Respiratory Care Modalities Chapter 21

Chapter 21 Respiratory Care Modalities Oxygen Therapy ❖ Administration of oxygen at greater than 21% to provide adequate transport of oxygen in the blood while: o Decreasing the work of breathing and reducing stress on the myocardium ❖ Hypoxemia: a decrease in the arterial oxygen tensio...

Chapter 21 Respiratory Care Modalities Oxygen Therapy ❖ Administration of oxygen at greater than 21% to provide adequate transport of oxygen in the blood while: o Decreasing the work of breathing and reducing stress on the myocardium ❖ Hypoxemia: a decrease in the arterial oxygen tension in the blood ❖ Hypoxia: a decrease in oxygen supply to the tissues and cells that can also be caused by problems outside the respiratory system ❖ Severe hypoxia can be life threatening ❖ Refer to Chart 21-1 Copyright © 2018 Wolters Kluwer · All Rights Reserved Oxygen Toxicity ❖ May occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period ❖ Symptoms include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates on x-ray ❖ Prevention: o Use lowest effective concentrations of oxygen o PEEP or CPAP prevent or reverse atelectasis and allow lower oxygen percentages to be used Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Oxygen Administration ❖ Cylinder, piped-in, concentrator ❖ Classified as low flow or high flow ❖ Devices (Refer to Table 21-1) o Nasal cannula o Oropharyngeal catheter o Masks o Transtracheal catheter Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? The primary oxygen administration method for a patient with COPD is a nasal cannula Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer to Question #1 False The primary oxygen administration method for a patient with COPD is a Venturi mask, not a nasal cannula Copyright © 2018 Wolters Kluwer · All Rights Reserved Incentive Spirometry ❖ Two types: volume or flow ❖ Device encourages patient to inhale slowly and deeply to maximize lung inflation and alveoli expansion ❖ Used to prevent or treat atelectasis ❖ Indications: post surgery ❖ Nursing care o Positioning of patient, encourage use, set realistic goals, and record outcomes o Patient education, refer to Chart 21-3 Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Question #2 Is the following statement true or false? The patient should be encouraged to use an incentive spirometer approximately 10 breaths per hour between treatments while awake Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer to Question #2 True The patient should be encouraged to use an incentive spirometer approximately 10 breaths per hour between treatments while awake Copyright © 2018 Wolters Kluwer · All Rights Reserved Mini-Nebulizer Therapy ❖ Handheld apparatus that disperses a moisturizing agent or medication into the lungs ❖ Indication o Difficulty in clearing secretions, reduced vital capacity, and unsuccessful with simpler methods ❖ Nursing care: Refer to Chart 21-4 o Instruct patient to take slow, deep breaths through the mouth and hold a few seconds o Encourage patient to cough o Monitor effectiveness of therapy Copyright © 2018 Wolters Kluwer · All Rights Reserved Chest Physiotherapy (CPT) ❖ Includes: o Postural drainage o Chest percussion and vibration o Breathing retraining ❖ Goals: o Remove secretions o Improve ventilation o Increased efficiency of respiratory muscles Copyright © 2018 Wolters Kluwer · All Rights Reserved Postural Drainage ❖ Because the patient usually sits in an upright position, secretions are likely to accumulate in the lower parts of the lungs ❖ Allows force of gravity to assist in removal of bronchial secretions ❖ Secretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing or suctioning ❖ Used to prevent or relieve bronchial obstruction caused by accumulation of secretions ❖ Refer to Figure 21-3 for positions Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Chest percussion and vibration ❖ Chest percussion is carried out by cupping the hands and lightly striking the chest wall in a rhythmic fashion over the lung segment to be drained ❖ Vibration is the technique of applying manual compression and tremor to the chest wall during the exhalation phase of respiration ❖ See Figure 21-4 ❖ An inflatable HFCWO vest may be used to provide chest therapy (Figure 21-5) Copyright © 2018 Wolters Kluwer · All Rights Reserved Home Oxygen ❖ Nurse instructs the patient about oxygen: o Safe methods for administering in the home o Available in gas, liquid, concentrated o Portable devices o Humidity must be provided ❖ See Chart 21-2 Copyright © 2018 Wolters Kluwer · All Rights Reserved Emergency Management of Upper Airway Obstruction ❖ Acute upper airway obstruction may be caused by food particles, vomitus, blood clots, or anything that obstructs the larynx or trachea ❖ Rapid observations: o Inspection o Palpation o Auscultation ❖ As soon as it is identified, nurse takes emergency measures Copyright © 2018 Wolters Kluwer · All Rights Reserved Endotracheal Intubation ❖ Passing an endotracheal tube through the nose or mouth into the trachea ❖ Provides patent airway, access for mechanical ventilation, facilitates removal of secretions ❖ Nursing Care, refer to Chart 21-7 Copyright © 2018 Wolters Kluwer · All Rights Reserved Endotracheal Tube Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Tracheostomy ❖ Surgical procedure in which an opening is made into the trachea ❖ The indwelling tube inserted into the trachea is called a tracheostomy tube (Fig. 21-7) ❖ Preventing Complications Associated With Endotracheal and Tracheostomy Tubes, refer to Chart 21-8 ❖ Guidelines for performing tracheal suctioning, refer to lww.com/Brunner14e Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Management of Tracheostomy ❖ Continuous monitoring and assessment ❖ Maintain patency by proper suctioning ❖ Semi-Fowler ❖ Administer analgesia and sedatives ❖ Provide an effective means of communication Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Mechanical Ventilation ❖ Positive or negative pressure device to maintain ventilation and oxygenation for a prolonged period ❖ General Indications, refer to Chart 21-9 ❖ Classification of Ventilators, see Figure 21-8 ❖ Prevention of VAP, refer to Chart 21-11 ❖ Patient perspective, refer to Chart 21-12 Copyright © 2018 Wolters Kluwer · All Rights Reserved Noninvasive Positive-Pressure Ventilation ❖ Method of positive-pressure ventilation that can be given via facemasks that cover the nose and mouth, nasal masks, or other oral or nasal devices such as the nasal pillow ❖ Eliminates need for endotracheal intubation or tracheostomy ❖ Continuous positive airway pressure (CPAP) ❖ Bilevel positive airway pressure (BiPAP) ❖ Contraindications: respiratory arrest, serious dysrhythmias, cognitive impairment, head/facial trauma Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: The Patient Receiving Mechanical Ventilation Assessment ❖ Systematic assessment of all body systems: o In-depth respiratory assessment including all indicators of oxygenation status o Neurologic status o Effective coping and emotional needs o Comfort level and ability to communicate needs ❖ Assessment of the equipment and settings, refer to Table 21-2 Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Planning ❖ Goals include: o Maintenance of patent airway o Optimal gas exchange o Absence of trauma or infection o Attainment of optimal mobility o Adjustment to nonverbal methods of communication o Successful coping measures Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Diagnoses ❖ Impaired Gas Exchange ❖ Ineffective Airway Clearance ❖ Risk for Trauma ❖ Impaired Physical Mobility ❖ Impaired Verbal Communication ❖ Defensive Coping ❖ Powerlessness Copyright © 2018 Wolters Kluwer · All Rights Reserved Collaborative Problems ❖ Ventilator problems ❖ Alterations in cardiac function ❖ Barotrauma ❖ Pulmonary infection and sepsis ❖ Delirium Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Interventions ❖ Enhancing gas exchange ❖ Promoting effective airway clearance ❖ Preventing trauma and infection ❖ Promoting optimal level of mobility ❖ Promoting optimal communication ❖ Promoting coping ability Copyright © 2018 Wolters Kluwer · All Rights Reserved Enhancing Gas Exchange: Interventions ❖ Judicious use of analgesics to relieve pain without suppressing respiratory drive ❖ Frequent repositioning to diminish the pulmonary effects of immobility ❖ Monitor for adequate fluid balance: o Assess peripheral edema o I&O and daily wts ❖ Administer medications to control primary disease Copyright © 2018 Wolters Kluwer · All Rights Reserved Effective Airway Clearance: Intervention ❖ Assess lung sounds at least every 2 to 4 hours ❖ Measures to clear airway: suctioning, CPT, position changes, promote increased mobility ❖ Humidification of airway ❖ Administer medications Copyright © 2018 Wolters Kluwer · All Rights Reserved Trauma and Infection: Interventions ❖ Infection control measures ❖ Tube care ❖ Cuff management ❖ Oral care ❖ Elevation of HOB Copyright © 2018 Wolters Kluwer · All Rights Reserved Other Interventions ❖ ROM and immobility ❖ Communication methods ❖ Stress reduction techniques ❖ Interventions to promote coping ❖ Include in care: family teaching, and the emotional and coping support of the family Copyright © 2018 Wolters Kluwer · All Rights Reserved Monitor and Manage Potential Complications ❖ Alterations in cardiac function ❖ Barotrauma and pneumothorax ❖ Pulmonary infection ❖ Delirium Copyright © 2018 Wolters Kluwer · All Rights Reserved Weaning #1 ❖ Process of withdrawal of dependence upon the ventilator ❖ Three stages: o Patient is gradually removed from the ventilator o Then from either the endotracheal or tracheostomy tube o And finally from oxygen ❖ Successful weaning is a collaborative process Copyright © 2018 Wolters Kluwer · All Rights Reserved  Weaning #2 ❖ Criteria for weaning ❖ Patient preparation ❖ Methods of weaning, Refer to Chart 21-16 Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Thoracic Surgery ❖ Procedures to relieve conditions: o Lung abscesses o Lung cancer o Cysts o Benign tumors o Emphysema Copyright © 2018 Wolters Kluwer · All Rights Reserved Preoperative Management ❖ Assessment and diagnosis ❖ Improving airway clearance ❖ Educating the patient ❖ Relieving anxiety Copyright © 2018 Wolters Kluwer · All Rights Reserved Postoperative Management ❖ Vital signs checked frequently ❖ Oxygen ❖ Careful positioning ❖ Medication for pain ❖ Mechanical ventilation ❖ Chest drainage Copyright © 2018 Wolters Kluwer · All Rights Reserved Postoperative Nursing Management-Thoracic Surgery ❖ Monitoring respiratory and cardiovascular status ❖ Improving gas exchange and breathing ❖ Improving airway clearance ❖ Relieving pain and discomfort ❖ Promoting mobility and shoulder exercises ❖ Maintaining fluid volume and nutrition ❖ Monitoring and managing potential complications` Copyright © 2018 Wolters Kluwer · All Rights Reserved Chest Tube Drainage System ❖ Chest drainage systems have: o A suction source o A collection chamber for pleural drainage o And a mechanism to prevent air from reentering the chest with inhalation ❖ Used in removal of air and fluid from the pleural space and re-expansion of the lungs ❖ Wet (water seal) or dry suction control Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Patient Teaching and Home Care Considerations ❖ Signs and symptoms to report ❖ Use of home respiratory treatment modalities ❖ Importance of progressive increased activity ❖ Instruction on shoulder exercises ❖ Refer to Chart 21-22 for additional patient education Copyright © 2018 Wolters Kluwer · All Rights Reserved