Ch 28 assisting with respiration and oxygen delivery PDF

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Fundamental Concepts and skills for nursing textbook...

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Chapter 28: Assisting with Respiration and Oxygen Therapy • •

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Which structures are involved in respiration? o Nose, mouth, pharynx, larynx and trachea Functions o Carry air to and from lungs o Warmed and humidified o Cilia to clean out o Cns controls respiration o Chemoreceptors located in aorta and carotid arteries sense changes in oxygen or carbon dioxide and send signals to brainstem Aging o After 70: dec elasticity of thorax and resp disease o Total body water dec 50% after age 70 leading to dry respiratory membranes and thicker mucus o Cilia experience degree of impairment o Loss of elastic recoil during expiration and resp muscles must be used to complete expiration o Tissue changes cause thickening of alveolar membrane o Less resp reserve Hypoxemia o Anoxia: condition of being without oxygen occurs, cell metabolism slows down and some cells begin to die o Most common type of respiratory insufficiency is airway obstruction o Decreased amount of oxygen in the bloodstream is called hypoxemia and leads to less oxygen available to meet cellular needs o Inc level of carbon dioxide in blood is called hypercapnia o Dyspnea: difficulty breathing o Symptoms ▪ Judgement, intellectual ability ▪ Heart and retina of the eye and also highly vulnerable to hypoxia ▪ Other organs affected like kidneys, which retain more sodium when hypoxic ▪ Tachypnea (fast breathing rate) or stridor (high pitched, harsh or musical sounds on inspiration) ▪ Arrhythmias (irregular heartbeat) develops as amount of oxygen supplied to the heart muscle is reduced ▪ Cyanosis and retractions (muscles moving inward on inspiration) ▪ Susceptible to respiratory tract infections Pulse oximetry o Measure's oxygen saturation by determining the percentage of hemoglobin that is bound with oxygen Airway obstruction and respiratory arrest o Unconscious person: most common cause of airway obstruction is the tongue o Cpr

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Clearing respiratory secretions o Simple method of clearing the air passages is to cough effectively o Deep breathing and coughing are two standard measures used to clear secretions and prevent hypoxia o Deep breathing inc oxygenation, opens alveoli, and may precipitate coughing o Many patients with lung disease cannot expel forcibly a volume of air need to be taught to cough effectively o Forceful exhalation: patient takes two deep breaths, inhales deeply again, then rapidly and forcefully exhale with the mouth open Administering abdominal thrusts o Fist upward rotating motion o Unconscious: open airway, see object in throat, attempt to ventilate in breaths o Conscious infant: place infant face down straddling arm and keeping head lower than trunk, place your hand under chest and around the jaw for support ▪ 5 blows between shoulder blades ▪ Sandwich that infant between arms and turn her over, hold back of head for support with head down, deliver five chest thrusts using two fingers over the lower half of the sternum o Unconscious infant ▪ Cpr with 30 compressions ▪ Head tilt chin to open airway and see object ▪ Ventilate with mouth o Special considerations ▪ Pregnant: chest thrusts rather than abdominal thrust ▪ Obese victim: chest thrusts Cardiopulmonary resuscitation o Cpr started whenever someone found in respiratory or cardiac arrest meaning without breathing or without heartbeat o Activate ems o Place victim supine o Depress 2 inch for 30 compressions at rate of 100-120 min o Place aed on Postural drainage o Different positions are used to drain different segments of lungs so that secretions can be cleared o Specific segments of lung drained into bronchi, patient is able to cough more effectively and cough up o Assume each position for 5-10 minutes two to four times a day o Nebulizer: dispenses liquid in a fine spray with bronchodilator or liquefying medications may be used as inhalation therapy to hin out secretions and relax spasms within bronchial tree o May be loosened by percussion of chest: percussion is clapping with cupped hands over thoracic area not over spine or sternum (cough up secretions) Oxygen administration

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o Cannula Administering oxygen o Connect flow meter o Attach humidifier and connect tubing to oxygen delivery device and turn on the oxygen adjusting the flow through oxygen delivery device o Humidifier attached to flow meter and situated between flowmeter through container of water and moisturized before entering air passages Cannula o Nasal cannula consists of a plastic tube with short curved prongs Masks o Oxygen concentrations above 60% are rarely used because of danger of oxygen toxicity Artificial airways o Relieve an obstruction, protect airway, facilitate suctioning and provide artificial ventilation o Nasopharyngeal and oropharyngeal airways o Used to keep tongue from falling back into throat o Post op o Endotracheal tubes maintain airway in those for unconscious patients o Removed after 48-72 hr o May cause a mucosal ulcer after 5-7 days of use

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Nasopharyngeal suctioning o Removing secretions o Pharyngeal suctioning involves upper air passages of nose, mouth, pharynx o Infants, debilitated or unconscious patients, those with an ineffective cough o Yankauer suction tip attached to suction connecting tubing and mouth and top of pharynx are suctioned o Suction pressure should be set between 80- and 120-mm Hg o Oral suctioning tried before nasopharyngeal suctioning bc it is a more comfortable procedure o Suction cath based on size of patient's tube and thickness of secretions to be removed o Smaller 8-12 cath for thin secretions o 14-16 cath for an adult with tenacious (sticky) or thick secretions o Place the thumb over suctioning o Aseptic technique o Never reuse cath that has been in the mouth for nasopharyngeal or tracheobronchial suctioning Tracheobronchial suctioning o Deep suctioning of lower resp passages stimulates cough reflex and removes secretions from trachea and bronchi o Frequently performed when patient has been intubated or has a tracheostomy o Sterile technique is mandatory for deep suctioning in the tracheobronchial tree and for the intubated patient Tracheostomy o Surgical incision int throat and insertion of tube to aerate the lungs performed on patients who have apnea (absence of breathing) o Tracheostomy tube has a cuff its inflated to seal the space between the tube and tracheal wall to prevent fluid from being aspirated into lungs and allow only minimal leakage of air o Positive pressure ventilator to treat respiratory failure must have a cuffed trach or endotracheal tube for effective use of ventilator o Inflated cuff present: check cuff pressure at least every 8 hours o Perform pharyngeal suctioning before deflating the cuff o Never leave patient alone when cuff is deflated because of danger of aspirating fluid

Cuff reinflated: check for air leakage by holding a hand in front of the patients nose and mouth and asking them to blow o Air movement is felt cuff seal is underinflated Chest drainage tubes o Emergency treatment o Attached to drainage system o Drainage systems used to drain air or fluid out of pleural space and to keep the air or fluid from the pleural space and to keep the air or fluid from beginning sucked back into the chest o Gravity drainage sucked back into the chest o Gravity drainage is inadequate to remove air and fluids from a patient with a large pleural leak, suction can be applied using either wall suction or a portable suction machine o Disposable chest drainage has a suction control chamber to prevent excessive negative pressure in pleural space as well as water seal chamber and drainage chamber o Suction used in water seal system, there should be constant bubbling in suction chamber o Waterless system that uses one way valve in suction chamber o Some given mobile chest drainage unit so they can be discharged home o Mobile devices designed so that the drainage o Maintaining a disposable water seal chest drainage system ▪ Position unit below level of chest tube, tubing should be straight ▪ Fill water seal chamber to correct level; refill with sterile water as needed. The suction chamber may also require sterile solution. ▪ Attach unit to wall suction and set suction to measure 20 cm on the suction control chamber gauge, or to the amount ordered; there should be mild continuous bubbling in suction chamber ▪ Tape connections; no kinks ▪ Lift tubing and use gravity to drain any blood in tubing frequently ▪ Do not milk or strip the tubing unless there is a medical order ▪ Mark and record drainage output each shift ▪ Help patient deep breath and cough and change positions in frequent intervals Application of nursing process o Listen to lungs o Document findings o Assess respirations, rate, depth, and character: patient may be breathing shallowly and not oxygenating well o Auscultate lungs to assess patency of airways: secretions ay be present that interfere with gas exchange or areas of lung may not be inflating o Assess for subtle signs of hypoxemia: restlessness, confusion, combativeness, dec ability to concentrate, lethargy, an headache can all indicate that the patient is not obtaining enough oxygen o Assess mucous membranes and nail beds for cyanosis o

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Character of cough is present: deep rattling cough indicates retained secretions, shallow represents throat irritation o Assess amount and character of sputum and times at which it is produced: sputum produced only in morning may indicate sinus drainage rather than a problem in lungs o Assess patient's ability to cough effectively: ineffective coughing will not clear secretions or open lower airways o Assess for factors that restrict respiratory effort: fractured ribs, severe arthritis, and many diseases can cause restrictive resp disorders and thus compound the problems of a resp illness Tracheostomy care o Tracheostomy tube is curved, hollow cannula made of plastic or metal o Some have inner and outer cannula so that inner can be removed o All tracheostomy tubes come with a piece called obturator o May be needed as frequently as 15-30 min o Suctioning is carried out only as needed, and need is indicated by audible respirations or dyspnea o Strict aseptic technique and use separate catheters and solution when both nasopharyngeal area and the trachea o No longer than 10 sec in length o Pre ox patient o Reuse sleeved or inline cath several times o Always suction nasopharynx before deflating cuff Chest tube care o Listen to lungs o Mark drainage level on container along with time recorded observe tube and level of drainage in collection chamber each time you enter patient's room Nebulizer treatments o Patient having difficulty bringing up mucous secretions trapped in lung a nebulizer treatment may be ordered o With nebulization, medication changed from a liquid into mist for easy absorption through lung tissue o Deliver bronchodilators to the lung to relieve bronchospasm Patient education o

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