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Course: Fundamentals of Nursing�Topic: Oxygenation

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the physiological processes regulating oxygenation, including cardiopulmonary and neurochemical processes of respiration.
Differentiate normal and abnormal pathophysiological changes in oxygenation across the lifespan.
Discuss nursing interventions that promote oxygenation in primary, secondary, and tertiary care settings.

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Respiratory System

The Main Function of the Respiratory System

Works with the circulatory system to provide this oxygen and to remove the waste products of metabolism.
Helps to regulate pH of the blood.
To achieve these functions, muscles and structures of the thorax create the mechanical movement of air into and out of the lungs called ventilation or breathing.
Respiration: Is the sequence of events that results in the exchange of oxygen and carbon dioxide between the atmosphere and the body cells.

National Cancer Institute, n.d
Ernstmeyer, & Christman, 2021

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Types of Respiration

External Respiration: During ventilation, there is an exchange of gases between the lungs and the blood.
Internal (Cellular) Respiration:

There is an exchange of gases between the blood and tissue.
The blood transports the gases to and from the tissue cells and Finally, the cells utilize the oxygen for their specific activities: this is called cellular metabolism, or cellular respiration.

Together, these activities constitute respiration.

National Cancer Institute,n.d

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Mechanics of Ventilation

The air moves through the lung passages due to pressure gradients that are produced by the contraction of the diaphragm and thoracic muscles.
Mechanisms that drive pulmonary ventilation.

Atmospheric pressure (Patm)
the air pressure within the alveoli, called intra-alveolar pressure (Palv); and
the pressure within the pleural cavity, called intrapleural pressure (Pip)

Gordon Betts et al., 2013

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Mechanics of Ventilation

Gordon Betts et al., 2013

Pulmonary ventilation.

Inspiration: the process that causes air to enter the lungs.
Expiration: the process that causes air to leave the lungs.

In general, two muscle groups are used during normal inspiration:

the diaphragm and
the external intercostal muscles

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Mechanics of Ventilation conti..

When the diaphragm contracts, it moves inferiorly toward the abdominal cavity, creating a larger thoracic cavity and more space for the lungs.
Contraction of the external intercostal muscles moves the ribs upward and outward, causing the rib cage to expand, which increases the volume of the thoracic cavity.
Due to the adhesive force of the pleural fluid, the expansion of the thoracic cavity forces the lungs to stretch and expand as well.
This increase in volume leads to a decrease in intra-alveolar pressure, creating a pressure lower than atmospheric pressure.
As a result, a pressure gradient is created that drives air into the lungs.

Gordon Betts et al., 2013

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Critical Thinking Question

What are the muscles and their functions that are used during normal inspiration?

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Neurochemical Process of Ventilation

Gordon Betts et al., 2013

Multiple regions in the brain signal the muscles used in pulmonary ventilation to contract.
Neurons that innervate the muscles of the respiratory system are responsible for controlling and regulating pulmonary ventilation .
The major brain centers involved in pulmonary ventilation are

the medulla oblongata and
the pontine respiratory group

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Neurochemical Process of Ventilation:

Primary Respiratory Center

The medulla oblongata contains:

the dorsal respiratory group (DRG) and
the ventral respiratory group (VRG)

The DRG maintains a constant breathing rhythm by stimulating the diaphragm and intercostal muscles to contract, resulting in inspiration.
When activity in the DRG ceases, it no longer stimulates the diaphragm and intercostals to contract, allowing them to relax, resulting in expiration.
The VRG is involved in forced breathing, as the neurons in the VRG stimulate the accessory muscles.

Gordon Betts et al., 2013

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Neurochemical Process of Ventilation:

Secondary Respiratory Center

The Pontine Respiratory Group consisting of:

the apneustic and
Pneumotaxic centers

The apneustic center is a double cluster of neuronal cell bodies that stimulate neurons in the Dorsal Respiratory Group (DSR), controlling the depth of inspiration, particularly for deep breathing.
The pneumotaxic center is a network of neurons that inhibits the activity of neurons in the DRG, allowing relaxation after inspiration, and thus controlling the overall rate.

Gordon Betts et al., 2013

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Respiratory Volumes and Capacities

Tidal volume (TV): The amount of air that normally enters the lungs during quiet breathing, which is about 500 milliliters.
Residual volume (RV): The air left in the lungs after exhaling as much air as possible.

Makes breathing easier by preventing the alveoli from collapsing.

Inspiratory reserve volume: Extra volume that can be brought into the lungs during a forced inspiration.
Expiratory reserve volume (ERV): The amount of air that can forcefully be exhaled past a normal tidal expiration, (up to 1200 milliliters for men).

Gordon Betts et al., 2013

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Measuring Oxygen, Carbon Dioxide, and Acid Base Levels

Ernstmeyer, & Christman, 2021

A client’s oxygenation status is easily assessed using pulse oximetry, referred to as SpO2.
SpO2 for an adult is 94-98%.
People with chronic lung conditions such as COPD, have a target range for SpO2 that is often lower at 88% to 92%
A more specific measurement of oxygen and carbon dioxide in the blood is obtained using an arterial blood gas (ABG)

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Critical Thinking Question

For clients with chronic respiratory conditions, such as COPD, the target range for SpO2 is often _________ SpO2 ranges for clients without chronic conditions

Equal to
Less than
More than

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Arterial Blood Gas (ABG)

ABG result indicators.

Oxygen (PaO2): Normal Level: 80-100 mmHg.

The partial pressure of oxygen in the arterial blood.
Measures the pressure of oxygen dissolved in the arterial blood and how well oxygen is able to move from the lungs into the blood.

Carbon dioxide(PaCO2): Normal Level: 35-45 mmHg.

Measures the pressure of carbon dioxide dissolved in the blood and how well carbon dioxide is able to move out of the body.

PH: (acidic or base) The level for arterial blood is 7.35-7.45.
Bicarbonate (HCO3): Normal level: 22-26.
SaO2: Calculated arterial oxygen saturation: 95-100%.

Ernstmeyer, & Christman, 2021

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Hypoxia

Ernstmeyer, & Christman, 202)

Hypoxia:

A reduced level of tissue oxygenation.
Several causes including respiratory and cardiac conditions and anemia anemia.

Hypoxemia:

Decreased partial pressure of oxygen in the blood (PaO2).
Early signs: Anxiety, confusion, and restlessness.
Late signs: Bluish discoloration of the skin and mucous membranes (cyanosis)
A sign of chronic hypoxia is clubbing, a gradual enlargement of the fingertips.

Figure: Cyanosis

Fig: Clubbing

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Hypercapnia

Ernstmeyer, & Christman, 2021

Also referred to as hypercarbia, is an elevated level of carbon dioxide in the blood (PaCO2) is greater than 45.
Caused by hypoventilation or when the alveoli are ventilated but not perfused.
In a state of hypercapnia, the pH of the blood drops, leading to a state of respiratory acidosis.
Symptoms of hypercapnia:

Tachycardia
Dyspnea
Flushed skin
Confusion,
Headaches, and dizziness

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Critical Thinking Question

What is the normal level of partial pressure of of oxygen (PaO2) in normal healthy adult?

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Treatment of Hypoxia

Ernstmeyer, & Christman, 2021

Acute hypoxia is a medical emergency and should be treated promptly with oxygen therapy.
Although oxygen is considered a medication that requires a prescription, oxygen therapy may be initiated without a physician’s order in emergency situations as part of the nurse’s response to the “ABCs”.

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Treatment of Hypoxia

Ernstmeyer, & Christman, 2021

Prescription orders for oxygen therapy include two measurements of oxygen to be delivered:

The oxygen flow rate:

the number dialed up on the oxygen. flow meter between 1 L/minute and 15 L/minute.

The fraction of inspired oxygen (FiO2):

Fio2 is the concentration of oxygen the clientinhales.
Room air contains 21% oxygen concentration.
So the FiO2 for supplementary oxygen therapy will range from 21% to 100% concentration.

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Oxygenation Equipments

Pulse Oximeter
Oxygen Flow meter
Portable Oxygen Supply Devices

Fig: Portable Pulse Oximeter

Fig: Oxygen Flowmeter

Fig: Portable Oxygen Supply Devices

(Ernstmeyer, & Christman, 2021)

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Oxygenation Equipments

Ernstmeyer, & Christman, 2021

Nasal Cannula:

Consists of oxygen tubing connected to two short prongs.
Used with stable clients who require low amounts of oxygen.
Flow rate: can have a flow rate ranging from 1 to 5 liters per minute (L/min), with a 4% increase in FiO2 for every liter of oxygen.
Convenient because the client can talk and eat while receiving oxygen.
Are not as effective in the case of blocked nostrils, a deviated septum, or nasal polyps.

Fig: Nasal Cannula

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Oxygenation Equipments

Ernstmeyer, & Christman, 2021

High Flow Nasal Cannula:

Capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 60 liters per minute.
Clients with high-flow nasal cannulas are generally in critical condition and require advanced monitoring.

Fig: High Flow Nasal Cannula

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Oxygenation Equipments

Ernstmeyer, & Christman, 2021

Simple Mask:

Fits over the mouth and nose of the client and contains exhalation ports (i.e., holes on the side of the mask through which the client exhales carbon dioxide) which should always remain open.
Flow Rate: Should be set to a flow rate of 6 to 10 L/min, resulting in (FiO2) levels of 35%-50%.
Should never be set below 6 L/min because this may result in the client rebreathing their exhaled carbon dioxide.

Fig: Simple Mask

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Oxygenation Equipments

Ernstmeyer, & Christman, 2021

Non-Rebreather Mask:

Consists of a mask attached to a reservoir bag
Used for clients who can breathe on their own but require higher concentrations of oxygen
Flow rate: The flow rate for a non-rebreather mask should be set to deliver a minimum of 10 to 15 L/minute.
The reservoir bag should be inflated prior to placing the mask on the client
Can deliver between 60% and 80% FiO2

Fig: Non- Rebreather Mask

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Critical Thinking Question

What is the flow rate of simple mask?

1-5 litre
> 6 litre
< 6 litre
1-4 litre

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Oxygenation Equipments

Partial Rebreather Mask:

Looks very similar to the non-rebreather mask.
The difference between the masks is that the partial rebreather mask does not contain one-way valves, so the client’s exhaled air mixes with their inhaled air.
A partial rebreather mask requires 10-15 L/min of oxygen, but only delivers 35-50% FiO2.

Venturi Mask:

Indicated for clients who require a specific amount of supplemental oxygen to avoid complications, such as those with chronic obstructive pulmonary disease (COPD).

Ernstmeyer, & Christman, 2021

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Oxygenation Equipments

Ernstmeyer, & Christman, 2021

Continuous Positive Airway Pressure (CPAP):

Used for people who are able to breathe spontaneously on their own but need help in keeping their airway unobstructed, such as those with obstructive sleep apnea.

BiPAP: A Bilevel Positive Airway Pressure

Similar to a CPAP device in that it is used to prevent airways from collapsing.
Have two pressure settings, One setting occurs during inhalation and a lower pressure setting is used during exhalation

Fig: CPAP

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Oxygenation Equipments

Ernstmeyer, & Christman, 2021

Bag Valve Mask (Ambu Bag):

Used in emergency situations for clients who are not breathing (respiratory arrest) or who are not breathing adequately (respiratory failure).
Flow rate: The flow rate for a bag valve mask attached to an oxygen source should be set to 15 L/minute, resulting in FiO2 of 100%.

Fig: Bag Valve Mask

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Interventions for Managing Hypoxia

Raise the head of the bed
Encourage enhanced breathing and coughing techniques
Manage oxygen therapy and equipment
Assess the need for respiratory medications
Provide oral suctioning if needed
Provide pain relief If needed
Consider the side effects of pain medications
Consider using other devices to enhance clearance of secretions
Plan frequent rest periods between activities
Consider other potential causes of dyspnea
Consider obstructive sleep apnea
Anxiety

Ernstmeyer, & Christman, 2021

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Enhanced Breathing and Coughing Techniques

Ernstmeyer, & Christman, 2021

Pursed-Lip Breathing: instruct the person to inspire through the nose and exhale through the mouth with lips pursed together at a slow controlled flow.
Incentive Spirometry:

Is a medical device often prescribed after surgery to prevent and treat atelectasis.
It encourages the client to take deep breaths.

Fig: Pursed Lip Breathing

Fig: Using an Incentive Spirometer

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Coughing and Deep Breathing

Ernstmeyer, & Christman, 2021

Huffing Technique:

Helpful for clients who have difficulty coughing.
Teach the client to inhale with a medium-sized breath and then make a sound like “Ha” to push the air out quickly with the mouth slightly open.

Vibratory PEP Therapy:

Uses handheld devices such as “flutter valves” or “Acapella” devices for clients who need assistance in clearing mucus from their airways.

Fig: Flutter valve Device

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Nursing Interventions

Ernstmeyer, & Christman, 2021

Anxiety Reduction:

Use a calm, reassuring approach.
Explain all procedures.
Provide factual information concerning diagnosis, treatment, and prognosis.
Stay with the client to promote safety and reduce fear.
Encourage the family to stay with the client, as appropriate.
Listen attentively.
Encourage verbalization of feelings, perceptions, and fears.
Provide diversional activities.
Instruct the client on the use of relaxation techniques.

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Nursing Interventions

Ernstmeyer, & Christman, 2021

Respiratory Monitoring:

Monitor rate, rhythm, depth, and effort of respirations.
Note chest movement, symmetry and use of accessory muscles.
Monitor breathing patterns.
Monitor oxygen saturation levels in sedated clients.
Auscultate lung sounds, areas of decreased or absent ventilation and presence of adventitious sounds.
Monitor client’s ability to cough effectively.
Note onset, characteristics, and duration of cough.
Monitor the client’s respiratory secretions.

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Health Education

Health Promotion Education

Receive an annual influenza vaccine.
Receive a pneumococcal vaccine every five years as indicated.
Stop smoking.
Drink adequate fluids to thin respiratory secretions.
Participate in physical activity regularly and as tolerated.

Ernstmeyer, & Christman, 2021

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Critical Thinking Question

How does raising the head of the bed manage Hypoxia?

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References

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0.

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Skills by Chippewa Valley Technical College is licensed under CC BY 4.0.

Gordon Betts et al., (2013). Anatomy and Physiology. OSCRiceUniversity is licensed under a Creative Commons Attribution 4.0.https://opentextbc.ca/anatomyandphysiologyopenstax/

SEER Training Modules, Cancer Registration and Surveillance Module, Anatomy and Physiology. Respiratory System . U. S. National Institutes of Health, National Cancer Institute. (27 July 2021) <https://training.seer.cancer.gov/>

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