N201 Respiratory

• Oxygenation


  The cellular exchange of oxygen and carbon dioxide
• Oxygenation in the surgical patient


  • Why is it important?
• Respiratory Assessment


  • Breathing pattern
  • RR rate
  • Auscultation
  • O2 sat
• Oxygenation-related Diagnostic tests


  • Pulmonary function testing
  • Arterial blood gas analysis
  • CBC- complete blood count
  • Chest X-ray
  • ECG - Electrocardiogram
• Contributors to impaired oxygenation in the surgical patient

  • Pre-existing respiratory disease, e.g., COPD, bronchitis, pneumonia, etc.
  • Comorbidities-obesity, cardiac
  • Smoking
  • Effect of anaesthetic
  • People with Obstructive Sleep Apnea (OSA)
  • Particular surgeries -airway, thoracic, abdominal
  • Post op complications – hypovolemia, blood loss
• Smoking


  • Increased risk for PO pulmonary complications
  • Chronic smoker has increased amount & thickness of mucous secretions in the lungs
  • General anaesthetics increase airway irritation & stimulate pulmonary secretions
  • Reduction in ciliary activity during anaesthesia causes increased retention of secretions
• Effect of anaesthetic


  • General anaesthesia causes loss of sensation and loss of consciousness
  • Control of ventilation and protection of airway are the responsibility of the anesthetist and surgical team
  • Procedural (conscious) sedation with analgesia causes depressed levels of consciousness
  • Opioids – produce dose-related respiratory depression
• OSA – Obstructive Sleep Apnea

  • Increasingly prevalent form of sleep-disordered breathing
  • Characterized by periods of partial or complete obstruction of upper airway
  • Resulting in Oxygen desaturations
  • Can lead to angina, cardiac arrhythmias, systemic and pulmonary hypertension
  • And ultimately may lead to cardiac arrest and death if untreated
• OSA Patients


  • 20-24% of surgical population; 90% undiagnosed
  • Risk factors include: Obesity, Craniofacial & upper airway structure abnormalities, Older age (>50), Neck circumference >43 cm (17 in.), Sex – twice as common in men than women
  • During general anesthesia, definitive airway management is crucial to maintain ventilation and oxygenation of OSA patient
• OSA Patients - Pre-op Screening

  1. Questionnaire tool – determines dx, clinical presentation, anesthetist order for monitoring PO, or ICU admission

  2. Anesthesiologist determines patient's level of risk pre-op, if a patient requires a monitored bed PO

  3. STOP-BANG questionnaire – part of FHA pre-risk assessment for OSA

  4. SafetyNet - Monitoring system FHA; PO monitored beds for 1st 12 hours; monitor pulse oximetry, HR, RR with alarms and recording on main monitor
• OSA patients - Nursing assessment

  • Frequent Respiratory assessment
  • RR, depth & quality of Respiration
  • Pulse oximetry
  • Patient alertness (Sedation scale)
  • Ability to DB & C
  • When assessing oxygenation status, don't rely on O2 sat alone. You need to auscultate, assess sedation level, etc. assess your patient!
• Interventions


  1. Supplemental O2 - how much?, mode of delivery, what do you want O2 sats to be maintained at?, when would you use caution with supplemental O2?

  2. Positioning

  3. Meds?

  4. DB+C

  5. Incentive spirometer
• Oxygen Therapy


  • Used if patient had general anaesthesia or if the anaesthesiologist orders (or both)
  • Aids in elimination of anesthetic agent
  • Meets increased O2 demand from blood loss or increased metabolism
  • Used to treat increased demand for oxygen requirements as patient is rewarmed post op
• Most common post op nursing diagnosis

  • Airway Obstruction
  • Hypoxemia
  • Hypoventilation
• Other potential respiratory risks

  • Pleural effusion – accumulation of fluids in the pleural space
  • COMMON IMMEDIATE POST OP RESPIRATORY COMPLICATIONS
• Potential Alterations in Respiratory function PO

  • Airway obstruction
  • Hypoxemia
  • Hypoventilation
  • Atelectasis
  • Aspiration
• Signs & Symptoms of Hypoxemia

  • Rapid breathing
  • Gasping
  • Apprehension
  • Restlessness
  • Rapid, thready pulse
  • Decreased O2 sat (<90-92%)
• Atelectasis


  • A common cause of Post op hypoxemia
  • May result from bronchial obstruction from retained secretions or decreased respiratory excursion
  • Atelectasis and pneumonia commonly occur after abdominal and thoracic surgery
  • Related to mucous plugs and decreased surfactant, hypoventilation, recumbent position, ineffective coughing, and hx of smoking
• Aspiration


  • of gastric contents
  • Symptoms include: Bronchospasm, Atelectasis, Alveolar hemorrhage, Hypoxemia, Interstitial edema, Respiratory failure
• Nursing Assessment/Management PO surgical unit

  1. Regular monitoring of VS with pulse oximetry

  2. Note characteristics of sputum

  3. Auscultation

  4. DB & C exercises

  5. Presence of hypoxemia may be reflected by rapid breathing, gasping, apprehension, restlessness, and rapid, thready pulse
• Nursing diagnoses


  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Impaired gas exchange
  • Potential complication: hypoxemia
  • Potential complication: pneumonia
  • Potential complication: atelectasis
• Post-Op Management of Respiratory Complications

  1. Close monitoring and assessment of patient – VS, chest assessment, O2

  2. Proper positioning- to facilitate respirations and protect airway

  3. DB&C: teach techniques

  4. Lab diagnostics – to monitor and assess improvement