FOR FINALS LECTURES FUNDAMENTALS IN NURSING

MODULE 6 Hygiene Perineal Care

Hygiene - is a science of health and its maintenance. Personal hygiene
is the self-care by which people attend to functions as bathing,
toileting, general body hygiene and grooming.
Hygiene is a highly personal matter determined by individual and
cultural values and practices. It involves care of the skin, feet, nails,
oral and nasal cavities, teeth, hair, eyes, ears, and perineal-genital
areas.
(Hygienic Care)
Early Morning - Care is provided to clients as they awaken in the
morning. This care consists of providing a urinal or bedpan to the
client confined to bed, washing the face and hands, and giving oral
care.
Morning Care - provided after clients have breakfast sometimes
before breakfast, providing urinal or bedpan if not ambulatory, a
bath or shower, perineal care, back massage, oral, nail and hair
care. Making client’s bed or changing linen is part of morning care.
Hour of sleep or PM Care - is provided to clients before they retire for the night. It
usually involves providing for elimination needs, washing face and hands, giving oral
care, and giving a back massage.
As needed (PRN) Care - is provided as required by the client. For example, a client who
is diaphoretic (sweating profusely) may need more frequent bathing and a change of
clothes and linen.
(Bed Bath)
Purposes of Bed Bath:
.to remove microorganisms, body secretions and excretions
and dead skin cells.
. to improve circulation of the skin.
. to promote relaxation and comfort
. to prevent or eliminate body odors.
. to promote sense of well-being.
. to assess the client.
. to provide activity and exercise
(Back Rub)
is a massage of the back with two chief objectives:
. to relax relieves muscle tensions
. stimulates blood circulation to the tissues and muscles.
(Types of Back Rub)
. Effleurage
. Petrissage
. Tapotement
Effleurage - is a smooth, long stroke, moving the hands up and down the back. The hands
are moved lightly down the sides of the back, maintaining contact with the skin but are
moved firmly at the back.
Petrissage - is a large pinch of the skin, subcutaneous tissue and muscle quickly done. The
pinch is taken first up the vertebral column and then the entire back, also known as
kneading.
Tapotement - the little finger sides of each hand are used in a sharp hacking movement on
the back. Care must be taken with this type of rub, do not hurt the client, also called
tapping.
(Perineal-Genital Care)
Perineal-genital care is also referred to as perineal care or peri care.
Purposes:
. To remove normal perineal secretions and odors
. To promote client comfort
(ASSESSMENT)
Assess for the presence of:
>Irritation, excoriation, inflammation, swelling
>Excessive discharge
>Odor; pain or discomfort
>Urinary or fecal incontinence
>Recent rectal or perineal surgery
>Indwelling catheter
>Determine Perineal-genital practices
>Self-care abilities
(Perineal-Genital Care)
Equipment:
>Perineal-genital care provided in conjunction with the bed bath
>Bath towel
>Bath blanket
>Clean gloves
>Bath basin with warm water at 43 to 46 degrees Celsius
>Soap
>Washcloth
(Special perineal-genital care)
>Bath towel
>Bath blanket
>Clean gloves
>Solution bottle, pitcher, or container filled with warm water or a prescribed solution
>Bedpan to receive rinse water
>Perineal pad
(Implementation)
Preparation:
>Determine whether the client is experiencing any discomfort in the perineal-genital area
>Obtain and prepare the necessary equipment and supplies.
(Performance)
Prior to performing the procedure, introduce self and verify the client's identity using
agency protocol. Explain to the client what you are going to do, why it is necessary,
and how to participate, being particularly sensitive to any embarrassment displayed
by the client.
1. Perform hand hygiene and observe other appropriate infection prevention
procedures.
2. Provide for client privacy by drawing the curtain around the bed or closing the door
to the room. Some agencies provide signs indicating the need for privacy
3.Rationale: Hygiene is a personal matter
4.Prepare the client
(Performance cont.)
Prepare the client:
1. Fold the top bed linen to the foot of the bed and fold the gown up to expose the
genital area.
2.Place a bath towel under the client's hips.
3. Rationale: The bath towel prevents the bed from becoming soiled.
4.Position and drape the client and clean the upper inner thighs and inguinal areas.
(For FEMALE clients)
1.Position the female in a back-lying (lithotomy) position with the knees flexed and
spread well apart.
2. Cover her body and legs with the bath blanket positioned so a corner is at her head,
the opposite corner at her feet, and the other two on the sides.
3. Drape the legs by tucking the bottom corners of the bath blanket under the inner sides of
the legs. Rationale: Bring the middle portion of the base of the blanket up and then over
the pubic area.
4.Rationale: Minimum exposure lessens embarrassment and help provide
Warmth When ready to begin care, fold the sheet or towel back to expose the penis and perineal
area.
5. Apply gloves and wash and dry the upper innero thighs and inguinal areas.
Inspect the perineal area.
 6. Note particular areas of inflammation, excoriation, or swelling, especially between the
labia in females and the scrotal folds in males.
7. Also note excessive discharge or secretions from the orifices and the presence of
odors.
(Wash and dry the perineal-genital area)
For FEMALE clients:
>Clean the labia majora and perineum from front to back, from pubis to the rectum.
Use a separate clean area for the washcloth for each area or a new washcloth for each
stroke.
Rationale: Using separate quarters of the washcloth or new wipes prevents the
transmission of microorganisms from one area to the other.
>Wipe from the area of least contamination (the pubis) to that of greatest (the rectum). Do
not place the washcloth in the basin
Rationale: This prevents cross-contamination (the movement of
microorganisms from one client to another).
>Separate the labia with one hand to expose the urethra and vaginal opening. Using a
different washcloth, wash the labia minora from the fron to back on one side.
>Take a separate clean area of the washcloth or a new cloth and wash the other side from
top to bottom
Rationale: Secretions that tend to collect around the labia minora facilitate
bacterial growth.
>Using a separate clean area of the washcloth or a new washcloth, wash the urethra
front to back, in a downward motion.
Rationale: This action uses the principle of washing from a clean to dirty area
to prevent a urinary tract infection.
>For menstruating women and clients with indwelling catheters, use clean wipes instead of
washcloths.
>Use a clean wipe for each stroke. Rinse the area well. You may place the client on a
bedpan ad use Peri-Wash or a solution
>bottle to pour warm water over the area. Dry the perineum thoroughly, paying particular
attention to the folds between the labia.
Rationale: Moisture supports the growth of many microorganisms.
(Implementation)
Performance:
For MALE clients:
>If the client is uncircumcised, retract the prepuce (foreskin) to expose the glans penis (the
tip of the penis) for cleaning. Replace the foreskin after cleaning and drying the glanspenis.
Rationale: Retracting the foreskin is necessary to remove the smegma (thick,
cheesy secretion) that collects under the foreskin and facilitates bacterial
growth, Replacing the foreskin prevents constriction of the penis, which may
cause edema.
>Hold the shaft of the penis gently and securely in one hand.
>Clean the tip of the penis at the urethral meatus in a circular motion from the center
>outward and wash down the shaft with soap and water. Use a clean area of the washcloth
or a new washcloth when washing a new area.
Rationale: This prevents cross-contamination
>Rinse and dry with new washcloth
>Wash and dry the scrotum. The posterior folds of the scrotum may need to be cleaned
Wash and dry the scrotum. The posterior folds of the scrotum may need to be cleaned
when the buttocks are cleaned
Rationale: The scrotum tends to be more soiled than the penis because of its proximity to the
rectum; thus, it is usually cleaned after the penis. This follows the principle of cleaning from the
least contamination to that of the greatest.
>Inspect perineal orifices for intactness
>Inspect particularly around the urethra in clients with indwelling catheters
Rationale: A catheter may cause excoriation around the urethra. Clean between the gluteal folds and
the entire buttocks.
>Assist the client to turn onto the side facing away from you.
>Pay particular attention to the anal area and posterior folds of the scrotum in males. Clean
>the anus with a wipe or toilet tissue before washing it, if necessary. Dry the area well
>For post deliveryor menstruating women, apply a perineal pad as needed from front to
back.
Rationale: This prevents contamination of the vagina and urethra from the anal area
 >Remove and discard gloves
>Perform hand hygiene
>Document any unsual findings such as redness, excoriation, skin breakdown, discharge
or drainage, and any localized areas of tenderness.
(Evaluation)
>Compare current assessment to previous assessments.
>Conduct appropriate follow-up such as prescribed ointment for excoriation.
>Report any deviation from normal to the primary care provider
(MODULE 6 Nursing Interventions to Promote Healthy Physiologic Response)
REST AND SLEEP:
Rest- is a condition in which the body is in a decrease state of activity without physical,
emotional stress and freedom from anxiety.
>calmness
>relaxation without emotional stress
>freedom from anxiety
Sleep –state of rest accompanied by altered level of consciousness and relative inactivity
and perception to environment are decreased.
Sleep is a basic human need; it is universal biological process common to all individuals.
We require sleep for many reasons;
>to cope with daily stresses;
>to prevent fatigue;
>to conserve energy;
>to restore the mind and body;
>to enjoy life more fully
(Physiology of Sleep)
Sleep is an altered state of consciousness in which the individual's
perception of and reaction to the environment are decreased. Sleep is
characterized by:
>minimal physical activity
>variable levels of consciousness
>changes in the body's physiologic processes
> decreased responsiveness to external stimuli.
The cyclic nature of sleep is controlled by centers located in the lower part of
the brain. Reticular Activating System (RAS) is a network of ascending nerve fibers in the
reticular formation in the brainsteam which maintains a state of wakefulness and mediates
some stages of sleep.
Circadian Rhythms latin "circa dies" about a day
>is a 24-hour internal biological clock.
>body temperature, blood pressure and other physiologic functions also
follow a circadian pattern and are affected by changes in sleep patterns
>circadian regularity begins to develop by the 6th week of life, and by 3 to 6
months most infants have a regular sleep-wake cycle.
(Types of Sleep)
Sleep Architecture refers to the basic organization of
normal sleep. The two types of sleep are;
>NREM (Non-rapid-eye-movement) Sleep
>REM (Rapid-eye-movement) Sleep
During sleep, NREM and REM sleep alternate in cycles. Changes in the architecture of
one's sleep can be linked to physiologic or psychosocial changes.
(NREM Sleep) occurs when activity in the RAS is inhibited. About 75% of
sleep during a night is NREM sleep. NREM sleep is divided into three
stages;
Stage 1
>stage of very light sleep and lasts only a few minutes.
>During this stage, the individual feels drowsy and relaxed, the eyes roll from side to side,
and the heart and respiratory rates drop slightly. The sleeper can be readily awakened and
may deny that he or she was sleeping.
Stage 2
>stage of sleep during which body processes continue to slow
down.
>The eyes are generally still, the heart and respiratory rates
decrease slightly, and body temperature falls.
>An individual in stage 2 requires more intense stimuli than in
stage 1 to awaken, such as touching or shaking.
Stage 3
>stage of deep sleep, differing only in the percentage of delta waves
recorded during a 30-second period.
>During deep sleep or delta sleep, the sleeper's heart and respiratory
rates drop 20% to 30% below those exhibited during waking hours.
The sleeper is difficult to arouse.
>The individual is not disturbed by sensory stimuli, the skeletal
muscles are very relaxed, reflexes are diminished, and snoring is
most likely to occur.
>This stage is essential for restoring energy and releasing important
growth hormones.
REM sleep usually recurs about every 90 minutes and lasts 5 to 30 minutes. Most dreams
take place during REM sleep but usually will not be remembered unless the individual
arouses briefly at the end of the REM period.
>During REM sleep, the brain is highly active, and brain metabolism may increase as
much as 20%. levels of acetylcholine and dopamine increase (neurotransmitters associated
with
cortical activation).
>REM sleep is also called paradoxical sleep because electroencephalogram (EEG)
activity resembles that of wakefulness.
>Distinctive eye movements occur, voluntary muscle tone is dramatically decreased,
and deep tendon reflexes are absent
>The sleeper may be difficult to arouse or may wake spontaneously, gastric secretions
increase, and heart and respiratory rates often are irregular.
>Regions of the brain used in learning, thinking and organizing information are
stimulated during REM sleep.
(Sleep Cycles)
During a sleep cycle, individuals typically pass through NREM and REM sleep, the
complete cycle usually lasting about 90 to 110 minutes in adults.
In the first sleep cycle, a sleeper usually passes through the first two stages of NREM
sleep in a total of about 20 to 30 minutes. Stage 3 lasts about 50 to 60 minutes.
>After stage 3 NREM, the sleep passes back through stages 2 and 1 over about 20
minutes.
>Thereafter, the first REM stage occurs, lasting about 10 minutes, completing the first
sleep cycle. It is not unusual for the first REM period to be very brief or even skipped
entirely.
>The healthy adult sleeper usually experiences four to 6 cycles of sleep during 7 to 8 hours.
>The sleeper who is awakened during any stage must begin anew at stage 1 NREM sleep
and proceed through all stages to REM sleep.
(Functions of Sleep)
>Sleep, in some way, restores normal levels of activity and normal balance among parts of
the nervous system.
>Sleep is also necessary for protein synthesis, which allows repair processes to occur.
>The role of sleep-in psychologic well-being is best noticed by the deterioration in mental
functioning related to sleep loss.
>Individuals with inadequate amounts of sleep tend to become emotionally irritable, have
poor concentration, and experience difficulty in making decisions.
(Normal Sleep Patterns and Requirements)
Newborns:
>Newborns sleep 12 to 18 hours a day, on an irregular schedule with period of 1 to 3 hours
spent awake.
>Unlike children and adults, newborns enter REM sleep (called active sleep during the
newborn period) immediately.
Rapid eye movements are observable through closed lids, and the body movements and
irregular respirations may be observed.
>NREM sleep (also called quiet sleep during the newborn period) is characterized by regular
respirations, closed eyes, and the absence of body and eye movements.
Infants:
>At first, infants awaken every 3 to 4 hours, eat, and then go back to sleep.
>Periods of wakefulness gradually increase during the first months.
>By 6 months, most infants sleep through the night (from midnight to 5 A.M.) and begin to
establish a pattern of daytime naps.
>At the end of the first year, an infant usually takes two naps per day and should get about
14 to 15 hours of sleep in 24 hours.
>About half of the infant’s sleep is spent in light sleep-in which infants exhibits a great deal
of activity, such as movement, gurgles, and coughing.
Toddler:
>Between 12 to 14 hours of sleep are recommended for children 1 to 3 years old.
>Most still need an afternoon nap, but the need for morning naps gradually decreases.
>The toddler may exhibit a great deal of resistance to going to bed and may awaken during
the night.
>Nighttime fears and nightmares are also common.
>A security object such as a blanket or a stuffed animal may help.
>Maintaining a daily sleep schedule and consistent bedtime
routine will promote good sleep habits for the entire family.
Preschoolers:
>The preschool-age child (3 to 5 years of age) requires 11 to 13 hours of sleep per night,
particularly of the child is in preschool.
>Sleep needs fluctuate in relation to activity and growth sports. Dislikes bedtime and resist
by requesting another story, game, or television program.
>The 4- to 5-year-old may become restless and irritable if sleep requirements are not met
>Often limiting or eliminating TV will reduce the number of nightmares as preschool children
wake up frequently at night, and they may be afraid of the dark or experience nightmares.
School-Age Children:
>needs 10 to 11 hours of sleep per night, but most receive less because of increasing
demands (e.g., homework, sports, social activities)
>They may also be spending more time at the computer and watching TV. SOme may be
drinking caffeinated beverages.
Adolescents:
>Adolescents (12 to 18 years of age) require 8 to 10 hours of sleep each night; however,
few actually get that much sleep
>Circadian rhythm tends to shift. Natural tendency for teenagers is to stay up late at night
and wake up later in the morning.
>During adolescence, boys begin to experience nocturnal emissions
(Orgasm and emission of semen during sleep), known as ‘’wet dreams’’ several times each
month.
Sleep Deprivation and Sleep Problems in Teens The teen:
>Has difficulty waking in the morning for school
>Falls asleep in class or during quiet times of the day.
>Increases the use of caffeinated beverages like coffee, soda, or energy drinks.
>Feels tired, making it difficult to initiate or persist in projects such as a school assignment.
>Is irritable, anxious, and angers easily on days when he or she gets less sleep.
>Is involved in many extracurricular activities, has a job, and stays up alte doing homework
every night, cutting into sleep time.
>Sleeps extra long periods of time on the weekend.
Adults
>healthy adults get 7 to 9 hours of sleep per night
>Sufficient amount of sleep assists in decreasing daytime sleepiness and contribute to
health
>Signs that may indicate that an individual is not getting enough sleep include falling asleep
during a task that is not fatiguing (e.g., listening to a presentation), not being able to
concentrate or remember information, and being unreasonably irritable with others.
>Lack of sleep also contributes to short-term memory loss and inadequate performance on
newly learned tasks.
Older Adults
>A hallmark change with age is a tendency toward earlier bedtime and wake times.
>Older adults (65 to 75 years) usually awaken 1.3 hours earlier and go to bed approximately
1 hour earlier than younger adults (ages 20 to 30).
>Older adults may show an increase in disturbed sleep that can create a negative impact on
their quality of life, mood and alertness.
>Awaken an average of six times during the night.
>Older clients with dementia may experience sundown syndrome, refers to a pattern of
symptoms (e.g., agitation, anxiety, aggression, and sometimes delusions) that occur in the
late afternoon.
FACTORS AFFECTING SLEEP
Both the quality and the quantity of sleep are affected by a number of factors.
Sleep quality is a subjective characteristic and is often determined whether an individual
wakes up feeling energetic or not.
Quantity of sleep is the total time the individual sleeps.
1. Illness
>Illness that causes pain or physical distress (e.g., arthritis, back pain) can result in sleep
problems.
>Individuals who are ill require more sleep than normal, and the normal rhythm of sleep and
wakefulness is often disturbed.
>Respiratory conditions can disturb an individual’s sleep. SHortness of breath often makes
sleep difficult.
2. Environment
>Physical stimuli (e.g., noise)
>Temperature (e.g., too hot or cold)
>Light
>Sleeping equipment; size of bed, no. of pillows
3. Lifestyle
>Irregular morning and nighttime schedule
>Exercise
>Ability to relax before retiring
4. Emotional stress
One of the greatest causes of difficulties in falling asleep.
Clients who are consistently exposed to stress will
increase the activation of the hypothalamic-pituitaryadrenal (HPA) axis leading to sleep
disorders.
Anxiety
5. Stimulants and Alcohol
Caffeine-containing beverages act as stimulants of the central nervous system (CNS).
Alcohol disrupts REM sleep.
6. Diet
>Weight gain has been associated with reduced total sleep as well as broken sleep and
early awakening
>Weight loss is associated with an increase in total sleep time and less broken sleep.
>Dietary L-tryptophan, found in cheese and milk, may induce sleep, a fact that might explain
why warm milk helps some individuals get to sleep.
7. Smoking
>Nicotine has stimulating effect on the body, and smokers have more difficulty falling asleep
than non-smokers.
>Smokers are usually easily aroused and often describe themselves as light sleepers.
8. Medication
>Hypnotics- suppress REM sleep
>Beta blockers- known to cause insomnia and nightmares
>Narcotics (i.e. morphine)- suppress REM sleep and cause frequent awakenings and
drowsiness
>Tranquilizers
>Antidepressants- therapeutic effect
>Nicotine has stimulating effect on the body, and smokers have more difficulty falling asleep
than non-smokers.
>Smokers are usually easily aroused and often describe themselves as
8. Motivation.
Drugs that Disrupt Sleep These drugs may disrupt REM sleep, delay onset of sleep,
or decrease sleep time:
>Alcohol
>Amphetamines
>Antidepressants
>Beta-blockers
>Bronchodilators
>Caffeine
>Decongestants
>Narcotics
>Steroids
COMMON SLEEP DISORDERS
INSOMNIA described as the inability to fall asleep or remain asleep. Acute insomnia lasts
one to several nights and is often caused by personal stressors or worry.
Symptoms of insomnia includes;
>Difficulty falling asleep
>Waking up too early or frequently during the night
>Difficulty returning to sleep
>Waking up too early in the morning
>Unrefreshing sleep
>Daytime sleepiness
>Difficulty concentrating
>Irritability
>Non-restorative sleep
>Fatigue and irritability
>Difficulty at work or school
>Difficulty with personal relationship
(Excessive Daytime Sleepiness)
Clients may experience excessive daytime sleepiness as a result of hypersomnia,
narcolepsy, sleep apnea, and insufficient sleep.
Hypersomnia refers to condition where the affected individual obtains sufficient sleep at
night but still cannot stay awake during the day.
Narcolepsy is a disorder of excessive daytime sleepiness caused by the lack of the
chemical hypocretin in the area of the CNS that regulates sleep. Clients with narcolepsy
have sleep attacks or excessive daytime sleepiness.
Majority of clients also have cataplexy or the sudden onset of weakness or paralysis in
association with strong emotion, sleep paralysis (transient paralysis when falling asleep
or wking up), hypnagogic hallucinations (visual, auditory, or tactile hallucinations at
sleep onset or when waking up), and/or fragmented nightime sleep.
Sleep Apnea Sleep apnea is characterized by frequent short breathing pauses during sleep.
Although all individuals have occasional periods of apnea during sleep, more than five
apneic episodes or five breathing pauses longer than 10 seconds per hour is considered
abnormal and should be evaluated by a sleep medicine specialist.
Symptoms suggestive of sleep apnea include:
>loud snoring
>frequent nocturnal awakenings
>excessive daytime sleepiness
>difficulties falling asleep at night
>morning headaches
>memory and cognitive problems
>irritability
(Types of Sleep Apnea)
Three common types of sleep apnea are;
Obstructive apnea structures of the pharynx or oral cavity block the flow of air (e.g.,
enlarged tonsils and adenoids, deviated nasal septum, nasal polyps, obesity).
Central apnea involves a defect in the respiratory center of the brain. All actions involved in
breathing, such as chest movement and airflow, cease (e.g., brainstem injuries and
muscular dystrophy).
Mixed apnea is a combination of central apnea and obstructive apnea.
Parasomnias is behavior that may interfere with sleep and may even
occur during sleep. it is characterized by physical events such as movements
or experiences that are displayed as emotions, perceptions, or dreams.
Examples of Parasomnias;
Bruxism. usually occurring during stage 2 NREM sleep, this clenching and grinding of the
teeth can eventually erode dental crowns, cause teeth to come loose, and lead to
deterioration of the temporomandibular (TMJ) joint, which is called TMJ
syndrome.
Enuresis. Bed-wetting during sleep can occur in children over 3 years old. More males than
females are affected. It often occurs 1 to 2 hours after sleeping, when arousing from NREM
stage 3.
Periodic limb movement disorder (PLMD). In this condition, the legs jerk twice or three
times per minute during sleep. It is most common among older adults. The kicking motion
can wake the client and result in poor sleep.
Sleeptalking. Talking during sleep occurs during NREM sleep before REM sleep. It rarely
presents a problem to the individual unless it becomes troublesome to others.
Sleepwalking. Sleepwalking (somnambolism) occurs during stage 3 of NREM sleep. It is
episodic and usually occurs 1 to 2 hours after falling asleep. Sleepwalkers tend not to notice
dangers (e.g., stairs) and often need to be protected from injury.
(OXYGENATION)
The respiratory system provides the movement and transfer of gases between the
atmosphere and the blood. Impaired function of the system can significantly affect our ability
to breathe, transport gases, and participate in everyday activities.
Respiration is the process of gas exchange between the individual and the environment and
involves four components:
1.Ventilation or breathing- the movement of air in and out of the lungs as we inhale and
exhale
2.Alveolar- capillary gas exchange, which involves the diffusion of oxygen and carbon
dioxide between the alveoli and the pulmonary capillaries.
3.Transport of oxygen and carbon dioxide between the tissues and the lungs. Movement of
oxygen and carbon dioxide between the systemic capillaries and tissues.
(RESPIRATORY PROCESS)
Pulmonary Ventilation The first process of the respiratory system, ventilation of the lungs,
is accomplished through the act of breathing: inspiration (inhalation) as air flows into the
lungs, and expiration (exhalation) as air moves out of the lungs.
Tidal volume is the amount of air that moves in or out of the lungs with each respiratory
cycle. It measures around 500 mL in an average healthy adult male and approximately 400
mL in a healthy female.
Lung compliance is the expansibility or stretchability of lung tissue and plays a significant
role in the ease of ventilation. Lung compliance tends to decrease with aging, making it
more difficult to expand alveoli and increasing the risk for atelectasis, or collapse of a portion
of the lung.
Lung recoil is the continual tendency of the lungs to collapse away from the chest wall. Just
as lung compliance is necessary for normal inspiration, lung recoil is necessary for normal
expiration. The surface tension of fluid lining in the alveoli has the greatest effect on recoil.
Surfactant, is a lipoprotein produced by specialized alveolar cells, reduces the surface
tension of alveolar fluid. Without surfactant, lung expansion is exceedingly difficult and the
lung collapse. Premature infants whose lungs are not yet capable of producing adequate
surfactant often develop respiratory distress syndrome.
Alveolar Gas Exchange After the alveoli are ventilated, the second phase of the respiratory
process- the diffusion of oxygen from the alveoli and into the pulmonary blood vessels
begins.
Diffusion is the movement of gases or other particles from an area of greater pressure or
concentration to an area of lower pressure or concentration. Pressure differences in the
gases on each side of the respiratory membrane affect diffusion. Carbon dioxide diffuses
from the blood into the alveoli, where it can be eliminated with expired air.
(Transport of Oxygen and Carbon Dioxide)
The third part of the respiratory process involves the transport of respiratory gases. Oxygen
needs to be transported from the lungs to the tissues, and carbon dioxide must be
transported from the tissues back to the lungs.
Normally most of the oxygen (97%) combines loosely with hemoglobin (oxygen-carrying red
pigment) in the red blood cells (RBCs) and is carried to the tissues as oxyhemoglobin (the
compound of oxygen and hemoglobin).
Factors affecting the rate of oxygen transport from the lungs to the tissues:
1.Cardiac output Any pathologic condition that decreases cardiac output (e.g., damage to
the heart muscle, blood loss or pooling of blood in the peripheral blood vessels) diminishes
the amount of oxygen delivered to the tissues.
2.Number of erythrocytes and blood hematocrit
>Hematocrit is the percentage of the blood that is erythrocyte; Normal values, 40%-54% in
males; 37%-50% in females Excessive increases in the blood hematocrit raise the blood
viscosity, reducing the cardiac output, thus, reducing oxygen transport Low blood
hematocrit, such as in anemia, reduce oxygen transport.
3. Exercise In well-trained athletes, oxygen transport can be increased up to 20 times the
normal rate, due in part of increased cardiac output and to increased used of oxygen by the
cells.
Systemic Diffusion The fourth process of respiration if diffusion of oxygen and carbon
dioxide between the capillaries and the tissues and cells down to a concentration
gradient similar to diffusion at the alveolar-capillary level.
(Respiratory Regulation) Respiratory regulation includes both neural and chemical
controls to maintain the correct concentration of oxygen, carbon dioxide and hydrogen ions
in the body fluids. The nervous system of the body adjusts the rate of alveolar ventilations to
meet the needs of the body so thatPO2 and PCO2 remains relatively constant.
The body’s “respiratory center” is actually a number of groups of neurons located in the
medulla oblongata and pons of the brain.
(Factors affecting Respiratory Function) Factors that influence oxygenation affect the
cardiovascular system as well as the respiratory system. These factors include age,
environment, lifestyle, health status, medication and stress.
1. Age Developmental factors have important influences on respiratory function. Changes of
aging that affect the respiratory system of older adults becomes especially important if the
system is compromised by changes such as infection, physical or emotional stress, surgery,
anesthesia, or other procedures.
These types of changes are seen:
>Chest wall and airways become more rigid and less elastic.
>The amount of exchanged air is decreased.
>The cough reflex and cilia actions are decreased.
>Mucous membranes become drier and more fragile.
>Decreases in muscle strength and endurance occur
>If osteoporosis is present, adequate lung expansion may be compromised.
>increases the risk of aspiration. The aspiration of stomach contents into the
>lungs often causes bronchospasm by setting up an inflammatory response.
2. Environment
>Altitude; higher altitude, lower PO2
>Heat and Cold
>Air pollution
3. Lifestyle
>Physical exercise and activity
>Sedentary lifestyle (lack alveolar expansion and deepbreathing patterns)
>Occupation; exposure to substances which cause lung disease
4. Health Status In the healthy individual, the respiratory system can provide sufficient
oxygen to meet the body’s needs. Diseases of the respiratory system, however can
adversely affect the oxygenation of the blood.
5. Medications variety of medications can decrease the rate and depth of respirations.
When administering medications, the nurse must carefully monitor respiratory status,
especially when the medication is begun or when the dose is increased.
Examples:
>Benzodiazepine sedative-hypnotics and antianxiety drugs (e.g., diazepam,
lorazepam, midazolam, barbiturates)
>Opioids (i.e., morphine)
6. Stress When stress and stressors are encountered, both psychologic and physiologic
responses can affect oxygenation. Some individuals may hyperventilate in response to
stress.
Physiologically, the sympathetic nervous system is stimulated and epinephrine is released
during stress. Epinephrine causes the bronchioles to dilate, increasing blood flow and
oxygen delivery to active muscles.
(Alterations in Respiratory Function)
>Respiratory function can be altered by conditions that affect Patency (open airway)
>The movement of air into or out of the lungs
>The diffusion of oxygen and carbon dioxide between
>the alveoli and the pulmonary capillaries
>The transport of oxygen and carbon dioxide via the blood to and from the tissue cells.
(Conditions Affecting the Airway)
>An upper airway obstruction, in the nose, pharynx or larynx, can occur when a foreign
object such as food is present, when the tongue falls back into the oropharynx when an
individual is unconscious, or when secretions collect in the passageways.
>Lower airway obstruction involves partial or complete occlusion of the passage ways in the
bronchi and lungs most often due to increased accumulation or mucus or inflammatory
exudate.
Stridor, a harsh, high-pitched sound, may be heard during inspiration. The client may have
altered arterial blood gas levels, restlessness, dyspnea and adventitious breath sounds
(abnormal breath sounds.
The term breathing patterns refers to the rate, volume, rhythm, and relative ease or effort of
respiration.
Eupnea –normal breathing; is quiet, rhythmic, and effortless.
Tachypnea- rapid respirations; seen with fevers, metabolic acidosis, pain and hypoxemia.
Bradypnea- abnormally slow respiratory rate; seen in clients who have taken drugs
such as morphine or sedatives, who have metabolic alkalosis or who have increased
intracranial pressure
Apnea- absence of breathing
Orthopnea - is the inability to breath easily unless sitting upright or standing.
Dyspnea is difficulty of breathing or the feeling of being short of breath (SOB). Dyspnea has
many causes, most of which stem from cardiac or respiratory disorders.
Hypoventilation, inadequate alveolar ventilation, may be caused by either slow or shallow
breathing or both. Hypoventilation may lead to increased levels of carbon dioxide
(hypercarbia or hypercapnia) or low levels of oxygen (hypoxemia).
Hyperventilation is the increased movement of air into and out of the lungs. During
hyperventilation, the rate and depth of respirations increase and more CO2 is eliminated
than is produced. Hyperventilation can also occur in response to stress or anxiety.
(Conditions Affecting Diffusion)
Hypoxemia, or reduced oxygen levels in the blood, may be caused by conditions that impair
diffusion at the alveolar-capillary level such as pulmonary edema or atelectasis (collapsed
alveoli) or by low hemoglobin levels.
Hypoxia, insufficient oxygen anywhere in the body resulting from severe hypoxemia
Cyanosis, bluish discoloration of the skin, nailbeds and mucous membranes due
to reduced hemoglobin and decreased oxygen saturation, may be present with
hypoxemia or hypoxia Adequate oxygenation is essential for cerebral functioning. The
cerebral cortex can tolerate hypoxia for only 3 to 5 minutes before permanent damage
occurs.
(Conditions Affecting Transport) Conditions that decrease cardiac output, such as heart
failure or hypovolemia, affect tissue oxygenating and also the body’s ability to compensate
for hypoxemia.
(Promoting Oxygenation)
Most individuals in good health give little thought of their respiratory function. Changing
position frequently, ambulating, and exercising usually maintain adequate ventilation and
gas exchange.
Interventions by the nurse to maintain the normal respirations of clients include:
>Positioning the client to allow for maximum chest expansion The semi-Fowler’s or high-
Fowler’s position allows maximum chest expansion in clients who are confined to bed,
particularly those with dyspnea.
>Encouraging or providing frequent changes in position
>Encourage clients to turn from side to side frequently so that alternate sides of the chest
are permitted maximum expansion. Clients with severe pneumonia or other pulmonary
disease in one lung, if positioned laterally, should be generally positioned with “good lung
down” to improve diffusion of oxygen to the blood from functioning alveoli.
>Encouraging deep breathing and coughing
>Encouraging ambulation
>Implementing measures that promote comfort, such as giving pain
Medications.
(Oxygen Therapy) The medical administration of supplemental oxygen is considered to be
a process similar to that of administering medications and requires similar nursing actions.
Oxygen therapy is prescribed by the healthcare provider, who orders the concentration,
method of delivery, and depending on the method, liter flow per min (L/min). When
administering oxygen as an emergency measure, the nurse may initiate the therapy, and
then contact the healthcare provider for an order. The fraction of inspired oxygen (FiO2) is
the concentration of oxygen in the gas mixture.
Nasal Cannula The nasal cannula (nasal prongs) is the most common and inexpensive
device used to administer oxygen. The nasal cannula is easy to apply and does not interfere
with the client’s ability to eat or talk. It delivers a relatively low concentration of oxygen (245
to 45%) at flow rates of 2 to 6 L/min. Above 6 L/min, the client tends to swallows air and the
FiO2 is not increased. Limitations of the plain nasal cannula include inability to deliver higher
concentrations of oxygen, and that it can be drying and irritating to mucous membranes.
Face Mask Some mask have reservoir bags, which provide higher oxygen concentrations to
the client. A portion of the client’s expired air is directed into the bag. Because this air comes
from the upper respiratory passages (e.g., the trachea and bronchi), where it does not take
part in gaseous exchange, its oxygen concentration remains the same as that of inspired air.
The simple face mask delivers oxygen concentrations from 35% to 65% at liter flows of 8 to
12 L/min, respectively. The partial rebreather mask delivers oxygen concentrations from
40% to 60% at liter flows of 6 to 10 L/min, respectively. The oxygen reservoir bag that is
attached allows the client to rebreathe about the first third of the exhaled air in conjunction
with oxygen. Thus, it increases the FiO2 by recycling expired oxygen.
The non-rebreather mask delivers the highest oxygen concentration possible- 60% to 100%-
by means other than intubation or mechanical ventilation, at liter flows of 6 to 15 L/min. One
way valves on the mask and between the reservoir bag and the mask prevent the room air
and the client’s exhaled air from entering the bag so only the oxygen in the bag is inspired.
The venturi mask delivers oxygen concentrations varying from 24% to 40% or 50% at liters
flo of 4 to 10 L/min. The venture mask has wide-bore tubing and color-coded jet adapters
that correspond to a precise oxygen concentration and liter flow.
Face Tent Face tents can replace oxygen masks when masks are poorly tolerated by
clients. Face tents provide varying concentrations of oxygen, for example, 28% to 100%
concentration of oxygen at 8 to 12 L/im. It is convenient for providing humidification and
oxygenation; however, oxygen concentration cannot be controlled. The nurse frequently
inspects the client’s facial skin for dampness or chafing, and dry and treat as needed. As
with face mask, the client’s facial skin must be kept dry. A transtracheal catheter is placed
through a surgically created tract in the lower neck directly into the trachea. Oxygen applied
to the catheter at greater than 1 L/min should be humidified, and high flow rates, as much as
15 to 20 L/min, can be administered.
(Noninvasive Positive Pressure Ventilation NPPV)
Noninvassive positive pressure ventilation uses mechanical assistance to deliver air or
oxygen under pressure without the need for an invasive tube such as an endotracheal or
tracheostomy tube. Conditions requiring noninvasive ventilation include acute and chronic
respiratory failure, pulmonary edema, COPD, and obstructive sleep apnea (OSA). CPAP
Continuous positive airway pressure A mask fitted over the client’s nose during sleep
provides air underpressure during inhalation and exhalation so that the airway is kept open
and cannot collapse. The most common and least invasive treatment for OSA.
(Artificial Airways)
Artificial airways are inserted to maintain a patent air passage for clients whose airways
have become or become obstructed. A patent airway is necessary so that air can flow to and
from the lungs. Four of the more common types of airways are oropharyngeal,
nasopharyngeal, endotracheal, and tracheostomy.
(Oropharyngeal and Nasopharyngeal Airways)
Oropharyngeal and nasopharyngeal airways are used to keep the upper air passages open
when secretions or the tongue may obstruct them. Oropharyngeal airways stimulate the gag
reflex and are only used for clients with altered levels of consciousness with no gag reflex.
Nasopharyngeal airways are tolerated better by alert clients because the nasal airway does
not cause the client to gag. They are inserted through the nares, terminating in the
oropharynx.
Endotracheal Tubes (ETTs) are most commonly inserted in clients who have had general
anesthetics or for those in emergency situations where mechanical ventilation is required.
An ETT is inserted by an anesthesiologist, primary care provider, certified registered nurse
anesthetist (CRNA), or respiratory therapist with specialized education. It is inserted through
the mouth or the nose and into the trachea, using a laryngoscope as a guide. The tube may
have an air-filled cuff to prevent air leakage around it. Because an ETT passes through the
epiglottis and glottis, the client is unable to speak while it is in place.
A tracheostomy is an opening into the trachea through the neck. A tube is usually inserted
through this opening and an artificial airway is created. A curve tracheostomy tube is
inserted to extend through the stoma into the trachea. A fenestrated tracheostomy tube has
an opening that allows air to pass through to the vocal cords, thus, allowing the client to
communicate.
Suctioning is the aspiration of secretions through a catheter connected to a suction
machine or wall suction outlet. Suctioning is done when clients have difficulty handling their
secretions or an artificial airway is in place. It is necessary to clear air passages Even
though the upper airways (the oropharynx and nasopharynx) are not sterile, sterile
technique is recommended for all suctioning to avoid introducing pathogens into the
airways. Good nursing judgment and critical thinking are necessary.
Frequent suctioning;
>irritates mucous membranes;
>can increase secretions if performed too frequently;
>can cause the client’s oxygen saturation to drop further; and
>can increase intracranial pressure if the client has a
head injury.
Suctioning is associated with several complications: hypoxemia, trauma to the airway,
healthcare-associated infection, and cardiac dysrhythmia, which is related to the hypoxemia.
The following techniques are used to minimize or decrease risk of complications:
>Suction only as needed
>Sterile technique
>No saline installation
>Hyperinflation
This involves giving the client breaths that are greater than the tidal volume
set on the ventilator through the ventilator circuit or via a manual
resuscitator bag. Three to five breaths are delivered before and after each
pass of the suction catheter.
Hyperventilation Both hyperinflation and hyperventilation help prevent suction hypoxemia;
however, they should be used with caution because they can cause injury as a result of
overdistention of the lungs.
Hyperoxygenation This can be done with a manual resuscitation bag or through the
ventilator and is performed by increasing the oxygen flow (usually by 100%) before
suctioning and between suction attempts. This is the best technique to avoid suction-related
hypoxemia.