NR 341
(EDAPT WEEK 2 NOTES)
COMPLEX OXYDNATION ALTERNATIONS
Complex Adult Health
,WEEK 2 NR 341 EDAPT:
COMPLEX OXYDNATION ALTERNATIONS:
Breathing is essential to healthy living. If a person stops breathing, they will die within
minutes. Providing nursing care to adults with complex alterations of their breathing and
oxygenation requires knowledge of the disease pathophysiology, available treatments, an
attitude of calm professionalism, and the skills to use the equipment needed to support
the client’s oxygenation needs.
Which method(s) can the nurse use to communicate with a client who is alert and
intubated?
A communication board, writing notes, and asking yes or no questions are simple
methods used to communicate with clients who are unable to speak due to the use of
respiratory support equipment, including when they are intubated.
Unless the client and nurse are fluent in American sign language (ASL), it will not be an
effective means of communication.
The nurse is assessing a client with a diagnosis of chronic emphysema. The client is
receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns
the nurse immediately?
RR of 8/min
For clients with chronic emphysema, the stimulus to breathe is a low serum oxygen level
(the normal stimulus is a high carbon dioxide level). This client’s oxygen flow is too high and
is causing a high serum oxygen level, which results in a decreased respiratory rate. If the
nurse does not intervene, the client is at risk of respiratory arrest. Crackles, barrel chest,
and assumption of a sitting position leaning over the nightstand are common in clients
with chronic emphysema.
The nurse is assigned to care for four clients. Which client should the nurse assess
first?
The client with asthma did not achieve relief from shortness of breath after using the
bronchodilator and is at risk for respiratory complications. This client’s needs are urgent.
The other clients need to be assessed as soon as possible, but their situations are not
urgent. In clients with chronic obstructive pulmonary disease (COPD), pulse oximetry
oxygen saturation of 90% or above is acceptable in most clients.
When caring for adults with complex alterations in breathing, the nurse uses clinical
judgement and the nursing process in the same way they are used during all client-nurse
interactions. Review this information to see how the nursing process is applied in the care
of clients with complex alterations in breathing.
,NOTE:
All care should start with the client, not the equipment.
Assessment
Continuous cardiac (telemetry), vital signs, and oxygen saturation monitoring are
commonly used, alone or together
Conduct more frequent assessments of
lung sounds
work of breathing (respiratory rate, use of accessory muscles, and ability to
speak)
indicators of oxygenation (orientation/confusion, arterial blood gases [ABGs],
capillary refill, and cyanosis)
equipment used to support ventilation and oxygenation (i.e., if using
continuous positive airway pressure [CPAP], assessing the mask, tubing, and
settings as well as the client's tolerance of treatment)
Diagnosis/Analysis
related to underlying pathology
impaired gas exchange
impaired ventilation
ineffective airway clearance
anxiety
related to treatment/equipment
impaired verbal communication
risk for infection
Planning
Ensure the availability of backup respiratory support in case of equipment or power
failure.
Keep a bag-valve-mask resuscitator at the bedside for clients using
mechanical ventilation.
Oxygen tanks should be available in case the wall oxygen supply fails.
Respiratory support and other vital medical equipment should be plugged into
power outlets connected to a back-up generator (emergency outlets should have
red covers and be marked).
Include the client and family when planning for communication with the client who
is unable to speak (i.e., written notes, communication board, etc.).
Implementation
, Collaborate with respiratory therapy to optimize the care for the client.
Position the client to optimize breathing or reposition to promote lung expansion.
If not on a ventilator, encourage the client to turn, cough, and deep breathe to
promote open airways and expectoration of secretions.
If using an oxygen mask, provide an alternate delivery method during meals (such
as a nasal cannula).
Evaluation
ongoing and frequent (i.e., check arterial blood gases [ABGs] 30 minutes after
changing ventilator settings)
cues remaining subtle as those during an assessment (i.e., changes in mental status
often precede other manifestations of hypoxia)
often measuring progress toward an outcome, rather than if the outcome was met
or not met
Lifespan changes and the respiratory system assessment:
As a person ages, certain body changes are to be expected. In the older adult, some of
these changes can impact the respiratory system and put the client at risk for
complications that are less likely to occur in a younger person.
Physiological changes:
chest wall distensibility (costal cartilage calcifies)
alveolar surface area (enlarged alveoli)
alveolar elasticity
vital capacity and ventilatory reserves
diffusing capacity
physiologic compensatory mechanisms in response to hypercapnia or hypoxia
respiratory muscle strength and endurance
decreased cough and gag
Normal assessment with aging:
kyphosis
barrel chest
decreased chest expansion
lower arterial PaO2 levels
Increased risk with aging:
secretion retention and pneumonia
poor gas exchange
(EDAPT WEEK 2 NOTES)
COMPLEX OXYDNATION ALTERNATIONS
Complex Adult Health
,WEEK 2 NR 341 EDAPT:
COMPLEX OXYDNATION ALTERNATIONS:
Breathing is essential to healthy living. If a person stops breathing, they will die within
minutes. Providing nursing care to adults with complex alterations of their breathing and
oxygenation requires knowledge of the disease pathophysiology, available treatments, an
attitude of calm professionalism, and the skills to use the equipment needed to support
the client’s oxygenation needs.
Which method(s) can the nurse use to communicate with a client who is alert and
intubated?
A communication board, writing notes, and asking yes or no questions are simple
methods used to communicate with clients who are unable to speak due to the use of
respiratory support equipment, including when they are intubated.
Unless the client and nurse are fluent in American sign language (ASL), it will not be an
effective means of communication.
The nurse is assessing a client with a diagnosis of chronic emphysema. The client is
receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns
the nurse immediately?
RR of 8/min
For clients with chronic emphysema, the stimulus to breathe is a low serum oxygen level
(the normal stimulus is a high carbon dioxide level). This client’s oxygen flow is too high and
is causing a high serum oxygen level, which results in a decreased respiratory rate. If the
nurse does not intervene, the client is at risk of respiratory arrest. Crackles, barrel chest,
and assumption of a sitting position leaning over the nightstand are common in clients
with chronic emphysema.
The nurse is assigned to care for four clients. Which client should the nurse assess
first?
The client with asthma did not achieve relief from shortness of breath after using the
bronchodilator and is at risk for respiratory complications. This client’s needs are urgent.
The other clients need to be assessed as soon as possible, but their situations are not
urgent. In clients with chronic obstructive pulmonary disease (COPD), pulse oximetry
oxygen saturation of 90% or above is acceptable in most clients.
When caring for adults with complex alterations in breathing, the nurse uses clinical
judgement and the nursing process in the same way they are used during all client-nurse
interactions. Review this information to see how the nursing process is applied in the care
of clients with complex alterations in breathing.
,NOTE:
All care should start with the client, not the equipment.
Assessment
Continuous cardiac (telemetry), vital signs, and oxygen saturation monitoring are
commonly used, alone or together
Conduct more frequent assessments of
lung sounds
work of breathing (respiratory rate, use of accessory muscles, and ability to
speak)
indicators of oxygenation (orientation/confusion, arterial blood gases [ABGs],
capillary refill, and cyanosis)
equipment used to support ventilation and oxygenation (i.e., if using
continuous positive airway pressure [CPAP], assessing the mask, tubing, and
settings as well as the client's tolerance of treatment)
Diagnosis/Analysis
related to underlying pathology
impaired gas exchange
impaired ventilation
ineffective airway clearance
anxiety
related to treatment/equipment
impaired verbal communication
risk for infection
Planning
Ensure the availability of backup respiratory support in case of equipment or power
failure.
Keep a bag-valve-mask resuscitator at the bedside for clients using
mechanical ventilation.
Oxygen tanks should be available in case the wall oxygen supply fails.
Respiratory support and other vital medical equipment should be plugged into
power outlets connected to a back-up generator (emergency outlets should have
red covers and be marked).
Include the client and family when planning for communication with the client who
is unable to speak (i.e., written notes, communication board, etc.).
Implementation
, Collaborate with respiratory therapy to optimize the care for the client.
Position the client to optimize breathing or reposition to promote lung expansion.
If not on a ventilator, encourage the client to turn, cough, and deep breathe to
promote open airways and expectoration of secretions.
If using an oxygen mask, provide an alternate delivery method during meals (such
as a nasal cannula).
Evaluation
ongoing and frequent (i.e., check arterial blood gases [ABGs] 30 minutes after
changing ventilator settings)
cues remaining subtle as those during an assessment (i.e., changes in mental status
often precede other manifestations of hypoxia)
often measuring progress toward an outcome, rather than if the outcome was met
or not met
Lifespan changes and the respiratory system assessment:
As a person ages, certain body changes are to be expected. In the older adult, some of
these changes can impact the respiratory system and put the client at risk for
complications that are less likely to occur in a younger person.
Physiological changes:
chest wall distensibility (costal cartilage calcifies)
alveolar surface area (enlarged alveoli)
alveolar elasticity
vital capacity and ventilatory reserves
diffusing capacity
physiologic compensatory mechanisms in response to hypercapnia or hypoxia
respiratory muscle strength and endurance
decreased cough and gag
Normal assessment with aging:
kyphosis
barrel chest
decreased chest expansion
lower arterial PaO2 levels
Increased risk with aging:
secretion retention and pneumonia
poor gas exchange
