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wvc ch. 30 Iggy
Care for pts who need oxygen administration/tracheostomy
| Question | Answer |
|---|---|
| When a problem occurs in the respiratory system that interferes with adequate oxygenation, what systems work harder to restore balance and maintain oxygenation and tissue perfusion? | *cardiac system *hematologic system |
| Oxygen is a drug used for relief of… | *hypoxemia (low levels O2 in blood) *hypoxia (decreased tissue oxygenation) |
| Oxygen content of atmospheric air… | 21% |
| Oxygen therapy is prescribed when… | the oxygen needs of the pt cannot be met by atmospheric or “room air” alone. |
| Conditions outside respiratory syst that increase oxygen demand, decrease oxygen-carrying capability ob blood, or decrease cardiac output that also require oxygen therapy… | *Heart Failure *sepsis *fever *some poisons *decreased hgb levels *poor hgb quality |
| The goal of oxygen therapy… | to use the lowest fraction of inspired oxygen (FiO2) to have an acceptable blood oxygen level without causing harmful side effects. |
| Hypercarbia | increased partial pressure of arterial carbon dioxide (PaCO2) levels |
| Hypercarbia needs… | lower levels of oxygen delivery, usually 1 to 2 L/min via nasal cannula to prevent decreased respiratory effort. |
| A low PaO2 level is the pts… | primary drive for breathing. |
| What is the best measure for determining the need for oxygen therapy? | Arterial Blood Gas (ABG) analysis |
| Hazards and complications of Oxygen Therapy… | *Combustion *Oxygen-Induced Hypoventilation *Oxygen toxicity *Absorption Atelectasis *Drying of mucous membranes *Infection |
| Oxygen-Induced Hypoventilation | assess for this in a pt whose main respiratory drive is hypoxia (hypoxic drive) such as in pts with chronic lung disease who has CO2 retention (hypercarbia) |
| What happens in pts with Oxygen-Induced Hypoventilation? | arterial CO2 (PaCO2) level for these pts ↑ over time. central chemoreceptors in the brain(medulla) are normally sensitive to PaCO2 levels.when these chemoreceptors are active, they stimulate breathing and ↑ RR.when PaCO2 ↑ over 60-65 mm Hg, this normal m |
| Loss of sensitivity to rising levels of PaCO2… | CO2 necrosisin these pts, the stimulus to breathe is a DECREASED arterial OXYGEN level. |
| Oxygen Therapy needed for a pt with Oxygen-Induced Hypoventilation | *lowest liter flow: 1, 2, or 3 L/min to tx hypoxemia *Venturi Mask (a system that delivers more precise O2 levels) |
| Manifestations of hypoventilation can be seen within… | the first 30 minutes of oxygen therapy.-->pts color typically improves to pink from ashen gray d/t increased in PaO2 levels before apnea or respiratory arrest occurs from loss of hypoxic drive |
| Therefore, you want to observe and monitor for what in Oxygen-Induced Hypoventilation… | *LOC *Resp. pattern and rate *pulse oximetry |
| Oxygen Toxicity | realted to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung disease present |
| Typically, an oxygen level greater than what may damage the lungs? | oxygen level greater than 50% given continuously for more than 24-48 hrs may damage the lungs. |
| Initial s/s of oxygen toxicity | *nonproductive cough *substernal chest px *GI upset *dyspnea |
| Prolonged exposure to high levels of oxygen can damage lung tissues and lead to… | *Atelectasis *pulmonary edema *hemorrhage *hyaline membrane formation |
| Closely monitor arterial blood gases (ABG’s) during oxygen therapy and notify the physician of… | PaO2 levels >90 mmHg. |
| Absorption Atelectasis | when high levels of oxygen are delivered and the nitrogen is diluted, oxygen diffuses from the alveoli into circulation and the alveoli collapse |
| Nitrogen in the air normally helps… | maintain patent airways and alveoli |
| Nitrogen makes up… | 79% of room air -- >prevents alveolar collapse |
| Absorption Atelectasis is detected by… | auscultatio-- >monitor closely for crackles and decreased breath sounds every 1-2 hours when oxygen is started |
| When oxygen flow rate is higher than ___ L/min, humidity is added. | 4 L/min thru a bubble humidifier, large volume jet nebulizer in mist (aerosol) form |
| The purpose for humidifying oxygen delivery? | to prevent drying out the mucous membranes |
| A heated nebulizer raises the humidity even more and is used when… | oxygen is delivered thru artificial airway (endotracheal tube) |
| For pts to properly receive humidified oxygen, the humidifier/nebulizer must have.. | a sufficient amount of sterile water and the flow rate must be adequate. |
| Condensation often forms in the tubing that needs to be removed by… | disconnecting the tubing and emptying-- >need to be careful to not drain this condensation back into humidifier/nebulizer to prevent bacterial contamination |
| The humidifier/nebulizer itself may be a source of bacteria, especially if it is heated. What is the protocol for changing this equipment? | change every 24 hrs for humidification systems and every 7 days or prn for nasal cannulas and masks. |
| The type of oxygen delivery system used depends on… | *O2 concentration needed *O2 conc. Achieved by a delivery syst. *Importance of accuracy and control of the O2 conc. *pt comfort *expense to pt *importance of humidity *pt mobility |
| Oxygen delivery systems are classified by… | the rate of oxygen delivery. |
| There are two oxygen delivery systems: | *low-flow systems *high flow systems |
| Low flow systems do not provide enuf flow of oxygen to… | meet the total oxygen needs and air volume of a pt. |
| High flow systems have a flow rate able to… | meet the entire oxygen need and tidal volume regardless of pts breathing patterns. |
| High-flow systems are used for | critically ill pts and delivery of precise levels of oxygen is needed. |
| Low-flow delivery systems include… | *nasal cannula *simple facemask *partial rebreather mask *non-rebreather mask |
| A disadvantage of low flow delivery systems | the actual amount of oxygen delivered varies and depends on pts breathing pattern. |
| Nasal Cannula | *flow rate of 1-6 L/min *oxygen concentrations of 24% (at 1 L/min) to 44% (at 6 L/min) can be achieved |
| The nasal cannula is often used for pts with.. | chronic lung disease or any pt needing long term therapy |
| The pt who retains CO2 rarely is prescribed to receive oxygen at a rate higher than… | 2-3 L/min d/t risk of losing the drive to breathe. |
| Facemasks | *able to deliver a wide range of oxygen flow rates/concentrations *there are simple facemasks, partial rebreather and non-rebreather masks |
| Simple facemasks | *deliver O2 conc. of 40-60% for short term O2 therapy or in emergency *a minimum of 5 L/min needed to prevent rebreathing of exhaled air *give special attention of skin care under mask and elastic strap and proper fitting so inspired O2 levels are maint |
| Partial rebreather masks | *deliver O2 conc. of 60-75% w/ flow rates of 6-11 L/min *mask with a reservoir bag w/ no flaps |
| How partial rebreather masks work | pt first rebreaths with each breath 1/3 of the exhaled tidal volume, which is high in oxygen and provides a high fraction of inspired oxygen (FiO2) |
| When using a partial rebreather mask, be sure that… | the bag remains slightly inflated at the end of inspiration, otherwise the pt will not be getting the desired amount of oxygen |
| Non-rebreather masks | *provide highest O2 level of low flow systems *Inspired air(FiO2) of greater than 90% *has a one-way valve between the mask and reservoir and two flaps over the exhalation ports |
| Non-rebreather masks are often used for pts whose… | respiratory status is unstable and who may require intubation. |
| How a non-rebreather mask works | during exhalation, air leaves thru exhalation ports while the one-way valve prevents exhaled air from re-entering the reservoir bag. |
| Flow rate of O2 for non-rebreather masks | 10-15 L/min to keep bag inflated during inhalation |
| High-Flow oxygen delivery systems include | *venture mask *aerosol mask *face tent *tracheostomy collar *T-piece |
| These high-flow oxygen delivery systems deliver… | an accurate oxygen level that meets the pts oxygen needs when properly fitted. |
| A high-flow oxygen system delivers oxygen concentrations from… | 24% to 100% at 8-15 L/min |
| Venturi Masks (aka venti masks) | *delivers the most accurate O2 concentration *works by pulling in a proportional amount of room air for each liter flow of oxygen *adapter between bottom of mask and oxygen source |
| These adaptors on the venturi's masks have holes of different sizes that allow… | specific amounts of air to mix with the oxygen being administered-- >more precise delivery of O2 results |
| Each adaptor also determines… | the needed flow rate. |
| What is not needed for a venture mask? | humidification |
| A Venturi mask is best used for a pt with… | chronic lung disease because it delivers a more precise oxygen concentration. |
| Face tents, aerosol masks, tracheostomy collars, and T-pieces are often used… | to provide humidity with oxygen delivery |
| Face Tent | *fits over chin, with top extended half way across face *O2 level delivered varies *useful for facial trauma/burns d/t loose fit |
| Aerosol Mask | *used when high humidity is needed after extubation or upper resp. surgery or for thick secretions |
| Tracheostomy collars are used… | to deliver high humidity and the desired oxygen to the pt with a tracheostomy |
| T-piece | special adaptor used to deliver any desired inspired oxygen to the pt with tracheostomy, laryngectomy or endotracheal tube. |
| Non-invasive Positive-Pressure Ventilation | a technique in using positive pressure to keep the alveoli open to improve gas exchange w/o the need for airway intubation. |
| NPPV can deliver oxygen or may use… | just room air-- >a nasal mask or full-face mask delivery system allows mechanical delivery of either bi-level positive airway pressure (BiPAP) or nasal continuous positive airway pressure (CPAP) |
| BiPAP | a cycling machine delivers a set inspiratory positive airway pressure each time the pt begins to inspire. As pt begins to exhale, machine delivers a lower set end-expiratory pressure. Together these two pressures increase TIDAL VOLUME. |
| Nasal CPAP | delivers set positive airway pressure thru out each cycle of inhalation and exhalation *effect is to open collapsed alveoli |
| Pts who benefit from CPAP | *those with atelectasis after surgery *or cardiac induced pulmonary edema *for sleep apnea-- >used for this to hold open upper airways. |
| Transtracheal Oxygen Therapy (TTO) | long-term method of delivering oxygen directly into lungs thru flexible catheter passed into trachea-- >pts claim more cosmetically acceptable than nasal cannula. |
| Home oxygen therapy is provided in 3 ways: | *compressed gas in a tank/cylinder *liquid oxygen in a reservoir *oxygen concentrator—>humidification is rarely used for any of these, but may be helpful when flow rate > 4L/min |
| A safety precaution for oxygen in tanks/cylinders | tanks must always be placed in a stand or rack upright. |
| Liquid Oxygen | *pt fills portable tank from a large stationary liquid vessel *lasts longer than gaseous oxygen in tank *however, is expensive and evaporates if not used continuously |
| Oxygen concentrator | removes nitrogen, water vapor, and hydrocarbons from room air *O2 concentrated from room air and delivered at more than 90% *machine is noisy, large *least expensive system *does not need to be filled *used in home as stationary system |
| Tracheotomy | surgical incision into trachea to create an airway. |
| Tracheostomy | the tracheal stoma, or opening that results from the tracheotomy *can be an emergency procedure or scheduled *can be temporary or permanent |
| Some indications for a tracheostomy | *acute airway obstruction *need for airway protection *laryngeal trauma *airway involvement during head/neck surgery. |
| Nursing Dx for tracheostomy | *Impaired gas exchange *Impaired verbal comm.. *Imbalanced Nutrition *Risk for infection *Impaired Oral Mucous Membranes *Impaired social interaction |
| Complications associated with Tracheostomy | *tube obstruction *Tube dislodgement or accidental decannulation *Pneumothorax *Subcutaneous Emphysema *Bleeding *Infection |
| Tube obstruction occurs as a result of… | secretions or cuff displacement |
| Indicators of obstruction: | *difficulty breathing *noisy respirations *difficulty inserting a suction catheter |
| Suctioning maintains… | a patent airway and promotes gas exchange by removing secretions |
| Suctioning is needed when… | audible or noisy secretions, crackles, or wheezes are heard on auscultation or when restlessness, increased pulse or RR, or mucous in the artificial airway are present or at pt request. |
| Suctioning is performed most often… | through and artificial airway but can be accomplished either thru the nose or the mouth. |
| Suctioning can cause… | *hypoxia *tissue (mucosal) trauma *infection *vagal stimulation *bronchospasm *cardiac dysrhythmias |
| Hypoxia can be caused by these factors in the pt with a tracheostomy | *ineffective oxygenation before, during and after suctioning *use of a catheter that is too large for artificial airway *prolonged suctioning time *excessive suction pressure *too frequent suctioning. |
| Prevent hypoxia by… | hyperoxygenating the pt with 100% oxygen with a manual resuscitation bag attached to an oxygen source |
| If possible, what should be monitored while suctioning is taking place? | Heart rate or pulse oximetry to assess tolerance of the procedure. |
| How to assess for hypoxia | *increased HR and BP *oxygen desaturation *cyanosis *restlessness/anxiety *cardiac dysrythmias |
| Oxygen saturation below ____% by pulse oximetry indicates hypoxemia. | 90% |
| What to do if hypoxia occurs: | *stop procedure (suctioning) *reoxygenate pt with 100% oxygen delivery system until baseline is reestablished |
| Use a catheter of the ________ _________ to reduce the risk of hypoxia. | correct size-- >size should not exceed half of the size of the tracheal lumen. (usual adult size is 12-14 fr) |
| ________ _________ can also occur from excessive suctioning or prolonged suctioning, or excessive suction pressure and rotation of catheter. | tissue trauma |
| Apply suction only during… | the withdrawl of the catheter using a twirling motion to prevent grabbing of the mucosa. |
| In addition, prolonged suctioning can cause… | alveolar collapse |
| Infection is possible d/t… | each catheter pass introduces bacteria into the trachea. |
| Vagal stimulation and bronchospasm are also possible during… | suctioning |
| Vagal stimulation results in… | *severe bradycardia *hypotension *heart block *ventricular tachycardia *asystole or other dysrythmias. |
| What to do if vagal stimulation occurs. | *stop suctioning, immediately reoxygenate pt manually with 100% oxygen. |
| Bronchospasm sometimes occurs when… | the catheter passes into the airway.--> pt may need a bronchiodilator to relieve bronchospasm and resp. distress. |
| Tracheostomy care should be performed… | every shift or prn |
| The need for suctioning and tracheostomy care is determined by… | *amount and consistency of secretions *medical dx (spec. pulmonary diseases) *ability of pt to cough/deep breathe *need for mechanical ventilation and wound care. |
| Actions taken to promotelung expansion, gas exchange and help removing secretions: | *turn or reposition every 1-2 hrs *support out-of-bed activities *encourage ambulation |
| Oral hygiene is also important in maintaining a patent airway and it is important to know that you should not use certain products to do so: | glycerin swabs and mouthwash with alcohol because these products dry the mouth, change pH, and promote bacterial growth. |
| Help pts with a tracheostomy rinse their mouths every_______ hours while awake or as needed… | 4 hours |
| It is important to also examine the mouth for any loss of mucosal integrity or dental problems, but also… | apply lip balm or water soluble jelly to prevent cracked lips or skin breakdown and to promote pt comfort. |
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wvc
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