Oxygenation - Med Surg II

• respiration = act of breathing in and out (exchange of gases)

• ventilation = the movement of air in and out of alveoli

• COPD!!

• pulmonary embolism

• asthma

• cystic fibrosis

• anaphylaxis

• pneumothorax

• pneumonia

• PULMONARY EMBOLISM!!

• in COPD, the lungs will keep getting more expanded, but not fully squeeze back to normal :((

• ventilation 4L air/minute

• perfusion 5L blood/minute

  • REMEMBER THAT PERFUSION is higher than ventilation

• VQ scans are used to verify a suspected PE

  • a CT with contrast can also be done to check this

• severe contrast allergy

• unable to get a 20 G IV

• pregnancy

• renal disease with low GFR and NOT on hemodialysis (unable to get rid of contrast!!)

• normal range = 80-100

• you can get a PaO2 over 100 if the patient receives too much oxygen → INVESTIGATE WHY IT IS LOWER !!!

• normal SaO2 = 88-90 for COPD

• if on oxygen and they get to 96%, you start to wean them off because they can become RELIANT on it (NO BUENO)

oxyhemoglobin

the volume of O2 dissolved in the plasma

• PFTs

• ABGs

• pulse ox

• cultures

• sputum studies

• chest x-ray

• CT scan

• MRI

• pulmonary angiography

• VQ scan

• bronchoscopy

• thoroscopy

• thoracentesis

• dizziness

• anxiety/SOB

• decreased LOC/mental status (LATER ON)

• cyanosis (blue lips/fingernails)

• headache

• clubbing nails

• oxygen is a medication, NEED AN ORDER

• WITHOUT an order, a nurse may administer 2 L of O2

COPD patients hold on to CO2 so their drive to breathe is a low pO2 (88-92 is THEIR normal); therefore if pt gets too much O2, the drive to breathe is knocked out, causing their CO2 to rise even higher causing acidosis (NO BUENO!!)

keeping them on LESS oxygen is MORE beneficial in the long run (maintains their drive to breathe)

• 6L is the max you can give; going over will NOT increase the amount of oxygen going in (POINTLESS AF)

VERY specific with the amount of oxygen being given, ensuring one doesn’t over/underdo it

ESSENTIALLY BREATHING PURE OXYGEN (does not allow you to breathe anything but oxygen)

• this is the step just below intubation

• PRIORITIES - airway, breathing, circulation

  • do NOT add to the question by making up airway issues (ex: airway for COPD vs. airway for hip fracture (no relationship whatsoever))

• LARGE NECK CIRCUMFERENCE!!

• genetics

• sleepy during the day

• snoring

• significant other sent them to get checked out (OMG LMAO SO FUNNY)

SLEEP STUDY!!

• CPAP (continuous positive air pressure (into pt; patient still breathes on their own)

• BiPAP (blows air and forcefully has them expel a breath too (REALLY good for COPD patients!!)

• removal of the tonsils

  • usually only done in pediatrics (not for adults)

• ENFORCE LUNG COMPLIANCE!! (to encourage lung expansion)

• hoarse voice

• FEELS like swollen lymph nodes (but no pain)

• Air way is being blocked!!!

• CT to show mass

• biopsy to confirm cancer

TOTAL LARYNGECTOMY!! (removal of the upper airway)

SMOKING!!

• tracheostomy = surgical opening to access the tracheal lumen WITH the entire larynx remaining intact

• laryngectomy = surgery where ENTIRE larynx is removed and the trachea is brought to the skin as a stoma, which no longer has any anatomical connection with the oropharyngeal cavity and digestive tract

• work with speech therapist!! (esophageal speech / artificial electric larynx)

• fluid overload

• laying down/not moving (for long periods of time)

• DIMINISHED!!!! (NOT crackles)

CHEST X-RAY!!!

• INCENTIVE SPIROMETER!!

• ambulation!!

• promote lung expansion

• chest tube (if severe)

• thoracentesis

• pleur-x catheter (LONG TERM!! patient is able to drain fluid by themselves)

• MAINTAIN STERILITY!!

• provide patient education!

• AT HOME? - patient will always have a home care nurse to monitor them and provide education

pleural effusion that has become infected (due to lack of sterility, bacteria build, or patient has pneumonia, etc)

• infection (fever; elevated WBC; tachycardia; low BP; lung symptoms such low SaO2)

• antibiotics

• fluid drainage (think about the pleural effusion drainage techniques!)

air in the thoracic cavity, collapsing the lung

• simple/spontaneous (usually occuring in tall skinny males)

• traumatic (gunshot, stabbing, etc)

• hemothorax (blood in thoracic cavity)

• surgery (open heart surgery (EXPECTED); bilateral chest tubes are placed after surgery to fix lungs)

chest x-ray indicates heart and trachea migration (on x-ray, BLACK indicates air, white is structures)

a catheter needle (to expel air)

1. make sure chest tube is SECURE!! (they move excessively and are uncomfy); make it a priority keep it secure with FOAM TAPE!!

   1. assess tubing to ensure there’s no kinks/clots

2. drainage system = UPRIGHT at all times!!

3. drainage system = BELOW level of chest

4. assess for crepitus (RICE CRISPIES!!); caused usually by an air leak

5. suction? - need an order

6. CHECK FOR AIR LEAKS (look for bubbles)

1. foam dressing/tape (at insertion site to prevent air from leaking)

2. hemostats (to clamp off chest tube; if tubing disconnects from chamber system, air can easily get into the chest cavity)

3. Vaseline gauze with a covering (XEROFORM)

   1. prevents air from leaking in AT the insertion site

• DVT (clot breaks off and goes to lungs)

• orthopedic surgeries (anesthesia, decreased mobility, laying down)

• cerebral palsy

• clotting disorders

• smoking

• birth control users/pregnant women

  • INCREASED ESTROGEN LEVELS, which increases clotting factors

• obesity

• SOB (air flow is good, but NO GAS EXCHANGE!!!)

• diminished lung sounds / cyanosis

• increased HR and BP

• impending doom (I feel like I am going to die)

a VERY large blood clot that prevents blood flow to BOTH lungs (very unlikely to live from it)

a test that indicates if there is a blood clot in the body (NOT specific)

CHEST x-ray (shows structures, not vessels) - NOT RELIABLE :(

• d-dimer (indicates blood clot SOMEWHERE in body)

• CT chest with contrast (check kidney function to ensure pt can get rid of contrast; start on heparin drip if clot is confirmed!!)

• VQ scan (HIGH ventilation, low perfusion)

• ABG (shows respiratory alkalosis (hyperventilation))

• ECG (sinus or tachycardia; right sided heart failure symptoms also start occurring)

• ambulation / mobility

• SCDs

• subq heparin / lovenox (to prevent); heparin drip (clot detected, prevents it from getting BIGGER/adhere to wall preventing migration)

(alveoli collapse due to BLOCKED AIR PASSAGE)

SURGERY

use incentive spirometry!!!!

chest pain, SOB, shallow respirations

CAN BECOME PNEUMONIA (increased mucus in collapsed lung leads to infection)

PNEUMONIA!!

SPUTUM CULTURE!!

1. CAP

2. HAP

   1. VAP

3. Aspiration

usually after a recent illness (PREDICTABLE!!)

CAP

1. strep-pneumo

2. H-flu

pt. admitted in hospital for AT LEAST 48 hours, and then pneumonia develops

NOOOO, which is why sputum cultures are SOOO important

a pneumonia the forms due to lack of hand hygiene/sterility on a ventilated patient, who has been on the ventilator for AT LEAST 48 hours

1. stroke (swallow reflex is weakened; CONFIRM GOOD SWALLOW EVAL before giving anything PO)

2. parkinson’s

• food you eat goes into the lungs, preventing gas exchange; as well, vomiting while laying down can cause it too

• Oxygenation monitor​

• Adequate fluid intake (help with dehydration / loosen secretions)​

• Elevate head of bed​

• Incentive spirometry​

• Ambulation (to promote lung expansion​

• Encourage coughing / deep breathing / suctioning

• Antibiotics!!!​

• IV fluids​

• Chest x-ray​

• Sputum culture (need an order to send it, but can collect it without an order) (NEEDS TO BE COLLECTED BEOFRE ANTIBIOTIC ADMINISTRATION, as it can alter results)​

• Antipyretic to lower the fever!!!

N95 mask!!!

• ground glass opacities (in a CT scan)

• older age

• obese

• immunocompromised

• underlying lung disease patients

• continuous cardiorespiratory monitoring (rapid decompensation is prevalent!!)

• encourage patient to self-prone as often as possible/tolerated

• supplemental oxygen (nasal cannula; non-rebreather; CPAP; and if still not enough, ET intubation)

abnormal accumulation of fluid in the alveoli, lung tissue, or both; NO GAS EXCHANGE occurs

• congestive heart failure (already fluid overloaded)

• damage to pulmonary lining (from trauma for example)

• PINK FROTHY SPUTUM!!

• very crackly lung sounds

• low pulse ox

LOTS OF WHITE (fluid)

LUNG CANCER!!

from the time of diagnosis to 5 years later, only 5% are still alive

• why? THEY DON’T STOP SMOKING

• chronic cough

• sputum

• pulse ox will STILL LOOK NORMAL if they don’t have COPD (same symptoms as COPD!!)

CAT scans can be administered (insurance included) to catch lung cancer early (lose dose radiation/contrast)!!!

1. biopsy (to prove cancer)

2. bronchoscopy (to verify place of cancer)

SYMPTOM management :)

4 treatments:

• surgery

• chemo

• radiation

• palliative

  • patient / provider decide what treatment they want, depending on the stage of cancer they’re in

• stage 0 = Precancer (found a polyp)

• stage 1 = on surface of organ (remove it and you’re good)

• stage 2 = invading deeper from the surface

• stage 3 = spread to the surrounding lymph nodes (feel for swelling); this is HOW cancer metastasizes

• stage 4 = more than one organ has cancer :(

• lidocaine (to numb the gag reflex / prevent pain during procedure)

• atropine (to prevent hypotension (caused by hitting vagal nerve); keep the heart rate up; DRY SECRETIONS (preventing aspiration))

• monitor O2 status

• monitor HR/BP

• AVOID FOOD AND FLUID UNTIL GAG REFLEX IS BACK

• monitor for lung collapse (tracheal deviation and other symptoms)

• monitor for any bleeding (minor hemoptysis is expected)

COPD

a disease state characterized by chronic airflow limitation that is irreversible (chronic bronchitis and emphysema)

• patients are able to have lung expansion, but no ability to squeeze to exhale (lungs get BIGGER and BIGGER overtime)

alveolar walls are destroyed, resulting in impaired gas exchange; overtime this will ead to chronic hypoxemia and CO2 retention

HIGH CO2, because their ability to exhale is impaired, causing them to retain more CO2

position them into a tripod position