Ch. 25- Respi. Care Modalities

7/21/2019 Ch. 25- Respi. Care Modalities

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Copyright 2008 Lippincott Williams & Wilkins.

Chapter 25Respiratory Care Modalities


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Oxygen Therapy

Administration of oxygen at greater than 21% (theconcentration of oxygen in room air) to provide adequatetransport of oxygen in the blood, to decrease the work ofbreathing, and to reduce stress on the myocardium

Assess for signs and symptoms of hypoxia (occur CNS, mayresemble to alcohol intoxication: lack of coordination &impaired judgment)

Fatigue, drowsiness, apathy, inattentiveness & delayed

reaction time.

Types of Hypoxia See Chart 25-1

arterial blood gas results, and pulse oximetry.

Oxygen administration systems

See Table 25-1


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Table 25-1 OXYGEN ADMINISTRATION DEVICES

Device SuggestedFlowRate

O2 %Setting

Advantages Disadvantages

Low-Flow SystemsCannula

Oropharyngeal catheter

Mask, simple

Mask, partial rebreather

Mask, non-rebreatherHigh-Flow SystemsTranstracheal catheter

Mask, Venturi

Mask, aerosol

Tracheostomy collar

T-piece

Face tentOxygen Conserving

DevicesPulse dose (or demand)

12356

16

68

811

12

144

4668810

810

810810

1040mL/breath

23303040

422342

4060

5075

80100

60100

24, 26, 2830, 35, 40

30100301003010030100

Lightweight, comfortable, inexpensive,continuous use with meals and activity

Inexpensive, does not require a

tracheostomy

Simple to use, inexpensive

Moderate O2 oncentration

High O2 concentration

More comfortable, concealed byclothing, less oxygen liters per minute

needed than nasal cannulaProvides low levels of supplemental O2Precise FiO2, additional humidityavailableGood humidity, accurate FiO2Good humidity, comfortable, fairlyaccurate FiO2

Same as tracheostomy collarGood humidity, fairly accurate FiO2

Deliver O2 only on inspiration,conserve 50% of O2 used

Nasal mucosal drying, variableFiO2

Nasal mucosa irritation; catheter

should be changed frequently toalternate nostrilPoor fitting, variable FiO2, must remove to eatWarm, poorly fitting, must removeto eatPoorly fitting, must remove to eat

Requires frequent and regularcleaning, requires surgical

interventionMust remove to eat

Uncomfortable for some

Heavy with tubingBulky and cumbersome

Must carefully evaluate functionindividually


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Venturi Mask, Nonrebreathing Mask,Partial Rebreathing Mask

FIGURE 25-1. Types of oxygen masks used to deliver varying concentrations of oxygen.


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T-Piece and Tracheostomy Collar

FIGURE 25-2. T-pieces & tracheostomy

collars are devices used weaning patients

from mechanical ventilation.


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Complications of Oxygen Therapy

Oxygen toxicity

Reduction of respiratory drive in patients with chronic lowoxygen tension

Fire


7/48Copyright 2008 Lippincott Williams & Wilkins.

Oxygen Toxicity

Oxygen concentrations of greater than 50% for extendedperiods of time (longer than 48 hours) can cause anoverproduction of free radicals, which can severelydamage cells.

Symptoms include substernal discomfort, paresthesias,dyspnea, restlessness, fatigue, malaise, progressiverespiratory difficulty, refractory hypoxemia, alveolaratelectasis, and alveolar infiltrates on x-ray.

Prevention:

Use lowest effective concentrations of oxygen.

PEEP or CPAP prevents or reverses atelectasis andallows lower oxygen percentages to be used.



Incentive Spirometer (See Chart 25-3)

Types: volume and flow

Device ensures that a volume of air is inhaled and thepatient takes deep breaths.

Used to prevent or treat atelectasis

Nursing care

Positioning of patient, teach and encourage use, setrealistic goals for the patient, and record the results.



Intermittent Positive-Pressure Breathing

Indicated for patients who need to increase lungexpansion

Rarely used

Monitor for side effects, which may includepneumothorax, increased intracranial pressure,hemoptysis, gastric distention, psychological

dependency, hyperventilation, excessive oxygenadministration, and cardiovascular problems.



Mini-Nebulizer Therapy

A hand-held apparatus that disperses a moisturizingagent or medication such as a bronchodilator into the

lungs. The device must make a visible mist. Nursing care: instruct patient in use.

Patient is to breathe with slow, deep breaths throughmouth and hold a few seconds at the end of

inspiration. Coughing exercises may be encouraged to mobilize

secretions after a treatment.

Assess patient before treatment and evaluate patient

response after treatment.



Chest Physiotherapy

Includes postural drainage, chest percussion and vibration, andbreathing retraining. Effective coughing is also an importantcomponent.

Goals are removal of bronchial secretions, improvedventilation, and increased efficiency of respiratory muscles.

Postural drainage uses specific positions to use gravity to assistin the removal of secretions.

Vibration loosens thick secretions by percussion or vibration.

Breathing exercises and breathing retraining improveventilation and control of breathing and decrease the work ofbreathing. See Chart 25-4



CHART 25-4 PATIENT EDUCATION Breathing ExercisesGeneral Instructions

Breathe slowly and rhythmically to exhalecompletely and empty the lungs completely. Inhale through the nose to filter, humidify, andwarm the air before it enters the lungs. If you feel out of breath, breathe more slowly byprolonging the exhalation time. Keep the air moist with a humidifier.

Diaphragmatic Breathing

Goal: To use and strengthen the diaphragm duringbreathing Place one hand on the abdomen (just below theribs) and the other hand on the middle of the chestto increase the awareness of the position of thediaphragm and its function in breathing. Breathe in slowly and deeply through the nose,lettingthe abdomen protrude as far as possible. Breathe out through pursed lips while tightening(contracting) the abdominal muscles. Press firmlyinward and upward on the abdomenwhilebreathing out. Repeat for 1 minute; follow with a rest period of 2minutes. Gradually increase duration up to 5 minutes,severaltimes a day (before meals and at bedtime).

Pursed-Lip BreathingGoal: To prolong exhalation and increase airwaypressureduring expiration, thus reducing the amount oftrapped air and the amount of airway resistance. Inhale through the nose while slowly counting to3the amount of time needed to say Smell a rose. Exhale slowly and evenly against pursed lips

while tightening the abdominal muscles. (Pursingthe lips increases intratracheal pressure; exhalingthrough the mouth offers less resistance to expiredair.) Count to 7 slowly while prolonging expirationthroughpursed lipsthe length of time to say Blow out thecandle. While sitting in a chair:Fold arms over theabdomen. Inhale through the nose while countingto 3 slowly. Bend forward and exhale slowlythrough pursed lips while counting to 7 slowly. While walking:Inhale while walking two steps.Exhale through pursed lips while walking four orfivesteps.



Postural Drainage Positions: lower lobes,anterior basal segment



Postural Drainage Positions: lower lobes,superior segments



Postural Drainage Positions: lower lobes,lateral basal segment



Postural Drainage Positions: upper lobes,anterior segment



Postural Drainage Positions: upper lobes,posterior segments



Postural Drainage Positions: upper lobes,apical segment



Percussion and Vibration

Proper hand position

for percussion.

Proper technique for vibration.

The wrists & elbows remain stiff;

the vibrating motion is produced

by the shoulder muscles.

Proper hand position for

vibration.



High-Frequency Chest Wall OscillationVest



Patient Teaching: Home Oxygen (SeeChart 25-2)

Safety considerations

Flow rate and flow adjustment

Maintenance of equipment

Identification of malfunction

Humidification

Ordering of supplies and oxygen

Signs and symptoms to report

Diet and activity, travel

Electrical outlets


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CHART 25-2 HOME CARE CHECKLIST Oxygen Therapy

At the completion of the home care instruction, the patient orcaregiver will be able to:

PATIENT CAREGIVER

State proper care of and administration of oxygen to patient State physicians prescription for oxygen and the manner in which it is to be used Indicate when a humidifiershould be used

Identify signs and symptoms indicating the need for change in oxygen therapy Describe precautions and safety measures to be used when oxygen is in use Know NOT to smoke while using oxygen Post No smokingoxygen in use signs on doors Notify local firedepartment and electric company of oxygen use in home Keep oxygen tank at least 15 feet away from matches, candles, gas stove,or other source of flame Keep oxygen tank 5 feet away from TV, radio, and other appliances Keep oxygen tank out of direct sunlight When traveling in automobile, place oxygen tank on floorbehind front seat If traveling by airplane, notify air carrier of need for oxygen at least 2 weeks in advance State how and when to place an order for more oxygen Describe a diet that meets energy demands

Maintain equipment properly Demonstrate correct adjustment of prescribed flowrate Describe how to clean and when to replace oxygen tubing Identify when a portable oxygen delivery device should be used Demonstrate safe and appropriate use of portable oxygen delivery device Identify causes of malfunction of equipment and when to call for replacement ofequipment Describe the importance of determining that all electrical outlets are working properly


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Endotracheal Intubation

Placement of a tube to provide a patent airway formechanical ventilation and for removal of secretions

Purpose and complications related to the tube cuff

Assessment of cuff pressure

See Charts 25-7 and 25-8

Patient assessment

Risk for injury/airway compromise related to tuberemoval

Patient and family teaching


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Chart 25-7Care of the Patient With an Endotracheal Tube

Immediately After Intubation1. Check symmetry of chest expansion.2. Auscultate breath sounds of anterior and lateral chestbilaterally.3. Obtain order for chest x-ray to verify proper tubeplacement.4. Check cuff pressure every 68 hours.5. Monitor for signs and symptoms of aspiration.

6. Ensure high humidity; a visible mist should appear inthe T-piece or ventilator tubing.7. Administer oxygen concentration as prescribed byphysician.8. Secure the tube to the patients face with tape, andmark the proximal end for position maintenance.a. Cut proximal end of tube if it is longer than 7.5 cm (3inches) to prevent kinking.b. Insert an oral airway or mouth device to prevent thepatient from biting and obstructing the tube.9. Use sterile suction technique and airway care toprevent iatrogenic contamination and infection.10. Continue to reposition patient every 2 hours and asneeded to prevent atelectasis and to optimize lungexpansion.11. Provide oral hygiene and suction the oropharynxwhenever necessary.

Extubation (Removal of Endotracheal Tube)1. Explain procedure.2. Have self-inflatingbag and mask ready in caseventilatory assistance is required immediately afterextubation.3. Suction the tracheobronchial tree and oropharynx,removetape, and then deflatethe cuff.4. Give 100% oxygen for a few breaths, then insert a

new, sterile suction catheter inside tube.5. Have the patient inhale. At peak inspiration remove thetube, suctioning the airway through the tube as it ispulled out.Note: In some hospitals this procedure can be performedby respiratory therapists; in others, by nurses. Checkhospital policy.Care of Patient Following Extubation1. Give heated humidity and oxygen by face mask andmaintain the patient in a sitting or high Fowlers position.2. Monitor respiratory rate and quality of chestexcursions.Note stridor, color change, and change in mentalalertness or behavior.3. Monitor the patients oxygen level using a pulseoximeter.4. Keep NPO or give only ice chips for next few hours.5. Provide mouth care.6. Teach patient how to perform coughing and deep

breathing exercises.


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Endotracheal Tube

Endotracheal tube in place. The tube has been

inserted using the oral route. The cuff has beeninflated to maintain the tubes position & to minimize

the risk of aspiration.


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Tracheostomy (See Chart 25-9)

Bypasses the upper airway to bypass an obstruction,allow removal of secretions, permit long-term mechanical

ventilation, prevent aspirations of secretions, or replacean endotracheal tube

Complications include bleeding, pneumothorax,aspiration, subcutaneous or mediastinal emphysema,laryngeal nerve damage, posterior tracheal wall

penetration.

Long-term complications include airway obstruction,infection, rupture of the innominate artery, dysphagia,fistula formation, tracheal dilatation, and trachealischemia and necrosis.


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Tracheostomy Tubes

Fenestrated tube, w/c allows pt. To talk.

Double-cuffed tube. Inflating the 2 cuffs

alternately can help prevent tracheal damage.


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Nursing Diagnoses: Patients withEndotracheal Intubation or Tracheostomy

Communication

Anxiety

Knowledge deficit

Ineffective airway clearanceSee Chart 25-10

Potential for infection


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Mechanical Ventilation

Positive or negative pressure breathing device tomaintain ventilation or oxygenation

IndicationsSee Chart 25-11

Negative pressure

Iron lung, chest cuirass

Positive pressure

Pressure-cycled

Time-cycled

Volume-cycled


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Ventilators


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Noninvasive Positive-Pressure Ventilation

Use of mask or other device to maintain a seal andpermit ventilation

Indications

Continuous positive airway pressure (CPAP)

Bi-level positive airway pressure (bi-PAP)


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Nursing Process: The Care of Patients whoare Mechanically Ventilated: Assessment Assessment of the patient

Systematic assessment; include all body systems In-depth respiratory assessment, including all

indicators of oxygenation status

Comfort

Coping, emotional needs

Communication

Assessment of equipmentSee Table 25-2


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Nursing Process: The Care of Patients whoare Mechanically Ventilated: Diagnosis

Impaired gas exchange

Ineffective airway clearance Risk for trauma

Impaired physical mobility

Impaired verbal communication Defensive coping

Powerlessness


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Collaborative Problems

Alterations in cardiac function

Barotrauma

Pulmonary infection

Sepsis


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Nursing Process: The Care of Patients whoare Mechanically Ventilated: Planning

Goals include optimal gas exchange, maintenance ofpatent airway, optimal mobility, absence of trauma or

infection, adjustment to nonverbal methods ofcommunication, acquisition of successful copingmeasures, and absence of complications.


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Impaired Gas Exchange

Monitor ABGs and other indicators of hypoxia. Notetrends.

Auscultate lung sounds frequently.

Judicious use of analgesics

Monitor fluid balance.

A complex diagnosis that requires a collaborativeapproach


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Impaired Airway Clearance

Assess lung sounds at least every 2-4 hours.

Measures to clear airway: suctioning, CPT, position

changes, promote mobility

Humidification

Medications


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Risk for Trauma and Infection

Infection control measures

Tube care

Cuff management

Oral care

Elevation of HOB


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Other Interventions

ROM and mobility; get out of bed

Communication methods

Stress reduction techniques

Interventions to promote coping

Include in care: family teaching, and the emotional and

coping support of the family.

Home ventilator careSee Chart 25-13and 25-14


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Weaning

Process of withdrawal of dependence upon the ventilator

Successful weaning is a collaborative process.

Criteria for weaning

Patient preparation

Methods of weaning

See Chart 25-15


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Patients Undergoing Thoracic Surgery

Preoperative assessment

Preoperative preparation

Patient teaching

Reduction of anxiety

Postoperative expectations

Strategies to reduce postoperative complications:atelectasis and infection


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Chest Drainage

Used to treat spontaneous and traumatic pneumothorax

Used postop to re-expand the lung & remove excess air, fluid,

blood

Types of drainage systems: See Table 25-3

Traditional water seal

Dry suction water seal

Dry suction

Management: See Chart 25-18

Prevention of cardiopulmonary complications: See Chart 25-19


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Chest Tube Drainage System


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Heimlich Valve


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Patient Teaching and Home CareConsiderations

Breathing and coughing techniques

Positioning

Addressing pain and discomfort

Promoting mobility and arm and shoulder exercises

Diet

Prevention of infection

Signs and symptoms to report


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Technique for Supporting Incision While aPatient Coughs


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Arm and Shoulder Exercises

Ch. 25- Respi. Care Modalities

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