Care of patients with o2 or tracheostomy – Chapter 28 – Flashcards
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oxygen therapy
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-used for hypoxemia (low o2 in blood) -used for hypoxia (low oxygenation) -atmosphere is about 21% -use this therapy when needs can not be met by this 21% alone -normal flow with someone with hypoxia requires flow at 2-4 l/min via cannula -40% flow with a venturi mask -giving oxygen helps body compensation when something is going wrong with either the respiratory, cardiac, or blood
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BEST PRACTICES AND OXYGEN THERAPY
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-check the prescription for the type of delivery and also the rate -of rate is at 4l or more, obtain a humidification equipment -be sure everything functions properly -check the skin sight every 4-8 hours for irritation -mouth care q 8 hours -pad the elastic tubing and move it every so often to prevent skin breakdown -rinse the tubing every 4-8 hours with warm clear water
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hazards and complications of o2: combustion
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-o2 does not burn but if there is a fire it would burn quicker -open fires even small ones should not be in the same room as oxygen therapy -grounded plugs in the same room -pretty much anything that can cause as flame should not be around oxygen.
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hazards and complications of o2: o2 induced hypoventilation
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-at first it was thought that anyone with chronic lung disease could not have o2 therapy because they thought it induced hypoventiliation and hypercarbia (co2 elevation) -research now disproves this hypoxic drive theory and it is now none people with respiratory distress are at risk for hypercapnia but not reduced respiratory effort -o2 is given at lowest liter flow to manage hypoxemia (venturi mask preferred)
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hazards and complications of o2: oxygen toxicity
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-related to the concentration of oxygen delivered, duration, and degree of lung disease that patient has -50% greater than 24-48 hours can damage the lungs initial problems: -dyspnea, nonproductive cough, chest pain beneath the sternum, GI upset, crackles on auscultation later problems: -decreased vital capacity, decreased compliance, hypoxemia prolonged exposure: -atelectasis, pulmonary edema, hemorrhage, hyaline membrane formation may result -lowest level needed for that patient is prescribed for this patient as treatment -monitor ABGs during therapy -high levels of oxygen will become avoided unless a crisis develops
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hazards and complications of o2: absorptive atelectasis
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-79% of RA is nitrogen and this prevents the collapse of alveolar -nitrogen becomes diluted when high flow oxygen is given and the alveoli collapse -collapsed alveoli cause atelectasis which can be detected as crackles and decreased breath sounds on auscultation action alert; monitor a patient getting high levels of o2 closely for indications of absorptive atelectasis (new onset crackles and decreased breathe sounds) every 1 to 2 hours when o2 therapy is started.
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hazards and complications of o2: drying of mucuous membrane
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-higher than 4l a minute you should humidify the delivery system. watch for o2 bubbles -another method is a large volume jet nebulizer in most form (aerosol) -heated nebulizer raises the humidity even more and is used for o2 delivery through an artificial airway -these humidity delivery systems use sterile water -some tubings have a water trap to avoid this problem -watch for condensation in the tubing and remove it by disconnecting the tubing and emptying the water
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hazards and complications of o2: infection
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-the humidifier or nebulizer can be a source of bacteria especially if heated -o2 delivery equipment can be a good place for organisms -change equipment per policy which is usually every 24 hours to 7 days
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WHICH MANIFESTATIONS IN A CLIENT RECEIVING OXYGEN THERAPY AT 60% FOR MORE THAN 24 HOURS ALERT THE NURSE TO THE POSSIBILITY OF OXYGEN TOXICITY?
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discomfort or pain under the sternum -wasn't o2 saturation higher than 100 -wasn't decrease rate and depth (A. atelectasis) -wasn't wheezing on inhalation and exhale
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oxygen delivery systems
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-usually depends on; concentration needed for the patient concentration achieved by the system accuracy and control of the concentration patient comfort importance of humidity patient mobility -classified by rate of o2 delivery and considered either low or high flow systems. -low flow system has a low fraction of inspired o2 (fio2) and therefore do not provide enough o2 to meet total o2 need and air volume of the patient. -in simple words this patient is still getting air from the room and is not solely relying on the delivery system. -high flow systems have a flow rate that meets requirements regardless of the patient's breathing pattern. -used for critically ill people
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low flow oxygen delivery systems
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-nasal cannula -simple facemask -partial rebreather mask -non rebreather mask -these systems are easy to use but the o2 delivered amounts varies and depends on the patient's breathing pattern -oxygen is delivered with room air (21%) and lowers the amount actually inspired
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nasal cannula (with chart from chap)
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NASAL CANNULA; 24% = 1l/min 28% = 2l/min 32% = 3l/min 36% = 4l/min 40% = 5l/min 44% = 6l/min -ensure prongs facing the right way -apply water soluble jelly at nares -assess the nostrils -assess the respiratory patterns -flow greater than 6l/min do not increase gas exchange because of the anatomic dead space (place where air flows but the structures are too thick for gas exchange) is full -also high flows = mucosal irritation -cannula is common for anyone with chronic lung disease and anyone needing long term therapy.
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simple facemask (chart included)
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40% at 5l/min 45% at 6l/min 55% at 8l/min -be sure mask goes over the nose and mouth -assess the skin and provide skin care -monitor the patient for risk of aspiration -provide emotional support -switch to cannula during meals (ask hcp) -used to delivery oxygen concentrations of 40-60% for short term delivery of oxygenation -minimum of 5l/min is needed to prevent rebreathing of exhaled air
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partial rebreather mask (chart included)
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60-75% at 6-11 l/min is used -liter flow rate high enough to maintain reservoir bag two thirds full during inspiration and expiration -make sure the bag does not twist or kink which results in a deflated bag -adjust the flow rate to keep the reservoir bag inflated -it is a mask with a reservoir bag -with each breath, the patient rebreathes one third of the exhaled tidal volume, which is high in o2 and increases fraction of inspired o2 -the bag must remain slightly inflated at the end of the inspiration
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non-rebreather mask (chart included)
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80-95% fio2 at a liter flow high enough to maintain reservoir bag 2/3 full -provides the highest o2 delivery of low flow and can delivery an fio2 of 90% or greater -this is used commonly for someone with an unstable respiratory status or may require incubation -has a one way valve between the mask and the reservoir has 2 flaps over the exhale ports -valve allows the patient to draw all needed o2 from the bag, and the flaps prevent room air from entering though the exhalation ports diluting the o2 concentration. -exhalation the air leaves through the exhalation ports while the one way valve prevents exhaled air from re entering there reservoir bag.
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high flow delivery systems
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venturi mask aerosol mask face tent tracheostomy collar t-piece
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venturi mask
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-delivers the most accurate oxygen concentration without intubation -it pulls an amount of room air from each liter flow of oxygen which is predetermined -an adaptor is located at the bottom of the mask and oxygen source. -adaptors can change with bigger or smaller holes to allow a certain amount of room air into the oxygen (very accurate) -humidification is not needed with a venturi mask
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other high flow systems
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-include the face tent, aerosol mask, tracheostomy collar, and the t piece -often used to provide high humidity with o2 delivery -a dial on the humidity source regulates this delivery -face tent is good for someone with facial trauma or burns -aerosol mask is used when high humidity is needed -trach collar is used to delivery high humidity and o2 to someone with a tracheostomy -t piece is used to delivery any desired fio2 to a patient with a trace, laryngectomy, or endotracheal tube
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noninvasive positive pressure ventilation (NPPV)
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-technique using positive pressure to keep alveoli open without intubation -used to manage dyspnea, hypercarbia, and acute exacerbations of COPD -although this avoids some issues of intubation it has issues of its own -mask must fit tightly for a proper seal which can cause skin breakdown -leaks can cause uncomfortable pressure around the eyes -gastric insufflation can lead to vomiting -NPPV is only used for alert patients who can protect their airway
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NPPV cont.
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-can delivery o2 or just room air -three most common systems of NPPV; continuous positive airway pressure (CPAP) -delivers a set positive airway pressure throughout each cycle of inhale and exhale volume limited or flow limited -set tidal volume with the patient's inspiration effort pressure limited -includes pressure support, pressure control, and bi level positive airway pressure (biPAP) which cycles different pressures at inspiration and expiration
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BiPAP
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-cycling machine delivers a set inspiratory positive pressure each time the patient inspires. -as he begins to exhale, the machine delivers a lower set expiratory pressure -these two pressure changes improve tidal volume, reduce respiratory rate, and may relieve dyspnea.
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CPAP
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-the effect is to open collapsed alveoli -atelectasis patients or COPD or cardiac induced pulmonary edema -it doesn't work well for someone with respiratory failure following extubation
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alternate uses and NPPV
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-can be used for sleep apnea -effect holds open the airways -DNR order and the use of a NPPV is controversial
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transtracheal oxygen therapy
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-transtracheal oxygen (TTO) is a long term method of delivering oxygen directly into the lungs. -a small flexible catheter is passed into the trachea through a small incision. -avoids the use of a cannula and is less visible -TTO team gives information on this to the patient and the care of it that is needed -flow rates are prescribed for rest and activity -cannula is used when this gets cleaned
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home care management
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-must be stable before home o2 is considered -must have severe hypoxemia and paps less than 55 or arterial o2 sat less than 88 on room air and at rest for insurance purposes.
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self management education
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-use and safety aspects -given in 1 of 3 ways; 1 = compressed gas in a tank 2 = liquid o2 in a reservoir (o2, evaporates without continuous use) 3 = compressed gas in an o2 tank (green). this option is most commonly used. large tank for stationary purposes and a small tank to travel -tanks must always be u right on a rack -if they get knocked over could decompress and move in an uncontrolled manner
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oxygen concentrator
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-is a machine that removes nitrogen from the room air increasing oxygen levels to above 90% (nitrogen to prevent collapse of alveoli?) -not an expensive system and does not need to be filled -used at home as a stationary system
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FOR WHICH ACTIVITY DOES THE NURSE TEACH THE CLIENT WHO IS RECEIVING O2 BY A TTO DELIVERY SYSTEM TO SWITCH TO A NASAL CANNULA O2 DELIVERY SYSTEM?
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cleaning the catheter. -eating a meal does not interfere -sleeping at night does not interfere -performing mouth care does not interfere
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tracheostomy
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-tracheotomy is the incision into the trachea to create an airway. -tracheostomy is the opening as the result of this surgery -can be an emergency or scheduled -temporary or permanent -key for temporary placement is assess the readiness of the patient to decannulation
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NANDA priorities
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-impaired gas exchange r/t weak chest muscles, obstruction, physical problems that caused the need for the trach -impaired verbal communication -potential for infection
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pre operative care
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-focus on their knowledge deficit through teaching, discuss care, communication, and speech
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operative procedure
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-neck is extended and an endotracheal tube is placed by the provider to maintain the airway -incision are made through the neck and tracheal rings to enter the trachea -ET tube is removed when the trachea tube is inserted -trach tube is secured in place with sutures and ties or velcro tube holders -chest x ray determines proper placement
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post operative care
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-focus care on ensuring patent airway -confirm the presence of bilateral breathe sounds -perform respiratory assessment hourly
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complications: tube obstruction
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-secretions or by cuff displacement -indicators include difficulty breathing, noisy respirations, difficulty inserting a suction catheter, thick dry secretions, and unexplained peak pressures -assess the patient hourly for tube patency -prevent obstruction by helping the patient cough and deep breathe
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complications: tube dislogement
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-can occur when the tube is not secure -do not pull on the patient -tube dislogement within the first 72 hours is a emergency because the trachea tract has not matured and replacement is hard -"false passage" is when the tube is in the subcutaneous tissue instead of the trachea -obese or people with short or long necks make recannulation difficult -make sure there is a tracheostomy tube on the bedside that is exactly the same -if decannulation occurs after 72 hours, extend the neck and open the tissue with a curved kelly clamp to secure the airway -the doctor will determine if the patient is high risk and the facility will have precautions in place -critical rescue; is tube is dislodged on an immature track, ventilate the patient using manual resuscitation bag and face mask while another nurse calls rapid response
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pneumothorax (air in the chest cavity)
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-is basically a collapsed lung -can happen during the procedure if the chest cavity is entered -chest x ray post placement is used to assess for pneumothorax
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subcutaneous emphysema
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-occurs when there is an opening or a tear in the trachea and air escapes into the fresh tissue planes of the neck -air can progress throughout the chest and other tissues into the face -inspect and palpate for air under the skin around the new tracheostomy critical rescue; if the skin around a new track is puffy and you feel a crackling sensation when pressing on the skin, notify the physician right away
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bleeding
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-bleeding is small amounts from the incision is expected for the first few days -constant oozing is abnormal -wrap gauze around the tube and pack the gauze gently into the wound to apply pressure to the bleeding site
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infection
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-can occur at any time -sterile technique is used to prevent infection at the hospital during suctioning and trach care -assess the stoma site at least q 8 hours for purulent drainage, redness, pain, or swelling -trach dressing are used to keep the stoma clean and dry -do not cut dressings because small bits of gauze can be aspirated through the tube
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tracheostomy tube information
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-many types of tubes are used -depends on the needs of the patient -many sizes and plastic or metal -can be either with a cuff or an inner cannula -mechanical ventilation = cuffed tube -noncuffed tube = mechanical ventilation not required -for tubes with a reusable inner cannula, inspect, suction, and clean the inner cannula -perform cannula care every 30 to 60 minutes for the first 24 hours or as needed -teach the patient to remove this inner cannula and check for cleanliness at home. -must also teach about suctioning and tracheostomy cleaning -breathing and swallowing move the tube, a cuffed tube does not protect against aspiration -cuffed tube inflated may give a false sense of security that aspiration cannot occur during feeding or mouth care -pilot balloon does not reflect weather the correct amount of air is present in the cuff -PAGE 524 PICTURES
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fenestrated tube
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-functions in many different ways -when the inner cannula is in place, fenestration is closed and this tube works like a double lumen tube -air can pass through the fenestration around the tube and up through the natural airway so a patient can speak and cough -if they have trouble with this they should be evaluated -this tube may or may not have a cuff -with a cuff some air flows through the natural airway action alert; always deflate the cuff before capping the tube with decannulation cap otherwise there is no airway
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care issues for a patient with a trach: tissue damage
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-can occur at the point where the cuff presses against the tracheal mucosa -mucosal ischemia can occur from too much pressure on the mucosa -keep the cuff pressure at 14-20 mm hg -check cuff pressure at least once per shift -other risks for damage include malnourished, dehydration, hypoxic, older, or receiving corticosteroids -all of this = risk for tissue damage -tube friction and movement damage the mucosa and lead to tracheal stenosis
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ensuring air warming and humification
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-this tube bypasses the nose and mouth which is what normally warms and humidifies inspired air. -tracheal damage can occur without this warming -thick dried secretions can occlude airways -humidify the air as prescribed to avoid this -assess for a fine mist emerging from the trach collar or t piece during ventilation -warming device can also be used attached to the water source with a temp probe in the tubing circuit -monitor temps of this hourly by feeling the tubing and checking the probe -air should be 98.6 - 100.4
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suctioning and trach care
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-this maintains patent airway and promotes gas exchange -assess the need for suctioning (audible or noisy secretions, crackles, wheezes heard, restlessness, increase RR, mucus present in airway) -another indicator is increased peak airway pressure on the ventilator
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deep endotracheal suctioning
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-is painful -provide verbal communication of the discomfort and reassurance when the procedure will end
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sucioning cont.
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-usually performed through an artificial airway but the nose or mouth can be used -suctioning can cause hypoxia, mucosal trauma, infection, vagal stimulation, bronchospasm, cardiac dysrhythmias -suction only for 10 to 15 seconds -assess for hypoxia while suctioning -don't suction too often, prolonged, or non rotation of the catheter -trach first then suction nose or mouth
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nose suctioning
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-similar complications as through any other airway and also causes pain and discomfort
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vagal stimulation and bronchospams
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-vagal stimulation = bradycardia, hypotension, heart block, ventricular tachycardia, or other dysrhythmias -stop suctioning and give o2 therapy with manual 100% o2 -bronchospasm may occur when the catheter passes the airway
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DURING NASOTRACHEAL SUCTIONING, THE CLIENT'S HEART RATE GOES FROM 78 TO 48. WHAT IS THE NURSE'S BEST FIRST ACTION?
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-immediately stop suctioning
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providing tracheostomy care
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-keeps the tube free of secretions, maintains the airway, and provides wound care -usually every 8 hours or as needed -keep the tube secure because movement can cause irritation, coughing, decannulation critical rescue; prevent decannulation during care by keeping old ties or holder on the tube while applying new ties or holder or by keeping a hand on the tube until it is stable. (with another person)
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TRACHEOSTOMY CARE
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1 assemble the necessary equipment 2 wash hands maintain standard precautions 3 suction the trach tube as needed 4 remove old dressings and excess secretions 5 set up the sterile field 6 remove and clean inner cannula. hydrogen peroxide half strength to clean and sterile saline to rinse it. 7 clean the stoama site why hydrogen peroxide half strength and sterile saline. 8 change trach ties if they are soiled. secure new ties in place before removing old ones. only 1 finger should be able to be placed between the tie tape and the neck 9 wash hands. document.
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providing bronchial and oral hygiene
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-bronchial promotes a patent airway and prevents infection -turn and reposition the patient every 2 hours -support out of bed activities -use a sponge cleaner for oral hygiene to have a clean moist environment -rinse mouth every 4 hours with normal saline -examine mouth for any sores or damage or dental issues
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ensuring nutrition
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-can be very tough for this patient -trach tube can sometimes tether the larynx in place not allowing it to lift and move forward like normal -result of this is difficulty swallowing -keep the head of the bed elevated for at least 30 minutes post meal
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PREVENTING ASPIRATION DURING SWALLOWING
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-don't eat while fatigued -provide small and frequent meals -provide time and don't rush these people -close supervision -emergency suction equipment near by -avoid thin liquids -thicken all food and liquids -be upright -slow eating -don't consecutively swallow
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maintaining communication
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-patient can speak when there is a cuffless tube, fenestrated tube, and when he fenestrated tube is capped or covered -until natural speech is feasible, teach them another way of communication means -writing, pictures, flash cards, hand signals, computer, call light -this is a stressor for the patient and is identified as a important nursing action -when the patient is ready they can place a finger over the tube on exhalation, forcing air through the larynx and mouth allowing speech -one way valve tool to allow for speech rather than a finger occlusion -valve allows them to breathe through the tube and on exhale the valve is closed forcing air through the vocal cords -must not have a ventilator or have a cuff inflated. must be able to breathe around the tube
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the weaning process
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1 - cuff is deflated when the patient can manage secretions and does not need mechanical ventilation 2 - tube is changed to an uncuffed tube. 3 - size of tube is gradually decreased tracheostomy button can be used for transition to natural breathing -button maintains stoma patency and assists inbreathing
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community based care
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-most of the teaching is done prior to discharge -patient will know how to care for it, eat, suction, and learn communication -use a shower shield over the tube to prevent water into the airway
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SAFE AND EFFECTIVE CARE
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-do not allow water condensation back into the system -use sterile technique while performing endo trach suctioning -inspect oral mucous membrane each shift -keep an extra tube and insertion tray on bedside for first 72 hours after a tracheostomy has been made -never use oral suction to suction an artificial airway
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HEALTH PROMOTION AND MAINTAINENCE
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-home management and oxygen therapy, don't smoke around it, no open flames in the same room as the oxygen (candle, smoking)
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PHYSIOLOGICAL INTEGRITY
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-apply o2 to anyone who is hypoxemic -humidify o2 therapy -monitor ABGs and saturation for anyone with o2 therapy -assess the skin under the mask or plastic tubing every shift for breakdown -assess skin of the nares and under the elastic band every shift -observe anyone getting a flow rate higher than 50% for oxygen toxicity including signs of dyspnea, nonproductive cough, chest pain, GI upset -use manual resuscitation bag to ventilate someone with a dislodged tube and call for help -assess new stoma once per shift for infection -keep tracheal cuff pressure between 14 and 20 to prevent tissue injury in the trachea
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---------------CHAPTER ENDS ------------
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--------------------PRACTICE QUESTIONS BEGIN-----------------
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The peak pressure alarm is sounding on the ventilator of a client with a recent tracheostomy. What intervention should be done first?
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Assess the client's respiratory status. The client must always be assessed before attention is turned to equipment. If the alarm is sounding as an indicator of worsening client condition, reducing the sensitivity is harmful. Suctioning the client may not even be needed; the client's respiratory status must be assessed before such a determination can be reached.
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Which action is a priority safety precaution when performing tracheostomy care?
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Securing new ties before removing the old ones Keeping the tube in place to prevent accidental decannulation is critical. Old ties or Velcro should be kept in place until the new ones are secure. Cleaning the stoma, replacing the disposable cannula, and assessing for skin breakdown are important, but maintaining the placement of the tube is the priority.
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The client coughs and expels the tracheostomy tube. The nurse inserts a new tracheostomy tube and auscultates the lungs, but cannot hear breath sounds. What is the nurse's next best action?
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Ventilate with a bag-valve-mask and ensure the Rapid Response Team is notified. The nurse may request assistance from another nurse, a respiratory therapist, or a health care provider if needed and should ventilate the client with a bag-valve-mask until the airway can be secured. The Rapid Response Team should be notified by another nurse. A simple facemask should not be used because the client has a tracheostomy. Ordering a chest x-ray for a pneumothorax is not an appropriate intervention. Assessing for air under the tracheostomy should be done, but is not a priority.
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When assessing the adequacy of a client's oxygenation, which information is important for the nurse to note?
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Partial pressure of arterial oxygen (Pao2) Pao2 is a measure of the amount of oxygen in the arterial blood. Fio2 is a measure of the inspired oxygen, which may not all be absorbed. PEEP is a measure of positive expiratory pressure for a client on a ventilator. CPAP is a delivery system, not a measure of oxygenation.
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To minimize hypoxia during suctioning of a tracheostomy, which action must the nurse perform?
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Preoxygenate for 30 seconds to 3 minutes before suctioning. Applying and/or increasing the oxygen level before suctioning a tracheostomy can improve presuctioning levels and thus decrease hypoxia with the procedure. Suction should be applied to the catheter only during withdrawal, or it increases hypoxia. Suctioning frequently for at least 20 seconds would be a safety risk for the client. Suctioning may trigger coughing; however, this will not decrease hypoxia.
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The nurse is caring for a client the day after tracheostomy placement and notes new swelling around the tube. When gently palpating the area, the nurse feels a crackling sensation. What is the appropriate response?
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Notify the health care provider immediately. This assessment finding indicates there is subcutaneous emphysema. The provider should be notified immediately because this can worsen as air spreads into the surrounding tissues of the face and chest. An occlusive pressure dressing will not correct this complication. Routine care of securing and protecting the tracheostomy does not address the problem.
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A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first?
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Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. Because a fresh tracheostomy stoma will collapse, the client will lose airway patency, which will require the nurse to ventilate the client through the mouth and nose while waiting for assistance to recannulate the client. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the client. Auscultation of the client's breath sounds at this time will not improve the client's respiratory status and will be ineffective until airway patency is restored. Further, auscultation should not be done while a nasal cannula is simultaneously applied. Effective use of a 100% non-rebreather mask requires a patent airway. During the first 72 hours following a tracheostomy, reinsertion of the tube is difficult and should not be attempted by the nurse. Reinsertion of the tracheostomy tube should be done once a Rapid Response Team is available to accomplish this.
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The risk of aspiration during oral intake with a tracheostomy is related to which factor?
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Proximity of the tracheostomy tube to the epiglottis Due to the normal close proximity of the trachea and the esophagus, a tracheostomy tube can potentially interfere with protecting the airway during swallowing. A pressurized cuff on a tracheostomy tube doesn't provide assurance against aspiration during swallowing. Although xerostomia will make eating more challenging, it doesn't directly cause an increased risk of aspiration.
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The nurse is caring for a client with facial burns from a house fire. Which mode of oxygen delivery is recommended for this client?
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face tent The face tent allows oxygen delivery without touching the face. It is recommended for facial trauma and facial burns to reduce the risk of pressure-related complications and to promote healing. Because a simple facemask, Venturi mask, and nasal cannula rest on the face, they would not provide this benefit.
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The nurse is assisting a client with a tracheostomy to eat. Which is an important nursing action to help the client swallow and avoid aspiration?
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Elevate the head of the bed for at least 30 minutes after eating. The nurse should elevate the head of the bed during eating and for at least 30 minutes after eating to prevent aspiration and reflux. The client should be encouraged to take "dry swallows" between bites of food to clear the esophagus. Increasing the pressure puts pressure on the esophagus. Clients should take small amounts of fluids from a spoon to facilitate swallowing.
