Acute Final

• Oxygen Therapy


  Delivering oxygen to cells to prevent permanent organ injury and death
• How Oxygen is Delivered to Cells

  1. Adequate ventilation

  2. Adequate hemoglobin

  3. Adequate cardiac output

  4. Adequate extraction
• Causes of inadequate oxygen delivery

  • Pneumonia
  • Airway diseases (asthma, COPD)
  • Lung malignancies
  • PE
  • CHF, pulmonary edema
  • Pneumothorax, rib fracture
  • Post anesthesia/excessive sedation
  • Hemorrhage
  • Anemias
  • Inadequate volume (FVD/dehydration, CHF/pulmonary edema)
  • Angina, MI, arrhythmias
  • Congenital heart defects
  • Septic shock
  • Severe edema
  • Cyanide poisoning—smoke inhalation
  • Carbon monoxide poisoning
• Signs and Symptoms of Trying to Increase Oxygen


  • Increased respiratory rate
  • Increase or decrease in depth
  • SOB
  • Noisy breathing
  • Feeling or sense of air hunger or panic
  • Increased heart rate
  • Increased or decreased depth—bounding or weak
  • Hypo or hypertension
• Signs of Ineffective Compensation

  • Confusion
  • Combativeness, restlessness
  • Feelings of impending doom
  • Decreased LOC—especially new onset
  • Shunting blood from periphery to protect organs
  • Weak pulses
  • Hypotension
  • Decreased cap refill—cool, cyanotic, pale, diaphoretic
• SpO2


  Average percentage of O2 that hemoglobin molecules are carrying in arterial blood
• PaO2


  Amount of oxygen dissolved in plasma portion of arterial blood
• PaO2 normal range is 60-100mmHg, <60 is hypoxemia
• SpO2 normal range is 95-100%, <92 is low (unless in COPD)
• SpO2 is more important than PaO2
• Oxygen can only be carried from lungs to cells if attached to hemoglobin
• Higher PaO2 means more oxygen available in plasma to 'push' oxygen onto hemoglobin, increasing SpO2
• Initiating Oxygen Therapy


  1. Requires an order

  2. Confirm SpO2 ASAP if client suddenly deteriorates

  3. Initiate oxygen immediately

  4. Notify MRP

  5. Use caution with chronic lung diseases or neuromyopathies
• Oxygen Therapy


  Used to prolong life of patient with hypoxemia, hypoxia
• Complications of Oxygen Therapy


  • Combustion
  • Oxygen toxicity
  • Absorption atelectasis
  • Infection
• Combustion


  Oxygen supports combustion and increases rate of burning
• Oxygen Toxicity


  Oxygen overdose, causes damage to alveolar-capillary membranes and inactivates surfactant leading to respiratory distress syndrome
• Absorption Atelectasis

  Alveoli in lung collapse, preventing gas exchange, caused by high level of oxygen administration
• Infection


  Heated nebulizers can increase risk of infection, humidity supports bacterial growth
• Nebulizer Therapy


  1. Goals are to provide humidity and medications

  2. Air or oxygen driven

  3. You will see a mist

  4. Used for clearing secretions, medications

  5. Teach diaphragmatic breathing

  6. Breathe slowly and deeply through mouth, hold breath at end of inspiration
• Respiratory Dysfunction


  Disturbance in respiratory function, caused by infection, trauma, pathological conditions, or genetic factors
• Lung Cancer


  Uncontrolled division of epithelial cells that line respiratory tract, malignant tumours that grow and spread uncontrollably
• Types of Lung Cancer

  • Small-cell lung cancer
  • Non-small cell lung cancer (squamous cell, large cell anaplastic carcinoma, adenocarcinoma)
• Risk Factors for Lung Cancer

  • Smoking
  • Environmental exposure (asbestos, radon, etc.)
  • Age
  • Health conditions (COPD, TB)
• Signs and Symptoms of Lung Cancer

  • Airway disruption and pneumonia
  • Hemoptysis, cough, wheezing
  • Loss of appetite, weakness, weight loss
  • Early disease is usually asymptomatic
  • SCLC can cause hormonal effects (SIADH, ACTH, PTH)
• In Ontario, high-risk clients qualify for CT lung cancer screening if they are 55-74 years old and have smoked cigarettes every day for 20 years (doesn't have to be consecutive)
• Lung Cancer Treatments


  • Drug therapy (chemotherapy, adjunct to surgery, extend life in non-resectable)
  • Radiation therapy (localized, treatment or palliative)
  • Surgery (wedge resection, segmentectomy, lobectomy, pneumonectomy)
  • Clinical drug trials
• Thoracotomy


  Surgical incision between ribs on side and back, portion of rib removed for access
• VATS (Video Assisted Thoracic Surgery)

  Lobectomy for stage I and II lung cancers, small incision
• Perioperative Care Phases


  • Pre-operative
  • Intraoperative
  • Post-operative
• Pre-Operative Nursing


  1. Pre-admission (pre-op assessment and teaching, involve family, verify understanding, complete diagnostics, review advance directive, begin discharge planning)

  2. Pre-op Assessments (determine risk and goals, health/family history, subjective questioning, VS and physical exam, labs and investigations)

  3. Therapeutic and Strength-Based Approaches (support systems, pain, culture and beliefs, feelings and expectations)

  4. Admission (preop assessment, risk of complications, report unexpected findings, verify consent, coordinate care, review teaching, explain periop phases and expectations)
• Informed Consent


  Legal mandate, voluntary written informed consent required before all non-emergent procedures, surgeon's role is to explain procedure, risks, benefits, alternatives, complications
• Labs and investigations


  • CBC, lytes, Cr, ECG
  • Glucose, Liver, Lung, clotting, pregnancy
  • Blood products—type, group and screen
• Therapeutic and Strength-Based Approaches

  • Support systems
  • Pain
  • Culture and beliefs
  • Feelings and expectations
• Admission


  1. Preop assessment

  2. Report unexpected findings to MRP

  3. Verify signed consent

  4. Coordinate client care with IP team

  5. Reviews pre-op teaching

  6. Explains peri-op phases and expectations, answer questions
• Informed Consent


  • Legal mandate—client's decision, and have right to refuse
  • Voluntary written informed consent required before all non-emergent procedures
• Surgeon's role in informed consent

  • Explain procedure, risks, benefits, alternatives, complications, what to expect
  • Answer questions
• Nurse's role in informed consent

  • Document witnessing consent
  • Confirm client's understanding
  • Notify MRP if client needs more info
  • Avoid administering sedation before consent discussion
  • Determine if SDM required
• Pre-op Interventions


  • Provide patient education
  • Manage nutrition and fluids
  • Provide psychosocial support
  • Prepare the bowel
  • Prepare the skin
  • Maintain patient safety
• On-call to OR

  1. Be ready within 15 minutes once they call

  2. Appropriate PPE—hat and gown

  3. Wristband, include allergy info

  4. Remove unnatural items

  5. Administer pre-op meds

  6. Calm and quiet environment

  7. Documentation

  8. Complete pre-op checklist

  9. Ensure consent completed and on chart