Nursing diagnosis and care of the client with oxygenation problems vc – Flashcards
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NANDA nursing diagnoses related to oxygenation
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Ineffective breathing pattern. Ineffective airway clearance. Impaired gas exchange. Activity intolerance. Risk for aspiration.
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Ineffective breathing pattern
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NANDA diagnosis related to oxygenation. Inspiration and/or expiration that does not provide adequate ventilation. It is an umbrella diagnosis. Defining characteristics: bradycardia, orthopnea (can't breathe lying down), tachypnea, alterations in depth, dysrhythmic, dyspnea, use of accessory muscles, nasal flaring. If a person is obese. Under sedation
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Ineffective airway clearance
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NANDA diagnosis related to oxygenation. State in which a client experiences inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Defining characteristics: ineffective or absent cough, inability to remove airway secretions. Cystic fibrosis, asthma, hear ronchi
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Impaired gas exchange
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NANDA diagnosis related to oxygenation. State in which a person experiences and actual or potential decreased passage of gases between the alveoli of the lungs and the vascular system. Defining characteristic: dyspnea on exertion. Minor: three point positioning, pursed-lip breathing, lethargy and fatigue, decreases oxygen sat, cyanosis. Pneumonia, COPD-something affecting exchange of gases, pathophysiologic reason.
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Activity intolerance
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NANDA diagnosis related to oxygenation. Insufficient physiologic or psychological energy to endure or complete required or desired daily activities. Defining characteristics: respiratory-exertional dyspnea, excessively increased or decreased, rate, shortness of breath; pulse-weak, increased or decreased, rhythm change, pre-activity level within 3 minutes, EKG changes; blood pressure-abnormal blood pressure response, failure to increase with activity, increased diastolic pressure greater than 15 mmHg. Orthostatic hypertension
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Risk for aspiration
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NANDA diagnosis related to oxygenation. State in which a person is at risk for entry of secretions, solids, or fluids into the tracheobronchial passages. Risk fasters: level of consciousness: drowsy, sedated; depressed gag/cough; impaired swallowing. Stroke, numbness of the throat.
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Health promotion
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Vaccinations: influenza, pneumococcal. Healthy lifestyle: eliminating risk factors, eating right, regular exercise. Environmental pollutants: secondhand smoke, work chemicals, and pollutants
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Interventions to promote oxygenation
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Monitor hydration. Humidification. Administer medications via inhaler or nebulizer-expectorants/mucolytics/bronchodilators/anti-inflammatory agents. Teach effective coughing and breathing. Perform P&PD or chest physiotherapy. Suction the airway. Artificial airways.
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Hydration
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Intervention to promote oxygenation. Keeps secretions thin, white, watery, and easily removable with minimal coughing. Excessive coughing to clear thick, tenacious secretions is fatiguing and energy depleting. Provide a fluid intake of 1500 to 2500 mL/day
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Humidification
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Intervention to promote oxygenation. Process of adding water to gas. Humidity keeps the airways moist and loosens and mobilizes secretions. Humidify oxygen for 4L/min or greater. May need to add in dry environment. Administration over 24 hours. Sterile distilled water. Mucous membranes don't dry out-nose bleeds
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Nebulization
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Intervention to promote oxygenation. Adds moisture or medications to air. used to administer bronchodilators and mucolytic agents. Enhances mucociliary clearance.
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Coughing and deep breathing
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Intervention to promote oxygenation. Diaphragmatic breathing-technique increases air to the lower lungs-expand diaphragm. Abdomen moves out when breathing in and sinks in when breathing out. Deep breathing loosens secretions. Coughing-every 2 hours while awake for patients with respiratory conditions and postop, patients with large amount of secretions cough every 1 hour while awake and every 2-3 hours at night
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Pursed-lip breathing
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Intervention to promote oxygenation. Deep inspiration and prolonged expiration. Used to prevent alveolar collapse. Patient to be in sitting position and take a deep breath and exhale slowly through pursed lips as if blowing through a straw. Exhalation phase is longer than inhalation phase. Used in chronic obstructive pulmonary disease patients to control shortness of breath
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Chest physiotherapy CPT/pulmonary toilet
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Intervention to promote oxygenation. Mobilizes and drains secretions from gravity dependent areas of the lung. Chest percussion. Vibration. Postural drainage
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Chest percussion
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Chest physiotherapy CPT. Cup hand and smack patient's chest
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Vibration
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Chest physiotherapy CPT. Vest hooked to a machine to loosen secretion
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Postural drainage
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Chest physiotherapy CPT. Reverse Trendelenburg so secretions go to front
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Suctioning
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Intervention to promote oxygenation. Necessary when patients are unable to clear secretions. Oropharyngeal and nasopharyngeal-used when patient is able to cough but unable to clear secretions by expectorating. Orotracheal and nasotracheal-used when patient is unable to manage secretions by coughing. Tracheal-performed through an artificial airway such as ET or trach. Usually with mouth
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Artificial airways
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Intervention to promote oxygenation. Oral airway. Endotracheal and tracheal airways. Tracheostomy
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Oral airway
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Artificial airway. Short-term. Prevents obstruction of the trachea by displacement of the tongue into the oropharynx-sedated or unconscious
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Endotracheal and tracheal airways
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Artificial airway. Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions. Nose or mouth
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Tracheostomy
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Artificial airway. Long-term assistance, surgical incision made into trachea. Indications: acute airway obstruction, airway protection (after head/neck surgery), facilitate removal of secretions, prolonged intubation: less damage to airway, more comfortable, allowed to eat, mobility is improved (tube more secure)
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Types of trachs
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Shiley trach. Jackson trach
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Jackson trach
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Type of trach. Reusable inner cannula, some metal. No cuff. Obturator
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Shiley trach
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Type of trach. Disposable inner cannula. Cuff. Obturator.
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Cuffed trach
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On Shiley trach. Purpose: creates snug fit in trachea so as to: helps prevent aspiration, helps ventilator give stronger breaths, air won't get around it. Only inflated if: patient is being mechanically ventilated, if inflation is specifically ordered by physician, with meals.
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Deflate the cuff
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1. Suction oropharynx beforehand 2. Deflate cuff 3. Suction trachea afterwards
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Dangers of prolonged or over-inflation of cuff
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Increased mucosal pressure, causing ischemia, softening cartilage & mucosal erosion (hole in trachea)
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Passy-Muir speaking tracheostomy valve
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Allows patient to talk with a trach tube. Cuff must be deflated before inserting
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Tube dislodgement & accidental decannulation
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Keep obturator taped at bedside AAT. Attempt re-insertion using a spare tracheostomy tube with or without obturator. If unsuccessful at first attempt, position patient in semi-Fowler's, extend neck, and make another attempt to re-insert tracheostomy tube. Remove obturator immediately. Check bilateral breath sounds. Secure trach.
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NANDA nursing diagnoses related to patient with tracheostomy
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Ineffective airway clearance. Impaired verbal communication. Risk for infection. Impaired swallowing. Body image disturbance. Anxiety. Ineffective therapeutic regimen management
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Maintenance and promotion of lung expansion
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Ambulation. Positioning. Incentive spirometer. Noninvasive ventilation.
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Ambulation
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Maintenance and promotion of lung expansion. Immobility is a major factor in developing atelectasis, ventilator associated pneumonia. Studies show early ambulation improves lung expansion. Dangle and stand intubated patients. Get patients out of bed as soon as possible-day of surgery. Alveoli collapse onto themselves.
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Positioning
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Maintenance and promotion of lung expansion. Position for maximum respiratory function: change positions frequently, 45 degree semi-Fowler's is the most effective, unilateral disease promote perfusion to healthy lung, prevent drainage toward health lung
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Incentive spirometer
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Maintenance and promotion of lung expansion. Encourages deep breathing by providing visual feedback. Promoted deep breathing and prevents atelectasis. How to use? patient inhales slowly, even flow ball keeps breathing slow and deep, volume indicator provided feedback of level raised, 5-10 breaths every hour while awake. Inform patients the IS encourages coughing. Also teach patients how to splint.
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Noninvasive ventilation
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Maintenance and promotion of lung expansion. Continuous positive airway pressure. Bi-level positive airway pressure
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Continuous positive airway pressure (CPAP)
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Noninvasive ventilation. Used for sleep apnea or heart failure. A positive pressure keeps airway from collapsing
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Bi-level positive airway pressure (BiPAP)
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Noninvasive ventilation. Provides both inspiratory positive airway pressure and expiratory airway pressure-a push to keep airway & alveoli open. Used to prevent ET tube in patients with respiratory failure, pulmonary edema, exacerbation of COPD. Constant pressure to breathe in
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Chest tube
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Invasive intervention to prevent lung expansion. Catheter inserted through the thorax to remove air and fluids from the pleural space, to prevent air or fluid from reentering the pleural space, or to reestablish normal intrapulmonic pressures
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Nursing care of chest tube
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Keep the system closed and below the chest. Monitor for air leaks. Monitor chest fluid drainage. Encourage turn, cough, and deep breathing and incentive spirometer
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Oxygen therapy
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Intervention to improve hypoxemia. Percentage of oxygen in inspired air is referred to as fraction of inspired oxygen or FiO2; room air = FiO2 of 21%. Delivery of oxygen by some device in concentration greater than room air (21%). Decreases workload of heart/lungs & protects from tissue hypoxia
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Safety precautions of oxygen therapy
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Oxygen must be used according to government regulations. Oxygen toxicity-cover eyes. Oxygen is a medication and must be ordered, administered using rights of med admin and monitored (check meter and connections). Combustible (flammable). Secure oxygen cylinders. Always check tanks prior to use
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Types of oxygen therapy
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Nasal cannula. Simple face mask. Partial rebreather mask. Non-rebreather mask. Variable flow rate mask-venturi mask
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Nasal cannula
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Oxygen therapy. Low concentrations. Oxygen is delivered through plastic cannulas via nares (24-44%). Plastic prongs face down. Turn flow meter to correct level prior to putting cannula on patient. Usually 1-6 L/min. Prevent and check for breakdown over years. Give minimal amount they need
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Simple face mask
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Oxygen therapy. Moderate to high concentrations. Oxygen enters through entry port at bottom of mask and exits through large holes on sides of masks. Usually 40-60% oxygen at a flow rate of 5-8 L/min. Use nasal cannula during meals. Most commonly used mid-range device
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Partial nonrebreather mask
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Oxygen therapy. High concentrations. Has reservoir bag for the collection of first part of client's exhaled air; this air is mixed with oxygen for the next breath. Delivers 40-70% oxygen at 6-1 L/min. Reservoir bag should not collapse during inhalation. Not common
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Non-rebreather mask
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Oxygen therapy. High concentration. Delivers highest oxygen concentrations possible for the spontaneously breathing client. Exhaled air goes out one way flap; does not allow room air to enter; breathes only oxygen from bag. Delivers up to above 60% at 10L/min. Emergency short-term intervention
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Variable flow rate mask. Venturi mask
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Oxygen therapy. Only mask that delivers specific concentration of oxygen. 4L/min: 24-28%. 8L/min: 35-40%. 12L/min:50-60%. Most accurate. Chronic obstructive pulmonary disease clients. Higher oxygen
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Complications of oxygen therapy
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Drying effects of respiratory mucosa. Oxygen toxicity. Supports combustion. Skin breakdown
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Hypoxic drive
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Most people breath because of high carbon dioxide levels (carbon dioxide). Some chronic obstructive pulmonary disorder patients are carbon dioxide retainers so their carbon dioxide levels are always high. These patients breath because of low oxygen levels. If we give them too much oxygen and raise their oxygen levels they will stop breathing. End-stage COPD. Patients with sudden changes in their vital signs, level of consciousness, or behavior are possibly experiencing profound hypoxia.
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Assess oxygen therapy
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Is oxygen level correct? The type of deliver system (cannula, mask, etc). Liter per minute ordered by the physician. Check the physician's orders on the chart. Caution with COPD patients. Are they carbon dioxide retainers?
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Evaluation
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Ask about: degree of breathlessness, if distance ambulated without fatigue has increased, rating the breathlessness from 0 to 10, which interventions reduce dyspnea, frequency of cough and sputum production. Perform: observe respiratory rate before, during, and after any activity, assess any sputum produced, auscultate lung sounds for improvement in adventitious sounds.
