50

Oxygenation
 Learning Outcomes

1. Outline the structure and function of the

respiratory system.
2. Describe the processes of breathing
(ventilation) and gas exchange (respiration).
3. Explain the role and function of the
respiratory system in transporting oxygen
and carbon dioxide to and from body tissues.

continued on next slide

 Learning Outcomes

4. Describe the mechanisms for respiratory

regulation.
5. Identify factors influencing respiratory
function.
6. Identify four major types of conditions that
can alter respiratory function.
7. Describe nursing assessments for
oxygenation status.
8. Describe nursing measures to promote
respiratory function and oxygenation.
continued on next slide
 Learning Outcomes

9. Explain the use of therapeutic measures

such as medications, inhalation therapy,
oxygen therapy, and artificial airways, to
promote respiratory function.
10.State outcome criteria for evaluating client
responses to measures that promote
adequate oxygenation.

continued on next slide

 Learning Outcomes

11.Verbalize the steps used in:

a. Administering oxygen by cannula, face mask,
or face tent.
b. Oropharyngeal suctioning.
c. Suctioning a tracheostomy or endotracheal
tube.
d. Providing tracheostomy care.

continued on next slide

 Learning Outcomes

12.Recognize when it is appropriate to delegate

aspects of oxygen therapy.
13.Demonstrate appropriate documentation and
reporting of oxygen therapy.
Structure and Processes of the
Respiratory System
• The function of the respiratory system
is gas exchange.
• Oxygen is required for cell functioning.
• Movement of oxygen and CO2 involves
integration of several body systems.
Structure and Processes of the
Respiratory System
• Oxygen from inspired air diffuses from
alveoli in lungs into blood in pulmonary
capillaries.
• Carbon dioxide produced during cell
metabolism builds up in tissues and
diffuses from blood into the alveoli to
be exhaled.
 Structure of the Respiratory
System
• Upper respiratory tract
▪ Mouth
▪ Nose
• Air enters
• Warmed and filtered
▪ Pharynx
• Shared pathway for air and food
• Nasopharynx
• Oropharynx
continued on next slide
 Structure of the Respiratory
System
• Upper respiratory tract
▪ Larynx
• Externally identified as Adam's apple
• Epiglottis is inlet.
 Structure of the Respiratory
System
• Lower respiratory tract
▪ Trachea
▪ Bronchi
▪ Bronchioles
▪ Alveoli
• Respiratory membrane
▪ Pulmonary capillary network
▪ Pleural membranes
Figure 50–1 A, Organs of the respiratory tract; B, respiratory bronchioles, alveolar ducts, and alveoli.
 Pulmonary Ventilation

• Inspiration (inhalation)
▪ Air flows into lungs.
• Expiration (exhalation)
▪ Air flows out of lungs.
 Pulmonary Ventilation

• Ventilation depends on:

▪ Clear airways (cilia)
▪ Intact CNS and respiratory center
▪ Ability of thorax to expand and contract

continued on next slide

 Pulmonary Ventilation

• Ventilation depends on:

▪ Lung compliance and lung recoil
• Compliance
• Expansibility or stretchability of lung
tissue
• Recoil
• Continual tendency of lungs to collapse
away from the chest wall

continued on next slide

 Pulmonary Ventilation

• Ventilation depends on:

▪ Lung compliance and lung recoil
• Factors
• Intrapleural pressure
• Intrapulmonary pressure
• Tidal volume
• Atelectasis
• Surfactant
 Pulmonary Ventilation

• Inspiration (inhalation)
▪ Diaphragm and intercostals contract.
▪ Thoracic cavity size increases.
▪ Volume of lungs increases.
▪ Intrapulmonary pressure decreases.
▪ Air rushes into lungs to equalize
pressure.
 Pulmonary

• Expiration (exhalation)
▪ Diaphragm and intercostals relax.
▪ Volume of the lungs decreases.
▪ Intrapulmonary pressure rises.
▪ Air is expelled.
Figure 50–2 Gas exchange occurs between the air on the alveolar side and the blood on the capillary side.
 Alveolar Gas Exchange

• Occurs after alveoli are ventilated.

• Pressure differences on each side of
respiratory membranes affect diffusion.
▪ Partial pressure
• Pressure exerted by each individual gas
in a mixture according to its
concentration in the mixture
▪ Torr
 Alveolar Gas Exchange

• Diffusion of oxygen from alveoli into

pulmonary blood vessels on inspiration
• Diffusion of carbon dioxide from
pulmonary blood vessels into alveoli for
expiration
Transport of Oxygen and Carbon
Dioxide
• Oxygen
▪ Transported from lungs to tissues
▪ 97% of oxygen combines with
hemoglobin in red blood cells and is
carried to tissues as oxyhemoglobin.
▪ Remaining oxygen is dissolved and
transported in plasma (as PaO2).

continued on next slide

Transport of Oxygen and Carbon
Dioxide
• Oxygen
▪ Rate of transport affected by:
• Cardiac output
• Erythrocytes (RBCs) and hematocrit
• Normal hematocrit 40–54% in men, 37–
50% in women
• Exercise
Transport of Oxygen and Carbon
Dioxide
• Carbon dioxide
▪ Must be transported from tissues to
lungs
▪ Continually produced in process of cell
metabolism

continued on next slide

Transport of Oxygen and Carbon
Dioxide
• Carbon dioxide
▪ 65% is carried inside RBCs as
bicarbonate.
▪ 30% combines with hemoglobin as
carbahemoglobin.
▪ 5% transported in solution in plasma
and as carbonic acid.
 Systemic Diffusion

• Diffusion down to capillary-tissue-cell

level is comparable to capillary-alveolar
level in the lungs.
• Pressure gradients determine direction
of diffusion.
• Reduced blood flow (as in shock)
decreases capillary blood flow and
interferes with tissue oxygen delivery.
 Respiratory Regulation

• Includes both neural and chemical

controls to maintain correct
concentrations
• Nervous system adjusts rate to
maintain constant PO2 and PCO2.
 Respiratory Regulation

• Respiratory center in medulla oblongata

and pons of the brain
▪ Chemosensitive receptors in medulla
oblongata respond to changes in blood
and hydrogen ion concentration.
▪ Increased CO2 most strongly affects
stimulation of respiration.

continued on next slide

 Respiratory Regulation

• Respiratory center in medulla oblongata

and pons of the brain
▪ Neural receptors to O2 in carotid bodies
stimulate respiratory center.
• In clients with emphysema, O2
concentration affects respiration more
strongly (hypoxic drive) because of
constant buildup of CO2 in blood.
 Factors Affecting Respiratory
Function
• Age
▪ Changes especially important if system
compromised by infection, physical or
emotional stress, surgery, anesthesia,
or other procedures.
▪ Chest wall, airways more rigid and less
elastic
▪ Drier mucous membranes
▪ Increased risk of aspiration from GERD
 Factors Affecting Respiratory
Function
• Environment
▪ Altitude
▪ Pollution
• Lifestyle
▪ Physical activity
▪ Occupation
• Health status
 Factors Affecting Respiratory
Function
• Medications
▪ Benzodiazepine sedative-hypnotics
▪ Antianxiety drugs
• Stress
▪ Hyperventilation
▪ Epinephrine
Alterations in Respiratory Function

• Conditions affect:
▪ Patency
▪ Movement of air into, out of lungs
▪ Diffusion of oxygen and carbon dioxide
between alveoli, pulmonary capillaries
▪ Transport of oxygen and carbon dioxide
via blood to and from tissue cells
 Conditions Affecting Airway

• Partially obstructed airway indicated by

low-pitched snoring during inhalation
▪ Upper airway
• Gurgly or bubbly sound passing
obstruction
▪ Lower airway harder to observe
• Stridor
• Harsh, high-pitched sound in inspiration
• Adventitious (abnormal) breath sounds
 Conditions Affecting Airway

• Completely obstructed airway

▪ Extreme inspiratory effort with no chest
movement
Conditions Affecting Movement
of Air
• Breathing patterns
▪ Eupnea (normal)
▪ Tachypnea (rapid)
▪ Bradypnea (slow)
▪ Apnea (absent)
▪ Hypoventilation
• Hypercarbia, hypercapnia
• Increased levels of carbon dioxide
• Hypoxemia
continued on next slide
Conditions Affecting Movement
of Air
• Breathing patterns
▪ Kussmaul breathing
▪ Cheyne-Stokes respirations
• Rhythmic waxing, waning of respirations
from very deep to very shallow
▪ Biot (cluster) respirations
▪ Orthopnea
• Difficulty breathing while lying down

continued on next slide

Conditions Affecting Movement
of Air
• Breathing patterns
▪ Dyspnea
• Difficulty breathing
• Shortness of breath (SOB)
• Nostril flaring
• Increased heart rate
• Stems from cardiac or respiratory
problem
 Conditions Affecting Diffusion

• Hypoxemia
▪ Reduced oxygen level in blood
▪ May be caused conditions that impair
alveolar-capillary diffusion (e.g.,
pulmonary edema)
• Compensation by increased heart rate
and cardiac output
 Conditions Affecting Diffusion

• Hypoxia
▪ Condition of insufficient oxygen in body
tissue
▪ Results from unresolved hypoxemia
▪ Signs and symptoms
• Rapid pulse
• Rapid, shallow respirations and dyspnea
• Increased restlessness or
lightheadedness
continued on next slide
 Conditions Affecting Diffusion

• Hypoxia
▪ Signs and symptoms
• Flaring of nares
• Substernal or intercostal retractions
• Cyanosis
▪ Bluish discoloration of skin, nail beds,
mucous membranes due to reduced
hemoglobin-oxygen saturation
▪ Anemia or epinephrine diminish signs.
Conditions Affecting Transport

• Conditions that decrease cardiac output

▪ Congestive heart failure
▪ Hypovolemia
 Assessing

• Nursing history
▪ Current and past respiratory problems
▪ Lifestyle, risk factors for impaired
oxygen status
▪ Presence of cough and sputum or pain
▪ Medications for breathing
 Assessing

• Physical examination
▪ Nurse observes rate, depth, rhythm,
and quality of respirations
▪ Inspects variations of shape of thorax
Figure 50–3 The relationship of lung volumes and capacities. Volumes (mL) shown are for an average adult
male; female volumes are 20% to 25% smaller.
 Assessing

• Diagnostic studies
▪ Sputum specimens
▪ Throat cultures
▪ Visualization procedures
▪ Venous and arterial blood specimens
▪ Pulmonary function tests
• Require active client participation
 Diagnosing

• Ineffective Airway Clearance

• Ineffective Breathing Pattern
• Impaired Gas Exchange
• Activity Intolerance
 Diagnosing

• Etiology of other nursing diagnoses

▪ Anxiety
▪ Fatigue
▪ Fear
▪ Powerlessness
▪ Insomnia
▪ Social Isolation
 Planning

• Maintain a patent airway

• Improve comfort and ease of breathing
• Maintain or improve pulmonary
ventilation and oxygenation
• Improve ability to participate in
physical activities
 Planning

• Prevent risks associated with

oxygenation problems such as skin and
tissue breakdown, syncope, acid–base
balances, and feelings of hopelessness
and social isolation.
 Planning

• Planning for home care

▪ Client
• Self-care abilities
• Exercise/activity pattern
• Assistive devices required
• Environmental risk factors
• Home and community
• Current level of knowledge of client
condition and community resources
continued on next slide
 Planning

• Planning for home care

▪ Client's family
• Availability, skills, and responses
• Role changes and coping, respite
caregivers
 Implementing

• Facilitate pulmonary ventilation

• Facilitate alveolar–capillary diffusion
• Dependent interventions
▪ Oxygen therapy
▪ Tracheostomy care
▪ Maintenance of chest tube
 Implementing

• Promoting oxygenation
▪ Position client for maximum chest
expansion (semi- or high Fowler's)
▪ Encourage or provide frequent position
changes
▪ Encourage deep breathing and coughing
▪ Encourage ambulation
▪ Implement comfort measures
 Implementing

• Deep breathing and coughing

▪ Raise secretions high enough to
expectorate or swallow
▪ Routine exercises for clients with
chronic conditions
▪ Normal forceful cough
▪ Alternative huff coughing
 Implementing

• Hydration
▪ Maintains moist mucous membranes to
aid removal of secretions
▪ Normal secretions thin, easily moved by
ciliary action
▪ When dehydrated, secretions tenacious
• Humidifier
▪ Fluids as much as client tolerates
 Implementing

• Medications
▪ Bronchodilators
▪ Anti-inflammatory drugs
• Glucocorticoids
• Leukotriene modifiers
▪ Expectorants

continued on next slide

 Implementing

• Medications
▪ Cough suppressants
▪ Others that improve cardiovascular
function
• Digitalis glycosides
• Beta-adrenergic stimulating agents
• Beta-adrenergic blocking agents
• Must be monitored closely
 Implementing

• Incentive spirometry
▪ Sustained maximal inspiration device
(SMI)
• Improves pulmonary ventilation
• Counteracts effects of anesthesia or
hypoventilation
• Loosens respiratory secretions
• Facilitates respiratory gaseous exchange
• Expands collapsed alveoli
Figure 50–5 A, Flow-oriented SMI; B, volume-oriented SMI.

A B
 Implementing

• Percussion, vibration, and postural

drainage
▪ Percussion
• Cover area with towel or gown to reduce
discomfort
• Ask client to breathe slowly and deeply
• Alternately flex and extend wrists rapidly
to slap the posterior chest
• Percuss each affected lung segment for
1–2 minutes
continued on next slide
Figure 50–6 Percussing the upper posterior chest.
 Implementing

• Percussion, vibration, and postural

drainage
▪ Vibration
• Place hands, palms down, on chest area
to be drained
• Ask client to inhale deeply and exhale
slowly
• During exhalation vibrate the hands

continued on next slide

 Implementing

• Percussion, vibration, and postural

drainage
▪ Vibration
• Vibrate during five exhalations
• After each vibration, ask client to cough
and expectorate secretions

continued on next slide

Figure 50–7 Vibrating the upper posterior chest.
 Implementing

• Percussion, vibration, and postural

drainage
▪ Postural drainage
• Place client in appropriate positions to
allow gravity to drain affected areas of
lung
• Lower lobes require drainage more often
than upper lobes
• Usually scheduled before meals to
prevent vomiting
 Implementing

• Mucus clearance devices

▪ Clients with excessive secretions
• Cystic fibrosis
• COPD
▪ Flutter device one example
▪ Client inhales slowly, holds cheeks firm
while exhaling fast
▪ Vibrations loosen mucus for
expectoration.
Figure 50–8 Flutter mucus clearance device.
 Implementing

• Oxygen therapy
▪ Check vital signs and oxygen saturation
level
▪ Ordered for clients with hypoxemia,
anemia, blood loss
▪ Primary care provider specifies
concentration, method of delivery, liter
flow per minute.
• May call for titration to achieve
therapeutic level continued on next slide
 Implementing

• Oxygen therapy
▪ Nurse may initiate in emergency, then
call provider.
▪ Portable or wall outlet
▪ Humidifier for high flow to prevent
drying

continued on next slide

 Implementing

• Oxygen therapy
▪ Safety precautions
• Handle and store with caution to prevent
falls and breakage
• Highly flammable
• No smoking in room with oxygen
- No-smoking signs
• Avoid faulty electrical equipment and
static

continued on next slide

 Implementing

• Oxygen therapy
▪ Safety precautions
• Highly flammable
• Avoid use of volatile flammable materials
nearby (nail polish remover, oil, alcohol)
• Ensure grounding of all electrical
equipment
• Fire extinguishers available and staff
trained in use
 Implementing

• Oxygen delivery systems

▪ Cannula
• Nasal cannulas
▪ Face mask
• Partial rebreather mask
• Nonrebreather mask
• Venturi mask
▪ Face tent
▪ Transtracheal catheter
Figure 50–9 An oxygen humidifier attached to a wall outlet oxygen flow meter.
Figure 50–10 Insert flow meter into the wall unit.
Figure 50–11 This flow meter is set to deliver 2 L/min.
Figure 50–12 A, Nasal cannula; B, mustache reservoir nasal cannula; C, pendant reservoir nasal cannula.

A B C
Figure 50–13 A, A simple face mask; B, a partial rebreather mask; C, a nonrebreather mask; D, a Venturi
mask.

A B

C D
Figure 50–14 An oxygen face tent.
 Implementing

• Oxygen delivery systems

▪ Noninvasive positive pressure
ventilation
• Most common type is continuous positive
airway pressure (CPAP).
• Bilevel positive airway pressure (BiPAP)
• Used in sleep apnea, COPD, etc.
Skill 50–1 Administering Oxygen by Cannula, Face
Mask, or Face Tent

continued on next slide

Skill 50–1 (continued) Administering Oxygen by Cannula, Face Mask, or Face Tent

continued on next slide

Skill 50–1 (continued) Administering Oxygen by
Cannula, Face Mask, or Face Tent

continued on next slide

Skill 50–1 (continued) Administering Oxygen by Cannula, Face Mask, or Face Tent
 Implementing

• Artificial airways
▪ For client whose airway has or may
become obstructed
▪ Oropharyngeal and nasopharyngeal
airways
• Easy to insert; low risk of complications
• Oropharyngeal for unconscious clients
• Nasopharyngeal for alert clients with gag
reflex
continued on next slide
 Implementing

• Artificial airways
▪ Endotracheal tubes
• Anesthesia or ventilation
▪ Tracheostomy
• Opening into trachea
• Client cannot speak.
• Tube with outer and inner cannula,
obturator, flange with tubes or ties

continued on next slide

 Implementing

• Artificial airways
▪ Tracheostomy
• Cuffed tracheostomy tubes
• Airtight seal prevents aspiration and air
leakage.
• Nursing care involves cleaning and
suctioning.
• Humidity may need to be provided.
• Mist collar
• Swedish nose
Figure 50–18 An oropharyngeal airway in place.
Figure 50–19 A nasopharyngeal airway in place.
Figure 50–25 A tracheostomy mist collar.
Figure 50–26 Heat moisture exchange device.
 Implementing

• Suctioning
▪ Aspirating secretions through a catheter
connected to suction machine or wall
suction outlet
▪ Assess for signs of respiratory distress
• Client inability to cough up and
expectorate secretions

continued on next slide

 Implementing

• Suctioning
▪ Assess for signs of respiratory distress
• Dyspnea
• Poor skin color
• Bubbling or rattling breath sounds
• Decreased O2 saturation

continued on next slide

 Implementing

• Suctioning
▪ Can lead to hypoxemia, trauma to
airways, nosocomial infection, cardiac
dysrhythmia
▪ Decrease complications by:
• Suctioning only as needed
• Using sterile technique
• Not instilling saline

continued on next slide

 Implementing

• Suctioning
▪ Decrease complications by:
• Hyperinflation
• Hyperoxygenation
• Hyperventilation
• Gently rotating catheter, withdrawing
while suctioning, and suctioning for 5–10
seconds
Figure 50–27 Types of suction catheters: A, open tipped; B, whistle tipped.
Figure 50–28 Oral (Yankauer) suction tube.
Skill 50–2 Oropharyngeal, Nasopharyngeal, and
Nasotracheal Suctioning

continued on next slide

Skill 50–2 (continued) Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning

continued on next slide

 Skill 50–2 (continued) Oropharyngeal,
Nasopharyngeal, and Nasotracheal Suctioning

continued on next slide

Skill 50–2 (continued) Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning
 Skill 50–2 (continued) Oropharyngeal,
Nasopharyngeal, and Nasotracheal Suctioning
Skill 50–3 Suctioning a Tracheostomy or
Endotracheal Tube

continued on next slide

Skill 50–3 (continued) Suctioning a
Tracheostomy or Endotracheal Tube

continued on next slide

Skill 50–3 (continued) Suctioning a
Tracheostomy or Endotracheal Tube

continued on next slide

Skill 50–3 (continued) Suctioning a
Tracheostomy or Endotracheal Tube

continued on next slide

Skill 50–3 (continued) Suctioning a
Tracheostomy or Endotracheal Tube

continued on next slide

Skill 50–3 (continued) Suctioning a
Tracheostomy or Endotracheal Tube

continued on next slide

Skill 50–3 (continued) Suctioning a
Tracheostomy or Endotracheal Tube

continued on next slide

Skill 50–3 (continued) Suctioning a
Tracheostomy or Endotracheal Tube
Skill 50–4 Providing Tracheostomy Care

continued on next slide

Skill 50–4 (continued) Providing Tracheostomy
Care

continued on next slide

Skill 50–4 (continued) Providing Tracheostomy
Care

continued on next slide

Skill 50–4 (continued) Providing Tracheostomy
Care

continued on next slide

Skill 50–4 (continued) Providing Tracheostomy
Care

continued on next slide

Skill 50–4 (continued) Providing Tracheostomy
Care

continued on next slide

Skill 50–4 (continued) Providing Tracheostomy
Care

continued on next slide

Skill 50–4 (continued) Providing Tracheostomy
Care

continued on next slide

Skill 50–4 (continued) Providing Tracheostomy
Care

continued on next slide

Skill 50–4 (continued) Providing Tracheostomy
Care

continued on next slide

Skill 50–4 (continued) Providing Tracheostomy
Care
 Implementing

• Chest tubes and drainage systems

▪ Negative pressure between pleural
layers lost by disease, surgery, trauma
leads to:
• Pneumothorax (air)
• Hemothorax (blood)
• Pleural effusion (excessive fluid in pleural
space)

continued on next slide

 Implementing

• Chest tubes and drainage systems

▪ Chest tube to restore pressure and
drain fluid or blood
• Pneumothorax tube (upper chest)
• Hemothorax tube (lower chest)

continued on next slide

 Implementing

• Chest tubes and drainage systems

▪ Disposable chest drainage system
• Suction control chamber
• Water seal chamber
• Closed collection chamber

continued on next slide

Figure 50–31 A disposable chest drainage system.
 Implementing

• Chest tubes and drainage systems

▪ Heimlich chest drain valve
• 1-way flutter valve allows air to escape
from lung.
• For ambulatory clients
▪ Pneumostat system has 1-way valve
and collection chamber
• For pneumothorax

continued on next slide

Figure 50–32 Heimlich chest drain valve.
Figure 50–33 The Pneumostat is an example of a device often used for clients with a pneumothorax. It has a
one-way valve and a small collection chamber.
 Implementing

• Chest tubes and drainage systems

▪ Maintain patency of system
▪ Monitor VS
▪ Observe dressing q 4 h
▪ Ask about pain and medication if
needed

continued on next slide

 Implementing

• Chest tubes and drainage systems

▪ Encourage deep breathing/coughing q 2
h, except with lung removal
▪ Reposition q 2 h
• When on affected side, provide rolls to
protect patency of tubing
▪ Assist with ROM exercise

continued on next slide

 Implementing

• Chest tubes and drainage systems

▪ Ensure secure placement of device and
keep chamber below client's chest
▪ Check system often
▪ Assess drainage tube and chamber and
measure per schedule
▪ Avoid aggressive manipulation or
clamping
• Can produce tension pneumothorax
continued on next slide
 Implementing

• Chest tubes and drainage systems

▪ If tube becomes disconnected,
submerge the end in 1 inch sterile saline
or water
▪ If chest tube is pulled out, immediately
cover with dry sterile dressing
• Do not occlude opening completely, as
this can cause tension pneumothorax

continued on next slide

 Implementing

• Chest tubes and drainage systems

▪ Use PPE when manipulating system or
when assisting with insertion or removal
▪ When transporting and ambulating
client
• Keep water seal unit below chest level
and upright

continued on next slide

 Implementing

• Chest tubes and drainage systems

▪ When transporting and ambulating
client
• Disconnect drainage system from suction
before ambulating
• Ensure air vent is open

continued on next slide

 Implementing

• Chest tubes and drainage systems

▪ Tube insertion and removal
• Sterile technique
• Removal is brief but painful.
• Medicate and prepare dressing prior to
removal
 Evaluating

• Collect data to evaluate effectiveness of

interventions.
• If outcomes not achieved, explore
reasons before modifying the care plan
▪ Review client perceptions and
symptoms, medications, and treatments
 Evaluating

• If outcomes not achieved, explore

reasons before modifying the care plan
▪ Inquire about exposure to URI, other
factors
▪ Ask about sleep, rest, assistive devices,
assistance with ADL, nutrition
Concept Map Ineffective Airway Clearance