Chapter 41: Oxygenation Part 2 (Nursing Process) Flashcards
During assessment gather a
complete history
History of Respiratory Function
- presence of cough: productive/nonproductive, hemoptysis
- dyspnea (asthma, bronchitis, pneumonia)
- pain: rule out chest pain
- environmental exposure/allergies
- frequency of respiratory tract infections: +TB, HIV
- pulmonary risk factors
- past respiratory problems
- current medications
- smoking history and/or secondhand smoke exposure
Types of Chest Pain
- pleuritic chest pain
- pericardial chest pain
- musculoskeletal pain
pleuritic chest pain
radiates to scapular regions
coughing and inspiration worsen pain.
pericardial chest pain
results from inflammation of the pericardia sac.
occurs on inspiration, does not usually radiate
musculoskeletal pain
usually following exercise, rib trauma, prolonged coughing episodes
Breathing Patterns include
- Kussmaul Respirations
- Cheyne-Stokes
- Apnea
Kussmaul Respirations
increased rate and depth in response to decreased pH
Cheyne-Stokes
due to decreased blood flow or injury the the brainstem.
deep breaths mixed with shallow breaths mixed with apnea.
apnea
absence of respirations for a period of time
During assessment, the nurse needs to
- inspect chest wall movement (retraction, use of accessory muscles)
- palpate peripheral pulses, capillary refill
- auscultate: normal/abnormal lung and/or heart sounds
- review diagnostic tests
Nursing Diagnosis RT Oxygenation
- Decreased CO
- Fatigue
- Activity Intolerance
- Impaired Gas Exchange
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Risk for Aspiration
Implementations RT Oxygenation
- health promotion
- airway maintenance
- mobilization of pulmonary secretions
- suctioning
- artificial airways
- maintenance and promotion of lung expansion
Health promotion includes
- vaccinations: pneumococcal, influenza
- healthy lifestyle: low-fat, high-fiber diet, maintain body weight, exercise
- environmental pollutants: smoke/secondhand smoke, chemicals
hydration
fluid intake of 1500-2500/day unless contraindicated
humidification
keeps airways moist and loosens pulmonary secretions. Necessary for patients receiving > or equal to 4 L of O2/NP
Nebulization
adds moisture to medication-enhances mucociliary clearance
Chest physiotherapy (CPT)
- postural drainage
- chest percussion
- vibration
Mobilization of Pulmonary Secretions include
- hydration
- humidification
- nebulization
- coughing and deep breathing
- chest physiotherapy
Suctioning Techniques
process no longer than 15 sec.
includes oro and naso pharyngeal; oro and naso tracheal
Oro and Naso pharyngeal
patient able to cough but can not expectorate the secretions
Oro and Naso tracheal
sterile technique
unable to manage by coughing
Artificial Airways
places patient at high risk for infection.
includes oral, endotracheal and tracheal airways
Oral airway
maintains the tongue in the normal position