Hypoxemia
Low levels of oxygen in the blood
Hypoxia
Decreased tissue oxygenation
What is the oxygen content of air?
The oxygen content of atmospheric air is about 21%.
When is oxygen therapy prescribed?
Oxygen therapy is prescribed when the oxygen needs of the patient cannot be met by atmospheric or "room air" alone. It is used for both acute and chronic breathing problems that cause decreased blood and tissue oxygen levels as indicated by decreased part
What is the purpose of oxygen therapy?
The purpose of oxygen therapy is to use the lowest fraction of inspired oxygen (FiO2) to have an acceptable blood oxygen level without causing harmful side effects.
Hypercarbia
Increased partial pressure of arterial carbon dioxide [PaCO2] levels
When do you need to assess for oxygen-induced hypoventilation?
Assess for oxygen-induced hypoventilation in the patient whose main respiratory drive is hypoxia (hypoxic drive), such as in the patient with chronic lung disease who also has carbon dioxide retention (hypercarbia). The arterial carbon dioxide (PaCO2) lev
CO2 Narcosis
Loss of sensitivity to high levels of PaCO2
At what oxygen level are the lungs at risk for injury?
Oxygen toxicity is related to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung disease present. In general, an oxygen level greater than 50% given continuously for more than 24 to 48 hours may damage the lungs.
Which is the greater threat to life: oxygen-induced hypoventilation or hypoxemia?
Although oxygen-induced hypoventilation is a serious concern, untreated or inadequately treated hypoxemia is a greater threat to life.
What are the causes and manifestations of lung injury from oxygen toxicity?
The causes and manifestations of lung injury from oxygen toxicity are the same as those for acute respiratory distress syndrome (ARDS).
Initial symptoms include dyspnea, nonproductive cough, chest pain beneath the sternum, and GI upset. As exposure to hig
Absorption Atelectasis
Nitrogen in the air helps maintain patent airways and alveoli. Making up 79% of room air, nitrogen prevents alveolar collapse because it does not cross the alveolar-capillary membranes and remains in the airways and alveoli. When high oxygen levels are de
At what rate do you humidify the oxygen delivery system?
When the prescribed oxygen flow rate is higher than 4 L/min, humidify the delivery system. For the patient to receive properly humidified oxygen, the humidifier or nebulizer must have a sufficient amount of sterile water and the flow rate must be adequate
How often should oxygen delivery equipment be changed?
The humidifier or nebulizer may be a source of bacteria, especially if it is heated. Pseudomonas aeruginosa is often the organism involved. Oxygen delivery equipment such as cannulas and masks can also harbor organisms. Change equipment as per policy or p
What are low-flow delivery systems?
Low-flow delivery systems include the nasal cannula, simple facemask, partial rebreather mask, and non-rebreather mask.
What are low-flow delivery systems advantages and disadvantages?
These systems are inexpensive, easy to use, and fairly comfortable. A disadvantage is that the actual amount of oxygen delivered varies and depends on the patient's breathing pattern. The oxygen is diluted with room air (21% oxygen), which lowers the amou
At what flow rates and oxygen concentrations can you use nasal cannula?
The nasal cannula, or nasal prongs, is used at flow rates of 1 to 6 L/min. Oxygen concentrations of 24% (at 1 L/min) to 44% (at 6 L/min) can be achieved. Flow rates greater than 6 L/min do not increase oxygenation because the anatomic dead space (places w
Which patients shouldn't receive oxygen at rates higher than 2 to 3 L/min?
The patient who retains carbon dioxide is rarely prescribed to receive oxygen at a rate higher than 2 to 3 L/min because of the risk for losing the drive to breathe, thereby increasing the risk for apnea or respiratory arrest.
Simple Facemasks
Simple facemasks are used to deliver oxygen concentrations of 40% to 60% for short-term oxygen therapy or in an emergency. A minimum flow rate of 5 L/min is needed to prevent the rebreathing of exhaled air. Ensure the mask fits well to maintain inspired o
Partial Rebreather Masks
Partial rebreather masks provide oxygen concentrations of 60% to 75% with flow rates of 6 to 11 L/min. It is a mask with a reservoir bag but no flaps. With each breath, the patient rebreathes one third of the exhaled tidal volume, which is high in oxygen
Non-rebreather Masks
Non-rebreather masks provide the highest oxygen level of the low-flow systems and can deliver an Fio2 greater than 90%, depending on the patient's breathing pattern. This mask is often used with patients whose respiratory status is unstable and who may re
What are high-flow oxygen delivery systems?
High-flow systems include the Venturi mask, aerosol mask, face tent, tracheostomy collar, and T-piece. These devices deliver an accurate oxygen level when properly fitted.
Venturi Mask
Venturi masks (commonly called Venti masks) deliver the most accurate oxygen concentration without intubation. It works by pulling in a proportional amount of room air for each liter flow of oxygen. An adaptor is located between the bottom of the mask and
Which oxygen delivery system is best for patients with chronic lung disease?
Venturis masks are best for the patient with chronic lung disease because it delivers a more precise oxygen concentration.
Noninvasive positive-pressure ventilation (NPPV)
Noninvasive positive-pressure ventilation (NPPV) is a technique using positive pressure to keep alveoli open and improve gas exchange without the need for airway intubation. NPPV is now being used to manage dyspnea, hypercarbia and acute exacerbations of
What are some advantages/disadvantages of noninvasive positive-pressure ventilation (NPPV)?
Although NPPV prevents the complications associated with intubation, including ventilator-associated pneumonia (VAP), some risks and complications are associated with this type of therapy. Masks must fit tightly in order to form a proper seal. This can le
What are the 3 most common modes of delivery for noninvasive positive-pressure ventilation NPPV?
The three most common modes of delivery for NPPV are (1) CPAP, which delivers a set positive airway pressure throughout each cycle of inhalation and exhalation; (2) volume-limited or flow-limited, which delivers a set tidal volume with the patient's inspi
BiPAP
For BiPAP, a cycling machine delivers a set inspiratory positive airway pressure each time the patient begins to inspire. As he or she begins to exhale, the machine delivers a lower set end-expiratory pressure. Together, these two pressures improve tidal
CPAP
For CPAP, the effect is to open collapsed alveoli. Patients who may benefit from this form of oxygen or air delivery include those with atelectasis after surgery or cardiac-induced pulmonary edema or those with COPD. It is not beneficial for patients with
Transtracheal oxygen (TTO)
Transtracheal oxygen (TTO) is a long-term method of delivering oxygen directly into the lungs. A small, flexible catheter is passed into the trachea through a small incision with the patient under local anesthesia. TTO avoids the irritation that nasal pro
When will Medicare cover the cost of home oxygen therapy?
For Medicare to cover the cost of home oxygen therapy, the patient must have severe hypoxemia defined as a partial pressure of arterial oxygen (PaO2) level of less than 55 mm Hg or an arterial oxygen saturation (SpO2) of less than 88% on room air and at r
Home care preparation for oxygen therapy
The nurse or respiratory therapist teaches the patient about the equipment needed for home oxygen therapy, including the oxygen source, delivery devices, humidity sources, and safety aspects of using and maintaining the equipment.
Home oxygen therapy is provided in one of three ways: compressed gas in a tank or a cylinder, liquid oxygen in a reservoir, or an oxygen concentrator. Describe each.
Compressed gas in an oxygen tank (green) is the most often used oxygen source.
Liquid oxygen for home use is oxygen gas that has been liquefied. A concentrated amount of oxygen is available in a lightweight and easy-to-carry container similar to a Thermos
Tracheotomy
The surgical incision into the trachea to create an airway.
Tracheostomy
The (tracheal) stoma, or opening, that results from the tracheotomy.
Priority problems for patients requiring tracheostomy include(5):
1. Reduced oxygenation related to weak chest muscles, obstruction, or other physical problems
2. Inadequate communication related to tracheostomy or intubation
3. Inadequate nutrition related to presence of endotracheal tube
4. Potential for infection rel
What are some indications that tracheostomy tube has become obstructed?
Indicators of obstruction include difficulty breathing; noisy respirations; difficulty inserting a suction catheter; thick, dry secretions; and unexplained peak pressures (if a mechanical ventilator is in use). Assess the patient at least hourly for tube
When is a cuffed tube required for a tracheostomy?
For patients receiving mechanical ventilation, a cuffed tube is used in acute care settings. A noncuffed tube is used when mechanical ventilation is not required.
Tissue damage can occur at the point where the inflated cuff presses against the tracheal mucosa. At what pressure should the cuff be inflated?
To reduce the risk for tracheal damage, keep the cuff pressure between 14 and 20 mm Hg or 20 and 30 cm H2O (ideally, 25 cm H2O or less)
What assessments signal the need for suctioning?
Suctioning is needed when secretions are audible or noisy, when crackles or wheezes are heard on auscultation, or when restlessness, increased pulse or respiratory rates, or mucus in the artificial airway is present. Other indications include patient requ
How do you prevent hypoxia while suctioning a client?
Prevent hypoxia by hyperoxygenating the patient with 100% oxygen with a manual resuscitation bag attached to an oxygen source. If the patient can take deep breaths, instruct him or her to do so three or four times with the existing oxygen delivery system
What can be a problem with tracheostomy patients?
The tracheostomy tube sometimes tethers the larynx in place, making it unable to move effectively. The result is difficulty in swallowing. Also, when the tracheostomy tube cuff is inflated, it can balloon backwards and interfere with the passage of food t
How is a patient weaned from a tracheostomy tube?
First, the cuff is deflated as soon as the patient can manage secretions and does not need mechanical ventilation. This change allows him or her to breathe through the tube and through the upper airway. Next, the tube is changed to an uncuffed tube. If th
What should the air temperature entering the tracheostomy be between?
98.6� and 100.4� F (37� and 38� C), and never exceed 104� F (40� C).
An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best?
A. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula
B. The client with chr
The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula
Which value indicates clinical hypoxemia and the need to increase oxygen delivery?
A. Hemoglobin of 22 g/dL
B. PaCO2 of 30 mm Hg
C. PaO2 of 65 mm Hg
D. Oxygen saturation of 88%
PaO2 of 65 mm Hg
For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube?
A. Hyperoxygenate before and after suctioning.
B. Repeat suctioning until the tube is clear.
C. Apply suction during inse
Hyperoxygenate before and after suctioning.
A client with chronic obstructive pulmonary disease has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN?
A. Adjust the posi
Adjust the position of the oxygen tubing.
The client with a new tracheostomy has a soiled dressing. What is the best nursing intervention?
A. Cut sterile 4 � 4 gauze to fit around the tracheostomy tube.
B. Reinforce the dressing with sterile 4 � 4 gauze.
C. Replace the dressing with clean, folded
Replace the dressing with sterile, folded 4 � 4 gauze.
An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN?
A. Complete the referral form for a home health agency.
B. Suction the tracheostomy using sterile technique.
C
Suction the tracheostomy using sterile technique.
The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first?
A. Assess the client's respiratory status.
B. Decrease the sensitivity of the alarm.
C. Ensure that the connecting tubi
Assess the client's respiratory status.
A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first?
A. Suction as needed.
B. Clean the tracheostomy inner cannula and stoma.
C. Listen to lung sounds.
D.
Listen to lung sounds.
A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response?
A. "You can quit when you are ready."
B. "It's never too late to quit
You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous.
The client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response?
A. "But you know you need this to breathe, right?"
B. "Do you have a pretty scarf or a large loose collar that you
Do you have a pretty scarf or a large loose collar that you could place over it?
Which client has the most urgent need for frequent nursing assessment?
A. An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask
B.
An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask
The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period?
A. Computer keyboard
B. Magic Slate
C. Picture board
D. Pen and paper
Picture board
Respirations of the sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse?
A. Humidifying the oxygen source
B. Increas
Suctioning the client
A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially?
A. Face tent
B. Venturi mask
C. Nasal cannula
Face tent
A "Do not resuscitate" (DNR) client has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first?
A. Ensures that the tubing is patent and that oxygen flow is high
B. Notifies the chaplain and the family member of re
Ensures that the tubing is patent and that oxygen flow is high
A client with a tracheostomy is at increased risk for aspiration. Which nursing intervention(s) will reduce this risk? Select all that apply.
A. Encourage frequent sipping from a cup.
B. Encourage water with meals.
C. Inflate the tracheostomy cuff during
Maintain the client upright for 30 minutes after eating.
Provide small, frequent meals.
Teach the client to "tuck" the chin down in the forward position to swallow.
A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first?
A. Auscultate the client's breath sounds while ap
Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask.
The client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care?
A. "I can only take baths, no showers."
B. "I can put normal saline in my tracheostomy to keep
I can only take baths, no showers.
The client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the physician requests a nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immedi
Decreasing respiratory rate
The client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most
Lung sounds may indicate absorption atelectasis.
A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral Valium 4 hours ago in the
The client is receiving oxygen at 4 L/min (this is based on flow rates for the simple facemask)