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respiratory system includes

upper airways, lungs, lower airways, and alveolar air sacs (base of lungs)


the lungs aid the body

in oxygenation and tissue perfusion


noninvasive procesures

- chest x-ray (CXR): use lead sheild for adults who are childbearing age
- pulse oximetry
- pulmonary function tests
- sputum culture
- ct scan
- mri



when there is a limited amount of oxyegen in the blood



- when the muscles are pulled inward and occur between the ribs when inspiration occurs
- intercostal retractions are a sign that the airway is blocked



lack of oxygen at the cellular level


clinical manifestation of hypoxia and hypoemia

pale skin and mucous membranes
elevated blood pressure
use of accessory muscles, nasal flaring, adventitious lung sounds


nursing actions for hypoxia and hypoxemia

- monitor respiratory rate and pattern, level of consciousness
- provide oxygen therapy at the lowest liter flow that will correct hypoxia
- make sure the mask creates a secure seal over the nose and mouth
- assess/monitor restlessness, hypertension, and headache
- wheezing because of inflammation on inhaling or exhale
- auscultate the lungs for breath sounds and adventitious sounds (crackles and wheezes)
- assess/ monitor oxygenation status with pulse oximetry
- promote oral hygiene
- encourage turning, coughing, deep breathing, and the use of incentive spirometry and suctioning
- promote rest and decrease environmental stimuli


oxygen therapy

- a therapeutic gas that treats hypoxemia (low levels of arterial oxygen)
- administering and adjusting oxygen requires a prescription


oxygen delivery devices

- nasal cannula
- simple face mask
- partial rebreather mask
- non-rebreather mask
- venturi mask
- aerosol mask, face tent
- t-piece


nasal cannula

tubing with two small prongs for insertion into the nares
- fraction of inspired oxygen: delivers an Fio2 of 24% to 44% at a flow rate of 1-6 l/min


nasal cannula advantages

- safe, simple, easy to apply method
- cannula is comfortable and well tolerates
- client is able to eat, talk, and ambulate


nasal cannula disadvantages

- FiO2 varies with flow rate, and the rate and depth of the clients breathing
- extended use can lead to skin breakdown and dry mucous membranes
- tuning is easily dislodged


nasal cannula nursing actions

- assess the patency of the nares
- ensure that the prongs fit in the nares properly
- use water-soluble gel to prevent dry nares
- provider humidication for flow rates of 4l/min and greater ****


simple face mask

- covers the client's nose and mouth
- delivers an Fi02 of 35% to 50% at flow rates of 6 to 12 l/min
- minimum flow rate is 6l/min to ensure flushing of CO2 from the mask


simple face mask advantages

- face mask is easy to apply and can be more comfortable than a nsal cannula
- provides humidified oxygen


simple face mask disadvantages

- flow rates less than 6L/min can result in rebreathing of co2
- clients who have anixety or claustrophobia do not tolerate it well
- eating, drinking, and talking are impaires. mositure and pressure can collect under mask and cause skin breakdown
- face mask pose a greater risk of aspiration


simple face mask nursing actions

- assess proper fit to ensure a secure seal over the nose and mouth
- make sure the client wears a nasal cannula during meals
- use with caution for clients who have a high risk of aspiration or airway obsutrction
- monitor for skin breakdown


non-rebreather mask fraction of inspired oxygen

- delivers an FiO2 of 80% to 95% at flow rates of 10-15 l/min to keep the reservoir bag 2/3 full during inspiration and expiration


non-rebreather mask advantages

- it delivers the highest 02 concentration possible
- a one-way valve situated between the mask and reservoir allows the client to inhale maximum 02 from the reservoir bag
- the two exhalation ports have flaps covering them that prevent room air from entering the mask


non-rebreather mask disadvantage

- the valve and flap on the mask must be intact and functional during each breath
- it is poorly tolerated by clients who have anxiety or claustrophobia
- eating drinking and talking are impaired
- use with caution for clients who have high risk of aspiration or airway obstruction


non-rebreather mask nursing actions

- perform and hourly assessment of the valve and flap
- assess proper fit to ensure a secure seal over the nose and mouth
- assess for skin breakdown beneath the edges of the mask and bride of the nose. make sure the client uses a nasal cannula during meals


oxygen complications

- oxygen toxicity can result from high concentrations of oxygen (typically greater than 50%)
- long duration of oxygen therapy (typically more than 24 to 48 hours) and the severity of lung disease


oxygen toxicity manifsations

- nonproductive cough
- substernal pain
- nausea
- vomiting
- fatigue
- dyspnea
- restlessness
- paresthesias


oxygen toxicity nursing actions

- use the lowest level of oxygen necessay to maintain an adequate spo2
- monitor abg and notify the provider if sp02 levels are outside the expected reference range
- decrease the fio2 as the clients spo2 imrpoves


combustion nursing actions

- post "no smoking" or "oxygen in use" signs to alert others of the fire hazard. known where to find the closest fire extinguisher
- educate about the fire hazard of smoking with oxygen use
- have clients wear a cotton gown because synthetic or wool fabrics can generate static electricity



- ensure that all electric devices (razors, hearing aids, radios) are working well
- make sure all electric machinery (monitors, suction machines is grounded
- do not sure volatile, flammable materials (alcohol, acetone) near clients receiving oxygen


specimen collection and airway clearance

- mucoasl secretion buildup or aspiration of emeis can obstruct a clients airway
- adequate hydration and coughing help the client maintain airway patency
- these interventions promote adequate gas exchange and lung expansion


specimen collection and airway clearance nursing actions that mobilize secretions and maintain airway patency include:

- assistance with coughing
- hydration
- positioning
- humidification
- nebulizer therapy
- chest phsiotherapy
- suctioning



don the required personal protective equitment
- assist the client to high-fowelers or fowlers position for suctioning if possible
- encourage the client to breathe deeply and cough in a an attempt to clear secretions without artifical suction