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pulse oximetry, abg values, water seal drainage
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RESPIRATORY MODALITIES
OBJECTIVE
After the lecture, the learner will be able to:
Have enhanced knowledge on selected respiratory diagnostic test and procedures (ie. Pulse Oximeter, ABG Analysis and Chest Tubes)
Understand the implications of the test results
Identify the nursing implications of the various procedures used for diagnostic evaluation of respiratory function.
Provide optimal patient care before, during and after the test or procedure.
Interpret arterial blood gas measurements.
Explain the principles of chest drainage and the nursing responsibilities related to the care of the patient with a chest drainage system.
ANATOMY & PHYSIOLOGY
PURPOSE OF THE RESPIRATORY SYSTEM
The lungs, in conjunction with the circulatory system, deliver oxygen to and expel carbon dioxide from the cells of the body.
The upper respiratory system warms and filters air.
The lungs accomplish gas exchange.
STRUCTURES OF THE UPPER RESPIRATORY TRACT
Nose
Sinuses and nasal passages
Pharynx
Tonsils and adenoids
Larynx: epiglottis, glottis, vocal cords, and cartilages
Trachea
PARANASAL SINUSES
CROSS-SECTION OF NASAL CAVITY
UPPER RESPIRATORY SYSTEM
STRUCTURES OF THE LOWER RESPIRATORY SYSTEM
Lungs
Pleura
Mediastinum
Lobes of the lungs:
Left: upper and lower
Right: upper, middle, and lower
Bronchi and bronchioles
Alveoli
AVEOLI
Where gas exchange takes place
Alveolar-capillary membrane Types of alveolar cells Surfactant
LOWER RESPIRATORY SYSTEM
THE LOBES OF THE LUNGS AND BRONCHIOLE TREE
VENTILATION: THE MOVEMENT OF AIR IN AND OUT OF THE AIRWAYS.
Thoracic cavity airtight chamber.
Diaphragm
Floor
Inspiration contraction of the diaphragm (movement of this
chamber floor downward) contraction of the external intercostal muscles
increases the space in this chamber Lowered intrathoracic pressure causes air to
enter through the airways and inflate the lungs.
Expiration: with relaxation Diaphragm moves up and intrathoracic
pressure increases Increased pressure pushes air out of the
lungs. Expiration requires the elastic recoil of
the lungs. Inspiration normally is 1/3 of the respiratory
cycle and expiration is 2/3.
GAS EXCHANGE AND RESPIRATORY FUNCTION
VENTILATION-PERFUSION RATIOS:A- NORMAL RATIOB- SHUNTS C- DEAD SPACED- SILENT UNIT
LIGHTER SIDE
HOW good is HOW good is your clinical your clinical eye?eye?
READ OUT LOUD THE TEXT READ OUT LOUD THE TEXT INSIDE THE TRIANGLE BELOW.INSIDE THE TRIANGLE BELOW.
MORE THAN LIKELY YOU SAID, "A BIRD IN THE BUSH."
If this IS what YOU said, then you failed to see that
the word
THE
is repeated twice!
Sorry, look again.
NEXT, LET'S PLAY WITH NEXT, LET'S PLAY WITH SOME WORDS.SOME WORDS.
WHAT DO YOU SEE? WHAT DO YOU SEE?
WHAT DO YOU SEE?WHAT DO YOU SEE?
PULSE OXIMETRY A noninvasive method to monitor the oxygen saturation
of the blood (SaO2)
Does not replace ABGs
Normal level is 95-100%.
May be unreliable
cardiac arrest
shock
when dyes (ie, methylene blue) or vasoconstrictor medications
severe anemia
high carbon monoxide level.
SPO2
Oxygen saturation
ratio of oxyhemoglobin (HbO2) to the total concentration of hemoglobin (HbO2 + deoxyhemoglobin)
Figure 2 660nm910nmHboHb20.110RedIRPhotodiode
PULSE OXIMETER
RECOMMENDED CONTINUOUSLY FOR
critical or unstable airway
post-operative clients
conscious sedation for diagnostic procedure
history with risk for significant desaturation
known lung dysfunction
morbidly obese/obstructive apneas
with acute pain who received analgesics
cardiopulmonary disorder
transfers of critically ill clients
during hemodialysis
INTERMITTENTLY
on supplemental oxygen tracheotomy long term mechanical ventilator
for stable, chronic respiratory failure
NOT RECOMMENDED
during cardiopulmonary resuscitation
hypovolemia
assess of adequacy of ventilatory support
detecting worsening lung function in patients on high concentration of oxygen
NURSING CONSIDERATIONS
Be familiar with the manufacturer's recommendations for the device.
Use the correct size to avoid skin complications and ensure accurate readings
Reevaluating the sensor site periodically. When using disposable sensors, assess the site
every two to four hours and replace the sensor every 24 hours.
When using a reusable sensor, the site should be checked every two hours and changed every four hours.
Manufacturer's recommendations regarding cleaning agents should also be followed.
NURSING CONSIDERATIONS
Check that the right type of sensor is being used.
To exclude motion artifact caused by shivering, patients should be kept warm.
To avoid potential interference from ambient light, the sensor can be covered with the patient's linens. Nail polish or artificial nails should be removed.
NURSING CONSIDERATIONS
Nurses should explain why pulse oximetry is being used, how it works, and what the readings indicate in language the patient and family can comprehend.
NURSING CONSIDERATIONS
HOW GOOD IS YOUR CLINICAL EYE?
ARTERIAL BLOOD GASES
Measurement of arterial oxygenation and carbon dioxide levels.
Used to assess the adequacy of alveolar ventilation and the ability of the lungs to provide oxygen and remove carbon dioxide.
Also assesses acid-base balance
ABG ANALYSIS
Pre-test: Secure equipments- heparinized
syringe, needle, container with ice Choose site carefully, perform the
Allen’s test
Intra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial), no air on the syringe
Post-test: Apply firm pressure for 5 minutes or 15 minutes
with patients on anticuagulants,
Label specimen correctly noting oxygenation and amount or room air if applicable,
Place in the container with ice
Assess for swelling, bruising, numbness, tingling, and pain
pH/PaCO2/PaO2/HCO3 O2 saturation on a specified FiO2
pH = arterial blood pH
PaCO2 (or PCO2) = arterial pressure of CO2, in mm Hg
PaO2 (or PO2) = arterial pressure of O2, in mm Hg
HCO3 = serum bicarb. conc., in mEq/liter
O2 saturation = % hemoglobin saturated with O2
FiO2 = fraction of inhaled gas that is O2
7.49/42/88/32 97% O2 saturation on 100% O2
7.41/39/88/32 95% O2 saturation on 100% O2
7.21/75/41/20 on room air
7.32/50/98/22 99% O2 saturation on room air
ABG ANALYSIS
ABG normal values
pH 7.35- 7.45
PaCO2 35-45 mmHg
HCO3 22- 26 mEq/L
PaO2 80-100 mmHg
O2 Sat 95-99%
THE 6 EASY STEPS TO ABG ANALYSIS:
1. Is the pH normal?
2. Is the CO2 normal?
3. Is the HCO3 normal?
4. Match the CO2 or the HCO3 with the pH
5. Does the CO2 or the HCO3 go the opposite direction of the pH?
6. Are the PaO2 and the SaO2 saturation normal?
METABOLIC ACIDOSIS
Due to renal failure
Manifestations: headache, confusion, drowsiness, increased respiratory rate and depth, decreased blood pressure, decreased cardiac output, dysrhythmias, shock; if decrease is slow, patient may be asymptomatic until bicarbonate is 15 mEq/L or less
Correct the underlying problem and correct the imbalance; bicarbonate may be administered
With acidosis, hyperkalemia may occur as potassium shifts out of the cell
As acidosis is corrected, potassium shifts back into the cell and potassium levels decrease
Monitor potassium levels
Serum calcium levels may be low with chronic metabolic acidosis and must be corrected before treating the acidosis
METABOLIC ALKALOSIS
Most commonly due to vomiting or gastric suction; may also be caused by medications, especially long-term diuretic use
Hypokalemia will produce alkalosis Manifestations: symptoms related to decreased
calcium, respiratory depression, tachycardia, and symptoms of hypokalemia
Correct underlying disorder, supply chloride to allow excretion of excess bicarbonate, and restore fluid volume with sodium chloride solutions
RESPIRATORY ACIDOSIS
Always due to a respiratory problem with inadequate excretion of CO2
With chronic respiratory acidosis, the body may compensate and may be asymptomatic; symptoms may include a suddenly increased pulse, respiratory rate, and BP; mental changes; feeling of fullness in the head
Potential increased intracranial pressure
Treatment is aimed at improving ventilation
RESPIRATORY ALKALOSIS
Always due to hyperventilation
Manifestations: lightheadedness, inability to concentrate, numbness and tingling, and sometimes loss of consciousness
Correct cause of hyperventilation
O2 SATURATION VS. ABG
MEMORIZE THESE 4 SETS OF NUMBERS:
mm Hg O2 sat.
27 50% - 50% saturation.
40 75% -PvO2
60 90% - Sats < 90% are entering the steep
100 98% -PaO2
GAS EXCHANGE AND RESPIRATORY FUNCTION
pHPaCO2
mmHg
HCO3
mEq/L
PaO2
mmHg
SaO2
%
Remarks
7.27 53 24 50 79
7.52 29 23 100 98
7.18 44 16 92 95
7.60 37 35 92 98
7.30 30 14 68 92
LET’S EXERCISE!
Lighter SideLighter Side
I cdnuolt blveiee taht I cluod aulaclty I cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I was rdanieg. The uesdnatnrd waht I was rdanieg. The phaonmneal pweor of the hmuan phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at mnid, aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn't Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be in the taht the frist and lsat ltteer be in the rghit pclae. The rset can be a taotl rghit pclae. The rset can be a taotl mses and you can sitll raed it wouthit mses and you can sitll raed it wouthit a porbelm. Tihs is bcuseae the huamn a porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. istlef, but the wrod as a wlohe. Amzanig huh? yaeh and I awlyas Amzanig huh? yaeh and I awlyas tghuhot slpeling was ipmorantt!tghuhot slpeling was ipmorantt!
CAN YOU READ THIS?
CHEST DRAINAGE
Used to treat spontaneous and traumatic pneumothorax
Used postop to re-expand the lung & remove excess air, fluid, blood by restoring negative intrapleural pressure.
To assess and measure drainage from the intrapleural space.
To re-establish an adequate ventilation-perfusion ratio.
CHEST TUBES long, semi-stiff, clear plastic tubes that are inserted into the
chest, so that they can drain collections of fluids or air from the space between the pleura
INDICATION
Pneumothorax: a collection of air in the pleural space.
Closed
Open
Tension
Hemothorax: a collection of blood in the pleural space, maybe from surgery, maybe from a traumatic injury.
Empyema: Pus can collect in the pleural space
Pleural effusion: Fluid, usually serous, maybe from CHF, sometimes from a tumor process, will collect between the pleura
64
67
69
CLOSED-CHEST DRAINAGE SYSTEM
76
CHEST TUBE DRAINAGE SYSTEM
DO
Keep the system closed and below chest level.
Make sure all connections are taped and the chest tube is secured to the chest wall.
Ensure that the suction control chamber is filled with sterile water to the 20-cm level or as prescribed.
If using suction, make sure the suction unit’s pressure level causes slow but steady bubbling in the suction control chamber.
Make sure the water-seal chamber is filled with sterile water to the level specified by the manufacturer. You should see fluctuation (tidaling) of the fluid level in the water-seal chamber; if you don’t, the system may not be patent or working properly, or the patient’s lung may have reexpanded.
Look for constant bubbling in the water-seal chamber, which indicates leaks in the drainage system. Identify and correct external leaks. Notify the health care provider immediately if you can’t identify an external leak or correct it.
DO
Assess the amount, color, and consistency of drainage in the drainage tubing and in the collection chamber.
Mark the drainage level on the outside of the collection chamber (with date, time, and initials) every 8 hours or more frequently if indicated.
Report drainage that’s excessive, cloudy, or unexpectedly bloody.
DO
Encourage the patient to perform deep breathing, coughing, and incentive spirometry. Assist with repositioning or ambulation as ordered. Provide adequate analgesia.
Assess vital signs, breath sounds, SpO2, and insertion site for subcutaneous emphysema as ordered.
When the chest tube is removed, immediately apply a sterile occlusive petroleum gauze dressing over the site to prevent air from entering the pleural space.
DO
DON’T
• Don’t let the drainage tubing kink, loop, or interfere with the patient’s movement.
• Don’t clamp a chest tube, except momentarily when replacing the CDU, assessing for an air leak, or assessing the patient’s tolerance of chest tube removal, and during chest tube removal.
• Don’t aggressively manipulate the chest tube; don’t strip or milk it.
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
-Goethe
Knowledge is a process of piling up facts; wisdom lies in their simplification.
- Fisher
THANK YOU!
QUIZ TIME!