NURSING INTERVENTIONS TO PROMOTE

HEALTHY PHYSIOLOGIC RESPONSES

Oxygenation and Perfusion

• Oxygenation is a basic human need. The
respiratory system replenishes the body’s oxygen
supply and eliminates waste from the body in the
form of carbon dioxide
 ANATOMY AND PHYSIOLOGY OF THE
RESPIRATORY SYSTEM

• RESPIRATION: the process of gaseous exchange

between the individual and the environment
I. The AIRWAYS

Tracheobronchial Tree
Right & Left mainstem bronchi
Segmental bronchi
Subsegmental bronchi
Terminal bronchi
 FUNCTIONS OF THE UPPER AIRWAYS

1. Transport of gases to the lower airways

2. Protection of the lower airways from foreign
matter
3. Warming, filtration and humidification of inspired
air
 FUNCTIONS OF THE LOWER AIRWAYS

1. Clearance mechanism
Cough
Mucociliary system
Macrophages
lymphatics
2. Immunologic responses
Cell – mediated immunity in the alveoli
3. Pulmonary protection in injury
Respiratory epithelium
Mucociliary system
• Nostrils or Nares: the opening of the nose on the face
area
• Each nostril leads to a cavity called vestibule
• Vibrissae: hair that lines the vestibule and filters foreign
bodies
• Paranasal sinus: open areas within the skull, lined with
mucous membrane, which helps in phonation.
• Pharynx: funnel-shaped tube extending from the
nose to the larynx. It is a common opening
between the digestive and respiratory system
• Larynx: voice box
• Epiglottis: covers the larynx. It closes when
eating, it opens when speaking
• Trachea: “windpipe” is 12 cm (4-5 in) long. Carina is
the point that which it divides
• Trachea and Bronchi are lined with cilia and goblet
cells
• Cilia: microscopic hair-like projections which have rapid,
coordinated, unidirectional upward motion, and sweep
out debris and excessive mucous from the lungs
• Goblet cells: secrete 120 ml of mucous per day. The
mucous secretions entrap debris in the respiratory tract
II. PLEURA
- The plurae are serous membranes that encloses the lungs
- The visceral pleura directly covers the lungs
- The parietal pleura lines the cavity of each hemithorax
- Pleural space is a potential space between the two
pleurae. Only few ml of serous fluid is found in the
pleural space, to serve as lubricant
III. LUNGS
III. The two lungs are separated by a space called mediastinum
IV. Approximately, 300 hundred million alveoli are in the lungs
V. Residual volume is the amount of air that remains in the
lungs after forceful expiration. It prevents collapse of the
lungs during expiration (1200 ml)
• Inspiratory reserve volume: the amount of extra air that can
be exhaled, beyond the tidal volume
• Expiratory reserve volume: the amount of extra air that can
be exhaled after a normal breath
• Total lung capacity: the total of all four volumes (residual,
tidal, inspiratory reserve and expiratory reserve)
• Pneumocytes: Type I (line the alveoli; Type II (produce
surfactant)
4. Thorax and diaphragm
Thorax provides protection for the lungs, heart and great
vessels
It is made up of 12 pairs of ribs, bounded anteriorly by the
sternum and posteriorly by the thoracic vertebrae
The main respiratory muscle for inspiration which is
supplied by phrenic nerve
Accessory muscles for inspiration (sternocleidomastoid,
scalene, parasternal, trapezius, pectoralis muscles
5. Respiratory Control
Central nervous system control (medulla oblongata, pons)
Reflex control (cough reflex)
Peripheral control (carotid and aortic bodies)
 MEASURES THAT PROMOTES ADEQUATE
RESPIRATORY FUNCTION

1. Adequate oxygen supply from the environment

2. Deep breathing and coughing exercises (to promote maximum lung expansion and to loosen mucous
secretions)
3. Positioning
4. Patent airway (to promote gaseous exchange between the person and the environment)
- causes of airway obstruction:
Tongue (among unconscious client tends to fall back)
Mucous secretions
Edema of airways (rhinitis, laryngitis, bronchitis)
Spasm of airways (laryngospasm, bronchospasm)
Foreign bodies (aspirated foods, fluids)
 MEASURES THAT PROMOTES ADEQUATE
RESPIRATORY FUNCTION

5. Adequate hydration (to maintain moisture of the mucous membrane lining and
respiratory tract; prevents irritation and infection)
6. Avoid environmental pollutants, alcohol and smoking (inhibits mucociliary function)
7. Chest Physiotherapy (CPT)
- Percussion (clapping) forceful striking of the skin with cupped hands. It can
mechanically dislodge tenacious secretions from the bronchial walls
- Vibration a series of vigorous quivering produced by hands that are placed flat
against the client’s chest wall. It is done to loosen mucous secretion
- Postural drainage: expulsion of secretions from various lung segments by gravity
• Postural drainage
- Each position during postural drainage will be assumed by the client 10-15 minutes
- The entire treatment should last only for 30 minutes
- To prevent exhaustion and postural hypotension, gradual change of position should
be observed
- Bronchodilator medication or nebulization therapy is given in order to loosen
mucous secretion before postural drainage
- Before meals in the morning upon awakening and at bedtime: best time to do
postural drainage
- Not performed immediately after meals, may cause vomiting thereby aspiration
- Provide good oral hygiene after the procedure
 MEASURES THAT PROMOTES ADEQUATE
RESPIRATORY FUNCTION

8. Bronchial hygiene measures

Steam inhalation:
Purposes:
a.To liquefy mucous secretions
b.To warm and humidify inspired air
c.To relieve edema of airways
d.To soothe irritated airways
e.To administer medications
It is a dependent nursing function. Heat application requires
physician’s order
Inform the client and explain the purpose of the procedure
Place the client in semi-fowler’s position (for maximum inhalation of
steam)
Cover the client’s eyes with wash cloth to prevent irritation
Check the electrical device fore use to prevent injury
Place the steam inhalator in a flat, stable surface to prevent
scalding from hot water
Place the spout 12-18 inches away from the client’s nose or adjust
distance necessary
CAUTION: avoid burns
Cover the chest with towel to prevent burns due to dripping of
condensate from the steam. Assess for redness on the side of the face
which indicates first degree burn
• Render steam inhalation therapy 15-20 minutes, in order to
be effective
• Instruct to perform deep breathing and coughing exercises
after the procedure to facilitate expectoration of mucous
secretions
• Provide good oral hygiene after procedure
• Do after care of equipment
• document
Aerosol inhalation
done among pediatric clients to administer bronchodilators or
mucolytic-expectorants

Medimist inhalation
Done among adults clients to administer bronchodilators or
mucolytic-expectorants
 MEASURES THAT PROMOTES ADEQUATE
RESPIRATORY FUNCTION

9. SUCTIONING:
- Perform to clear airways from mucus secretions
 OROPHARYNGEAL AND NASOPHARYNGEAL
SUCTIONING

1. Assess indications for suctioning

Audible secretions during respiration
Adventitious breath sounds
2. Position
Conscious: Semi-fowler’s
Unconscious: Lateral position
 OROPHARYNGEAL AND NASOPHARYNGEAL
SUCTIONING

3. Determine the pressure of suction equipment in order

to prevent trauma to mucus membrane of airways

WALL UNIT PORTABLE UNIT

Adult: 100-120 mmHg Adult: 10-15 mmHg

Child: 95-110 mmHg Child: 5-10 mmHg

Infant: 50-95 mmHg Infant: 2-5 mmHg

 OROPHARYNGEAL AND
NASOPHARYNGEAL SUCTIONING

4. Choose the appropriate size of sterile suction catheter,

to prevent trauma to mucus membranes of airways
Adult: Fr 12-18
Child: Fr 8 – 10
Infant: Fr 5 - 8
 OROPHARYNGEAL AND
NASOPHARYNGEAL SUCTIONING

5. Use sterile gloves

6. Consider the length of the catheter
- Measure from the tip of the client’s nose to the earlobe
or about 13 cm (5 in) for an adult
7. Lubricate catheter to reduce friction
- Nasopharyngeal suction tip-water soluble lubricant
- Oropharyngeal suction tip-sterile water or NSS
 OROPHARYNGEAL AND
NASOPHARYNGEAL SUCTIONING

8. Apply suction during withdrawal of the suction catheter (never during

insertion), to prevent trauma to the mucous membrane.
9. Apply suction for 5 – 10 seconds (maximum of 15 seconds). Oversuctioning
causes hypoxia and vagal stimulation
10. Hyperventilate the client with 100% oxygen before and after suctioning to
prevent hypoxia
11. Allow 20 – 30 seconds interval between each suction to bring up mucous
secretions into the upper airways, and prevent hypoxia.
 OROPHARYNGEAL AND
NASOPHARYNGEAL SUCTIONING

12. Provide oral and nasal hygiene

13. Dispose contaminated equipment/articles safely.
- Use one sterile suction catheter for each episode of suctioning
14. Assess effectiveness of suctioning
15. Documentation
 MEASURES THAT PROMOTES ADEQUATE
RESPIRATORY FUNCTION

10. Incentive Spirometry

Enhances deep inspiration
11. Intermittent Positive Pressure Breathing (IPPB)
Ordered for children and adults with chronic
lung conditions. Most often used for clients
with cystic fibrosis
To administer oxygen at pressures higher than
the atmospheric pressure
Assists clients to breath more easily by
liquefying mucous
 MEASURES THAT PROMOTES ADEQUATE
RESPIRATORY FUNCTION

12. Supplemental Oxygen Administration

Indication: Hypoxemia
Signs of hypoxemia
a. Restlessness (initial sign)
b. Increased pulse rate
c. Rapid, shallow respiration and dyspnea
d. Light-headedness
e. Nasal flaring
f. Substernal or intercostal retractions
g. Cyanosis (late sign)
 OXYGEN SYSTEMS

A. Low flow administration devices

Nasal cannula (24 – 45% at 2 – 6 LPM)
- May be used in clients with COPD at 2 -3 L/min , if venture mask
is not available)
Simple face mask (40 – 60% at 5-8 LPM)
Partial rebreathing mask (60 – 90% at 6 – 10 LPM)
Non-rebreathing mask (95 – 100% at 6 – 16 LPM)
Croupette
Oxygen tent
OXYGEN SYSTEMS
 OXYGEN SYSTEMS

B. High flow administration devices

Venturi mask
- Low concentration venture-type mask is preferred for client with COPD
because it provides accurate amount of oxygen. It requires 2 – 3 L/min or
28% oxygen
Face mask
Oxygen hood – can be used for low and high flow concentration
Incubator/Isolette – can be used for low and high flow concentration
OXYGEN SYSTEMS
 NURSING IMPLICATIONS

• Leakage cannot be detected since oxygen is colorless,

odorless, tasteless gas
• It can irritate mucous membrane of the airways since
oxygen is a dry gas
• It can cause fire, since oxygen supports combustion
 NURSING CONSIDERATIONS DURING
ADMINISTRATION OF OXYGEN THERAPY

1. Assess signs and symptoms of hypoxemia

2. Check doctor’s order
3. Position patient on semi-fowler’s preferably to enhance lung expansion
4. Open source of oxygen before insertion of oxygen device ( to check for
malfunctioning of the device)
5. Regulate oxygen flow accurately. Excessive administration of oxygen can
cause oxygen narcosis (respiratory alkalosis)
6. Place a “No Smoking” sign at the bedside
 NURSING CONSIDERATIONS DURING
ADMINISTRATION OF OXYGEN THERAPY

7. Avoid use of oil, greases, alcohol and either near the client receiving
oxygen. (may further support combustion)
8. Check electrical appliances before use. Small spark may cause a fire if there
is leakage of oxygen
9. Avoid materials that generate static electricity, such as woolen blankets and
synthetic fabrics. Use cotton blankets
10. Humidify oxygen. Place sterile water into the oxygen humidifier to prevent
dryness and irritation of mucous membranes of the airways
 NURSING CONSIDERATIONS DURING
ADMINISTRATION OF OXYGEN THERAPY

11. To prevent dryness and irritation of mucous membrane, provide good oronasal
hygiene
12. Lubricate nares with water-soluble lubricant to soothe the mucous membrane.
13. Assess effectiveness of oxygen therapy
Check vital signs especially RR
- EUPNEA is normal breathing which is effortless and noiseless
Note quality of respiration
Evaluate arterial blood gas (ABG)
14. Documentation
 ALTERATIONS IN RESPIRATORY FUNCTION

• Hypoxia: insufficient oxygen of tissues

Early signs Late signs

Tachycardia Bradycardia
Increased rate and depth of respiration Dyspnea
Slight increase in systolic BP Decreased systolic BP
Cough
Hemoptysis
 Other clinical signs of acute Other clinical signs of chronic
hypoxia hypoxia
Nausea and vomiting Fatigue, lethargy
Oliguria, anuria Pulmonary ventilation increases
Headache RBC count increases
Apathy Hgb concentration increases
Dizziness Clubbing of fingers
Irritability
Memory loss
 ALTERATIONS IN RESPIRATORY FUNCTION

Altered Breathing Pattern

A.Rate:
Tachypnea: rapid RR
Bradypnea: slow RR
Apnea: cessation of breathing
 Altered Breathing Pattern
B.Volume:
Hyperventilation - excessive amount of air in the lungs;
results from deep rapid respirations
Hypoventilation – decreased rate and depth of
respiration; causes retention of carbon dioxide
 Altered Breathing Pattern
C.Rhythm
Cheyne-stokes: marked rhythmic waxing and waning of respirations from
very deep to very shallow breathing and temporary apnea
Kussmaul’s: increased rate and depth of respiration (hyperventilation)
Apneustic: prolonged gasping inspiration followed by a very short, usually
inefficient expiration
Biot’s: shallow breaths interrupted by apnea
 Altered Breathing Pattern
D.Ease of effort
Dyspnea: difficult or labored breathing
Orthopnea: inability to breath except in upright or
sitting position
 NURSING DIAGNOSIS

1. Ineffective airway clearance

2. Ineffective breathing pattern
3. Decreased cardiac output
4. Impaired gas exchange
5. Activity intolerance
6. Anxiety
7. Ineffective individual coping