Oxygen Needs and Respiratory Therapies Chapter 25 Oxygen Needs and Respiratory Therapies All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Oxygen Oxygen (O2) is a gas. It has no taste, odor, or color. It is a basic need required for life. Death occurs within minutes if breathing stops. Brain damage and serious illness can occur without enough oxygen. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2

Factors Affecting Oxygen Needs Altered function of any system affects oxygen needs. Oxygen needs are affected by: Respiratory system status Circulatory system function Red blood cell (RBC) count Nervous system function Aging Exercise The respiratory and circulatory systems must function properly for cells to get enough oxygen. Respiratory system structures must be intact and function properly. Blood must flow to and from the heart. Capillaries and cells must exchange O2 and CO2. Red blood cells (RBCs) contain hemoglobin that picks up O2 in the lungs and carries it to the cells. The bone marrow must produce enough RBCs. Blood loss also reduces the number of RBCs. Nervous system diseases and injuries can affect respiratory muscles. Narcotics and depressant drugs slow respirations. Respiratory muscles weaken with aging. Lung tissue is less elastic. Older persons are at risk for respiratory complications after surgery. O2 needs increase with exercise. Persons with heart and respiratory diseases may have enough oxygen at rest, but even slight activity can increase O2 needs. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3

Factors Affecting Oxygen Needs (Cont’d) Fever Pain Drugs (respiratory depression, respiratory arrest) Smoking Allergies—bronchitis and asthma are risks Pollutant exposure Nutrition—vitamins and iron are needed to produce RBCs Alcohol—depresses the brain Fever and pain increase oxygen needs, rate and depth increase to meet the body’s needs. Medications depress the respiratory center in the brain. Respiratory depression means slow, weak respirations at a rate of fewer than 12 per minute. Respiratory arrest is when breathing stops. Narcotics (morphine, Demerol, and others) can have these effects. Smoking causes lung cancer and chronic obstructive pulmonary disease (COPD). Allergies or sensitivities to a substance can cause the body to react with runny nose, wheezing, and congestion. Mucous membranes in the upper airway swell. With severe swelling, the airway closes. Shock and death are risks. Pollen, dust, foods, drugs, insect bites, and cigarette smoke often cause allergies. A pollutant is a harmful chemical or substance in the air or water. They damage the lungs. An example is asbestos. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4

Altered Respiratory Function Respiratory function involves three processes. Air moves into and out of the lungs. O2 and carbon dioxide (CO2) are exchanged at the alveoli. The blood carries O2 to the cells and removes CO2 from them. Hypoxia means that cells do not have enough oxygen. Anything that affects respiratory function can cause hypoxia. The brain is very sensitive to inadequate O2. Hypoxia is life threatening. Report to the nurse at once the signs and symptoms of hypoxia listed in Box 25-1 on p. 418. Restlessness, dizziness, and disorientation are early signs of hypoxia. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5

Abnormal Respirations Adults normally have 12 to 20 respirations per minute. They are quiet, effortless, and regular. Both sides of the chest rise and fall equally. Tachypnea is rapid breathing. Respirations are 20 or more per minute. Hypoxemia is a reduced amount of oxygen in the blood. Bradypnea is slow breathing. Respirations are fewer than 12 per minute. Apnea is the lack or absence of breathing. Hypoventilation means respirations are slow, shallow, and sometimes irregular. Hyperventilation means respirations are rapid and deeper than normal. Fever, exercise, pain, pregnancy, airway obstruction, and hypoxemia are common causes of tachypnea. Drug overdose and nervous system disorders are common causes of bradypnea. Apnea occurs in sudden cardiac arrest and respiratory arrest. Sleep apnea is another type of apnea. Lung disorders affecting the alveoli, such as pneumonia, are common causes of hypoventilation. Nervous system and musculoskeletal disorders affecting the respiratory muscles also are causes. Causes of hyperventilation include asthma, emphysema, infection, fever, nervous system disorders, hypoxia, anxiety, pain, and some drugs. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6

Abnormal Breathing Patterns Dyspnea is difficult, labored, or painful breathing. With Cheyne-Stokes respirations: Respirations gradually increase in rate and depth. Then they become shallow and slow. Breathing may stop (apnea) for 10 to 20 seconds. Orthopnea means breathing deeply and comfortably only when sitting. Biot’s respirations are rapid and deep respirations followed by 10 to 30 seconds of apnea. Kussmaul respirations are very deep and rapid respirations. Heart disease and anxiety are common causes of dyspnea. Drug overdose, heart failure, renal failure, and brain disorders are common causes of Cheyne-Stokes respirations. Cheyne-Stokes respirations are common when death is near. Common causes of orthopnea are emphysema, asthma, pneumonia, angina, and other heart and respiratory disorders. Biot’s respirations occur with nervous system disorders. Kussmaul respirations signal diabetic coma. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 7

Assisting with Assessment and Diagnostic Tests Altered respiratory function may be an acute or chronic problem. The doctor orders tests to find the cause of the problem. Chest x-ray (CXR) Lung scan Bronchoscopy Thoracentesis Pulmonary function tests Arterial blood gases (ABGs) Sputum specimens Review Box 25-2 on p. 419. Cyanosis is a bluish color to the skin, lips, mucous membranes, and nail beds. Hemoptysis is bloody (hemo) sputum (ptysis means “to spit”). Note if the sputum is bright red, dark red, blood-tinged, or streaked with blood (see Chapter 28). Report your observations promptly and accurately. Review Focus on Communication: Assisting With Assessment and Diagnostic Tests on p. 418. Respiratory disorders cause the lungs, bronchi, and trachea to secrete mucus. Mucus from the respiratory system is called sputum when expectorated (expelled) through the mouth. Sputum specimens are studied for blood, microbes, and abnormal cells. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 8

Pulse Oximetry Pulse oximetry measures the oxygen concentration in arterial blood. The normal range is 95% to 100%. A sensor attaches to a finger, toe, earlobe, nose, or forehead. An alarm sounds if: O2 concentration is low. The pulse is too fast or slow. Other problems occur. A good sensor site is needed. Use SpO2 when recording the oxygen concentration value: S = saturation p = pulse O2 = oxygen Check the resident’s identification (ID) before using a pulse oximeter. Oxygen concentration is the amount (percent) of hemoglobin containing O2. Measurements are used to prevent and treat hypoxia. If, for example, only 90% contains O2, tissues do not get enough oxygen. However, concentrations as low as 85% may be normal for persons with some chronic diseases. A sensor attaches to a finger, toe, earlobe, nose, or forehead. Blood pressure cuffs affect blood flow. If using a finger, do not measure blood pressure on that side. Review Promoting Safety and Comfort: Pulse Oximetry on p. 420. Review Delegation Guidelines: Pulse Oximetry on p. 420. Review the Using a Pulse Oximeter procedure on p. 421. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 9

Promoting Oxygenation To get enough oxygen, air must move deep into the lungs. Air must reach the alveoli, where O2 and CO2 are exchanged. Measures to meet oxygen needs are found in care plans. Positioning Breathing is usually easier in semi-Fowler’s and Fowler’s positions. Persons with difficulty breathing often prefer the orthopneic position. Frequent position changes are needed. Disease and injury can prevent air from reaching the alveoli. Pain, immobility, and some drugs interfere with deep breathing and coughing. Oxygen needs must be met. The following measures are common in care plans. The orthopneic position is sitting up and leaning over a table to breathe (Fig. 25-5 on p. 422). Unless the doctor limits positioning, the person must not lie on one side for a long time. Secretions pool. The lungs cannot expand on that side. Position changes are needed at least every 2 hours. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10

Respiratory Support Deep breathing and coughing Deep breathing moves air into most parts of the lungs. Coughing removes mucus. Deep-breathing and coughing exercises promote oxygenation and: Help persons with respiratory problems Are done after surgery and during bedrest Help prevent pneumonia and atelectasis The goal of incentive spirometry is to improve lung function. Atelectasis is prevented or treated. Review Focus on Communication: Deep Breathing and Coughing on p. 422. Review Delegation Guidelines: Deep Breathing and Coughing on p. 422. Review Promoting Safety and Comfort: Deep Breathing and Coughing on p. 422. Review the Assisting with Deep-Breathing and Coughing Exercises procedure on pp. 422-423. Atelectasis is the collapse of a portion of the lung. A spirometer is a machine that measures the amount (volume) of air inhaled. With incentive spirometry the person is encouraged to inhale until reaching a preset volume of air. Review Delegation Guidelines: Incentive Spirometry on p. 424. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 11

Assisting with Oxygen Therapy Oxygen is treated as a drug. The doctor orders: The amount of oxygen to give The device to use When to give it The person may need: Oxygen constantly Oxygen for symptom relief Disease, injury, and surgery often interfere with breathing. When the amount of O2 in the blood is less than normal, the doctor orders oxygen therapy. Persons with respiratory diseases may have enough oxygen at rest. With mild exercise or activity, they become short of breath. Oxygen helps relieve chest pain and shortness of breath. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 12

Oxygen Therapy You do not give oxygen. Oxygen is supplied as follows: You assist the nurse in providing safe care. Oxygen is supplied as follows: Wall outlet Oxygen tank Oxygen concentrator Liquid oxygen system Common oxygen devices include: Nasal cannula Simple face mask Partial-rebreather mask Non-rebreather mask Venturi mask When oxygen tanks are used, small tanks are used during emergencies and transfers, and by persons who walk or use wheelchairs (Fig. 25-12, p. 426). A gauge tells how much oxygen is left (Fig. 25-13, p. 426). A power source is needed for an oxygen concentrator (Fig. 24-14, p. 426). A portable oxygen tank is needed for power failures and mobility. Review Promoting Safety and Comfort: Oxygen Sources on p. 426. Review Teamwork and Time Management: Oxygen Sources on p. 426. With a nasal cannula (Fig. 25-16 on p. 427) , the prongs are inserted into the nostrils. Tight prongs can irritate the nose. Pressure on the ears and cheekbones is possible. A simple face mask covers the nose and mouth (Fig. 25-17 on p. 427). With a partial-rebreather mask (Fig. 25-18 on p. 427), a bag is added to the simple face mask. With a non-rebreather mask (Fig. 25-19 on p. 427), exhaled air and room air cannot enter the bag. With a Venturi mask (Fig. 25-20 on p. 427), precise amounts of oxygen are given. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 13

Oxygen Therapy (Cont’d) Talking and eating are hard to do with a mask. Moisture can build up under the mask. Keep the face clean and dry. Masks are removed for eating. The oxygen flow rate The flow rate is the amount of oxygen given. It is measured in liters per minute (L/min). The nurse or respiratory therapist sets the flow rate. When giving care and checking the person: Always check the flow rate. Tell the nurse at once if it is too high or too low. Know your center’s policy about nursing assistants adjusting oxygen flow rates. Usually oxygen is given by cannula during meals. The doctor orders 2 to 15 L/min. The nurse and care plan tell you the person’s flow rate. If needed, a nurse or respiratory therapist will adjust the flow rate (Fig. 25-21, p. 428). Some states and centers let nursing assistants adjust O2 flow rates. Know your center’s policy. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 14

Oxygen Therapy (Cont’d) Oxygen administration set-up If not humidified, oxygen dries the airway’s mucous membranes. Distilled water is added to the humidifier. Bubbling in the humidifier means that water vapor is being produced. You assist the nurse with oxygen therapy. You do not give oxygen. You do not adjust the flow rate unless allowed by your state and center. Low flow rates (1 to 2 L/min) by cannula are not usually humidified. Review Delegation Guidelines: Oxygen Administration Set-Up on p. 428. Review Promoting Safety and Comfort: Oxygen Administration Set-Up on p. 428. Review Teamwork and Time Management: Oxygen Administration Set-Up on p. 428. Follow the safety rules for oxygen therapy listed in Box 25-3 on p. 428. Follow the safety measures for fire and the use of oxygen in Chapter 10 of the textbook. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 15

Assisting with Respiratory Therapy Some persons need inhalers, nebulizer treatments, artificial airways, suctioning, mechanical ventilation, and chest tubes. The goals for respiratory rehabilitation are to help the person: Reach his or her highest level of function Live as independently as possible Return home Artificial airways keep the airway patent (open). Intubation means inserting an artificial airway. Often persons who need respiratory rehabilitation are very ill. They need complex procedures and equipment. The nurse may ask you to assist in their care. The center must teach and train you to provide needed care. Some people need medication to keep their air passages open, asthma, bronchitis, and emphysema (see Chapter 35) are examples. Inhalers (Fig. 25-23, p. 429) help open the air passages quickly. Nebulizer treatments (Fig. 25-24 on p. 430) give the person medication that is inhaled in the form of a mist. Artificial airways are needed when disease, injury, secretions, or aspiration obstructs the airway, for mechanical ventilation (p. 430), and by some persons who are semiconscious or unconscious. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 16

Intubation Intubation means inserting an artificial airway. These airways are common: Oropharyngeal airway Endotracheal (ET) tube Tracheostomy tube An oropharyngeal airway is inserted through the mouth and into the pharynx (Fig. 25-25A, p. 430). A nurse or respiratory therapist inserts the airway. An endotracheal (ET) tube is inserted through the mouth or nose and into the trachea (Fig. 25-25B, p. 430). A doctor inserts it using a lighted scope. Some RNs and respiratory therapists are trained to insert ET tubes. A cuff is inflated to keep the airway in place. A tracheostomy tube is inserted through a surgically created opening (stomy) into the trachea (tracheo) (Fig. 25-25C, p. 430). Cuffed tubes are common. The cuff is inflated to keep the tube in place. Doctors perform tracheostomies. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 17

Artificial Airway Care for persons with artificial airways Vital signs are checked often. Observe for hypoxia and other signs and symptoms. If an airway comes out or is dislodged, tell the nurse at once. Frequent oral hygiene is needed. Follow the care plan. Persons with ET tubes cannot speak. (Some tracheostomy tubes allow speech.) Always keep the signal light within reach. Gagging and choking feelings are common. Imagine something in your mouth, nose, or throat. Comfort and reassure the person. Remind the person that the airway helps breathing. Use touch to show you care. Paper and pencils, Magic Slates, and communication boards are ways to communicate. Hand signals, nodding the head, and hand squeezes are common for simple “yes” and “no” questions. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 18

Tracheostomy Tracheostomies are temporary or permanent. A tracheostomy has three parts (the obturator, the inner cannula, and the outer cannula). The cuffed tracheostomy tube is used for mechanical ventilation. The tube must not come out (extubation). The tube must remain patent (open). Call for the nurse if: You note signs and symptoms of hypoxia or respiratory distress. The outer cannula comes out. Nothing must enter the stoma. Follow Standard Precautions and the Bloodborne Pathogen Standard when assisting with tracheostomy care. A tracheostomy is a surgically created opening (stomy) into the trachea (tracheo). Tracheostomies are permanent when airway structures are surgically removed. Cancer, severe airway trauma, or brain damage may require a permanent tracheostomy. Review the three parts of the tracheostomy (Fig. 25-26, p. 431). The obturator is used to guide the insertion of the outer cannula (tube). Then it is removed. The inner cannula is removed for cleaning and mucus removal. The outer cannula is not removed. It keeps the tracheostomy tube patent. Review Promoting Safety and Comfort: Tracheostomies on p. 431. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 19

Tracheostomy Care The care of a tracheostomy involves: Cleaning the inner cannula to remove mucus and keep the airway patent Cleaning the stoma to prevent infection and skin breakdown Applying clean ties or a Velcro collar to prevent infection When secretions collect in the upper airway, they can: Obstruct airflow into and out of the airway Provide an environment for microbes Interfere with O2 and CO2 exchange Usually, coughing removes secretions. Tracheostomy care is done daily or every 8 to 12 hours. It also is done as needed for excess secretions, soiled ties or collar, or soiled or moist dressings. For an adult, a finger should slide under the ties or the collar (Fig. 25-27, p. 431). All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 20

Suctioning Persons who cannot cough or whose cough is too weak to remove secretions need suctioning. Suctioning is the process of withdrawing or sucking up fluid (secretions). These routes are used to suction the airway: Oropharyngeal Nasopharyngeal Lower airway If not done correctly, suctioning can cause serious harm. Hypoxia and life-threatening problems can occur. Cardiac arrest can occur. Infection and airway injury are possible. A tube connects to a suction source at one end and to a suction catheter at the other end. The catheter is inserted into the airway. Secretions are withdrawn through the catheter. The Yankauer suction catheter is often used for thick secretions. The nose, mouth, and pharynx make up the upper airway. The trachea and bronchi make up the lower airway. The person’s lungs are hyperventilated before suctioning an ET or a tracheostomy tube. Hyperventilate means to give extra breaths. Oxygen is treated like a drug. You do not give drugs. Check if your state and center allow you to use an Ambu bag attached to an oxygen source. Review Promoting Safety and Comfort: Suctioning on p. 432. Review Box 25-4 on p. 433. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 21

Mechanical Ventilation Mechanical ventilation is using a machine to move air into and out of the lungs. Mechanical ventilation may be needed for a variety of health care problems. Mechanical ventilation is started in the hospital. Alarms sound when something is wrong. When any alarm sounds on a mechanical ventilator: First, check to see if the person’s tube is attached to the ventilator. If not, attach it to the ventilator. Then tell the nurse at once about the alarm. Do not reset alarms. Persons needing mechanical ventilation are very ill. An ET or tracheostomy tube is needed for mechanical ventilation. Mechanical ventilation is using a machine to move air into and out of the lungs (Fig. 25-30, p. 433). Mechanical ventilation may be short- or long-term. Often the person needs weaning from the ventilator. That is, the person needs to breathe without the machine. The respiratory therapist and RN plan the weaning process. Weaning can take many weeks. Review Box 25-5 on p. 434. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 22

Chest Tubes The doctor inserts chest tubes to remove air, blood, or fluid from the pleural space. Pneumothorax is air in the pleural space. Hemothorax is blood in the pleural space. Pleural effusion is the escape and collection of fluid in the pleural space. Chest tubes attach to a drainage system. Water-seal drainage keeps the system airtight. The pleural space is the space between the covering of the lungs and the inside of the chest wall. The pleural space does not normally contain air, blood, or excess fluid. Chest tube insertion is performed as a sterile procedure in surgery, in the emergency room, or at the bedside by the physician (Fig. 25-31, p. 434). Chest tubes collect to a drainage system (Fig. 25-32, p. 435) Pressure occurs when air, blood, or fluid collects in the pleural space. The pressure collapses the lung. Air cannot reach affected alveoli. O2 and CO2 are not exchanged. Respiratory distress and hypoxia result. Pressure on the heart affects the heart’s ability to pump blood. Review Box 25-6 on p. 435. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 23

Quality of Life To safely perform or assist with complex procedures and care: Know your limits. Do not perform any procedure that you do not understand. Do not perform unfamiliar procedures. Remember your legal and ethical responsibilities. Protect the right to privacy. Residents have the right to safe care. Perform only procedures that you understand. You do not give oxygen. You assist in providing safe care to persons receiving oxygen. You need to understand oxygen therapy and its safety rules. Careful observation is needed. Promptly report observations and complaints. Some treatments and procedures have severe side effects and complications. Every sign, symptom, or complaint is important. Respiratory support and therapies involve complex care. Serious problems can occur from the wrong care. You have the right to refuse a function or task. Do not function beyond your legal scope, preparation, and skill level. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 24