1
Q
Oxygenation is a part of which Gordon’s functional pattern?
A
Activity and Exercise
2
Q
In Gordon’s functional pattern ACTIVITY-EXERCISE what is assessed?
A
- mobility routine
- exercise routine
- leisure activities
- cardiovascular status= cardiac/respiration/oxygenation
3
Q
What 2 systems are interdependently related to oxygenation?
A
respiratory and cardiovascular
4
Q
What is affected when there is impaired function in the respiratory and cardiovascular systems?
A
- amount of oxygen related to the changes in pulse and respiration (P&R)
- impairment causes changes in ability to breathe, transport gas, & elimination of waste
- can impact ADL’s
5
Q
What factors affect oxygenation?
A
- lifestyle
- physiology
- environment
6
Q
What factors of lifestyle will affect oxygenation?
A
NUTRITION EXERCISE SMOKING SUBSTANCE USE STRESS MEDICATION OCCUPATION
7
Q
What are some examples of how nutrition can affect oxygenation?
A
- decreased iron, b12, results in low Hb
- obesity can prevent full chest expansion
- obesity can affect circulation
- malnutrition causes muscle wasting
- high cholesterol can cause clogs, reducing oxygenation
8
Q
What are some examples of the affects of smoking on oxygenation?
A
- thick black mucous covers alveoli resulting in less oxygenation
- vessels constriction
- stroke
- lung cancer
- COPD
9
Q
What are some examples of the affects of stress on oxygenation?
A
- effects breathing and binging
10
Q
What are some examples of the affects of substance use on oxygenation?
A
- increase or decrease in vessel size
11
Q
What are some examples of the affects of medications on oxygenation?
A
- some side effects can suppress respiration
12
Q
What are some examples of the affects of occupation on oxygenation?
A
- fumes, dust, chemicals, weather, repetition, strain & stress
13
Q
What PHYSIOLOGICAL FACTORS affect oxygenation?
A
- any reduction in oxygen carrying capacity (sickle cell, low Hb, poor nutrition)
- pain- altered rhythm- shallow breathing
- hypovolemia (low blood volume)
- oxygen concentration in blood (respiratory problems chronic diseases
- fever increases Basal metabolic rate and oxygen demand
- positioning
14
Q
What ENVIRONMENTAL FACTORS affect oxygenation?
A
- air pollution
- increased altitude
- heat (increases oxygen demand)
- cold (decreases oxygen demand)
- environmental hazards
15
Q
What do nurses ASSESS in regards to OXYGENATION?
A
- CHEST WALL MOVEMENT during inspiration and expiration
- RESPIRATORY RATE (normal adult 12-20 breathes permin)
- RESPIRATORY DEPTH (deep gets more oxygen and shallow gets less)
- RESPIRATORY RHYTHM (regularity)
16
Q
Define trachypnea.
A
increased respiration
17
Q
Define apnea.
A
abscense of breathing
18
Q
Define hyperventilation.
A
breathing too fast
19
Q
Define hypoventilation.
A
breathing too slow
20
Q
Define hypoxia.
A
- inadequate tissue oxygenation FROM.. - deficiency or inability to use - impaired ventilation/cardiac system - decreased blood flow to cells (shock) - medications that depress respiratory centre
21
Q
What are some signs of inadequate oxygenation?
A
- confusion, irritability (may be first sign in older adults)
- apprehension and restlessness, fatigue and agitation, inability to concentrate, decline in level of consciousness, dizziness
- increased pulse rate, BP, increase rate and depth of breathing
22
Q
Define orthopnea.
A
difficulty breathing when lying down
23
Q
Define wheezing.
A
high pitch sound during inspiration and expiration due to restricted air way
24
Q
Define dyspnea.
A
shortness of breathe
25
Define cyanosis.
bluish skin due to less oxygenation
26
Define central cyanosis.
bluish on the lips (central portion of body)
27
Define peripheral cyanosis.
bluish on the peripheral body (test with cap refill test)
28
Define diaphoresis.
perfuse sweating and poor oxygen levels
29
Define pallor.
pale colour of the skin
30
What are characteristics you need to note with a cough?
TIME OF DAY IT OCCURS
- may COUGH EARLY in morning to clear sinuses
- chronic bronchitis, asthma, emphysema, etc COUGH ALL DAY
- is the cough PRODUCTIVE? or NOT?
31
Define sputum.
mucous that is coughed up from the lower air way
32
What characteristics of sputum should you note?
- COLOUR (clear, white, yellow, green, brown, red)
- QUANTITY (increase or decrease)
- CONSISTENCY (frothy, watery, thick)
- ODOR (none, foul)
- PRESENCE OF BLOOD (hemoptysis)
33
Define Hemoptysis.
presence of blood in sputum
34
For Oxygenation, what things are assessed?
1. Cough and Sputum
2. Pain
3. Fatigue
4. Smoking
5. Environment of geographic exposure
6. Respiratory infections
7. Allergies
8. Medications
35
When assessing pain what characteristic should be noted?
- chest pain: location and severity
- how does the pain impact respiration
- pleuritic related to inflammation of the pleurae or infection in the pleural space
36
Define Pleuritic.
INFLAMMATION of the pleurae (SEROUS MEMBRANE lining THORACIC cavity), which impairs their lubricating function and causes pain when breathing. It is caused by pneumonia and other diseases of the chest or abdomen.
37
When assessing characteristics of fatigue what is noted?
- subjective data
| - usually indicates condition worsening
38
When assessing characteristics of smoking what is noted?
- 1st, 2nd or 3rd hand smoke
| - how many, how long per day
39
When assessing characteristics of environment or geographical exposure what is noted?
- inhaled substances
- investigate home and work place
- most common are radon (rare radioactive gas), smoke from the cigarettes
- employment history and exposure to asbestos (highly carcinogenic), coal, cotton fibres, chemical inhalants
40
When assessing characteristics of respiratory infection what is noted?
- presence duration, number per year, severity
41
When assessing characteristics of allergies what is noted?
- substance which irritate and creates various symptoms
42
When assessing characteristics of medications what is noted?
- may have toxic level of meds
- may react to meds
- is there overdose
43
What are some nursing strategies for oxygenation?
- ASSESS (colour, respiration, oxygen saturation, pulse, history)
- EDUCATE (healthy lifestyle; reducing risks)
- EXERCISE (3-4 times per week 20-30 min)
- REDUCE THE CHANCE OF INFECTION (avoid crowds, cover mouth when you cough, avoid touching mucous membranes, flu shot)
- AVOID EXTREME TEMPERATURES
- MAINTAIN ADEQUATE HYDRATION (aids in keeping secretions moist)
- MANAGE STRESS (develop coping skills)
- eliminate or minimize ENVIRONMENTAL POLLUTANTS
44
Examples of nursing diagnosis related to oxygenation.
- impaired gas exchange..
- altered breathing pattern..
- ineffective airway clearance..
45
If the client is experiencing DYSPNEA (shortness of breathe) or ORTHOPNEA (shortness of breathe when lying flat) what would the nursing diagnosis be?
Altered breathing pattern
46
If the client is UNABLE TO EFFECTIVELY CLEAR HIS AIRWAY what would the nursing diagnosis be?
Ineffective airway clearance
47
If the client is confused, fatigued, restless it may be because of hypoxia (deficiency in oxygen), so what would the nursing diagnosis be?
Impaired gas exchange
48
What are some nursing interventions?
- assess respiration (rhythm, rate, depth) & pulse (BPM)
- assess chest movement, nasal flaring, use of accessory muscles
- monitor oxygen saturation
- assess skin colour
- encourage ambulation as tolerated
- promote comfort/ pain management appropriately as to not depress respiration
- provide fluid and humidity
- oxygen is ordered by a physician
NRS 125
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