8.1. OXYGENATION INTRODUCTION
Learning Objectives
Assess the patient for objective and subjective manifestations of impaired oxygenation
Distinguish normal and abnormal assessment data
Adapt care based on oxygenation assessment data
Interpret diagnostic tests and lab values indicative of a disturbance in oxygenation
Identify evidence-based practices
Sufficient oxygenation is vital to maintain life. When prioritizing nursing interventions, we often refer to using the “ABCs,” an acronym used to signify the importance of maintaining a patient’s airway, breathing, and circulation. Several body systems work collaboratively during the oxygenation process to take in oxygen from the air, carry it through the bloodstream, and adequately oxygenate tissues. It is important that all parts of the system work together to ensure that oxygen is delivered appropriately to tissues within each system. Any alteration in these systems can have catastrophic implications on a patient’s health. First, the airway must be open and clear. The chest and lungs must mechanically move air in and out of the lungs. The bronchial airways must be open so that air can reach the alveoli, where the exchange of oxygen and carbon dioxide occurs. The heart must effectively pump oxygenated blood from the lungs and through the systemic arteries. There must be adequate amounts of hemoglobin in the blood to sufficiently carry the oxygen molecules to the tissues. However, several medical conditions such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, heart disease, and anemia can impair the body’s ability to effectively complete this oxygenation process.[1]This chapter will review these basic concepts related to oxygenation and apply the nursing process to patients who are experiencing alterations in oxygenation.
References
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This work is a derivative ofNursing SkillsbyOpen RNlicensed underCC BY 4.0↵.
8.2. OXYGENATION BASIC CONCEPTS
Several body systems contribute to a person’s oxygenation status, including the respiratory, cardiovascular, and hematological systems. These systems are reviewed in the following sections.
Respiratory System
The main function of our respiratory system is to provide the body with a constant supply of oxygen and to remove carbon dioxide. To achieve these functions, muscles and structures of the thorax create the mechanical movement of air into and out of the lungs calledventilation. Gas exchange occurs at the alveolar level where blood is oxygenated and carbon dioxide is removed, which is calledrespiration. Several respiratory conditions can affect a patient’s ability to maintain adequate ventilation and respiration, and there are several medications used to enhance a patient’s oxygenation status. Use the following hyperlinks to review information regarding the anatomy and physiology of the respiratory system, common respiratory conditions, and classes of respiratory medications.
Read additional information about the “Respiratory System” in Open RNNursing Pharmacologyor use the following hyperlinks to go to specific subsections of the chapter:
Review theanatomy and physiologyof the respiratory system.
Learn aboutcommon respiratory disorders.
Read about commonrespiratory medications
.
Cardiovascular System
In order for oxygenated blood to move from the alveoli in the lungs to the various organs and tissues of the body, the heart must adequately pump blood through the systemic arteries. The amount of blood that the heart pumps in one minute is referred to ascardiac output. The passage of blood through arteries to an organ or tissue is referred to asperfusion. Several cardiac conditions can adversely affect cardiac output and perfusion in the body. There are several medications used to enhance a patient’s cardiac output and maintain adequate perfusion to organs and tissues throughout the body. Use the following hyperlinks to review information regarding the anatomy and physiology of the cardiovascular system, common cardiac disorders, and various cardiovascular system medications.
Read additional information about the cardiovascular system in the “Cardiovascular & Renal” chapter in Open RNNursing Pharmacologyor use the following hyperlinks to go to specific subsections of this chapter:
Review theanatomy and physiologyof the cardiovascular system.
Learn aboutcommon cardiac disorders.
Read about commoncardiovascular system medications.
Hematological System
Although the bloodstream carries small amounts of dissolved oxygen, the majority of oxygen molecules are transported throughout the body by attaching to hemoglobin within red blood cells. Each hemoglobin protein is capable of carrying four oxygen molecules. When all four hemoglobin structures contain an oxygen molecule, it is referred to as “saturated.”[1]See Figure 8.1[2]for an image of hemoglobin protein within a red blood cell with four sites for carrying oxygen molecules.
Figure 8.1
Hemoglobin
When oxygenated blood reaches tissues within the body, oxygen is released from the hemoglobin, and carbon dioxide is picked up and transported to the lungs for release on exhalation. Carbon dioxide is transported throughout the body by three major mechanisms: dissolved carbon dioxide, attachment to water as HCO3-, and attachment to the hemoglobin in red blood cells.[3]See Figure 8.2[4]for an illustration of carbon dioxide transport.[5]
Figure 8.2
Carbon Dioxide Transport
Measuring Oxygen, Carbon Dioxide, and Acid Base Levels
Because the majority of oxygen transported in the blood is attached to hemoglobin, a patient’s oxygenation status is easily assessed using pulse oximetry, referred to asSpO2. See Figure 8.3[6]for an image of a pulse oximeter. This reading refers to the amount of hemoglobin that is saturated. The target range of SpO2 for an adult is 94-98%.[7]For patients with chronic oxygenation conditions such as COPD, the target range for SpO2 is often lower at 88% to 92%. Although SpO2 is an efficient, noninvasive method for assessing a patient’s oxygenation status, it is not always accurate. For example, if a patient is severely anemic, the patient has a decreased amount of hemoglobin in the blood available to carry the oxygen, which subsequently affects the SpO2 reading. Decreased perfusion of the extremities can also cause inaccurate SpO2 levels because less blood delivered to the tissues causes a false low SpO2. Additionally, other substances can attach to hemoglobin such as carbon monoxide, causing a falsely elevated SpO2.
Figure 8.3
Portable Pulse Oximeter
A more specific measurement of oxygen and carbon dioxide in the blood is obtained using anarterial blood gas (ABG). ABG results are often used for patients who have deteriorating or unstable respiratory status requiring emergency treatment. An ABG is a blood sample that is typically drawn from the radial artery by a respiratory therapist. ABG results indicate oxygen, carbon dioxide, pH, and bicarbonate levels. The partial pressure of oxygen in the arterial blood is referred to asPaO2. PaO2 measures the pressure of oxygen dissolved in the arterial blood and how well oxygen is able to move from the lungs into the blood. The normal PaO2 level of a healthy adult is 80 to 100 mmHg. The PaO2 reading is more accurate than a SpO2 reading because it is not affected by hemoglobin levels. The partial pressure of carbon dioxide in the arterial blood is thePaCO2level. The PaCO2 level measures the pressure of carbon dioxide dissolved in the blood and how well carbon dioxide is able to move out of the body. It is typically used to determine if sufficient ventilation is occurring at the alveolar level. The normal PaCO2 level of a healthy adult is 35-45 mmHg. The normal range ofpHlevel for arterial blood is 7.35-7.45, and the normal range for the bicarbonate (HCO3-) level is 22-26. TheSaO2level is also calculated in ABG results, which is the calculated arterial oxygen saturation level.[8]
Hypoxia and Hypercapnia
Hypoxiais defined as a reduced level of tissue oxygenation. Hypoxia has many causes, ranging from respiratory and cardiac conditions to anemia.Hypoxemiais a specific type of hypoxia that is defined as decreased partial pressure of oxygen in the blood (PaO2) indicated in an arterial blood gas (ABG) result.
Early signs of hypoxia are anxiety, confusion, and restlessness. As hypoxia worsens, the patient’s level of consciousness and vital signs will worsen with an increased respiratory rate and heart rate and decreased pulse oximetry readings. Late signs of hypoxia include bluish discoloration of the skin and mucous membranes called cyanosis. See Figure 8.4[9]for an image of cyanosis.
Figure 8.4
Cyanosis
Hypercapnia, also referred to as hypercarbia, is an elevated level of carbon dioxide in the blood. This level is measured by the PaCO2 level in an ABG test and is indicated when the PaCO2 level is greater than 45. Hypercapnia is caused by hypoventilation or when the alveoli are ventilated but not perfused. In a state of hypercapnia, the accumulation of carbon dioxide in the blood causes the pH of the blood to drop, leading to a state of respiratory acidosis. You can read more about respiratory acidosis in the “Acid-Base Balance” section of the “Fluids and Electrolytes” chapter. Patients with hypercapnia have symptoms such as tachycardia, dyspnea, flushed skin, confusion, headaches, and dizziness. If the hypercapnia develops gradually over time, symptoms may be mild or may not be present at all. Hypercapnia is managed by addressing its underlying cause. A noninvasive positive pressure device such as a BiPAP may be used to help eliminate the excess carbon dioxide, but if this is not sufficient, intubation may be required.[10]You can read more about BiPAP devices and intubation in the “Oxygen Therapy” chapter in Open RNNursing Skills.
It is important for a nurse to recognize early signs of respiratory distress and report changes in patient condition to prevent respiratory failure. See Table 8.2a for symptoms and signs of respiratory distress.[11]
Table 8.2a
Symptoms and Signs of Respiratory Distress
Treating Hypoxia and Hypercapnia
Hypoxia and/or hypercapnia are medical emergencies and should be treated promptly by calling for assistance as indicated by agency policy.
Failure to initiate oxygen therapy when needed can result in serious harm or death of the patient. Although oxygen is considered a medication that requires a prescription, oxygen therapy may be initiated without a physician’s order in emergency situations as part of the nurse’s response to the “ABCs,” a common abbreviation for airway, breathing, and circulation. Most agencies have a protocol in place that allows nurses to apply oxygen in emergency situations and obtain the necessary order at a later time.[12]
In addition to administering oxygen therapy, there are several other interventions a nurse can implement to assist an hypoxic patient. Additional interventions used to treat hypoxia in conjunction with oxygen therapy are outlined in Table 8.2b.
Table 8.2b
Interventions to Manage Hypoxia
Enhanced Breathing and Coughing Techniques
In addition to oxygen therapy and the interventions listed in Table 8.2b, there are several techniques a nurse can teach a patient to use to enhance their breathing and coughing. These techniques include pursed-lip breathing, incentive spirometry, coughing and deep breathing, and the huffing technique. Additionally, vibratory positive expiratory pressure (PEP) therapy can be incorporated in collaboration with a respiratory therapist.
PURSED-LIP BREATHING
Pursed-lip breathingis a technique that decreases dyspnea by teaching people to control their oxygenation and ventilation. See Figure 8.5[13]for an illustration of pursed-lip breathing. The technique teaches a person to inhale through the nose and exhale through the mouth at a slow, controlled flow. This type of exhalation gives the person a puckered or pursed-lip appearance. By prolonging the expiratory phase of respiration, a small amount of positive end-expiratory pressure (PEEP) is created in the airways that helps to keep them open so that more air can be exhaled. This subsequently reduces air trapping that commonly occurs in conditions such as chronic obstructive pulmonary disease (COPD). Pursed-lip breathing relieves the feeling of shortness of breath, decreases the work of breathing, and improves gas exchange. People also regain a sense of control over their breathing while simultaneously increasing their relaxation.[14]
Figure 8.5
Pursed-Lip Breathing
INCENTIVE SPIROMETRY
Anincentive spirometeris a medical device commonly prescribed after surgery to expand the lungs, reduce the buildup of fluid in the lungs, and prevent pneumonia. See Figure 8.6[15]for an image of a patient using an incentive spirometer. While sitting upright, if possible, the patient should place the mouthpiece in their mouth and create a tight seal with their lips around it. They should breathe in slowly and as deeply as possible through the tubing with the goal of raising the piston to their prescribed level. The resistance indicator on the right side should be monitored to ensure they are not breathing in too quickly. The patient should attempt to hold their breath for as long as possible (at least 5 seconds) and then exhale and rest for a few seconds. Coughing is expected. Encourage the patient to expel the mucus and not swallow it. This technique should be repeated by the patient 10 times every hour while awake.[16]The nurse may delegate this intervention to unlicensed assistive personnel, but the frequency in which it is completed and the volume achieved should be documented and monitored by the nurse.
Figure 8.6
Using an Incentive Spirometer
Using an incentive spirometer can feel monotonous to patients, resulting in the lack of performing this important activity to prevent pneumonia. It is helpful to encourage patients to create easy reminders to complete the activity. For example, many patients watch television. Create the reminder to use the incentive spirometer each time they view a commercial. This is a helpful trigger to use the incentive spirometer frequently.
COUGHING AND DEEP BREATHING
Coughing and deep breathingis a breathing technique similar to incentive spirometry but no device is required. The patient is encouraged to take deep, slow breaths and then exhale slowly. After each set of breaths, the patient should cough. This technique is repeated 3 to 5 times every hour.
HUFFING TECHNIQUE
Thehuffing techniqueis helpful to teach patients who have difficulty coughing. Teach the patient to inhale with a medium-sized breath and then make a sound like “ha” to push the air out quickly with the mouth slightly open.
VIBRATORY PEP THERAPY
Vibratory Positive Expiratory Pressure (PEP) Therapyuses handheld devices such as flutter valves or Acapella devices for patients who need assistance in clearing mucus from their airways. These devices require a prescription and are used in collaboration with a respiratory therapist or advanced health care provider. To use vibratory PEP therapy, the patient should sit up, take a deep breath, and blow into the device. A flutter valve within the device creates vibrations that help break up the mucus so the patient can cough and spit it out. Additionally, a small amount of positive end-expiratory pressure (PEEP) is created in the airways that helps to keep them open so that more air can be exhaled. See the supplementary video below regarding how to use the flutter valve device.
View this video onUsing a Flutter Valve Device (Acapella).[17]
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8.3. APPLYING THE NURSING PROCESS
Now that we have discussed various concepts related to oxygenation and hypoxia, we will explain how a nurse uses the nursing process to care for patients with alterations in oxygenation.
Assessment
When assessing a patient’s oxygenation status, there are several subjective and objective assessments to include.
Subjective Assessment
The primary symptom to assess when a patient is experiencing decreased oxygenation is their level of dyspnea, the medical term for the subjective feeling of shortness of breath or difficulty breathing. Patients can be asked to rate their dyspnea on a scale of 0-10, similar to using a pain rating scale.[1]The feeling of dyspnea can be very disabling for patients. There are many interventions that a nurse can implement to help improve the feeling of dyspnea and, thus, improve a patient’s overall quality of life.
It is also important to ask patients if they are experiencing a cough. If a cough is present, determine if sputum is present, and if so, the color and amount of sputum.Sputumis mucus and other secretions that are coughed up from the mouth. The body always produces mucus to keep the delicate tissues of the respiratory tract moist so small particles of foreign matter can be trapped and forced out, but when there is an infection in the lungs, an excess of mucus is produced. The body attempts to get rid of this excess by coughing it up as sputum. The color of a patient’s sputum can provide cues for underlying medical conditions. For example, sputum caused by a respiratory infection is often yellow or green and often referred to aspurulent sputum.[2]See Figure 8.7[3]for an image of purulent sputum.
Figure 8.7
Purulent Sputum
Patients should be asked if they are experiencing chest pain. Chest pain can occur with several types of respiratory and cardiac conditions, some which are emergent. If the patient reports chest pain, first determine if it is an emergency by asking questions such as:
“Does it feel like something is sitting on your chest?”
“Is the pain radiating into your jaw or arm?”
“Do you feel short of breath, dizzy, or nauseated?”
If any of these symptoms are occurring, seek emergency medical assistance according to agency policy. If it is not a medical emergency, perform a focused assessment on the chest pain, including onset, location, duration, characteristics, alleviating or aggravating factors, radiation, and if any treatment has been used for the pain.[4]
Objective Assessment
Focused objective assessments for a patient experiencing decreased oxygenation include assessing airway, evaluating respiratory rate and heart rate, analyzing pulse oximetry readings, and auscultating lung sounds for adventitious sounds.
Review detailed interview questions and how to perform a physical examination of the respiratory system in the “Respiratory Assessment” chapter in the Open RNNursing Skillstextbook.
Signs of cyanosis or clubbing should be noted.Clubbingis the enlargement of the fingertips that occurs with chronic hypoxia such as in chronic obstructive pulmonary disease (COPD) or congenital deficits in pediatric patients. See Figure 8.8[5]for an image of clubbing.
Figure 8.8
Clubbing of Fingertips
Another sign of chronic hypoxia that often occurs in patients with chronic obstructive pulmonary disease (COPD) includes an increased anterior-posterior chest diameter, often referred to as abarrel chest. A barrel chest results from air trapping in the alveoli. See Figure 8.9[6]for an image of a barrel chest.
Figure 8.9
Comparison of Chest with Normal Anterior/Posterior Diameter (A) to a Barrel Chest(B)
DIAGNOSTIC TESTS AND LAB WORK
Diagnostic tests and lab work are based on the patient’s medical condition that is causing the decreased oxygenation. For example, patients with a productive cough may have a chest X-ray or sputum culture ordered, and patients experiencing respiratory distress often have arterial blood gas (ABG) tests performed.
A chest X-ray is a fast and painless imaging test that uses certain electromagnetic waves to create pictures of the structures in and around the chest. This test can help diagnose and monitor conditions such as pneumonia, heart failure, lung cancer, and tuberculosis. Health care providers also use chest X-rays to see how well certain treatments are working and to check for complications after certain procedures or surgeries. Chest X-rays are contraindicated during pregnancy.[7],[8]See Figure 8.10[9]for an image of a chest X-ray.
Figure 8.10
Chest X-ray
A sputum culture is a diagnostic test that evaluates the type and number of bacteria present in sputum. The patient is asked to cough deeply and spit any mucus that comes up into a sterile specimen container. The sample is sent to a lab where it is placed in a special dish and is watched for two to three days or longer to see if bacteria or other disease-causing germs grow.[10]See Figure 8.11[11]for an image of a sputum culture.
Figure 8.11
Sputum Culture
For patients experiencing respiratory distress, arterial blood gas (ABG) tests are often ordered. Additional details about ABG tests are discussed in the “Oxygenation Basic Concepts” section of this chapter, as well as in the “Acid-Base Balance” section of the “Fluid and Electrolytes” chapter. See Table 8.3a for a summary of normal ranges of ABG values in adults.
Table 8.3a
Normal Ranges of ABG Values in Adults
Diagnoses
Commonly used NANDA-I nursing diagnoses for patients experiencing decreased oxygenation and dyspnea includeImpaired Gas Exchange, Ineffective Breathing Pattern, Ineffective Airway Clearance, Decreased Cardiac Output, andActivity Intolerance. See Table 8.3b for definitions and selected defining characteristics for these commonly used nursing diagnoses.[12]Use a current, evidence-based nursing care plan resource when creating a care plan for a patient.
Table 8.3b
NANDA-I Nursing Diagnoses Related to Decreased Oxygenation and Dyspnea
For example, nurses commonly care for patients with chronic obstructive pulmonary disease (COPD). To select an accurate nursing diagnosis for a specific patient with COPD, the nurse compares findings obtained on patient assessment with the defining characteristics of various nursing diagnosis. The nurse selectsIneffective Breathing Patternafter validating this patient is demonstrating the associated signs and symptoms related to this nursing diagnosis:
Dyspnea
Increase in anterior-posterior chest diameter (e.g., barrel chest)
Nasal flaring
Orthopnea
Prolonged expiration phase
Pursed-lip breathing
Tachypnea
Use of accessory muscles to breathe
Use of three-point position
Outcome Identification
A broad goal(s) for patients experiencing alterations in oxygenation is:
The patient will have adequate movement of air into and out of the lungs.[13]
A sample “SMART” outcome criteria for a patient experiencing dyspnea is:
The patient’s reported level of dyspnea will be within their stated desired range of 1-2 throughout their hospital stay.
Planning Interventions
According toNOC and NIC Linkages to NANDA-I and Clinical Conditions[14]andNursing Interventions Classification (NIC),[15]Anxiety ReductionandRespiratory Monitoringare common categories of independent nursing interventions used to care for patients experiencing dyspnea and alterations in oxygenation.Anxiety Reductionis defined as, “Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger.”[16]Respiratory Monitoringis defined as, “Collection and analysis of patient data to ensure airway patency and adequate gas exchange.”[17]Selected nursing interventions related to anxiety reduction and respiratory monitoring are listed in the following box.
Selected Nursing Interventions to Reduce Anxiety and Perform Respiratory Monitoring
Anxiety Reduction
Use a calm, reassuring approach
Explain all procedures, including sensations likely to be experienced during the procedure
Provide factual information concerning diagnosis, treatment, and prognosis
Stay with the patient to promote safety and reduce fear
Encourage the family to stay with the patient, as appropriate
Listen attentively
Create an atmosphere of trust
Encourage verbalization of feelings, perceptions, and fears
Identify when level of anxiety changes
Provide diversional activities geared toward the reduction of tension
Instruct the patient on the use of relaxation techniques
Administer medications to reduce anxiety, as appropriate
Respiratory Monitoring
Monitor rate, rhythm, depth, and effort of respirations
Note chest movement, watching for symmetry and use of accessory muscles
Monitor for noisy respirations such as snoring
Monitor breathing patterns
Monitor oxygen saturation levels in sedated patients
Provide for noninvasive continuous oxygen sensors with appropriate alarm systems in patients with risk factors per agency policy and as indicated
Auscultate lung sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds
Monitor patient’s ability to cough effectively
Note onset, characteristics, and duration of cough
Monitor the patient’s respiratory secretions
Provide frequent intermittent monitoring of respiratory status in at-risk patients
Monitor for dyspnea and events that improve and worsen it
Monitor chest X-ray reports as appropriate
Note changes in ABG values as appropriate
Institute resuscitation efforts as needed
Institute respiratory therapy treatments as needed
In addition to the independent nursing interventions listed in the preceding box, several nursing interventions can be implemented to manage hypoxia, such as teaching enhanced breathing and coughing techniques, repositioning, managing oxygen therapy, administering medications, and providing suctioning. Refer to Table 8.2b in the “Oxygenation Basic Concepts” section earlier in this chapter for information about these interventions.
For additional details regarding managing oxygen therapy, see the “Oxygen Therapy” chapter in Open RNNursing Skills.
Read more information aboutrespiratory medicationsin the “Respiratory” chapter in Open RNNursing Pharmacology.
Patients should also receive individualized health promotion patient education to enhance their respiratory status. Health promotion education includes encouraging activities such as the following:
Receiving an annual influenza vaccine
Receiving a pneumococcal vaccine every five years as indicated
Stopping smoking
Drinking adequate fluids to thin respiratory secretions
Participating in physical activity as tolerated
Implementing Interventions
When implementing interventions that have been planned to enhance oxygenation, it is always important to assess the patient’s current level of dyspnea and modify interventions based on the patient’s current status. For example, if dyspnea has worsened, some interventions may no longer be appropriate (such as ambulating), and additional interventions may be needed (such as consulting with a respiratory therapist or administering additional medication).
Evaluation
After implementing interventions, the effectiveness of interventions should be documented and the overall nursing care plan evaluated. Focused reassessments for evaluating improvement of oxygenation status include analyzing the patient’s heart rate, respiratory rate, pulse oximetry reading, and lung sounds, in addition to asking the patient to rate their level of dyspnea.
References
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8.4. PUTTING IT ALL TOGETHER
The following patient care scenario applies information from this chapter to create an abbreviated nursing care plan and sample documentation note.
Patient Scenario
Mr. Smith is an 82-year-old patient in a long-term care facility and has a history of chronic obstructive pulmonary disease (COPD).
This morning Mr. Smith told the CNA as he was getting ready for breakfast, “I’m feeling short of breath and tired today.” The CNA obtained vital signs and reported them to you: respiratory rate 24, O2 sat 86%, pulse 88, and temperature 36.8 C.
Applying the Nursing Process
Assessment:You auscultate Mr. Smith’s breath sounds and find scattered wheezing and rhonchi anteriorly, with diminished breath sounds in the posterior lower lobes. You ask Mr. Smith to rate his shortness of breath now on a scale from 0-10 and he reports it is a “4,” but usually a “2” during activity. While assessing Mr. Smith, you note he is using accessory muscles to breathe and is sitting up in the tripod position. He also has a barrel chest. You quickly check his chart and note the following orders and scheduled medications:
Tiotropium (Spiriva) inhaler daily
Fluticasone (Flovent) inhalers daily
Oxygen via nasal cannula at 1-2 L per minute as needed to maintain O2 saturation greater than 90%
Albuterol nebulizer as needed for wheezing
Based on this information, you formulate the following nursing care plan:
Nursing Diagnosis:Ineffective Breathing Pattern related to respiratory muscle fatigue as manifested by tachypnea and use of accessory muscles to breathe and patient stating, “I’m feeling short of breath and tired today.”
Overall Goal:The patient will have adequate movement of air into and out of the lungs.
SMART Expected Outcome:Mr. Smith’s reported level of dyspnea will be within his stated desired range of 1-2 by the end of the shift.
Planned Nursing Interventions with Rationale:
| Interventions | Rationale |
|---|---|
| Establish a baseline status for today and continue to monitor for improvement or worsening as interventions are implemented. |
| 2. Implement NIC Interventions forAnxiety Reduction(as outlined in Box 8.3). | Dyspnea creates feelings of anxiety. Decreasing the patient’s anxiety levels will help decrease the feeling of dyspnea. |
| 3. Place patient in high Fowler’s or tripod position as needed to reduce feelings of dyspnea. | Positioning will assist in maximum expansion of lungs. |
| 4. Apply oxygen via nasal cannula, starting at 1 L/min and titrate until 90% pulse oximetry reading is obtained per standing order. | Oxygen therapy will reduce the work of breathing. |
5. Administer scheduled and PRN medications:
| Each medication has a different mechanism of action that will assist Mr. Smith’s dyspnea.
|
| Pursed-lip breathing will help keep the airways open longer on expiration so that more air can then be inhaled on inspiration. Huff coughing will help clear secretions. |
| 7. Encourage fluids (2000 mL/24 hours) and monitor intake and output. | Additional fluids will help thin secretions so they can more easily be coughed up. Mr. Smith does not have fluid restrictions, but it is important to monitor intake/output when encouraging fluids, especially in elderly patients who have increased risk for developing fluid overload. |
| 8. Schedule care activities to allow frequent rest periods. | Resting frequently decreases oxygen demand. |
| 9. Encourage ambulation as tolerated, with the CNA, in the hallway, after the O2 saturation is greater than 90%. | Ambulation will help to mobilize the secretions so they can be removed. |
Evaluation:
After administering medications and applying the oxygen, you reassess Mr. Smith and find the following: respiratory rate 16, pulse 78, and O2 sat 90% with NC at 1 L/min. The wheezing and rhonchi in the anterior lungs have diminished. You ask Mr. Smith how he is feeling. He rates his current level of dyspnea as a “2” and states, “I feel less short of breath but I am still tired.” The SMART outcome was “met.” You encourage Mr. Smith to rest after eating breakfast, but encourage a walk in the hallway later that morning. You enter the following documentation note in the patient record.
Sample Documentation Note
Upon awakening, the patient reported a dyspnea level of a “4” and stated, “I’m feeling short of breath and tired today.” Vital signs were respiratory rate 24, O2 sat 86%, pulse 88, and temperature 36.8 C. Scattered wheezing and rhonchi present anteriorly, with diminished breath sounds in the posterior lower lobes. Oxygen applied via nasal cannula at 1 L/min; albuterol nebulizer and scheduled medications were administered. Patient was placed in tripod position at edge of bed and encouraged to use pursed-lip breathing and Huff coughing. Post albuterol administration, vital signs were respiratory rate 16, pulse 78, and O2 sat 90% on room air. The wheezing and rhonchi in the anterior lungs were diminished. Patient reported dyspnea decreased to a “2” but stated, “I feel less short of breath but I am still tired.” Encouraged patient to push fluids and ambulate as tolerated today, along with frequent rest breaks. Will continue to monitor respiratory rate, pulse, lung sounds, and reported level of dyspnea every four hours today.
8.5. LEARNING ACTIVITIES
Learning Activities
(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
- 1.
You are providing care for Mrs. Jones, an 83-year-old female patient admitted to the medical surgical floor with worsening pneumonia. Upon auscultation of the patient’s lung fields, you note scattered crackles and diminished breath sounds throughout all lung fields. Mrs. Jones requires 4L O2 via nasal cannula to maintain an oxygen saturation of 94%. You have constructed a nursing care diagnosis ofIneffective Breathing Pattern. What nursing interventions might you consider to help improve the patient’s breathing pattern?
“Gas Exchange Case Study” by Susan Jepsen forLansing Community Collegeare licensed underCC BY 4.0
VIII GLOSSARY
- Apnea
Temporary cessation of breathing. When apnea occurs during sleep, it is often caused by the condition called Obstructive Sleep Apnea (OSA).
- Arterial Blood Gas (ABG)
Diagnostic test performed on an arterial sample of blood to determine its pH level, oxygenation status, and carbon dioxide status.
- Barrel chest
An increased anterior-posterior chest diameter, resulting from air trapping in the alveoli, that occurs in chronic respiratory disease.
- Bilevel Positive Airway Pressure (BiPAP)
A BiPAP is an oxygenation device similar to a CPAP device in its use to prevent airways from collapsing, but it has two pressure settings. One setting occurs during inhalation and a lower pressure setting is used during exhalation. BiPAP devices may be used in the home to treat obstructive sleep apnea or in hospitals to treat patients in acute respiratory distress. For more information, see the “Oxygenation Equipment” section of the “Oxygen Therapy” chapter in Open RNNursing Skills.
- Bradypnea
Decreased respiratory rate less than the normal range according to the patient’s age.
- Cardiac output
The amount of blood the heart pumps in one minute.
- Continuous Positive Airway Pressure (CPAP)
A CPAP is an oxygenation device is typically used for patients who are able to breath spontaneously but need assistance in keeping their airway unobstructed, such as those with obstructive sleep apnea. The CPAP device consists of a mask that covers the patient’s nose, or nose and mouth, and is attached to a machine that continuously applies mild air pressure to keep the airways from collapsing. For more information, see the “Oxygenation Equipment” section of the “Oxygen Therapy” chapter in Open RNNursing Skills.
- Clubbing
Enlargement of the fingertips that occurs with chronic hypoxia.
- Coughing and deep breathing
A breathing technique where the patient is encouraged to take deep, slow breaths and then exhale slowly. After each set of breaths, the patient should cough. This technique is repeated 3 to 5 times every hour.
- Cyanosis
Bluish discoloration of the skin and mucous membranes.
- Dyspnea
A subjective feeling of not getting enough air. Depending on severity, dyspnea causes increased levels of anxiety.
- Endotracheal Tube (ET tube)
An ET tube is inserted by an advanced practitioner to maintain a secure airway when a patient is experiencing respiratory failure or is receiving general anesthesia. For more information, see the “Oxygenation Equipment” section of the “Oxygen Therapy” chapter in Open RNNursing Skills.
- HCO3
Bicarbonate level of arterial blood indicated in an arterial blood gas (ABG) result. Normal range is 22-26.
- Huffing technique
A technique helpful for patients who have difficulty coughing. Teach the patient to inhale with a medium-sized breath and then make a sound like “ha” to push the air out quickly with the mouth slightly open.
- Hypercapnia
Elevated level of carbon dioxide in the blood.
- Hypoxemia
A specific type of hypoxia that is defined as decreased partial pressure of oxygen in the blood (PaO2) indicated in an arterial blood gas (ABG) result.
- Hypoxia
A reduced level of tissue oxygenation. Hypoxia has many causes, ranging from respiratory and cardiac conditions to anemia.
- Incentive spirometer
A medical device commonly prescribed after surgery to reduce the buildup of fluid in the lungs and to prevent pneumonia. While sitting upright, the patient should breathe in slowly and deeply through the tubing with the goal of raising the piston to a specified level. The patient should attempt to hold their breath for 5 seconds, or as long as tolerated, and then rest for a few seconds. This technique should be repeated by the patient 10 times every hour while awake.
- Mechanical ventilator
A mechanical ventilator is a machine attached to an endotracheal tube to assist or replace spontaneous breathing. For more information, see the “Oxygenation Equipment” section of the “Oxygen Therapy” chapter in Open RNNursing Skills.
- Orthopnea
Difficulty in breathing that occurs when lying down and is relieved upon changing to an upright position.
- PaCO2
Partial pressure of carbon dioxide level in arterial blood indicated in an ABG result. Normal range is 35-45 mmHg.
- PaO2
Partial pressure of oxygen level in arterial blood indicated in an ABG result. Normal range is 80-100 mmHg.
- Perfusion
The passage of blood through the arteries to an organ or tissue.
- Pursed-lip breathing
A breathing technique that encourages a person to inhale through the nose and exhale through the mouth at a slow, controlled flow.
- Purulent sputum
Yellow or green sputum that often indicates a respiratory infection.
- Respiration
Gas exchange occurs at the alveolar level where blood is oxygenated and carbon dioxide is removed.
- SaO2
Calculated oxygen saturation level in an ABG result. Normal range is 95-100%.
- SpO2
Hemoglobin saturation level measured by pulse oximetry. Normal range is 94-98%.
- Sputum
Mucus and other secretions that are coughed up from the mouth.
- Tachypnea
Elevated respiratory rate above normal range according to the patient’s age.
- Tripod position
A position that enhances air exchange when a patient sits up and leans over by resting their arms on their legs or on a bedside table; also referred to as a three-point position.
- Ventilation
Mechanical movement of air into and out of the lungs.
- Vibratory Positive Expiratory Pressure (PEP) Therapy
Handheld devices such as flutter valves or Acapella devices used with patients who need assistance in clearing mucus from their airways.
