Oxygenation

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 reexpand

- 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 noncongested with nonproductive 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.

B.

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

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