Monitor respiratory rate, depth, and effort. Alveolar hypoventilation and associated hypoxemia lead to respiratory distress or failure. Auscultate breath sounds. Identifies areas of decreased ventilation (atelectasis) or airway obstruction and changes as patient deteriorates or improves, reflecting effectiveness of treatment, dictating therapy needs. Note declining level of consciousness. Signals severe acidotic state, which requires immediate attention. Note: In recovery, sensorium clears slowly because hydrogen ions are slow to cross the blood-brain barrier and clear from cerebrospinal fluid and brain cells. Monitor heart rate and rhythm. Tachycardia develops early because the sympathetic nervous system is stimulated, resulting in the release of catecholamines, epinephrine, and norepinephrine, in an attempt to increase oxygen delivery to the tissues. Dysrhythmias that may occur are due to hypoxia (myocardial ischemia) and electrolyte imbalances. Note skin color, temperature, moisture. Diaphoresis, pallor, cool or clammy skin are late changes associated with severe or advancing hypoxemia. Encourage and assist with deep-breathing exercises, turning, and coughing. Suction as necessary. Provide airway adjunct as indicated. Place in semi-Fowler’s position. These measures improve lung ventilation and reduce or prevent airway obstruction associated with accumulation of mucus. Restrict use of hypnotic sedatives or tranquilizers. In the presence of hypoventilation, respiratory depression and CO2 narcosis may develop. Discuss cause of chronic condition (when known) and appropriate interventions and self-care activities. Promotes participation in therapeutic regimen, and may reduce recurrence of disorder. Assist with identification or treatment of underlying cause. Treatment of disorder is directed at improving alveolar ventilation. Addressing the primary condition (oversedation, lung and respiratory system trauma, pulmonary edema, aspiration) promotes correction of the acid-base disorder. Monitor and graph serial ABGs, pulse oximetry readings; Hb, serum electrolyte levels. Evaluates therapy need and effectiveness. Note: Bedside pulse oximetry monitoring is used to show early changes in oxygenation before other signs or symptoms are observed. Administer oxygen as indicated. Increase respiratory rate or tidal volume of ventilator, if used. Prevents and corrects hypoxemia and respiratory failure. Note: Must be used with caution in presence of emphysema because respiratory depression or failure may result. Assist with ventilatory aids: IPPB in conjunction with bronchodilators. Monitor peak flow pressure. Increases lung expansion and opens airways to improve ventilation, preventing respiratory failure. Maintain hydration (IV/PO) and provide humidification. Assists in correction of acidity and thinning and mobilization of respiratory secretions. Provide appropriate chest physiotherapy, including postural drainage and breathing exercises. Aids in clearing secretions, which improves ventilation, allowing excess CO2 to be eliminated. Administer IV solutions such as lactated Ringer’s solution or 0.6 M solution of sodium lactate. May be useful in nonemergency situations to help control acidosis, until underlying respiratory problem can be corrected. Administer medications as indicated: Naloxone hydrochloride (Narcan) May be useful in arousing patient and stimulating respiratory function in presence of drug overdose and sedation, or acidosis resulting from cardiac arrest. Sodium bicarbonate (NaHCO3) May be given in small IV doses in emergency situations to quickly correct acidosis if pH is less than 7.25 and hyperkalemia coexists. Note: Rebound alkalosis or tetany may occur. Potassium chloride (KCl) Replaces potassium that shifts out of cells during acidotic state. Correction of the acidosis may cause a relative serum hypokalemia as potassium shifts back into cells. Potassium imbalance can impair neuromuscular or respiratory function, causing generalized muscle weakness and cardiac dysrhythmias. Bronchodilators Helps open constricted airways to improve gas exchange. Provide low-carbohydrate, high-fat diet (Pulmocare feedings), if indicated. Helps reduce CO2 production and improves respiratory muscle function and metabolic homeostasis. Show
Chapter 5. Oxygen Therapy Hypoxemia or hypoxia is a medical emergency and should be treated promptly. Failure to initiate oxygen therapy can result in serious harm to the patient. The essence of oxygen therapy is to provide oxygen according to target saturation rate, and to monitor the saturation rate to keep it within target range. The target range (SaO2) for a normal adult is 92 – 98%. For patients with COPD, the target SaO2 range is 88 – 92% (Alberta Health Services, 2015; Kane, et al., 2013; Perry et al., 2014). Although all medications require a prescription, oxygen therapy may be initiated without a physician’s order in emergency situations. Hypoxia is considered an emergency situation. Most hospitals have a protocol in place allowing health care providers to apply oxygen in emergency situations. The health care provider administering oxygen is responsible for monitoring the patient response and keeping the oxygen saturation levels within the target range. The most common reasons for initiating oxygen therapy include acute hypoxemia related to pneumonia, shock, asthma, heart failure, pulmonary embolus, myocardial infarction resulting in hypoxemia, post operative states, pneumonthorax, and abnormalities in the quality and quantity of hemoglobin. There are no contradictions to oxygen therapy if indications for therapy are present (Kane et al., 2013). Hypoxic patients must be assessed for the causes and underlying reasons for their hypoxia. Hypoxia must be managed not only with supplemental oxygen but in conjunction with the interventions outlined in Table 5.3. Table 5.3 Interventions to Treat and Prevent Hypoxia
Applying and Titrating Oxygen TherapyWhen providing oxygen therapy, remember the following (Kane et al., 2013):
Oxygen is available in hospitals through bulk liquid oxygen systems that dispense oxygen as a gas through outlets in rooms. It can also be provided in cylinders (large or small) for easy transport for patient use while mobile or when moving around the hospital. An oxygen flow meter regulates the flow in litres per minute. Oxygen therapy may be short- or long-term depending on the SaO2 requirements of the patients and underlying diseases processes (Perry et al., 2014). Checklist 41 reviews the steps for applying and titrating oxygen therapy (see Figure 5.2). Checklist 41: Applying and Titrating Oxygen Therapy
Special considerations:
Which of the following conditions produces hypoxemia and hypercapnia due to a decreased drive to breathe?Obesity Hypoventilation Syndrome
Obesity alters lung and chest wall mechanics leading to hypoventilation and resultant hypercapnia. The patient initially compensates by increasing respiratory drive and work of breathing. However, respiratory fatigue rapidly ensures that hypercapnia and hypoxia occur.
Which of the following are clinical indicators of respiratory failure quizlet?Clinical indicators of respiratory failure include pulse oximetry of less than 91% on room air, PaO2 level less than 60 mmHg, and a pCO2 level of over 50 mmHg.
Which assessment finding indicates the individual has to work harder to breathe?Nose flaring.
The openings of the nose spreading open while breathing may mean that a person is having to work harder to breathe.
Which of the following diseases will result in a high ventilation perfusion V Q mismatch?Characteristic features of ventilation/perfusion mismatch
Some common causes of hypoxemia due to V/Q mismatch include asthma, COPD, bronchiectasis, cystic fibrosis, interstitial lung diseases (ILDs), and pulmonary hypertension.
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