Respiratory Care PDF

CHAPTER 8 Respiratory care Clare Bennett Aims and learning outcomes This chapter introduces the fundamental principles of respiratory assessment and symptom management. By the end of the chapter you should be able to: carry out fundamental aspects of respiratory assessment...

CHAPTER 8 Respiratory care Clare Bennett Aims and learning outcomes This chapter introduces the fundamental principles of respiratory assessment and symptom management. By the end of the chapter you should be able to: carry out fundamental aspects of respiratory assessment, including the following: obtain a patient’s history; make observations of res- piratory rate, depth and rhythm, cyanosis and sputum; record peak expiratory flow rate and pulse oximetry administer oxygen safely administer nebulizer therapy describe the general principles of correct inhaler technique perform oropharyngeal and nasopharyngeal suctioning. Respiratory assessment The respiratory tract is made up of the nose, pharynx, larynx, trachea, bronchi and lungs. A problem arising in any part of the tract may result in breathlessness. Additionally, disturbances in the circulatory, haema- tological and metabolic systems have the potential to affect normal respiratory patterns. Respiratory assessment begins with observing a patient’s general appearance. Factors to observe include: 178  Respiratory care Facial expression – does the patient appear alert, orientated, exhausted, confused, anxious or unresponsive? Are there any non- verbal expressions of pain, for example, grimaces, facial distortion, lip biting? Is there any evidence of facial flushing or cyanosis? Posture – is the patient sitting erect, or in a slouched or crouched-forward posture? Does the posture suggest pain in a particular place? Does the posture indicate anxiety or fear? Does the patient suffer from orthopnoea (i.e. breathlessness when lying down)? Physical symptoms – can the patient talk in full sentences or is breathlessness only upon exertion? Is there an increase in chest size (barrel-chested), coughing, or production of sputum? The second aspect of respiratory assessment requires information from the patient concerning his symptoms, their onset and his past medical and social history. It is necessary to know: the nature and severity of symptoms (e.g. breathlessness, increased sputum production, pain, cough, fever) precipitating factors such as exposure to infection, smoking, known allergies and exposure to irritants duration of symptoms past medical history related to breathing difficulties general health status medications taken psychosocial history, including age, occupational history, informa- tion concerning the patient’s living conditions and the patient’s perception of the illness. TIP! When gathering information from an acutely breathless patient, use short questions that can be answered ‘Yes’ or ‘No’. These are called ‘closed’ questions. The patient may not have enough breath to talk in sentences. Look in the notes for extra information to avoid wearing the patient out with repeated questions that other staff have already asked. The third aspect of respiratory assessment uses physical examina- tion and observations. These will be explained in the following nursing interventions. The specific values and times have not been 179 Key Nursing Skills included as every patient will have slightly different needs when considering frequency of observations. Normal values Normal respiratory values will vary according to a patient’s age, gender and medical history. The normal rate of breathing at rest is 12–20 times per minute for a healthy adult. Terminology apnoea when there is no breathing; periods of apnoea may be interspersed with bradypnoea bradypnoea abnormally slow rate of breathing (less than 12 breaths per minute); possible causes include hypo- thermia and depression of the central nervous system dyspnoea difficult, laboured or uncomfortable breathing hyperpnoea an increase in the volume of air breathed per minute; this is caused by an increase in the depth and/or respiratory rate tachypnoea an abnormally fast rate of breathing (more than 20 breaths per minute); this is usually one of the first signs of respiratory distress Normal breathing On inspiration the diaphragm descends, the lower part of the rib cage moves upward and outward and there is slight expansion of the upper chest. Expiration is passive and is slightly longer than inspiration. A short pause is normal between expiration and the next inspiration. Chest movement should be equal, bilateral and symmetrical. It is important to monitor the respiratory rate, rhythm and depth of any patient who has an altered respiratory status. Normal breathing should be barely audible to the naked ear, but with a stethoscope will be equal on both sides and audible in all the lung zones. The following sounds are significant: Noisy respiration is a sign of respiratory distress. 180  Respiratory care Stridor is a high-pitched sound usually occurring on inspiration; it is caused by laryngeal or tracheal obstruction, such as tumour or foreign body. A ‘wheeze’ is characterized by a noisy musical sound caused by the turbulent flow of air through narrowed bronchi and bronchioles (Jevon and Ewens 2001). A ‘wheeze’ is often more pronounced on expiration and is associated with asthma, chronic bronchitis and emphysema. A ‘rattly chest’ is caused by the presence of fluid (pulmonary oedema or sputum) in the upper airway. Snoring sounds, in the unconscious patient, may be associated with the tongue blocking the airway. NURSING PROBLEM 8.1 Patient history: Mr Brown has been admitted to the ward with breathlessness and a productive cough. Problem: Mr Brown’s respirations are rapid and irregular (30 breaths per minute). Goal: Mr Brown’s respirations will return to normal parameters (x breaths per minute) within y hours of admission. TIP! When observing an individual’s respiratory rate, rhythm and depth it is advisable not to let the patient know you are doing this, since people tend to breathe differently if they know someone is watching. It is therefore a good idea to make these observations immediately after taking the pulse. As you are continuing to hold the patient’s wrist he will not be aware that you are actually observing his respirations. Intervention: measuring respiratory rate The most sensitive indicator of respiratory distress is a rise in an indi- vidual’s respiratory rate (Hinds and Watson 1996). 181  Key Nursing Skills Ensure that Mr Brown has been at rest for approximately five minutes. Continue to hold the wrist you used to take Mr Brown’s pulse and watch his chest rise and fall. Look at your watch and count the number of times the chest rises in 60 seconds. This is Mr Brown’s respiratory rate, measured as ‘breaths per minute’. Record the measurement on Mr Brown’s observations chart and inform a senior member of staff in the event of any change in res- piratory rate. TIP! Ifculttheto patient’s breathing is very shallow and therefore diffi- see, place your hand on the patient’s chest or abdomen to feel for movement. Count the number of times your hand rises in 60 seconds. This is the patient’s respiratory rate, measured as ‘breaths per minute’. Intervention: observing respiratory rhythm Normal breathing is regular and rhythmic. When measuring respirat- ory rate observe the pattern of breathing and its regularity. For example, the ‘Cheyne-Stokes’ pattern of breathing is characterized by periods of apnoea alternated with periods of increasingly rapid and deep breath- ing. This often occurs in patients nearing the end of life. ‘Kussmaul’ breathing is characterized by deep rapid respirations triggered by stim- ulation of the respiratory centres in the medulla and pons of the brain- stem, caused by metabolic acidosis and is a result of renal failure or diabetic ketoacidosis. Intervention: monitoring respiratory depth Air entry is assessed through observing and feeling chest movements in addition to listening to breath sounds. Observe Mr Brown for use of the accessory muscles of ventilation. These are to be seen in the neck, upper chest and abdomen (ster- nocleidomastoid, trapezius and pectoral muscles). In adults, the use of these accessory muscles suggests respiratory distress. In the elderly, abdominal breathing is considered normal. If the patient is using these muscles, it should be reported and documented. 182 Respiratory care ‘Ballooning out’ of the intercostal spaces (i.e. the spaces between the ribs) during exhalation or retraction during inspiration should be documented and reported. Your observations of Mr Brown’s respiratory depth should be doc- umented and a senior member of staff should be informed of any changes. Intervention: measuring effectiveness of respiration Observe for evidence of cyanosis (blue tinge to the skin). Normal saturated haemoglobin gives mucous membranes their characteristic pink colour. Unsaturated haemoglobin gives mucous membranes a bluish/purple discoloration. Cyanosis is associated with excessive deoxygenation of haemoglobin and hypoxia. It is therefore characterized by a dusky bluish colour of the mucous membranes. Peripheral cyanosis is observed in the skin and nail beds and is most noticeable around the lips, earlobes, mouth and fingertips. In dark-skinned people cyanosis is most noticeable in the lips or nailbeds, which become dusky in colour. Peripheral cyanosis alone suggests cir- culatory problems rather than respiratory disease. Central cyanosis is best observed in the tongue; it may be an acute sign of hypoxia (e.g. asphyxia) or a chronic sign of respiratory disease (e.g. chronic obstructive pulmonary disease). Your assessment and findings regarding any peripheral and central cyanosis should be documented in Mr Brown’s notes and communicat- ed to a senior member of staff. Intervention: measuring pulse oximetry Assessing the amount of oxygen absorbed in the arterial blood will give an indication of the effectiveness of the patient’s breathing and/or oxygen therapy. This can be done by using pulse oximetry. A two-sided probe is used to transmit an alternating light through a finger, toe or earlobe. The wavelength of the light that emerges indicates the per- centage of oxyhaemoglobin present in the capillaries (Woodrow 1999). Normal values of oxygen saturation are 95–99%. Readings of 90–95% are usually a cause for concern. However, the patient’s med- ical history must be taken into consideration when interpreting read- ings; for example, a patient with chronic obstructive pulmonary disease may usually have an oxygen saturation of 85% (Woodrow 1999). 183  Key Nursing Skills TIP! When monitoring a patient’s pulse oximetry, don’t rely exclu- sively on the pulse oximeter recording to tell you if the patient is receiving adequate ventilation. Watch for signs of respira- tory distress and changes in skin colour too. Equipment Pulse oximeter. Appropriate sensor. Trolley/table to mount monitor on. Procedure Explain the procedure to Mr Brown to gain his consent and co- operation. Assess Mr Brown’s peripheral circulation in order to select an appropriate sensor. The most commonly used sensor is a finger sensor, but others are available that can be attached to the earlobe and external nose. Clean the skin and dry the area thoroughly. If using a finger sen- sor, false nails and nail polish should be removed to prevent an inaccurate reading. Attach the sensor according to the manufacturer’s instructions, attach the cable from the sensor to the pulse oximeter and switch the machine on. Observe the pulse waveform or digital readout to ensure that the pulse waveform is registering. Set alarm limits on the pulse oximeter. Change the sensor site every 4 hours if continuous monitoring is required, in order to relieve pressure and any irritation from ad- hesive sensors. If intermittent monitoring is required remove the sensor between readings. Document Mr Brown’s oxygen saturation in the nursing records and report any changes or abnormal readings immediately. ALERT! Never attach a finger sensor by using adhesive tape, since this has the potential to cause tissue necrosis. 184 Respiratory care Intervention: recording peak expiratory flow rate (PEFR) The peak expiratory flow rate (PEFR) is a measurement of the maxi- mum flow rate, in litres per minute, that can be expelled from the lungs during a forced exhalation. Measuring PEFR indicates how severe the patient’s airway obstruction may be. Equipment Peak flow meter (Figure 8.1). Disposable mouthpiece. Recording chart. Figure 8.1 The Mini- Wright peak flow meter. Procedure Explain the procedure to Mr Brown to gain his cooperation. Advise Mr Brown to stand; if this is not possible, he should sit as upright as possible to allow for maximum lung expansion. Attach the disposable mouthpiece to the peak flow meter. Place the cursor at the bottom of the numbered scale. Advise Mr Brown to inhale as deeply as possible, to place his lips around the mouthpiece creating a complete seal, and hold the meter horizontally to exhale as hard and fast as possible, as if blow- ing out a candle. 185  Key Nursing Skills Note the measurement obtained. Ask Mr Brown to repeat this process two more times, as long as this does not cause distress. If it is not possible for him to obtain further measurements document this on the observations chart. TIP! Ifis Mr Brown is very breathless and his second peak flow level less than the first, don’t ask him to do it a third time as he may develop bronchospasm. Seek medical advice. Record the highest of three measurements; by having three attempts poor technique should be overcome. Report any variation from previous readings to a senior colleague. TIP! To ensure you get the best reading in a PEFR: get a good seal between the patient’s lips and the mouthpiece zero the meter before blowing keep fingers out of the way of the measurement indicator. Intervention: making regular observations of temperature, blood pressure and heart rate It is important to monitor a breathless patient’s vital signs in order to exclude or identify underlying causes of breathlessness. The breathless patient will initially exhibit tachycardia; however, severe hypoxia can lead to bradycardia. Measurement of temperature, blood pressure and heart rate is detailed in Chapter 2. ECG monitoring may be required for some breathless patients. TIP! Additional training and skills are needed to per-form ECG monitoring effectively. Intervention: observation of cough and production of sputum The assessment of Mr Brown’s cough includes observation of the following characteristics: frequency length of time coughing takes 186 Respiratory care presence or absence of pain distinctive sounds (e.g. whoop or bark) strength of cough any association with specific activities (e.g. after eating or drinking). These observations should be noted in Mr Brown’s notes and commu- nicated to other members of the care team. Intervention: positioning to assist breathing Position Mr Brown in an upright position, well supported with pillows. People who are feeling breathless tend to be more comfortable, and respiratory function is maximized, in this position. Breathless patients may find sitting in a chair more comfortable than lying in bed. Chronically breathless patients may be reluctant to change pos- ition frequently and therefore it is important to provide pressure- relieving aids for the sacrum and heels. Mr Brown may appreciate a bed table with a pillow on it, placed in front of him so that he can lean forward to aid lung expansion. A fan may be positioned to ‘blow’ over Mr Brown to give him the sensation of more circulating air. This can provide psychological relief. Intervention: administering oxygen The administration of oxygen is used to increase the saturation of the oxyhaemoglobin in the blood to compensate for hypoxia. ALERT! When administering oxygen it is essential that the following precautions are observed to prevent fire: Smoking in the area is prohibited. Signs regarding the prohibition of smoking are displayed. Matches and lighters should be removed from the patient’s bedside. The use of oil- and alcohol-based skincare products is avoided. 187 Key Nursing Skills To administer oxygen an oxygen delivery system is required. This consists of: An oxygen supply: this may provided through oxygen ports on the walls of hospital wards or via portable cylinders which are coloured black with a white top and marked ‘oxygen’. Flow meter: this allows the flow rate of oxygen to be set in litres/ minute. Oxygen tubing: this connects the oxygen source to the delivery device. Delivery device: there are various methods of oxygen delivery. These may provide either a variable concentration of oxygen, or a fixed, accurate concentration. These are termed variable or fixed performance devices respectively (see below). The device used should reflect the individual patient’s oxygen requirements, as well as his comfort and individual choice. ALERT! Oxygen should always be prescribed by a doctor, stating the flow rate, delivery system, duration and monitoring of treatment. Humidifier: humidification is recommended for patients who receive flow rates of oxygen which are greater than 4 litres per minute, or when oxygen is being delivered directly to the trachea, for example, via a tracheostomy tube (Jevon and Ewens, 2001). Humidification warms and moistens the oxygen during adminis- tration, thus preventing dehydration of the mucous membranes and pulmonary secretions (see below). Fixed performance devices If a fixed performance device is required, systems such as Venturi devices (Figure 8.2) may be used. These systems allow: Specific levels of air entry so that air is mixed with the oxygen administered, to deliver precisely controlled percentages of high flow oxygen at low to mid concentration (24–60 per cent). The valves are colour coded according to the percentage of 188 Respiratory care Figure 8.2 Venturi mask. oxygen delivered. These masks are particularly useful when it is important to administer accurate concentrations of oxygen, for example, in patients with chronic obstructive pulmonary disease. Other fixed performance devices include continuous positive airway pressure (CPAP) and non-rebreathable masks. Variable performance devices If variable performance devices are acceptable, Hudson oxygen masks (Figure 8.3.1) or nasal cannulas may be used (Figure 8.3.2). These devices deliver an unpredictable oxygen concentration, determined by the patient’s respiratory pattern; they are therefore not suitable for patients with chronic respiratory disease. Nasal cannulae are of limited use for the extremely breathless patient who mouth breathes since the concentration of oxygen will be further diluted (Dunn and Chrisholm 1998). However, nasal cannulae are highly appropriate when patients cannot tolerate face masks. Humidification devices Humidification devices vary between Trusts and include: aerosol generators humidified ventimask systems condensers water bath humidifiers. 189  Key Nursing Skills Figure 8.3.1 Hudson mask. Figure 8.3.2 Nasal cannula. Figure 8.3.1–2 Variable performance devices. TIP! Ifbore using warm humidification, water will collect in the wide- ‘elephant’ tubing. This should be emptied by turning off the oxygen, disconnecting the tubing from the humidifier, pouring the water into a receiver, and reconnecting the tubing and re-commencing oxygen therapy. Water will empty out more easily if the tube is slightly stretched and shaken when emptied. 190 Respiratory care Intervention: administering medication as prescribed Depending upon the cause of breathlessness, medications may include: bronchodilators (inhaled, nebulized or intravenous) intramuscular adrenaline intravenous antibiotics steroids (nebulized, inhaled or intravenous). Chapter 6 explains the principles of medicine administration. Mrs Jones’s care plan later in this chapter outlines the administration of nebulizers and inhalers. Intervention: explaining all procedures and the plan of care to Mr Brown Breathlessness is an extremely frightening experience that often leads to anxiety, which may be aggravated by hypoxia. Anxiety may, in turn, contribute further to Mr Brown’s dyspnoea. Discussing with Mr Brown and his family and the provision of information concerning the disease/ illness, its management and the plan of care may relieve these common worries. Privacy should be provided and the relatives involved in his care. Relaxation and breathing techniques to improve lung expansion may also be of value. Intervention: administering oxygen as prescribed Equipment Nasal cannulae or appropriate face mask. Oxygen tubing. Humidifier. Oxygen source with flow meter. ‘No Smoking’ signs. Procedure Check prescription for accuracy. Explain the procedure to Mr Brown to reduce his anxiety and gain consent. 191 Key Nursing Skills Wash hands and dry thoroughly. Prepare equipment. Explain the dangers of smoking when oxygen is in use to Mr Brown and his visitors and relatives. Check Mr Brown’s identity band. Attach the oxygen tubing to the oxygen supply and the delivery device (mask or nasal cannulae). Turn on the oxygen flow meter and set the prescribed flow rate. Ensure that Mr Brown is positioned upright, if possible, to maxi- mize lung expansion. If using a face mask, place the mask over Mr Brown’s nose and mouth with the elastic strap over the ears to the back of the head. The mask should cover the nose and mouth securely, so it may be necessary to alter the length of elastic. If using humidification, connect the humidifier to the oxygen port according to the manufacturer’s instructions. Connect wide-bore ‘elephant’ tubing which comes from the humidifier to the face mask. Set the flow meter as required. Adjust the position of the oxygen mask to cover the nose and mouth securely. If using nasal cannulae, the prongs of the cannulae should be placed inside the nostrils and the external tubing should be placed over the ears and either under the chin or behind the head (Figure 8.3.2). The flow rate of oxygen with nasal cannulae must not exceed 4 litres/minute to prevent discomfort and damage to the nasal mucosa (Lifecare 2000). Place a sputum pot, tissues and mouthwash near to Mr Brown to use as required. Wash hands. Document the care given. Monitor and record oxygen saturation and respiratory rate, depth and rhythm. Report any abnormalities. Intervention: comfort measures for patients requiring oxygen therapy Assess facial pressure points that contact mask or elastic, nasal cannula (nostrils, external nose and ears) for skin irritation or 192  Respiratory care signs of breakdown every 4 hours. Placing gauze under the elastic may relieve pressure and provide comfort. Oral hygiene and oral fluids should be offered frequently to pre- vent drying of the oral mucosa. Cleansing and drying of the face should be offered as required. Oxygen tubing and delivery devices should be labelled with the patient’s name and hospital number to prevent patient’s equip- ment being used by others in error. This will help to reduce the risk of cross-infection. TIP! Ifderusing an oxygen cylinder, ensure that a replacement cylin- is available when the volume gauge indicates that the cylinder is a quarter full. TIP! Ifensure the patient has to leave the ward for investigations, that the portable oxygen cylinder is full and that the department the patient is visiting knows that continuous oxygen will be required. ALERT! The administration of oxygen, except in a very low con- centration (24–28 per cent), could be fatal to patients with chronic pulmonary disease. This is because carbon dioxide is retained in the blood (chronic hypercapnia) and the chemoreceptors in the brain become less sensitive to high blood levels of carbon dioxide. The patient then becomes dependent on low oxygen (hypoxia) to stimulate res- piration. Thus if oxygen is given to correct hypoxia, the patient’s respiratory drive may be removed. Intervention: observing and collecting sputum Observe quantity and nature of sputum and obtain a sputum specimen for microscopy, culture and sensitivity. 193 Key Nursing Skills Sputum is a clinical feature of respiratory disease and can provide valuable information for assessing a breathless patient. Sputum should be observed for consistency, colour and quantity. Patients may refer to it as phlegm. Thick, viscid sputum is an indication of severe asthma. Thin, watery sputum is a feature of acute pulmonary oedema. White mucoid sputum is characteristic of asthma and chronic bronchitis. Purulent green or yellow sputum may suggest respiratory infection. Blood may indicate carcinoma of the lung or pulmonary embolism. Foul smelling sputum is suggestive of a respiratory tract infection (Jevon and Ewens 2001). Equipment Universal specimen pot. Specimen bag. Laboratory request form. Mouthwash. Receiver. Tissues. Handwashing facilities. Procedure Prepare equipment. Encourage Mr Brown to sit upright and take some deep breaths. Ask Mr Brown to cough and expectorate into the specimen con- tainer. Several coughs may be required to obtain a sufficient spec- imen. Some patients may need to be taught by a physiotherapist how to cough effectively and expectorate without strain. Seal the lid and complete Mr Brown’s details on the specimen pot. Place pot and laboratory request form in a plastic specimen bag and send to the appropriate laboratory. Wash hands. If a delay in transporting the specimen to the laboratory is envisaged place it in the refrigerator immediately. Offer the patient a mouthwash and tissues. Document that a specimen has been obtained, noting colour, smell and consistency. 194  Respiratory care TIP! Mr Brown may find it easier to produce a specimen on wak- ing up in the morning as he may have more energy for deep coughing and sputum may have settled in the upper lobes of his lungs overnight. Evaluation Has Mr Brown’s respiration reverted to its normal rate, rhythm and depth? Has his colour and perfusion improved? If Mr Brown’s respira- tion has not returned to its normal pattern within the stated time the plan of care will need to be revised accordingly. NURSING PROBLEM 8.2 Patient history: Mrs Jones gets severe asthma, particularly in the summer when the pollen count is high. She has just been admit- ted to the ward with an acute asthma attack. Problem: Mrs Jones is experiencing difficulty in breathing due to acute severe asthma. Goal: Mrs Jones respiratory status will return to her normal measure- ments. Interventions Mrs Jones requires all the care described for Mr Brown. However, because the cause of her respiratory distress is known it is possible to be more specific about certain aspects of her care. These are listed below, and described above in more detail, in Mr Brown’s care plan. The interval between observations has not been given since the degree of her respiratory distress is not known. Observe and record Mrs Jones’ respiratory rate, depth and rhythm every x hours. Observe for evidence of cyanosis. Record Mrs Jones’ pulse oximetry every x hours. 195 Key Nursing Skills Record Mrs Jones’ peak expiratory flow rate every x hours. Record Mrs Jones’ blood pressure, pulse and temperature every x hours. Position Mrs Jones in an upright position, well supported with pillows. Explain all procedures and the plan of care to Mrs Jones. Administer oxygen as prescribed. Obtain sputum specimen. Intervention: assist Mrs Jones in meeting the activities of daily living Mrs Jones will require assistance in meeting all of her activities of daily living due to her breathlessness. Intervention: administer nebulizers as prescribed A nebulizer is a device that turns liquid medication into a fine mist con- taining particles small enough to reach deep into the bronchial tree. Nebulizers use compressed gas to change a liquid drug into a vapour, so delivering drugs into the lungs in a mist of particles small enough to reach the bronchioles and sometimes the alveoli (Muers and Corris 1997). Nebulizers are used in preference to inhalers for adults: when large drug doses are needed when it is not possible for patients to control and coordinate their breathing to make the use of inhalers possible (e.g. in acute severe asthma or an exacerbation of COPD) when inhalers have been found to be ineffective in managing the patient’s chronic lung disease when preparations such as antibiotics and lignocaine are required, since such preparations are unavailable as inhalers. Bronchodilators, steroids, antibiotics, rhDNase, pentamadine, ligno- caine and 0.9% sodium chloride are available for nebulization. Water should not be nebulized since it may cause bronchoconstriction (Muers and Corris 1997). 196 Respiratory care Nebulizers with masks are better for acutely ill patients who may find holding the nebulizer tiring. Nebulizers with mouthpieces should be used: if patients find masks claustrophobic if steroids are being used, to prevent deposition on the face for nebulized antibiotics, so that a filter can be used to prevent exhalation of antibiotic into the air with certain anticholinergic drugs, since they may exacerbate glaucoma. The mouth should be rinsed out after nebulizing steroids and antibiotics to prevent the development of oral thrush (Muers and Corris 1997). ALERT! Patients with acute severe asthma should have their nebu- lizers administered via oxygen or they will become hypoxic. Air should be used for all other lung diseases unless oxygen is prescribed. If necessary, low-flow oxygen can be adminis- tered via nasal cannulae to patients while a drug is nebu- lized with air. This is because it requires a high flow of oxy- gen to nebulize a drug (6–8 litres/minute) and if the patient has chronic respiratory disease he will require only a low level of oxygen to stimulate his respiration. Intervention: to administer Mrs Jones’s nebulizer Equipment Appropriate gas source. Nebulizer and face mask/mouthpiece. Gas supply tubing. Nebulizer solution (at room temperature to prevent bronchospasm). Prescription chart. 197 Key Nursing Skills Procedure Explain the procedure to Mrs Jones to reduce anxiety and gain consent. Wash hands. Prepare equipment. Assist Mrs Jones to sit upright, to allow for maximum lung expansion. Prepare the nebulizer solution, adhering to the guidelines set out in Chapter 6 and check Mrs Jones’s identity. Unscrew the base of the nebulizer, add the solution to the cham- ber and screw the nebulizer together again. Attach a face mask to the nebulizer, and if necessary attach tub- ing to the nebulizer and attach this to the air or oxygen cylinder (depending upon prescription). Advise Mrs Jones that she will need to remain sitting upright, and should take normal steady breaths (tidal breathing) throughout the treatment. She should also be instructed not to talk during the nebulization and to keep the nebulizer upright. Set the flow meter to 6–8 litres/minute if a cylinder or piped gas is being used (Muers and Corris 1997); otherwise switch the com- pressor to On if a portable electric/battery compressor is being used. Assist Mrs Jones to place the mask over her nose and mouth and secure it by placing the elastic straps over the ears and back of head. Advise Mrs Jones to breathe normally and remain sitting upright throughout the duration of the treatment – approximately 10 minutes. Provide Mrs Jones with a sputum pot, tissues and mouthwash, as she is likely to need to expectorate during and after administration of the nebulizer. If antibiotics or steroids have been nebulized the patient’s mouth must be washed out to prevent the development of oral candida. Document the therapy, any complications and the response to treatment. Intervention: refer patient to Clinical Nurse Specialist in Respiratory Care It is advisable to refer poorly controlled asthmatic patients to the rel- evant Clinical Nurse Specialist to review their asthma management. 198  Respiratory care Evaluation Has Mrs Jones experienced relief in response to the interventions? Have her vital signs changed towards her normal parameters? NURSING PROBLEM 8.3 Problem: Mrs Jones cannot use her inhaler correctly. Goal: Mrs Jones will be able to demonstrate correct inhaler technique. Intervention: using inhalers Inhalers allow drugs to be administered directly to the lungs – thus allowing smaller doses to be used and reducing systemic side effects. An inhaler is a device consisting of a reservoir of drug, either in aerosol or powder form, and a mouthpiece through which the drug is inhaled. Devices are either activated through inspiration (breath-activated) or by manual action. The range of drugs available and the devices for the delivery of such drugs is vast and continually developing. Drugs found in inhalers include the following. Short-acting bronchodilators These are also known as ‘relievers’. Examples include Salbutamol and Ipratropium Bromide. These drugs have varying speeds of onset of effect. For example, Salbutamol may have an effect within 5 minutes yet Ipratropium Bromide may take 20 minutes before an effect is felt. Inhalers in this group are usually coloured blue or grey. Long-acting bronchodilators Salmeterol is an example of this group. These drugs have long-lasting actions (e.g. a 12-hour effect) but take longer to act initially. These drugs are therefore prescribed for regular administration, such as twice daily, rather than on an ‘as required’ basis. These inhalers are usually green in colour. 199  Key Nursing Skills TIP! For patients with persistent breathlessness, bronchodilators should be used before activity or to relieve the effort of eating. Inhaled steroids These are also known as ‘preventers’. These drugs have an anti-inflamma- tory effect. They have a slow onset of action and patients may feel no effect for several days after commencing treatment. Inhaled steroids should be taken regularly every day, even when the patient feels well, to prevent an increase in inflammatory changes in the bronchioles. These inhalers are brown/red/orange/pink in colour. The mouth should be rinsed out after inhaling steroids, to prevent the development of oral thrush. To ensure that the maximum amount of drug is deposited in the lungs, it is imperative that an appropriate device is chosen and that the patient’s technique is adequate. Many metered dose inhalers (MDIs) require considerable strength on the index finger and thumb to acti- vate the aerosol release: finger strength, manual dexterity and coordi- nation therefore need to be assessed. In addition, the patient’s mem- ory needs to be assessed, so that if required a simpler inhaler can be pre- scribed or a carer can help to give it. Inhaler technique Before teaching a patient it is advisable to assess his or her knowledge of the subject. This can prevent unnecessary repetition and can also identify areas of misunderstanding. In this instance you could ask Mrs Jones to tell you what she knows about her inhaler and to demonstrate how she thinks it should be used. Everybody learns in a different way, and it is important to assess how Mrs Jones learns best. Mrs Jones may find that it is useful to learn inhaler technique by having the procedure broken into easy stages and repeating these until the final stage is learnt and the whole procedure accomplished. However, some patients feel more comfortable with written guidance, private practice and finally performance in front of a health care professional. Other patients may have problems with understanding English and others may be unable to read. Ask Mrs Jones how she learns a practical skill before you start. Using the above information, a teaching session will need to be devised to facilitate Mrs Jones in learning to use her inhaler. In certain 200  Respiratory care Trusts a Clinical Nurse Specialist in Respiratory Care will deliver the teaching session but this varies from Trust to Trust. Mrs Jones will first need to learn about the type of inhaler she has. The following details give the procedure for a variety of different inhalers. It is good practice to teach a patient using placebo devices. These are widely available from manufacturers, pharmacy departments and specialist nurses. TIP! When a patient needs to take more than one inhaled drug at the same time it is usual for the short-acting bronchodilator to be administered first so that the other drugs can penetrate the lungs more efficiently. Pressurized/aerosol metered dose inhalers (MDIs) MDIs (Figure 8.4) are used very widely; however, many patients find it very difficult to coordinate inhalation and activation so certain inhaler devices have short spacing attachments to assist with this. For people with weak fingers or arthritis, a Haleraid hand grip may be applied to allow the inhaler to be activated by a squeezing action rather than a pressing action. Figure 8.4 Metered dose inhaler. Procedure for administration of MDI Sit or stand upright. Remove cap, shake inhaler. 201 Key Nursing Skills Breathe out gently. Place lips around mouthpiece. Inhale slowly and deeply through the mouth, at the same time activating the aerosol once only. Remove the inhaler from mouth and keep mouth closed. Hold the breath for 10 seconds or as long as possible. Repeat the procedure as required, waiting approximately 30 seconds between each activation. Breath-actuated MDIs These inhalers (e.g. Autohalers and Easi-breathe) are activated by the patient’s inspiration. These devices can help overcome coordination problems (Figure 8.5). Figure 8.5.1 Autohaler. Figure 8.5.2 Easi-breathe device Figure 8.5.1–2 Breath-activated metered dose inhalers. 202 Respiratory care Procedure for use of the Autohaler device Sit or stand upright. Remove cap, shake inhaler. Breathe out gently. Place lips around mouthpiece. Inhale slowly and deeply through the mouth. Do not stop breathing when the inhaler ‘clicks’ – continue to take a very deep breath. Remove the inhaler from mouth and keep mouth closed. Hold the breath for 10 seconds or as long as possible. Repeat the procedure as required, waiting approximately 30 seconds between each activation. NB: the lever must be pushed up (On) before each dose, and pushed down again (Off) afterwards, otherwise it will not operate. Procedure for use of the Easi-breathe device Sit or stand upright. Hold the inhaler upright. Open cap. Breathe out gently. Place lips around mouthpiece. Inhale slowly and deeply through the mouth. Do not stop breath- ing when the inhaler ‘puffs’ – continue to take a very deep breath. Remove the inhaler from mouth and keep mouth closed. Hold the breath for 10 seconds or as long as possible. After use, hold the inhaler upright and immediately close the cap. Repeat the procedure as required, waiting approximately 30 seconds between each actuation. Dry powder devices These inhalers are triggered by a deliberate inhalation from the device. Such devices include Spinhalers, Rotahalers, Aerohalers, Aerolizers, Diskhalers, Accuhalers and Turbohalers (Figure 8.6). All dry powder devices are loaded and prepared differently. It is advisable to consult the manufacturer’s instructions for this informa- tion since it frequently changes. However, correct dry powder inhaler technique follows these general principles. 203 Key Nursing Skills Figure 8.6.1 Figure 8.6.2 Spinhaler. Rotahaler Figure 8.6.3 Figure 8.6.4 Aerohaler. Accuhaler. Figure 8.6.5 Figure 8.6.6 Diskhaler Turbohaler Figure 8.6.1–6 Examples of dry powder devices. Load the inhaler as instructed by the manufacturer. Sit or stand upright. Breathe out gently and tilt the head back. Place lips around the mouthpiece. 204 Respiratory care Inhale quickly and deeply through the mouth. Remove the inhaler from mouth and keep mouth closed. Hold the breath for 10 seconds or as long as possible. Spacer devices If a patient uses a spacer device in hospital it should be named so that others do not use it – so reducing the risk of cross-infection. Spacer devices offer the following advantages: There is no need to coordinate actuation of the canister with inhalation. There is no cold impact of cold aerosol particles on the back of the throat, which may make some people gag or cough. Larger drug particles, which would otherwise be deposited in the mouth and throat, are deposited in the chamber, reducing the pos- sibility of oral candida from oral steroids. Procedure for use of spacer devices Ensure that the spacer and inhaler are compatible. Each make varies and they are not interchangeable. Place the two halves of the spacer together. Remove the cap and shake the inhaler. Place mouthpiece of inhaler into port of spacer (Figure 8.7). Figure 8.7 Volumatic spacer device. Sit upright. Breathe out gently. Place lips around spacer mouthpiece. 205  Key Nursing Skills Hold spacer level and place one actuation into the spacer. Inhale slowly and deeply. If a deep inhalation is not possible the patient should breathe in deeply several times, exhaling into the canister. Remove the inhaler from mouth and keep mouth closed. Hold the breath for 10 seconds or as long as possible. Repeat the procedure as required, waiting approximately 30 seconds between each actuation. Care of the spacer The spacer should be washed each week in warm soapy water and left to dry. It is important that the inside is not wiped dry as this may dam- age the anti-static coating. If an individual is too breathless to use an MDI correctly and FIRST no medical aid is available, a polystyrene cup may be used as AID a spacer device: insert the mouthpiece of the inhaler through TIP! the bottom of a cup; place the cup, with the attached inhaler, over the individual’s nose and mouth; activate the device; and encourage the casualty to breathe deeply through their nose and mouth. Seek emergency assistance. Evaluation In order to evaluate whether the goal has been met the following ques- tions could be used when checking Mrs Jones’s inhaler technique: Is Mrs Jones sitting upright? Has the device been prepared correctly? (For example, if using an MDI, was this shaken?) Has Mrs Jones taken single actuations only, i.e. not ‘multi-puffing’? It is important that patients only take one puff at a time, since tak- ing multiple inhalations at one time is ineffective and can stimu- late a cough reflex. Has Mrs Jones inhaled sufficiently? Has the full dose been delivered (e.g. did any mist escape)? Was the breath held for at least 10 seconds? 206  Respiratory care NURSING PROBLEM 8.4 Patient history: Mr Barrett is an elderly gentleman with a chest infection, but is too weak and tired to cough and expectorate. When listening to his breathing he has a ‘rattly’ chest, which he and his relatives find distressing. Problem: Mr Barrett is too weak to clear his airway effectively. Goal: Mr Barrett’s airway will remain patent. Intervention: oropharyngeal suction This care plan assumes that Mr Barrett is conscious. However, if he were unconscious he should be nursed on his side (to prevent his tongue blocking the airway and to facilitate the drainage of secretions) and an artificial airway may be required. Oral or nasopharyngeal suctioning may be used. Oral suction is used for: unconscious or semi-conscious patients, e.g. post-operative recov- ery patients who are vomiting and do not have a gag reflex to pre- vent them from inhaling vomit or secretions patients who have had oral surgery or trauma resulting in blood and mucous secretions which need to be removed patients who are too weak to expectorate sputum from the pharynx. Oral and nasopharyngeal suction are not the same as tracheal suction as they do not completely occlude a patient’s airway. As suctioning by these routes does not enter a sterile area the procedure is clean, rather than aseptic. However, the Yankuer (oral) sucker should be used for one patient only and changed daily. It can be a very distressing pro- cedure for the patient and should not be undertaken for prolonged periods. It may be used in conjunction with a Guedel airway if the air- way needs to be maintained. 207  Key Nursing Skills Equipment for oral suctioning Suction machine/piped suction. Suction tubing and oral suction catheter (e.g. Yankuer sucker). Sterile distilled water. Face mask. Eye shield. Towel or absorbent pad to protect patient’s clothes and bed linen. Gloves. Procedure for oral suctioning Explain procedure to Mr Barrett. (Even if the patient is uncon- scious explanations should be given, since many unconscious indi- viduals are able to hear.) Wash hands. Prepare equipment. Attach suction tubing to suction machine and attach oral sucker to suction tubing, ensuring a tight fit. TIP! You should regularly check that the suction machine is work- ing and ready for use by plugging it in, switching it on and kinking the suction tubing. This should cause the pressure dial to rise. Ensure that clean suction tubing is changed between patients, and that a Yankuer (oral) sucker and flexible catheters are easily accessible to the machine. Position Mr Barrett in a semi-recumbent position with head turned towards you. If he is unconscious he should be nursed in a semi-prone position, facing you. Place a towel or pad under Mr Barrett’s chin. Switch the suction machine on and set suction level. Oral or nasopharyngeal suction should be gentle so that the mucous mem- brane, teeth, or gums are not damaged. Ideal suction levels for oral suction have little supporting evidence but experience suggests that 20 kilopascals (kPa) or 120 mmHg for wall suction units is the maximum pressure. 208  Respiratory care Put on gloves, eye shield and mask. Ask Mr Barrett to open his mouth and assist him if necessary. Insert the Yankuer sucker into the mouth along one side and guide it along the inside of the cheek towards the oropharynx without applying suction. Suction is prevented by either kinking the suc- tion catheter or leaving the hole in the Yankuer sucker open. Apply suction by either unkinking the tubing or occluding the hole in the Yankuer sucker, and remove secretions and debris from mouth as required. Do not force the sucker between the teeth or touch the posterior pharyngeal wall of the soft palate as it can make the patient gag or vomit. Release suction and remove oral sucker from Mr Barrett’s mouth. Oral suction should not be for prolonged periods as it can be very distressing to the patient. TIP! Hold your breath while you suction because when you feel the need to breathe again that will indicate that the episode of suctioning is long enough. Clean the sucker and tubing by suctioning through sterile water until all debris has been cleared. If further suctioning is required allow Mr Barrett to rest for at least 30 seconds and repeat above procedure. If he is able, ask him to deep breathe and/or cough between suctions so that secretions can rise to the upper airway. Wash hands. Document the quantity, colour, consistency and odour of secre- tions and the patient’s response to the procedure. Intervention: nasopharyngeal suctioning Nasopharyngeal suction is indicated when the oral sucker cannot pass to the back of the pharynx. This may be due to teeth clenching, den- tal or oral surgery or trauma, or if the patient cannot tolerate the Yankuer sucker at the back of the pharynx. It is particularly useful for 209 Key Nursing Skills patients with a lot of secretions at the back of the throat but who can- not cough or expectorate. It may be used in conjunction with a nasopharyngeal airway, which is tolerated quite well by semi-conscious patients. Equipment Suction machine/piped suction. Suction tubing and sterile catheter (12–16 Fr). Gloves. Sterile distilled water. Face mask. Towel or absorbent pad to protect patient’s clothes and bed linen. Procedure Explain procedure to Mr Barrett. (Even if Mr Barrett is uncon- scious, explanations should be given, since many unconscious individuals are able to hear.) Wash hands. Prepare equipment. Attach suction tubing to suction machine and attach oral sucker to suction tubing, ensuring a tight fit. Check that the suction machine and equipment are working. Position Mr Barrett in a semi-recumbent position with head turned towards you. If he is unconscious he should be nursed semi- prone, facing you. Place a towel or pad under Mr Barrett’s chin. Switch the suction machine on and set suction level for up to 20 kPa or 120 mmHg for wall suction units (see ‘Oral suction’). It is important that excessive suction is not used since this may cause damage to the mucosa. Put on gloves, eye shield and mask. Attach a sterile catheter to the suction tubing and approximate the distance between the patient’s ear lobe and tip of the nose, marking this point with gloved thumb and forefinger. This ensures that the catheter length inserted will remain in pharyngeal area and not enter the trachea. Moisten the catheter tip with sterile water and apply suction to 210  Respiratory care sterile water. This will lubricate the tip to ease insertion and ensures that the equipment is working. Without applying suction (see above) insert the catheter into one nostril. Guide it along the floor of the nasal cavity. If there is any obstruction, remove catheter. Apply suction and gently rotate the catheter as you withdraw it to gather secretions on removal. The procedure should take no longer than 15 seconds to prevent damage to the patient due to oxygen insufficiency. Observe Mr Barrett’s colour and facial expression to detect signs of respiratory distress. If the procedure stimulates coughing the catheter has entered too far into the respiratory passages and should be with- drawn. TIP! Removal of secretions from the nasopharyngeal route should not interfere with the patient’s oxygen levels if done for short periods of 10–15 seconds only. It should improve the patient’s comfort and breathing ability as it is an effective method of clearing the airway. Use the catheter once and then discard by wrapping it around your gloved hand and taking off the glove with the catheter inside. Clean the suction tubing by suctioning through sterile water until all debris has been cleared. Allow Mr Barrett to rest for at least 30 seconds before repeating the procedure. There should be an audible improvement in his breathing if suction is effective. Wash hands. Document the quantity, colour, consistency and odour of secre- tions and the patient’s response to the procedure. ALERT! The older adult with cardiac or pulmonary disease may be able to tolerate only 10-second periods of suctioning since they are at greater risk of developing cardiac arrhythmia as a result of hypoxia (Perry and Potter 1998). 211 Key Nursing Skills Intervention: refer to chest physiotherapist Chest physiotherapy will facilitate the removal of secretions. The physiotherapist will also be able to help and teach Mr Barrett to cough effectively and assist in positioning Mr Barrett to promote postural drainage. Evaluation Evaluation of the care given to Mr Barrett will focus upon whether his airway remains free of secretions. If Mr Barrett’s level of consciousness alters, the plan of care will need to be reviewed accordingly. Further reading Abley C (1997) Teaching elderly patients how to use inhalers: a study to evaluate an education programme on inhaler technique for elderly patients. Journal of Advanced Nursing 25(4): 699–708. Bell C (1995) Is this what the doctor ordered? Accuracy of oxygen therapy prescribed and delivered in hospital. Professional Nurse 10(5): 297–300. Cowan T (1996) Nebulisers for use in the community. Professional Nurse 12(3): 215–20. Dodd M (1996) Nebuliser therapy: what nurses and patients need to know. Nursing Standard 10(31): 39–42. Fell H, Boehm M (1998) Easing the discomfort of oxygen therapy. Nursing Times 94(38): 56–58. Finkelstein L (1996) Sputum testing for TB: getting good specimens. American Journal of Nursing 96(2): 14. Grap MJ (1998) Protocols for practice: applying research at the bedside – pulse oxim- etry. Critical Care Nurse 18(1): 94–99. Hall J (1996) Evaluating asthma patient inhaler technique. Professional Nurse 11(11): 725–29. Jain P, Kavuru MS, Emerman CL, Ahmad M (1998) Utility of peak expiratory flow monitoring. Chest: The Cardiopulmonary Journal 114(3): 861–76. Manolio TA, Weinmann GG, Buist AS, Furberg CD, Pinsky JL, Hurd SH (1997) Pulmonary function testing in population-based studies. American Journal of Respiratory and Critical Care Medicine 156(3, Pt. 1): 1004–10. Mathews PJ (1997) Using a peak flow meter: monitoring the air waves. Nursing 27(6): 57–59. McConnell EA (1999) Clinical do’s and don’t’s: performing pulse oximetry. Nursing 29(11): 17. Muers M, Corris P (1997) Current best practice for nebuliser treatment. Thorax: the Journal of the British Thoracic Society 52(Supp. 2). O’Callaghan C, Barry P (1997) Spacer devices in the treatment of asthma. British Medical Journal 314(7087): 1061–62. 212 Respiratory care Owen A (1998) Respiratory assessment revisited. Nursing 28(4): 48–49. Talbot L, Curtis L (1996) The challenges of assessing skin indicators in people of color. Home Healthcare Nurse 14(3): 167–73. Wilson J, Arnold C, Connor R, Cusson R (1996) Evaluation of oxygen delivery with the use of nasopharyngeal catheters and nasal cannulas. Neonatal Network: Journal of Neonatal Nursing 15(4): 15–22. 213