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Key Points
 Oxygen-poor blood returns to the right side of the heart and flows into the lungs, where it picks up oxygen
before flowing into the left side of the heart. The left side of the heart pumps the oxygenated blood out to the
body to supply oxygen to the tissues.
 Factors that interfere with the heart’s ability to pump effectively:
o Pacemaker disturbances: An irregular heartbeat may arise due to malfunctioning of the internal primary
pacemaker or SA node.
o Cardiac conduction disturbances: An electrolyte disturbance can also interfere with the transmission of
electrical impulses generated by the SA node and lead to an irregular heartbeat.
o Contraction disturbances: The inability of the heart to contract, and pump, effectively may result from
damage to a heart valve, a buildup of fluid and pressure in the sac surrounding the heart (pericardial
effusion), vitamin B deficiency, or damaged blood vessels.
o Impaired myocardial blood flow: Decreased blood flow to the myocardium may also impair the heart’s
ability to pump blood effectively. Interrupted blood flow to the myocardium may occur from thrombus
formation or narrowing of the coronary arteries.
 Coronary artery blood flow can become blocked with a thrombus or by plaque, cutting off blood flow to a
portion of the myocardium, which will result in a myocardial infarction if blood flow is not restored.
 Chronic obstructive pulmonary disease (COPD) is a term used for a group of disorders characterized by impaired
airflow in the lungs.
 Clinical manifestations associated cardiovascular alterations may result from the effects of cardiac muscle
hypoxia or heart pump failure.
 Clinical manifestations associated with respiratory alterations may result from the effects of the inability to
either take in oxygen or exhale carbon dioxide, or both.
 A focused cardiopulmonary assessment is performed for a patient with a known history of cardiac or respiratory
disease or presents with clinical manifestations suggesting an oxygenation or perfusion problem.
 Patient interview questions related to oxygenation and perfusion status include questions that focus on the
patient’s cardiovascular and respiratory systems.
 Disorders of oxygenation and perfusion are often reflected in changing vital signs. The presence of a pulse deficit
may indicate abnormal peripheral perfusion.
 Physical assessments including inspection, palpation, auscultation, cough assessment, and peripheral vascular
assessment help the nurse obtain objective data to identify the presence of health problems related to
oxygenation and perfusion.
 The two main diseases within the COPD group are emphysema and chronic bronchitis. Emphysema is a
progressive COPD characterized by inflamed and damaged alveolar walls in the lungs, while in chronic bronchitis,
the lining of the larger airways is damaged, leading to increased difficulty clearing mucus.
 Asthma, pneumonia, and atelectasis are different types of airway disease that can lead to hypoventilation and
decreased oxygenation.
 The three types of diagnostic tests used in patient assessment are cardiovascular system tests, respiratory
system tests, and multisystem tests.
 Cardiovascular system tests include lipid profile, cardiac enzymes, chest x-ray, electrocardiogram,
echocardiogram, and cardiac catheterization. If vital signs and other physical assessments indicate a cardiac
disease, additional diagnostic tests are ordered by the provider to help identify the disease.
 Respiratory system tests include chest-x-ray and pulmonary function tests. A chest x-ray shows up areas of
increased density in the lungs, the proximity of organs to each other, and other pulmonary anomaly. Pulmonary
function tests measure how well the lungs work.
 Multisystem tests include basic metabolic panel, complete blood count, and arterial blood gases. The nurse uses
the results to anticipate potential interventions and changes to the patient care plan.

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Test What it Measures Normal Reading Alterations seen in COPD

Forced vital Amount of air expelled after 4 liters (varies with age Lower in patients with chronic airway
capacity (FVC) lungs are maximally inflated and size of patient) diseases, such as COPD, that cause poor
airflow
Forced expiratory Volume of air expelled in 1 75% to 85% of FVC Causes lower FEV1 due inability to expel
volume in 1 second second from the beginning of air
(FEV1) the FVC
Forced expiratory flow Maximal flow rate during the Varies by body size Result is usually 25% of predicted value
(FEF) middle of the FVC maneuver due to air trapping in distal airways
Residual volume (RV) Amount of air remaining in 1 liter Patients’ results may be up to four times
the lungs after forced the expected normal value
expiration
Functional residual Volume of air that is left in Approximately 2.3 liters The volume may be increased up to
capacity (FRC) the patient's lung after 200% over the expected amount due to
normal expiration air trapping

Nursing Diagnosis Related to Oxygenation and Perfusion

Selecting and Individualizing Nursing Diagnoses Related to Oxygenation and

Perfusion—Examples
The structure of a nursing diagnosis statement accommodates individualization in the
second (related to) and third (as evidenced by) parts of the statement. The information
included in these two parts is based on data collected during the assessment phase
of the nursing process.
Select each tab to read examples of individualizing common North American Nursing
Diagnosis Association International (NANDA-I) nursing diagnoses related to
oxygenation and perfusion.

Impaired gas exchange related to the destruction of alveolar walls, as evidenced by

SpO2 of 90% and patient complaint of an inability to breathe.
An example of patient assessment data that would support this nursing diagnosis:
 Patient diagnosed with emphysema
 SpO2 90%
 Adventitious breath sounds bilaterally
 Respiratory rate 26 breaths/min and shallow
 Speaks in short sentences
The following are common International Classification for Nursing Practice (ICNP) diagnoses related to decreased
oxygenation:
 Impaired Gas Exchange
o Supporting Data: SpO2 of 90% on 2 L of oxygen via nasal cannula, patient complaints of difficulty
breathing.
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 Impaired Breathing
o Supporting Data: Ineffective movement of air into and out of the lungs, difficulty breathing with activity
and at rest, use of pursed-lip breathing.
 Impaired Cardiac Output
o Supporting Data: Decreased pumping ability of the heart, decreased activity tolerance.

Ineffective airway clearance related to bronchoconstriction, increased production of mucus, as evidenced by thick

sputum, prolonged coughing incidents, adventitious breath sounds, and complaint of dyspnea.
An example of patient assessment data that would support this nursing diagnosis:
 Patient diagnosed with pneumonia
 Decreased bilateral breath sounds in lower lungs
 Cough with thick, green sputum
Ineffective peripheral tissue perfusion related to decreased oxygen levels in the blood, as evidenced by fatigue with
exercise and cyanosis.
An example of patient assessment data that support this nursing diagnosis:
 Patient sitting in wheelchair with oxygen in place
 Report of fatigue with ambulation
 SpO2 with oxygen 92%, without oxygen 82%
The following are common International Classification for Nursing Practice (ICNP) diagnoses related to decreased
oxygenation:
 Impaired Gas Exchange
o Supporting Data: SpO2 of 90% on 2 L of oxygen via nasal cannula, patient complaints of difficulty
breathing.
 Impaired Breathing
o Supporting Data: Ineffective movement of air into and out of the lungs, difficulty breathing with activity
and at rest, use of pursed-lip breathing.
 Impaired Cardiac Output
o Supporting Data: Decreased pumping ability of the heart, decreased activity tolerance.

Activity Intolerance

Activity intolerance related to low oxygen levels and the need for more oxygen with activity, as evidenced by complaints
of fatigue dropping O2 saturation levels with activity, and slow gait.
An example of patient assessment data that would support this nursing diagnosis:
 Patient diagnosed with chronic bronchitis
 SpO2 92% at rest and 84% after walking 20 feet
 Respiratory rate of 36 breaths/min after exercise
 Can’t walk more than 20 feet without sitting down to rest
Ineffective breathing pattern related to ineffective movement of air in and out of the lungs, as evidenced by difficulty in
breathing with activity and at rest and use of pursed-lip breathing.
An example of patient assessment data that would support this nursing diagnosis:
 Patient sitting up straight on side of bed with pursed-lip breathing
 Decreased breath sounds bilaterally to lower lobes
 Speech in short 1–2 word sentences
The following are common International Classification for Nursing Practice (ICNP) diagnoses related to decreased
oxygenation:
 Impaired Gas Exchange

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o Supporting Data: SpO2 of 90% on 2 L of oxygen via nasal cannula, patient complaints of difficulty
breathing.
 Impaired Breathing
o Supporting Data: Ineffective movement of air into and out of the lungs, difficulty breathing with activity
and at rest, use of pursed-lip breathing.
 Impaired Cardiac Output
o Supporting Data: Decreased pumping ability of the heart, decreased activity tolerance.

Anxiety and Acute Pain

Anxiety related to difficulty in breathing, as evidenced by irritability and verbalization of nervousness about health
status.
An example of patient assessment data that would support this nursing diagnosis:
 Patient diagnosed with a cold
 History of COPD
 States “I am anxious and worried that I will have to be hospitalized if the cold gets bad. My lungs don’t bounce
back anymore and if I get sick it gets bad.”
Acute pain related to damage to the heart muscle, as evidenced by pain rating at 7 out of 10, increased respiratory rate
and diaphoresis.
An example of patient assessment data that support this nursing diagnosis:
 Patient diagnosed with an acute myocardial infarction
 Diaphoretic and respiratory rate 36 breaths/min
 Complains of nausea and difficulty in breathing
The following are common International Classification for Nursing Practice (ICNP) diagnoses related to decreased
oxygenation:
 Impaired Gas Exchange
o Supporting Data: SpO2 of 90% on 2 L of oxygen via nasal cannula, patient complaints of difficulty
breathing.
 Impaired Breathing
o Supporting Data: Ineffective movement of air into and out of the lungs, difficulty breathing with activity
and at rest, use of pursed-lip breathing.
 Impaired Cardiac Output
o Supporting Data: Decreased pumping ability of the heart, decreased activity tolerance.

Planning RT oxygenation and perfusion

Writing goals can be a challenge in patients with oxygenation and perfusion problems because diseases of the
respiratory and cardiovascular systems can permanently alter the anatomy and physiology of the organs. As a result,
measurable parameters, such as blood pressure, heart pattern, and arterial blood gas values may become permanently
altered. The nurse must be aware of the patient’s altered baseline values so that realistic measures are used in each goal
statement.
Four criteria should be included when writing patient goal statements. Select the tabs to learn more about writing
patient goals.

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Realistic
The goals should be realistic. The patient must be able to attain the goals.
Avoid goals that are too ambitious for the patient to achieve.
 Avoid a timeframe that is too short
 Be aware of barriers that must be overcome before the goal can be achieved

Patient-Centered
The goals should be specifically written for the patient, i.e., they should reflect patient rather than nurse’s activities.
Goal statements should begin with the patient.
 Example: “ Patient’s temperature will return to between 98.2° and 98.6°  within 48 hr.” The goal begins with
reference to the patient, making it clear that this is a patient-centered goal.

Measurable
The goals should be specific, with numeric parameters or other method of judging goal attainment.
 Example: “Patient will  maintain SpO 2 at 92% or greater with activity within 48 hours.” The numeric parameter
of 92% or greater makes this goal measurable.

Time-Limited
The goals should include a time for evaluation.
 In hospitalized patients, the evaluation may occur daily or within several days, whereas in homecare settings,
evaluation may occur weekly.
 Example: “Patient’s lungs will be clear to auscultation  within 24 hours .” The 24-hour time limit informs the
nurse exactly when to evaluate the patient’s progress toward goal attainment.

Time-Limited
The goals should include a time for evaluation.
 In hospitalized patients, the evaluation may occur daily or within several days, whereas in homecare settings,
evaluation may occur weekly.
 Example: “Patient’s lungs will be clear to auscultation  within 24 hours .” The 24-hour time limit informs the
nurse exactly when to evaluate the patient’s progress toward goal attainment.

Key Points
 Selection and individualization of nursing diagnoses is dependent on accurate and thorough collection of
assessment data and appropriate data clustering.
 Nursing diagnosis statements are designed to accommodate individualization in their “related to” and “as
evidenced by” segments.
 Prioritization of nursing diagnoses in patients with problems of oxygenation and perfusion can often follow ABC
priorities (airway, breathing and/or tissue perfusion), in that order. Resolving nursing diagnoses in the order of
priority may help resolve lower level priority diagnoses.
 A priority nursing diagnosis is one that will cause harm or impede healing if it is not addressed for the specific
patient situation.
 Some common nursing diagnoses related to decreased oxygenation and perfusion are:
o Impaired gas exchange
o Ineffective airway clearance
o Activity intolerance
o Ineffective breathing pattern
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o Ineffective peripheral tissue perfusion

o Anxiety
o Acute pain
 During the planning phase, the assessment data and nursing diagnoses are used to develop individualized goals.
 Goals should be specific and measurable and focused on the expected outcome.
 Goals are used to determine appropriate interventions to meet the expected outcome.
 Collaboration is an essential part of the planning process and data may be collected from multidisciplinary
sources.
 Goals may be short-term (e.g., hours to days) or long-term (e.g., weeks to months).
 Goal statements should be realistic, patient-centered, measurable, and time-limited.

Implementation and Evaluation of Interventions RT Oxygenation and Perfusion

Oxygen Therapy & Delivery System

Clinical Indications
 Laboratory results indicating hypoxemia (low arterial oxygen, low hemoglobin oxygen saturation)
 Hypoxemia signs (Tachycardia -increased heart rate and Tachypnea – increased respiratory rate)
 Dyspnea (shortness of breath)
 Cyanosis (bluish discoloration of the skin)
 A feeling of distress

Goals
 Decreasing symptoms related to hypoxemia
 Decreasing the workload on the cardiovascular system
 Maintaining PaO2 of 60 mm Hg at rest (normal PaO2 is 80-100 mm Hg)
 Maintaining an oxygen saturation level of more than 90% (normal SpO 2 is 96-100%)

Benefits
 Increased daily function
 Improvements in oxygenation and mental status of patient
 Increased tolerance to activity

Cautions
 Oxygen therapy is a type of medication administration – Follow all rights of medication administration.
 High oxygen levels can be toxic and damage lungs.
 Oxygen is flammable; keep away from open flames.
 Ensure oxygen signage is prominently displayed to indicate that oxygen is in use.
 In patients with chronic obstructive pulmonary disease (COPD), low-flow oxygen delivery is used (2 L/min or
less).
 Humidification is recommended for any oxygen delivery system.

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Oxygen Therapy Using Nasal Cannula

The nasal cannula (NC) is a commonly used low-flow thumb, each liter L/min % Inspired O2
system to deliver supplemental oxygen. It consists of a raises the 0 21
lightweight tube connected to an oxygen source, with a percentage of 1 24
flowmeter. Humidification is recommended at all levels oxygen inspired 2 28
of therapy but especially at levels of 4 L/min and higher. by 4%, as shown 3 32
Nasal cannulas are contraindicated for patients of any in the table. 4 36
age with obstructed nasal passages.
5 40
Increasing the oxygen flow rate alters the percentage of
oxygen being breathed by the patient. As a rule of 6 44
Higher than 6 Contraindicated
Correct application of the nasal cannula is essential to assure that the patient receives the optimal effects from the
therapy. Encourage the patient to breathe through the nose and exhale through the mouth at a comfortable and natural
rate.
Monitor the patient for 15 to 30 minutes after starting the oxygen, and repeat assessments as needed, depending on the
patient’s status. Monitor the ears where the nasal cannula tubing rests and apply gauze or tubing covers as needed to
prevent sores and protect the skin. Reassess the patient frequently for relief of hypoxemia signs and symptoms.

Oxygen Therapy Using Masks

Mask delivery systems gather and store oxygen between patient breaths. Masks are often used to deliver higher
percentages of oxygen than can be delivered with a nasal cannula.
Two masks, the partial rebreather and non-rebreather, have a flexible 1-liter reservoir bag with an oxygen inlet.
Sometimes referred to as “reservoir masks”, these masks have a valve system and can deliver higher levels on inspired
oxygen.
Select the tabs to learn about the purpose and description of each type of mask.

Simple Face Mask

 Simple face masks do not have reservoir bags.
 Allows room air to be inspired with the oxygen delivered
 Every increase of 1 L/min of oxygen relates to approximately a 5% increase in oxygen concentration delivered.
Examples include:
o 5 L/min = 40%
o 6 L/min = 45%
o 7 L/min = 50%
o 8 L/min = 55%
o higher than 8 L/min = 60%

Partial Rebreather Mask

 Partial rebreather masks are a type of reservoir mask
 Allow some of the exhaled air to enter the reservoir.
o Rebreathing exhaled air, which contains carbon dioxide, acts as a stimulus for some patients, i.e. COPD.
 Flow rates and percentage oxygenation values are:
o 6 to 15 L/min = 70% to 90% (10 L/min needed to maintain reservoir inflation)

Non-Rebreather Mask
 Non-rebreather masks are a type of reservoir mask.
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 One-way valve does not allow any exhaled air to enter the reservoir bag.
 Additional one way valves allow air to be exhaled through the mask, however no room air can be inhaled
through the valves.
 Flow rates should be higher than 10 L/min to maintain bag inflation.
 Flow rates and percent oxygen values range from:
o 10 L/min to 15 L/min = 60% to 100% (10 L/min needed to maintain reservoir inflation)

Venturi Mask
 Venturi masks ensure accuracy of the oxygen concentration delivered.
o Often used with patients that retain CO 2, such as COPD patients.
 Color-coded adaptors or a dial, with corresponding liters-per-minute setting listed, can be attached to the mask.
o The dial setting specifies the concentration of oxygen that will be delivered to the patient.
 To change the concentration, the nurse changes an adaptor inside the tubing or turns the dial to set to the
desired percent oxygenation.
 Flow rates and percent oxygenation values range from:
o 4 to 12 L/min = 24% to 60%

Correct positioning of all types of oxygen masks is essential to assure delivery of the prescribed concentration of oxygen.
There should be no large gaps or openings between the mask and skin. If the mask includes a reservoir bag, insure that
the bag is filled before placing the mask on the patient.
On placement of an oxygen mask the nurse evaluates the patient’s tolerance to the mask and makes any adjustments to
the fit. A focused respiratory assessment is conducted at 15 to 30 minutes after initiation of therapy and at regular
intervals thereafter, based on the patient’s changing status. The patient’s response to the oxygen is evaluated (e.g., signs
of reversal of hypoxemia, such as improving vital signs and oxygen saturation values). If improvement or further
deterioration in the patient’s condition is noted, the provider is promptly contacted and the plan of care is adjusted as
needed.

Oxygen Therapy Using Bag-Valve-Mask (BVM) Devices

The bag-valve-mask (BVM) device, also known as an Ambu bag, uses a one-way valve to support, ventilate, and
oxygenate a patient who needs ventilatory support. All emergency crash carts are supplied with a BVM unit. Only
personnel who have been properly trained and certified in the use of the devices should administer ventilation using the
BVM units.
When possible, an oral airway is inserted and the BVM is attached to a high-flow oxygen source. When the BVM is
attached to a mask, it is important to adequately seal the mask to the patient’s face. If the patient is not intubated, it is
necessary to maximize the amount of air moved into the lungs with each ventilation. The bag is compressed in a
rhythmic fashion delivering an adequate level of oxygen and appropriate tidal volume for the size of the patient.
While ventilating the patient, inspect for chest rise to determine if adequate ventilation is being delivered and reposition
mask as needed to ensure adequate seal. The patient’s oxygen saturation is monitored as an indication of the
effectiveness of the therapy and adjustments are made to oxygen concentration and tidal volumes, as needed.

Oxygen Therapy Using Positive Air Pressure Application

When a patient is not able to maintain an open airway (e.g., obstructive sleep apnea), forced air (and oxygen, if ordered)
may be administered through a mask over the nose or through nasal pillows at the nares, which keeps the airway open
at all times.
There are two types of positive air pressure devices that can be used to maintain a patent airway:
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1. Continuous positive airway pressure (CPAP), which provides the same pressure during both inhalation and
exhalation
2. Bilevel positive airway pressure (BiPAP), which provides continuous bilevel positive airway pressure using a
higher pressure during inhalation and a lower pressure during exhalation
Patient adherence to using CPAP devices varies between 50% and 80% (Donohue, 2010). Dry nares, skin irritation,
claustrophobia, perceived inability to breathe against air, noise of the apparatus may be barriers to compliance and
need to be addressed. Patients complain about the rush of air pressure and tend to remove the mask during the night or
not wear it at all. To increase compliance, nurses must provide education about the effectiveness of the device in
treating and reducing the negative consequences of obstructive sleep apnea.

Purpose and Types of Artificial Airways

There are nonemergency and emergency situations when patients need assistance with maintaining a patent airway.
When this occurs an artificial airway is prescribed. An artificial airway can be inserted in patients who may or may not be
breathing on their own.
There are two basic types of artificial airways—pharyngeal and tracheal.
 A pharyngeal airway extends only to the back of the oral cavity, opening the upper airway by pulling the tongue
forward and away from the back of the throat.
 A tracheal airway extends beyond the pharynx, through the larynx and into the trachea, providing access to the
lower airway.
Select the tabs to learn more about these types of artificial airways.

Pharyngeal Airways

Useful for patients with:

 Decreased levels of consciousness
 Loss of muscle tone
 Frequent suctioning needs
Two types of tubes:
  Nasopharyngeal Tube
o Inserted through the nose
o Protects nares and provides a guide for catheter insertion in patients requiring frequent suctioning
 Oropharyngeal Tube
o Inserted through the mouth with the airway going over the tongue
o Should be removed from the airway every 4 to 8 hours
o Secure the airway in place with a holder or tape

Tracheal Airways

Useful for patients with:

 Inability to breathe effectively
 Need for positive pressure mechanical ventilation
 Long-term airway patency problems

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  Need for general anesthesia

 Blocked upper airway (tracheostomy tube)
Two types of tubes:
  Endotracheal Tube
o Semi-rigid, curved tube with a cuff at the distal end
o Inflated cuff prevents aspiration of gastric contents into the lungs
o Placed through the mouth
 Sealed with a balloon at the end of the tube
  Tracheostomy Tube
o Plastic polymer or metal tube that fits through a stoma in neck
o Most have an outer cannula with attached flange and a cuff and removable inner cannula
 Based on institutional policies, specific items are kept at the bedside in case of tracheostomy
dislodgement:
 May include: BVM device, oxygen and suction equipment, extra inner and outer
cannulas with obturators, extra tracheostomy care kit

Pharyngeal Airways

Nasopharyngeal tubes are measured from the ear tragus to the nostril, plus 1 inch. Lubricate the airway before
attempting insertion and insert gently. If resistance is encountered, try the other nostril. Remove the airway every 8 to
24 hours (or as required by institution policy), alternating nares. Secure the airway in place with a holder or tape.
Attempting to place an oropharyngeal tube into an awake patient may result in gagging, vomiting, and possible
aspiration. Therefore, it is important to fully assess the patient prior to attempting insertion. Other assessments include
mucous membrane and respiratory status and inspect tube placement routinely (improper placement may result in
inadequate ventilation).
Document the reason for insertion of airway, oral care given, and the patient’s tolerance of the airway.

Tracheal Airways

Tracheal airways require specific skills to manage safely and should not be handled without appropriate skills training.
Assessments related to tracheal airways includes tube patency and placement, need for suctioning, and security of ties.
In addition, the presence of the tip of tracheal airways in the lower airway, increases the patient’s risk of infection. For
this reason, the nurse should regularly assess for infection. Patients with a tracheostomy are assessed for the presence
of subcutaneous emphysema around the stoma.
Documentation needed after insertion of a tracheal airway includes the date, time, assessment, procedure, and patient's
response to the procedure.
Research findings regarding tracheostomy dressings suggest avoiding a dressing altogether, if possible. For excessive
secretions, a special foam dressing is recommended to prevent the most adverse events (Dennis-Rous & Davidson,
2008).

Introduction to Chest Physiotherapy, Suctioning, and Chest Tubes

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There are other interventions besides oxygen therapy and artificial airways that enhance oxygenation and perfusion.
These interventions include chest physiotherapy, suctioning, and chest tubes.
Select the tab to explore purposes for each of these interventions.

Chest Physiotherapy
 Mobilizes secretions to clear the respiratory tract
 Improves ventilation and perfusion
 Normalizes the functional residual capacity of the lungs
 Actions with chest physiotherapy include:
o Postural drainage
o Coughing and deep breathing technique
o Incentive spirometry
 Performed with patients who:
o Are unable or reluctant to change body positions
o Experience poor oxygenation due to position (i.e. unilateral lung diseases)
o Have difficulty removing secretions (i.e. cystic fibrosis or bronchiectasis)

Chest physiotherapy includes several techniques that aim to maintain or improve the patient’s
oxygenation status. Two of the techniques, coughing and deep breathing, and incentive
spirometry (IS) are important for prevention of postoperative and immobility complications.
Select the tabs to learn about these techniques.

Postural drainage
What it is:
 Therapeutic positioning of a patient to use gravity for mobilization of secretions out of the lungs
using positioning, percussion and vibration techniques
How it is done:
 Patient is placed in a series of specific positions that facilitate gravity drainage from a lung area.
 In each position, percussion and vibration are applied to the chest to loosen secretions.
 Patient is encouraged to take deep breaths and cough.
Who performs it:
 In many facilities, physical therapy performs this; however, the nurse may do this if trained.

Coughing/Deep breathing
What it is:
 A breathing technique that combines controlled coughing with deep breathing to maintain lung
expansion, and prevent atelectasis and pneumonia.
How it is done:
 Patient takes a series of deep breaths, holding each breath for 3 to 5 seconds, and then releases
the breath with a series of coughs.
Who performs it:
 The nurse, often as part of preoperative teaching, instructs the patient on the technique and the
patient practices.
 The patient performs the technique with encouragement from the nurse.

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Incentive spirometry (IS)

What it is:
 Patient attempts to reach a set inhalation volume using a special device called an incentive
spirometer.
 It encourages deep breathing, maintains lung expansion, and helps to prevent atelectasis and
pneumonia.
How it is done:
 A desired volume is preset on the IS device.
 While sitting upright, patient slowly inhales through a mouthpiece attached to the spirometer,
holding the breath for 3 to 5 seconds and then exhales slowly.
Who performs it:
 The nurse, often as part of preoperative teaching, instructs the patient.
 The patient performs IS with encouragement from the nurse or UAP.

Suctioning
 Removes mucus from the respiratory tract
 Assists the patient in clearing the airway
 Helps obtain specimens for ordered tests
 Prevents infections

Airway suctioning is the application of negative pressure through a tube device to remove fluids from the
patient’s oral cavity or trachea. Nurses perform suctioning to clear the airway for patients who are unable to
do so themselves or have an artificial airway. Common types of suctioning include tracheostomy,
nasotracheal and nasopharyngeal, and oral and oropharyngeal.
Two major types of airway suction are:
 Yankauer suction catheter – a rigid wand-like device used for oral or oropharyngeal suctioning
 Oral suction catheter – a small flexible tube used for all types of airway suctioning

Here are some important nursing considerations related to suctioning:

 Assess the need for suctioning and monitor patient’s tolerance to suctioning during and after procedure,
with special focus on the cardiac and respiratory status.
 A patient should not be suctioned unless necessary to reduce trauma to the airway.
 Tracheostomy and nasotracheal or nasopharyngeal suctioning of a patient may not be delegated to a
UAP; however oral and oropharyngeal suctioning may be performed by a specially trained UAP, according to
facility policy and procedures.
 Gather all necessary supplies and equipment; have them readily available at the bedside before
beginning procedure.
 Maintain a high level of awareness of the patient’s comfort and status throughout the suctioning
procedure, especially when performing tracheal suctioning.
 Meticulously follow proper suctioning techniques to avoid potential complications.

Clinical research investigating best practice suctioning techniques have proven beneficial to patients. Here is
one example of research that has changed nursing practice.
Current evidence shows that instilling normal saline into the airway to facilitate removal of secretions has no
benefit because the saline does not mix with the secretions. Introduction of liquid into the respiratory tract
can be emotionally disturbing and can produce harmful physiologic effects, such as decreasing oxygenation
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and lower respiratory tract infections. To aid in thinning and mobilization of secretions, airway
humidification and adequate hydration should be initiated (Halm & Krisko-Hagel, 2008).

Chest Tube
 Drains fluid or blood (hemothorax) and excessive air (pneumothorax) from the pleural space
 Promotes optimal respiratory functioning
 Allows the nurse to monitor drainage to ensure optimal lung expansion
 Prevents complications

The chest tube is a flexible catheter that is inserted through the chest wall by the healthcare provider
(HCP) to evacuate air or fluid. The tube is attached to a water-sealed chamber system that helps
regulate the pleural pressure. Most systems are based on older three-bottle systems but are disposable
self-contained plastic units.

The three drainage system chambers are:

1. Drainage collection chamber – accepts air and drainage from the patient
2. Water-seal chamber – contains water to prevent air from backing up into patient’s lung
3. Suction control chamber – Usually contains water and is attached to a suction source to control
amount of negative pressure being applied

Many nurses were taught to “strip” or “milk” the tubing of a chest tube when there was a lack of
drainage or an occlusion. Evidence shows, however, that this practice can result in pleural damage,
increased bleeding, trauma, and impairment of left ventricular function due to increased intrathoracic
pressure (Halm, 2007; Rushing, 2007). The practice of stripping or milking the tubing should therefore be
avoided.

Select the tabs to learn about the nurse’s responsibilities.

Before procedure
The nurse gathers supplies and explains the procedure to the patient.

During procedure
The nurse positions the patient and assures that the:
 tube is secured and patent
 dressing is secure
 drainage system is working properly

Post procedure
 Directly following the procedure the nurse sees to the comfort of the patient and documents the
date, time, assessment, procedure and patient’s response to the procedure.
 Care of the chest tube and chest tube system is the responsibility of the nurse and cannot be
delegated to a UAP.
 The nurse routinely monitors and documents:
 Patient comfort
 Patency of the chest tube
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 Chest tube dressing status

 Functioning of all drainage system chambers
 Volume and characteristics of drainage
 Correct placement of tubing
 Drainage system suction setting

 The nurse promptly reports significant drainage changes or drainage system malfunction to the
provider.

Medications for Pulmonary Diseases

Purpose and Description

Medications are used to treat lung disease by:
 Decreasing symptoms
 Improving the ability to exercise
 Decreasing the number of exacerbations
 Improving the patient’s health status.
The preferred route of pulmonary medications is inhalation. However, the medications can be administered orally and
intravenously for serious conditions. Several classification of medications are used for treating pulmonary diseases.

Medications to Treat Pulmonary Diseases

There are many different types of drugs, like anticholinergics and bronchodilators, that are used to treat pulmonary
disease. In general, these agents decrease symptoms, improve exercise ability, decreases disease flare-ups
(exacerbations), and improve health status.

Bronchodilators Effects: Vaccines Effects:

 Oral: Increase the diameter of  Provide protection against
the bronchi and bronchioles communicable disease
 Inhaled: Increase the diameter Results in:
of the bronchi  Decreased incidence of influenza
Results in:  Decreased incidence of
 Decreased wheezing and pneumonia
improved oxygenation

Anticholinergics Effects: Mucolytics Effects:

 Improve airway clearance  Decrease the thickness of
Results in: secretions
 Decreased wheezing Results in:
 Improved oxygenation  Improved airway clearance

Corticosteroids Effects: Leukotriene Effects:

 Decrease inflammation Modifiers  Decrease inflammation in the
Results in: airways
 Improved respiratory function Results in:
 Improved respiratory function

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Medications to Treat Cardiovascular Diseases

Many medications are available to treat cardiovascular diseases. Classifications commonly used include:
1. Antihypertensives -- Ordered to reduce blood pressure
o Includes a large group of drugs, such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin II
receptor antagonists, beta-blockers, and calcium channel blockers
2. Diuretics -- Often prescribed to treat heart failure or edema
3. Antiarrhythmics -- May be given to patients with arrhythmias or heart failure to slow the heart rate and increase
cardiac output.
4. Anticoagulants -- Used to stop the development of blood clots with atrial fibrillation by preventing clot
development in the atrium and prevent venous thrombo embolism (VTE) in acutely ill patients

Effects: Results in: Assessments:

Antihypertensives
 Lower  Reduced risk of complications of high blood pressure  Blood
arterial o A reduction of blood pressure by 5 mmHg can: Decrease pressure
blood the risk of stroke, heart disease; and reduce the  Adverse
pressure likelihood of dementia, heart failure, and mortality from reactions
cardiovascular disease such as
dizziness
and
hypotensio
n

Diuretics
 Promote the increased flow of  A decrease in blood pressure  Daily weights
urine and reduce excess water  A decrease in edema  Intake and output
in the body  A decrease in weight

Antiarrhythmi  Suppress abnormal rhythms of the  Return to normal heart  Heart

cs heart rate and rhythm rate and
 Treat or rhythm
prevent tachyarrhythmias including ven
tricular tachycardia and fibrillation
Anticoagulant  Prevent clot formation  Decreased incidence  Bleeding
s Results in: of thrombi and emboli   Complia
 Decreased incidence (e.g., pulmonary nce with
of thrombi and emboli (e.g., pulmonary emboli) regimen
emboli)

Anticoagulant Patient Teaching

Discharge teaching for a patient on anticoagulation therapy is crucial. The topics include:
 The importance of compliance with the prescribed regimen
o Including periodic laboratory blood draws
 Dietary advice regarding controlling foods high in vitamin K
o Limiting green leafy vegetables
 Signs of adverse reactions to anticoagulants, such as bleeding
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 Interactions with other medications

Key Points
 Supplemental oxygen is used as a therapy for support oxygenation and perfusion.
 Oxygen therapy is a type of medication administration and all rights of medication apply.
 A nasal cannula is a low-flow system used to deliver a continuous flow of supplemental oxygen.
 Masks deliver higher percentages of oxygen using a reservoir or nonreservoir system; they gather and store
oxygen between patient breaths.
 The bag-valve-mask (BVM) device, also known as an Ambu bag, uses a one-way valve to support, ventilate, and
oxygenate a patient who needs ventilatory support.
 Positive air pressure devices that can be used to maintain a patent airway by forced air may be administered
through a mask over the nose or through nasal pillows at the nares.
o CPAP provides the same pressure during both inhalation and exhalation.
o BiPAP provides continuous bilevel positive airway pressure using a higher pressure during inhalation and
a lower pressure during exhalation.
 An artificial airway can be used in emergency and nonemergency situations to maintain a patent airway.
 Pharyngeal airways keep obstruction from occurring by pulling the tongue forward and away from the back of
the throat. They are needed when a patient has a decreased level of consciousness and loss of muscle tone.
There are two types of pharyngeal airways:
o Nasopharyngeal (through the nose) – often used to facilitate frequent suctioning
o Oropharyngeal (through the mouth) – often used in unconscious patients to protect a patient airway
and for suctioning
 Tracheal airways go beyond the pharynx and into the trachea. Two types of tubes are used:
o Endotracheal tube
o Tracheostomy tube
 The tracheostomy tube fits through a stoma in the neck. Tracheostomies should be cleaned regularly and the
inner cannula changed.
 Tracheal airways require specific skills to deal with safely.
 Chest physiotherapy includes postural drainage, coughing and deep breathing technique, and incentive
spirometry. Its purposes are to facilitate clearance of secretions, maintain lung expansion, and prevent
atelectasis and pneumonia.
 Airway suctioning removes mucus from the respiratory tract, assists the patient in clearing the airway, obtains
specimens for ordered tests, and prevents infections. Types of suctioning include:
 Tracheostomy
 Nasotracheal and nasopharyngeal suctioning
 Oral and oropharyngeal suctioning
 Chest tubes:
 Drain fluid or blood (hemothorax) and excessive air (pneumothorax) from the pleural space
 Promote optimal respiratory functioning
 Allows the nurse to monitor drainage to ensure optimal lung expansion and prevents complications
 The nurse has many chest tube related responsibilities before, during and after chest tube placement.
 Medications are used to treat lung disease by:
o Decreasing symptoms and number of exacerbations
o Improving the ability to exercise and the patient’s health status.
 Inhalation, oral, and intravenous medications are used to treat pulmonary disease.

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 Key principles, key evidence, and evaluation criteria for each major drug used to treat or prevent pulmonary
disease are explored.
 There are many drug classifications used to treat cardiovascular diseases, including antihypertensives, diuretics,
antiarrhythmics, and anticoagulants.
 Antihypertensives lower the arterial blood pressure which reduces the risk of complications of high blood
pressure.
 Diuretics increase the flow of urine and reduce excess water in the body, which decreases blood pressure,
edema and weight.
 Antiarrhythmics suppress abnormal heart rates and rhythms which returns the rhythm back to its normal rate
and rhythm.
 Anticoagulants prevent clot formation which decreases the risk of thrombi and emboli.


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