FUNDAMENTALS: OXYGEN DEVICES

Ø KEY TERMS FOR LOW OXYGEN FROM:

TOPIC OUTLINE ü CVA Stroke
1 HYPOXIA VS HYPOXEMIA ü Increaesd ICP
2 OXYGEN THERAPY: OXYGEN DELIVERY DEVICES
3 ANATOMY OF BREATHING EARLY SIGNS
4 OXYGENATION & AIRWAY BRAIN MENTAL STATUS CHANGE NCLEX TIP
5 ASSESSING LUNG SOUNDS 1. Restlessness – “to freak out”
6 CHEST PHYSIOTHERAPY 2. Agitation – “irritability”
7 ABNORMAL LUNG SOUNDS 3. Confusion
HIGH VITAL Ø RR – Tachypnea (over 20 RR)
HYPOXIA VS HYPOXEMIA SIGNS Ø HR – Tachycardia (over 100 bpm)
Ø BP – Hypertension (over 140 systolic)

high lab values because the body

desperately tries to deliver around the
low O2 to the rest of the body
POSITIONING Ø Accessory muscle use
Ø Paradoxical breathing
Ø Tripoding
ü the client is leaning over /
forward as it tries to get
more oxygen

LATE SIGNS

LATE SIGNS
HYPOXIA VS HYPOXEMIA
LOW VITAL Ø RR – Bradypnea (less than 12 RR)
SIGNS Ø HR – Bradycardia (less than 60 bpm)
HYPOXEMIA HYPOXIA
Ø BP – Hypotension (less than 80
low oxygen levels in the low oxygen supply in the body systolic)
blood tissues
as the body fails to compensate
the body will try to from uncompensated CYANOSIS Ø skin that turns blue
compensate by increasing hypoxemia; the body cannot Ø blue skin color
respirations and heart rate adapt & get more oxygen ECG Ø “funky heart rhythm”
DYSRHYTHMIAS ü as the heart lacks oxygen
hypoxemia leads to hypoxia result of hypoxemia
low oxygen in the blood = low QUESTIONS
oxygen delivery in the body
tissues ATI QUESTION

HYPOXEMIA Q1: Which of the following are early indications that the client
is developing hypoxemia? SATA.
happens when our PaO2 is less than 80 mmHg • Restlessness
• Tachypnea
EARLY SIGNS • Bradycardia

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• Confusion
• Hypertension Ø 6 – 10 LPM
Ø 40 – 60 % O2
Ø PURPOSE:
OXYGEN THERAPY: OXYGEN DELIVERY DEVICES ü used in exchange for partial rebreather and non-
rebreather
Ø doesn’t have a reservoir bag
🚨 CAUTION

PARTIAL REBREATHER
AVOID COMBUSTION!
oxygen is highly inflammable
Ø 6 – 10 LPM
keeping patients away from blowing up is a
Ø 35 – 60 % O2
good thing
Ø PURPOSE:
ü allows some air to be recycled instead completely
NO! LIST preventing one from breathing air
ü use two-way valves
Ø BIG RISK FOR EXPLOSION! Ø has flutter valves & reservoir bag
KEEP YOUR PATIENT SAFE! J
NON-REBREATHER (NRB)
NO! LIST
NO SMOKING (OPEN this open flame can combust in Ø 10 – 15 LPM
FLAME) combination with oxygen Ø 60 – 100 % O2
NO STATIC synthetic / wool fabrics Ø PURPOSE:
ONLY COTTON! ü used for MEDICAL EMERGENCIES
NO FLAMMABLE MATERIAL alcohol
acetone (nail polish)
KEY POINTS:

OXYGEN DELIVERY DEVICES Þ used during carbon monoxide poisoning

ü since only high flow oxygen at 15 LPM will
OXYGEN DEVICES help eliminate that carbon monoxide and
1 NASAL CANNULA treat the HYPOXIA
2 SIMPLE FACE MASK
3 PARTIAL REBREATHER
Ø has a reservoir bag
4 NON-REBREATHER (NRB)
ü if the reservoir bag is FULLY DEFLATED ON
5 VENTURI MASK
INSPIRATION
6 FACE TENT
• INCREASE OXYGEN FLOW!
7 BILEVEL POSITIVE AIRWAY PRESSURE (BiPAP)
8 INTUBATION (ENDOTRACHEAL INTUBATION)
NURSING INTERVENTION
monitor the bag & to ensure the bag is more than
NASAL CANNULA
valves halfway full
DO NOT OPEN the must be closed to allow more
Ø 1 – 6 liters per minute (LPM)
flutter valves oxygen to get in during inhalation
Ø delivers 25 – 45% O2
DO NOT TIGHTEN face help reduce leaks directly but
Ø PURPOSE:
mask straps doesn’t necessarily increase the
ü used for short term use
reservoir bag
• low oxygen after surgery NCLEX TIP!
ü used for long term use
VENTURI MASK
• can dry out mucous membranes in the
nose
Ø 4 – 10 FiO2
• typically use humidification
Ø MOST PRECISE OXYGEN DELIVERY DEVICE!

SIMPLE FACE MASK

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MEMORY TRICKS RESPIRATORY FAILURE

V – Venturi Mask KEY TERMS: CAUSED BY..

V – Very Accurate O2
RESPIRATORY FAILURE
Ø PURPOSE:
HYPOXEMIC RESPIRATORY HYPERCAPNIC RESPIRATORY
ü used for patients with unstable COPD
FAILURE FAILURE
• who cannot tolerate changes in oxygen
concentration from other devices
from low O2 from high CO2 (over 45)

FACE TENT very common in clients with

worsening COPD
Ø high humidification (from decreased gas
Ø PURPOSE: exchange)
ü used for facial trauma & burns
PRIORITY INTERVENTION:
MEMORY TRICKS GIVE BiPAP

F – Face Tent MEMORY TRICK:

F – Face Trauma Hypercap
Give BiPAP

QUESTIONS
INTUBATION (ENDOTRACHEAL INTUBATION)
TOP MISSED EXAM QUESTION
Ø the ultimate solution to keep airway patent
AIRWAY PATENCY: allow air to flow freely
Q1: A patient recovering from surgery in the postoperative
Ø we stick a tube directly into the trachea to ventilate the
area suddenly becomes confused, pulse ox reading shows a
client manually via a
drop from 98% to 90% on room air. What is the most
appropriate intervention?
• Apply non-rebreather INTUBATION
• Apply simple face mask
ü bag valve
• Apply nasal cannula ü ventilator machine
• Raise the head of bed
Ø PURPOSE:
ü typically used during surgery
BILEVEL POSITIVE AIRWAY PRESSURE (BiPAP) • to keep airway open
ü used as a last line for clients with a compromised
Ø PURPOSE: airway
ü clients with worsening COPD • patients with code
• has high levels of CO2 = Respiratory PATIENT CODED: cardiac arrest
Acidosis
Ø a positive pressure machine that forcefully pushes air • patients with allergic reaction
deep into the lungs giving much oxygen while expelling swelling in the throat region
CO2 which closes the trachea
• patients who are post-thyroidectomy
FORCEFUL GAS EXCHANGE get swelling near the trachea
Ø COMPLICATIONS:
Ø primarily used to prevent respiratory failure Ventilator Associated Pneumonia (VAP)
ü caused by low O2 & high CO2 which is common
for clients with worsening COPD

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NURSING INTERVENTION ANATOMY OF BREATHING

Reposition side to
side every 2 hours how the lungs exactly work
Oral care followed with oral suctioning
CHLORHEXIDINE LOBES OF THE LUNGS
every 2 hours
Monitor Key Signs NCLEX TIPS! LUNGS
Ø Positive sputum culture Right Lung 3 lobes
Ø Fever Left Lung 2 lobes
Ø Chest X-ray: new infiltrates
ü indicates infection & Ø when listening to the lungs, we listen in between the
worsening VAP! ribs (intercostal space)
Intercostal space: in between the ribs

ANATOMY OF THE LUNGS

ALVEOLAR SACS

Ø “alveolar apples”
Ø where all the action happens
Ø where gas exchange occurs!
ü O2 in, CO2 out
ü it happens inside the little capillary beds of each
alveolus

PATHOPHYSIOLOGY: PULMONARY EDEMA

Ø fluid in the lungs

ü commonly seen for patients with heart failure

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Ø heavy fluid all over the body exhalation breathing out CO2
ü really wet lungs which blocks oxygen from
getting in FACTORS: BREATHING

FACTORS
1 CLEAR AIRWAY
2 INTACT CENTRAL NERVOUS SYSTEM
3 INTACT THORACIC CAVITY
4 ADEQUATE PULMONARY COMPLIANCE & RECOIL

PATHOPHYSIOLOGY: PNEUMONIA

Ø Atelectasis: when alveoli collapse

ü gas exchange can’t happen
ü infection settles in
ü resulting to pneumonia!

INTACT CENTRAL NERVOUS SYSTEM

Ø specifically the brain stem

Brain stem: control impulse to breathe

INTACT THORACIC CAVITY

Ø specifically the diaphragm

Diaphragm: which helps to expand the lungs to get
PATHOPHYSIOLOGY: BREATHING
oxygen in

Ø NORMAL GAS EXCHANGE:

ADEQUATE PULMONARY COMPLIANCE & RECOIL
Breathing in O2, Breathing out CO2
Þ too much CO2 = acidosis
Ø good condition of alveoli!
Ø when alveoli is scarred & hard
ü ex. from smoking for years
OXYGENATION & AIRWAY
• compliance and recoil decreases
• won’t allow gas exchange, as a result
• no O2 in and CO2 out!

TERMS
external respiration exchange of 02 & CO2 between alveoli
& pulmonary blood
internal respiration exchange of O2 & CO2 between blood
& cells in the body

LUNGS
inhalation breathing in O2

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FACTORS THAT AFFECT THE RESPIRATORY SYSTEM

FACTORS
1 ENVIRONMENT
2 LIFESTYLE
3 MEDICATIONS
4 ADVANCED AGE

ENVIRONMENT

environmental factors
ü pollution KEY TERMS: CONDITIONS AFFECTING MOVEMENT OF AIR
ü elevation
ü KEY TERMS
temperature
APNEA no breathing
ex. sleep apnea
LIFESTYLE
o serious sleep disorder in which
breathing repeatedly stops &
lifestyle factors
starts throughout the night
ü smoking
DYSPNEA difficulty breathing
ü stress
happens for any reason
ü sedentary lifestyle
commonly found on chronic conditions
ex. COPD
Ø leads to decrease lung compliance
o chronic destruction of the lungs
ü makes alveoli really hard and stiff
ORTHOPNEA difficulty breathing while lying flat
ex. Congestive Heart Failure (CHF)
MEDICATIONS
o fluid backs up into the body &
lungs, making it very difficult to
Ø some medications decrease lung capacity
breathe at night!
ü OPIOID MEDICATIONS
o as fluid accumulate in the lungs,
• pain meds relax the body = low &
essentially drowning the client
slow / shallow breaths
o typically relieved by sitting or
• opioids = low and slow vitals
standing
Low RR, HR, BP
o sometimes patient don’t realize
they have it
ADVANCED AGE

Ø seen in elderly clients

Ø as we age, the body slowly deteriorate
o INDICATION:
Ø naturally, the body begins to fall apart
1. sleeping with several pillows
Ø decreased lung capacity & elasticity + weaker
2. sleep on a recliner chair
respiratory muscles = increased work of breathing +
increased anterior and posterior chest diameter
MEMORY TRICK:
ü looking like a round, barrel chest
HF - Heart Failure
Ø decreased cough reflex
HF – Heavy fluid in lung / body
ü making it harder to expel a material
BRADYPNEA breathing too slow (less than 12 RR)
ü more trapped mucous
• increased risk for infection
MEMORY TRICK:
(pneumonia)
Brady Bunch = older TV show with slower
Ø sleep apnea
times
ü serous sleep disorder

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CAUSES OF SLOW BREATHING (BRADYPNEA) PRIMARY TREATMENT

TYPES OF PAIN PRIMARY TREATMENT

1 MEDICATIONS 1 SCREENING WITH ASSESSMENT
2 METABOLIC ALKALOSIS 2 LUNG SOUND ASSESSMENT
3 INCREASED ICP 3 HEALTH EDUCATION
4 POST OPERATIVE
MEDICATIONS
SCREENING WITH ASSESSMENT
Ø Opioid medications
Ø Opioids = low and slow vitals Ø look for subjective and objective data

INCREASED ICP HEALTH EDUCATION

Ø happens from any type of head trauma HEALTH EDUCATION

ü lifestyle
KEY TERMS ü habits
TACHYPNEA breathing too fast (over 20 RR) ü vices like smoking
doesn’t allow complete recoil of the lung
ü which reduces oxygen in the body POST OPERATIVE

CAUSES Ø encourage incentive spirometer use

ü pain ü to re-expand the alveoli & prevent infection
ü anxiety (pneumonia)
ü hypoxemia
ü metabolic acidosis
SECONDARY TREATMENT
MEMORY TRICK:
Tachy clothes = Too much going on! SECONDARY TREATMENT
1 OXYGEN TEHRAPY IF NEEDED
METABOLIC ACIDOSIS 2 IMPROVED HYDRATION TO THIN THE SECRETIONS
Ø body tries to breathe faster, blow 3 HUMIDIFICATION
off all CO2 out to get into alkalosis 4 MOBILIZE SECRETIONS
called as Kussmaul Respirations
IMPROVED HYDRATION TO THIN THE SECRETIONS
KUSSMAUL deep, rapid breathing pattern often seen
RESPIRATIONS when the body is too acidic Ø this make secretions easier to move & cough out
• common in clients with diabetes who
go on Diabetic Ketoacidosis (DKA) MOBILIZE SECRETIONS

CHEYNE- “death rattle” MOBILIZE SECRETIONS

STOKES very deep to very shallow breathing Medications Mucolytics – Acetylcysteine
most commonly seen right before death Ambulation walking
Position changes we breathe easier and better when
BASIC TREATMENT GUIDELINES sitting up
Chest client is thump on to move around the
BASIC TREATMENT GUIDELINES Physiotherapy mucous
1 PRIMARY TREATMENT
2 SECONDARY TREATMENT
3 TERTIARY TREATMENT TERTIARY TREATMENT

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TERTIARY TREATMENT Ø soft and low pitched breezy sound heard over
1 CLIENT EDUCATION & LIFESTYLE MODIFICATION most of the peripheral lung fields

CLIENT EDUCATION & LIFESTYLE MODIFICATION

ASSESSMENT OF LUNGS
Ø SMOKING CESSATION NCLEX TIP!
ü help client in making changes to quit smoking ASSESSMENT OF LUNGS
ü “you should try nicotine gum” 1 FRONT ANTERIOR (CHEST)
2 POSTERIOR (BACK)

ASSESSING LUNG SOUNDS

AUSCULTATION LOCATIONS

1. Anterior Auscultation
2. Posterior Auscultation

Ø POSITIONING:
ü position client upright in high fowler’s position
Ø STEPS:
1. Point the diaphragm downward & place it in the
ICS
NORMAL BREATH SOUNDS
• called vesicular breath sounds
FRONT ANTERIOR (CHEST)
Vesicular breath sounds: soft & low pitched
breezy sounds
1. RIGHT SIDE, ABOVE THE CLAVICLE
ü listen for a full inhalation & exhalation
2. LEFT SIDE, ABOVE THE CLAVICLE

QUESTIONS

KAPLAN QUESTION COMPARE

ü quality
Q1: Normal breath sounds? ü depth
• Vesicular breath sounds ü extra sounds

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1. LEFT SIDE, ABOVE THE CLAVICLE

EXTRA SOUNDS 2. RIGHT SIDE, ABOVE THE CLAVICLE
3. COMPARE
Ø called Adventitious breath sounds 4. AND SO ON WORKING YOUR WAY DOWN TO THE
Ø rhonchi, wheezes, crackles, pleural friction rub 6TH ICS

3. 2ND INTERCOSTAL SPACE (MIDCLAVICULAR), RIGHT

SIDE
ü middle of the clavicle
4. 2ND INTERCOSTAL SPACE (MIDCLAVICULAR), LEFT
SIDE
ü compare the three things
5. 3RD INTERCOSTAL SPACE (MIDCLAVICULAR), RIGHT
SIDE & LEFT SIDE THEN COMPARE
6. 4TH INTERCOSTAL SPACE, RIGHT SIDE & LEFT SIDE THEN
COMPARE
7. 5TH INTERCOSTAL SPACE, RIGHT SIDE & LEFT SIDE THEN
COMPARE
8. 6TH INTERCOSTAL SPACE (MIDAXILLARY), RIGHT SIDE
& LEFT SIDE THEN COMPARE
ü middle of the armpit
A – Axillary
A – Armpit
ü assess the lower lobes of the lung
• called Basilary – base of the lungs
ü BEST PLACE TO ASSESS FLUID IN THE LUNGS!
• clients with heart failure
• lung sound to assess: crackles
like velcro being pulled apart

CHEST PHYSIOTHERAPY
MEMORY TRICKS

Ø loosens up respiratory secretions & moves them into

Crackles = Crazy fluid
the central airways where coughing or suctioning can
remove it!

TECHNIQUES
ü Percussion
ü Vibration
ü Postural Drainage

POSTERIOR (BACK)

Ø POSITION:
ü have client lean forward with hands on the
lap to separate the shoulder blades
Ø STEPS:

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POSTURAL DRAINAGE ABNORMAL LUNG SOUNDS

Ø EXAMPLE: CYSTIC FIBROSIS

ü serious mucus all over the body
ü clients have a very thick secretions & unable
to clear their airways

CONTRAINDICATION

CONTRAINDICATION
ü Pregnant clients
ü Injury to rib/chest/head like increased ICP in the head
ü Recent abdominal surgery
ü Pulmonary Embolism (PE) – clot in the lungs ABNORMAL LUNG SOUNDS
ü Osteoporosis – clients with brittle bones 1 WHEEZES
2 CRACKLES
3 STRIDOR
4 RHONCHI
5 PLEURAL FRICTION RUB
6 CHEYNE-STOKES

WHEEZES (WHISTLE)

WHEEZES
DESCRIPTION high pitches “musical flute”
LOCATION entire lung
heard mainly on exhalation
PATHO narrow airways from bronchoconstriction
bronchoconstriction: inflamed lung
tissues
DISEASE CAUSE asthma attack & COPD exacerbation
TREATMENT ASTHMA ATTACK: AIM
NURSING ACTIONS A – Albuterol
Ø one and only rescue drug for
NURSING INTERVENTION asthma attack
done 1 hr before or 2 hrs to avoid throwing up a heavy meal I – Ipratropium
after meals Ø anticholinergic that dries secretion
Medications 30 mins to 1 hr prior to Ø you can’t pee with tropium = dries
bronchodilator or nebulizer out the body!
M – Methylprednisolone (Solu Medrol)
MEMORY TRICK: Ø slow acting steroid to treat the
B – Bronchodilator swelling
B – Before anything else
perform the actions as
the client EXHALES!
have the client cough to loosen up & expel all that
after each vibration mucous
client remains in each to allow for percussions, vibration
position for 10 – 15 mins & postural drainage to take effect

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CRACKLES (RALES) Ø found in child with whooping cough

After a Thyroid Surgery
CRACKLES Ø thyroid and parathyroid
DESCRIPTION for crazy fluid Ø NCLEX TIP!
liquidy bubbling or crackling TREATMENT Endotracheal intubation
TYPES FINE CRACKLES: high pitched (rubbing Surgery
hair between fingers)
COARSE CRACKLES: low pitched (velcro
pulled apart)
LOCATION lower lobes (base of lung – Basilary)

PATHO alveoli “popping” open from inflammation

& congestion
DISEASE CAUSE Pulmonary Edema
Ø fluid in lungs
Ø patients with CHF
Pneumonia
RHONCHI
Ø deep infection inside the lungs

RHONCHI
TREATMENT DIURETICS
DESCRIPTION “rumble”
Ø furosemide
low pitched rattling or rumbling (like
Ø heart failure patient with pulmonary
snoring)
edema
LOCATION bronchi (not alveoli)
ANTIBIOTICS
Ø infection (pneumonia)
PATHO mucous secretions or obstruction
DISEASE CAUSE Bronchitis
COPD
Pneumonia (infection)
Cystic Fibrosis (serious mucus)

TREATMENT Chest percussion (vibration with vest)

Fluids to loosen & thin mucus

STRIDOR

STRIDOR
DESCRIPTION “SERIOUS SQUEAK!”
medical emergency, indicates an airway
obstruction!
high pitched harsh inspiratory whistle
PLEURAL FRICTION RUB
LOCATION throat region during inhalation

PLEURAL FRICTION RUB

PATHO blockage of the larynx (voicebox) &
DESCRIPTION “pebbles friction”
trachea (windpipe)
low pitched dry rubbing (like 2 rocks
DISEASE CAUSE Choking obstruction
grinding)
Epiglottitis
LOCATION front side of the lung (during inhalation
Ø inflamed epiglottis
& exhalation)
Croup

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PATHO INFECTION
Ø causing inflammation of pleura Q4: Client with history of CHF presents new edema in lower
layer of the lungs extremities, sudden weight gain of 6 lbs (2.7 kg) in 2 days &
Ø and that is what’s rubbing coarse crackles at base of lungs.. First action?
together causing the grinding • Albuterol treatment
sound • Administer steroids
DISEASE CAUSE Worsening pneumonia (infection) • Anticipate IV furosemide
TREATMENT TCDB: Turn, Cough, Deep Breathe • Clock out for lunch
Ø to cough out all that infection Ø -ide = makes body dried!
Incentive Spirometer Ø KEY WORDS: “new” “sudden” – PRIORITY!
Antibiotics Ø #1 DRUG FOR WORSENING PULMONARY
EDEMA
ü drain fluid with diuretics
ü -ide ending diuretics
1. furosemide
2. bumetanide
3. torsemide
Ø bronchodilators = dilate tight lungs (constriction)

QUESTIONS

QUESTIONS HESI QUESTIONS

TOP MISSED NCLEX QUESTIONS Q1: Sibilant wheezes?

• Unilateral, high pitches, musical and whistle like
Q1: This lung sound is indicative of which condition? sound during inspiration
• Asthmatic wheezing Ø wheezing whistle = asthma (wheezes)
• Bronchitis
• Pleural friction rub
• Stridor Q2: On auscultation.. lung sounds are similar to hair being
Ø rhonchi = low pitch rumbling rolled between fingers.. in patient w/ heart failure..?
• Fine crackles
Ø HF: Heart Failure = HF: Heavy Fluid
Q2: Based on the lung sounds, what priority intervention? Ø crackles – crazy fluid
SATA.
• Administer nebulized albuterol treatment
• Administer ipratropium QUESTIONS
• Prepare for placement of chest tube (for
pneumothorax & hemopneumothorax)
KAPLAN QUESTIONS
• Prepare methylprednisolone
• Request for a chest x-ray
Q1: Cause of crackles?
Ø for asthma attacks1
• underlying inflammation or congestion

Q3: Lung sound for which condition?

Q2: Pleural friction rub?
• Croup
• grating sound or vibration heard during
• COPD
inspiration and expiration
• Pulmonary Edema
Ø
• Pneumothorax
Ø crackles – crazy fluid

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CHEYNE-STOKES

CHEYNE-STOKES
DESCRIPTION “death rattle”
signals death is very near
on average, a person lives only 23 hours
or less after this death rattle begins
abnormal breathing pattern with increase
& decrease in RR
Ø seen as start & stop breathing
PATHO apnea (no breathing)
Ø leading to high CO2
Ø Hyperventilation: blow off high
CO2
DISEASE CAUSE for the critically ill
Ø intracranial pressure
Ø strokes
Ø worsening heart failure
Ø end-stage kidney failure
TREATMENT Intubation
Mechanical ventilation

QUESTIONS

KAPLAN QUESTION

Q1: Cheyne-Stoke respirations?

• Gradual increase in depth of respirations followed
by a gradual decrease in depth, than a period of
apnea

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