OXYGENATION

I. COMMON DIAGNOSTIC METHODS TO ASSESS RESPIRATORY FUNCTIONING

A. PULMONARY FUNCTION STUDIES
- to evaluate pulmonary status and detect abnormalities
- spirometry studies measure lung capacity, volumes, and flow rates
while the patient inhales deeply
and exhales forcefully

spirometer – instrument that measures these volumes and airflow

- drugs affecting the respiratory tract (bronchodilators) are withheld

before this exam
- pulmonary function tests measure:
• tidal volume (TV) – amount of air inspired and expired in a normal
respiration (3,100 mL)
• inspiratory reserve volume (IRV) – amount of air that can be
inspired beyond tidal volume (3,100 mL)
• expiratory reserve volume (ERV) – amount of air that can be
exhaled beyond tidal volume (1,200 mL)
• residual volume (RV) – amount of air remaining in the lungs after
a maximal expiration (1,200 mL)
• vital capacity (VC) – maximal amount of air that can be exhaled
after a maximal inhalation (4,800 mL)
• inspiratory capacity (IC) – largest amount of air that can be
inhaled after a normal quiet exhalation (3,600 mL)
• functional residual volume (FRV) – equal to the expiratory
reserve volume plus the residual volume (2,400 mL)
• total lung capacity (TLC) – sum of TV, IRV, ERV, and RV (6,000
mL)

B. PEAK EXPIRATORY FLOW RATE (PEFR)

- refers to the volume of air that can be forcibly exhaled
- decrease in PEFR can signal airway obstruction
- measured by a peak flow meter
- test is noninvasive, inexpensive, quick and easy
- patient should be standing or sitting with back positioned as straight as
possible
- deep breath is taken and mouth placed around the mouthpiece
- forcibly exhale into meter and indicator rises to a number
- repeat these steps 3 times and highest number is recorded
- indicates the maximum flow rate during a forced expiration
- normal values are established in regard to height, age, and gender
- PEFR commonly measured at home to monitor airflow in
conditions such as asthma

C. PULSE OXIMETRY
- noninvasive technique that measures the oxygen saturation (SpO2) of
arterial blood
 - useful for monitoring patients receiving oxygen therapy, those at risk for
hypoxia, and postoperative
patients
- indicates trends in oxygen saturation but is not a replacement for
arterial blood gas analysis
- nurse should know patient’s hemoglobin level before measuring SpO2
because the test measures
only the percentage of oxygen carried by the available hemoglobin
- low hemoglobin could appear normal; however, patient may not
have enough oxygen to
meet body needs
- range of 95-100% considered normal; values less than 85% indicate
oxygenation is inadequate
D. THORACENTESIS
- procedure of entering the pleural cavity and aspirating fluid
- pleural cavity is normally not distended with fluid or air
- physician performs procedure at bedside with nurse assisting
- patient required to sign a permit for this procedure
- performed to obtain a specimen for diagnostic purposes or to remove
fluid that has accumulated in
the pleural cavity and is causing respiratory difficulty and
discomfort

Procedure:
- usually carried out with patient sitting on a chair or the edge of
the bed, legs supported and
arms folded and resting on a pillow on the bedside table
- if unable to sit up, patient may lie on the unaffected side with the
hand of the affected side
raised above the shoulder
- location where the sterile needle is inserted depends on where the
fluid is present and where
the physician can best aspirate it
- local anesthetic is administered and then the needle is inserted
between the ribs through
intercostal muscles and fascia and into the pleura
- during the procedure, fluid or air can be removed from the pleural
cavity with a syringe
- another method of removal is to drain the fluid into a sterile
bottle in which a partial
vacuum has been created
- with this technique, a small plastic catheter may be
threaded through the needle,
allowing the needle to be withdrawn (this reduces
possibility of puncturing the
lung)
- upper limit is generally 1,000 mL
- after the procedure, the needle or plastic catheter is removed and
a small sterile dressing is
placed over the entry site
 Nursing Interventions:
- collect baseline data before procedure and prepare patient
physically and emotionally
- instruct patient not to cough or breathe deeply during the
procedure
- urge patient to remain as still as possible
- administer analgesics before test as ordered
- observe patient’s reactions
- monitor patient’s color, pulse, and respiratory rates (fainting,
nausea, and vomiting may
occur)
- ensure specimens are taken to the lab immediately
- after procedure, assess patient for changes in respirations
- if large amount of fluid was removed, respirations usually
become easier
- if lung was punctured, respiratory distress becomes acute
- if blood appears in sputum or patient has severe coughing,
notify physician
immediately
- chest x-ray is usually done to verify absence of
complications

II. DIAGNOSING
- identifies a patient problem and suggests expected patient outcomes

A. ALTERATIONS IN RESPIRATORY FUNCTION AS THE PROBLEM

- nurse concludes either that there is no problem at this time or that
there is an actual or potential
respiratory problem that is amenable to independent or
interdependent nursing actions

Diagnoses:
Ineffective Airway Clearance - thick yellow secretions, fever, fatigue,
dehydration, poor nutrition
Ineffective Breathing Pattern - smokes one pack per day, works with
asbestos in auto factory, has had
a cold for 7 days
Impaired Gas Exchange - anxious about results of cardiac catheterization
and possible cardiac
surgery

Etiologies: inability to maintain proper position, pain or fear of pain,

viscous secretions, fatigue,
decreased level of consciousness, lack of knowledge,
smoking, allergy, mechanical
obstruction, medications, and decreased elasticity of the
lungs
B. ALTERATIONS IN RESPIRATORY FUNCTION AS THE ETIOLOGY
- alteration in respiratory functioning may affect other areas of human
functioning

Diagnoses: Activity Intolerance related to shortness of breath

Anxiety related to feeling of suffocation
Acute Pain related to pleural inflammation
Impaired Verbal Communication related to endotracheal
intubation
Ineffective Coping related to frequent hospitalization resulting
from acute symptoms of
COPD
Deficient Diversional Activity related to loss of ability to
perform specific activities
because of shortness of breath
Fatigue related to impaired oxygen transport system
Fear related to disabling respiratory illness
Dysfunctional Grieving related to loss of normal respiratory
functioning
Ineffective Health Maintenance related to smoking
Noncompliance related to side effects of therapy
Imbalanced Nutrition: Less than body requirements, related
to difficulty breathing
Impaired Oral Mucous Membrane related to presence of
endotracheal tube
Powerlessness related to inability for self-care because of
COPD
Chronic/Situational Low Self-Esteem related to loss of normal
respiratory function
Disturbed Sleep Pattern related to orthopnea and
bronchodilators
Social Isolation related to inability to walk to usual “people
places”
Risk for Suffocation related to child playing with a plastic bag
Risk for Aspiration related to reduced level of consciousness

III. OUTCOME IDENTIFICATION AND PLANNING

- nursing measures support expected outcomes:
• demonstrate improved gas exchange in the lungs by an absence of
cyanosis or chest pain and pulse oximetry reading of more than
95%
• relate the causative factors, if known, and demonstrate a method
of coping
• preserve pulmonary function by maintaining optimal level of
activity
• demonstrate self-care behaviors that provide relief from symptoms
and prevent further pulmonary problems
 - patient’s physical, psychosocial, and spiritual dimensions contribute to
alterations, individualized expected outcomes are developed with the
patient’s output

IV. IMPLEMENTING
A. TEACHING ABOUT POLLUTION-FREE ENVIRONMENTS
- teach patient to assess environment and make adjustments to factors that
impair respiratory functioning or
“triggers”
- actively plan to prevent exposure to triggers
- may include job change, use of protective equipment, requesting
enforcement of laws by government
agencies, or subcontracting jobs, dusting and vacuuming the office /
home at least twice a week,
exposure to industrial or occupational hazards (paint, varnish, gaseous
fumes) must be restricted
- cigarette smoking is the most important risk factor in pulmonary disease
- increases airway resistance, reduces ciliary action, increases mucous
production, causes thickening
of alveolar-capillary membrane, and causes bronchial walls to
thicken and lose their elasticity

B. PROMOTING OPTIMAL FUNCTION

- many with altered respiratory functioning experience anxiety as a result of
their symptoms and the actual or
potential loss of independence
- nurses should help institute measures to alleviate discomfort immediately,
use effective listening skills and
accurate observation to display a caring attitude, attempt to understand
the patient’s life experiences
and habits without judging

C. PROMOTING PROPER BREATHING

- breathing exercises are designed to help patients achieve more efficient and
controlled ventilations, to
decrease the work of breathing, and to correct respiratory deficits

1. Deep Breathing – exercises can be used to overcome hypoventilation

(decreased amount of air
entering and leaving the lungs)
- make each breathe deep enough to move the bottom ribs
- start slowly taking deep ventilations nasally and then expiring
slowly through the mouth
- breathing through the nose warms, filters, and humidifies the air
- patient’s respiratory status, motivation, and general clinical
condition dictate the timing of this
exercise, which should be done hourly while awake or four
times daily
 2. Using Incentive Spirometry – patient takes a deep breath and can see
the results of his or her
efforts on the equipment while sustaining that maximal inspiration,
providing immediate
positive reinforcement
- forces the patient to inflate the lungs, which keeps the alveoli
from collapsing so that gas
exchange can occur and secretions can be cleared and
expectorated
- validate the patient’s correct use of this equipment in both
healthcare and home environs.

3. Pursed-Lip Breathing – trains the muscles to prolong exhalation,

increasing airway pressure during
expiration and reducing the amount of airway trapping and
resistance
- patient inhales through the nose while counting to three and then
exhales slowly and evenly
against pursed lips while tightening the abdominal muscles
- during exhalation, patient counts to seven
- to purse the lips, patient should position the lips as though he or
she was sucking through a
straw or whistling
- when walking, patient should inhale while taking two steps and
then exhale through pursed
lips while taking the next four steps, then repeat the cycle

4. Abdominal or Diaphragmatic Breathing – this exercise is helpful to

those with COPD and breathe in
a shallow, rapid and exhausting pattern
- diaphragmatic breathing, which reduces the respiratory rate,
increases tidal volume, and
reduces the functional residual capacity
- patient places one hand on the stomach and the other on the
middle of the chest
- breathes in slowly through the nose, letting the abdomen
protrude as far as it will go
- then breath out through pursed lips while contracting the
abdominal muscles, with
one hand pressing inward and upward on the abdomen
- repeat these steps for 1 minute, followed by a rest for 2
minutes
- practice this breathing pattern several times per day

V. MANAGING CHEST TUBES

- patients with pleural effusion (fluid), hemothorax (blood) or
pneumothorax (air) in the pleural
space require a chest tube to drain these substances and allow the
compressed lung to re-
expand
 - chest tube is a firm plastic tube with drainage holes in the proximal end
that is inserted in the pleural
space
- secured with a suture and tape, covered with an airtight dressing,
and attached to a drainage
system that may or may not be attached to suction
- components include closed water-seal drainage system that
prevents air from re-entering the
chest once it has escaped and suction control chamber that
prevents excess suction
pressure from being applied to pleural cavity
- suction chamber may be water-filled (regulated by amount of
water in chamber) or dry
chamber (automatically regulated to changes in patient’s
pleural pressure)
- placement is determined by the type of drainage
- when air is to be drained, tube is placed higher in the chest
- when fluid is to be drained, tube is placed lower in the lung
because fluids settle at the base
- nursing responsibilities include assisting with insertion and removal of
chest tube, monitoring
patient’s respiratory status and vital signs, checking the dressing,
and maintaining the patency
and integrity of drainage system

VI. PROMOTING AND CONTROLLING COUGHING

cough - cleansing mechanism of the body
- means of helping to keep the airway clear of secretions and other
debris
- mechanism consists of an initial irritation; deep inspiration; quick,
tight closure of glottis
together with forceful contraction of expiratory intercostals
muscles; upward push of
diaphragm
- causes explosive movement of air from lower to upper
respiratory tract
- to be effective, should have enough muscle contraction to
force air to be expelled
and to propel liquid or solid on its way out of respiratory
tract
- most effective when patient is sitting upright with feet flat on the
floor

congested – excessive fluids or secretions in an organ or body tissue

- secretions or fluid in the lungs is called congested lungs
- dry cough = congested with a nonproductive cough
- cough produces respiratory secretions = congested with
productive cough

phlegm – thick respiratory secretions

 - cough with no congestion or secretions produced is called non-
congested with non-
productive cough

A. PROMOTING VOLUNTARY COUGHING

- important aspect of preoperative and postoperative care
- difficult to motivate patients to follow through and perform this exercise
on their own
- remind patients throughout the day
- develop specific schedule for coughing on plan of care
- coughing early in the morning after rising removes secretions that have
accumulated during the night
- coughing before meals improves the taste of food and oxygenation
- coughing at bedtime removes any buildup of secretions and improves
sleep patterns
- for a person unable to cough voluntarily, manual stimulation over the
trachea and prolonged
exhalation can be helpful
- if neither method is successful, mechanical endotracheal
suctioning with a catheter may be
necessary
- a patient with a neuromuscular disorder and is unable to cough
physically, an assisted cough (firm
pressure placed on the abdomen below the diaphragm in rhythm
with exhalation – similar to
Heimlich maneuver but with less force) may be used

B. PROMOTING INVOLUNTARY COUGHING

- involuntary coughing often accompanies respiratory tract infections and
irritations which lead to the
production of respiratory secretions which in turn trigger the cough
mechanism
- productive coughs help clear the airway
- nonproductive coughs can fatigue and irritate
- medications may control involuntary coughing (observation of breathing
and coughing are necessary
to determine appropriate type)

1. Using Cough Medications

a. Cough Suppressants – drugs that depress the cough reflex
- Codeine is generally considered the preferred ingredient;
however, it can be
addictive, therefore, a prescription is required
- drowsiness (common with antihistamines) is a side
effect so it is not safe to
use when the person must remain alert
- Dextromethorphan is a non-addictive ingredient and may be
found in many OTC
cold and cough remedies
 - irritating nonproductive cough without congestion may be
appropriately treated with
suppressants
- suppression of the productive cough is usually not
recommended unless patient is
trying to sleep
- if suppressed, secretions can be retained, leading to
pulmonary infection

b. Expectorants – drugs that facilitate the removal of respiratory tract

secretions by reducing the
viscosity of the secretions
- extremely tenacious (thick) secretions may need to be
liquefied for the cough to be
effective
- nonproductive cough with lung congestion can become
productive
- without congestion, expectorants are inappropriate
- Guaifenesin is widely used as an expectorant in cold and
cough preparations
- adequate fluid intake and air humidification are considered
effective expectorants

c. Lozenges – small, solid medication intended to be held in mouth

until it dissolves
- can relieve mild, nonproductive coughs without congestion
- control coughs by the local anesthetic effect of benzocaine
- act on sensory and motor nerves, controlling primary
irritation and inhibiting
afferent and efferent impulses

2. Teaching about Cough Medicines

- teach about the appropriate choice of expectorants and
suppressants and about the misuse
of cough mixtures
- ex. cough syrups with high sugar or alcohol content can disturb
metabolic balance of those
with diabetes or trigger a relapse for recovering alcoholics
- ex. preparations with antihistamines have an anticholinergic
action, causing serious
problems for those with glaucoma or urinary retention in
those with enlarged prostates
- ex. detrimental to those with hypertension or thyroid or cardiac
diseases
- prolonged use of self-prescribed cough preparations can conceal
more serious health
problems
- if cough lasts longer than 7 days, urge patient to contact a
physician
 - encourage person to increase fluid intake if secretions are
too thick to expectorate

VII. PROMOTING COMFORT

A. POSITIONING
- proper positioning (one that allows free movement of diaphragm and
expansion of chest wall) is
important in easing respirations
- those with dyspnea and orthopnea are most comfortable in a high
Fowler’s position
- those with pulmonary disease who are acutely ill, turn to the prone
position
- posterior dependent sections of the lungs are better ventilated
and perfused
- partially prone position appears to be sufficient to achieve better
ventilation while at the
same time allowing access to invasive lines and the airway

B. MAINTAINING ADEQUATE FLUID INTAKE

- drinking 2 – 3 quarts of clear fluids daily helps to keep secretions thin
- fluid intake should be increased to maximum that the patient’s health
state can tolerate
- those with right-sided heart failure should not exceed 1.5 quarts
- increased fluids are needed for those who have an elevated
temperature, who are breathing through
the mouth, who are coughing, or who are losing excessive body
fluids in other ways

C. PROVIDING HUMIDIFIED AIR

- inspiring dry air removes the normal moisture in the respiratory
passages that protect against
irritation and infection
- especially troublesome for patients who cannot breathe through
their nose
- may be necessary to humidify air with room humidifiers or
vaporizers
- electric humidifiers produce steam or cool mist are helpful, but neither
has a greater therapeutic
value than the other
- cool mist vaporizers reduce the danger of burns, but can be a
medium for pathogen growth if
not adequately cleaned
- steam vaporizers do not present this risk because heat kills most
pathogens

VIII. PERFORMING CHEST PHYSIOTHERAPY

- helps loosen and mobilize secretions
- especially helpful for patients with large amounts of secretions or
ineffective cough
A. PERCUSSING
- involves use of cupped palm to loosen pulmonary secretions so that
they can be expectorated with
greater ease
- hand is held in a rigid, dome-shaped position over the area of the lung
lobes to be drained and struck
in a rhythmic pattern
- patient is positioned supine or prone and should not experience any
pain
- cupping is never done on bare skin or performed over surgical incisions,
below the ribs, or over the
spine or breasts because of the danger of tissue damage
- each area is typically percussed for 30 – 60 seconds, several times a
day
- for tenacious secretions, the area may be percussed for up to 3 –
5 minutes several times
per day

B. VIBRATING
- rhythmic contraction and relaxation of arm and shoulder muscles while
holding the hands flat on the
patient’s chest wall as patient exhales
- purpose is to help loosen respiratory secretions so that they can be
expectorated with ease
- at a rate of about 200 per minute, can be done several minutes, several
times a day
- never done over the patient’s breast, spine, sternum, and lower rib cage

C. PROVIDING POSTURAL DRAINAGE

- gravity is used to drain secretions from the lungs, with patient
positioned in a way that promotes
drainage of secretions from smaller pulmonary branches into larger
ones, where they can be
removed by coughing
- often preceded by vibration, percussion, or both
- carried out 2 – 4 times a day for 20 – 30 minutes (should discontinue if
patient feels weak or faint)
- procedure should be delayed for 1 – 2 hrs. after meals to avoid vomiting

Positions:
High Fowler’s position – drains apical section of the upper lobes of the
lungs
Lying position (half on abdomen, half on the side) – drains posterior
sections of upper lobes of the
lungs
- left side with pillow under the chest wall drains right lobe of lung
Trendelenburg position – drains lower lobes of the lungs

IX. MEETING RESPIRATORY NEEDS WITH MEDICATIONS

 - monitoring patient’s response and development of side effects is an
independent nursing action

A. ADMINISTERING INHALED MEDICATIONS

- inhaled medications may be administered to open narrowed airways
(bronchodilators), to liquefy or
loosen thick secretions (mucolytic agents), or to reduce
inflammation in airways
(corticosteroids)

1. Nebulizers – disperse fine particles of medication into deeper passages

of respiratory tract, where
absorption occurs

2. Metered-Dose Inhaler (MDI) – delivers controlled dose of medication

with each compression of the
canister

Common mistakes: failing to shake canister holding

inhaler upside down
inhaling too rapidly inhaling 2 sprays
with 1 breath
inhaling through the nose rather than the mouth
stopping inhalation when cold propellant is felt in
the throat
failing to hold breath after inhalation

- device must be activated while continuing to inhale

- spacer (acts as reservoir) or extender device may be necessary to
aid delivery of medication
- administration is less complicated and dose is more
predictable

3. Dry Powder Inhalers (DPI) – require less manual dexterity than MDI
and are actuated by patient’s
inspiration, so there’s no need to coordinate delivery with
inhalation
- medication will clump if exposed to humidity

X. PROVIDING SUPPLEMENTAL OXYGEN

- oxygen is considered a medication and must be ordered by a healthcare
provider
- provide clear explanations about procedures

A. SOURCES OF OXYGEN
- wall outlet has a flowmeter attached and valve regulates the oxygen
flow
- portable steel cylinders or tanks are delivered with protective caps to
prevent accidental damage to
 outlet
- to release oxygen safely and at desired rate, a regulator is used
- regulator has 2 gauges: one nearest the tank shows pressure or
amount of oxygen in tank
other gauge indicates number of liters of
oxygen per minute being
released

B. OXYGEN FLOW RATE

- flow rate, measured in liters per minute, determines the amount of
oxygen delivered to patient
- rate varies depending on condition of patient and route of
administration
- physician’s written order prescribes the rate of oxygen administration
- excessive levels of carbon dioxide in the blood stimulate the
patient to breathe
- chronic lung disease becomes insensitive to carbon dioxide and
respond to hypoxia to
stimulate breathing
- excessive oxygen may stop breathing completely
- most can tolerate oxygen at 2 L/min
- arterial blood gas results should be monitored closely

C. HUMIDIFICATION
- humidifying devices (supplying 20 – 40% humidity) are commonly used
when oxygen is delivered at
rates higher than 2 L/min
- distilled or sterile water is commonly used to humidify oxygen
- when moving patients receiving humidified oxygen, make sure that
water from the humidifier does
not enter the tubing through which the oxygen is flowing

D. PRECAUTIONS FOR OXYGEN ADMINISTRATION

- oxygen, which constitutes 20% of normal air, is a tasteless, odorless,
colorless gas and supports
combustion
- avoid open flames in patient’s room
- place “no smoking” signs in conspicuous places in patient’s room
or home
- check to see that electrical equipment used in the room (electric
bell cords, razors, radios,
suctioning equipment) is in good working order and emits no
sparks
- avoid wearing and using synthetic fabrics that build up static
- avoid using oils in the area - - oil can ignite spontaneously in the
presence of oxygen

E. OXYGEN ADMINISTRATION
1. Nasal Cannula – also called nasal prongs
- most commonly used oxygen delivery device
 - disposable plastic device with two protruding prongs that are
inserted into the nostrils
- cannula is connected to an oxygen source with a humidifier and
flowmeter
- does not impede eating or speaking and is easily used in the
home
- can easily be dislodged and can cause dryness of nasal mucosa
- check frequently that both prongs are in patient’s nares
- never deliver more than 2 – 3 L/min to patient with chronic
lung disease

2. Nasal Catheter – infrequently used because it is uncomfortable for

patient and may cause trauma to
respiratory mucous membranes
- inserted into the nose through one nostril, with the end of the
catheter resting in the
oropharynx
- must be changed to other nostril every 8 hrs
- gastric distention often occurs because the gas flow can be
misdirected into the stomach

3. Face Masks – disposable and reusable are available

- fitted carefully to patient’s face to avoid leakage of oxygen and
should be comfortably snug
but not tight against the face

a. Simple Mask – connected to oxygen tubing, a humidifier, and

flowmeter, just like nasal
cannula
- has vents on its sides that allow room air to leak in at many
places, diluting the
source oxygen
- vents allow exhaled carbon dioxide to escape
- used when an increased delivery of oxygen is needed for
short periods (less than 12
hrs.)
- patient may have difficulty keeping the mask in place over
the nose and mouth, and
because of this pressure and presence of moisture, skin
breakdown is
possible
- monitor patient frequently to check placement of
mask
- eating or talking with mask in place can be difficult
- due to risk of retaining carbon dioxide, never apply simple
face mask with a delivery
flow rate of less than 5 L/min
- support patient if claustrophobia is a concern
- secure physician’s order to replace mask with nasal cannula
during meal times
 b. Partial Rebreather Mask – equipped with reservoir bag for collection
of first part of patient’s
exhaled air with the remaining exhaled air exiting through
vents
- reservoir is mixed with 100% oxygen for the next inhalation
- patient rebreathes about 1/3 of expired air from reservoir
bag
- patient can inhale room air through openings in mask if
oxygen supply is briefly
interrupted
- eating and talking are difficult, a tight seal is required and
there is the potential for
skin breakdown
- if reservoir bag deflates completely, the flow rate should be
increased until only a
slight deflation is noted
- set flow rate so that mask remains 2/3 full during
inspiration
- keep reservoir bag free of twists or kinks

c. Non-rebreather Mask – delivers highest concentration of oxygen via

a mask
- two one-way valves prevent the patient from rebreathing
exhaled air
- reservoir bag is filled with oxygen that enters the mask on
inspiration
- exhaled air escapes through side vents
- malfunction of bag could cause carbon dioxide buildup and
suffocation
- maintain flow rate so reservoir bag collapses only slightly
during inspiration
- check that valves and rubber flaps are functioning properly
(open during expiration
and closed during inhalation)
- monitor SpO2 with pulse oximeter

d. Venturi Mask – allows mask to deliver most precise concentration of

oxygen
- has large tube with an oxygen inlet
- side ports (should always be open) are adjusted according
to prescription for oxygen
concentration
- requires careful monitoring

XI. SUCTIONING THE AIRWAY

- use sterile technique
- frequency of suctioning varies with amount of secretions present but
should be done often enough to
keep ventilation effective and as effortless as possible
 - suction catheter should be small enough not to occlude airway being
suctioned but large enough to
remove secretions

hypoxemia – insufficient oxygen in blood

- patient must be hyperoxygenated before suctioning (have patient take

several deep breaths before
insertion of catheter)
- suctioning provides comfort by relieving respiratory distress
- can increase anxiety and pain and cause respiratory arrest
- anticipate administering analgesic medication for those who have
had surgery or
experienced trauma because the cough reflex will be
stimulated
- complications include infection, cardiac arrhythmias, hypoxia,
mucosal trauma, and death
- wear gloves on both hands, goggles, mask and gown, if necessary
- monitor patient’s color and heart rate and secretions’ color, amount and
consistency
- if cyanosis, excessively slow or rapid heart rate, or suddenly
bloody secretions are notes,
stop suctioning immediately, administer oxygen, and notify
physician
- cyanosis can indicate hypoxemia and blood can indicate damage
to mucosa

XII. USING ARTIFICIAL AIRWAYS

A. OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAYS
- semicircular tube of plastic or rubber inserted into the back of the
pharynx through the mouth (oro) or
nose (naso) for one breathing spontaneously

1. Oropharyngeal – used to keep tongue clear of airway

- used for postoperative patients until they regain consciousness
- tape is not used to hold airway in place because patient should be
able to expel the airway
once he or she becomes alert

2. Nasopharyngeal – nasal trumpet

- inserted through nares and protrudes into back of pharynx
- allows for frequent nasotracheal suctioning without trauma
- may be left in place, without much discomfort

B. ENDOTRACHEAL TUBE
- polyvinylchloride airway that is inserted through the nose or the mouth
into the trachea, using a
laryngoscope as a guide
- used to administer oxygen, by mechanical ventilator, to suction
secretions easily, or to bypass upper
 airway obstructions
- orotracheal insertion is often the method of choice
- insertion is easier and a larger sized tube can be used, making
ventilation easier
- placement of tube is more difficult and requires the use of a narrower
tube
- cuffed endotracheal rube is used
- prevents air leakage and bronchial aspiration of foreign material
while allowing more precise
control of oxygen and mechanical ventilation
- careful monitoring of cuff pressure is necessary
- smallest amount of air that results in an airtight seal between the
trachea and tube is
desirable and less likely to result in complications

Insertion: use airway that is correct size – should reach from opening of
mouth to back angle of
jaw
explain what you are doing to patient
wash your hands and don gloves
remove dentures if present
position patient on his or her back with neck hyperextended
open patient’s mouth by using your thumb and index finger
to gently pry teeth apart
insert airway with curved tip pointing up toward roof of
mouth
slide airway across tongue to back of mouth
rotate airway 180° as it passes uvula
ensure adequate ventilation by auscultating breath sounds
position patient on his or her side
remove for brief period every 4 hrs

C. TRACHEOSTOMY
- artificial opening made into trachea through which curved tube is
inserted
- inserted to replace endotracheal tube, to provide method for
mechanical ventilation of patient, to
bypass an upper airway obstruction, or to remove tracheobronchial
secretions
- inserted in operating room or I.C.U. under sterile conditions
- may be temporary or permanent
- made of semiflexible plastic, rigid plastic, or metal - - conditions and
needs of patient determines
selection
- consists of:
outer cannula or main shaft – remains in place in the trachea
inner cannula – removed for cleaning or replaced with a new one
- necessary when patient has excessive secretions or
difficulty clearing secretions
 obturator – guides direction of outer cannula and is inserted into
tube during placement and
removed once outer cannula of tube is in place
- trach tubes may be either cuffed or cuffless
- inflated cuff seals opening around tube against air leakage,
prevents aspiration, and permits
mechanical ventilation
- always deflate cuff before oral feeding unless patient is at high
risk for aspiration
- balloon can cause pressure that extends through the trachea and
onto the esophagus,
possibly impeding swallowing or causing erosion of tissue
- held in place by twill tapes or Velcro strap around patient’s neck
- sterile, square gauze pad precut by manufacturer is placed
between skin and outer wings of
tube and must be kept dry to prevent infection and skin
irritation
- regularly check cuff pressure
- administer heated, humidified oxygen to prevent secretions from
becoming dry
- keep trach tube free from foreign objects and nonsterile materials

1. Suctioning – may be performed by passing a sterile catheter though

mouth (orotracheal), through the
nose (nasotracheal), or through an endotracheal tube
- addition of liquid into airway further reduces oxygenation, has no
effect on thinning
secretions, and may dislodge bacteria adhering to tube and
flush it into the lungs

2. Tracheostomy Care – inner cannula requires cleaning or replacement to

prevent accumulation of
secretions that can interfere with respiration and occlude airway
- soiled dressings and ties place patient at risk for development of
skin breakdown and
infection
- use dressing gauze that are not filled with cotton
- clean skin to prevent buildup of dried secretions and skin
breakdown
- exercise care to prevent accidental decannulation or expulsion of
tube