

Check rate and rhythm
Normal rate for adult 60-100, average 80

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physical exam – lungs

Normal—Clear to auscultation (CTA)
Abnormal
- Crackles: fluid in the lungs
- Rhonchi
- Wheezes
if you don’t hear a clear blowing sound, then it’s abnormal

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physical exam – BP

Systolic—pressure in arteries with contraction
of ventricles
- “top” number—should be < 120
Diastolic—pressure in arteries during resting
phase of heart
- “bottom” number—should be < 80
Pulse pressure
- Difference between systolic and diastolic
Orthostatic hypotension: shift position and BP drops. lying to sitting –> BP drops and heart rate increases

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diagnostics

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Hemoglobin & hematocrit (H&H)
- Hemoglobin (carries oxygen throughout the body)
  - Men 14-18
  - Women 12-16
Hematocrit (solid part of the blood)
- Men 40-45
- Women 38-43
Arterial Blood Gases: measure oxygen status in the pts blood
Electrocardiogram (EKG)
- Should be Normal sinus
  rhythm (NSR)
Chest X-ray (CXR)
- Should be clear

pulse oximetry

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Normal >95%
False elevated with CO
exposure
False low oxygen
saturation with poor
circulation
- if fingers are cold, they can be falsely low

nursing diagnostic category: ineffective airway clearance

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Difficulty keeping airway passages clear of secretions
or obstructions (Gulanick & Meyer p. 11-14)
may have secretions in chest but doesn’t have a cough to cough it up
Ineffective or absent cough***
Inability to remove airway secretions***
Abnormal breath sounds: if you have secretions, lungs will sound crackly
Abnormal respiratory rate, rhythm, depth

nursing diagnostic category: activity intolerance

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Inability to perform physical activity without experiencing symptoms such as shortness of breath or fatigue. (Gulanick & Meyer p.8)
bc I have an issue w/ my lungs it makes it hard for me to do activities
Defining characteristics (supportive data) are about altered physiologic response to activity
VS should return to normal within 3 minutes of activity

nursing diagnostic category: impaired breathing

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Difficulty passing air
through airway passages during inhalation and/or exhalation (Gulanick & Meyer p. 25)
pt is not able to breath properly
- pt with asthma
- pt who is hyperventilating
air can’t flow freely back and forth
not enough oxygenation

nursing diagnostic category: impaired gas exchange

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A change in the ability to adequately exchange oxygen and carbon dioxide in the lungs which may alter the body’s acid-base balance (Gulanick & Meyer p. 58)
Not enough O2 or too much CO2 in blood
Blood gases or pulse oximetry

interventions/implementation TCDB q2 hours

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turn, cough, deep breathing

interventions/implementation deep breathing

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Incentive Spirometry: helps open up alveoli and then you’ll be able to cough and do some deep breathing than can help excel those situations
- Treats atelectasis
- Usually done 5-6x q 1-2h

interventions/implementation chest physiotherapy

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requires MD order in many situations

interventions/implementation hydration

- loosen secretions to get it out - for adult, at least 1500-2500 ml/day

interventions/implementation humidified O2

- caution as O2 supports combustion

interventions/implementation early mobilization

* Gradually increase activity * Involve IP team (OT: ADL; PT: ambulation, muscle strengthening) * Monitor VS, dizziness, dyspnea after activity

interventions/implementation suctioning -- only if necessary

not good for lungs when done too frequently

interventions/implementation administer meds

* Physician order * Nebulized medication

interventions/implementation NIC

* Cough enhancement * Respiratory monitoring * Oxygen therapy

Which of the following areas of the body provides the best site to determine cyanosis in a person with dark skin?

A. The earlobes B. The beds of the fingernails C. Mucous membranes of the mouth (CORRECT) D. Whites of the eyes

Which of the following observations by the nurse may indicate an alteration in the oxygenation status of the client?

A. Neck veins are flat B. Chest expansion is symmetrical C. Needing to sit up to breathe (CORRECT)(orthapnea) D. Even unlabored respirations

Which of the following is the most correctly stated outcome for the Nursing DX: Ineffective airway clearance r/t thick mucus secretions?

A. Airway clearance will be effective --> goal B. Will turn, cough, deep breathe q 2 hours --> intervention C. Intake of 2500 ml of fluid per day --> intervention D. Lungs CTA (how will ik. when i listen to them lungs will be clear. CORRECT)

Which of the following are appropriate interventions to increase airway clearance? Select all that apply.

A. Perform Chest PT as ordered (CORRECT) B. Teach patient controlled coughing (CORRECT) C. Encourage the client to stay in bed until her strength returns. (NO. ambulate) D. Increase fluid intake to 2500 ml/ day (CORRECT) E. Encourage patient to use incentive spirometer once a day (maybe?)

All of the following are oxygen delivery methods. Place in order from that which can deliver the highest oxygen concentration to the method that provides the lowest O2 concentration

A. Face mask. 3 B. Nasal canula. 4 lowest C. Non-rebreather mask. 1 highest D. Partial rebreather mask. 2

The patient has a pulse oximetry reading of 88% on room air. Based on this information alone you would hypothesize that the most likely nursing diagnosis for this patient is

A. Activity intolerance B. Impaired gas exchange (CORRECT) C. Ineffective airway clearance D. Ineffective breathing patterns

oxygenation Flashcards

(36 cards)