Handouts.docx

Suctioning I.A Definition Suctioning is a method of removing mucous from the lungs. People with a spinal cord and/or brain injury may have problems breathing due to congestion. The muscles that help with breathing and coughing may not work well I.B Purpose: Tracheostomy suctioning removes thick mucus and secretions from the trachea and lower airway that you are not able to clear by coughing. Suctioning is done when you wake up in the morning and right before you go to bed in the evening. Suctioning is also done after any respiratory treatments. I.C Equipment's needed: 1. 2. 3. 4. 5. 6. 7.

Suction machine Connecting tubing Disinfected suction catheter One non-sterile, clean glove Distilled water Clean, small paper cup Clean basin

I.D Indications: 1. Patient has an ineffective cough and unable to clear the secretion spontaneously (audible secretion sound in patients under mechanical ventilation) 2. Retained secretion is causing patient distress or physiological derangement (e.g. increased work of breathing, respiratory rate, impaired oxymetry or blood gases) 3. Maintain airway patency with secretion clearance 4. When all other less invasive secretion clearance interventions have failed (e.g. cough assist (manual or mechanical), positioning, other breathing/coughing techniques) 5. To stimulate cough 6. To obtain sputum sample for microbiology or cytological analysis I. E Contraindications: 1. Severe bleeding disorder, unexplained hemoptysis 2. Severe bronchospasm or laryngeal spasm, irritable airway 3. Epiglottitis or croup 4. Basal skull fractures / facial injury 5. Cerebral spinal fluid leak 6. Recent nasal, oral or esophageal surgery 7. Occluded nasal passage, nasal bleeding 8. Loose teeth, denture or crown. I. F Basic procedure in Suctioning:

1. Wash hands. Reduces transmission of microorganisms.

2. Assess patient’s need for suctioning. Since endotracheal suctioning can be hazardous and causes discomfort, it is not recommended in the absence of apparent need. Coarse breath sounds Coughing; increased respirations Increased PIP on ventilator 3. Don goggles and mask or face shield. Potential for contamination 4. Turn on suction apparatus and set vacuum regulator to appropriate negative pressure. Recommend 80-120 mmHg; adjust lower for children and the elderly. Significant hypoxia and damage to tracheal mucosa can result from excessive negative pressure. 5. Prepares suction apparatus. Secure one end of connecting tube to suction machine, and place other end in a convenient location within reach. 6. Use in-line suction catheter or open sterile package (catheter size not exceeding one-half the inner diameter of the airway) on a clean surface, using the inside of the wrapping as a sterile field. 7. Prepares catheter and prevents transmission of microorganisms. Catheter exceeding one-half the diameter increases possibility of suction-induced hypoxia and atelectasis. 8. Prepare catheter flush solution.With in-line catheter use sterile saline bullets to flush catheter. With regular suctioning set up sterile solution container and being careful not to touch the inside of the container, fill with enough sterile saline or water to flush catheter. 9. With in-line suction catheter use clean gloves. With regular suctioning, done sterile gloves. Maintain sterility. Universal precautions. In regular suctioning the dominant hand must remain sterile throughout the procedure. 10. Pick up suction catheter, being careful to avoid touching nonsterile surfaces. With nondominant hand, pick up connecting tubing. Secure suction catheter to connecting tubing. Maintains catheter sterility. Connects suction catheter and connecting tubing 11. Ensures equipment function. Check equipment for proper functioning by suctioning a small amount of sterile saline from the container. (skip this step in in-line suctioning) 12. Remove or open oxygen or humidity device to the patient with nondominant hand. (skip this step with in-line suctioning). Opens artificial airway for catheter entrance. Have second person assist when indicated to avoid unintentional extubation. 13. Replace O2 delivery device or reconnect patient to the ventilator. Hyperoxygenate and hyperventilate via 3 breaths by giving patient additional manual breaths on the ventilator before suctioning. Hyperoxygenation with 100% O2 is used to offset hypoxemia during interrupted oxygenation and ventilation. Preoxygenation offsets volume and O2 loss with suctioning. Patients with PEEP should be suctioned through an adapter on the closed suction system. 14. Without applying suction, gently but quickly insert catheter with dominant hand during inspiration until resistance is met; then pull back 1-2 cm. Catheter is now in tracheobronchial tree. Application of suction pressure upon insertion increases hypoxia and results in damage to the tracheal mucosa.

15. Apply intermittent suction by placing and releasing dominant thumb over the control vent of the catheter. Rotate the catheter between the dominant thumb and forefinger as you slowly withdraw the catheter. With in-line suction, apply continuous suction by depressing suction valve and pull catheter straight back. Time should not exceed 10-15 seconds. Intermittent suction and catheter rotation prevent tracheal mucosa when using regular suctioning methods. Unable to rotate with closed- suction method. 16. Replace oxygen delivery device. Hyperoxygenate between passes of catheter and following suctioning procedure. Replenishes O2. Recovery to base PaO2 takes 1 to 5 minutes. Reduces incidence of hypoxemia and atelectasis. 17. Rinse catheter and connecting tubing with normal saline until clear. Removes catheter secretions. 18. Monitor patient’s cardiopulmonary status during and between suction passes. Observe for signs of hypoxemia, e.g. dysrhythmias, cyanosis, anxiety, bronchospasms, and changes in mental status. 19. Once the lower airway has been adequately cleared of secretions, perform nasal and oral pharyngeal or upper airway suctioning. Removes upper airway secretions. The catheter is contaminated after nasal and oral pharyngeal suctioning and should not be reinserted into the endotracheal or tracheostomy tube. 20. Upon completion of upper airway suctioning, wrap catheter around dominant hand. Pull glove off inside out. Catheter will remain in glove. Pull off other glove in same fashion and discard. Turn off suction device. Reduces transmission of microorganisms. 21. Reposition patient. Supports ventilatory effort; promotes comfort; communicates caring attitude. 22. Reassess patient’s respiratory status. Indicates patient’s response to suctioning 23. Dispose of suction liners and connecting tubing, sterile saline solution every 24 hours and set up new system. Decreases incidence of organism colonization and subsequent pulmonary contamination. Universal precautions.

Oxygen Therapy I.A Definition Oxygen Therapy - is a treatment that delivers oxygen gas for you to breathe. You can receive oxygen therapy from tubes resting in your nose, a face mask, or a tube placed in your trachea, or windpipe. This treatment increases the amount of oxygen your lungs receive and deliver to your blood. I.B Purpose: The purpose is to increase oxygen saturation in tissues where the saturation levels are too low due to illness or injury. Breathing prescribed oxygen increases the amount of oxygen in the blood, reduces the extra work of the heart, and decreases shortness of breath. I.C Equipment's needed:     

Oxygen supply (piped or cylinder) Regulator (oxygen flow meter) Flow meter adapter Humidifier (Sterile water)  Oxygen tubing Oxygen delivery device

I.D Indications: • Administration of oxygen is based on the provider’s assessment of the patient. Oxygen may be used in following conditions – Respiratory problems – Cardiac problems – Altered Mental Status – Shock – Trauma patients – Seizure patients  

I. E Contraindications:   

There are no contraindications to administering oxygen. If a nurse has any concerns about providing oxygen they should contact physician. Exercise caution with oxygen administration in chronic obstructive pulmonary disease (COPD) patients.

I. F Basic procedure in Oxygen Therapy: 1. Starting oxygen therapy

The following procedure should be followed when starting oxygen therapy in patients who are acutely ill (not those in peri-arrest):  Ensure pulse oximetry is available to monitor response to oxygen therapy  Document baseline observations including saturations, respiratory rate, blood pressure and pulse  Note respiratory effort, colour, level of consciousness

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Check that there is a prescription for oxygen with a stated target saturation range (except in periarrest situation) Where there is no known risk of carbon dioxide retention (target 94-98%), start oxygen therapy using a reservoir mask at 10-15L/min. Where there is a risk of carbon dioxide retention (target 8892%), start oxygen therapy using a 28% Venturi device and mask Ensure delivery device is connected via tubing to oxygen supply and turned on to the appropriate flow rate (if cylinder, check fill level of cylinder and be aware of duration time) Explain procedure to the patient and gain consent where possible. In patients who are acutely sick, this may not be possible and clinicians should act in the patient’s best interests Place the oxygen mask on the patient’s face, adjusting the nose clip and elastic straps to ensure a close fit Monitor response to oxygen therapy – recheck oxygen saturations, vital signs, colour and level of consciousness Titrate oxygen according to oxygen saturations to maintain saturations within prescribed target range. Allow five minutes at each dose before further adjustment. Sudden withdrawal of oxygen in a patient with hypercapnia leads to rebound hypoxaemia Document all adjustments to inspired oxygen (FiO2), with saturations recorded

I. G Delivery Devices: Delivery devices Oxygen is delivered via variable-performance or fixed-performance devices. The amount of oxygen delivered by variable-performance devices (also known as uncontrolled oxygen systems) is dependent on the:  Oxygen flow rate;  Patient’s inspiratory volumes;  Respiratory rate;  Proportion of room air added during breathing. Reservoir mask (non-rebreathing mask) Oxygen at 10-15L/min via a reservoir mask delivers oxygen at concentrations of 60-85% and is recommended for short-term use in patients who are critically ill. The reservoir bag must be filled with oxygen before use and the mask positioned to ensure a close fit on the patient’s face. Simple face mask The simple, or “low flow”, face mask is intended for short-term use, such as post-operative recovery. Oxygen is delivered at 2-10L/min and supplemented with air drawn into the mask during breathing. The FiO2 achieved cannot be predicted as it depends on the rate and depth of the patient’s breathing. Oxygen flow rates of <5L/min may result in the patient rebreathing exhaled carbon dioxide, which may build up in the mask. Simple face masks should not be used for patients at risk of type 2 respiratory failure. Nasal cannulae are comfortable and well tolerated by most patients. They do not need to be removed when the patient is talking or eating. Oxygen is inhaled even when breathing through the mouth. Nasal cannulae are useful:  For patients who are stable;  To provide supplemental oxygen therapy during meals;

 To provide air-driven nebulised therapy for those requiring controlled oxygen therapy. They are commonly used to deliver oxygen in the home setting. Flow rates above 4L/min can cause considerable drying of nasal mucosa and are more difficult to tolerate.

Fixed-performance devices (also known as controlled oxygen delivery systems) deliver a fixed proportion of air and oxygen via a Venturi valve, ensuring an accurate concentration of oxygen is delivered, regardless of inspiratory volumes and respiratory rate Fixed-performance devices should be used in acute illness in patients who are at risk of carbon dioxide retention. Venturi valves are colour-coded to denote the fixed percentage of oxygen delivered; these range from 24% (blue) to 60% (green), provided that the minimum oxygen flow rate on the barrel of the device is given. The minimum flow rate varies between oxygen-mask manufacturers, so it is important to check the minimum rate that is recommended on the device in use.