Contents
Interviewing and counselling ..................................................................................... 296
Conclusion ..................................................................................................................... 297
Suggested activities for students ................................................................................ 297
Section 2: General nursing science
Chapter 17: Oxygen need ................................................................... 301
Introduction ................................................................................................................... 304
Normal factors influencing respiration ...................................................................... 305
The process of breathing ........................................................................................ 305
Respiration ............................................................................................................... 305
Causes of inadequate oxygenation of cells and tissues ........................................... 305
Nursing assessment of respiratory function .............................................................. 306
Patient history ......................................................................................................... 306
Physical examination ............................................................................................. 307
Nursing implications .............................................................................................. 311
Diagnostic tests ....................................................................................................... 312
Common respiratory problems .................................................................................... 314
Cough ....................................................................................................................... 314
Dyspnoea ................................................................................................................. 318
Haemoptysis ............................................................................................................ 320
Cyanosis ................................................................................................................... 320
Acute respiratory failure ........................................................................................ 320
Oxygen therapy ............................................................................................................ 322
Systems for the delivery of oxygen ..................................................................... 323
Humidification systems .......................................................................................... 330
The artificial airway ............................................................................................... 331
Nursing implications .............................................................................................. 335
Conclusion ..................................................................................................................... 335
Suggested activities for learners ................................................................................. 335
Chapter 18: Circulation need .......................................................... 337
Introduction ................................................................................................................... 340
Function of the circulatory system ............................................................................ 340
The heart................................................................................................................... 341
The arteries .............................................................................................................. 341
The arterioles ........................................................................................................... 342
Capillaries ................................................................................................................ 342
,Juta’s Manual of Nursing
Veins.......................................................................................................................... 342
Blood pressure ......................................................................................................... 342
Nursing assessment of circulatory function .............................................................. 343
Taking the pulse ...................................................................................................... 343
Taking the blood pressure ...................................................................................... 344
Temperature ............................................................................................................. 344
Urine output and fluid balance ............................................................................. 344
Electrocardiogram (ECG) ........................................................................................ 344
Pulse oximetry ........................................................................................................ 344
Common circulatory or cardiovascular problems .................................................... 345
Blood pressure ......................................................................................................... 345
Hypertension ........................................................................................................... 345
Hypotension ............................................................................................................ 347
Abnormal cardiac rhythm ..................................................................................... 349
Conclusion ..................................................................................................................... 349
Suggested activities for students ................................................................................ 349
Chapter 19: Temperature regulation need ......................... 351
Introduction ................................................................................................................... 353
Temperature and the mechanisms of heat production and heat loss .................... 353
Heat production ...................................................................................................... 353
Heat loss ................................................................................................................... 354
Heat loss from other sources ................................................................................. 355
Regulation of body temperature ................................................................................. 355
Normal variations in body temperature .................................................................... 356
Measurement of body temperature ............................................................................ 356
Contraindications for using the various sites to measure body temperature .... 357
Management of common clinical problems related to temperature regulation ... 358
Pyrexia...................................................................................................................... 358
Rigors ....................................................................................................................... 359
Malignant hyperpyrexia/hyperthermia ................................................................ 360
Heat stroke ............................................................................................................... 361
Hypothermia ............................................................................................................ 362
Conclusion ..................................................................................................................... 363
Suggested activities for students ................................................................................ 364
,chapter
Oxygen
17 need
Learning objectives
On completion of this chapter, the student should be able to do the following:
• Describe the factors influencing respiration.
• Differentiate between breathing and respiration.
• Identify the common causes of inadequate oxygenation of cells and tissues.
• Describe the assessment of a patient with unmet oxygenation needs.
• List common problems related to unmet oxygenation needs.
• Describe the signs and symptoms of common problems related to unmet oxygen
needs.
• Formulate nursing diagnoses related to unmet oxygenation needs.
• Care for patient with common disorders related to unmet oxygenation needs.
• Identify indications for oxygen therapy.
• List various methods of administration of oxygen.
• Describe the management of a patient on oxygen therapy.
Key concepts and terminology
Anaerobic respiration: A process in which cellular respiration occurs in the absence of
oxygen.
Breathing: A process of taking in oxygen from the external environment during
inhalation and releasing carbon dioxide during exhalation.
Cellular respiration: A process utilised by cells to obtain energy from the oxidation of
organic compounds accompanied by the consumption of oxygen and the release of
carbon dioxide.
Cough: Sudden, forcible, noisy expulsion of air from the lungs in an effort to clear the
airways from mucus or other extraneous matter.
Cyanosis: Bluish discolouration of the skin and the mucous membranes due to lack of
oxygen in the blood.
Dyspnoea: Difficulty in breathing.
Haemoptysis: Coughing up of blood.
Hypoxaemia: Low oxygen concentration in the blood.
Hypoxia: Low oxygen uptake in the brain. ➙
301
, Orthopnoea: A sensation of breathlessness in the recumbent position, relieved by sitting
or standing.
pH: A measure of the hydrogen ion concentration in body fluids, indicating the acidity
or alkalinity of body fluids.
Respiration: A metabolic process in which respiratory gases are exchanged in the
alveoli, where carbon dioxide is excreted and exhaled, and oxygen is absorbed by the
red blood cells.
Tachypnoea: Rapid breathing.
Prerequisite knowledge
The nurse should have knowledge of the following:
• Anatomy and physiology of the cardiovascular system and the respiratory system
• Applied biophysics and chemistry.
Medico-legal considerations
• By definition, oxygen is a drug, and as such it should be prescribed by a doctor and
administered in accordance with medical instructions and precautionary measures.
It frequently occurs, however, that a nurse is required to commence oxygen therapy
for a distressed patient pending the arrival of a medical practitioner, according
to the knowledge and skills of the nurse. When the doctor arrives, the nurse’s
initial prescription may be modified. (Many institutions have regulations that limit
the percentage of oxygen that may be prescribed by a nurse. Note that this is an
institutional requirement and is not based on the scope of practice for nurses.)
• The scope of practice for professional nurses directs them to ensure the maintenance
of a supply of oxygen to patients. This means that, depending on the knowledge and
expertise of the nurse, a spectrum of techniques may be used to achieve this aim,
provided that the nurse is competent in those skills, such as:
–– opening the airway by positioning the head correctly
–– clearing the oropharynx of secretions
–– inserting an airway
–– endotracheal intubation
–– endotracheal suctioning
–– administering oxygen using a facemask, ambu-bag, mouth-to-mouth resuscitation
and mechanical ventilation.
Key ethical considerations
The nursing of patients with respiratory problems frequently presents ethical problems, for
example:
• The right of a patient in respect of oxygen relates to the patient’s right to life. ➙
302
Interviewing and counselling ..................................................................................... 296
Conclusion ..................................................................................................................... 297
Suggested activities for students ................................................................................ 297
Section 2: General nursing science
Chapter 17: Oxygen need ................................................................... 301
Introduction ................................................................................................................... 304
Normal factors influencing respiration ...................................................................... 305
The process of breathing ........................................................................................ 305
Respiration ............................................................................................................... 305
Causes of inadequate oxygenation of cells and tissues ........................................... 305
Nursing assessment of respiratory function .............................................................. 306
Patient history ......................................................................................................... 306
Physical examination ............................................................................................. 307
Nursing implications .............................................................................................. 311
Diagnostic tests ....................................................................................................... 312
Common respiratory problems .................................................................................... 314
Cough ....................................................................................................................... 314
Dyspnoea ................................................................................................................. 318
Haemoptysis ............................................................................................................ 320
Cyanosis ................................................................................................................... 320
Acute respiratory failure ........................................................................................ 320
Oxygen therapy ............................................................................................................ 322
Systems for the delivery of oxygen ..................................................................... 323
Humidification systems .......................................................................................... 330
The artificial airway ............................................................................................... 331
Nursing implications .............................................................................................. 335
Conclusion ..................................................................................................................... 335
Suggested activities for learners ................................................................................. 335
Chapter 18: Circulation need .......................................................... 337
Introduction ................................................................................................................... 340
Function of the circulatory system ............................................................................ 340
The heart................................................................................................................... 341
The arteries .............................................................................................................. 341
The arterioles ........................................................................................................... 342
Capillaries ................................................................................................................ 342
,Juta’s Manual of Nursing
Veins.......................................................................................................................... 342
Blood pressure ......................................................................................................... 342
Nursing assessment of circulatory function .............................................................. 343
Taking the pulse ...................................................................................................... 343
Taking the blood pressure ...................................................................................... 344
Temperature ............................................................................................................. 344
Urine output and fluid balance ............................................................................. 344
Electrocardiogram (ECG) ........................................................................................ 344
Pulse oximetry ........................................................................................................ 344
Common circulatory or cardiovascular problems .................................................... 345
Blood pressure ......................................................................................................... 345
Hypertension ........................................................................................................... 345
Hypotension ............................................................................................................ 347
Abnormal cardiac rhythm ..................................................................................... 349
Conclusion ..................................................................................................................... 349
Suggested activities for students ................................................................................ 349
Chapter 19: Temperature regulation need ......................... 351
Introduction ................................................................................................................... 353
Temperature and the mechanisms of heat production and heat loss .................... 353
Heat production ...................................................................................................... 353
Heat loss ................................................................................................................... 354
Heat loss from other sources ................................................................................. 355
Regulation of body temperature ................................................................................. 355
Normal variations in body temperature .................................................................... 356
Measurement of body temperature ............................................................................ 356
Contraindications for using the various sites to measure body temperature .... 357
Management of common clinical problems related to temperature regulation ... 358
Pyrexia...................................................................................................................... 358
Rigors ....................................................................................................................... 359
Malignant hyperpyrexia/hyperthermia ................................................................ 360
Heat stroke ............................................................................................................... 361
Hypothermia ............................................................................................................ 362
Conclusion ..................................................................................................................... 363
Suggested activities for students ................................................................................ 364
,chapter
Oxygen
17 need
Learning objectives
On completion of this chapter, the student should be able to do the following:
• Describe the factors influencing respiration.
• Differentiate between breathing and respiration.
• Identify the common causes of inadequate oxygenation of cells and tissues.
• Describe the assessment of a patient with unmet oxygenation needs.
• List common problems related to unmet oxygenation needs.
• Describe the signs and symptoms of common problems related to unmet oxygen
needs.
• Formulate nursing diagnoses related to unmet oxygenation needs.
• Care for patient with common disorders related to unmet oxygenation needs.
• Identify indications for oxygen therapy.
• List various methods of administration of oxygen.
• Describe the management of a patient on oxygen therapy.
Key concepts and terminology
Anaerobic respiration: A process in which cellular respiration occurs in the absence of
oxygen.
Breathing: A process of taking in oxygen from the external environment during
inhalation and releasing carbon dioxide during exhalation.
Cellular respiration: A process utilised by cells to obtain energy from the oxidation of
organic compounds accompanied by the consumption of oxygen and the release of
carbon dioxide.
Cough: Sudden, forcible, noisy expulsion of air from the lungs in an effort to clear the
airways from mucus or other extraneous matter.
Cyanosis: Bluish discolouration of the skin and the mucous membranes due to lack of
oxygen in the blood.
Dyspnoea: Difficulty in breathing.
Haemoptysis: Coughing up of blood.
Hypoxaemia: Low oxygen concentration in the blood.
Hypoxia: Low oxygen uptake in the brain. ➙
301
, Orthopnoea: A sensation of breathlessness in the recumbent position, relieved by sitting
or standing.
pH: A measure of the hydrogen ion concentration in body fluids, indicating the acidity
or alkalinity of body fluids.
Respiration: A metabolic process in which respiratory gases are exchanged in the
alveoli, where carbon dioxide is excreted and exhaled, and oxygen is absorbed by the
red blood cells.
Tachypnoea: Rapid breathing.
Prerequisite knowledge
The nurse should have knowledge of the following:
• Anatomy and physiology of the cardiovascular system and the respiratory system
• Applied biophysics and chemistry.
Medico-legal considerations
• By definition, oxygen is a drug, and as such it should be prescribed by a doctor and
administered in accordance with medical instructions and precautionary measures.
It frequently occurs, however, that a nurse is required to commence oxygen therapy
for a distressed patient pending the arrival of a medical practitioner, according
to the knowledge and skills of the nurse. When the doctor arrives, the nurse’s
initial prescription may be modified. (Many institutions have regulations that limit
the percentage of oxygen that may be prescribed by a nurse. Note that this is an
institutional requirement and is not based on the scope of practice for nurses.)
• The scope of practice for professional nurses directs them to ensure the maintenance
of a supply of oxygen to patients. This means that, depending on the knowledge and
expertise of the nurse, a spectrum of techniques may be used to achieve this aim,
provided that the nurse is competent in those skills, such as:
–– opening the airway by positioning the head correctly
–– clearing the oropharynx of secretions
–– inserting an airway
–– endotracheal intubation
–– endotracheal suctioning
–– administering oxygen using a facemask, ambu-bag, mouth-to-mouth resuscitation
and mechanical ventilation.
Key ethical considerations
The nursing of patients with respiratory problems frequently presents ethical problems, for
example:
• The right of a patient in respect of oxygen relates to the patient’s right to life. ➙
302
