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OXYGENATION LECTURE

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  1. OXYGENATION LECTURE M. Catherine Hough, Ph.D, RN University of North Florida COH - Department of Nursing

  2. Respiratory System... Structure & Function Lower Respiratory Tract… • Alveolar ducts • Alveoli- FUNCTIONAL UNIT OF THE LUNG • ~300,000,000 ALVEOLI IN THE LUNG • Total Volume of ~ 2500 ml • Surface area for gas exchange that is about the size of a tennis court • SURFACTANT

  3. NURSING DIAGNOSIS (definition and defining characteristics: • Ineffective airway clearance • Gas Exchange, Impaired

  4. NOCs Review the following: • Respiratory status: • Gas Exchange • Ventilation • Tissue Perfusion: • Pulmonary • Acid-Base Balance

  5. NICs • Acid-Base Management • Gas exchange, Impaired

  6. Ventilation and Perfusion • Alveolar Dead Space • + ventilation • - perfusion • Intrapulmonary Shunting • - ventilation • + perfusion

  7. OBSTRUCTIVE SLEEP APNEA • Periodic apneic or hypopneic episodes during sleep associated with • Upper airway obstruction due to pharyngeal collapse, leading to • Awakening and resulting restoration of airway patency • Sleep recurs almost immediately and the cycle repeats itself, often hundreds of times each night

  8. Epidemiology Prevalence estimated at 4% male; 2% female (NEJM 328:1230, 1993) May be as much as 40-50% of hypertensive Pts 90% of pts with nocturnal angina (Lancet 4/29/95) Incidence greatest age 40-60 Highly underdiagnosed, perhaps due to the gradual onset of s/s More underdiagnosed in women than men. Mean duration of s/s before dx in one series of women was 10years

  9. Pathogenesis • There is normally a moderate degree of hypoventilation during sleep resulting from partial pharyngeal collapse and resulting increase in upper airway resistance. • This is due to decreased activity of the "upper airway dilator musculature" during sleep. • Occasional apneic or hypopneic episodes are normal, esp. in elderly. • Prolonged and repetitive apneic/hypopneic episodes are not normal.

  10. Structural factors In most OSA patients, there are no evident structural abnormalities. Most experts, however, believe that subtle underlying structural factors are involved: a. Narrower upper airway (OSA patients have narrower upper airways on average, but there' much overlap) b. More "collapsible" airways (+/- evidence for this)

  11. Structural factors … • In rare instances, clear structural abnormalities are found • nasal obstructing lesions • Deviated nasal septum • chronic rhinitis • masses of the soft palate • large T & A's • Structural abnormalities may play a larger role in women • 48% of women with OSA in one series had abnormalities of the hard palate • >70% with mild OSA • In one series of women with OSA, most weren't overweight, but BMI was correlated with severity (freq. of apneic/hypopneic episodes)

  12. Functional factors • OSA pts may have altered sleep • Influences on palatal muscle control, e.g. the reflexes which normally keep palate open during inspiration • May have impaired ventilatory drive or arousal mechanisms • (Sources: Disease-a-month, 4/94; Lancet 344:653, 1994; 344: 656, 1994; Ann. Int. Med. 122: 493, 1995) • TREATMENT • Surgical - Remove obstruction • Mechanical - Nasal CPAP • Support Groups

  13. Problems of the LOWER AIRWAY Statistics: • Decrease number of deaths R/T acute & chronic respiratory infections due to antibiotics • Increase in TB over last ten years, especially the last 5years due to AIDS/HIV • More people living with COPD (>17 million) • ^ incidence of lung cancer, especially among women • ^ number of teenagers starting to smoke • Pneumonia is the leading cause of death by infectious disease in the U.S.

  14. PREVENTION • Education/advocacy for smoke-free environment (The use of tobacco is the #1 risk to developing COPD and lung cancer • Most people start smoking in high school • Nicotine addiction results in withdrawal symptoms • Smoking is tied to ETOH consumption and lower achievement • Advertising targets fantasies and insecurities of teens and young adults

  15. Restrictive Lung Disorders General head injuries, tumors, OD Neuromuscular GB, ALS, MD, Polio Chest Wall trauma Pleural Disorders pleural effusion, pleurisy Parenchmal atelectasis, pneumonia, TB, pulmonary fibrosis Obstructive Lung Disorders Asthma COPD Acute Bronchitis Chronic Bronchitis Emphysema Obstructive & Restrictive Lung Disorders Extrapulmonary Also referred to as Chronic Airflow Limitation (CAL) Intrapulmonary

  16. Restrictive Reduced Vital Capacity Reduced Total Lung Capacity Normal or reduced Functional Residual Capacity Cause difficulty with inspiration Obstructive Decreased resistance to airflow Normal or decreased Vital Capacity Increased Total Lung Capacity Increased Functional Residual Capacity Increased Residual Volume Characteristics of Lung Disorders

  17. OBSTRUCTIVE Characterized by: INCREASED TO AIR FLOW RESTRICTIVE Characterized by: DECREASED COMPLIENCE OF THE LUNG OR CHEST WALL OR BOTH

  18. OBSTRUCTIVE LUNG DISORDERS

  19. EMPHYSEMA • Loss of elastic recoil secondary to breakdown of lung tissue and enlargement of alveolar spaces - leads to retention of CO2 • Emphysema is the most severe form of COPD is characterized by abnormal, permanent enlargement of the air spaces past the terminal bronchioles, resulting in the destruction of the alveolar walls • The affected terminal bronchioles contain mucus plugs and the eventual resulting loss of elasticity of the lung parenchyma resulting in difficulty in exhaling

  20. Emphysema … • 1963 - Discovery of deficiency of AAT (Alpha Protease Inhibitor) which is associated with serous and premature development of emphysema. These enzymes (Pancreatic Elastase, Trypsin, Chymotrypsin, Granulocyte Elastase) defend the lungs against destructive processes R/T Neutrophil Elastase which destroys tissue. • Bullous Emphysema is the result

  21. AAT (alpha-1-protease inhibitor) • Familial emphysema have a hereditary deficiency of AAT • Number of Americans with this genetic deficiency small (~70,000) • 1 in 3,000 newborns have a genetic deficiency of AAT • 1 to 3 percent of all cases of emphysema are due to AAT deficiency • Critical that these people not smoke

  22. Healthy Lung Emphysema Lung

  23. The destruction of elastin that occurs in emphysema is believed to result from an imbalance between two proteins in the lung: • An enzyme called elastase which breaks down elastin, and • AAT which inhibits elastase. • In normal individuals, there is enough AAT to protect elastin so that abnormal elastin destruction does not occur

  24. Permanent destruction of the alveoli • Due to irreversible destruction of the protein elastin • Elastinis important for maintaining the strength of the alveolar walls • The loss of elastin also causes collapse or narrowing of the bronchioles • End result of above sequence limits airflow out of the lungs.

  25. ETIOLOGY • Precise cause is unknown, but thought to involve destruction of the connective tissue of the lung by protease's that may be facilitated by the effects of cigarette smoking

  26. EPIDEMIOLOGY • Symptoms usually occur in the fifth or sixth decade of life • Typical patient is male over the age of 55 with a history of tobacco smoking • Heredity • Environmental irritants/pollution

  27. Centrilobular Emphysema(CLE) Distention and damage of the respiratory bronchioles Uneven disease distribution throughout the lung Usually more severe in the upper portions More common than Panlobular emphysema (PLE) Panlobular Emphysema (PLE) More uniform enlargement and destruction of the alveoli in the pulmonary acinus More diffuse and is more severe in the lower lungs PATHOPHYSIOLOGY

  28. ASSESSMENT S&S Subjective • Hx and onset of symptoms • Smoking Hx • Family Hx • Past or present exposure to environmental irritants • Activity intolerance, fatigue • Anorexia, weight loss • Symptoms of hypoxemia - restlessness, confusion • Medications and therapies and their effectiveness

  29. Objective Increased airway resistance Decreased Expiratory Force Mild hypoxemia Barrel Chest Increased AP diameter Increased Accessory Muscles ABG’s show compensation Increased respiratory rate Dyspnea Decreased breath sounds Late inspiratory crackles Decreased O2 saturation Assessment...

  30. LAB FINDINGS • ABG’s may be normal due to compensation for the destruction by increased resp rate Even in the presence of hypoxemia overcompensation may result in respiratory alkalosis • PO2 normal or slightly low at rest, but drops with activity • CBC usually normal

  31. DIAGNOSTIC TESTS • Chest X-Ray -- positive findings indicate increased radiolucency of lungs with diaphragm in low position • AAT assay to check for deficiency • Pulmonary functions tests -- • Increased residual volume, functional residual capacity, total lung capacity • Diffusing capacity is reduced because of tissue destruction • Decreased Forced Expiratory Volume • Vital Capacity may be normal or slightly reduced until late state of disease

  32. INTERVENTIONS • Bronchodilators may provide relief from symptoms but will not improve • Antibiotics if there is an infectious process occurring • Steroids during acute exacerbation's • Low flow oxygen (1-2 liters) • Breathing exercises • Respiratory therapy & CPT • Lung reduction surgery • Performed only on pts with severe emphysema • Avg. hospital LOS ~ 2 weeks • Require pre and post op extended pulmonary rehab • Falling out of favor in the prior year

  33. Stop smoking Avoid work-related exposures to dust & fumes Avoid air pollution, and curtail physical activity during alerts Refrain from contact with people that have URI… Get pneumonia vaccination and yearly influenza shots Avoid excessive heat, cold and high altitudes Drink fluids Maintain good nutrition – high protein Consider allergy shots Patients with COPD can help themselves in many ways

  34. Another Nursing Diagnosis Altered nutrition: less than body requirements related to dyspnea, sputum production, or fatigue Interventions: • Explain importance of consuming adequate amounts of nutrients • Provide a pleasant, relaxed atmosphere for eating Expected Outcomes: • Pt will verbalize & understand importance of adequate nutrition • Pt will use a comfortable environment for meals • Pat will eat slower and smaller meals

  35. More NURSING DIAGNOSIS • Ineffective airway clearance • Altered Gas Exchange Breathing pattern, Ineffective • Activity Intolerance • Infection: Actual or Potential • Risk for Nutrition: Less than Body Requirement • Fear • Anxiety • Knowledge Deficit

  36. Nursing Diagnoses • Ineffective airway clearance r/t bronchospasm, ineffective cough, excessive mucus production, • Anxiety r/t difficulty breathing, perceived or actual loss of control, and fear of suffocation and restlessness • Ineffective therapeutic regimen management r/t lack of information about COPD and its treatment

  37. Nursing Diagnoses • Activity intolerance r/t fatigue, energy shift to meet muscle needs for breathing to overcome airway obstruction • Disturbed body image r/t decreased participation in physical activities • Impaired home maintenance r/t deficient knowledge regarding control of environmental triggers • Ineffective coping r/t personal vulnerability to situational crisis

  38. Nursing Interventions • Airway Management • Administer humidified air or oxygen immediately • Regulate fluid intake • Monitor respiratory and oxygenation status • Administer drug therapy (bronchodilators, corticosteroids) • Auscultate lung sounds before and after treatments • Cough Enhancement • Positioning for chest expansion • Deep breathing, hold for 2 seconds, and cough 2-3 times

  39. Nursing Interventions • Respiratory Monitoring • Rate, rhythm, depth, and effort (overall patterns) • Monitor for increased restlessness, anxiety, and air hunger • Note changes in SaO2, ABG values

  40. Nursing Interventions • Anxiety Reduction • Calming & reassuring attitudes • Stay with patient • Encourage slow breathing (pursed lips)

  41. Nursing Interventions • Teaching: Disease Process & Prescribed Medication • Identify level of knowledge • Instruct on measure to prevent/minimize side effects of treatment • Evaluate patient’s ability to self-administer medications • Instruct patient on purpose, action, dosage, and duration of each medication • Include family and significant others

  42. Pulmonary Function Tests

  43. Arterial Blood Gases (ABGs) • Arterial Blood Gases (ABGs) • Determines how much oxygen is available to perfuse peripheral tissues • Normal values: • pH: 7.35 - 7.45 • PaCO2: 35 - 45 • PaO2: 80 - 100 • HCO3: 22 - 26 • SaO2: 95 - 100 • Hypoxemia occurs with early respiratory alkalosis, or in severe cases, respiratory acidosis.

  44. Planning & Intervention Treatment Medications: • Bronchodilators – to relax smooth muscles in the airways and reduce congestion • Xanthine Compounds– Theophylline to reduce mucosal edema and smooth muscle spasms – also strengthens contractility of the diaphragm • Sympathetic Agents: PO, Inhalation (Albuterol, Terbutaline) • Rescue inhalers – Albuterol… • Corticosteroids– Solu Medrol – IV or PO to alleviate acute symptoms by decreasing inflammation • Antibiotics – to manage respiratory tract infections • Mucolytics and expectorants – to thin and aid in removal of mucus • Analgesics

  45. Given early October to mid November (however can be given any time during the flu season Given yearly Cost for people > 65 is paid by Medicare Recommended for: >50 years old Chronic heart or lung disease HIV Anyone living in large groups People who may transmit the flu to high risk groups Nurses, doctors, and other healthcare workers Flu Shots Treatment

  46. You should NOT get the flu shots if Allergic to eggs Hx of Guillain-Barre Syndrome Acute illness or fever Side effects <1 out of 3 develop site soreness Rare to have fever, aches Recent research shows that flu shots do not increase asthma attacks Flu Shots… Treatment Note: flu vaccine is made from a virus that is no longer active – NO one can catch the flu from a flu shot

  47. PULMONARY EMBOLISM MEDICAL INTERVENTIONS • Anticoagulants • Thrombolytic therapy SURGICAL INTERVENTIONS • Embolectomy NURSING DIAGNOSIS • Impaired gas exchange

  48. Pulmonary Embolism…. Risk factors for PE • Recent surgery • Recent fx of a lower extremity, especially with immobilization • Immobilization, particularly complete bedrest or LE paralysis • Previous DVT or PE • Family history of DVT or PE • Cancer • Obesity • Cardiovascular disease • Postpartum period • Sub therapeutic heparin dose • Age > 40 years