CHAPTER

9

Respiration

Oxygenation / Gas Exchange

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The process of respiration includes both oxygenation and gas exchange. Oxygenation is the process of providing cells with oxygen through pulmonary ventilation (breathing) and perfusion (the movement of blood to the tissues). Gas exchange is the process by which oxygen moves passively by diffusion across the capillaries to the cells while carbon dioxide is removed from the body through the respiratory system. Nurses encounter alterations in oxygenation and gas exchange in all ages of clients and must identify problems and intervene quickly to prevent life-threatening complications.

Next Gen Clinical Judgment:

•   What are the different assessment findings for a client with oxygenation problems versus perfusion problems?

•   Can a client have adequate respirations but inadequate oxygenation? Explain.

•   Why is “airway” first when talking about airway-

breathing-circulation?

•   What is the role of respirations in the acid-base balance of the body?

•   List diseases and illnesses that are related to the respiratory system.

NurseTim.com                                                                                                                                                               Chapter 9 - Respiration                                                                                                                                                                    111

Go To Clinical Case

While caring for this client, be sure to review the concept maps in chapters 3 and 4.

Case 1: Impaired Oxygenation with Secondary Infection

Related Concepts: Acid-Base Balance, Infection

Threaded Topics: Medication Calculations, Delegation, Health Promotion

Luanne Yazzie is a 56-year-old who has lived her life around second-hand smokers. Her parents smoked in the home she grew up in, her first husband smoked before dying from complications of diabetes, and she works as a card dealer in a Nevada casino which allows smoking. Although she has never smoked, Luanne learned a year ago that she had developed early symptoms of emphysema.

1.        Next Gen Clinical Judgment!

Which symptoms does Luanne demonstrate that indicate early signs of emphysema? Select all that apply.

1.     Increasing shortness of breath when climbing stairs.

2.     Production of dark yellow-green sputum.

3.     Wheezing with exhalation.

4.     Increased morning mucus production.

5.     Barrel chest.

2.        Luanne comes to the clinic for increasing shortness of breath and worsening symptoms. The health care provider considers several pulmonary lab and diagnostic tests. Match the diagnostic test on the left with the appropriate client teaching on the right.

3.        Luanne’s provider prescribes a chest x-ray (CXR) and pulmonary function tests (PFT). These confirm that she is at a moderate (Stage 2) disease with a forced expiratory volume in one second (FEV1) of 65% of normal. Luanne has many questions for the nurse about what this means. How should the nurse respond?

1.     The chest x-ray shows damage to the air sacs of your lungs.

2.     Your lungs are not functioning at full capacity any longer, explaining your shortness of breath.

3.     Your disease has improved from when the symptoms started a year ago.

4.     This information needs to be explained by your provider.

4.        Next Gen Clinical Judgment!

The registered nurse reviews the assessment documented by the LPN/LVN and diagnostic findings.

Which assessment inconsistencies require re-evaluation by the RN? Select all that apply.

1.     Temperature, heart rate, blood pressure.

2.     Respiratory rate and oxygen saturation.

3.     Orientation.

4.     Lung sounds.

5.     Bowel sounds.

6.     Pain level.

Clinical Hint: The RN is responsible for confirming the client is safe. If the data or assessment information provided by the LPN or UAP is questionable, the RN should reassess.

Luanne is discharged from the clinic with these new prescriptions.

7.        Luanne does not understand the need for two inhalers. How should the nurse explain the differences?

1.     They both work to expand your lungs and improve your ability to breathe.

2.     One will help your breathing; the other will repair the damage to your lungs.

3.     One is a short-term for immediate relief, and the other is for long-term control.

4.     One opens your airways, and the other decreases the inflammation.

Luanne is managed well on the two inhalers for over a year. One morning she awakens feeling more short of breath than usual. She goes to work but has to leave early since her breathing is more difficult and the cough is getting worse despite the use of her albuterol inhaler every 1-2 hours.

She goes to the urgent care on the way home.

9.     The health care provider prescribes albuterol per small volume nebulizer (SVN). Luanne asks the nurse how it’s different from the metered dose inhaler (MDI) she takes at home. How should the nurse respond?

1.     The MDI is less portable to use.

2.     The SVN uses compressed air to distribute the medication into your lungs.

3.     The SVN provides oxygen during delivery of the medication.

4.     The MDI has a lower dosage and is less potent.

10.  The nurse is instructing Luanne on how to use the nebulizer. What should be included in the instructions? Select all that apply.

1.     Fully exhale before taking the medication.

2.     Rinse your mouth after use.

3.     Firmly place your lips around the mouthpiece.

4.     Take normal breaths during administration.

5.     You may feel your heartbeat increase with administration.

6.     Let me know if you feel lightheaded or dizzy.

Luanne is discharged after her oxygen saturation increased to 94% on room air. She was started on an oral antibiotic and told to get rest and not to return to work for 7 days. She returned to work after 2 days since she was feeling better, and could not afford to take 7 days off of work.

11.  What else could the nurse suggest that would be helpful for Luanne’s recovery? Select all that apply.

1.     Increase fluid intake.

2.     Ambulate around the block twice each day.

3.     Complete the full dose of antibiotics.

4.     Consume at least 2000 calories each day.

5.     Avoid smoky environments.

After a week the shortness of breath has returned. Her son notices that she seems mildly confused. He takes her to the emergency department. The triage nurse takes her vital signs and performs a focused assessment.

12.    THIN Thinking Time!

Reflect on the events that have occurred since Luanne Yazzie came to the emergency department and apply THIN Thinking.

T – Low oxygen saturation, tachypnea and confusion                             

H –elevate the head of the head to improve breathing                         

I –risk for tissue hypoxia and hypoxemia due to poor oxygenation  

N –assess the patient respiratory rate, oxygen saturation and administer supplemental oxygen adequate oxygenation of body tissues.                                                                   

13.    What should be the nurse’s next action? Place in order of priority. 1          , 2       , 5                     , 4       ,3

1.     Raise the head of the bed.

2.     Apply oxygen at 2 L/nasal cannula.

3.     Complete a more comprehensive assessment.

4.     Notify the health care provider.

5.     Encourage pursed-lip breathing.

14.    Luanne’s son asks why she is so confused. How should the nurse respond?

1.     The medications that your mom is taking can sometimes cause confusion.

2.     She may have had a stroke, and we’ll run some tests.

3.     She’s probably just tired of being sick.

4.     Her oxygen levels are low which can cause confusion.

T - Top 3

H - Help Quick

I - Identify Risk to Safety

N - Nursing Process

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16.    The nurse gathers information and begins to prepare an SBAR telephone conversation for the health care provider. Complete each section of the communication form.

S –hello. I am the FPN N. Dugen caring for the patient Luanne Yazzie who is 56 years allergic to strawberries with a full status code. I am calling because the patient has tachypnea, respiratory acidosis, adventitious breath sounds and worsening dyspnea.

B – Patient came in today in the morning. She has a history of living with smokers and working in a casino where smoking is legal. Was diagnosed with emphysema an year ago which she has been managing with long and short acting bronchodilators. About a week ago she went to urgent care due to worsening cough and dyspnea not relieved by albuterol she was taking. She was diagnosed with pneumonia  and discharged with oral antibiotic. The condition further worsened.

A – Patient is sick looking and confused. Her vital signs are: BP 100/58, HR 108, RR 26, and O2 89%. ABGs results are pH of 7.25, CO2 of 51, and HCO3 of 28 indicating respiratory acidosis. Crackles were heard in the right lower lobe, accompanied with inspiratory and expiratory wheezes on auscultation. Her cough is moist with use of accessory muscles and SOB

R –

We consider prescribing sodium bicarbonate to prevent worsening symptoms of acidosis, start IV fluids, and increase the percentage of supplemental oxygen being administered. Also, obtain a chest x-ray, take sputum specimen for culture and sensitivity in order to start antibiotics?

Before initiating the orders, the nurse performs another focused assessment on Luanne.

Over the next 24 hours, Luanne’s condition improves. Read the nurse’s notes and answer the questions below.

19.    On the day of admission, what additional information would be most important for the nurse to document?

1.     Urinary output.

2.     Results of the sputum culture.

3.     Orientation.

4.     Last bowel movement.

The nurse reviews the oxygen titration record.

Go To Clinical Case

While caring for this client, be sure to review the concept maps in chapters 3 and 4.

Case 2: Impaired Oxygenation and Gas Exchange from Fluid Accumulation

Related Concepts: Comfort, Cellular Regulation, Nutrition, Protection Threaded Concepts: Legal Issues, Communication, Delegation, Medication Calculation, Use of Social Media

Eric Van Sickle is a 16-year-old with a history of Non-Hodgkin’s Lymphoma. He was treated aggressively with chemotherapy and radiation and has been in remission for three years. He considers

lymphoma a problem of the past and is working hard to live a healthy lifestyle. He sleeps 6-7 hours a night and eats a diet of lean proteins, fruits, and vegetables. He also commits to running 1-2 miles each morning.

He is active at school, an honor student, and class president. He tells his mom that he is having trouble

taking a deep breath, just over the last week. She makes a clinic appointment.

1.        The admitting nurse assesses his oxygenation/gas exchange status. What should the nurse include? Select all that apply.

1.     Lung sounds.

2.     Oxygen saturation.

3.     Lymph node palpation.

4.     Capillary refill.

5.     Depth and symmetry of respiration.

Eric’s health care provider orders a chest x-ray. Review the report below.

4.    What assumptions can the nurse make from the x-ray report?

1.     Eric’s lungs have an infection and should resolve with antibiotics.

2.     Additional tests are needed to determine the problem.

3.     Eric’s x-ray is inadequate and needs to be repeated.

4.     Eric’s x-ray report is normal.

After consulting a pulmonologist, Eric is admitted to the children’s hospital for further workup. A thoracentesis is performed using IV conscious sedation in interventional radiology. He returns to the medical floor after the procedure.

Handoff Report

Eric Van Sickle received a thoracentesis under fluoroscopy where 800 mL cloudy pink fluid was removed from his right lower lobe and sent to the lab for cytology, and culture & sensitivity. He received midazolam 2 mg IV. His vital signs have been stable throughout the procedure. He’s now on room air. He’s arousable to touch. His parents are at the bedside.

6.     The nurse enters the room and notes that Eric’s respirations are 10 per minute, even, and unlabored, the oxygen saturation reading is 99% and the head of the bed is flat. What should be the nurses next action?

1.     Continue to allow him to sleep.

2.     Gently arouse him by touching his arm.

3.     Place him on oxygen.

4.     Raise the head of the bed.

Over the next hour, the nurse records post-procedural care.

7.       Before the nurse contacts the health care provider, what additional assessments are priority? Select all that apply.

1.     Auscultation of lung sounds.

2.     Assessment of thoracentesis dressing.

3.     Assessment for a tracheal shift.

4.     Measurement of urine output.

5.     Orientation to person, place, and time.

8.       After further assessment, the nurse discovers a tracheal shift to the left and absent breath sounds on the right side. A call is placed to the health care provider. Complete the communication form.

S – Hello. My name is nurse (Name) taking care of the patient Eric Van Sickle who is 16 year with NKDFA with a full code status. The patient has SOB at rest, non -radiating pain in the chest rated 4 on a scale of 1-10 scale that worsen with deep breath over the last week. Also, dry and irritating cough. The patient has signs of pneumothorax.

B – Erick was admitted today and the primary physician is J. Johansen, M.D. he has a history of Non-Hodgkin’s Lymphoma. He was treated aggressively with chemotherapy and radiation and has been in remission for three years. Erick was admitted for thoracocentesis and subsequent work ups. 800 mL cloudy pink fluid was removed from his right lower lobe and sent to the lab for cytology, and culture & sensitivity.  He received midazolam 2mg IV

A – The vital signs are BP 122/80mmHg, PR 101b/min, RR 24b/min labored and SPO2 94%. Patient is on oxygen 2 L/NC. He is oriented*3. The tracheal shift is to the left and there are absent breath sounds on the right.

R – We should obtain a chest x-ray and prepare the patient for chest tube insertion.  Will you be on your way soon or make arrangements with interventional radiology for a chest tube placement?

These verbal orders are received, and the provider says he will arrange with interventional radiology for a chest tube placement.

9.       The nurse returns to the room and finds Eric is anxious and afraid. His parents went to the cafeteria for a cup of coffee. The nurse needs to explain what is going on and obtain consent for the chest tube placement. How should the nurse proceed?

1.     See if Eric has a sedative ordered.

2.     Tell him you will get his parents from the cafeteria.

3.     Explain the situation to Eric and obtain consent.

4.     Stay with Eric and send someone else to get his parents.

Once Eric’s parents return to the room, the nurse pulls up a chair to the bedside, sits down, and explains the situation to the family. “Eric is having more difficulty breathing as you can see. We think he may have experienced a pneumothorax from the thoracentesis. I’ve spoken with the health care provider, and we are getting another

x-ray. If it confirms a pneumothorax, Eric will need to have a chest tube with a closed chest drainage system. Here is the consent that you need to sign for the procedure. What questions do you have?”

10.    Critique how the nurse communicated with the family and determine what should/could have been done differently.

11.    The x-ray showed a 70% pneumothorax, and a chest tube is placed. Eric returns to the floor with a right- sided 20 french chest tube connected to a chest tube drainage system at -20 cm H₂O of suction. Prioritize the sequence of assessments. 2          , 3       , 1       , 4       .

1.     Drainage System: setting for suction, fluid in the collection chamber, bubbles in the water seal chamber.

2.     Respiratory Status: rate and depth, saturation level, lung sounds.

3.     Dressing: chest tube dressing intactness.

4.     Pain: discomfort in chest from tube.

The next day, the nurse is reviewing the chest tube assessment flow sheet for the previous 24 hours.

12.    THIN Thinking Time!

Reflect on the care of the chest tube over the last 24 hours and apply THIN Thinking.

T – Tachypnea, shallow respirations, chest tube dressing and pain           

H – Dressings should be changed or reinforced because it is not secure       

I – risk of infection and safety due the dislodgement of loose dressing             

N – Adequate pain control to allow him take deep breaths. Bilateral crackles indicate atelectasis hence the need for deep breathing, effective coughing or incentive spirometer                            

T - Top 3

H - Help Quick

I - Identify Risk to Safety

N - Nursing Process

Scan to access the 10-Minute-Mentor on THIN Thinking.

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13.    The nurse is evaluating the fluid within the collection chamber and the intermittent bubbling in the water seal chamber. What conclusion can be made?

1.     The color of the fluid is concerning.

2.     The amount of the fluid is concerning.

3.     The bubbling is concerning.

4.     The findings are to be expected.

14.    The nurse identifies the need for several interventions. Which can be delegated to the UAP? Select all that apply.

1.     Changing the chest tube dressing.

2.     Obtaining an incentive spirometer.

3.     Positioning the client for the dressing change.

4.     Obtaining pain medication.

5.     Instructing about the importance of taking deep breaths.

The nurse decides to deliver morphine sulfate (MS) 2.5 mg IVP for pain rated at a 6 on a 1-10 scale and re-evaluate the response after 15 minutes (peak time 20 minutes).

16.  The morphine pre-filled syringe includes morphine sulfate 5 mg in 2 mL of solution. The nurse draws up

2.5 mg, then further dilutes the MS to a total of 10 mL of solution. It is recommended that the dose of 2.5 mg be administered over 5 minutes. At what rate should the nurse deliver the IV push pain medicine?

2         mL/minute

17.  After 15 minutes, the nurse performs an evaluation. Which finding will determine the medication was effective?

1.     Pain is tolerable.

2.     Respiratory rate of 16 breaths per minute.

3.     Client is sleeping.

4.     Blood pressure is 110/67 (81) mmHg.

18.  The UAP tells the nurse that Eric has a temporal temperature of 100.4°F (38°C). What should be the nurse’s next action?

1.     Deliver a dose of acetaminophen.

2.     Ask the UAP to retake the temperature orally.

3.     Auscultate the lung sounds.

4.     Observe the chest tube collection chamber drainage.

20.  A couple of days later, Eric’s chest tube was pulled, and he was ready for discharge. His cytology report came back positive for malignancy, and he was scheduled to see the oncologist the next day for treatment options. Eric asks the nurse if he can “friend” her on social media so they can stay in touch. How should the nurse respond?

1.     “Sure, why not. I’d like to hear how you do with your cancer.”

2.     “I’m not on social media.”

3.     “It’s not considered professional for me to “friend” my patients on social media.”

4.     “Let me check with my manager; I’m not sure.”

Conceptual Debriefing & Case Reflection

1.        Compare the impaired respiration that Luanne Yazzie experienced with the impaired respiration of Eric Van Sickle. How are they the same and how are they different?

Luanne Yazzie impaired respirations occurred due to inflammation of the lung parenchyma while Eric Van Sickle was a result of presence of fluid (pleural effusion).

2.        What was your single greatest learning moment while completing the case of Luanne Yazzie? What about Eric Van Sickle?

Each patient has their own unique characteristics therefore nursing process should be individualized to meet their needs. The care provided should be patient centered.

3.        How did the nursing care provided to Luanne Yazzie and Eric Van Sickle change the outcome for each of them?

Luanne Yazzie- administration of supplemental oxygen alleviated respiratory distress and medications i.e albuterol alleviated brochial obstruction.

Eric Van Sickle-

4.        Identify safety concerns for both Luanne Yazzie and Eric Van Sickle for each case.

Luanne Yazzie- risk for oxygen toxicity

Eric Van Sickle- risk for infection due to the presence of dressings of loose dressings on the edges of the chest placement tube.

5.        In what areas of each case study was basic care and comfort utilized?

Bronchodilators and corticosteroids were administered to Luanne to relieve respiratory distress. Eric Van Sickle was given opiod analgesics and chest tubes inserted for drainage. All of these are aimed at enhancing the patient comfort and relieve pain.

6.        What steps in each case did the nurse take that prevented hospital-acquired injury?

The nurse adhered to aseptic techniques when administering IV fluids, medications and performing procedures such as dressing of the chest drainage tubes. Also, observing the rights of medications.