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Chapter 28
Care of
Patients Requiring
Oxygen Therapy
Or Tracheostomy
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Why Do We Need Oxygen?
Essential for life and function of cells/tissues
Respiratory, cardiovascular, hematologic
systems work together, providing sufficient
tissue perfusion to the body
Oxygen therapy improves oxygenation and
tissue perfusion
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Clinical Manifestations of
Respiratory Distress
Dyspnea
Nasal flaring
Use of accessory muscles to breathe
Pursed-lip or diaphragmatic breathing
Decreased endurance
Skin, mucous membrane changes (pallor,
cyanosis)
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Respiratory Assessment
Nose and sinuses
Pharynx, trachea, larynx
Lungs and thorax
Movement/symmetry/fremitus
Resonance
Breath sounds
General appearance (muscle development)
Skin and mucous membranes
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Oxygen Intake and
Oxygen Delivery
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Assessment of Oxygenation
ABG analysis is best way to determine need
for oxygen therapy.
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Oxygen Therapy
Purpose—relieves hypoxemia
Hypoxemia—low levels of oxygen in the blood
Hypoxia—decreased tissue oxygenation
Goal—use lowest fraction of inspired oxygen
for acceptable blood oxygen level without
causing harmful side effects
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Hazards & Complications
of Oxygen Therapy
Combustion
Oxygen-induced hypoventilation
Hypercarbia—retention of CO2
CO2 narcosis—loss of sensitivity to high levels of
CO2
Oxygen toxicity
Absorption atelectasis—new onset of
crackles/decreased breath sounds
Drying of mucous membranes
Infection
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Oxygen Delivery Systems
Type used depends on:
Oxygen concentration required/achieved
Importance of accuracy and control of oxygen
concentration
Patient comfort
Importance of humidity
Patient mobility
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Low-Flow Oxygen Delivery Systems
Does not provide enough flow to meet total
oxygen and air volume
Nasal cannula (1-6 L)
Facemask
•
•
•
Simple
Partial rebreather
Non-rebreather
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Nasal Cannula
Flow rates of 1-6 L/min
O2 concentration of 24%44% (1-6 L/min)
Flow rate >6 L/min does not
increase O2 because
anatomical dead space is full
Assess patency of nostrils
Assess for changes in
respiratory rate and depth
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Simple Facemask
Delivers O2 up to 40%-60%
Minimum of 5 L/min
Mask fits securely over nose and mouth
Monitor closely for risk of aspiration
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Partial Rebreather Mask
Provides 60%-75% with flow rate of 6-11 L/min
One third exhaled tidal volume with each
breath
Adjust flow rate to keep reservoir bag inflated
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Non-Rebreather Mask
Highest O2 level
Can deliver FIO2
greater than 90%
Used for unstable
patients requiring
intubation
Ensure valves are
patent and functional
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High-Flow Oxygen
Delivery Systems
High-flow—can deliver 24%-100% at 8-15
L/min
Venturi mask
Face tent
Aerosol mask
Tracheostomy collar
T-piece
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Venturi Mask
Adaptor located between
bottom of mask and O2
sources
Delivers precise O2
concentration—best
device for chronic lung
disease
Switch to nasal cannula
during mealtimes
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T-Piece
Delivers desired FIO2 for
tracheostomy,
laryngectomy, ET tubes
Ensures humidification
through creation of mist
Mist should be seen
during inspiration and
expiration
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Noninvasive Positive-Pressure
Ventilation (NPPV)
Uses positive pressure to keep alveoli open,
improve gas exchange without airway
intubation
BiPAP
CPAP
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CPAP (Cont.)
Delivers set positive airway pressure
throughout each cycle of inhalation and
exhalation
Opens collapsed alveoli
Used for atelectasis after surgery or cardiacinduced pulmonary edema; sleep apnea
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Transtracheal Oxygen
Delivery (TTO)
Long-term delivery of O2 directly into lungs
Small flexible catheter is passed into trachea
through small incision
Avoids irritation that nasal prongs cause; is
more comfortable
Flow rates prescribed for rest, activity
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Home Oxygen Therapy
Criteria for equipment
Patient education:
Compressed gas in tank or cylinder
Liquid oxygen in reservoir
Oxygen concentrator
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Tracheostomy
Tracheotomy—surgical incision into trachea
for purpose of establishing an airway
Tracheostomy—stoma (opening) that results
from tracheotomy
May be temporary or
permanent
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Possible Complications
of Tracheostomy
Pneumothorax
Subcutaneous emphysema
Bleeding
Infection
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Tracheostomy Tubes
Disposable or reusable
Cuffed tube or tube without cuff for airway
maintenance
Inner cannula disposable or reusable
Fenestrated tube
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Tracheostomy Tubes
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Care Issues for the Patient
with a Tracheostomy
Prevention of tissue damage:
Cuff pressure can cause mucosal ischemia
Use minimal leak and occlusive techniques
Check cuff pressure often
Prevent tube friction and movement
Prevent/treat malnutrition, hemodynamic
instability, hypoxia
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Causes of Hypoxia in the
Tracheostomy
Ineffective oxygenation before, during, after
suctioning
Use of catheter that is too large for the
artificial airway
Prolonged suctioning time
Excessive suction pressure
Too frequent suctioning
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Tracheostomy Care
Assess the patient
Secure tracheostomy tubes in place
Prevent accidental decannulation
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Air Warming and Humidification
Tracheostomy tube bypasses nose and
mouth, which normally humidify, warm, and
filter air
Air must be humidified
Maintain proper temperature
Ensure adequate hydration
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Suctioning
Maintains patent airway, promotes gas
exchange
Assess the need in patients who cannot
cough adequately
Done through nose or mouth
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Complications of Suctioning
Hypoxia
Tissue (mucosal) trauma
Infection
Vagal stimulation, bronchospasm
Cardiac dysrhythmias from induced hypoxia
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Bronchial and Oral Hygiene
Turn/reposition every 1 to 2 hours, support
out-of-bed activities, encourage early
ambulation
Coughing and deep breathing, chest
percussion, vibration, and postural drainage
promote pulmonary cure
Avoid glycerin swabs or mouthwash
containing alcohol for oral care; assess for
ulcers, bacterial/fungal growth, infection
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Nutrition with Tracheostomy
Swallowing can be a major problem for
patients with tracheostomy tube
If balloon is inflated, can interfere with
passage of food through the esophagus
Elevate head of bed for at least 30 min after
eating to prevent aspiration during swallowing
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Weaning from a
Tracheostomy Tube
Weaning—gradual decrease in tube size;
ultimate removal of tube
Cuff is deflated when patient can manage
secretions; does not need assisted ventilation
Change from cuffed to uncuffed tube
Size of tube decreased by capping; use
smaller fenestrated tube
Tracheostomy button has potential danger of
getting dislodged
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A patient was admitted with a diagnosis of
respiratory failure 3 weeks ago. She required an
artificial airway (tracheostomy) to help clear her
secretions. The previous shift nurse reports that
the patient had a very restless night with a drop
in her O2 saturation level several times despite
her O2 being set at 40% via trach collar. The
previous shift nurse also reports that the patient
experienced tachycardia and tachypnea during
the night.
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(Cont.)
The nurse immediately checks on the patient
and finds that she appears anxious and her vital
signs are as follows:
Blood pressure: 128/84 mm Hg
Heart rate: 114 (sinus tachycardia)
Respiratory rate: 24 and labored
Temperature: 99.4º F (axillary)
O2 saturation: 91% on 40% O2 via trach collar
Which of these findings are cause for concern?
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(Cont.)
Based on the patient’s vital signs, what is the
appropriate nursing action?
A. Inform the provider of abnormal vital signs.
B. Complete an assessment of airway and
respiratory status.
C. Provide patient teaching regarding relaxation
techniques.
D. Notify the Rapid Response Team for extra
assistance.
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(Cont.)
As the assessment is completed, the nurse observes
that the patient has a large amount of thick secretions
visible in the trach.
What is the priority nursing action?
A. Add pulmonary toileting to daily interventions.
B. Instruct the UAP to sit with the patient until she is calmer.
C. Call the respiratory therapist for a stat bronchodilator
treatment.
D. Suction the artificial airway and remove the secretions.
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(Cont.)
After morning care, the student nurse is to perform
tracheostomy care under the RN’s supervision.
Which instructions does the RN give the student nurse?
(Select all that apply.)
A.
B.
C.
D.
E.
Create a sterile field.
Change trach ties if soiled.
Remove old dressings and excess secretions.
Suction the tracheostomy tube after the trach care.
Clean the inner cannula with full-strength hydrogen
peroxide.
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Chapter 28
Audience Response System
Questions
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Question 1
True or False: Flammable solutions containing
high concentrations of alcohol or oil should not
be used in rooms with oxygen. Therefore, hand
hygiene using alcohol-based foams or gels
should be avoided when caring for patients on
oxygen therapy.
A. True
B. False
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Question 2
The nurse is caring for a patient with a cuffed
tracheostomy and is aware the patient is at risk
for developing which complication?
A.
B.
C.
D.
Pneumothorax
Tracheomalacia
Subcutaneous emphysema
Trachea–innominate artery fistula
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Question 3
While suctioning a patient, vagal stimulation
occurs. What is the appropriate nursing action?
A.
B.
C.
D.
Instruct the patient to cough.
Place the patient in a high Fowler’s position.
Oxygenate the patient with 100% oxygen.
Instruct the patient to breathe slowly and deeply.
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Chapter 27
Assessment of the
Respiratory System
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Anatomy & Physiology Review
Upper respiratory tract
Lower respiratory tract
Lungs
Accessory muscles of respiration
Oxygen delivery and the oxygen-hemoglobin
dissociation curve
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Role of the Respiratory System
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Relevant Patient History
Family and personal data
Smoking (pack-years)
Drug use
Allergies
Travel, geographic area of residence
Nutritional status
Cough, sputum production, chest pain,
dyspnea, PND, orthopnea
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Assessment of the
Nose & Sinuses
External nose – Deformities or tumors
Nares – Symmetry of size and shape
Nasal cavity – Color, swelling, drainage,
bleeding
Mucous membranes – Abnormalities
Septal deviation
Turbinates
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Assessment of the
Nose & Sinuses (Cont.)
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Assessment of the
Pharynx, Trachea, & Larynx
Mouth
Posterior pharynx
Neck – Symmetry, alignment, masses,
swelling, bruises, use of accessory neck
muscles for breathing
Trachea – Palpate for position, mobility,
tenderness, masses
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Assessment of the
Pharynx, Trachea, & Larynx (Cont.)
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Assessment of the
Lungs & Thorax
Inspect thorax with patient sitting up
Observe chest, compare one side with the
other
Work from the apex, move downward toward
base (from side to side)
Rate, rhythm, depth of inspiration as well as
symmetry of chest movement
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Assessment of the
Lungs & Thorax (Cont.)
Examine AP diameter with lateral diameter
Distance between ribs (intercostal space)
Palpate to assess respiratory movement,
symmetry
Crepitus
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Assessment of the
Lungs & Thorax (Cont.)
Diaphragmatic excursion
Lung sounds
Bronchial
Bronchovesicular
Vesicular
Adventitious sounds
Crackles
Wheezes
Rhonchi
Pleural friction rub
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Assessment of the
Lungs & Thorax (Cont.)
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Other Indicators of
Respiratory Adequacy
Clubbing of fingers
Weight loss
Unevenly developed muscles
Skin and mucous membrane changes
General appearance
Activity tolerance
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Psychosocial Assessment
Stress may worsen some respiratory
problems
Chronic respiratory disease may cause
changes in family roles, social isolation,
financial problems due to unemployment or
disability
Discuss coping mechanisms, offer access to
support systems
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Laboratory Tests
Blood
Sputum
Standard chest x-rays, digital chest
radiography, CT
Ventilation and perfusion scan
Pulse oximetry (noninvasive)
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Pulmonary Function Testing
Noninvasive
Evaluate lung volumes and capacities, flow
rates, diffusion capacity, gas exchange,
airway resistance, distribution of ventilation
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Capnometry & Capnography
Noninvasive
Measure amount of carbon dioxide present in
exhaled air
Normal pressure of PETCO2 is between 20
and 40 mm Hg
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Other Noninvasive Testing
Exercise testing
Skin testing
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Invasive Diagnostic Tests
Bronchoscopy
Thoracentesis – Aspiration of pleural
fluid or air from pleural space
Stinging sensation and feeling of
pressure
Correct position
Motionless patient
Follow-up assessment for
complications
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Lung Biopsy
Invasive
Obtain tissue for histologic analysis, culture,
cytologic examination
May be performed in patient’s room
Follow-up care:
Assess vital signs, breath sounds at least every 4
hours for 24 hours
Assess for respiratory distress
Report reduced/absent breath sounds immediately
Monitor for hemoptysis
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Chapter 27
Audience Response System
Questions
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Question 1
The nurse understands that the expected
assessment for the older adult related to the
natural aging process of the respiratory system
includes which finding?
A.
B.
C.
D.
Tightening of the vocal cords
Decrease in residual volume
Decrease in the anteroposterior diameter
Decrease in respiratory muscle strength
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Question 2
The nurse knows that under normal physiologic
conditions of tissue perfusion, a patient will
have what percent of oxygen dissociate from
the hemoglobin molecule?
A.
B.
C.
D.
25%
50%
75%
100%
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Question 3
The nurse understands which symptom to be a
hallmark subjective sign of lung disease?
A.
B.
C.
D.
Cough
Dyspnea
Chest pain
Sputum production
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