Chapter 40—Oxygenation

Scientific Knowledge Base o Cardiovascular physiology

Structure and function Myocardial pump

o Coronary artery disease (CAD) and cardiomyopathy (enlarged heart) result in decreased pumping action and a decrease in the volume of blood ejected from the ventricles (stroke volume).

o Hemorrhage and dehydration cause a decrease in circulating blood volume and a decrease in stroke volume.

o Myocardial fibers have contractile properties allowing them to stretch during filling. In a healthy heart this stretch is proportionally related to the strength of contraction. As the myocardium stretches, the strength of the subsequent contraction increases; this is known as Frank-Starling law of the heart.

Myocardial flow o To maintain adequate blood flow to the pulmonary and

systemic circulation, myocardial blood flow must supply sufficient oxygen and nutrients to the myocardium itself.

o Blood flow through the heart is unidirectional. Coronary artery circulation

o The coronary circulation is the branch of the systemic circulation that supplies the myocardium with oxygen and nutrients and removes waste.

o The coronary arteries fill during ventricular diastole. o The left coronary artery, the most abundant blood

supply, feeds the left ventricular myocardium, which is more muscular and does most of the heart’s work.

Systemic circulation o The arteries and veins of the systemic circulation deliver

nutrients and oxygen to and remove waste from the tissues.

Blood flow regulation o The amount of blood ejected from the left ventricle

each minute is the cardiac output. Normal is 4-6 L/min for 150 lb person

o The circulation volume of blood changes according to the oxygen and metabolic needs of the body.

o Cardiac index (CI) more precise and takes into consideration tissue perfusion and the client’s body surface area (BSA).

Cardiac output / BSA; normal is 2.5-4L/min/m2

o Stroke volumeamount of blood ejected from the left ventricle with each contraction.

o The amount of blood in the left ventricle at the end diastole (preload), the resistance to left ventricular ejection (afterload), and myocardial contractility all affect stroke volume.

o Some drugs increase the force of myocardial contraction, such as digitalis preparations, epinephrine, and sympathomimetic drugs (drugs that mimic effects of SNS).

Conduction system The heart’s conduction system generates the impulse needed to

initiate the electrical chain of events of a normal heartbeat. Sympathetic nerve fibers, which increase the rate of impulse

generation and the speed of impulse transmission, innervate all parts of the atria and ventricles. The parasympathetic fibers originating form the vagus nerve decrease the rate and also innervate all parts of the atria and ventricles as well as the SA and AV nodes.

The conduction system originates with the SA node. In the right atrium at an intrinsic rate b/w 60-100 bpm.

The AV node mediates impulses b/w atria and ventricles b/w 40 and 60 bpm.

o Assists atrial emptying by delaying the impulse before transmitting it through the bundle of His and the ventricular Purkinje network.

Intrinsic rate of the bundle of His and the ventricular Purkinje network is b/w 20 and 40 bpm.

An ECG reflects the electrical activity of the conduction system. It does not reflect the muscular work of the heart. Normal sequence on ECG is normal sinus rhythm (NSR).

o Respiratory physiology Structure and fuciton

The respiratory muscles, pleural space, lungs, and alveoli are essential for ventilation, perfusion, and exchange of respiratory gases.

Ventilation process of moving gases into and out of the lungs. Perfusionrelates to the ability of the cardiovascular system to

pump oxygenated blood the tissues and return deoxygenated blood to the lungs.

Diffusion is responsible for moving the respiratory gases to another.

Work of breathing o WOB is the effort required to expand and contract the

lungs. o Inspiration active process, stimulated by chemical

receptors in the aorta.

o Expiration passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work.

o Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing.

o Clients with advanced COPD lose the elastic recoil of the lungs and thorax.

o Clients with COPD, especially emphysema, frequently use accessory muscles of respiration to increase lung volume.

Elevation of the clavicles during inspiration can indicate ventilatory fatigue, air hunger, or decreased lung expansion.

o Compliance is the ability of the lungs to distend or to expand in response to increased intraalveolar pressure.

o Airway resistance is the pressure difference between the mouth and alveoli in relation to the rate of flow of inspired gas. Airway obstruction, asthma, and tracheal edema increase airway resistance.

Lung volumes o Spirometry measures the volume of air entering or

leavings the lungs. Pulmonary circulation

o The primary function of the pulmonary circulation is to move blood to and form the alveolar capillary membrane for gas exchange.

o The pulmonary circulation also acts as a filter, removing small thrombi before they reach vital organs.

Respiratory gas exchange Diffusion of respiratory gases occurs at the alveolar capillary

membrane. Increased thickness of the membrane impedes diffusion

because gases take longer to transfer across the membrane. Oxygen transport

o Delivery depends on the amount of oxygen entering the lungs (ventilation), blood flow to the lungs and tissues (perfusion), rate of diffusion, and oxygen carrying capacity.

o Three things influence the capacity of the blood to carry oxygen: amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the tendency of hemoglobin to bind with oxygen.

Carbon dioxide transport o Reduced hemoglobin (deoxyhemoglobin) combines

with carbon dioxide, and the venous blood transports the majority of carbon dioxide.

Regulation of respiration Regulation of respiration is necessary to ensure sufficient

oxygen intake and carbon dioxide elimination to meet the body’s demands.

Neural regulation includes the CNS control of respiratory rate, depth, and rhythm.

Chemical regulation involves the influence of chemicals such as carbon dioxide and hydrogen ions on the rate and depth of respiration.

o Factors affecting oxygenation Physiological factor any condition affecting the cardiopulmonary

functioning directly affects the body’s ability to meet oxygen demands. Decreased oxygen-carrying capacity

o Anemia and inhalation of toxic substances decrease the oxygen-carrying capacity of blood by reducing the amount of available hemoglobin to transport oxygen.

o Carbon monoxide is the most common toxic inhalant decreasing the oxygen-carrying capacity of blood.

Decreased inspired oxygen concentration o Decreases in the fraction of inspired oxygen

concentration (FIO2) are caused by an upper or lower airway obstruction limiting delivery of inspired oxygen to alveoli; decreased environmental oxygen, such as at high altitudes; or decreased inspiration, which occurs in drug overdoses.

Hypovolemia o With significant fluid loss, the body tries to adapt by

increasing the heart rate and peripheral vasoconstriction to increase the volume of blood returned to the heart and, in turn, increase the cardiac output.

Increased metabolic rate o Increased metabolic activity increases oxygen demand.

When body systems are unable to meet this demand, the level of oxygenation declines.

Conditions affecting chest wall movement Any condition reducing chest wall movement results in

decreased ventilation Pregnancy: as fetus grows during pregnancy, the enlarging

uterus pushes abdominal contents upward against diaphragm. In last trimester inspiratory capacity decreases causing dyspnea on exertion and increased fatigue.

Obesity: clients morbidly obese have reduced lung volumes from the heavy lower thorax and abdomen, particularly when the recumbent and supine positions.

o Morbidly obese clients have reduction in compliance as a result of encroachment of abdomen into chest,

increased work of breathing, and decreased lung volumes.

o Obese client is susceptible to pneumonia after surgery or an upper respiratory tract infection.

Musculoskeletal abnormalities: abnormal structural configurations impairing oxygenation include those affecting the rib cage, such as pectus excavatum, and the vertebral volume, such as kyphosis, lordosis, or scoliosis.

Trauma: unstable chest wall allows the lung underlying the injured area to contract on inspiration and bulge on expiration, resulting in hypoxia.

Neuromuscular diseases: affect tissue oxygenation by decreasing the client’s ability to expand and contract the chest wall. Ventilation is impaired, and atelectasis, hypercapnia, and hypoxemia occur.

CNS alterations: when medulla oblongata is affected, neural regulation of respiration is damaged and abnormal breathing patterns develop. When the phrenic nerve is damaged, the diaphragm does not descend properly, thus reducing inspiratory lung volumes and causing hypoxemia.

o Injury of C3-C5 results in paralysis of phrenic nerve. o Alterations in cardiac functioning

Disturbances in conduction: electrical impulses that do not originate from the SA node cause conduction disturbances. These rhythm disturbances are called dysrhythmias, meaning a deviation from the normal sinus heart rhythm.

Occur as a primary conduction disturbance, such as in response to ischemia, valvular abnormality, anxiety, or drug toxicity; as a result of caffeine, alcohol, or tobacco use; or as complications of acid-base or electrolyte imbalance.

Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation.

Altered cardiac output Failure of myocardium to eject sufficient volume to systemic

and pulmonary circulations results in heart failure. Left-sided heart failure

o Assessment findings include fatigue, breathlessness, dizziness, and confusion as a result of tissue hypoxia form the diminished cardiac output.

o As the left ventricle continues to fail, blood begins to pool in the pulmonary circulation, causing pulmonary congestion.

Right-sided heart failure

o Right-sided heart failure more commonly results from pulmonary disease or as a result of long-term left sided failure

o The primary pathological factor in right-sided failure is elevated pulmonary vascular resistance (PVR).

o As the failure continues, the amount of blood ejected from the right ventricle declines, and blood begins to back up in the systemic circulation.

o Clinically the client has weight gain, distended neck veins, hepatomegaly and splenomegaly, and dependent peripheral edema.

Impaired valvular function When stenosis occurs, the flow of blood through the valves is

obstructed. Over time the stenosis causes the ventricle to hypertrophy, and

if the condition is untreated, left- or right sided heart failure occurs.

When regurgitation occurs, there is a backflow of blood into an adjacent chamber.

Myocardial ischemia Results when the supply of blood to the myocardium from the

coronary arteries is insufficient to meet myocardial oxygen demands.

Angina: angina pectoristransient imbalance between myocardial oxygen supply and demand.

o This condition results in chest pain that is aching, sharp, tingling, or burning, or that feels like pressure.

o Typically chest pain is left sided or substernal and often radiates to the left or both arms, and to the jaw, neck and back.

Pain usually lasts 1-15 minutes Myocardial infarction

o Results from sudden decrease in coronary blood flow or an increase in myocardial oxygen demand without adequate coronary perfusion.

o Chest pain associated with MI in men is usually described as crushing, squeezing, or stabbing.

o Pain occurs at rest or excretion and lasts more than 30 minutes.

o Most common initial symptom in women is angina, but atypical symptoms of fatigue, indigestion, vasospasm, SOB, or back or jaw pain are also present.

o Alterations in respiratory functioning The goal of ventilation is to produce a normal arterial carbon dioxide

tension between 35-45 mm Hg (PaCO2) and maintain a normal arterial oxygen tension (PaO2) between 95-100 mm Hg.

Hyperventilation

State of ventilation in excess of that required to eliminate the carbon dioxide produced by cellular metabolism. Anxiety, infections, drugs, or an acid-base imbalance induce hyperventilation, as well as hypoxia associated with pulmonary embolus or shock.

Salicylate (aspirin) poisoning causes excessive stimulation of the respiratory center as the body attempts to compensate for excess carbon dioxide.

Amphetamines also increase ventilation by raising CO2 production.

Hypoventilation Occurs when alveolar ventilation is inadequate to meet the

body’s oxygen demand or to eliminate sufficient carbon dioxide. Atelectasiscollapse of alveoli, prevents normal exchange of

oxygen and carbon dioxide. In clients with COPD, the administration of excessive oxygen

results in hypoventilation. Their stimulus to breathe is a decreased arterial oxygen (PaO2)

level. Administration of oxygen greater than 24%-28% (1-3 L/min)

prevents the PaO2 from falling and obliterates the stimulus to breathe, resulting in hypoventilation.

Hypoxia Inadequate tissue oxygenation at the cellular level. Causes include (1) decreased hemoglobin and lowered oxygen-

carrying capacity of the blood; (2) a diminished concentration of inspired oxygen, which occurs at high altitudes; (3) the inability of tissues to extract oxygen form the blood, as with cyanide poisoning; (4) decreased diffusion of oxygen from the alveoli to the blood, as in pneumonia; (5) poor tissue perfusion with oxygenated blood, as with shock; and (6) impaired ventilation, as with multiple rib fractures or chest trauma.

Nursing Knowledge Base o Developmental factors

Infants and toddlers: are at risk for upper respiratory tract infections as a result of frequent exposure to other children and exposure to secondhand smoke.

School-age children and adolescents: exposed to respiratory infections and respiratory risk factors such as secondhand smoke and cigarette smoking.

Young and middle-age adults: exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, and OTC and prescription drugs not used as intended, illegal substances, and smoking.

Older adults: changes include calcification of the heart valves, SA node, and costal cartilages. The arterial system develops the atherosclerotic plaques. Osteoporosis leads to changes in the size and shape of the thorax.

The trachea and large bronchi enlarged form calcification of the airways.

The alveoli enlarge, decreasing the surface area available for gas exchange. The number of functional cilia is reduced, causing a decrease in the effectiveness of the cough mechanism, putting the older adult at increased risk for respiratory infections.

o Lifestyle factors Risk factor modification is important and includes smoking cessation,

weight reduction, and a low-cholesterol and a low-sodium diet, management of hypertension, and moderate exercise.

Nutrition: severe obesity decreases lung expansion, and increased body weight increases tissue oxygen demands.

The malnourished client experiences respiratory muscle wasting, resulting in decreased muscle strength and respiratory excursion.

Client is at risk for retention of pulmonary secretions. Cardioprotective nutrition includes diets rich in fiber; whole

grains; fresh fruits and vegetables; nuts; antioxidants; lean meats; fish; and chicken; and omega-3 fatty acids.

Potatoes and citrus fruit juices are Cardioprotective in women, but not men.

Exercise: people who exercise for 30-60 minutes daily have a lower pulse rate and BP, decreased cholesterol level, increased blood flow, and greater oxygen extraction by working muscles.

Smoking: inhaled nicotine causes vasoconstriction of peripheral and coronary blood vessels, increasing blood pressure and decreasing blood flow to peripheral vessels.

Women who take birth control pills and smoke cigarettes have an increased risk for thombophlebitis and pulmonary emboli

Substance abuse: first, the person who chronically abuses substances often has a poor nutritional intake.

Second, excessive use of alcohol and certain other drugs depresses the respiratory center, reducing the rate and depth of respiration and the amount of inhaled oxygen.

Stress: a continuous state of stress of severe anxiety increases the body’s metabolic rate and the oxygen demand.

o Environmental factors Incidence of pulmonary disease is higher in smoggy, urban areas than in

rural areas Nursing Process—Assessment

o Nursing assessment cardiopulmonary functioning includes an in-depth history of the client’s normal and present cardiopulmonary function, past impairments in circulatory or respiratory functioning, and measures that the client uses to optimize oxygenation.

o Nursing history: focuses on the clients’ ability to meet oxygen needs. The nursing history for cardiac function includes pain and characteristic

of pain, dyspnea, fatigue, peripheral circulation, cardiac risk factors and the presence of past or concurrent cardiac conditions.

The nursing history for respiratory function includes the presence of a cough, SOB, wheezing, pain, environmental exposures, frequency of respiratory tract infections, pulmonary risk factors, past respiratory problems, current medication use, and smoking history or secondhand smoke exposure.

Pain: presence of chest pain needs immediate thorough evaluation, including location, duration, radiation, and frequency.

Pericardial pain results from inflammation of the pericardial sac, occurs on inspiration, and does not usually radiate.

Pleuritic chest pain is peripheral and radiates to the scapular regions.

Fatigue: fatigue in the client with cardiopulmonary alterations is often an early sign of a worsening of the chronic underlying process.

Smoking: important to determine clients’ direct and secondary exposure to tobacco.

Dyspnea: is a clinical sign of hypoxia. It is the subjective sensation of difficult or uncomfortable breathing.

Is associated with exaggerated respiratory effort, use of the accessory muscles of respiration, nasal flaring, and marked increases in the rate and depth of respirations.

Orthopnea client uses multiple pillows when lying down or must sit with the arms elevated and learning forward to breathe.

Cough: coughing is a protective reflex to clear the trachea, bronchi and lungs of irritants and secretions.

A productive cough results in sputum production, material coughed up from the lungs that the client swallows or expectorates.

If hemoptysis (bloody sputum) is present, determine if it is associated with coughing and bleeding from the upper respiratory tract, from sinus drainage, or from the GI tract (hematemesis).

Wheezing: associated with asthma, acute bronchitis, or pneumonia. Environmental or geographical exposures: most common exposures in

the home are cigarette smoke, carbon monoxide, and radon. Respiratory infections: obtain information about the client’s frequency

and duration of respiratory tract infections. On average, clients will have four colds per year. Presentation with Pneumocystis carinii pneumonia (PCP) or

Mycoplasma pneumonia. o Presentation with either indicates a significant

depression of the client’s immune system and progression to AIDS.

Allergies: inquire about your client’s exposure to airborne allergens Safe nursing practice also includes obtaining information about

food, drug, or insect sting allergies. Health risks: determine familial risk factors, such as a family history of

lung cancer or cardiovascular disease.

Medications: clients taking warfarin (Coumadin) for blood thinning will prolong the prothrombin time (PT)/international normalized ratio (INR) results if they are taking gingko biloba, garlic, or ginseng with the anticoagulation.

Clients need to recognize adverse reactions and be aware of the dangers in combining prescribed medications with OTC drugs.

o Physical examination Inspection: using inspection techniques perform a head-to-toe

observation of the client for skin and mucous membrane color, general appearance, level of consciousness, adequacy of systemic circulation, breathing patterns, and chest wall movement. (table 40-3)

Clubbed nails, obliteration of the normal angle between the base of the nail and the skin often occur in clients with prolonged oxygen deficiency, endocarditis, and congenital heart defects.

Conditions such as emphysema, advancing age, and COPD cause the chest to assume a rounded “barrel” shape.

Palpation: palpation of the extremities provides data about the peripheral circulation, the presence and quality of peripheral pulses, skin temperature, color, and capillary refill.

Auscultation: of the cardiovascular system include assessment for normal S1 and S2 sounds, the presence of abnormal S3 and S4 sounds (gallops), and murmurs or rubs.

Planning o Goals and outcomes: clients with impaired oxygenation require a nursing care

plan directed toward meeting actual or potential oxygenation needs. o Setting priorities: the client’s level of health, age, lifestyle, and environmental

risks affect the level of tissue oxygenation. Implementation

o Health promotion Prevention of respiratory infections is foremost in maintaining optimal

health. Vaccinations: annual influenza vaccines are recommended for children

6-59 months, adults over 50, and clients with chronic illnesses. Persons who should not be vaccinated include those with a

known hypersensitivity to eggs or other components of the vaccine and adults with an acute febrile illness.

Healthy lifestyle behavior: encourage clients to eat a healthy low-fat, high-fiber diet; monitor their cholesterol, triglyceride, HDL, and LDL levels; reduce their stress; exercise; and maintain a body weight in proportion to their height.

Elimination of cigarettes and other tobacco, reduction of pollutants, monitoring of air quality, and adequate hydration are additional healthy behaviors.

o During the hot summer months teach clients to limit their activities to early in the day or late in the evening, when temperatures are lower.

o Shoveling snow is especially risky and often precipitates a cardiac event. Other events such as hanging holiday lights and decorations in the extreme cold, will possibly precipitate chest pain and bronchospasm.

o Acute care Clients with acute pulmonary illnesses require nursing interventions

directed toward halting the pathological process. Dyspnea management

Treat underlying process causing dyspnea, then add additional therapies

Pharmacologic agents include bronchodilators, inhaled steroids, muculytics, and low-dose antianxiety medications.

Airway maintenance: requires adequate hydration to prevent thick, tenacious secretions

Suctioning, chest physiotherapy, and nebulizer therapy assist in managing alterations in airway clearance.

Mobilization of pulmonary secretions: ability of a client to mobilize pulmonary secretions makes the difference between a short-term illness and a long recovery involving complications.

Humidification: process of adding water to gas Air or oxygen with a high relative humidity keeps the airways

moist and helps loosen and mobilize pulmonary secretions. Humidification is necessary for clients receiving oxygen therapy

at greater than 4 L/min. Nebulization: adds moisture or medications to inspired air by mixing

particles of varying sizes with the air. Humidification through Nebulization enhances mucociliary

clearance, the body’s natural mechanism for removing mucus and cellular debris from the respiratory tract.

Chest physiotherapy: group of therapies used to mobilize pulmonary secretions.

Chest physiotherapy is recommended for clients who produce greater than 30 mL of sputum per day or heave evidence of atelectasis by chest x-ray examination.

Suctioning techniques: suctioning is necessary when the client is unable to clear respiratory secretions from the airways.

In most cases use sterile technique for suctioning because the oropharynx and trachea are considered sterile.

Too-frequent suctioning puts the client at risk for development of hypoxemia, hypotension, arrhythmias, and possible trauma to the mucosa of the lungs.

Oropharyngeal and nasopharyngeal suctioning: is used when the client is able to cough effectively but is unable to clear secretions by expectorating or swallowing.

Orotracheal and nasotracheal suctioning: is necessary when the client with pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway present.

Tracheal suctioning: occurs through an artificial airway, such as an endotracheal tube or tracheostomy tube.

Make sure the suction catheter is no greater than half of the size of the internal diameter of the artificial airway.

Open suctioning involves a sterile catheter that is opened at the time of suctioning.

o Wear sterile gloves during procedure Closed suctioning involves a multiple-use suction catheter that

is encased in a plastic sheath o Most often used on clients who require mechanical

ventilation to support their respiratory efforts, because it permits continuous delivery of oxygen while suction is performed, thus reducing the risk of oxygen desaturation.

Artificial airways: for clients with decreased level of consciousness or airway obstruction and aids in removal of tracheobronchial secretions.

Oral airway: simplest type of artificial airway, prevents obstruction of the trachea by displacement of the tongue into the oropharynx.

Endotracheal and tracheal airway: presence of an artificial airway places the client at high risk for infection and airway injury.

Endotracheal tubes (ETs) are short-term artificial airways to administer mechanical ventilation, relieve upper airway obstruction, protect against aspiration, or clear secretions.

Positioning: frequent changes of position are simple and cost-effective methods for reducing stasis of pulmonary secretions and decreased chest wall expansion, both of which increase the risk of pneumonia.

The 45-degree semi-Fowler’s position is the most effective position.

This position uses gravity to assist in lung expansion and reduces pressure from the abdomen on the diaphragm.

Incentive spirometry: encourages voluntary deep breathing by providing visual feedback to clients about inspiratory volume.

Promotes deep breathing and prevents or treats atelectasis in the postoperative client.

A postoperative inspiratory capacity ½- ¾ of the preoperative volume is acceptable because of postoperative pain.

Chest tubes: a chest tube is a 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 intrapleural and intrapulmonic pressures.

Mobile drains reduce the length of time needed for the chest tube, improve ambulation, and decrease the length of time in the hospital.

A pneumothorax is a collection of air in the pleural space. A hemothorax is an accumulation of blood and fluid in the

pleural cavity between the parietal and visceral pleurae, usually as a result of trauma.

o Produces a counterpressure and prevents the lung from full expansion.

Special considerations: clamping a chest tube is contraindicated when ambulating or transporting the client

o Will possibly result in a tension pneumothorax. o Maintain the drainage device below the client’s chest.

Oxygen therapy: goal of oxygen therapy is to prevent or relive hypoxia. Has dangerous side effects, such as atelectasis or oxygen

toxicity. Safety precautions: although it does not spontaneously burn or cause an

explosion, it can easily cause a fire in a client’s room if it contacts a spark from an open flame or electrical equipment.

Nasal cannula: is a simple, comfortable device used for oxygen delivery. Two cannulas, about 1.5 cm long, protrude from the center of a

disposable tube and are inserted into the nares. Be alert for skin breakdown over the ears and in the nares from

too tight an application of the nasal cannula. Oxygen masks: device used to administer oxygen, humidity, or heated

humidity. Simple face mask is used for short-term oxygen therapy

o Fits loosely and delivers oxygen concentrations form 30%-60%.

o Is contraindicated for clients with carbon dioxide retention because retention can be worsened.

A plastic face mask with a reservoir bag and a Venturi mask are capable of delivering higher concentrations of oxygen.

o When used as a nonrebreather, the plastic face mask with a reservoir bag delivers from 60%-95% oxygen with a flow rate of 6-10 L/min.

o The Venturi mask delivers oxygen concentrations of 24% to 60% with oxygen flow rates of 4-12 L/min.

Home oxygen therapy: indications for home oxygen therapy include an PaO2 of 55 mm Hg or less or an SaO2 of 88% or less on room air at rest, on exertion, or with exercise.

Restoration of cardiopulmonary functioning: if a client’s hypoxia is sever and prolonged, cardiac arrest will result.

Permanent heart, brain, and other tissue damage occur within 4-6 min.

The ABCs of cardiopulmonary resuscitation are to establish an Airway, initiate Breathing, and maintain Circulation.

The purpose of CPR is to circulate oxygenated blood to the brain to prevent permanent tissue damage.

o Restorative and continuing care Cardiopulmonary rehabilitationhelps the client to achieve and

maintain an optimal level of health through controlled physical exercise, nutrition counseling, relaxation and stress management techniques, and prescribed medications and oxygen.

Hydration: maintenance of adequate systemic hydration keeps mucociliary clearance normal

The best way to maintain thin secretions is to provide a fluid intake of 1500-200 mL/day unless contraindicated by cardiac status.

Coughing techniques: coughing is effective for maintaining a patent airway.

Permits the client to remove secretions from both upper and lower airways.

Encourage clients with a large amount of sputum to cough every hour while awake and every 2-3 hours while asleep until the acute phase of mucus production has ended.

With the cascade cough, the client takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles.

The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways.

The quad cough technique is for clients without abdominal muscle control, such as those with SCI.

Respiratory muscle training: improves muscle strength and endurance, resulting in improved activity tolerance

Prevents respiratory failure in clients with COPD Breathing exercises

Pursed-lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse.

Diaphragmatic breathing is more difficult and requires the client to relax intercostal and accessory respiratory muscles while taking deep respirations.

Evaluationo Evaluation of arterial blood gas levels, pulmonary function tests, vital signs, ECG

tracings, and physical assessment data provide objective measurement of the success of therapies and treatments.