NF 28 Assisting with Respiration and Oxygen Delivery.pdf

c ha p t e r 28 Assisting with Respiration and Oxygen Delivery http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Explain how the respiratory system functions. 2. Identify three causes of hypoxia. 3. Outline...

c ha p t e r 28 Assisting with Respiration and Oxygen Delivery http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Explain how the respiratory system functions. 2. Identify three causes of hypoxia. 3. Outline procedures to follow in the event of respiratory or cardiac arrest. 4. Describe the various methods used for oxygen delivery. 5. List safety precautions to be observed when patients are receiving oxygen therapy. Clinical Practice 1. Prepare to assist patients in clearing the airway via coughing, postural drainage, suctioning, abdominal thrusts (Heimlich maneuver), and inhalation therapy. 2. Regulate oxygen flow and correctly apply an oxygen delivery device. 3. Prepare to provide care for the tracheostomy patient. 4. Prepare to care for the patient who has a chest tube and drainage system. Skills & Steps Skills Skill 28.1 Skill 28.2 Skill 28.3 Skill 28.4 Using a Pulse Oximeter 512 Administering Abdominal Thrusts (Heimlich Maneuver) 514 Cardiopulmonary Resuscitation 515 Administering Oxygen 520 Skill 28.5 Skill 28.6 Skill 28.7 Nasopharyngeal Suctioning 525 Endotracheal and Tracheostomy Suctioning 527 Providing Tracheostomy Care 535 Steps Steps 28.1 Maintaining a Disposable Water-Seal Chest Drainage System 530 Key Terms anoxia (ă-NŎX-ē-ă, p. 510) apnea (ĂP-nē-ă, p. 529) atelectasis (ă-tĕ-LĔK-tă-sĭs, p. 532) cannula (KĂN-ū-lă, p. 518) cyanosis (sī-ă-NŌ-sĭs, p. 511) dyspnea (DĬSP-nē-ă, p. 510) endotracheal (ĔN-dō-TRĀ-kē-ăl, p. 526) expectorate (ĕk-SPĔK-tō-rāt, p. 518) expiration (p. 509) humidifier (hū-MĬ-dĭ-fī-ĕr, p. 519) hypercapnia (hī-pĕr-KĂP-nē-ă, p. 510) Concepts Covered in This Chapter • • • • • • • • • • Acid Base Balance Anxiety Collaboration Gas Exchange Infection Inflammation Mobility Pain Patient Education Safety 508 hypoxemia (hī-pŏx-SĒ-mē-ă, p. 510) hypoxia (hĭp-ŎX-ē-ă, p. 510) inspiration (p. 509) nebulizer (NĔ-bū-lī-zĕr, p. 518) obturator (ŎB-tŭ-rā-tŏr, p. 537) retractions (p. 511) stridor (STRĪ-dŏr, p. 510) tachypnea (tă-KĬP- nē-ă, p. 510) tenacious (tĕ-NĀ-shŭs, p. 525) tracheostomy (trā-kē-ŎS-tō-mē, p. 526) OVERVIEW OF THE STRUCTURE AND FUNCTION OF THE RESPIRATORY SYSTEM WHICH STRUCTURES ARE INVOLVED IN RESPIRATION? • The nose, mouth, pharynx, larynx, and trachea comprise the upper respiratory system (Fig. 28.1). • The trachea divides into the right and left main bronchi, which lead to the right and left lungs. • The right lung has three lobes, and the left lung has two lobes. Assisting with Respiration and Oxygen Delivery CHAPTER 28 509 Pharynx Right primary bronchus Secondary (lobar) bronchi Trachea Pulmonary artery Bronchiole Tertiary (segmental) bronchi Alveolar duct Pulmonary vein Alveoli Bronchioles FIGURE 28.1 The respiratory system. • Within each lung, the bronchi divide into smaller and smaller branches and then divide into bronchioles attaching to the alveoli. • The alveoli (air sacs) are the terminal respiratory units of the lung and are lined with mucous membrane. There are between 300 million and 1 billion alveoli in the lungs. • The diaphragm beneath the lungs moves, causing enlargement of the thoracic cavity. Because of negative pressure within the cavity, inspiration (movement of air into the lungs) occurs. When the diaphragm muscle relaxes, the thoracic cavity space is decreased and air is forced out of the lungs in expiration (movement of air out of the lungs). • The chest muscles combine with diaphragm action to move air in and out of the lungs. • The respiratory muscles depend on nerve impulses from the spinal cord. • The thoracic cage allows the respiratory muscles to function correctly. WHAT ARE THE FUNCTIONS OF THE RESPIRATORY STRUCTURES? • The upper respiratory pathways carry air to and from the lungs. • Air is warmed and humidiied as it passes through the upper airway passages. • The bronchi channel air to and from the lungs. The mucous membrane lining the bronchial tree contains tiny hairlike projections, or cilia, to trap and help remove small foreign particles that are inhaled. • The mucous membrane secretes mucus that assists cilia in cleansing foreign substances from the respiratory tract. • The alveoli contain macrophages that quickly phagocytize inhaled bacteria and other foreign particles. • The mucus and cilia propel the foreign substances toward the entrance of the respiratory tract; the cough relex works to expel the secretions. • The central nervous system controls respiration. • Chemoreceptors located in the aorta and carotid arteries sense changes in oxygen or carbon dioxide and send signals to the brainstem. • Changing levels of hydrogen ions (indicated by pH), carbon dioxide, and oxygen in the blood trigger the respiratory center in the medulla to send signals through the spinal cord to the nerves that control the respiratory muscles, causing an increased or decreased rate of respiration. • During normal breathing, about 500 mL of air moves in and out of the lungs with each breath. • Oxygen diffuses across the alveolar membrane into the blood; carbon dioxide diffuses across the alveolar membrane from the blood to the alveoli. • The blood transports oxygen to the cells and carries carbon dioxide from the cells to the lungs. Most of the oxygen is transported attached to the hemoglobin molecule in the red blood cells. Most of the carbon dioxide is transported to the lungs in the plasma portion of the blood. WHAT CHANGES OCCUR WITH AGING THAT AFFECT RESPIRATION? • After age 70 there is decreased elasticity of the thorax and respiratory tissues. • Total body water decreases 50% after age 70, leading to dry respiratory membranes and thicker mucus. 510 UNIT VI Meeting Basic Physiologic Needs • Airway cilia experience some degree of impairment, decreasing their eficiency in removing mucus and foreign material. • There is a loss of elastic recoil during expiration, and respiratory muscles must be used to complete expiration. • Tissue changes cause thickening of the alveolar membrane, decreasing the ease of gas diffusion across the membrane. Oxygen saturation decreases, with partial pressure of oxygen (PaO2) dropping to 75 to 80 mm Hg from the usual 80 to 100 mm Hg. • The older adult has less respiratory reserve, making it more dificult for the body to meet increased oxygen demands. HYPOXEMIA Maintaining an open airway and providing adequate ventilation for every patient are primary nursing responsibilities. When anoxia (condition of being without oxygen) occurs, cell metabolism slows down, and some cells begin to die. Through the act of breathing, we take in air that contains approximately 21% oxygen. The most common cause of respiratory insuficiency is airway obstruction. Fortunately, obstruction is often easily reversed with positioning and suctioning techniques. Nurses must identify patients with breathing problems, take appropriate nursing actions to help relieve airway obstructions, and competently initiate or maintain oxygen therapy when it is used in the patient’s treatment. The foremost problem of the respiratory system is a disturbance in the levels of the gases oxygen and carbon dioxide in the bloodstream. This disturbance causes respiratory insuficiency, the body’s inability to meet its oxygen needs and remove excess amounts of carbon dioxide. The decreased amount of oxygen in the bloodstream is called hypoxemia and leads to less oxygen available to meet cellular needs, or hypoxia. The increased level of carbon dioxide in the blood is called hypercapnia. QSEN Considerations: Safety Hypoxemia Hypoxemia poses a dangerous threat to patients. The onset of hypoxemia may be rapid and obvious, or it may be insidious and gradual, with no clear-cut symptoms of dyspnea (dificulty breathing) or shortness of breath (SOB). The nurse must promptly recognize the problem and act swiftly when airways become obstructed. Box 28.1 lists common causes of hypoxia. QSEN Considerations: Teamwork and Collaboration Teamwork for Hypoxic Patients Persistent hypoxic states require the collaboration of a team consisting of a physician, a respiratory therapist, a laboratory technologist, and a nurse. Box 28.1 Common Causes of Hypoxia OBSTRUCTION OF THE AIRWAY • Occlusion by the tongue or mucous secretions • Inflammation from croup, asthma, tracheobronchitis, or laryngitis • Occlusion by foreign body (e.g., aspiration or vomitus) • Chemical and heat burns with inflammation • COPD causing airway collapse • Near drowning: occlusion by water RESTRICTED MOVEMENT OF THE THORACIC CAGE OR THE PLEURA • Abdominal surgery (incisional pain restricting movement) • Chest injuries (e.g., flail chest or penetrating wounds) • Pneumothorax (spontaneous or traumatic) • Extreme obesity (restricts thoracic movement) • Diseases (spinal arthritis, peritonitis, ascites, or kyphoscoliosis) DECREASED NEUROMUSCULAR FUNCTION • Depressed central nervous system (drugs, including sedatives and anesthesia agents; brain trauma; stroke) • Coma (diabetic, uremic, and from brain injuries) • Diseases (multiple sclerosis, myasthenia gravis, poliomyelitis, or Guillain-Barre syndrome) DISTURBANCES IN DIFFUSION OF GASES • Diseases (pulmonary ibrosis or emphysema) • Trauma (contusion) • Emboli, fat embolus • Tumors, benign or malignant • Respiratory distress syndrome ENVIRONMENTAL CAUSES • High altitude (decreased oxygen in the atmosphere) SYMPTOMS OF HYPOXIA The symptoms of hypoxia result from decreased oxygenation of various organs. The tissues of the body differ in their ability to survive by means of anaerobic (without oxygen) metabolism. Brain cells, however, cannot withstand deprivation of oxygen and very quickly show the effects of hypoxia. The areas of memory, judgment, and intellectual ability are most quickly affected. The heart and the retina of the eye are also highly vulnerable to hypoxia. Other organs are also affected, such as the kidneys, which retain more sodium when hypoxic. Because the brain, the retina, and the heart are most susceptible to slight changes in oxygenation, the earliest signs of hypoxia involve these organs. Patients just do not “seem right” even though the vital signs are within normal limits. There may be signs of confusion. Patients who have dificulty breathing often become anxious, and their anxiety increases the respiratory rate, although the higher rate may not increase the oxygenation. Tachypnea (fast breathing rate) or stridor (high pitched, harsh, or musical sounds on inspiration) may be present. Arrhythmias (irregular heartbeats) develop as the amount of oxygen supplied to the heart muscle is reduced. Patients with labored breathing, as Assisting with Respiration and Oxygen Delivery CHAPTER 28 Table 28.1 511 Signs of Hypoxia and Respiratory Insufficiency EARLY SIGNS Sits up to breathe INITIALLY Increased blood pressure LATER Decreased blood pressure LATEST Cyanosis Complains, “I can’t catch my breath” Increased pulse Decreased pulse Muscle retractions Memory lapse Increased respirations Arrhythmia — Mental dullness — Use of accessory muscles — Restlessness — Stridor — Think Critically High altitude Airway obstruction Gas diffusion disturbance Decreased neuromuscular function Thoracic cage movement restriction PaO2 Irritability Tachypnea HYPOXIA Restlessness Anxiety Confusion Retractions Dysrhythmia Cyanosis Cause Early sign or symptom Late sign or symptom CONCEPT MAP 28.1 Causes, signs, and symptoms of hypoxia. How would you know that a patient is in respiratory distress? What signs and symptoms might be present? PULSE OXIMETRY Pulse oximetry is used for any patient thought to be at risk of hypoxia. With the pulse oximeter, changes in arterial oxygen saturation can be continuously monitored. The device measures oxygen saturation by determining the percentage of hemoglobin that is bound with oxygen. A sensor or probe is attached to the patient on an appendage through which infrared and red light can reach the capillary vascular bed (Skill 28.1, Fig. 28.2). Oxyhemoglobin absorbs more infrared than red light. A microprocessor in the monitor receives the information from the sensor or probe, computes the saturation value, and displays it on the monitor screen. Adhesive sensors can be applied to the nose or the forehead. Clip-on probes are used on the earlobe, the ingertip, the toe, or an infant’s foot. Adhesive sensors are generally disposable, whereas clip-on probes may be reusable. Pulse oximetry is not recommended in certain situations. Clinical Cues seen in obstructive pulmonary disease or lung ibrosis, use 30% to 50% of their energy just to breathe. Cyanosis (blue tinge to skin or mucous membrane) and retractions (muscles moving inward on inspiration) of accessory muscles of the neck, chest, and abdomen are late signs of respiratory insuficiency (Table 28.1 and Concept Map 28.1). Hypoxia depresses body functions and disturbs the body’s acid base balance. Less oxygen in the bloodstream leads to respiratory acidosis (Chapter 25). Hypoxia is treated by administering oxygen and correcting the cause. Blood gases are a valuable tool for determining the degree and possible cause of hypoxia. Patients suffering from hypoxia are highly susceptible to respiratory tract infections. Inadequate inlation of the lungs results in pooling of secretions and provides a medium for growth of microorganisms. It is essential to protect the respiratory patient from hospital-acquired infections. Keep personnel and visitors with respiratory tract infections out of the patient’s environment. If the patient has on nail polish, the sensor may function best if the polish is removed or the sensor is positioned on the sides of the inger. Sensor misplacement, cyanosis, cold ingertips, reduced peripheral pulses, ambient light, and anemia are other factors that may cause inaccurate readings. Another way to measure oxygenation is by determining oxygen saturation. This is an invasive procedure usually done in the critical care unit (see Chapter 24). AIRWAY OBSTRUCTION AND RESPIRATORY ARREST Sometimes the airway becomes obstructed with a foreign object or food that is swallowed incorrectly. If a person seems to be choking and cannot breathe, there are speciic procedures that must be performed. In some cases the person will exhibit the universal signal for choking, signaling for help (Fig. 28.3). In this event, you should perform abdominal thrusts (Heimlich Skill 28.1 Using a Pulse Oximeter Pulse oximetry provides the pulse oxygen saturation level (SpO2), which is a reliable measure of oxygen saturation of the blood. It is a noninvasive measurement of the amount of oxygen carried by hemoglobin. In this manner, intermittent or continuous monitoring of oxygen saturation can be obtained. This is a painless procedure that allows immediate evaluation of the patient’s response to treatment for hypoxia. The procedure may not be accurate if the patient has had recent tests using intravenous dye, or is jaundiced. The oximeter sensor contains both red and infrared light-emitting diodes (LEDs) and a photodetector. The photodetector registers light passing through the vascular bed, and the microprocessor determines oxygen saturation from the data received. It is most accurate when there is no direct sunlight or luorescent light on the patient. The normal SpO2 is greater than 90%. The sensor should be placed on a site that is free of moisture and has good local circulation. SUPPLIES • Pulse oximeter • Probe (clip-on or adhesive) Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) Assessment (Data Collection) 1. Assess for an appropriate site for placement of the sensor. (The ingertip is the most common site because light easily passes through the tissue.) Planning 2. Set up the oximeter; plug in machine, turn on the power, and check for proper function. (Prepares machine to measure oxygen saturation. Check the manufacturer’s instruction book.) Implementation 3. Remove dark nail polish or artiicial nail if using a ingertip sensor. (Dark nail polish or artiicial nails may distort readings.) 4. Attach the correct sensor for the site lush to the skin and secure it. (Different sensor probes are used for the ingertip, the toe, or the earlobe. Probe must be in contact with the skin to produce accurate readings.) 5. Set machine alarms to predetermined saturation levels if monitoring is to be continuous. Tell patient alarm will sound if probe falls off or is moved. Correlate oximeter pulse rate with patient’s radial pulse. (Alarm sounds if saturation falls below set level or if probe is loosened or dislodged. Lets patient know what to expect.) 6. Read oxygen saturation level on screen and record it. (Provides baseline data for beginning of monitoring; 10 seconds to 2 minutes are required for stabilization of unit.) Evaluation 7. Note and record the oximeter readings every hour. (Normal SpO2 is 90% to 100%. When levels fall below 90%, action should be initiated immediately because the patient is on the brink of hypoxia; as PaO2 falls, a more rapid decrease occurs in oxygen saturation of the blood because of the oxyhemoglobin dissociation curve.) 8. Rotate site of the clip-on probes every 4 hours and disposable probes at least every 24 hours. (Skin breakdown can occur with prolonged use of a probe. Apply skin cream to previously used areas if skin dryness occurs.) 9. Adjust oxygen low according to readings and primary care provider’s orders. (Oxygen low rate may be increased or decreased per orders depending on the SpO2 level.) 10. Check the oximeter’s calibration per manufacturer’s directions at least once a day. (Ensures that saturation readings are accurate.) 11. When the order for pulse oximetry is discontinued, take a inal reading, remove the probe, disconnect the machine, and clean the sensor site and the equipment. (Prepares equipment for next use.) 12. Record the time that procedure is discontinued and inal oximetry reading. (Veriies that testing has been discontinued.) Documentation Documentation Example Step 2 10/12 1400 SpO2 92%; O2 by nasal cannula at 4 L/min. (Nurse’s electronic signature) Assisting with Respiration and Oxygen Delivery CHAPTER 28 Special Considerations • A small portable oximeter can be used to spotcheck a patient’s oxygen saturation. The probe is applied in the same manner as in this skill. 513 Critical Thinking Questions 1. What are two nursing actions you could take if your patient, who has had trauma to the ribs and a leg fracture, develops a PaO2 of 86%? 2. What simple measures can a patient take that might increase the PaO2 when it begins to decrease? For a choking victim who becomes unconscious, start cardiopulmonary resuscitation (CPR) (Skill 28.3). Current guidelines for performing adult CPR for the health care worker and lay rescuer are listed in Table 28.2. CPR trained community bystanders are to give 30 chest compressions for every two rescue breaths. For those not CPR trained, Hands-Only (compression-only) CPR should be performed on the adult who collapses, which emphasizes the need to “push hard and fast” on the center of the chest (American Heart Association, 2015). Think Critically What are two advantages of pulse oximetry over arterial blood gases for monitoring oxygenation? CLEARING RESPIRATORY SECRETIONS FIGURE 28.2 Monitoring oxygen saturation with the pulse oximeter. FIGURE 28.3 The hand grasping the throat is the universal signal for choking. maneuver) on adults and children older than 1 year of age. For the infant less than 1 year, back slaps and chest thrusts should be delivered (Skill 28.2). For an infant, the ability to cry is the best sign that the airway is unobstructed. In the unconscious person, the most common cause of airway obstruction is the tongue. THE EFFECTIVE COUGH Mucus and secretions of the respiratory tract are typical causes of obstruction of the free passage of air. The simplest method of clearing the air passages is to cough effectively. Deep breathing and coughing are two standard measures used to clear secretions and prevent hypoxia. Deep breathing increases oxygenation, opens alveoli, and may precipitate coughing. Many patients with lung disease or the inability to expel forcibly a volume of air need to be taught how to cough effectively. They must learn to make the most of their air volume to remove the obstructing materials. Ineffective coughing spasms may produce additional hypoxia, lead to the rupture of alveoli, or even precipitate the collapse of air passages. Although forceful exhalation can be used with patients who are lying down, it is more effective in the sitting position. For forceful exhalation, the patient takes two deep breaths, inhales deeply again, then rapidly, and forcefully exhales with the mouth open. This moves secretions up the bronchial tree. Repeated forceful exhalation can bring the secretions up to a point where they can be more easily coughed up. Patient Education Deep Breathing and Coughing Have the patient sit up on the side of the bed or in a chair leaning slightly forward. If the patient cannot sit up, raise her to a high Fowler position. Demonstrate the following steps and then Text continues on page 517 514 UNIT VI Meeting Basic Physiologic Needs Skill 28.2 Administering Abdominal Thrusts (Heimlich Maneuver) Abdominal thrusts below the diaphragm, also called the Heimlich maneuver, are administered to a conscious victim with an airway obstruction. The purpose of the maneuver is to dislodge whatever is obstructing the airway and reestablish normal respiration. ACTION (RATIONALE) For a Conscious Person 1. Ask person if she can speak. (Establishes whether person can get air into and out of the lungs.) 2. If person is unable to talk or coughing is proving ineffective, position her to deliver abdominal thrusts. (Person needs assistance to dislodge obstruction.) 3. Stand behind the person and place arms around her waist. (Places hands at correct height to deliver the thrusts.) 4. Make a ist with one hand and place the other hand over the ist. (Prepares the hands to deliver a solid thrust.) 5. Place the hands slightly above the umbilicus and well below the sternum with the thumb of the ist inward. (Locates correct position for thrust delivery.) 6. Using an upward rotating motion of the ist, forcefully thrust the hands into the abdomen at an upward angle. (Creates an artiicial cough, making the diaphragm move and forcing air out of the lungs.) For an Unconscious Person 8. Call for help and/or activate emergency medical services (EMS) and slide the victim to the loor and place on back. (Positions victim for airway opening maneuver and inger sweeps.) 9. Begin CPR. Start with compressions. (Chest compressions may dislodge the object.) 10. Before giving breaths, open the airway using the head tilt–chin lift maneuver. Look into the mouth. If foreign matter can be seen, use the index inger of the other hand to perform a inger sweep with a hook motion, being careful not to force the object farther down the throat. (Allows rescuer to visualize the object in the mouth; inger sweep removes the object.) 11. Open airway and attempt to ventilate by pinching off the nose and placing the mouth over the patient’s mouth; if unsuccessful, reposition head and try again. (Airway must be open for air to enter the lungs. Repositioning will often open the airway.) Step 11 Step 6 7. Repeat the thrusts until the foreign body is expelled or the person becomes unconscious. (The person cannot get air into the lungs until the obstruction is removed.) 12. If ventilation is still unsuccessful, continue CPR with compressions. (Chest compressions increase airway pressure and may dislodge the object.). 13. Open the airway. If a foreign object is seen, sweep with a curved inger down inside of the cheek toward the base of the tongue, sweeping debris out the other side of the mouth. (Removes any dislodged object.) 14. Attempt to ventilate. (If airway is open, breaths will go into victim’s lungs. If airway is still obstructed, the attempt to ventilate will be unsuccessful.) Assisting with Respiration and Oxygen Delivery CHAPTER 28 15. If ventilation is not successful, repeat steps 12 to 1. Repeat sequence until foreign object is dislodged. If person resumes breathing, turn to side with arms in front of the body. (Person cannot breathe if obstruction is present. Side-lying recovery position aids continued respiration and prevents aspiration if person vomits.) For the Conscious Infant 16. Place the infant face down straddling your arm, keeping the head lower than the trunk. Place your hand under the chest and around the jaw for support. (Positions the infant for effective back blows. This position helps object move up into or out of mouth and protects the infant’s head and neck. ) 17. Deliver ive blows between the shoulder blades. (Force of the blows should dislodge foreign body.) 18. Sandwich the infant between your arms and turn her over. Hold the back of the head for support. With the head down, deliver ive chest thrusts using two ingers over the lower half of the sternum. (Helps dislodge object. Protects the head and neck.) 19. Repeat steps 17 to 18 until object is dislodged or the infant becomes unconscious. (Infant cannot breathe when object is in airway.) For the Unconscious Infant 20. Call for help and/or activate EMS. Turn the infant onto her back and place on a irm, hard surface preferably above the ground. (Positions victim for airway opening and chest compressions.) 21. Begin CPR starting with 30 compressions. (Chest compressions increase airway pressure and may dislodge the object.) 22. Perform the head tilt–chin lift to open the airway. If you can see an object, carefully perform a inger sweep to remove it. (This position allows visualization of the object in the mouth; inger sweep removes object.) 23. Attempt to ventilate with your mouth over the infant’s mouth and nose. (If airway is unobstructed, the chest will rise.) 24. If the chest does not rise, reposition the head and attempt to ventilate again. (Airway is obstructed; repositioning may open it.) 25. If still unable to ventilate, continue CPR with 30 chest compressions. (No air can reach the lungs if the airway is obstructed.) 26. Perform head tilt–chin lift and, if you can see an object, inger sweep it out. (Removes the obstructing object.) 27. Attempt to ventilate. (If airway is open, breaths will go into victim’s lungs. If airway is still obstructed, the attempt to ventilate will be unsuccessful.) 28. If ventilation is not successful, repeat steps 25 to 27 until object is dislodged. If alone, activate EMS after 2 minutes of CPR. (Repeating sequences will dislodge the object. EMS activation will bring help.) Special Considerations • If the victim is pregnant, use chest thrusts rather than abdominal thrusts to dislodge the obstruction; make a ist with one hand and place it on the lower half of the sternum with the other hand on top of the isted hand. Press straight back to administer the chest thrusts. • If the victim is obese, chest thrusts may be more effective. Critical Thinking Questions 1. What do you think are the most common causes of choking in adults? 2. What should you teach parents of young children regarding types of foods to avoid serving and supervision when children are eating? Skill 28.3 Cardiopulmonary Resuscitation CPR must be started whenever someone is found in respiratory or cardiac arrest, meaning without breathing or without a heartbeat. It is vitally important to call for help while beginning to assess the victim. The following method is appropriate 515 for adults, and it relects the 2015 American Heart Association guidelines to focus on circulation (compressions) irst, followed by airway and breathing (C-A-B). 516 UNIT VI Meeting Basic Physiologic Needs ACTION (RATIONALE) 1. Check the scene for safety. (A rescuer cannot help if he or she is injured.) 2. Shake victim and shout name or “Are you OK?” (Arouses the victim if conscious.) 3. Call for nearby help. (It is reasonable to check for breathing and a pulse before fully activating emergency medical services [EMS].) 4. Check for breathing and signs of cardiac arrest for no more than 10 seconds. Kneel beside the person, locate the victim’s larynx with two ingers, and then slide your ingers slightly laterally with gentle pressure to locate the carotid pulse. (Positions the ingers over the carotid artery to assess pulse activity.) 5. Activate EMS and get an automated external deibrillator (AED) as soon as possible. (Emergency assistance and supplies for advanced life support should arrive within minutes.) 6. Place the victim supine on a irm surface. 7. If there is a pulse but victim is not breathing, perform rescue breathing at a rate of 1 breath every 5 to 6 seconds. (Circulation of blood does not improve patient outcome if it does not carry oxygen.) 8. If there is no pulse and no breathing, place the heel of one hand on the lower half of the sternum. Place the heel of the other hand on top of the irst hand, keeping the ingers off the chest. (Positions hands for effective chest compressions and prevents damage to the liver.) 9. With your body aligned directly over the hands, depress at least 2 inches (5 cm) but no more than 2.4 inches, with equal time for compression and release. Give 30 compressions at a rate of 100 to 120/ min and minimize interruptions to <10 seconds. Push hard and fast. (Pumps blood out of the heart at a rate suficient to provide adequate oxygenation to maintain tissue life.) Step 9 10. Stop compressions. Open the airway by placing the heel of one hand on the forehead and two ingers of your other hand on the bony prominence of the chin; lift the chin to open the airway. If a mask is available, place it over the victim’s nose and mouth with the bridge of the nose as a guide. If no mask is available, maintain the head tilt and pinch the nose with your ingers. Take a deep breath and, forming a seal around the victim’s mouth with your own, give two breaths. If the irst breath does not go in, the airway may have become obstructed; reposition with the head tilt–chin lift and try to deliver the breaths again, watching for the chest to rise and fall. If the breath still does not go in and the chest does not rise, the airway is obstructed, begin compressions. (Rescue breathing opens airway and provides oxygen.) Step 10 11. When the AED arrives, place it by the victim’s side. Turn the AED on and place the pads on victim’s bare chest to assess victim’s status and deibrillate as needed. Continue as instructed by the AED. (Allows for monitoring of heart and administration of shock if needed.) 12. If there is no pulse or signs of circulation (e.g., movement) or the victim is only gasping, continue CPR sequence of 30 compressions to 2 breaths until patient responds; you are relieved or you are too exhausted to continue; or if the scene becomes unsafe. If possible, compressors should rotate every 2 minutes to prevent fatigue and ensure quality compressions. (Compressions circulate oxygenated blood, and rescue breathing opens airway and provides oxygen.) Special Considerations • When a second trained rescuer is present, and the patient is intubated or has an advanced airway (i.e., a tracheostomy): perform two-rescuer CPR with continuous chest compressions at a rate of 100 to 120/min. Breaths are simultaneously delivered at a rate of 1 breath every 6 seconds, or 10 breaths/ min. The second person is positioned directly above the victim’s head to deliver the breaths with Assisting with Respiration and Oxygen Delivery CHAPTER 28 a bag-mask device. Interruptions in CPR should be brief and as few as possible to maximize cardiac output. Rescuers should switch roles after every 5 cycles. Communication during CPR is important. The irst rescuer should count aloud while performing compressions so that the second rescuer knows when to give breaths and when to switch roles. • For chest compressions when the victim is an infant up to 1 year of age, use 2 ingers on the lower Table 28.2 517 half of the sternum and depress at least one-third the chest depth, approximately 1.5 inches (4 cm). Critical Thinking Questions 1. What do you do if the victim vomits while you are performing CPR? 2. What do you do if you come upon a motor vehicle accident victim who is still in the car, has no signs of respiration or circulation, and might have a spinal injury? Cardiopulmonary Resuscitation for Adults COMPONENT Recognize symptoms and need for assistance ACTION FOR LAY RESCUER You ind an unresponsive victim and call for help. If help arrives, have that person call 911 and get an AED if available. If no one responds, call 911 and get an AED, if available. Check the victim for breathing. If the victim is not breathing or only gasping, start CPR. As soon as an AED is available, turn the AED on. Apply pads and deibrillate, if necessary. ACTION FOR HEALTH CARE PROVIDER You ind an unresponsive victim and call for help. Check for breathing and a pulse simultaneously. If help arrives, have that person call 911 and get an AED if available. If no one responds, call 911 and get an AED, if available. If no pulse, start CPR. As soon as an AED is available, turn the AED on. Apply pads and deibrillate, if necessary. If the victim has a pulse but is not breathing, begin rescue breathing. Pulse check Lay rescuers are not taught this step. Less than 10 seconds, carotid. CPR sequence C-A-B. C-A-B. Compression rate 100 to 120/min. Pushing hard, pushing fast, and 100 to 120/min. Pushing hard, pushing fast, and alallowing the chest to recoil between compreslowing the chest to recoil between compressions sions has been found to be the most effective. has been found to be the most effective. Compression depth At least 2 inches but no more than 2.4 inches for an average-sized adult (differs for children and infants).a At least 2 inches but no more than 2.4 inches for an average-sized adult (differs for children and infants).a Compression interruption Minimize interruptions in chest compressions. Limit interruptions to less than 10 seconds (i.e., rotating compressors, delivering shock, and pulse check). Rescuers should change compressors q 2 min to prevent fatigue and decreased eficiency of compressions. Airway Untrained lay rescuers should not delay compressions to perform airway maneuvers. Trained lay rescuers perform head tilt–chin lift. Head tilt–chin lift; use jaw thrust if cervical injury is suspected. Compressionto-breaths ratio (no advanced airway placed) 30:2 Compressions only for untrained lay rescuers. For adults, 30:2 for one or two health care rescuers For infants and children, 15:2 for two health care rescuers. AED use Use as soon as possible. Use as soon as possible. AED, Automated external deibrillator; C-A-B, compression-airway-breathing; CPR, cardiopulmonary resuscitation; EMS, emergency medical services. a pediatrics text and the American Heart Association guidelines for additional data that are speciic to children and infants. Adapted from deWit, S. C., & Kumagai, C. K. (2013). Medical Surgical Nursing: Concepts and Practice. St. Louis: Elsevier Mosby. aConsult coach the patient through the steps. These exercises should be performed for at least 72 hours after surgery and during treatment and recovery from a respiratory illness. Deep Breathing • Splint an abdominal or chest incision with a small pillow. • Inhale through the nose; hold the breath for 3 to 5 seconds and then exhale through pursed lips. Keep the shoulders level and use the diaphragm and abdominal muscles to bring air into the lungs. • Repeat the sequence four more times, breathing slowly. • Take 5 to 10 deep breaths every 2 hours while awake. Effective Coughing • Take a deep breath through the nose, hold it for 3 to 5 seconds, and then exhale through pursed lips. • Take another deep breath and, in short segments, forcibly exhale in a “huff-cough” with the mouth open. In a huffcough, the patient performs a series of coughs while saying the word “huff” which prevents the glottis from closing and helps clear secretions. Expel one-third of the expiratory volume with each huff-cough. Use a tissue to cover the mouth. 518 UNIT VI Meeting Basic Physiologic Needs • Perform the sequence three times or until all secretions have been cleared. • Expectorate the secretions into a tissue; dispose of the tissue in a sealable plastic bag. • Use the huff-coughing technique at least once every 2 hours while awake, preferably once an hour. Think Critically Why do you think postural drainage and percussion should not be done right before a meal or within an hour afterward? OXYGEN ADMINISTRATION Patient Education Obtaining a Coughed Sputum Specimen A sputum specimen is best obtained just after the patient awakens or after a nebulizer treatment, because this is when mucus is more available or easier to cough up. Provide a sterile sputum cup. Instruct patient to: • Rinse the mouth with water. • Open the sputum cup and place the lid upside down on the counter or table. • Take several deep breaths, forcefully huff-cough to move secretions up, and expectorate produced sputum into the cup. • Take several more deep breaths, force another huff-cough, and expectorate produced sputum into the cup. • Repeat until about a half teaspoon of sputum is in the cup. • Place the lid on the cup without contaminating the inside of the lid or the lip of the cup. • Cleanse the mouth. • Ring for the nurse, who will collect the specimen and send it to the laboratory. POSTURAL DRAINAGE Although the respiratory therapist usually is responsible for this procedure in the inpatient setting, in community and home settings the nurse must teach patients the procedure. Different positions are used to drain different segments of the lungs so that secretions can be cleared (Fig. 28.4). As speciic segments of the lung are drained into the bronchi, the patient is able to cough more effectively and expectorate (cough up and spit out) secretions. The lungs are auscultated before and after the procedure. Generally, the patient should assume each position for 5 to 15 minutes, two to four times a day as tolerated. To prepare a patient for postural drainage, a nebulizer (a device that dispenses liquid in a ine spray) with bronchodilator or liquefying medications may be used as inhalation therapy to thin out secretions and relax spasms within the bronchial tree. Best results occur when the procedure is carried out in the morning and 45 to 60 minutes before a meal. Clinical Cues Be certain to offer mouth care after postural drainage so that the appetite is not affected by a bad taste in the mouth from coughing up secretions. Secretions and mucus plugs may be loosened by percussion of the chest. Percussion is the rhythmic clapping with cupped hands over the thoracic area, but not over the spine or sternum. After percussion and postural drainage, the patient is assisted to cough effectively and expectorate the secretions. When the patient cannot maintain a suficient amount of oxygen in the body, supplemental oxygen is often ordered. Oxygen can be administered by cannula (a tube for insertion into a cavity), mask, tent, Croupette, or catheter. Although respiratory therapists are usually responsible for setting up and supervising oxygen equipment, nurses often need to initiate therapy or supervise its use on a PRN (as needed) basis (Skill 28.4). Oxygen is a colorless, tasteless, and odorless gas that is present in the air. Oxygen is considered a drug, and it should be administered following a prescribed order, noting low rate, frequency, and route. Oxygen supports combustion. High concentrations of oxygen can cause ires to burn rapidly, and when oxygen is used in patient care, great caution must be taken to prevent ires. Another disadvantage associated with the use of the gas is that it dries the tissues of the respiratory tract. Unless moisture is added, the dried tissues may become cracked and provide less resistance to infection. Overuse of oxygen can create damaging free radicals or physiologic changes in breathing. Thus, oxygen should never be administered if not needed. Patients should be monitored and weaned from oxygen as quickly as possible. QSEN Considerations: Safety Safety Alert OXYGEN THERAPY SAFETY • Place a “No Smoking: Oxygen in Use” sign on the patient’s door and at the foot of the bed or over the head of the bed. • Remind visitors about the hazard of smoking when oxygen is in use. Teach the family to smoke only far away (outside the building) from the room where oxygen is in use. • Check all electrical devices for frayed wires, and to see that they are in good working order, to prevent short-circuit sparks that could cause a ire. • Avoid the use of bedclothes and pajamas that are made of material that can generate static electricity. Cotton fabrics are best. • Do not use oils, grease-based ointments, alcohol, ether, acetone, or other lammable materials on or near the patient when oxygen is in use. • If oxygen cylinders are being used, handle with care. Be certain they are strapped securely into stands and transport devices to prevent them from falling. Situate the cylinders away from heat and heavy trafic pathways. • Monitor the patient for skin irritation from the oxygen delivery device. • Assess for dry mucous membranes, indicating a need for humidiication to prevent tissue breakdown and increased risk for infection. Assisting with Respiration and Oxygen Delivery CHAPTER 28 Drains posterior basal segment of lower lobe Drains lateral basal segment of lower lobe Drains anterior basal segment of lower lobe Drains superior segment of lower lobe Drains lateral and medial segments of middle lobe Drains superior and inferior lingular segment 519 Drains anterior segment of upper lobe Drains posterior segment of upper lobe Drains apical segment of upper lobe FIGURE 28.4 Positions for postural drainage. The pieces of equipment needed for oxygen therapy are the oxygen source, the lowmeter, the humidifier (device supplying moisture), the tubing, and the appropriate appliance for the method ordered. Most hospitals have a central oxygen supply with outlets mounted in the wall near the patient’s bed. The lowmeter is attached to the piped-in oxygen, and it regulates the amount given (Fig. 28.5). The rate of low is prescribed by the primary care provider and may range from 2 to 12 L/min. The low rate is based on the patient’s condition and on the blood gas report or pulse oximetry. Rates of 4 to 6 L/min are common. The low rate is adjusted by turning the valve to the “on” position and continuing to turn it until the desired low level is indicated in the gauge just above the low adjustment valve (Fig. 28.6). QSEN Considerations: Safety Safety Alert SAFE OXYGEN FLOW RATES Patients with obstructive lung diseases should be given only 2 to 3 L/min because higher concentrations of oxygen reduce the respiratory rate. This is because their incentive to breathe comes from lower oxygen levels rather than higher carbon dioxide levels in the blood. (These patients commonly have a continuous high level of carbon dioxide.) Check orders for oxygen carefully and always verify high flow rates with the prescribing care provider. 520 UNIT VI Meeting Basic Physiologic Needs Skill 28.4 Administering Oxygen Oxygen therapy is ordered for patients with respiratory illnesses or those who have musculoskeletal or neurologic problems that interfere with proper oxygenation, causing hypoxia. SUPPLIES • Oxygen source • Humidiier (optional) • Oxygen delivery device • Nasal cannula • Face mask • Face tent • Oxygen lowmeter • Connecting tubing Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) Assessment (Data Collection) 1. Check the medical record for the ordered low rate and oxygen delivery method. (Ensures that patient will receive oxygen therapy as ordered.) 2. Assess patient’s breathing and lung sounds. (Provides baseline for determining whether oxygen therapy is effective.) Planning 3. Plan amount of connecting tubing to the oxygen source needed by the patient. (Length of tubing needed depends on prescribed activity level and whether oxygen needs to be continuous or intermittent.) 4. Determine whether oxygen setup will need a humidiier. (Low-low oxygen does not need a humidiier to moisten the low. If patient suffers from sinus problems, it is best to add a humidiier. Oxygen is drying to mucosa. A humidiier provides moisture.) Implementation 5. Connect the lowmeter to the piped-in oxygen outlet on the wall by pressing it irmly into the outlet. Alternately, attach the lowmeter to the oxygen cylinder. (Prepares oxygen to be dispensed in a regulated low.) 6. Attach the humidiier and the connecting tubing to the oxygen delivery device and turn on the oxygen, adjusting the low to the ordered rate. Check for low through the oxygen delivery device. (Prepares delivery system for the patient. When knob is turned on the lowmeter, the metal ball inside the glass graduated gauge rises, indicating the rate of low being delivered. The delivery rate is ordered by the primary care provider, and is commonly between 2 and 5 L/min. Feel for the low with your ingertips.) 7. Correctly position the oxygen delivery device on the patient and secure it in place. (An oxygen cannula should be positioned with nasal prongs curved downward as they go into the nares. Tubing is looped over the ears and secured in place by raising the cinch device toward the chin. Be certain the tubing is not causing pressure on the ears. A facemask should it over the nose and mouth. A face tent its below the chin and rises to cover the lower part of the face. A small tentmask its just above the upper lip and comes to a point above the nares.) 8. Instruct patient and visitors regarding safety during oxygen use. (Helps prevent ires and injury.) Evaluation 9. Ask yourself: Is the patient able to tolerate the oxygen device? Is the oxygen low at the level ordered? Is an “Oxygen in Use” sign posted? Does patient understand instructions regarding safety during oxygen administration? Is breathing less labored with oxygen administration? Is oxygen saturation improving? (Answers determine whether patient tolerates the oxygen and whether procedure is effective.) Documentation 10. Include the reason for the oxygen therapy, the time that oxygen therapy is instituted, type of oxygen delivery device in use, low rate, and whether it is continuous or PRN (as needed). (Veriies that oxygen is administered as ordered; data support charges for oxygen administration.) Documentation Example 11/16 0945 SpO2 89%; O2 ordered. Nasal cannula at 3 L/min applied. 1100 SpO2 94%. Tolerating low by cannula without complaint; no evidence of redness on ears. (Nurse’s electronic signature) Special Considerations • If patient does not tolerate oxygen delivery by one method, an order to change to another device may be needed. • If oxygen is delivered PRN by cannula, instruct the patient that it is desirable to use the oxygen after meals and during activity, when oxygen demands are higher. • Cleanse the nares regularly when oxygen is in use to prevent excessive crusting. • It is important that the patient understands the reason for and potential beneits of using the oxygen Assisting with Respiration and Oxygen Delivery CHAPTER 28 before you apply the delivery device; otherwise, compliance with use may be low. • Check the low rate each time you enter the patient’s room; the patient or a visitor may change it from what is prescribed. • Oxygen delivery devices should be turned off when not in use; instruct the patient with PRN oxygen how to do this. QSEN Considerations: Safety Safety Education • Teaching safety precautions for the home care patient is especially important because there is no medical supervision after the nurse’s visit. 521 Critical Thinking Questions 1. If you have a patient with a history of frequent sinusitis who is receiving oxygen by nasal cannula at 3 L/min and that patient complains about nasal stufiness and sinus discomfort, what actions could you perform to alleviate the problem? 2. You have a postoperative patient who is receiving oxygen by nasal cannula. The patient keeps taking off the oxygen cannula. What might you say to convince the patient to leave the oxygen cannula in place? FIGURE 28.5 Wall oxygen lowmeter and humidiier setup. FIGURE 28.6 Adjusting the oxygen lowmeter valve control. The humidiier is attached to the lowmeter and is usually situated between the lowmeter and the tubing. The oxygen bubbles through the container of water and is moisturized before entering the air passages. Check the level of luid in the container periodically during the day to ensure that it is working. When the luid level is low, notify the respiratory care department so that the unit can be replaced or reilled. In the home setting, a portable oxygen tank may be used. Portable oxygen is also used when transporting oxygen-dependent patients within the hospital. An oxygen concentrator is frequently used in the home or long-term care setting (Fig. 28.7). The machine collects and concentrates oxygen from room air, storing it for use. The machine must be plugged into an electrical outlet. Portable (battery operated) oxygen FIGURE 28.7 Oxygen concentrator. (Courtesy AirSep Corp., Buffalo, NY.) 522 UNIT VI Meeting Basic Physiologic Needs Face mask Tracheostomy collar Face tent Non-rebreathing mask FIGURE 28.8 Oxygen cannula in use by a home care patient. Venturi mask concentrators (POCs) are now available, some as small as a coffee maker, others similar in size to carry-on luggage with wheels and a telescoping handle, allowing mobility and travel for people requiring oxygen. CANNULA The nasal cannula consists of a plastic tube with short, curved prongs that extend into the nostril about ¼ to ½ inch. The cannula is held in place by looping it over the ears and cinching the tubing under the chin; it can be easily adjusted for the patient’s comfort (Fig. 28.8). A Velcro holder may be placed on top of the head to keep the tubing from causing pressure sores on the ears. The nares should be checked to be certain they are unobstructed and are not becoming excoriated. A cannula is useful for patients requiring oxygen during meals. Assignment Considerations Detecting Skin Irritation Ask the unlicensed assistive personnel (UAPs) to check the backs of the ears and the nares for tissue irritation when they assist the patient with morning care. This is especially important for older adults, who have thin, easily damaged skin. MASKS Various types of masks are available for the administration of oxygen in concentrations ranging from 24% to 55% at low rates of 3 to 7 L/min (Fig. 28.9). Oxygen concentrations above 60% are rarely used because of the danger of oxygen toxicity. Some patients dislike this method of oxygen administration because the mask must be placed over the face, and they feel claustrophobic. FIGURE 28.9 Various oxygen delivery devices. Advantages and disadvantages of various oxygen devices are listed in Table 28.3. Oxygen tents are still sometimes used, particularly for small children. Oxygen halos, Oxyhoods, or Croupettes are used for infants. Think Critically How would you explain to a patient who has oxygen ordered by cannula PRN when to use the oxygen? ARTIFICIAL AIRWAYS Artiicial airways are used for several purposes: to relieve an obstruction, to protect the airway, to facilitate suctioning, and to provide artiicial ventilation. There are two types of pharyngeal airways: the nasopharyngeal airway and the oropharyngeal airway. 523 Assisting with Respiration and Oxygen Delivery CHAPTER 28 Table 28.3 Advantages and Disadvantages of Common Oxygen Administration Devices METHOD Nasal cannula (nasal prongs) O2 DELIVERY Low concentrations; dependent on rate and depth of breathing Flows: 1 L = 24% O2 2 L = 28% O2 3 L = 32% O2 4 L = 36% O2 5 L = 40% O2 6 L = 44% O2 ADVANTAGES Patient can move about, eat, and talk while receiving oxygen. Most COPD patients can tolerate 2 L/min flow. DISADVANTAGES Restless patients can easily dislodge the prongs. Risk of skin irritation at the nares, ears, and cheeks. Flow rate 3 L and above requires humidiication because it will dry and irritate nasal mucosa. NURSING IMPLICATIONS Prongs should be curved downward when inserted in the nose; check frequently because patients tend to replace the prongs incorrectly. Clean prongs every few hours. Simple face mask Low to medium concentrations; 35%-50% can be achieved with a low rate of 6-12 L/min. The mask provides adequate humidiication; delivers oxygen quickly for short-term therapy. Discomfort and risk of pressure necrosis caused by a tight seal between the face and mask. The device must be removed for the patient to eat, drink, or take medications. Mufles the voice when talking. Requires at least 5-L low to prevent accumulation of expired air in mask. Wash and dry under the mask and wipe out the mask q 1-2 h. The mask must it snugly. The straps at the ears may need to be padded to prevent necrosis. Partial rebreathing mask Higher concentrations; 40%-60% at low rates of 6-10 L/min. The mask is lightweight; the reservoir bag traps a portion of exhaled breath that is high in oxygen for rebreathing. Risk of pressure necrosis with long-term use. Cannot be used with high humidity. The bag should not be allowed to delate during inspiration. Check the skin under the straps frequently. Non-rebreather mask Highest concentrations; 60%-90% can be achieved. Delivers a high concentration of oxygen accurately. Cannot be used with The mask should it snugly; high humidity. The check skin contact areas low rate must be suffor pressure necrosis. icient to prevent the bag from delating during inspiration. Venturi mask (“Venti mask”) Delivers consistent The mask can provide FIO2 regardless of good humidiication; the breathing patgood for delivertern. Concentraing low, constant tion and liter low (yet precise) oxygen are marked on the concentrations to the mask apparatus; patient with COPD. available for 24%, 28%, 31%, 35%, 40%, and 50% O2. Discomfort and risk of Air ports must not be ocskin irritation. Must cluded. be removed for eatCheck skin contact areas ing, drinking, and takfrequently. ing oral medications. Talking is mufled. Transtracheal catheter Delivers oxygen eficiently. Catheter replacement is an invasive procedure. Not appropriate for someone with excessive mucus production. The low requirement is reduced 60%-80%, increasing the time that oxygen is available from the portable source. The catheter is less visible. Less nasal irritation occurs. Patient and family education about catheter replacement. Continued 524 UNIT VI Meeting Basic Physiologic Needs Table 28.3 Advantages and Disadvantages of Common Oxygen Administration Devices—cont’d METHOD Tracheostomy collar O2 DELIVERY Delivers O2 and humidiication via the tracheostomy; must be connected to a nebulizer with FIO2 set at 24%-100%. ADVANTAGES Adds humidity to help liquefy secretions. Loses some O2 low because the collar is not tight itting. DISADVANTAGES Must drain the condensation in the tubing often. Risk of respiratory infection. NURSING IMPLICATIONS Drain condensation from tubing into the receptacle, being careful not to allow luid to go into the tracheostomy. Remove and clean the collar device and check the skin under the straps at least q 4 h. T-bar (Briggs adapter) Delivers O2 and humidiication to the tracheostomy; must be connected to a nebulizer with FIO2 set at 24%-100%. Fits more tightly compared with tracheostomy collar. Adds humidity to liquefy secretions. Must drain the condensation in the tubing often. Risk of respiratory infection. Drain condensation from the tubing into the receptacle; be careful not to get luid into the tracheostomy. Remove and clean the T-bar device q 4 h. From deWit, S. C. & Kumagai, C. K. (2013). Medical Surgical Nursing: Concepts and Practice (2nd ed., pp. 323). St. Louis: Elsevier Mosby. FIGURE 28.10 Types of airways (top to bottom): endotracheal, nasal, and oropharyngeal. FIGURE 28.11 Yankauer suction tip is used for oral suction. These are used to keep the tongue from falling back into the throat and are frequently required for postoperative patients until they have recovered from anesthesia (Fig. 28.10). These airways are used for patients who can breathe on their own; however, you must never leave the bedside of a patient with this type of airway in place. Endotracheal tubes (ETTs) maintain an airway in those patients who are unconscious or unable to breathe on their own. The tube is inserted by a physician or an advanced practice nurse certiied in the procedure; intubation is often done under emergency circumstances. The tube is generally removed after 48 to 72 hours, but it may be left in place for a week or more. The patient with an endotracheal tube is unable to speak because the tube sits between the vocal cords; therefore, you must ind alternate means of communication such as a communication board or writing utensils. If intubation is needed for an extended period, the patient should have a tracheostomy performed. An endotracheal tube may cause a mucosal ulcer after 5 to 7 days of use, depending on cuff pressures or type of cuff used. NASOPHARYNGEAL SUCTIONING The purpose of suctioning is to maintain a patent airway by removing accumulated secretions. When air passages are obstructed by emesis or secretions, suctioning may be a lifesaving procedure. Pharyngeal suctioning involves the upper air passages of the nose, mouth, and pharynx. Among those who may require suctioning to remove obstructing luids are infants, gravely debilitated or unconscious patients, and those with an ineffective cough. When possible, the patient should be stimulated to cough because this moves secretions up into the trachea. Oral suctioning is usually tried before nasopharyngeal suctioning because it is a more comfortable procedure for the patient. A Yankauer suction tip is attached to the suction connecting tubing, and the mouth and top of the pharynx are suctioned (Fig. 28.11). If this does not remove secretions adequately, nasopharyngeal suctioning is performed. The suction pressure should be set between 80 and 120 mm Hg. Select the suction catheter based on the size of the patient’s tube and the thickness of the secretions to be removed. Use a smaller 8- to 12-Fr. catheter for thin Assisting with Respiration and Oxygen Delivery CHAPTER 28 secretions; use a size 14- or 16-Fr. catheter for an adult with tenacious (sticky) or thick secretions. To control the amount of pressure for suctioning, place the thumb over the suction port of the catheter or the open end of a Y connector between the tubing and the catheter. When suctioning, make every effort to prevent the introduction of pathogens into the airways. Countless microorganisms are found in the upper respiratory tract, and it is virtually impossible to maintain sterility when suctioning the nose or pharynx. Clean technique and thorough hand hygiene are essential for pharyngeal suctioning of the oral and nasal cavities, but aseptic 525 technique is mandatory for suctioning the trac