Oxygenation is the delivery of oxygen to the body’s tissues and cells for the maintenance of life and health. This depends on ventilation, alveolar gas exchange, oxygen transported, and cellular respirations.
Respiration
Respiration is the transport of oxygen from the outside air to the cross within tissues, and the transport of carbon dioxide in the opposite direction. Respiratory rate (RR) is the number of breaths within a minute, and is monitored as one of the vital signs.
ABCs of Life Support
All of the ABCs of Life are related to oxygenation. It stands for Airway, Breathing, and Circulation:
- Airway: patency is required to allow for ventilation.
- Breathing: ventilation itself.
- Circulation: pulse, blood pressure, and oxygen saturation, which is the internal transport of oxygen throughout the body.
| Breathing Patterns | Description |
|---|---|
| Tachypnea | RR>20 |
| Bradypnea | RR<12 |
| Apnea | Absence of breathing |
| Obstructive Sleep Apnea | Periods of apnea with irregular breathing |
| Dyspnea | ”Shortness of breath”; difficulty breathing |
| Paroxysmal Nocturnal Dyspnea | Dyspnea causing wakening to catch one’s breath |
| Air Hunger | Acute dyspnea occurring in terminal stages of hemorrhage |
| Kussmaul’s Breathing | Deep, sighing breathing |
| Cheyne-Stokes Respirations | Apnea alternating with slow, deep, then shallow respirations |
| Orthopnea | Dyspnea occurring when lying down |
| Hyperventilation | Rapid, deep breathing |
| Hypoventilation | Slow, shallow breathing |
Nursing Considerations
A major nursing responsibility in respiration is monitoring. Changes in respiration can be observed by changes in skin color; cyanosis of the nail beds, lips, skin either centrally or peripherally; changes in the level of consciousness, posturing (forward-leaning position), and clubbing.
- Assessment:
- History-taking: respiratory problems, lifestyle, presence of coughing, sputum, pain, medications, and risk factors
- Physical Examination: rate, depth, rhythm, quality of respirations, and shape of the thorax.
- Diagnostic Studies: sputum specimen, throat cultures, visualization procedures (laryngoscopy, bronchoscopy), venous and arterial blood specimens, and pulmonary function tests.
- Nursing Diagnosis: altered respiratory status, altered breathing pattern, altered gas exchange, inadequate physical energy for activities.
- Planning: overall outcomes/goals; maintain a patent airway, improve comfort and ease of breathing; maintain or improve pulmonary ventilation and oxygenation; improve the ability to participate in physical activities; prevent risks associated with oxygenation problems such as skin and tissue breakdown, syncope, acid-base imbalances, and feelings of hopelessness and social isolation; plan for home care- provide for continuity of care, learning needs, and needs for assistance with care in the home.
- Implementing: ensuring a patent airway, positioning, encouraging deep breathing and coughing, ensuring adequate hydration, suctioning, lung inflation techniques, administration of analgesics before deep breathing and coughing, postural drainage, percussion, and vibration.
- Promoting oxygenation: positioning the client to allow for maximum chest expansion with the tripod position, chest physiotherapy, incentive spirometry.
- Deep breathing and coughing: encouraging deep-breathing exercises and coughing to remove secretions from the airways.
- Hydration: adequate hydration maintains the moisture of the respiratory mucus membranes. Humidifiers are devices that add water vapor to inspired air. Room humidifiers provide cool mist to room air. Nebulizers are used to deliver humidity and medications.
- Medications: bronchodilators, antiinflammatory drugs, leukotriene modifiers, expectorants, beta-adrenergic stimulating agents, and beta-adrenergic blocking agents.
Promoting Healthy Breathing
- Sit straight and stand erect to permit full lung expansion.
- Exercise regularly.
- Breathe through the nose.
- Breathe in to expand the chest fully.
- Do not smoke cigarettes, cigars, or pipes.
- Eliminate or reduce the use of household pesticides and irritating chemical substances.
- Do not incinerate garbage in the house.
- Avoid exposure to second-hand smoke.
- Use building materials to do not emit vapors.
- Make sure furnaces, ovens, and wood stoves are correctly ventilated.
- Support a pollution-free environment.
Oxygen Therapy
The medical administration of supplemental oxygen, considered as medicine. This is a prescribed action by a healthcare provider who specifies the concentration, method of delivery, and flow rate. This may be used for patients with hypoxia/hypoxemia, hyperventilation, or those with substantial loss of lung tissue due to tumors or surgery. Severe anemia or blood loss may also require oxygen therapy.
Oxygen Therapy Safety Precautions
- Avoid smoking around oxygen-delivery devices. Oxygen is one of the core components of fire, and poses a fire hazard. Place a No Smoking: Oxygen in Use warning in prominent areas of the client’s room such as the door, foot or head of the bed, and on the oxygen tank.
- Avoid electrical devices such as razors, hearing aids, radios, televisions, and heating pads that can produce short-circuit sparks which may be a cause for fire. Necessary devices such as suction machines and portal diagnostic machines are electrically grounded.
- Avoid materials that generate static electricity, such as woolen blankets and synthetic fabrics. Cotton fabrics should be used for clothing and blankets.
- Avoid volatile, flammable materials such as oils, greases, alcohol, ether, and acetone.
- Make sure to take note of the presence and location of fire extinguishers. Personnel and family members should be trained for their use.
Oxygen Delivery Systems
- Low-Flow Systems feature small-bore tubing such as nasal cannulas, face masks, oxygen tents, and transtracheal catheters. The nasal cannulas are the most common and inexpensive device used to administer oxygen.
- High-Flow Systems supply all the oxygen required during ventilation in precise amounts regardless of the client’s respirations. The high-flow system used to deliver a precise and consistent FiO2 is the Venturi Mask with large-bore tubing.
| Delivery System | Flow | Flow Rate | FiO2 |
|---|---|---|---|
| Nasal Cannula | Low | ||
| Simple Face Mask | Low | 8 to 12 L/min. | 35% to 65% |
| Partial Rebreather Face Mask | Low | 6 to 10 L/min. | 40% to 60% |
| Non-Rebreather Face Mask | Low | 6 to 15 L/min. | 60% to 100% |
| Venturi Mask | High | 4 to 10 L/min. | 24% to 50% |
| Face Tent | Low | 8 to 12 L/min. | 28% to 100% |
Oxygen may be stored in tanks, also known as cylinders that are the system of choice for clients who need oxygen on a p.r.n. basis. Oxygen does not evaporate during storage and can be delivered at all rates (1 to 15 L/min.) These tanks are colored green.
They may also be stored as liquid oxygen. A tank is still used, but it is refilled at the large, stationary container. This system can store oxygen at a much smaller amount of space than compressed gas.
Oxygen concentrators are electrically powered systems that manufacture oxygen from room air with higher concentrations at lower flow rates, e.g., 95% at 1 L/min., but only 75% at 4 L/min.
Artificial Airways
Artificial airways may be required for patients who cannot maintain a patent airway such as in obstruction. A patent airway is necessary to allow air to flow to and from the lungs.
- Oropharyngeal and Nasopharyngeal Airways: upper airway passages for obstructive secretions or the tongue such as in sedation, comatose, or altered level of consciousnesses. Oropharyngeal airways stimulate the gag reflex, and is only used for patients with an absent gag reflex (e.g. in general anesthesia, overdose, head injury)
- Endotracheal Tubes are the most commonly inserted airways for clients who have had general anesthesia or those in emergency situations where mechanical ventilation is required. These are only inserted by anesthesiologists, primary care provider, certified registered nurse anesthetist (CRNA), or respiratory therapist with specialized education.
- Tracheostomy: surgical creation of an opening through the neck.
Chest Physiotherapy
Chest physiotherapy is a series of techniques used to improve ventilation by facilitating the removal of secretions from the airways:
- Percussion: “clapping”; a forceful striking of the skin with cupped hands. Mechanical percussion cups and vibrators are also available. The hands are cupped as if scooping up water, and alternatingly clapped against the patient’s back/chest wall.
- Vibration: a series of vigorous quiverings produced by the hands that are placed flat against the client’s chest wall. This is used after percussion to increase the turbulence of the exhaled air and thus loosen secretions. This is often done alternately with percussion.
- Postural Drainage: drainage of secretions from various lung segments with gravity. Secretions that remain in the lungs are sites of bacterial growth, leading to infection, along with being obstructive.
- Mucus Clearance Device: used for clients with excessive secretions such as in cystic fibrosis, COPD, and bronchiectasis.
Suctioning
Also read: Oxygenation by Ma’am Toni Notario
Suctioning is done to remove secretions that obstruct the airway. This facilitates ventilation, obtains secretions for diagnostic procedures, and prevents infections that may result from accumulated secretions.
- Nasotracheal Suctioning involves passing a suction catheter or nasal trumpet through the nares and into the oropharynx.
- Endotracheal Suctioning involves passing a suction catheter through the endotracheal tube or tracheostomy into the trachea and applying suction as the catheter is slowly withdrawn.
Equipment
- Catheter: the outer diameter of the suction catheter should not exceed one-half of the internal diameter of the artificial airway. A method to determine catheter size is to multiply the diameter of the artificial airway in millimeters by 2, e.g., 8 mm * 2 = Fr. 16 is safe to use for suctioning.
- Suctioning Systems for Ventilators: patients on ventilators may also require suctioning. This may be open, where the ventilator must first be disconnected, or closed, where the ventilator does not need to be disconnected for suctioning.
Equipment
Nasopharyngeal/Nasotracheal suctioning:
- Towel/moisture-resistant pad
- Portable or wall suction machine with tubing, collection receptacle, and suction pressure gauge
- Sterile disposable container for fluids
- Sterile normal saline or water
- PPE (goggles, face shield) if appropriate (suctioning is an aerosol-producing procedure).
- Moisture-resistant disposal bag
- Sterile gloves
- Sterile suction catheter kit
- Water-soluble lubricant (KY Jelly)
- Y-connector
- Sputum Trap
Oral/oropharyngeal suctioning:
- Yankauer suction catheter or suction catheter kit
- Clean gloves
Nursing Implementation
- Assessment: clinical signs that indicate the need for suctioning include restlessness, anxiety, adventitious breath sounds or respirations, changes in mental status, skin color, abnormal rate and pattern of respirations, pulse rate and rhythm, and decreased oxygen saturation.
- Planning: the nurse reviews standard procedures to avoid complications.
- Apply suction while withdrawing the catheter to avoid trauma to the mucous membranes.
- Utilize the sterile technique for nasopharyngeal and nasotracheal suctioning. Oropharyngeal suctioning may be done on a clean technique basis, but still requires a nurse or respiratory therapist to perform it.
- Suctioning may stimulate the gag reflex, cause hypoxia (hyperoxygenate the patient before and after every pass of the suction), or produce dysrhythmias. Prompt action is required to resolve these complications.
- Implementation: position the conscious patient in the semi-Fowler’s position, and the unconscious patient in a side-lying position, facing the dominant hand of the nurse.
- Advance the catheter about 10 to 15 cm (4 to 6 inches)
- Apply suction while withdrawing the catheter in a circular motion. This should only last for 10 to 15 seconds to avoid hypoxia.
- Provide a rest period between each pass of suctioning. Reassess for continued indication of the need for suctioning. The entire procedure should only last for 5 minutes.
- Documentation: document the date and time of the procedure, including details about the (a) indication for suctioning, (b) characteristics of the secretions suctioned, (c) equipment used, (c) client response i.e. oxygen saturation, respiratory rate, and lung sounds, and other pertinent information.
Sample Documentation of Suctioning Procedure
12/12/2020 08:30 AM Producing large amounts of thick, tenacious white mucus to back of oral pharynx but unable to expectorate into tissue. Client uses Yankauer suction tube as needed. O 2 sat increased from 89% before suctioning to 93% after suctioning. RR also decreased from 26 to 18–20 after suctioning. Lungs clear to auscultation throughout all lobes. Continuous O 2 at 2 L/min via n/c. Will continue to reassess every hour.
- Evaluation: conduct an appropriate follow-up, checking the appearance of secretions suctioned, breath sounds, respiratory rate, rhythm and depth, pulse rate and rhythm, and skin color. These are compared to previous findings if available. Significant deviations from normal are reported to the primary care provider.