Hypoxia
The tissue cells must have a constant oxygen supply to remain alive. Because the body does not store oxygen, the person normally obtains oxygen from the air (air is approximately 21% oxygen). In some types of illness, the body is unable to take in sufficient oxygen or cannot use it effectively. When the oxygen level in body tissues is inadequate, the client is said to have hypoxia (Box 86-1).
One of the most obvious signs of hypoxia is shortness of breath (SOB). Earlier signs of hypoxia may be seen with shortness of breath on exertion (SOBOE). When the client expresses this feeling, SOB is called dyspnea. The nurse may also observe SOB in the client through clinical observation. Signs include restlessness, apprehension, an anxious facial expression, panic, fatigue, or impaired coordination. As the need for more oxygen continues, the client’s rate and depth of respiration may increase.
Severe oxygen deficiency may be manifested by the person’s use of accessory breathing muscles of the neck and upper chest. Gasping, wheezing, or retractions of the breastbone or intercostal spaces are also late signs of hypoxia. Other manifestations include:
• Mental changes, confusion, stupor, and unconsciousness
• Cardiac symptoms, such as rapid pulse, dysrhythmias, fibrillation, and cardiac standstill (cardiac arrest) owing to the heart’s inability to provide blood, and thus oxygen, to the tissues, causing the heart to overwork
• Changes in skin color, such as cyanosis of skin, nail beds, and mucous membranes (resulting from either a marked lack of oxygen or severe blood loss) or pallor
Hypoxemic Hypoxia. Hypoxemic hypoxia is a state of decreased blood oxygen level, leading to a decreased amount of oxygen in the tissues. Many situations can result in hypoxemic hypoxia: The client’s airway may be blocked, in which case respiration ceases or is ineffective; the lungs may be congested, in which case respiration is difficult and gradually worsens; an injury to the chest or lungs may cause difficulty in breathing; or chronic or acute infections in the lungs may interfere with breathing.
TABLE 86-1. Possible Alterations in Respiratory Status
|
TERM |
SIGN/SYMPTOM OF |
|
Dyspnea: Labored or difficult breathing, painful breathing |
Inadequate ventilation, lowered oxygen level in blood |
|
Orthopnea: Difficulty breathing while lying down, relieved by sitting upright (orthopneic position) |
Cardiac disorders, pulmonary emphysema, congestive heart failure |
|
Tachypnea: Very rapid breathing |
High fever; pneumonia, alkalosis, salicylate overdose, brain stem lesions |
|
Hyperpnea: Increase in depth of breaths; maybe increase in rate (no feeling of increased respiratory effort) |
Strenuous exercise |
|
Bradypnea: Respiration slower than normal, regular in rhythm |
Normal during sleep; sign of drug overdose, disturbance in respiratory center of brain, metabolic disorder |
|
Hypoventilation: Respirations that have a reduced rate and depth (shallow), often irregular |
Obesity; neuromuscular disorders affecting the thorax (e.g., multiple sclerosis, muscular dystrophy); damage to lung tissue (e.g., emphysema) |
|
Hyperventilation: Increased rate and depth of respirations often leading to decreased carbon dioxide levels (hypocapnia) |
Exercise, asthma, early emphysema, fever, multiple central nervous system disorders, anxiety, pain |
|
Cheyne-Stokes breathing: Abnormal respiratory pattern that may start as slow and shallow that changes to deep and rapid respirations, followed by 10-20 seconds of apnea between cycles. Each cycle may last from 45 seconds to 3 minutes. |
Brain stem lesion, heart failure, brain damage |
|
Biot’s respirations: An abnormal respiratory pattern that may be sequences of 3-4 slow and deep or rapid and shallow breaths followed by periods of apnea, often accompanied by sighing. |
Brain stem lesion, heart failure, brain damage, overdose of hypnotic or narcotic drug Meningitis or increased intracranial pressure |
|
Apnea: Cessation of breathing for brief periods of time. Apneic periods may increase in length as with Cheyne-Stokes. Central apnea: No brain drive to breathe Obstructive apnea: No air flow owing to upper airway obstruction Mixed apnea: Central apnea immediately followed by obstruction Adult sleep apnea: Prolonged and frequent episodes of apnea during sleep |
Sleep apnea, Cheyne-Stokes respiration, sudden infant death syndrome Undeveloped respiratory center in preterm infants, adult brain stem lesion, high spinal cord injury Foreign object in airway excessive secretions, absent cough reflex Obstructive (tongue or throat structures relax), obesity Central (brain damage, brain lesion) |
|
Kussmaul’s respirations: Dyspnea with rapid (>20/min) gasping breaths, air hunger, panting, labored respirations |
Associated with diabetic ketoacidosis (metabolic acidosis), renal failure |
In these instances, oxygen decrease may be sudden or gradual. For example, if a person chokes on a piece of meat, oxygen supply is suddenly cut off, and the person will die if the airway is not restored within a matter of minutes. In many infectious or chronic conditions of the lungs, breathing is impaired but not stopped completely. In these instances, most of which are not emergencies, the nurse can assist the person to breathe or to obtain oxygen.
Circulation Hypoxia. Circulation hypoxia is caused by inadequate blood circulation. If blood cannot get to tissues, the body’s oxygen supply is cut off. The two chief circulatory disorders that account for a decrease in oxygen supply are failure of the heart to pump and blockage or rupture of a blood vessel.
Failure of the heart to pump may be caused by a lack of blood to the heart itself; weakening of the heart muscle; stoppage; or very irregular and rapid beating of the heart (fibrillation). If blood cannot get through a vessel because of a clot or stricture or developing atherosclerosis, the blood supply is reduced or stopped. This happens in a cerebrovascular accident (stroke) and in a thrombosis. In a ruptured aneurysm, the vessel explodes, and the channel for blood is absent.
Anemic Hypoxia. Anemic hypoxia is caused by reduction in the blood’s oxygen-carrying capacity. Hemoglobin, a constituent of red blood cells (RBCs), carries oxygen to the tissues. Anemia can result from decreased blood volume, decreased hemoglobin within the RBCs, or the inability of hemoglobin to take on oxygen. In sickle cell anemia, the malformed (sickle-shaped) RBCs cannot pass through the capillaries. Carbon monoxide poisoning is a form of anemic hypoxia because the carbon monoxide combines with hemoglobin, leaving no room for oxygen.
Histotoxic Hypoxia. Histotoxic hypoxia is caused by an inability of the tissues to use oxygen. Under the influence of certain chemicals, the cells are unable to use oxygen. The most common example is cyanide poisoning. Persons who have suffered smoke inhalation often have inhaled cyanide gas and may have histotoxic hypoxia.
PLANNING AND IMPLEMENTING
Together, the client, family, and healthcare team plan for effective individualized care to meet the client’s needs. For the client undergoing lung or chest surgery, provide preoperative and postoperative teaching and care. The client with a respiratory disorder may be anxious. This person may also require assistance in the management of portable oxygen. He or she may need assistance in meeting some or all basic needs, in dealing with emotional problems, and understanding more about the disorder, its prognosis, and its treatment.
Relieving Respiratory Distress
Orthopneic Position. Many people are unable to breathe unless they are in a sitting or semisitting position (orthopneic position) (see Table 48-1).
Turning, Coughing, and Deep Breathing. Turning, coughing, and deep breathing (TCDB) are vital for anyone who is in bed for a long period. Lung complications can occur when a person is immobile and develop more quickly when a respiratory problem is present (see In Practice: Nursing Care Guidelines 56-3 for specific instructions).
Administering Respiratory Treatments
Postural Drainage. Because postural drainage uses gravity, the person is placed in a head-downward position (see In Practice: Nursing Care Guidelines 86-1). Request training from the respiratory therapist specific to the individual. Rationale: Positions vary according to the specific disorder and the lung area being drained.
Breathing Exercises and Incentive Spirometer. The physician will probably order breathing exercises to help the client build up respiratory capacity. These are usually done with the aid of the incentive spirometer (see In Practice: Nursing Care Guidelines 56-3). Instructions will depend on the particular type of device the client uses. A major reason for postoperative incentive spirometry is to prevent atelectasis (deflated or collapsed alveoli), which can potentially obstruct small or large sections of pulmonary tissues.
Breathing Treatments. Several types of breathing treatments may be used. Intermittent positive pressure breathing (IPPB) treatment is not often used today, unless aerosolized medications are to be given. The most common uses of IPPB are in cystic fibrosis and neuromuscular disorders. Aerosol nebulizer (mini-nebulizer) treatments provide aerosolized medication via a mask or mouthpiece apparatus attached to oxygen or compressed air.
Oxygen. Many people with respiratory and other problems receive supplemental oxygen by cannula or mask, which assists them to breathe more easily and provides a higher concentration of oxygen than that of room air. Understand the precautions used when oxygen is administered.Provide emotional support because it may be a frightening experience for clients and their families.
Administering Nasal Treatments
People with respiratory disorders often use nasal sprays and nose drops (see In Practice: Nursing Care Guidelines 63-6). In addition, if the client has a purulent discharge that forms crusts in the nose, a nasal irrigation may be ordered. The irrigation solution flows into one nostril and out through the other. The important point to observe in giving a nasal irrigation is to use the correct amount of pressure. Too much pressure may force the fluid into the sinuses and the eustachian tubes, thus spreading the infection. This procedure is uncommon.
Suctioning to Remove Oral-Nasal Secretions
Many people with respiratory problems require suctioning to remove excess secretions and mucus from the airway (see In Practice: Nursing Procedure 86-1). Suctioning may also be indicated in the unconscious person or in clients with ineffective cough. Use a new, sterile suction kit each time to avoid introducing pathogens into the lungs. The client who cannot swallow may require only oral suctioning. In this case, use a tonsil-suction device and follow clean technique. The procedure for suctioning a tracheostomy is similar and is presented in Nursing Procedure 87-6.
Nursing Alert Suctioning can cause dysrhythmia (irregular heartbeat) and desaturation (loss of oxygenation). Continuously monitor the person being suctioned for symptoms of respiratory distress, decreased oxygenation, or cardiac dysrhythmias.
EVALUATION
Evaluate outcomes of care with the client, family, and other members of the healthcare team. Have short-term goals been met? Has the client shown evidence of improvement in his or her respiratory status? Are long-term goals still realistic? Planning for further nursing care considers the client’s prognosis, as well as any complications and the client’s response to care given.
INFECTIOUS RESPIRATORY DISORDERS
The Common Cold
The common cold is also known as acute rhinitis. Rhinitis is a term that means inflammation of the nasal mucous membranes. One or more filterable viruses cause colds; as many as 100 cold viruses have been identified. Colds are easily spread by talking, coughing, or sneezing. Individuals are contagious 48 hours before the appearance of the first symptoms. If fatigue, chilling, or substances that continually irritate the nasal membranes (e.g., smog) lower the person’s resistance, susceptibility to the virus is increased.
The usual symptoms include sneezing, nasal discharge or congestion, headache, sore throat, general malaise, cough, and sometimes a slight fever. The senses of smell and taste are blunted. This unpleasant condition usually lasts from 5 days to 2 weeks.
Treatment
The most important treatment for a cold is rest. Rest also keeps the person from infecting others. Rest during a cold is especially important for infants, older adults, and debilitated clients because they are more susceptible to serious complications. Drinking plenty of fluids is essential to help reduce fever, replace lost fluids, and thin secretions. Aspirin, acetaminophen, or ibuprofen helps to relieve discomfort and reduce fever. Some authorities believe that vitamin C is helpful in preventing and treating colds. Clients should use nose drops with discretion.
Remind the client to give strict attention to handwashing and using disposable tissues to prevent spreading the infection to others. The client should blow the nose gently to prevent the infection from spreading into the sinuses, ears, or eustachian tubes. Antibiotics are ineffective against cold viruses. They may, however, be prescribed for people who are immunocompromised, to reduce the risk of developing secondary bacterial infections.
The person should consult a physician if the fever continues for more than 2 days, if mild analgesics fail to relieve severe headache, or if severe coughing, earache, or chest pain occurs. The client should immediately consult a physician if he or she coughs up dark or bloody sputum. Sometimes, a throat culture is done. Culture can indicate strep throat, but a negative culture for streptococci does not necessarily mean that a strep infection is not present. The person with a chronic respiratory condition, such as asthma, should consult a physician at the first sign of a cold.
If the infection enters the lower respiratory tract, complications, such as laryngitis, bronchitis (inflammation of the bronchi), and pneumonia, can result.
Nursing Alert Usually nurses who have colds may continue working if they feel well. However it is essential that they follow all principles of infection control, especially handwashing. Some facilities require such nurses to wear masks and not to be assigned to high-risk clients.
Streptococcal Sore Throat
In strep throat, physical symptoms are more widespread than with ordinary sore throat, with general physical weakness and malaise, high fever, pus on the tonsils, and a headache. Many adults who have recurrent streptococcal throat infections have permanently plugged eustachian tubes; any change in atmospheric pressure is uncomfortable for them. Penicillin is the specific antibiotic prescribed for strep throat unless the person has an allergy or a penicillin-resistant streptococcal infection. The most dangerous complications of strep throat are rheumatic fever and glomerulonephritis .
Influenza
Influenza (commonly called the flu) is an active contagious respiratory disease caused by one of several strains of filterable viruses: types A, B, C, D, and others. Flu strains may also be described using the name of the place of origin, such as the Hong Kong or Asian flu. Influenza occurs in periodic epidemics, usually due to virus types A and B. Most people recover, but some die from complications, such as heart disease, pneumonia, or encephalitis. People may develop parkinsonism many years after having had the flu.
A dangerous complication of influenza is pneumonia. The person is particularly susceptible to any lung disorder after the flu because of general debility. Other complications are chronic disorders, such as bronchitis, sinusitis (inflammation of the sinuses), and ear infections.
Special Considerations :LIFESPAN
Complications in Influenza
Infants, older adults, and immunocompromised people are at a much higher risk for developing complications from influenza.
Signs and Symptoms
The client becomes suddenly very ill, with muscle pains, fever, headache, sensitivity to light, burning eyes, and chills. The person may sneeze, cough, have a nasal discharge, complain of sore throat, feel nauseous, and vomit often. Fever is high (100°F-103°F; 37.8°C-39.4°C) and lasts for 2 to 3 days. Other symptoms, especially the cough, persist longer. A cough may persist for several weeks after the person has had the flu.
Treatment and Nursing Considerations
Give the client large quantities of fluids, including fruit juices and plenty of water. Fluids help the body to flush out wastes created by the virus. (Do not give milk because it tends to form a film in the throat.) Clients may follow a regular diet, although they may be anorexic (without appetite). Often, bed rest, as well as mild analgesics to relieve headache, fever, and muscular pains, may be prescribed. Cough syrup may relieve the dry cough; the narcotic contained in some cough preparations (often, codeine) may also assist the client to sleep. Clients should keep warm and avoid exposure to other diseases. Respiratory isolation may be ordered. Watch for signs of secondary infection, such as chest pains, purulent or rose-colored sputum, a rise in temperature, or an increase in pulse rate.
Prevention
Encourage individuals at high risk for contracting influenza to be vaccinated yearly in the fall for protection. Stress the inoculation for older adults, persons with chronic disease, immunosuppressed persons, and healthcare workers.
During an outbreak, urge people to stay away from crowds. Sometimes, public gatherings are suspended. People should avoid visiting others in healthcare facilities during this time.
Laryngitis
Laryngitis is an inflammation of the larynx (voice box). It may accompany a respiratory infection or result from overuse of the voice or excessive smoking. The person coughs, is hoarse, and may lose the voice. He or she should avoid talking and smoking and should receive high-humidity inhalations to soothe the throat’s mucous membranes. If laryngitis is a complication of another infection, antibiotics may be prescribed. If laryngitis is viral in origin, it is highly contagious; the client should avoid exposing others.
Chronic laryngitis may be a complication of chronic sinusitis or chronic bronchitis or may follow repeated attacks of acute laryngitis. Continued irritation of the throat by public speaking, smoking, or irritating gases may contribute to the problem. People with chronic laryngitis must be carefully examined for signs of cancer, particularly if they smoke cigarettes.
Bronchitis
Bronchitis is an inflammation of the bronchial tubes (bronchi). Acute bronchitis often follows a respiratory infection, especially during the winter months. A dry cough is an early symptom; later, the cough produces mucus and pus. Other symptoms include fever and malaise.
Treatment includes bed rest, a nutritious diet, and plenty of fluids. Humidifiers help by moistening the air, whereas dry air aggravates the cough. Antibiotics are given to treat the infection, and precautions are taken to prevent the infection from spreading. Salicylates are sometimes given.
As in any respiratory disease, instruct the client to cover the mouth when coughing. Dispose of sputum and tissues using Standard Precautions. Acute bronchitis, if untreated, will often develop into chronic bronchitis.
Lung Abscess
A lung abscess is a localized area of infection in the lung that breaks down and forms pus. It can be caused by a foreign body or by aspiration of oral fluids or respiratory secretions and may follow pneumonia. Symptoms include chills and fever, with weight loss and a productive cough with foul, purulent sputum.
Surgery may be required to drain the lung abscess. If the cause of the abscess is an aspirated object, bronchoscopy can usually remove the object. Antibiotics usually are an effective treatment after the cause is eliminated.
Pneumonia
Pneumonia is an inflammation of the lung with consolidation or solidification (Fig. 86-3A). The lung becomes firm as the air sacs are filled with exudates. Pneumonia is classified according to its causative organism. It may be bacterial, viral, fungal, or chemical in origin. It may also be caused by aspiration of fluid or a foreign object into the lungs.
Special Considerations :LIFESPAN
Pneumonia
Pneumonia often occurs as a complication of another condition and is often a cause of death in older adults.
Types
Bacterial Pneumonia. Persons who are in poor general health or who are physically inactive, as well as older people and those with chronic lung disorders, are most susceptible to infectious bacterial pneumonia. Persons who abuse substances, such as alcohol and cocaine, are particularly susceptible.
Viral Pneumonia. A variant of the influenza virus causes viral pneumonia. Antibiotics are ineffective; however, they are often used to treat or prevent the secondary infections sometimes seen in viral pneumonia. The person is treated symptomatically. Viral pneumonia is rarely fatal, but it may leave the client in a weakened condition.
Pneumocystis Carinii Pneumonia. Pneumocystis carinii pneumonia (PCP) is caused by organisms that are not totally understood. Some authorities believe that the causative organism is a protozoan; others blame yeastlike fungi. PCP is most commonly seen as one of the opportunistic diseases in the person with advanced human immunodeficiency virus or acquired immunodeficiency syndrome (HIV/AIDS) infection. PCP is treated with medications such as cotrimox-azole (Bactrim, Septra).
Chemical Pneumonia. Chemical pneumonia is largely associated with aspiration of a chemical substance. Be aware that a person may aspirate into the lungs without any obvious evidence of vomiting. Some people are at an extremely high risk, including the elderly or postoperative clients, clients who abuse substances or are debilitated, and those with swallowing impairments.
Aspiration Pneumonia. If the person vomits or inhales a foreign object or substances, such as water or large amounts of mucus, the material may be drawn into the lungs. This aspiration not only causes the infectious process, but it also can cause additional edema and complications because of the acidity of the gastric contents.
Signs and Symptoms
The onset of pneumonia is characterized by a severe, sharp pain in the chest and chills, followed by fever that may be as high as 105oF or 106oF (40.6oC or 41.1°C). A painful cough, tenacious sputum, and pain on breathing are present. The person’s pulse is rapid. Respiration is rapid, and expiration is difficult. The individual feels very ill and may be cyanotic. The white blood cell count is high. Mental changes, such as delirium or anxiety, may be present.
Blood cultures and sputum cultures are sent for analysis to determine the causative organism. Sensitivity tests are done to determine which antibiotic is most effective. A CXR will show what part of the lung is affected and to what degree.
