Deck 37: Oxygenation

Question 1

IFields, L. (2008). Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. ournol of Neuroscience Nursing,40(S), 291-298.
This was a study of patients in a neurological intensive care unit who were intubated and mechanically ventilated. Nurses were already implementing the Institute of Healthcare Improvement's ventilator-associated pneumonia (we) bundle (which includes elevating the head of the bed to 30°, practicing good hand hygiene, and other interventions).A control group received theVAP bundle and the usual oral care.The intervention group used theVAP bundle and increased tooth brushing to every 8 hours. In the intervention group, theVAP rate dropped to zero within a week.
IHugonnet, S., Uckay, I., Pittet, D. (2007). Staffing level: A determinant of late-onset ventilator-associated pneumonia. Critical Care, 11(4), R80.
In this observational study of 936 patients who underwent mechanical ventilation during their stay in ICU, 262 VAP cases were diagnosed. Using statistical methods, researchers concluded that lower nurse-to-patient ratio is associated with increased risk for late-onset VAR.
Mateoso, J., Gonzalez, N., Sadaba, M., et al. (2011). Nursing II! care in the prevention of ventilator-associated pneumonia. Enferm Intensive,22(1), 22-30.
Researchers observed and described the care of 26 patients with more than 24 hours of invasive mechanical ventilation. They reported good nursing compliance with established protocols for oral hyrne,oropharyngeal suction, turning of patients, and patient tolerance of enteral nutrition. Incidence of VAP was low and well within internationally established ranges.They concluded, nevertheless, that incidence of VAP could be further reduced with better control of endotracheal tube cuff pressures and by elevating the head of the bed to between 30° and 45°.
Which study might you use to convince a hospital administrator to hire more nurses?

Answer 1

According to a study by "Hugonnet, Uckay, Pittett", the number of caregivers is connected with late-onset "ventilator-associated pneumonia." Fewer nurses may greatly increase the risk for developing late-onset VAP. This would contribute to an increase of the length of stay and would not be cost-effective for the hospital.

Question 2

Plan outcomes and interventions for maintaining and improving oxygenation.

Answer 2

Guidelines in planning nursing outcomes that help maintain and improve oxygenation:
The following criteria are used to guide in planning nursing outcomes for patients with oxygenation problems:
• Mechanical ventilation weaning response
• Airway patency
• Gas exchange
• Ventilation
• Vital signs

Question 3

Your patient has pneumonia in the right lower lobe. She is mildly dyspneic with any activity. Strategize how you would perform chest physiotherapy on this patient.What activities would you consider to make this procedure more tolerable for the patient?

Answer 3

Chest physiotherapy:
"Chest physiotherapy" is a procedure used to loosen "lungs and respiratory tract" secretions. It is especially useful for individuals with ineffective coughing or with great amount of "secretions."
It consists of vibration, postural drainage, chest percussion, and " external mechanical maneuvers " that can help in secretion mobilization through "diaphragmatic breathing" with pursed-lips and coughing.

Question 4

William (MeetYour Patients) has a right pneumothorax.Which of the two factors affecting the rate of gas diffusion is causing William to be hypoxemic? If you do not know what a pneumothorax is, look it up.

Question 5

You are the nursing supervisor on the night shift in a small community hospital.At the beginning of the shift, you have only one critical care bed available. During your shift, you receive calls for assistance on the following patients:
Patient A has burns on her face, scalp, and chest and is coughing up sputum with black streaks.
Patient B has pneumonia and has suddenly become confused.
Patient C is short of breath and complaining that he can't breathe. His skin is cool and moist, and he is coughing up clear sputum with small bubbles in it.
Which patient would you admit to the critical care bed? Why?

Question 6

• Describe the difference between pharyngeal and tracheal suctioning.
• How can you ensure that the suction catheter enters the trachea and not the esophagus?

Question 7

PATIENT SITUATION
Haley, a 15-year-old female high-school student, was admitted to the hospital with shortness of breath and right-sided chest pain when breathing. She states that she has had "the flu" for 3 days. She has a history of asthma since age 6, and smokes a half pack of cigarettes a day. Both her parents are heavy smokers, as well. An IV was initiated, and she is receiving 800 mg of vancomycin (an antibiotic) intravenously every 12 hours. She is not on oxygen therapy, but receives 10 incentive spirometer treatments per hour while awake. Her heart rate is 80 beats/min, respiratory rate 24 breaths/min, and blood pressure 110/70 mm Hg. Her skin is pale but warm, and capillary refill time is 2 seconds. She has no clubbing of the fingers. She is urinating approximately 400 mL of clear yellow urine every 8 hours and maintaining a normal bowel elimination pattern.
Laboratory results are:
Red blood cell count (RBCs): 3.56 x 10 6 (3.56 million/mm 3 )
White blood cell count (WBCs): 11,800/mm 3
Hemoglobin: 11.2 g/dL
Hematocrit: 32.7%
Haley says, "I feel really tired, and too weak to even pick up a glass of water." Her cough produces white, thick sputum. Spu-tum culture on admission confirms a diagnosis of streptococcal pneumonia. (Case adapted from C. Green, 2000, pp. 233-234.)
DOING
Practical Knowledge:
Twenty-four hours after the antibiotics were started, Haley's respiratory status becomes worse. She says, "It's so hard to breathe." It is decided to begin administering oxygen. Another sputum culture is prescribed. You are to collect a sputum specimen from the patient.
a. What position should Haley assume for this procedure?
b.What kind of protective clothing do you need for this procedure?
c. You remove the lid from the specimen container. When you hand it to Haley, she touches the inside of the container with her fingers. What should you do?
d. What would you tell Haley to do in order to expectorate the sputum specimen?

Question 8

• What areas should you include in a nursing history for a patient with oxygenation concerns who is undergoing a comprehensive assessment?
• When is a cough significant? What aspects of a cough should be assessed?
• Identify at least five signs that you may observe in a patient experiencing dyspnea.
• A patient has a respiratory rate of 30 breaths/min that is rhythmic and moderate in depth.What term would you use to describe this breathing pattern?

Question 9

Explain how to suction the upper and lower airways.

Question 10

• Describe two ways in which breathing is controlled.
• The level of which gas (oxygen or carbon dioxide) is the primary stimulant for breathing?

Question 11

Safely and correctly perform common nursing procedures related to oxygenation, breathing, and gas exchange.

Question 12

• What is the purpose of mechanical ventilation?
• Why is a chest tube inserted?
• What is the advantage of a three-chamber system (compared to a one-chamber or two-chamber system)?
• How does a portable chest drainage system compare to a water-seal drainage system?

Question 13

Assess oxygenation, breathing, and gas exchange.

Question 14

Review the patients presented in the MeetYour Patients scenario.
Which patients are experiencing respiratory distress? Identify the signs of distress in these patients.
Which patients require a comprehensive assessment, and which patients will need a rapid assessment and immediate treatment because of the severity of their symptoms?

Question 15

Provide care for patients requiring artificial airways.

Question 16

A patient has adequate blood oxygen levels, based on a pulse oximeter reading of 98%. Can you conclude that organ and tissue oxygenation are adequate? Explain your thinking.

Question 17

• What does a pulse oximetry reading tell you?
• What is the relationship between arterial P0 2 and Sa0 2 levels?
• Identify normal P0 2 , Sa0 2 , and PCO₂ levels.
• What effect does ventilation have on arterial PCO₂ ?
• How is PCO₂ related to oxygenation?

Question 18

Provide care for patients requiring mechanical ventilation.

Question 19

PATIENT SITUATION
Haley, a 15-year-old female high-school student, was admitted to the hospital with shortness of breath and right-sided chest pain when breathing. She states that she has had "the flu" for 3 days. She has a history of asthma since age 6, and smokes a half pack of cigarettes a day. Both her parents are heavy smokers, as well. An IV was initiated, and she is receiving 800 mg of vancomycin (an antibiotic) intravenously every 12 hours. She is not on oxygen therapy, but receives 10 incentive spirometer treatments per hour while awake. Her heart rate is 80 beats/min, respiratory rate 24 breaths/min, and blood pressure 110/70 mm Hg. Her skin is pale but warm, and capillary refill time is 2 seconds. She has no clubbing of the fingers. She is urinating approximately 400 mL of clear yellow urine every 8 hours and maintaining a normal bowel elimination pattern.
Laboratory results are:
Red blood cell count (RBCs): 3.56 x 10 6 (3.56 million/mm 3 )
White blood cell count (WBCs): 11,800/mm 3
Hemoglobin: 11.2 g/dL
Hematocrit: 32.7%
Haley says, "I feel really tired, and too weak to even pick up a glass of water." Her cough produces white, thick sputum. Spu-tum culture on admission confirms a diagnosis of streptococcal pneumonia. (Case adapted from C. Green, 2000, pp. 233-234.)
DOING
Nursing Process (Assessment): In the admission data, what important information is missing with regard to her respiratory status?

Question 20

Evaluate adequacy of oxygenation, breathing, and gas exchange, and modify nursing activities appropriately based on outcomes.

Question 21

Provide care for patients requiring chest tubes.

Question 22

• What are the major risks to oxygenation related to developmental factors?
• What environmental and lifestyle factors that influence ventilation can be avoided or minimized?

Question 23

You hear a pulse oximeter alarm sound in a nearby patient room and find it reading 75%.
What observations should you make?
What actions should you take?

Question 24

Provide measures to promote oxygenation.

Question 25

PATIENT SITUATION
Haley, a 15-year-old female high-school student, was admitted to the hospital with shortness of breath and right-sided chest pain when breathing. She states that she has had "the flu" for 3 days. She has a history of asthma since age 6, and smokes a half pack of cigarettes a day. Both her parents are heavy smokers, as well. An IV was initiated, and she is receiving 800 mg of vancomycin (an antibiotic) intravenously every 12 hours. She is not on oxygen therapy, but receives 10 incentive spirometer treatments per hour while awake. Her heart rate is 80 beats/min, respiratory rate 24 breaths/min, and blood pressure 110/70 mm Hg. Her skin is pale but warm, and capillary refill time is 2 seconds. She has no clubbing of the fingers. She is urinating approximately 400 mL of clear yellow urine every 8 hours and maintaining a normal bowel elimination pattern.
Laboratory results are:
Red blood cell count (RBCs): 3.56 x 10 6 (3.56 million/mm 3 )
White blood cell count (WBCs): 11,800/mm 3
Hemoglobin: 11.2 g/dL
Hematocrit: 32.7%
Haley says, "I feel really tired, and too weak to even pick up a glass of water." Her cough produces white, thick sputum. Spu-tum culture on admission confirms a diagnosis of streptococcal pneumonia. (Case adapted from C. Green, 2000, pp. 233-234.)
THINKING
Theoretical Knowledge:
a. According to the Centers for Disease Control and Prevention, should Haley have received a pneumonia immunization? Why or why not?
b.What is clubbing of the fingers? You may wish to refer to Chapter 21 for review, or to a medical-surgical nursing text.

Question 26

Interpret diagnostic testing related to oxygenation, breathing, and gas exchange.

Question 27

Identify at least three nursing interventions to promote optimal respiratory function in a hospitalized patient with chronic lung disease.

Question 28

Recognize medications used to enhance pulmonary function.

Question 29

• What happens to inhaled air in the airways? How does this occur?
• In which structures of the lung does gas exchange take place?
• What does surfactant do for alveoli?

Question 30

Review the MeetYour Patients scenario at the beginning of this chapter.
Which patient(s) may be experiencing developmental, environmental, or lifestyle-related problems with oxygenation?
Identify any additional information you need to know to answer this question.

Question 31

Describe a procedure for safe oxygen administration.

Question 32

Use identified outcomes to evaluate care for patients with oxygenation probl ems

Question 33

Describe the structure and function of the respiratory system.

Question 34

PATIENT SITUATION
Haley, a 15-year-old female high-school student, was admitted to the hospital with shortness of breath and right-sided chest pain when breathing. She states that she has had "the flu" for 3 days. She has a history of asthma since age 6, and smokes a half pack of cigarettes a day. Both her parents are heavy smokers, as well. An IV was initiated, and she is receiving 800 mg of vancomycin (an antibiotic) intravenously every 12 hours. She is not on oxygen therapy, but receives 10 incentive spirometer treatments per hour while awake. Her heart rate is 80 beats/min, respiratory rate 24 breaths/min, and blood pressure 110/70 mm Hg. Her skin is pale but warm, and capillary refill time is 2 seconds. She has no clubbing of the fingers. She is urinating approximately 400 mL of clear yellow urine every 8 hours and maintaining a normal bowel elimination pattern.
Laboratory results are:
Red blood cell count (RBCs): 3.56 x 10 6 (3.56 million/mm 3 )
White blood cell count (WBCs): 11,800/mm 3
Hemoglobin: 11.2 g/dL
Hematocrit: 32.7%
Haley says, "I feel really tired, and too weak to even pick up a glass of water." Her cough produces white, thick sputum. Spu-tum culture on admission confirms a diagnosis of streptococcal pneumonia. (Case adapted from C. Green, 2000, pp. 233-234.)
CARING
Self-Knowledge:
Describe one or two patient care experiences you might draw upon to help you in caring for Haley. In what ways were those patients similar to Haley, and how might that help you?

Question 35

You are caring for two patients, both of whom have a P0 2 of 95 mm Hg and Sa0 2 of 99%. Do they have similar lung function? Explain your answer.

Question 36

IFields, L. (2008). Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. ournol of Neuroscience Nursing,40(S), 291-298.
This was a study of patients in a neurological intensive care unit who were intubated and mechanically ventilated. Nurses were already implementing the Institute of Healthcare Improvement's ventilator-associated pneumonia (we) bundle (which includes elevating the head of the bed to 30°, practicing good hand hygiene, and other interventions).A control group received theVAP bundle and the usual oral care.The intervention group used theVAP bundle and increased tooth brushing to every 8 hours. In the intervention group, theVAP rate dropped to zero within a week.
IHugonnet, S., Uckay, I., Pittet, D. (2007). Staffing level: A determinant of late-onset ventilator-associated pneumonia. Critical Care, 11(4), R80.
In this observational study of 936 patients who underwent mechanical ventilation during their stay in ICU, 262 VAP cases were diagnosed. Using statistical methods, researchers concluded that lower nurse-to-patient ratio is associated with increased risk for late-onset VAR.
Mateoso, J., Gonzalez, N., Sadaba, M., et al. (2011). Nursing II! care in the prevention of ventilator-associated pneumonia. Enferm Intensive,22(1), 22-30.
Researchers observed and described the care of 26 patients with more than 24 hours of invasive mechanical ventilation. They reported good nursing compliance with established protocols for oral hyrne,oropharyngeal suction, turning of patients, and patient tolerance of enteral nutrition. Incidence of VAP was low and well within internationally established ranges.They concluded, nevertheless, that incidence of VAP could be further reduced with better control of endotracheal tube cuff pressures and by elevating the head of the bed to between 30° and 45°.
Based on these study fin dings, list two interventions a staff nurse could do to help prevent VAP.

Question 37

• What are some indirect indicators of tissue oxygenation?
• How are hyperventilation and hypoventilation related to carbon dioxide levels?
• What are the effects of carbon dioxide levels on the nervous system?

Question 38

• Why is oxygen humidified?
• Which oxygen delivery method is appropriate for the following patients? A patient prescribed to receive 2 Umin of oxygen A patient who complains of being claustrophobic and requires low-flow humidified oxygen A patient with chronic obstructive pulmonary disease (COPD) with an order for oxygen at an F10 2 of 24% A patient who wants to avoid intubation but requires an F10 2 of 100%

Question 39

You are assigned to care for an adult patient who has a medical condition with which you are not familiar.You look it up and find that the condition causes a dramatic loss of surfactant. Based on your knowledge of the function of surfactant,what problems is this patient at high risk for developing?

Question 40

Develop nursing diagnoses related to oxygenation, breathing, and gas exchange.

Question 41

Describe measures for mobilizing airway secretions.

Question 42

PATIENT SITUATION
Haley, a 15-year-old female high-school student, was admitted to the hospital with shortness of breath and right-sided chest pain when breathing. She states that she has had "the flu" for 3 days. She has a history of asthma since age 6, and smokes a half pack of cigarettes a day. Both her parents are heavy smokers, as well. An IV was initiated, and she is receiving 800 mg of vancomycin (an antibiotic) intravenously every 12 hours. She is not on oxygen therapy, but receives 10 incentive spirometer treatments per hour while awake. Her heart rate is 80 beats/min, respiratory rate 24 breaths/min, and blood pressure 110/70 mm Hg. Her skin is pale but warm, and capillary refill time is 2 seconds. She has no clubbing of the fingers. She is urinating approximately 400 mL of clear yellow urine every 8 hours and maintaining a normal bowel elimination pattern.
Laboratory results are:
Red blood cell count (RBCs): 3.56 x 10 6 (3.56 million/mm 3 )
White blood cell count (WBCs): 11,800/mm 3
Hemoglobin: 11.2 g/dL
Hematocrit: 32.7%
Haley says, "I feel really tired, and too weak to even pick up a glass of water." Her cough produces white, thick sputum. Spu-tum culture on admission confirms a diagnosis of streptococcal pneumonia. (Case adapted from C. Green, 2000, pp. 233-234.)
THINKING
Critical Thinking (Analyzing Assumptions): Why is it a positive finding for Haley that she does not have dubbed fingers?

Question 43

You are assessing a very anxious young man who looks frightened and is complaining of trouble breathing. His respiratory rate is 32 breaths/min and deep. He states his fingers and hands are numl
What is the most likely cause?
What blood levels would help you clarify what is going on?

Question 44

Review the MeetYour Patients scenario. For which of these patients should you recommend annual flu or pneumonia immunizations? Why?
A 24-year-old nursing student has no previous hospitalizations or known chronic health problems, takes no medications, and has no current respiratory symptoms. On routine purified protein derivative, or PPD, testing (tuberculin skin testing), the student has an area of induration measuring 5 mm. How would you interpret these results?

Question 45

• What is the difference between ventilation and respiration?
• Describe how the diaphragm, accessory muscles, and pressure changes within the lungs create inhalation and exhalation.
• How does hypoventilation affect risk for hypoxemia and hypoxia?

Question 46

PATIENT SITUATION
Haley, a 15-year-old female high-school student, was admitted to the hospital with shortness of breath and right-sided chest pain when breathing. She states that she has had "the flu" for 3 days. She has a history of asthma since age 6, and smokes a half pack of cigarettes a day. Both her parents are heavy smokers, as well. An IV was initiated, and she is receiving 800 mg of vancomycin (an antibiotic) intravenously every 12 hours. She is not on oxygen therapy, but receives 10 incentive spirometer treatments per hour while awake. Her heart rate is 80 beats/min, respiratory rate 24 breaths/min, and blood pressure 110/70 mm Hg. Her skin is pale but warm, and capillary refill time is 2 seconds. She has no clubbing of the fingers. She is urinating approximately 400 mL of clear yellow urine every 8 hours and maintaining a normal bowel elimination pattern.
Laboratory results are:
Red blood cell count (RBCs): 3.56 x 10 6 (3.56 million/mm 3 )
White blood cell count (WBCs): 11,800/mm 3
Hemoglobin: 11.2 g/dL
Hematocrit: 32.7%
Haley says, "I feel really tired, and too weak to even pick up a glass of water." Her cough produces white, thick sputum. Spu-tum culture on admission confirms a diagnosis of streptococcal pneumonia. (Case adapted from C. Green, 2000, pp. 233-234.)
CARING
Ethical Knowledge:
After you finish collecting the sputum specimen, what do you think Haley's biggest concern is right now?

Question 47

• In what circumstances would you use an oropharyngeal airway? A nasopharyngeal airway?
• What facts should you record if a patient is intubated?
• Describe seven interventions associated with caring for a patient with an endotracheal tube.

Question 48

Identify individual, environmental, and pathological factors that influence oxygenation.

Question 49

• Identify four pathophysiological conditions that affect pulmonary function. How are they similar? How are they different?
• What types of injuries are most likely to cause oxygenation problems?

Question 50

Implement measures for promoting optimal respiratory function (e.g., positioning).