Adult ATI: Airway Management Ch. 53 – Flashcards
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what does managing compromise include
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-respiratory assessment -measuring vital signs: O2 sats via pulse oximetry -administration of oxygen
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what does administering oxygen do for pts
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helps maintain adequate cellular oxygenation for clients who have many acute and chronic respiratory problems or are at risk for hypoxia
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what kind of pt's need to be administered oxygen
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-pt's who have acute/chronic respiratory problems (hypoxemia, cystic fibrosis, asthma) =pt's who are at risk for developing hypoxia (resp. illness, circulatory impairment)
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what is a nursing priority with airway management
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maintaining a patent airway
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what is involved with maintaining a patent airway
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-mobilizing secretions -suctioning airways -managing artificial airways (endotracheal tubes, tracheostomy tubes) promotes adequate gas exchange and lung expansion
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pulse oximeter
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a device with a sensor probe that attaches securely to the fingertip, toe, bridge of nose, earlobe, or forehead with a clip or band
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what does a pulse oximeter do
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measure pulse saturation (SPo2) via a wabe of infrared light that measures light absorption by oxygenated and deoxygenated hemoglobin in arterial blood
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what does SPO2 reflect
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the percent of saturation of hemoglobin (SaO2) when the SaO2 is greater than 70 percent
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how much of the atmospheric air is oxygen
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21 percent
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oxygen rates vary to maintain...
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an SpO2 of 95-100 using the lowest amount of oxygen to achieve the goal without risking complications
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FiO2 Fraction of inspired air
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the percentage of oxygen the client recieves
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what findings during your assessment would cause you to need the pulse oximetry
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-increased work of breathing -wheezing -coughing -cyanosis -changes in respiratory rate or rhythm -adventitious breath sounds -restlessness, irritability, confusion
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what are some interventions that can be done if you have a pulse oximetry reading of less than 90% (indicating hypoxemia)
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--confirm probe placement -confirm that o2 delivery system is functioning and that client is receiving the prescribed o2 levels -place the client in semi-fowler's or fowler's position to promote chest expansion and to maximize ventilation -encourage deep breathing -remain with the client and provide emotional support to decrease anxiety
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what is an acceptable range of the pulse ox.
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91-100 percent some illnesses states can allow from 85-89 percent readings of less than 90 reflect hypoxemia
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what reasons may cause a low pulse ox reading
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older adults clients who have darker skin hypothermia poor peripheral blood flow too much light low hemoglobin levels jaundice movement edema nail polish
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what is oxygen therapy used for
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treating hypoxemia (low levels of arterial oxygen)
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early manifestations of hypoxemia
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-tachypenia tachycardia restlessness anxiety confusion pale skin and mucous membranes elevated blood pressure use of accessory muscles, nasal flaring, tracheal tugging, adventitious lung sounds
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what are late manifestations of hypoxemia
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stupor cyanotic skin, mucous membranes bradypnea bradycardia hypotension cardiac dysrhythmias
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what are nursing actions that need to be considered with giving oxygen therapy
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-monitor respiratory rate and pattern -minitor level of conciousness -monitor SpO2 and ABG -provide ox. therapy at lower liter flow that will correct hypoxemia - make sure mask is placed on face correctly - assess/monitor for hypoxemia/hypercarbia (restlessness, hypertension, headache) -listen to lungs for breath sounds -assess/monitor pulse ox -promote oral hygiene -encourage turning, coughing, deep breathing and use of incentive spirometry and suctioning -assess and document the response to ox therapy -monitor for res. depression (decreased resp. rate and level of conciousness)
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what rate of flow is a nasal canula
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low flow
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nasal canula
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tubing with two small prongs fro insertion into the nares
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what is the fraction of inspired oxygen for the nasal cannula
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FIO2: 24%-44% flow rate: 1-6 L/min
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what are the advantages of a nasal cannula
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safe simple easy to apply comfortable well tolerated client able to eat, talk, ambulate
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what are the disadvantages of a nasal cannula
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FiO2 varies with the flow rate, and rate and depth of clients breathing extended use can lead to skin breakdown and dry mucous membranes tubing is easily dislodged
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what are some nursing actions to consider with the nasal cannula
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-assess patency of nares -ensure that the prongs fit in nares properly -use water soluble gel to prevent dry nares - provide humidification for flow rates of 4L/min and greater
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what rate of flow should you provide humidification
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4 L/min or greater
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Simple Face Mask
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covers clients nose and mouth
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what is the fraction of inspired ox with the simple face mask
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FiO2: 40-60 percent Flow rate: 5 L/min to ensure flushing of CO2 from mask
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what rate of flow is a simple face mask
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low flow
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what are the advantages of a simple face mask
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-easy to pply -more comfy -simple delivery method -provides humified ox
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disadvantages of a simple face mask
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-flow rate less that 5L/min can result in rebreathing of CO2 -clients who have anxiety or claustrophobia do not tolerate it well -eating, drinking and talking are impaired -moisture and pressure can collect under mask and cause skin breakdowns
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nursing actions for a simple face mask
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-assess for proper fit to ensure a secure seal over the nose and mouth -make sure client wears a nasal cannula during meals -use with caution for clients who have a high risk of aspiration or airway obstruction -look for skin breakdown
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what rate of flow is a partial rebreather mask
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low flow
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partial rebreather mask
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covers pt's nose and mouth
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what is the fraction of inspired ox for a partial rebreather mask
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FiO2: 40-70 percent Flow rate: 6-10 L/min
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what are the advantages of a partial rebreather mask
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the mask has a reservoir bag attached with no valve which allows the client to rebreath up to 1/3 of exhaled air together with room air
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disadvantages of partial rebreather
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-complete deflation of reservoir bag during inspiration causes CO2 buildup - the FiO2 varies with clients breathing pattern - clients who have anxiety or claustrophobia do not tolerate it well - eating, drinking and talking impaired
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nursing actions with a partial rebreather mask
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-keep bag from deflating by adjusting oxygen flow rate to keep bad 1/3 to 1/2 full on inspiration -asses fit to ensure a secure seal over nose and mouth -look at skin for breakdown -use with caution for pt's who have risk of aspiration/obstruction
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rate of flow for a nonbreather mask
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low flow
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what is the FiO2 and flow rate for a nonrebreather mask
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FiO2: 60-100 percent Rate: 10-15 L/min to keep bag 2/3 full during inspiration and expiration
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advantages of a nonrebreather mask
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-delivers highest O2 concentration possible (Except for intubation) - a one way valve situated between mask and reservoir allows client to inhale max o2 from reservoir bag. the two exhalation ports have flaps covering that that prevent room from entering the mask
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disadvantages of non rebreather mask
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-valve and flap on mask by be intact and functional during each breath -poorly tolerated by clients who anxiety/claustrophobia -eating, drinking, talking impaired -caution with pt with high risk of aspiration and obstruction of airway
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nursing actions of non rebreather mask
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-hourly assessment of valve and flap -asses pfit -assess for skin breakdown -use nasal canula durring meals
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low flow oxygen delivery systems
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-nasal cannula -simple face mask -partial rebreather -nonrebreather mask
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high flow oxygen delivery systems
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venturi mask aerosol mask
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what is the fraction of inspired oxygen and rate of flow for the venturi mask
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FiO2: 24-100 percent Rate: 4-12 l/min via diff. size adapters, which allow specific amounts of air to mix with oxygen
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advantages of venturi mask
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-delivers the most precise oxygen concentration -humidification not required -best for clients who have chronic lung disease
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disadvantages of venturi mask
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-use is expensive -eating, drinking, talking impaired
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nursing actions when using venturi mask
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-assess frequently to ensure an accurate flow rate -assess proper fit - assess for skin breakdown -make sure tubing is free of kinks -make sure pt's use nasal cannula sdu
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flow rate of a aerosol mask
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high flow
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aerosol mask
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aka a face tent
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tracheostomy collar
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small mask that covers the surgically created opening of the trachea
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what is the fraction of inspired ox for the aerosol mask
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FiO2: 24-100% rate: at least 10 L/mn provides high humidification with ox delivery
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advantages of aerosol mask
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-used with pt who do not tolerate masks well -useful for clients who have facial trauma, burns and thick secretions
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disadvantages of aerosol masks
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-high humidification requires frequent monitoring
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nursing actions with aerosol makss
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-empty condensation from tubing often -ensure adequate water in the humidification canister -ensure aerosol must leaves from vents during inspiration and expiration -make sure tubing does not pull on tracheostomy
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complications of oxygen therapy
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-oxygen toxicity -oxygen induced hypoventilation -combustion
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what can oxygen toxicity result from
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high concentrations of oxygen (greater than 50 percent) long durations of oxygen therapy (more than 24-48 hours) severity of lung disease
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manifestations of oxygen toxicity
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nonproductive cough substernal pain nasal stuffiness nausea vomiting fatigue headache sore throat hypoventilation
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nursing actions with oxygen toxicity
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-use lowest level of oxygen necessary to maintain an adequate SPO2 -monitor ABG's and notify provider if SPO2 levels are outside expected reference range -decrease FiO2 as the clients SPO2 improves
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what clients can oxygen induced hypoventilation happen in
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those that have conditions that cause alveolar hypoventilation can be sensitive to admin of oxygen
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nursing actions with oxygen induced hypoventilation
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-monitor respiration rate, pattern, level of conciousness, and SpO2 -provide oxygen therapy at the lowest liter flow rate that manages hypoxemia, -if they can tolerate it use a venturi mask to deliver precise oxygen levels -notify provider if impending respiratory depression such as a decreased rep. rate and a decreased LOC
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what are nursing actions that can be done to prevent combustion with use of oxygen
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-post no smoking or oxygen in use signes to alert others of a fire hazard -know where to find closest fire extinguisher - educate about the fire hazard of smoking with oxygen use -have clients ear a cotton gown because synthetic or wool fabrics can generate static electricity - ensure that all electric devices are working well -make sure all electric machinery are grounded -do not use volatile flammable materials near clients receiving oxygen
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what are nursing interventions that mobilize secretions and maintain airway patency what do these interventions do for the pt
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-assistance with coughing -hydration -positioning -humidification -nebulizer therapy -chest physiotherapy -suctioning -they promote adequate gas exchange and lung expansion
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what is at risk for developing airway compromise
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infants clients who have a neuromuscular disorders quadriplegic cystic fibrosis pt's
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indications that clients need help maintaining airway clearance
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-hypoxemia -restlessness -irritability -tachypnea -tachycardia -cyanosis -decreased levels of conciousness -adventitious breath sounds -visible secretions -absence of spontaneous cough
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what does humidification do for preventing obstruction of airways
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humidified oxygen moistens the airways which loosens and mobilizes pulmonary secretions
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what does nebulization do for ensuring airway clearance
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breaks up medications (bronchodilators, mucolytic agents) into minute particles that disperse throughout the resp. tract and improves clearance of pulmonary secretion
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what is chest physiotherapy
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the use of chest percussion, vibration , and postural drainage to help mobilize secretion
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what does chest percussion and vibration do for airway clearance
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it facilitates movement of secretions into the central airways
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what does postural drainage to for airway clearance
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one or more positions allow gravity to assist with the removal of secretions form specific areas of the lung
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what does early morning postural drainage to for airway clearance
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it mobilizes secretions that have accumulated through the night
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how should the nurse collect sputum specimens
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by suctioning during coughing
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whenever possible what should a nurse instruct the pt to do to collect a specimen or help airway clearance why?
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-encourage coughing -coughing is more effective that artificial suctioning at moving secretions into upper trachea and laryngopharynx
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what should the nurse do to avoid bacterial contamination when ensuring airway clearance and collecting a sputum specimen
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maintain surgical asepsis when performing any form of tracheal suctioning
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what is sputum specimen collection used for
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-cytology to id aberrant cell or cancer -for culture and sensitivity to grow and id micro-organisms and the antibiotics effective against them -to id acid fast bacillus to diagnose TB (requires three consecutive morning samples)
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when should you collect specimens for sputim
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in the morning
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if the pt eats when should you collect a sputum specimen and why
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wait 1 to 2 hours after they eat to decrease the likelihood of emesis or aspiration
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what kind of container should you use to collect a sputum specimen for cytology
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a container with a preservitive
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what kind of container would you use for a routine and AFB sputum specimen collection
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a sterile container
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how would you collect a sputum specimen if the client cannot cough effectively and expectorate sputum into the container
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collect the specimen by endotracheal suctioning
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when would chesty physiotherapy be contraindicated
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-pregnant -have a rib, head, chest or neck injury -have increased intracranial pressure -recent abdominal surgery -have pulmonary embolism -have bleeding disorders -have osteoporosis
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percussion
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the use of cupped hands to clap rhythmically on the chest to break up secretions
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vibrations
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the use of shaking movements during exhalation to help remove secretions
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postural drainage
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the use of various positions to allow secretions to drain by gravity
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when should you schedule chesty physiotherapy if the pt has eaten
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1 to 2 hours after eating and at bedtime to decrease the likelihood of vomiting or aspirating
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what should you do 30 min to 1 hour before postural drainage
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administer a bronchodilator meds or a nebeulizer
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how do you create vibrations to mobilize secretions in the chest
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-place hands on the affected area -tense hand and arm muscles -move the heal of the hands to create vibrations as the client exhales -have the client cough after each set of vibrations
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how long should each pt remain in each position during chest physiotherapy
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10 to 15 min to allow time for percussion, vibration, and postural drainage
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when should you discontinue chest physiotherapy
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faintness or dizziness
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what should you encourage pt's to do when you are suctioning
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breath deeply and cough in an attempt to clear the secretions with artificial suctioning
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what should you use for oropharyngeal suctioning
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a yankauer or tonsil tipped rigid suction catheter and move it around the mouth gum line and pharynx
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what do you use for nasopharyngeal suctioning and nasotracheal suctioning
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use a flexible catheter and lubricate the distal 6 to 8 cm with water soluble lubricant
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what do you use for endotracheal suctioning
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suction catheter should not exceed one half of the internal diameter of the endotracheal tube to prevent hypoxia
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the nurse should use what size ffrench suction cathetar when suctioning a 8mm endotracheal and tracheostomy tube
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16 frech
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how long should you limit each suction attempt
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10-15 secs to avoid hypoxia and the vagal response
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use suction pressure no higher than
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120-150 mmHg
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limit total suction time to
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5 min
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when should you insert the cathetar for nasopharyngeal or nastracheal suctioning
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during inhalation do not apply while inserting
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how far do you advanse the nasal suctioning cathetar
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the top of the nose to the base of the earloabe
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when do you apply suctioning nasaly
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only while withdrawing the catheter and rotating it with the thumb and forefinger
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how many passes do you do with nasopharangyl or nasotracheal suctioning
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no more than wo passes allow at least one min between passes for ventilation and oxygenation
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how far do you insert a endotracheal suctioning cathetar
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until resistance is met then pull back 1 cm prior to apply suction to prevent mucosal damage
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how should you suction with endotracheal suctioning
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intermittently by covering and releasing suction port with the thumb for 10 to 15 secs
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when do you apply suction when endotracheal suctiong
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only while withdrawing the catheter and rotating it with forefinger and thumb
