Prepared by:

Shellah Marie Ostrea- Mamawag

Nursing Fundamentals
Focus VIII


 oxygenation

-is a basic human need
- Breathing is synonymous to life, thus, oxygen is
required to sustain life

2 body systems that supply the body’s oxygen demands

 Cardiovascular system
 0 Respiratory system
 Pulse Oximetry

 Non-invasive
 Estimates arterial blood oxygen saturation (SpO2)
 Normal SpO2 95-100%
 < 70% - life threatening
 Detects hypoxemia (low oxygen; more in blood)
 Pulse Oximetry

Factors that affect accuracy include
 Hemoglobin level
 Circulation
 Activity
 Carbon monoxide poisoning
 Respiration

Processes
 Ventilation
 Diffusion
 Perfusion
 Ventilation

Factors influencing ventilation
 Adequate atmosphere oxygen
 Clear air passages
 Adequate pulmonary compliance and recoil
 Regulation of respiration
 Diffusion

Factors influencing diffusion of gasses
 Thickness of membrane
 Surface area of the membrane
 Diffusion coefficient of gasses
 Pressure gradient on each side of the membrane
 Perfusion

Factors affecting oxygen transport from lungs to the
tissues
 Cardiac output
 Number of erythrocytes
 Exercise
 Blood hematocrit
 Factors Affecting
Oxygenation

 Environment (altitude, heat, cold, air pollution)
 Exercise
 Emotions (fear, anxiety, anger)
 Lifestyles (smoking, occupations, sedentary life, etc)
 Health status (anemia [low red blood
cells]respiratory)
 Narcotics (morphine, demErol, etc)
 3 Major Alterations in
Respiratory Functions

1. Hypoxia
 Respiratory insufficiency
 Acapnia (absence of CO2 in blood)
 Hypocarbia -Depressed level of CO2 in the blood
 Hyperpnea (deep ,rapid breathing)
 Hypopnea (slow breathing)
 Rapid pulse,
 Signs of Hypoxia

Early/ acute signs
 Restlessness
 Increased pulse rate
 Increased rate and depth of respiration
 Increase in systolic blood pressures
 Signs of Hypoxia

Late/chronic signs
 Decreased pulse rate
 Decreased systolic blood pressure
 Dyspnea
 Fatigue and lethargy
 Cough
 Hemoptysis
 Clubbing of fingers
 3 Major Alterations in
Respiratory Functions

2. Altered breathing patterns
 - Rate
 - Volume (hypo or hyper)
 - Rhythm (Cheyne Stokes, Kussmaul’s, Apneustic,
and BiOt’s)
 Relative case of effort respiration (dyspnea and
orthopnoea)
 3 Major Alterations in
Respiratory Functions

3. Obstructive or particularly obstructive airways
 Upper airway, obstruction in nose, pharynx, larynx,
trachea
 Assessment of
Oxygenation

• Physical examination
–Inspection
–Palpation
–Percussion
–Auscultation
 Assessment of
Oxygenation (cont'd)

Diagnostic tests:
blood studies
–Complete blood count
–Cardiac enzymes
–Cardiac troponin I
–Serum electrolytes
–Cholesterol
 Assessment of
Oxygenation (cont'd)

Diagnostic tests:
cardiac function
–Electrocardiogram (ECG)
–Holter monitor
–Exercise stress test
–Thallium stress test
–Electrophysiological study (EPS)
–Echocardiography
–Scintigraphy
–Cardiac catheterization
 Assessment of
Oxygenation (cont'd)

Diagnostic tests:
ventilation studies
–Pulmonary function
–Peak expiratory flow rate (PEFR)
–Arterial blood gases
–Oximetry
–Chest x-ray
–Bronchoscopy
–Lung scan
 
 Diagnostic tests:
ventilation studies (cont'd)
–Thoracentesis
–Throat cultures
–Sputum specimens
 Planning

 Goals and outcomes
–Client’s lungs are clear on auscultation
–Client coughs productively
• Setting priorities
• Continuity of care
 Implementation: Health
Promotion

Body weight
• Diet
• Exercise
• Stress reduction
• Occupational safety
• Smoke-free
• Regular physical examinations
 
 Vaccinations/immunizations
–Influenza
–Pneumonia
 Implementation: Acute
Care

Dyspnea management
• Airway maintenance
–Mobilization of secretions
–Suctioning
–Artificial airways
 Implementation: Acute
Care (cont'd)

Maintenance and promotion of lung expansion
–Positioning
–Incentive spirometry
–Chest tubes
 Implementation: Acute
Care (cont'd)

Maintenance and promotion of oxygenation:
oxygen therapy
–Safety precautions
–Oxygen supply
–Methods of oxygen delivery
–Home oxygen therapy
 Implementation: Acute
Care (cont'd)

 Restoration of cardiopulmonary functioning
—CPR
 Implementation:
Restorative Care

• Hydration
• Coughing techniques
• Respiratory muscle training
• Breathing exercises
 Evaluation

Client care
• Client expectations
 Nursing Diagnoses

• Ineffective airway clearance
• Ineffective breathing pattern
• Decreased cardiac output
• Impaired gas exchange
• Risk for infection
• Ineffective tissue perfusion
• Impaired spontaneous ventilation
NANDA Nursing Diagnosis
Related to Oxygenation

1. Ineffective airway clearance
 Refers to inability of the individual to clear
secretions or obstruction from the respiratory tract to
maintain airway patency
 Tracheobrachial infections
 Obstructions, SECRETIONS
 NANDA Nursing
Diagnosis
Related to 
Oxygenation
2. Ineffective breathing pattern
 Refers to and individual’s inhalation or exhalation
pattern that inhibits adequate ventilation
 Neuromuscular
 Pain, anxiety
 Decreased energy and fatigue
 Inflammatory process
 NANDA Nursing
Diagnosis

Related to Oxygenation
3. Decreased cardiac output
 State in which the blood pumped by the heart is
sufficiently reduced that it is inadequate to meet the
needs of the body
 Structural alteration
 -Ventricular – septal rupture, valvular disease
 NANDA Nursing
Diagnosis
Related to 
Oxygenation
4. Impaired gas exchange
 State in which there is an imbalance between O2
And CO2 elimination at the alveolar capillary
membrane gas exchange area
 Altered O2 supply
 Altered bloOD
 NANDA Nursing
Diagnosis
Related to 
Oxygenation
 5. Altered tissue perfusion
>State in which an individual experiences a decrease
in nutrition and oxygenation at the cellular level
because of a deficit in capillary blood supply
>Interrupted venous or arterial flow
>Hypo/hypervolemia
 Measures That Promote
Adequate Respiratory
Function

 1. Ensure a patent airway
> To promote gaseous exchange between client and
environment
> Check for obstructions
>Foreign objects, mucus
2. Positioning
> To allow maximum chest expansion
Fowler’s position
Encourage frequent changes
 Measures That Promote
Adequate Respiratory
Function

 3. Deep breathing and coughing exercises
> To promote lung expansion and loosen secretions
E.g. abdominal breathing (diaphragmatic and
pursed lip)
4. Adequate hydration
 > Maintain moisture of the respiratory mucus
membrane
 > Use of humidifiers/ nebulizers
 >Steam/ aerosol/ medimist
 Measures That Promote
Adequate Respiratory
Function

5. Chest physiotherapy
> Percussion
Forceful striking of skin with cupped hands
>Vibration
Serves of vigorous quivering produced by hands that
are placed flat against clients chest wall; done during
exhalation
> Postural drainage
Drainage by gravity of secretions from various lung
segments
 Measures That Promote
Adequate Respiratory
Function

6. Proper suctioning
> A catheter – for 12-18 mmHg, tip of mouth to
earlobe 5 meters suction 5-10 seconds, max is 15
seconds, wall suction 80-120 mmHg
7. Avoid environmental pollutants = smoking
 Measures That Promote
Adequate Respiratory
Function

8. Using inflation devices
> Incentive spirometry – to enhance deep inspiration
>Intermittent positive pressure breathing
-To administer O2 at pressures higher than the
atmospheric pressure
9. Administration of supplemental O2
> Nasal cannula
 Nursing Implication

 Since oxygen is colorless, odorless, and tasteless,
leakage can’t be detected
 Since oxygen is dry, gas mucus membrane invitation
could happen
 Nursing Planning, Intervention,
and Evaluation in O2
Administration

 Assess Signs and Sx of hypoxemia
 Check doctor’s orders
 Open source before insertion of device
 Regulate accurately
 Place a “No Smoking” sign
 Avoid use of oil, grease, and alcohol
 Nursing Planning,
Intervention,
and Evaluation in O2

Administration
 Check of electrical device malfunction
 Avoid using materials that could generate static
electricity
 Humidify O2
 Provide good oro-nasal hygiene
 Lubricate with water soluble stuff
 Document
 Situation 1

Patient Jim diagnosed
Of COPD exacerbation.
S/Sx:
-wheezing on bilateral
upper lobes during
expiration.
- O2 sat. of 90%
- RR: 26 b/min
 Situation 2

Data:
“S/P Laparoscopic Cholecystectomy.
- Patient complaining of 8/10 acute aching pain to the
right upper quadrant of the abdomen
 Situation 3

Patient has history of HTN and patient having multiple
blood pressure medication.
Medications are: Norvasc 5 mg daily, atenolol 25mg
BID, Clonidine 0.1 mg PO q 6 hours PRN for systolic BP
greater than 160 or diastolic BP greater than 90.
Vital signs: BP -130/70 mmhg
PR- 88 b/min
 Situation 3

Mrs. Enad is a 41 years old, accounting staff who was
admitted to hospital with an elevated temperature,
fatigue,rapid loud respirations,and mild dehydration.
The nursing history reveals that Mrs. Has had a “ bad
cold” for several weeks that just wouldn’t go away. She
has been dieting for several months and skipping
meals .Mrs enad mention that in addition to her full
time job as a secretary she is attending college classes
two evening a week. She has smoked one package of
cigarettes per day since she was 20 years old. Chest X-
ray confirms Pneumonia.
 Physical Examination

 Height: 5’6 Dx Data:
 Weight: 54.4 kg
 Temperature: 39.4
 Chest X- Ray: Right
 Pulse: 68 beats/min lobar infiltration
 Respirations: 24/min  WBC: 14,000
 BP: 120/70 mmhg  Ph: 7.49
 Skin: Pale; cheeks flushed
 Chills; use of accessory
 PaCO2: 33 mmhg
muscles  HCO3: 20 meq/L
 Inspiratory crackles with  PaO2: 80 mmhg
diminished breath sounds
right base; expectorating  O2 sat: 88%
thick, yellow sputum
 We get up early and don’t
have time to drink coffee over
newspaper. We come home
late and are too tired to cook.
We work extra because we
know there are families who
needs us. We dont get excited
over minor crisis because we
deal with issues all day. We
have seen the worse. We dont
want to talk when we come
home.we have talked all day.
We dont want to move when Scared we will let our patients and
families down. We have to deal
we come home. We have with angry families and all the
moved all day. It may seem, we while do our best to help them. We
have left all our caring, our dont tell you the trauma we see
heart and our love at work, affects us and how stressed we are
then come home feeling empty. for the pain our families are going
We probably are empty but we through. Im a nurse, and there are
dont tell you that many times some days when its the hardest
at work we are scared work i have ever done