Basic Human Needs

SELFACTUALIZATION

SELF-ESTEEM

LOVE AND BELONGINGNESS

SAFETY AND SECURITY

PHYSIOLOGIC

COGNITIVE NEEDS To know and understand, explain, and analyze

SELF – ACTUALIZATION Fulfillment of unique potential SELF ESTEEM Self esteem and respect; prestige LOVE AND BELONGING Giving and receiving affection; companionship; group identification SAFETY Avoiding harm; security; and physical safety PHYSIOLOGIC NEEDS Biological needs for oxygen, water, food, sleep

AESTHETIC NEEDS Order, beauty, and symmetry



Physiological Needs These include the most basic needs that are vital to survival, including the need for water, air, food, and sleep. Maslow believed that these needs are the most basic and instinctive needs in the hierarchy because all needs become secondary until these physiological needs are met.



Security Needs These include needs for safety and security. Security needs are important for survival, but they are not as demanding as the physiological needs. Examples of security needs include a desire for steady employment, health insurance, safe neighborhoods, and shelter from the environment.



Social Needs These include needs for belonging, love, and affection. Maslow considered these needs to be less basic than physiological and security needs. Relationships such as friendships, romantic attachments and families help fulfill this need for companionship and acceptance, as does involvement in social, community or religious groups.



Esteem Needs After the first three needs have been satisfied, esteem needs becomes increasingly important. These include the need for things that reflect on self-esteem, personal worth, social recognition, and accomplishment.



Self-actualizing Needs This is the highest level of Maslow’s hierarchy of needs. Self-actualizing people are selfaware, concerned with personal growth, less concerned with the opinions of others, and interested fulfilling their potential.

 All

people have the same basic needs; however, each person’s needs are modified by his or her culture  People meet their own needs relative to their own priorities  Although basic needs generally must be met, some needs can be deferred

 Failure

to meet the needs results in one or more homeostatic imbalances, which can eventually result in illness  A need can make itself felt by either external or internal stimuli  A person who perceives a need can respond in several ways to meet it  Needs are interrelated

air conducting unit

respiratory unit

The respiratory membrane is composed of two epithelial cells  1.The type 1 pneumocyte- most abundant, thin and flat. This is where gas exchange occurs  2. The type 2 pneumocyte- secretes the lung surfactant

(4) Processes Involved in Respiration

• •

• •

Pulmonary Ventilation External Respiration Transport of Gases Internal Respiration

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(2) Phases of Breathing

Inhalation

1. •

Active phase

2. Exhalation •

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Passive phase

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inflow & outflow of air between the atmosphere & lung alveoli  INHALATION 

› Diaphragm contracts › Ribs move upward and outward › Sternum moves outward 

EXHALATION › Diaphragm relaxes › Ribs move downward and inward › Sternum moves inward

Inspiration: 1 – 1.5 sec.  Expiration: 2 – 3 sec. 

Respiratory Pressures 1.

2. 3.

Intraalveolar/ Intrapulmonary Intrapleural Transpulmonary

Atmospheric Pressure N – 760 mmHg

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

Compliance work - that required to expand the lungs against its elastic forces



Recoil- that required to collapse the lungs

Respiratory Volumes & Capacities

Volumes 1. TV 2. IRV 3. RV 4. ERV

Capacities 1. IC - TI 2. FRC - RE 3. VC - TIE 4. TLC - TIRE

The maximum volume ofexhaled air that can be inhaled after a a The maximum The volume volume volume ofofair air inhaled air inhaled & from exhaled after a normal withafter each expiration The The maximum maximum The volume volume of ofof airair remaining that can in bethe the exhaled lungs point forcibly of MAXIMUM a after The volume of air remaining in the lungs after a NORMAL The volume of air normal in thebreath lungs aml)MAXIMUM inspiration (5800 inhalation ml) (3500 (after 500 ml)(3000 MAXIMUM normal inspiration exhalation exhalation (4600 (1100 (1200 ml) ml) ml) expirationml)(2300 ml) 8/28/2009

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1. Residual volume  2. Functional residual volume  3. Total lung capacity 



DIFFUSION › Movement of gases or other particles from

an area of greater pressure or concentration to an area of lower pressure or concentration.



PARTIAL PRESSURE › Pressure exerted by each individual gas in a

mixture according to its concentration in the mixture

PaO2 in the alveoli is 100 mmHg  PaO2 in venous blood is 60 mmHg  PaCO2 in venous blood is 45 mmHg  PaCO2 in the alveoli is 40 mmHg 



1. OXYGEN- majority is transported in the blood loosely bound to hemoglobinoxyhemoglobin (97%)



2. CARBON DIOXIDE- majority is transported in the blood in the RBC as BICARBONATE (65%); Carbaminohemoglobin (30%); carbonic acid (5%)



Cardiac Output › Amount of blood pumped by the heart › 5 lpm



Number of Erythrocytes › 5 million/mL3

Exercise  Blood hematocrit 

› Percentage of blood that is erythrocytes › Packed cell volume per 100 mL › 40 – 54%

Respiratory center in the medulla  Controls the rate and depth of respiration  Increased CO2 is the most potent stimulus 



1. Chemoreceptors in the carotid and aortic bodies › Sensitive to changes in pH and O2 › Decreased O2 (HYPOXIA) increase respiration › Decreased pH (acidosis) increase respiration



2. Hering-Breurer reflex › Stretch receptors in the lungs limit the inspiration



AGE › Full lung inflation occurs at 2 weeks after birth › Infants have more rapid respiratory rate. They

have primary respiratory activity that is abdominal › Changes of aging affect the breathing pattern. These include loss of elasticity, decreased reflex/cilia action, fragile mucous membrane, osteoporosis, decreased immune system and gastro-esophageal reflux.



ENVIRONMENT › Altitude, heat, cold, air pollution affect

oxygenation.



LIFESTYLE › Physical exercise increases the rate and depth

of respiration › Sedentary lifestyle will cause decreased alveolar expansion › Certain occupation can affect respiratory function. › Smokers arte prone to develop COPD



HEALTH STATUS › Healthy persons have intact respiratory functions › Diseases of the lungs affect oxygenation. People

with chronic illnesses often have muscle wasting and poor muscle tone. Cardiac diseases make the body compromised because of fluid overload.



MEDICATIONS › Sedatives, Hypnotics, tranquilizers, barbiturates

and narcotics greatly depress respiratory drive.



STRESS

› Physiologic and Psychological responses to stress

can affect respiration. › Hyperventilation, lightheadedness, numbness and tingling sensation may result. › There are hormonal responses such as increased epinephrine and steroids.



PREGNANCY

› During the last trimester, the fetus and amniotic

sac grow large enough to displace the diaphragm upward. The mother’s respiratory rate becomes faster and the breath becomes shallower.

The normal breathing pattern is smooth, even and regular  A description of the patient’s breathing pattern should include information about the rater, rhythm, effort and character.  Normal quiet breathing at rest occurs at the rate of 12 to 21 breaths per minute in adult. 

The rhythm is steady. All breaths are evenly spaced, with an equal interval between each breath. Exhalation is normally TWICE as long as inspiration.  Each breath is about the same ―size‖. The chest of the normal adult who is breathing will be seen to rise and fall the same amount from breath to breath.  Normal breathing is nearly effortless. Little muscular work is required to move air through the lungs. No sounds are associated with it. 



HYPOXIA › A condition of insufficient oxygen in the lungs

and the body.

Signs of Hypoxia may be the following: Tachycardia, Tachypnea, Dyspnea, Restlessness, Light-headedness, Flaring of nostrils, Intercostal retractions, changes in sensorium and Cyanosis.



HYPOVENTILATION › Inadequate alveolar ventilation, which can

lead to hypoxia. When CO2 accumulates in the blood, there is HYPERCARBIA.



HYPOXEMIA › Reduced oxygen in the blood characterized

by a low partial pressure of O2 or low hemoglobin saturation.



CYANOSIS › Bluish discoloration of the skin, nail beds and

mucus membrane due to reduced hemoglobin-oxygen saturation. There must be

 about 5 grams or more of unoxygenated blood per 100 ml; and  Surface blood capillaries must be dilated, for this to manifest externally.



ALTERED BREATHING PATTERNS › EUPNEA- normal respiration which is quiet

› ›

› ›

and effortless TACHYPNEA- rapid breathing, more than 21 breaths per minute BRADYPNEA- abnormally slow respiration (less than 12) APNEA- cessation of breathing HYPERVENTILATION-increased in the movement of air into and out of the lungs.

KUSSMAUL’S BREATHING- Deep and rapid respiration seen in metabolic acidosis  CHEYNE-STOKES Respiration- Marked rhythmic waxing and waning of respiration from very deep to very shallow breathing and temporary apnea. Usually seen in cases of CHF, increased ICP and drug overdose.  BIOT’S respiration- Shallow breaths interrupted by apnea, seen in patients with CNS disorders. 

ORTHOPNEA- inability to breathe in a supine position.  DYSPNEA- difficulty or uncomfortable breathing. 

Decreased lung compliance

Increased airway resistance

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Exertional Dyspnea ExertionalDyspnea Dyspnea 1. Exertional 2. Sudden dyspnea • Sudden Most common Dyspnea Orthopnea • • PND Occurs with physical exertion & relieved rest or pulmonary Pneumothorax, airway obstruction, ARF,by ARDS, 3. 2. Orthopnea Sudden dyspnea • SOB when in reclining/ lying position •Occurs SOB withthe sudden onset • when body uses more oxygen and makes embolism Dyspnea with wheezes • •more Relieved by sitting Occurs during sleep or atexercise night carbon dioxide - up during or physical 4. 3. Dyspnea associated with • Asthma or COPD Orthopnea • •activity Heart disease or COPD Awakens patient with feeling of suffocation • Due to bronchoconstriction • Relieved by sitting up 4. wheezes Dyspnea associated with • Heart failure 5. Paroxysmal wheezes Nocturnal Dyspnea 1.

5. Paroxysmal Nocturnal Dyspnea

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Visible sternocleidomastoid contractions

DYSPNEA •

•

Difficult or labored breathing Shortness of breath (SOB)

Hyperexpansion of the chest (Increased AP diameter)

Anxious appearance Circumoral cyanosis Suprasternal retractions

Intercostal retractions Substernal retractions

Sitting posture with body slightly bent forward 47



OBSTRUCTED AIRWAY › Upper airway obstruction involves the nose,

› › › ›

pharynx and larynx. The most common clinical cause is the tongue! Lower airway obstruction involves the trachea, bronchi and lungs. Partial obstruction is manifested as low pitched snoring ( upper airway) Complete Obstruction is manifested as extreme inspiratory effort with no chest movement. STRIDOR- a harsh, high-pitched sound heard during inspiration



RESTRICTED LUNG MOVEMENT › Stiffer lungs tend to shrivel and the alveoli

collapse (atelectasis) › Lung tissues may swell and inflame › Respiratory muscles may be injured › Less oxygen is available to the blood for the tissue



VENTILATION-PERFUSION MISMATCH › Gas exchange across the alveolar-capillary

membrane is influenced by VentilationPerfusion mismatching, (V/Q mismatch) › Because of gravity, certain zones of the lungs may have better ventilation or perfusion than others at any given time. › Vasoconstriction and bronchoconstriction may be needed to better match ventilation to perfusion or vice-versa.

ratio of ventilation to pulmonary capillary blood flow  determine the effectiveness of gas exchange across the respiratory membrane 



When mismatching occurs, some alveolar regions will be well ventilated but poorly perfused (a condition known as DEADSPACE), while others may be well perfused but poorly ventilated (known as SHUNTING)



Zero Gas Exchange: › Ventilation-perfusion = 0 —means zero

alveolar ventilation but still blood flow to alveolar capillaries › Ventilation-perfusion = infinity — means that there is alveolar ventilation but no blood flow to alveolar capillaries 

Normal Gas Exchange: › both normal ventilation & normal pulmonary

blood flow

shunted blood: fraction of the venous blood that passes thorough the pulmonary capillaries that does not become oxygenated  physiologic shunt - total quantitative amount of shunted blood per minute 



The greater the physiologic shunt, the greater the amount of blood fails to be oxygenated as it passes through the lungs

when the ventilation is great, but blood flow is low—more available oxygen in the alveoli that can be transported from the alveoli to the flowing blood — large portion of ventilation wasted  ventilation of dead space areas of the lungs also wasted 



sum of this 2 wasted ventilation (physiologic dead space)



when physiologic dead space is very much great... much of the work of ventilation wasted because so much ventilated air never reaches the blood

 COUGH

› A reflex response to irritation in the airways. The primary function is to help

clear offending substances from the airways. It serves as a warning signal that there may be a harmful stimulus in the respiratory tract.

Cough Cough of worsens recent onset – Cough that Cough at night –– Dry, irritative cough acute infection when in supine Severe or changing cough – LSHF or Asthma Morning cough with sputum VIRAL respiratory tract position Sinusitis Bronchogenic carcinoma production Bronchitis infection

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Cough Productive? – color, consistency, odor & amount

Dry, hacking or wheezy

Particular time/event

Recent or gradual Smoking history/ past medical illness Strong or weak 58

Sputum Productio Increased production - profuse or small in amount Purulent, rusty, bloody, frothy or mucoid Thick (tenacious) or thin Offensive odor/ foul-smelling 59

Sputum Production Profuse Purulent Thick (yellowish, greenish or rusty-colored) – Bacterial infection Foul- smelling – lung abscess or Profuse, frothy, pink – pulmonary bronchiectasis edema Thin, mucoid – Viral bronchitis Pink-tinged mucoid – Lung tumor

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 SHORTNESS

OF BREATH

› Dyspnea- a subjective feeling of uncomfortable respiration.  CHEST

PAIN  CYANOSIS › Bluish discoloration of the skin caused by

a decrease in blood oxygen saturation.  Peripheral cyanosis  central cyanosis

• •

Due to inadequate amount of oxygen in the blood Appears when Hgb level = 5 g/dl

Central or Peripheral

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 CLUBBING

› Unusual phenomenon thought to occur due to long-term hypoxia causing altered

local blood flow to the fingertips affecting tissue growth.

 ENGORGED

NECK VEIN

› Conditions that may cause blood to back up into the large neck vein can cause distention.

 



ABNORMAL BREATH SOUNDS/ADVENTITIOUS BREATH SOUNDS Fine crackles- a dry, high pitched crackling, popping sound, of short duration, predominantly heard in inspiration. Sound is produced similar to rolling hair between fingers. Heard in COPD, CHF, Pneumonia, Pulmonary fibrosis Coarse crackles- Moist, low-pitched crackling, gurgling sound, of long duration predominantly in inspiration. Present in Pneumonia, pulmonary edema, bronchitis and atelectasis.

Sonorous wheeze- low-pitched, snoring sound predominantly in expiration, heard in asthma, bronchitis and foreign body obstruction  Sibilant wheeze- a high-pitched, musical sound predominantly in expiration, present in conditions like asthma, chronic bronchitis, emphysema, tumor and foreign body obstruction 

Friction rub- a creaking, grating sound heard both on inspiration and expiration, present in conditions like pleurisy, tuberculosis, lung abscess  Stridor- a crowing sound heard predominantly on inspiration, present in conditions like croup, foreign body obstruction and large airway tumors. 

APPLICATION OF THE NURSING PROCESS 1. ASSESSMENT

 Nursing

History  Physical Examination › Inspection › Palpation

› Percussion › Auscultation  Diagnostic

Exam

Normal Breathing pattern:  12-21 respiratory rate  Active inspiration with contraction of diaphragm  Passive expiration with relaxation of diaphragm  Steady rhythm and regular rate and size  I:E ratio is 1:2

Bronchial or tracheal

Over the sternum

Bronchovesicular Between scapula Vesicular

Periphery of chest

Rales or Crackles Wheeze

Fluid in Lungs

Stridor

Aspiration

Rhonchi

Obstruction: Upper tract Secretions

Friction Rub

Inflammation

Pleurisy

Obstruction: lower tract

CHF, Pneumonia Asthma

Sputum production

HISTORY  Reason for seeking care  Present illness  Previous illness  Family history  Social history

Health History Reasons for seeking health care 1. Dyspnea 2. Cough 3.

Sputum Production

4.

Chest Pain

5.

Wheezing

6.

Hemoptysis

7.

Cyanosis

8.

Clubbing of fingers

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Health History

Risk Factors • Smoking •

Personal / Family History

•

Occupational exposure

•

Allergens & environmental pollutants

•

Activities

•

Age-related changes

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LABORATORY EXAMINATION 1. ABG analysis 2. Sputum analysis 3. Direct visualization- Bronchoscopy 4. Indirect visualization- CXR, CT, MRI 5. Pulmonary function test



This test helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of an arterial sample

Pre-test: choose site carefully, perform the Allen’s test, secure equipments- syringe, needle, container with ice  Intra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial)  Post-test: Apply firm pressure for 5 minutes, label specimen correctly, place in the container with ice 

ABG normal values  PaO2 80-100 mmHg  PaCO2 35-45 mmHg  pH 7.35- 7.45  HCO3 22- 26 mEq/L  O2 Sat 95-99%

Value pH

Normal 7.35-7.45

paO2

95-100 mmHg 95-98% 35-45 mmHg 22-26 mEq/L

SaO2 paCO2 HCO3

Acidosis Below 7.35

Alkalosis Above 7.45

Respiratory Respiratory >45 <35 Metabolic <22

Metabolic >26

1. 2.

Gross Examination Microscopic examination

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

This test analyzes the sample of sputum to diagnose respiratory diseases, identify organism, and identify abnormal cells

Pre-test: Encourage to increase fluid intake  Intra-test: rinse mouth with WATER only, instruct the patient to take 3 deep breaths and force a deep cough, steam nebulization, collect early morning sputum  Post-test: provide oral hygiene, label specimen correctly 

Non-invasive method of continuously monitoring the oxygen saturation of hemoglobin  A sensor or probe is attached to the earlobe, forehead, fingertip or the bridge of the nose 



A direct inspection of the trachea and bronchi through a flexible fiber-optic or a rigid bronchoscope



Done to determine location of pathologic lesions, to remove foreign objects, to collect tissue specimen and remove secretions/aspirated materials

Pre-test: Consent, NPO x 6h, teaching  Intra-test: position supine or sitting upright in a chair, administer sedative, gag reflex will be abolished, remove dentures  Post-test: NPO until gag reflex returns, position SEMI-fowler’s with head turned to sides, hoarseness is temporary, CXR after the procedure, keep tracheostomy set and suction x 24 hours 



Pleural fluid aspiration for obtaining a specimen of pleural fluid for analysis, relief of lung compression and biopsy specimen collection

Pre-test: Consent  Intra-test: position the patient sitting with arms on a table or side-lying fowler’s, instruct not to cough, breathe deeply or move  Post-test: position unaffected side to allow lung expansion of the affected side, obtain CXR, maintain pressure dressing and monitor respiratory status 

Volume and capacity tests aid diagnosis in patient with suspected pulmonary dysfunction  Evaluates ventilatory function  Determines whether obstructive or restrictive disease 

Pre-test: Teaching, no smoking for 3 days, only light meal 4 hours before the test  Intra-test: position sitting, bronchodilator, nose-clip and mouthpiece, fatigue and dyspnea during the test  Post-test: adequate rest periods, loosen tight clothing 

APPLICATION OF THE NURSING PROCESS 2. DIAGNOSIS

   

   

Ineffective Airway Clearance Ineffective Breathing Pattern Impaired Gas Exchange Activity Intolerance Ineffective tissue perfusion Disturbed sleep pattern Acute pain Anxiety

APPLICATION OF THE NURSING PROCESS 3. PLANNING

1. 2. 3. 4. 5.

Maintain patent airway Improve comfort and ease of breathing Maintain or improve pulmonary ventilation and oxygenation Demonstrate improved gas exchanges Improve ability to participate in physical activities

6. Prevent risks associated with oxygenation problems such as skin and tissue breakdown, syncope, acid-base imbalance, and feelings of hopelessness and social isolation. 7. Maintain normal range of vital signs 8. Demonstrate knowledge regarding prevention of respiratory dysfunction. 9. Mobilize pulmonary secretions and effectively cope with changes in selfconcept and lifestyle.

APPLICATION OF THE NURSING PROCESS 4. IMPLEMENTATION

Positioning the client to allow for maximum chest expansion  Encouraging or providing frequent changes in position- usually Q2H  Encouraging ambulation  Giving pain medications before deep breathing and coughing 

 



 

These measures allow for the removal of secretions from the airway. Breathing exercises are frequently indicated for the clients with restricted chest expansion such as COPD Examples of breathing exercises include huffing, abdominal/diaphragmatic breathing and pursed-lip breathing. Abdominal breathing permits deep full breaths with little effort Pursed-lip breathing helps the client develop control over breathing.

technique to aid in the release of trapped air from the obstructed airways.  By pushing the air against the small orifice made by the pursed lips, pressure is created back through the airways.  This back pressure effect pushes the airways open through-out exhalation.  This allows more air to escape during exhalation and helps to prevent air trapping. 

This maintains the moisture of the respiratory mucous membrane.  Increased fluid intake as tolerated  Milk should be avoided as it increases the viscosity of secretions.  Use of humidifiers 



Use of nebulizers or aerosol therapy.

Aerosol is a suspension of microscopic liquid particles in the air given to: › Add humidity to certain oxygen delivery › › › ›

systems Hydrate thick sputum Relax bronchioles constricted by spasms Administer anti-inflammatory drugs or asthma preparations Deliver antibiotics to the lungs to fight infection

Keeps the lungs open and clear of secretions.  Movements help shift respiratory secretions in the airway. 

The nurse should change the position every 2 hours.  Whenever possible, each patient must be helped to increase exercise tolerance by encouraging independence. 

Bronchodilators  Anti-inflammatory drugs  Expectorants  Mucolytics  Cough suppressants 

This operates on the principle that spontaneous sustained maximal inspiration is most beneficial to the lungs and has virtually no adverse effects.  The incentive spirometer measures roughly the inspired volume and offers the ―incentive‖ of measuring progress.  The patient INHALES steadily and deeply, causing the bellows to deflate and rise as air is evacuated from the bellows.  The objective is to motivate the patient to INHALE more deeply each time the device is used. 

 Use

of incentive spirometers to measure the flow of air through the mouthpiece with the aim to › improve pulmonary ventilation › counteract the effects of anesthesia or hypoventilation

› loosen respiratory secretions › facilitate respiratory gaseous exchange › expand collapsed alveoli

Check MD order  Set marker at volume goal  Place mouth tightly around the mouthpiece  Instruct client to inhale slowly and reach for rate indicator  Remove mouthpiece and hold breath 23 sec then exhale pursed-lips  5-10 X q hour 

Chest physiotherapy is based on the fact that mucus can be knocked or shaken form the walls of the airways and helped to drain from the lungs.  The usual PVD SEQUENCE is as followsPOSITIONING, Percussion, Vibration, and removal of secretions by SUCTIONING or Coughing followed lastly by oral hygiene.  These are DEPENDENT nursing actions performed with a physician’s order. 



POSTURAL DRAINAGE

› drainage by gravity of secretions from various

lung segments using a variety of positions that drains the specific altered lung segments › By placing a mucus-filled portion of the lungs higher than the rest of the lungs, the mucus in that portion is given a down hill course on which to slide › The mucus enters the larger airways and is then more easily removed by cough or suctioning › Nebulization may be given BEFORE postural drainage to loosen secretions. The BEST times are BEFORE breakfast, BEFORE lunch, in the late afternoon, and BEFORE bedtime.



PERCUSSION › Forceful striking of the skin with cupped

hands which can mechanically dislodge tenacious secretions from the bronchial walls › Produces a wave of energy that is transmitted through the chest wall to the mucus-coated bronchioles. › Percussion is avoided over the breasts, sternum, spinal column and kidneys.



VIBRATION › A series of vigorous quivering produced by

hands that are placed flat against the chest wall › Used AFTER percussion to increase the turbulence of the exhaled air and loosen thick secretions. › The nurse’s hands are used like jackhammer, placed on patient’s chest and are rapidly or vigorously shaken during the patients’ exhalation. › This may help dislodge the secretions and may stimulate cough.

 Percussion

1-2 minutes. If with tenacious secretions 3-5 minutes  Vibration is done during 5 exhalations  Postural drainage is done for 15-20 minutes usually performed 3-4 times a day.  CONTRAINDICATIONS: pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery.

Use of cannula, face mask and venturi mask  Oxygen therapy is used primarily to reverse hypoxia.  GOALS: 

› Improve tissue oxygenation › Decrease work of breathing in dyspneic

patients › Decreased work of the heart in patients with cardiac problems

Oxygen is prescribed in terms of liters per minute (flow) and percent (FiO2)  A general rule for safe O2 administration is to use the lowest level of O2 possible to attain the acceptable FiO2.  Because 02 is drying to the mucosa, a humidification system is always used. 

Oxygen delivery systems can be via nasal cannula widely used because of its comfort, ease of use, ease of mobility, and it can handle form 1 to 6 liters per minute flow.  The venturi mask can be used if precise, low concentration delivery is required. When a higher concentration is required, a simple mask is utilized.  Pediatric delivery systems include the use of incubators, hoods and tents. 

Low flow devices (2-6 LPM) Nasal cannula Simple face mask Partial rebreathing mask Non-rebreathing mask Croupette Oxygen tent

High flow devices ( >6 LPM) Venturi mask Face mask Oxygen hood Incubator Isolette

These artificial airways are inserted to maintain patent air passages for clients whose airway have become or may become obstructed.  These are devices that provide a more direct route to the lungs than the natural airway 

Oropharyngeal airway (used only on clients with impaired sensorium)  Nasopharyngeal airways (used in alert patients)  Endotracheal tubes (For clients undergoing anesthesia procedures and when mechanical ventilators are necessary).  Tracheostomy is an artificial airway in which a plastic tube is surgically inserted just below the larynx into the trachea, bypassing the mouth and upper airway. 

 endotracheal

tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionally  tie new trache tie before removing the old tie to prevent accidental dislodgement  use precut gauze and perform care OD at least.  soak inner cannula in antiseptic soak with hydrogen peroxide, rinse well  suction prn, oral care prn

This is a mechanical aspiration of the airways involving the use of a catheter inserted through the nose, mouth or tracheal tube  The catheter is attached to a portable or wall unit SUCTION machine. Secretions are drawn up by a vacuum. 



When this is properly performed, suctioning can greatly improve the airflow into the lungs.

The nurse assesses the indication for suctioning.  It can cause hypoxia since O2 is extracted along with the secretions, the patient must first be hyperventilated with 100% O2 before each suction attempt.  The conscious patient is usually positioned on semi-fowler  The unconscious is positioned lateral. 

 

 



The usual suction pressure is between 80 to 120 mmHg (adults) or 60-80 mmHg (infants). The usual duration of suction per insertion of the catheter should be no longer than 15 seconds (5-10 seconds). The catheter for use are French 12-18 (adult), French 8-10 (child) and French 5-8 (infants). The length is measures from the tip of the nose to the earlobe or about 13 cm (5 inches) for adults. Allow 20-30 seconds interval between each suction.

Assess the patient’s respiratory status, VS, breath sounds. Monitor for any changes  Observe the dressing round the chest tube  Check that the drainage tube has no dependent loops or kinks. All connections should be secured with tape 

Keep drainage bottle below the chest level  Prepare two padded clamp, Vaseline gauze pads and sterile bottle with water at bedside.  Measure drainage output at the start and end of each shift. 



Monitor for the proper functioning of the drainage system: › Intermittent bubbling with oscillations on the

water seal bottle › Continuous gentle bubbling on the suction control bottle

Assist patient to maintain high fowler’s position to promote drainage.  Encourage coughing and deep breathing exercises. 

removal of airway obstruction (by Heimlich maneuver)  initiating CPR 

 Breathing

difficulty  Associated with many conditions- CHF, MG, GBS, Muscular dystrophy, obstruction, etc…

General nursing interventions:  Fowler’s position to promote maximum lung expansion and promote comfort. An alternative position is the ORTHOPNEIC position  O2 usually via nasal cannula  Provide comfort and distractions

Cough is a protective reflex  Sputum production has many stimuli  Thick, yellow, green or rust-colored bacterial pneumonia  Profuse, Pink, frothy pulmonary edema  Scant, pink-tinged, mucoid Lung tumor

General nursing Intervention  Provide adequate hydration  Administer aerosolized solutions  Advise smoking cessation  Oral hygiene

Bluish discoloration of the skin  A LATE indicator of hypoxia  Appears when the unoxygenated hemoglobin is more than 5 grams/dL  Central cyanosis observe color on the undersurface of tongue and lips  Peripheral cyanosis observe the nail beds, earlobes 

 Interventions:

› Check for airway patency › Oxygen therapy › Positioning › Suctioning › Chest physiotherapy › Check for gas poisoning › Measures to increased

hemoglobin

Expectoration of blood from the respiratory tract  Common causes: Pulmo infection, Lung CA, Bronchiectasis, Pulmo emboli  Bleeding from stomach  acidic pH, coffee ground material 

Interventions:  Keep patent airway  Determine the cause  Suction and oxygen therapy  Administer Fibrin stabilizers like aminocaproic acid and tranexamic acid

Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus membrane  Most common site- anterior septum  Causes 

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Trauma Infection Hypertension blood dyscrasias , nasal tumor, cardio diseases

Nursing Interventions  Position patient: Upright, leaning forward, tilted prevents swallowing and aspiration  Apply direct pressure. Pinch nose against the middle septum x 5-10 minutes  If unrelieved, administer topical vasoconstrictors, silver nitrate, gel foams  Assist in electrocautery and nasal packing for posterior bleeding

APPLICATION OF THE NURSING PROCESS 5. EVALUATION