OXYGENATION

LESSON II
Oxygenation –
Ventilation

❖ Nursing Care of Clients with Upper

Airway disorders
Objectives:
❖ To identify all the problems in
oxygenation
❖ To know the medical and nursing
responsibilities in each problem
❖ Nursing Assessment History and
Physical Assessment
❖ Etiology
❖ Pathophysiology
❖ Clinical Manifestation
❖ Diagnosis
❖ Treatment Modalities
❖ Medical and Surgical
❖ Dietetics
❖ Nursing Management of various
respiratory disorders
❖ Upper Respiratory Tract Infections
❖ Bronchitis
❖ Asthma
❖ Emphysema
❖ Empyema
❖ Atelectasis
❖ Chronic Obstructive Pulmonary
Disease (COPD)
❖ Bronchiectasis
❖ Pneumonia
❖ Pulmonary Tuberculocis (TB)
❖ Lung Abscess
❖ Pleural Effusion
❖ Cysts and Tumors
❖ Chest Injuries
❖ Respiratory Arrest and Insufficiency
❖ Pulmonary Embolism
❖Review the Anatomy
and Physiology of
Respiratory System
❖ Nursing Assessment –
History and Physical
Assessment
History Collection:
- Personal History
- Reason for Seeking Care
- Past Health History
- Present Illness / Problems
- Previous Illness
- Family History
- Occupational History
- Medications
Physical Examination
- Skin – Cyanosis, Pallor
- Nail Clubbing
- Cough and sputum production
- Inspect – Palpate – Percussion –
ex. Auscultate the thorax
Normal Breath Sounds:
❖ Vesicular: soft, low pitched, over
most lung fields, inspiration >
expiration

❖ Bronchovesicular: med pitched,

over main bronchus and R
posterior lung,
inspiration>expiration

❖ Bronchial: loud, high pitched,

over manubrium only, expiration
> inspiration extended in asthma

❖ Tracheal: very loud, high pitched,

over trachea only, inspiration >
expiration
Adventitious Sounds: Extra
Sounds, Always Abnormal

❖ Crackles or Rales : Discontinuous,

fine/medium/coarse, not cleared
by coughing, heard more often on
inspiration
- Dry or wet, due to small
airways being forced open in
a disruptive fashion
- Also heard in atelectasis from
disuse of the lung
❖ Rhonchi: Continuous, foghorn,
low-pitched, cleared on coughing
- From air passing through an
obstructed airway
Adventitious Sounds: Extra
Sounds, Always Abnormal
❖ Wheezes: Continuous, tea kettle
high pitch, usually diffuse and
bilateral
- Heard diffusely in asthma
- Unilateral = foreign body
aspiration
- From air being forced
through a constricted airway
❖ Rub: Pleural sound that is like leather
rubbing together
- Caused by inflamed pleural
surfaces rubbing together
- Come and go depending on
amount of fluid in pleural space
- Documentation: loudness, pitch,
quantity, location on lung fields,
inspiratory/expiratory, effect of
coughing, effect of position change
Common Respiratory Signs and
Symptoms
❖ Dyspnea
❖ Wheezing
❖ Chest pain
❖ Cough
❖ Hemoptysis
❖ Sputum production
Dyspnea
❖ Acute or chronic
➢ Causes
- Respiratory: bronchospasm,
bronchitis, pneumonia, pulmonary
embolism, pulmonary edema,
pneumothorax, upper airway
obstruction
- Cardiovascular: acute MI, CHFo
cardiac tamponade: water bottle
appearance of heart on CXR
- Something else: anemia, DKA,
deconditioning, anxiety, etc.
- If chronic: asthma, COPD, interstitial
lung disease, cardiomyopathy
Dyspnea

Investigation
❖ Good history & PE leads to accurate
diagnosis 2/3 of the time
❖ Oximetry or ABG
❖ CXR
❖ Spirometry
❖ CBC to r/o dyspnea from anemia
❖ ECG
Dyspnea

Treatment
❖ Treat the cause!
❖ Oxygen
❖ Pulmonary rehab: improves exercise
capacity, reduces perceived
breathlessness, improves quality of life,
reduces anxiety and depression,
improves survival
❖ Treat anxiety
Cough

❖ Acute if less than 3 weeks

❖ Persistent if 3-8 weeks
❖ Chronic if greater than 8 weeks
❖ Women more likely to develop
loss
Cough

Causes:
- URI, pneumonia, aspiration,
pulmonary embolism, pulmonary
edema
- In smokers it is usually low-grade
chronic bronchitis
- With increased intensity lung cancer
- In nonsmokers is usually postnasal
drip, asthma, GERD, or ACE inhibitors
- ROS may include: fatigue, insomnia,
headache, urinary incontinence, rib
fx
- Investigation
- CXR in smokers, fevers, and weight
Cough

Treatment: Care for underlying

cause, elimination of irritants
Hemoptysis

❖ Expectoration of blood originating

below the vocal cords

❖ Usually comes from bronchial arteries

(high pressure)

❖ Be aware of mimics: upper respiratory

tract bleed, upper GI bleed
Causes:
- Most commonly bronchitis,
bronchogenic carcinoma, pneumonia

Other Causes:
- Infection, Good pasture’s syndrome,
Wegener’s granulomatosis, autoimmune,
iatrogenic, cocaine, AV malformation,
pulmonary embolism, elevated pulmonary
capillary pressure, foreign body, airway or
parenchymal trauma, fistula formation,
idiopathic
Investigation:
- CXR, hematocrit, UA, renal labs,
coagulation profile, bronchoscopy
- Tumor workup with strong history of
smoking and > 1 week hemoptysis

Treatment:
Treat cause
Common Diagnostic
Evaluation
❖ Pulmonary Function Test
(PFT)
- Is non invasive diagnostic
test
- In this test the volume and
capacity test aid diagnosis in
patients with suspected
pulmonary dysfunction
- PFT evaluates ventilatory functions
- Determine whether obstructive or
irritative disease
- Can be utilize as screening test
ABG ( Arterial Blood Gas
Analysis )
❖ ABG analysis is a diagnostic
procedure that involves
measurement of Blood pH
and arterial oxygen and
carbon dioxide tensions are
both obtained when
managing patients with
respiratory problems and
adjusting oxygen as needed
ABG Normal Values

❖ PaO2 – 80 to 100 mmhg

❖ PaCO2 – 35 to 45 mmhg
❖ pH – 7.35 to 7.45
❖ O2 Saturation – 95 to 99 %
Pulse Oximeter
❖ Pulse oximetry is a non invasive
method of continuously monitoring
the oxygen saturation of
hemoglobin (02 Sat)
❖ A sensor or probe is attached to the
ear lobe, forehead, fingertip or the
bridge of the nose
Sputum Analysis
❖ The sputum test analysis
involves a sample of sputum to
diagnose respiratory disease,
identify organism and identify
abnormal cells and also identify
pathogenic organisms
Sputum Cultures
❖ Defining the respiratory tract
❖ Upper = nose, nasal cavity,
nasopharynx
❖ Lower = larynx, trachea, bronchi,
bronchioles, alveoli
❖ Specimens
• Sputum specimen: expectorated
matter from the trachea, bronchi,
and/or lungs through the mouth
• Endotracheal specimen: suctioned
sputum from an endotracheal or
tracheostomy tube (ideal because you
are bypassing the mouth flora)
• Bronchoalveolar lavage specimen:
wash collected from an area of the lung
during a bronchoscopy
When to Culture?
❖ Bronchitis never, almost always viral
❖ Pneumonia must ask for different
culture medium when suspecting
anaerobes(aspiration), atypicals,
pertussis, fungi
❖ Acid fast bacilli

❖ Culture: requires serial (3) early

morning sputum cultures because
there will:
- Stains
- Gram stain be a low yield of
bacteria in each sample
- Long incubation period, up to 6
weeks
Stains
❖ Gram stain
- Too many squamous epithelial cells
are indicative of oral mucosal
contamination
- Numerous neutrophils are indicative
of infection
* Although the absence of
neutrophils in a neutropenic or
immunocompromised patient does not
rule out infection
❖ Macrophages common in fungal, acid-
fast, and other atypical bacterial
infections
❖ Eosinophils indicate allergic reaction or
parasitic infection
❖ Mucus strands indicate direct attack
(antibodies and lysosomes) of inhaled
bacteria
Acid Fast Stain:
❖ Special stain to look for Mycobacterium
and other acid fast bacteria
❖ Low sensitivity, but a positive indicates
treatment should begin as long as
there is an appropriate clinical picture
- Must also report to health
department
Lung Biopsy
❖ Guided by bronchoscope or CT
❖ Fine-needle aspirate or core sample
❖ Core provides more tissue for testing
❖ Contraindicated for lesions < 1cm or
high bleed risk
❖ Small pneumothorax always occurs as
a result
❖ Resolves if tissue is healthy
Tuberculin Skin Testing
❖ Mantoux tuberculin skin test (PPD):
tuberculin antigen is injected beneath
the skin, with presence or absence of
reaction measured in 48-72 hours
❖ Induration (bump) not erythema
measured
❖ Will only Catch a developed immune
response against TB
- takes 2-12 weeks to develop a
response after an exposure
- problem if someone does not have a
strong enough immune system to
mount a response = potential false
negative
- prevent by using a control that
everyone is exposed to, such as
Candida albicans antigen
 - Problem when someone has latent TB
or old BCG vaccine with waning immunity
against it
*First PPD test will be negative but will
stimulate memory T-cells
*Second PPD will be positive
*This person is a “converter” = why
you frequently have to get “two-step” TB
tests to protect against this being missed
❖ Positive Reading:
❑ Patients at high risk for developing
active TB: immunosuppressed, recent
contacts, CXR demonstrating past
infection
❑ Positive if their skin test is ≥ 5 mm
❑ Other high risk groups: injection drug
users, residents/employees of
hospitals/nursinghomes/prisons/shelte
rs, lab workers, children under 4,
comorbid conditions
❑ Positive if their skin test is ≥ 10 mm
Imaging Studies
❖ Chest X – ray
❖ Computed Tomography (CT)
❖ MRI
❖ Fluoroscopic Studies
❖ Bronchoscopy
❖ Ventilation Perfusion Scan (VQ
Scan)
Computed Tomography
❖ Indications: CXR abnormality, lung
tumor, mediastinal mass, aortic injury,
dissection, aneurysm, complicated
infection
❖ When to use contrast:
- Not usually needed for pulmonary
imaging as most things will be of
differing density than lung tissue
- Best for vessel enhancement as in
PE, aortic aneurysm or dissection,
some tumor protocols
- See interlobular septal thickening in
interstitial lung disease
- Can visualize thrombus in
pulmonary artery during PE
- CXR frequently normal
Ventilation-Perfusion Scans (VQ
Scans)
❖ Benefits: Less radiation than CT
❖ Disadvantages: time consuming,
doesn’t provide as much anatomic
information as CT
❖ Involves inhalation as well as venous
injection of a radiotracer
❖ Detects areas of the lung that are being
perfused and those that are being
ventilated for comparison
❖ Imaging is graded based upon
probability of PE
❖ Use over a CTA if patient has a contrast
allergy or is pregnant (less radiation)
Thoracentesis

❖ Ultrasound or CT guided
❖ Can be diagnostic and/or therapeutic
❖ Short or long-term
❖ Drain is promptly removed if there is
no purulent fluid draining (no evidence
of infection)
Thoracentesis
❖ Pleural fluid aspiration for obtaining
a specimen of pleural fluid for
analysis, relief of lung compression
and biopsy specimen collection
Bronchoscopy
❖ Is the using for diagnostic and
therapeutic purpose. It’s involves a
direct inspection of the trachea and
bronchi through a flexible fiber optic
or a rigid Bronchoscopy
❖ Bronchoscopy is used to determine
location of pathologic lesions, to
remove foreign objects, to collect
tissues specimen and remove
secretions or any aspirated
materials
Common Diagnostic Test for
Respiratory Disorders
❖ Laboratory Tests
❖ Radiologic Studies
❖ Others
Assessment
❖ Health History ( allergies,
occupation, lifestyle, health habits)
❖ Inspection ( Client’s color, level of
consciousness, emotional state )
(rate, depth, quality, rhythm, effort
relating to respiration)
❖ Palpation and Percussion
❖ Auscultation ( Listening for normal
and adventitious Breath sounds)
❖ Common Upper
Respiratory Tract
Infections
❖ Rhinitis or common cold
❖ Allergic Rhinitis
❖ Sinusitis
❖ Pharyngitis
❖ Tonsilitis
❖ Laryngitis
Viral Rhinitis or Common
Cold
❖ Often is used when referring to a
symptoms of an upper respiratory
tract infection by nasal congestion,
sore throat and cough
❖ Cold referred to a febrile,
infectious, acute inflammation, of
the mucus membranes of the nasal
cavity
Rhinitis
❖ Rhinitis is a group of disorders
characterized by inflammation and
irritation of the mucous membranes
of the nose
❖ It may be acute or chronic, non
allergic or allergic
Causes of Rhinitis
❖ Idiopathic
❖ Abuse of nasal decongestants
❖ Irritants ( Smoke, air pollution)
❖ Foreign Bodies
Clinical Manifestations
❖ Rhinorrhea “ Excessive nasal
drainage
❖ Nasal Congestion, Itching and
sneezing
❖ Headache may occur
Medical Management of
Rhinitis
❖ Treatment of cause “antibiotics”
❖ Decongestant
❖ Antihistamine
❖ In severe cases corticosteroids
❖ teaching patient self care
Acute Sinusitis
❖ It is an inflammation of sinuses, it is
resolved

Clinical Manifestations
❖ Pressure, Pain over the sinus area
❖ Tenderness
❖ Purulent nasal secretions
Medical Management
❖ Antimicrobial agent “amoxicillin”
❖ Oral or Topical Decongestant
❖ Heated mist or Saline Irrigation

Nursing Management
❖ Teaching patient self care
Complications
❖ Meningitis and osteomylitis
❖ Brain abscess
❖ Ischemic infarction
Chronic Sinusitis
❖ It is an inflammation of sinuses that
persists for more than 8 weeks in
adult and or 2 weeks in children

Clinical Manifestations
❖ Impaired mucociliary clearness and
ventilation
❖ Chronic hoarseness and cough
❖ Chronic headache
❖ Facial pain
Acute Pharyngitis
❖ Is sudden inflammation of the
Pharynx
❖ It is a febrile inflammation of throat,
caused by virus about 70%,
uncomplicated viral infection usually
subsided promptly within 3 to 10
days
Clinical Manifestations
❖ Fiery red pharyngeal membrane
and tonsils
❖ Lymphoid follicles that are swollen
❖ Enlarge tender cervical lymph node
❖ Fever and malaise
❖ Sore throat, hoarseness and cough
Medical Management
❖ Supportive measure for viral
infection
❖ Pharmacologic therapy antibiotics
for 10 days “cephalosporin” /
analgesic for severe sore / anti
tussive medications
❖ Nutritional therapy: liquid or soft
diet “ If liquid is not tolerated IVF
administration is needed”
❖ Nursing management ( bed rest,
skin assessment, mouth care and
normal saline gargle and self care
teaching)
Chronic Pharyngitis

❖ Is a persistent inflammation of the

pharynx
❖ Common in adults who work or live
in dusty surrounding, use the voice
too excess, suffer from chronic
cough and habitually use alcohol
and tobacco
Clinical manifestations
❖ Constant sense of irritation or
fullness in throat
❖ Mucus expelled by coughing
❖ Difficulty in swallowing
Medical Management

❖ Relieving symptoms ( avoid

exposure to irritant, correct
respiratory and cardiac conditions)
❖ Antihistamine drugs
❖ Decongestant
❖ Controlling malaise
Nursing Management
❖ Patient teaching of self care
❖ Avoid alcohol, tobacco, exposure to
cold
❖ Face mask to avoid pollutant
❖ Warm fluids and warm saline
gargle
Tonsillitis
❖ Are composed of lymphatic tissue
and situated on each side of the
oropharynx, they frequently are the
site of acute infection

Clinical Manifestations
❖ Tonsils: sore throat, fever, snoring
and difficulty of swallowing
❖ Adenoids: ear ache, mouth
breathing, drainage ear, frequent
cold, bronchitis, noisy respiration,
foul smelling breath and voice
impairment
 Medical Management
❖ For recurrent tonsillitis
“Tonsillectomy”
❖ Conservative or symptomatic
therapy
❖ Antimicrobial therapy “penicillin” for
7 days
Nursing Management
❖ Provide post op care: V/S,
hemorrhage, position head turned
to side, water or ice chips
❖ Teaching patient: S&S of
hemorrhage
❖ Avoid too much talking or coughing
❖ Liquid or semi liquid diet for several
days
❖ Alkaline mouth washing with warm
saline
Laryngitis
❖ It is an inflammation of larynx, often
occur as a result of voice abuse or
exposure to dust, chemicals,
smoke, and other pollutants
❖ Common in winter and easily
transmitted
❖ The cause of infection is almost
virus
Clinical Manifestations

❖ Hoarseness or aphonia
❖ Severe cough
Medical Management
❖ Resting voice and avoid smoking
❖ Inhale cool stream or an aerosol
❖ Conservative treatment
❖ Antibiotics for bacterial organism
Nursing Management
❖ Rest voice
❖ Maintain a well humidified
environment
❖ Daily fluid intake