Module 11 Chapter 30 PDF

CHAPTER 14 Oxygenation FOCUSING ON PATIENT CARE This chapter will help you develop some of the skills related to oxygenation necessary to care for the following patients: Scott Mingus, age 35, who has a mediastinal chest tube after thoracic surgery Saranam Srivastava, age 58 with a history of smokin...

CHAPTER 14 Oxygenation FOCUSING ON PATIENT CARE This chapter will help you develop some of the skills related to oxygenation necessary to care for the following patients: Scott Mingus, age 35, who has a mediastinal chest tube after thoracic surgery Saranam Srivastava, age 58 with a history of smoking, who is scheduled for a bowel resection and needs preoperative teaching regarding an incentive spirometer Paula Cunningham, age 72, who is intubated and requires suctioning through her endotracheal tube LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Use a pulse oximeter. 10. Suction an endotracheal tube using an open system. 2. Teach a patient to use an incentive spirometer. 11. Suction an endotracheal tube using a closed system. 3. Administer oxygen by nasal cannula. 12. Secure an endotracheal tube. 4. Administer oxygen by mask. 13. Suction a tracheostomy. 5. Use an oxygen hood. 14. Provide tracheostomy care. 6. Use an oxygen tent. 15. Provide care of a chest drainage system. 7. Insert an oropharyngeal airway. 16. Assist with chest tube removal. 8. Insert a nasopharyngeal airway. 17. Use a bag and mask (handheld resuscitation device) to deliver oxygen. 9. Suction the nasopharynx and oropharynx. KEY TERMS alveoli: small air sacs at the end of the terminal bronchioles that are the site of gas exchange atelectasis: incomplete expansion or collapse of a part of the lungs cilia: microscopic, hair-like projections that propel mucus toward the upper airway so that it can be expectorated 700 dyspnea: difficult or labored breathing endotracheal tube: polyvinylchloride airway that is inserted through the nose or mouth into the trachea, using a laryngoscope expiration: act of breathing out LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 701 Aptara CHAPTER 14 Oxygenation KEY TERMS 701 continued extubation: removal of a tube (in this case, an endotracheal tube) hemothorax: blood in the pleural space around the heart hyperventilation: condition in which more than the normal amount of air is entering and leaving the lungs as a result of an increase in rate or depth of respiration or both hypoventilation: decreased rate or depth of air movement into the lungs hypoxia: inadequate amount of oxygen available to the cells inspiration: act of breathing in nasal cannula: disposable plastic device with two protruding prongs for insertion into the nostrils; used to administer oxygen nasopharyngeal airway (nasal trumpet): a curved, soft rubber or plastic tube inserted into the back of the pharynx through the mouth oropharyngeal airway: a semicircular tube of plastic or rubber inserted into the back of the pharynx through the mouth perfusion: the process by which oxygenated capillary blood passes through the tissues of the body personal protective equipment (PPE): equipment and supplies necessary to minimize or prevent exposure to infectious material, including gloves, gowns, masks, and protective eye gear pleurae: membranes that cover the lungs pleural effusion: fluid in the pleural space pneumothorax: air in the pleural space pulse oximetry: noninvasive technique that measures the oxygen saturation (SpO2) of arterial blood respiration: gas exchange between the atmospheric air in the alveoli and the blood in the capillaries spirometer: instrument used to measure lung capacity and volume; one type is used to encourage deep breathing (incentive spirometry) subcutaneous emphysema: small pockets of air trapped in the subcutaneous tissue; usually found around chest tube insertion sites tachypnea: rapid breathing tracheostomy: curved tube inserted into an artificial opening made into the trachea; comes in varied angles and multiple sizes ventilation (breathing): the movement of air into and out of the lungs A functioning respiratory system is necessary for life. The respiratory system (Figure 14-1) delivers oxygen to the cells and also removes carbon dioxide. The respiratory system performs its functions through pulmonary ventilation, respiration, and perfusion. Normal functioning depends on three essential factors: The integrity of the airway system to transport air to and from the lungs A properly functioning alveolar system in the lungs to oxygenate venous blood and to remove carbon dioxide from the blood A properly functioning cardiovascular and hematologic system to carry nutrients and wastes to and from body cells The air passages must remain patent (open) for oxygen to enter the system. Any condition that interferes with normal functioning must be minimized or eliminated to prevent pulmonary distress, which could lead to death. This chapter covers the skills necessary for the nurse to promote oxygenation. While performing skills related to oxygenation, keep in mind factors that affect respiratory function and how they might affect a particular patient (Fundamentals Review 14-1). LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 702 Aptara 702 UNIT II Promoting Healthy Physiologic Responses From pulmonary artery Alveolar duct Frontal sinus Nasal cavity Epiglottis Right Lung Right bronchus Sphenoidal sinus Nasopharynx Oropharynx Laryngeal pharynx Alveoli Pharynx Larynx and vocal cords Esophagus Capillaries B Trachea Mediastinum Right Lung Terminal bronchiole To pulmonary vein Left lung Diaphragm Thoracic vertebra Left Lung Parietal pleura Wall of thorax Pleural space Visceral pleura A C Sternum FIGURE 14-1. The organs of the respiratory tract. (A) Overview. (B) Alveoli (air sacs) of the lungs and the blood capillaries. (C) Transverse section through the lungs. LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 703 Aptara CHAPTER 14 Oxygenation 703 Fundamentals Review 14-1 FACTORS AFFECTING RESPIRATORY FUNCTION A variety of factors can impact/affect respiratory functioning. This display reviews six common factors. and the respiratory system) work together, so alterations in one may affect the other. For example, alterations in muscle function contribute to inadequate pulmonary ventilation and respiration. LEVEL OF HEALTH Acute and chronic illness can dramatically affect a person’s respiratory function. Body systems (e.g., the cardiovascular system and respiratory system or the musculoskeletal system DEVELOPMENTAL LEVEL Respiratory function varies across the lifespan. The table below summarizes variations. Infant (Birth–1 yr) Early Childhood (1–5 yrs) Late Childhood (6–12 yrs) Aged Adult (65 yrs) Respiratory rate 30–60 breaths/min 20–40 breaths/min 15–25 breaths/min 16–20 breaths/min Respiratory pattern Abdominal breathing, irregular in rate and depth Abdominal breathing, irregular Thoracic breathing, regular Thoracic, regular Chest wall Thin, little muscle, ribs and sternum easily seen Same as infant’s but with more subcutaneous fat Further subcutaneous fat deposited, structures less prominent Thin, structures prominent Breath sounds Loud, harsh crackles at end of deep inspiration Loud, harsh expiration longer than inspiration Clear inspiration is longer than expiration Clear Shape of thorax Round Elliptical Elliptical Barrel-shaped or elliptical MEDICATIONS ENVIRONMENT Many medications affect the function of the respiratory system. Many medications depress the respiratory system. The nurse should monitor patients taking certain medications, such as opioids, for rate and depth of respirations. Research indicates that there is a high correlation between air pollution and occupational exposure to certain chemicals and lung disease. Additionally, people who have experienced an alteration in respiratory functioning often have difficulty continuing to perform self-care activities in a polluted environment. LIFESTYLE Activity levels and habits can dramatically affect a person’s respiratory status. For example, people who exercise can better respond to stressors to respiratory health. Cigarette smoking (active or passive) is a major contributor to lung disease and respiratory distress. Cigarette smoking is the most important risk factor for developing COPD (Macnee, 2007). PSYCHOLOGICAL HEALTH Many psychological factors can have an impact on the respiratory system. Individuals responding to stress or anxiety may experience hyperventilation. In addition, patients with respiratory problems often develop some anxiety as a result of the hypoxia caused by the respiratory problem. 704 UNIT II Promoting Healthy Physiologic Responses 14-1 Using a Pulse Oximeter Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. A sensor, or probe, uses a beam of red and infrared light that travels through tissue and blood vessels. One part of the sensor emits the light and another part receives the light. The oximeter then calculates the amount of light that has been absorbed by arterial blood. Oxygen saturation is determined by the amount of each light absorbed; unoxygenated hemoglobin absorbs more red light and oxygenated hemoglobin absorbs more infrared light. Sensors are available for use on a finger, a toe, a foot (infants), an earlobe, forehead, and the bridge of the nose. It is important to use the appropriate sensor for the intended site; use of a sensor on a site other than what it is intended can result in inaccurate or unreliable readings (Haynes, 2007). Circulation to the sensor site must be adequate to ensure accurate readings. Pulse oximeters also display a measured pulse rate. It is important to know the patient’s hemoglobin level before evaluating oxygen saturation because the test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a patient with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the patient may not have enough oxygen to meet body needs. Also, take into consideration the presence of preexisting health conditions, such as COPD. Parameters for acceptable oxygen saturation readings may be different for these patients. Be aware of any medical orders regarding acceptable ranges and/or check with the patient’s physician. A range of 95% to 100% is considered normal SpO2; values less than 90% are abnormal, indicate that oxygenation to the tissues is inadequate, and should be investigated for potential hypoxia or technical error (Booker, 2008a; DeMeulenaere, 2007). Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. Pulse oximetry does not replace arterial blood gas analysis. Desaturation indicates gas exchange abnormalities. EQUIPMENT ASSESSMENT Assess the patient’s skin temperature and color, including the color of the nail beds. Temperature is a good indicator of blood flow. Warm skin indicates adequate circulation. In a well-oxygenated patient, the skin and nail beds are usually pink. Skin that is bluish or dusky indicates hypoxia (inadequate amount of oxygen available to the cells). Also check capillary refill; prolonged capillary refill indicates a reduction in blood flow. Assess the quality of the pulse proximal to the sensor application site. Auscultate the lungs (see Skill 2-3). Note the amount of oxygen and delivery method if the patient is receiving supplemental oxygen. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Decreased Cardiac Tissue Perfusion Ineffective Airway Clearance Risk for Ineffective Cerebral Tissue Perfusion Activity Intolerance Impaired Gas Exchange Other nursing diagnoses also may require the use of this skill, such as Decreased Cardiac Output, Excess Fluid Volume, Anxiety, and Risk for Aspiration. OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when caring for a patient with a pulse oximeter is that the patient will exhibit arterial blood oxygen saturation within acceptable parameters, or greater than 95%. Pulse oximeter with an appropriate sensor or probe Alcohol wipe(s) or disposable cleansing cloth Nail polish remover (if necessary) PPE, as indicated LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 705 Aptara 705 CHAPTER 14 Oxygenation IMPLEMENTATION ACTION R AT I O N A L E 1. Review chart for any health problems that would affect the patient’s oxygenation status. Identifying influencing factors aids in interpretation of results. 2. Bring necessary equipment to the bedside stand or overbed table. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. 6. Select an adequate site for application of the sensor. Inadequate circulation can interfere with the oxygen saturation (SpO2) reading. a. Use the patient’s index, middle, or ring finger (Figure 1). Fingers are easily accessible. b. Check the proximal pulse (Figure 2) and capillary refill (Figure 3) at the pulse closest to the site. Brisk capillary refill and a strong pulse indicate that circulation to the site is adequate. c. If circulation at the site is inadequate, consider using the earlobe, forehead, or bridge of nose. These alternate sites are highly vascular alternatives. d. Use a toe only if lower extremity circulation is not compromised. Peripheral vascular disease is common in lower extremities. 7. Select proper equipment: a. If one finger is too large for the probe, use a smaller one. A pediatric probe may be used for a small adult. Inaccurate readings can result if probe or sensor is not attached correctly. b. Use probes appropriate for patient’s age and size. Probes come in adult, pediatric, and infant sizes. c. Check if patient is allergic to adhesive. A nonadhesive finger clip or reflectance sensor is available. A reaction may occur if the patient is allergic to adhesive substance. FIGURE 1. Selecting an appropriate finger. FIGURE 2. Assessing pulse. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 706 Aptara 706 UNIT II 14-1 Promoting Healthy Physiologic Responses Using a Pulse Oximeter ACTION continued R AT I O N A L E FIGURE 3. Assessing capillary refill. 8. Prepare the monitoring site. Cleanse the selected area with the alcohol wipe or disposable cleansing cloth (Figure 4). Allow the area to dry. If necessary, remove nail polish and artificial nails after checking pulse oximeter’s manufacturer instructions. Skin oils, dirt, or grime on the site can interfere with the passage of light waves. Research is conflicting regarding the effect of dark color nail polish and artificial nails; refer to facility policy and pulse oximeter’s manufacturer instructions (Collins & Andersen, 2007; DeMeulenaere, 2007). 9. Apply probe securely to skin (Figure 5). Make sure that the light-emitting sensor and the light-receiving sensor are aligned opposite each other (not necessary to check if placed on forehead or bridge of nose). Secure attachment and proper alignment promote satisfactory operation of the equipment and accurate recording of the SpO2. FIGURE 4. Cleaning the area. FIGURE 5. Attaching probe to patient’s finger. 10. Connect the sensor probe to the pulse oximeter (Figure 6), turn the oximeter on, and check operation of the equipment (audible beep, fluctuation of bar of light or waveform on face of oximeter). Audible beep represents the arterial pulse, and fluctuating waveform or light bar indicates the strength of the pulse. A weak signal will produce an inaccurate recording of the SpO2. Tone of beep reflects SpO2 reading. If SpO2 drops, tone becomes lower in pitch. 11. Set alarms on pulse oximeter. Check manufacturer’s alarm limits for high and low pulse rate settings (Figure 7). Alarm provides additional safeguard and signals when high or low limits have been surpassed. LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 707 Aptara CHAPTER 14 Oxygenation ACTION 707 R AT I O N A L E FIGURE 6. Connecting sensor probe to unit. FIGURE 7. Checking alarms. 12. Check oxygen saturation at regular intervals, as ordered by primary care provider, nursing assessment, and signaled by alarms. Monitor hemoglobin level. Monitoring SpO2 provides ongoing assessment of patient’s condition. A low hemoglobin level may be satisfactorily saturated yet inadequate to meet a patient’s oxygen needs. 13. Remove sensor on a regular basis and check for skin irritation or signs of pressure (every 2 hours for spring-tension sensor or every 4 hours for adhesive finger or toe sensor). Prolonged pressure may lead to tissue necrosis. Adhesive sensor may cause skin irritation. 14. Clean nondisposable sensors according to the manufacturer’s directions. Remove PPE, if used. Perform hand hygiene. EVALUATION Cleaning equipment between patient use reduces the spread of microorganisms. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcome is met when the patient exhibits an oxygen saturation level within acceptable parameters, or greater than 95%, and a heart rate that correlates with the pulse measurement. DOCUMENTATION Guidelines Sample Documentation Documentation should include the type of sensor and location used; assessment of the proximal pulse and capillary refill; pulse oximeter reading; the amount of oxygen and delivery method if the patient is receiving supplemental oxygen; lung assessment, if relevant; and any other relevant interventions required as a result of the reading. 9/03/12 Pulse oximeter placed on patient’s index finger on right hand. Radial pulse present with brisk capillary refill. Pulse oximeter reading 98% on oxygen at 2 L via nasal cannula. Heart rate measured by oximeter correlates with the radial pulse measurement. —C. Bausler, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Absent or weak signal: Check vital signs and patient condition. If satisfactory, check connections and circulation to site. Hypotension makes an accurate recording difficult. Equipment (restraint, blood pressure cuff) may compromise circulation to site and cause venous blood to pulsate, giving an inaccurate reading. If extremity is cold, cover with a warm blanket. Inaccurate reading: Check prescribed medications and history of circulatory disorders. Try device on a healthy person to see if problem is equipment-related or patient-related. Drugs that cause vasoconstriction interfere with accurate recording of oxygen saturation. A bright light (sunlight or fluorescent light) is suspected of causing equipment malfunction: Turn off light or cover probe with a dry washcloth. Bright light can interfere with operation of light sensors and cause unreliable report. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 708 Aptara 708 UNIT II 14-1 Promoting Healthy Physiologic Responses Using a Pulse Oximeter continued SPECIAL CONSIDERATIONS General Considerations Accuracy of readings can be influenced by conditions that decrease arterial blood flow, such as peripheral edema, hypotension, and peripheral vascular disease. Correlate the pulse reading on the pulse oximeter with the patient’s heart rate. Variation between pulse and heart rate may indicate that not all pulsations are being detected and another sensor site may be required (Moore, 2007). Excessive motion of sensor probe site, such as with extremity tremors or shivering, can also interfere with obtaining an accurate reading. Bradycardia and irregular cardiac rhythms may also cause inaccurate readings. In patients with low cardiac index (cardiac output in liters per minute divided by body surface area in square meters), the forehead sensor may be better than the digit sensor for pulse oximetry (Fernandez et al., 2007). Infant and Child Considerations For infants, the oximeter probe may be placed on the toe or foot (Figure 8). FIGURE 8. Oximetry probe on infant’s toe. Older Adult Considerations Careful attention to the patient’s skin integrity and condition is necessary to prevent injury. Pressure or tension from the probe, as well as any adhesive used, can damage older, dry, thin skin. Home Care Considerations Portable units are available for use in the home or in an outpatient setting. EVIDENCE FOR PRACTICE Monitoring oxygen saturation by using pulse oximetry is a common method for assessing respiratory status in acutely ill patients. Several factors can adversely affect the performance of the device, such as movement by the patient, sensor adherence to the skin, and low blood flow to the sensor area. Related Research Fernandez, M., Burns, K., Calhoun, B., et al. (2007). Evaluation of a new pulse oximeter sensor. American Journal of Critical Care, 16(2), 146–152. The objective of this study was to examine agreement between oxygen saturation values obtained by using a digit-based pulse oximeter sensor and a forehead pulse oximeter sensor with arterial oxygen saturation in patients with low cardiac index (cardiac output in liters per minute divided by body surface area in square meters). Readings were obtained from a finger and a forehead sensor and by analysis of a blood sample. The forehead sensor differed less from the blood sample than did the digit-based sensor. The study concluded the forehead sensor was better than the digit-based sensor for pulse oximetry in patients with low cardiac index. 709 CHAPTER 14 Oxygenation Relevance for Nursing Practice 14-2 Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. Desaturation indicates gas exchange abnormalities. Nurses must assess for factors that could adversely affect the accuracy of pulse oximetry readings and use the appropriate technique for individual patients. In patients with low cardiac index, nurses should consider using a forehead sensor to provide the most accurate assessment data. Teaching Patient to Use an Incentive Spirometer Incentive spirometry provides visual reinforcement for deep breathing by the patient. It assists the patient to breathe slowly and deeply, and to sustain maximal inspiration, while providing immediate positive reinforcement. Incentive spirometry encourages the patient to maximize lung inflation and prevent or reduce atelectasis. Optimal gas exchange is supported and secretions can be cleared and expectorated. EQUIPMENT ASSESSMENT Assess the patient for pain and administer pain medication, as prescribed, if deep breathing may cause pain. Presence of pain may interfere with learning and performing required activities. Assess lung sounds before and after use to establish a baseline and to determine the effectiveness of incentive spirometry. Incentive spirometry encourages patients to take deep breaths, and lung sounds may be diminished before using the incentive spirometer. Assess vital signs and oxygen saturation to provide baseline data to evaluate patient response. Oxygen saturation may increase due to reinflation of alveoli. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Ineffective Breathing Pattern Risk for Injury Risk for Infection Deficient Knowledge Impaired Gas Exchange Activity Intolerance Acute Pain Other nursing diagnoses may require the use of this skill. OUTCOME IDENTIFICATION AND PLANNING The expected outcome is that the patient accurately demonstrates the procedure for using the spirometer. Other outcomes that may be appropriate include the following: patient demonstrates increased oxygen saturation level; patient reports adequate control of pain during use; and patient demonstrates increased lung expansion with clear breath sounds. Incentive spirometer Stethoscope Folded blanket or pillow for splinting of chest or abdominal incision, if appropriate PPE, as indicated IMPLEMENTATION ACTION R AT I O N A L E 1. Review chart for any health problems that would affect the patient’s oxygenation status. Identifying influencing factors aids in interpretation of results. 2. Bring necessary equipment to the bedside stand or overbed table. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 710 Aptara 710 UNIT II 14-2 Promoting Healthy Physiologic Responses Teaching Patient to Use an Incentive Spirometer ACTION continued R AT I O N A L E 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. 6. Assist patient to an upright or semi-Fowler’s position, if possible. Remove dentures if they fit poorly. Assess the patient’s level of pain. Administer pain medication, as prescribed, if needed. Wait the appropriate amount of time for the medication to take effect. If patient has recently undergone abdominal or chest surgery, place a pillow or folded blanket over a chest or abdominal incision for splinting. Upright position facilitates lung expansion. Dentures may inhibit the patient from taking deep breaths if the patient is concerned that dentures may fall out. Pain may decrease the patient’s ability to take deep breaths. Deep breaths may cause the patient to cough. Splinting the incision supports the area and helps reduce pain from the incision. (Refer to Skill 6-1.) 7. Demonstrate how to steady the device with one hand and hold the mouthpiece with the other hand (Figure 1). If the patient cannot use hands, assist the patient with the incentive spirometer. This allows the patient to remain upright, visualize the volume of each breath, and stabilize the device. FIGURE 1. Patient using incentive spirometer. 8. Instruct the patient to exhale normally and then place lips securely around the mouthpiece. Patient should fully empty lungs so that maximum volume may be inhaled. A tight seal allows for maximum use of the device. 9. Instruct patient to inhale slowly and as deeply as possible through the mouthpiece without using nose (if desired, a nose clip may be used). Inhaling through the nose would provide an inaccurate measurement of inhalation volume. 10. When the patient cannot inhale anymore, the patient should hold his or her breath and count to three. Check position of gauge to determine progress and level attained. If patient begins to cough, splint an abdominal or chest incision. Holding breath for 3 seconds helps the alveoli to re-expand. Volume on incentive spirometry should increase with practice. 11. Instruct the patient to remove lips from mouthpiece and exhale normally. If patient becomes light-headed during the process, tell him or her to stop and take a few normal breaths before resuming incentive spirometry. Deep breaths may change the CO2 level, leading to light-headedness. CHAPTER 14 Oxygenation ACTION 711 R AT I O N A L E 12. Encourage patient to perform incentive spirometry 5 to10 times every 1 to 2 hours, if possible. 13. Clean the mouthpiece with water and shake to dry. Remove PPE, if used. Perform hand hygiene. EVALUATION This helps to reinflate the alveoli and prevent atelectasis due to hypoventilation. Cleaning equipment deters the spread of microorganisms and contaminants. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcome is met when the patient demonstrates the steps for use of the incentive spirometer correctly and exhibits lung sounds that are clear and equal in all lobes. In addition, the patient demonstrates an increase in oxygen saturation levels, and verbalizes adequate pain control and the importance of, and need for, incentive spirometry. DOCUMENTATION Guidelines Documentation should include that the incentive spirometer was used by the patient, the number of repetitions, and the average volume reached. Document patient teaching and patient response, if appropriate. If the patient coughs, document whether the cough is productive or nonproductive. If productive cough is present, include the characteristics of the sputum, including consistency, amount, and color. Sample Documentation 9/8/12 Incentive spirometry performed  10, volume 1,500 mL obtained. Patient with nonproductive cough during incentive spirometry. —C. Bausler, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Volume inhaled is decreasing: Assess patient’s pain and anxiety level. Patient may have pain and not be inhaling fully, or patient may have experienced pain previously during incentive spirometry and have an increased anxiety level. If ordered, medicate patient when pain is present. Discuss fears with patient and encourage him or her to inhale fully or to increase the volume by 100 each time incentive spirometry is performed. Patient attempts to blow into incentive spirometer: Compare the incentive spirometer to a straw. Remind patient to exhale before beginning each time. SPECIAL CONSIDERATIONS General Considerations Reinforce importance of continued use by postoperative patients upon discharge. Older Adult Considerations Older adults have decreased muscle function and fatigue more easily. Encourage rest periods between repetitions. 14-3 Administering Oxygen by Nasal Cannula A variety of devices are available for delivering oxygen to the patient. Each has a specific function and oxygen concentration. Device selection is based on the patient’s condition and oxygen needs. A nasal cannula, also called nasal prongs, is the most commonly used oxygen delivery device. The cannula is a disposable plastic device with two protruding prongs for insertion into the nostrils. The cannula connects to an oxygen source with a flow meter and, many times, a humidifier. It is commonly used because the cannula does not impede eating or speaking and is used easily in the home. Disadvantages of this system are that it can be dislodged easily and can cause dryness of the nasal mucosa. A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. Table 14-1 compares amounts of delivered oxygen for these flow rates. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 712 Aptara 712 UNIT II Promoting Healthy Physiologic Responses 14-3 T A B L E 14-1 Administering Oxygen by Nasal Cannula continued OXYGEN DELIVERY SYSTEMS Method Amount Delivered FIO2 (Fraction Inspired Oxygen) Priority Nursing Interventions Nasal cannula Low Flow 1 L/min  24% 2 L/min  28% 3 L/min  32% 4 L/min  36% 5 L/min  40% 6 L/min  44% Check frequently that both prongs are in patient’s nares. May be limited to no more than 2–3 L/min to patient with chronic lung disease. Simple mask Low Flow 6–10 L/min  35% to 60% (5 L/min is minimum setting) Monitor patient frequently to check placement of the mask. Support patient if claustrophobia is a concern. Secure physician’s order to replace mask with nasal cannula during meal time. Partial rebreather mask Low Flow 6–15 L/min  70% to 90% Set flow rate so that mask remains two-thirds full during inspiration. Keep reservoir bag free of twists or kinks. Nonrebreather mask Low Flow 6–15 L/min  60% to 100% Maintain flow rate so reservoir bag collapses only slightly during inspiration. Check that valves and rubber flaps are functioning properly (open during expiration and closed during inhalation). Monitor SaO2 with pulse oximeter. Venturi mask High Flow 4–10 L/min  24% to 55% Requires careful monitoring to verify FIO2 at flow rate ordered. Check that air intake valves are not blocked. EQUIPMENT ASSESSMENT Assess the patient’s oxygen saturation level before starting oxygen therapy to provide a baseline for evaluating the effectiveness of oxygen therapy. Assess the patient’s respiratory status, including respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Other nursing diagnoses that may be appropriate include: Risk for Activity Intolerance Excess Fluid Volume Decreased Cardiac Output OUTCOME IDENTIFICATION AND PLANNING The expected outcome is that the patient will exhibit an oxygen saturation level within acceptable parameters. Other outcomes that may be appropriate include the following: patient will not experience dyspnea; and patient will demonstrate effortless respirations in the normal range for age group, without evidence of nasal flaring or use of accessory muscles. Flow meter connected to oxygen supply Humidifier with sterile, distilled water (optional for low-flow system) Nasal cannula and tubing Gauze to pad tubing over ears (optional) PPE, as indicated LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 713 Aptara CHAPTER 14 Oxygenation 713 IMPLEMENTATION ACTION 1. Bring necessary equipment to the bedside stand or overbed table. R AT I O N A L E Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. This ensures the patient’s privacy. 5. Explain what you are going to do and the reason for doing it to the patient. Review safety precautions necessary when oxygen is in use. Place “No Smoking” signs in appropriate areas. Explanation relieves anxiety and facilitates cooperation. Oxygen supports combustion; a small spark could cause a fire. 6. Connect nasal cannula to oxygen setup with humidification, if one is in use (Figure 1). Adjust flow rate as ordered (Figure 2). Check that oxygen is flowing out of prongs. Oxygen forced through a water reservoir is humidified before it is delivered to the patient, thus preventing dehydration of the mucous membranes. Low-flow oxygen does not require humidification. FIGURE 1. Connecting cannula to oxygen source. 7. Place prongs in patient’s nostrils (Figure 3). Place tubing over and behind each ear with adjuster comfortably under chin. Alternately, the tubing may be placed around the patient’s head, with the adjuster at the back or base of the head. Place gauze pads at ear beneath the tubing, as necessary (Figure 4). FIGURE 2. Adjusting flow rate. Correct placement of the prongs and fastener facilitates oxygen administration and patient comfort. Pads reduce irritation and pressure and protect the skin. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 714 Aptara 714 UNIT II 14-3 Promoting Healthy Physiologic Responses Administering Oxygen by Nasal Cannula ACTION FIGURE 3. Applying cannula to nares. continued R AT I O N A L E FIGURE 4. Placing gauze pad at ears. 8. Adjust the fit of the cannula, as necessary (Figure 5). Tubing should be snug but not tight against the skin. Proper adjustment maintains the prongs in the patient’s nose. Excessive pressure from tubing could cause irritation and pressure to the skin. 9. Encourage patients to breathe through the nose, with the mouth closed. Nose breathing provides for optimal delivery of oxygen to patient. The percentage of oxygen delivered can be reduced in patients who breathe through the mouth. 10. Reassess patient’s respiratory status, including respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea. 11. Remove PPE, if used. Perform hand hygiene. These assess the effectiveness of oxygen therapy. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. 12. Put on clean gloves. Remove and clean the cannula and assess nares at least every 8 hours, or according to agency recommendations (Figure 6). Check nares for evidence of irritation or bleeding. The continued presence of the cannula causes irritation and dryness of the mucous membranes. FIGURE 5. Adjusting cannula, if needed. FIGURE 6. Cleaning cannula, when indicated. CHAPTER 14 Oxygenation EVALUATION 715 The expected outcome is met when the patient demonstrates an oxygen saturation level within acceptable parameters. In addition, the patient remains free of dyspnea, nasal flaring, or accessory muscle use and demonstrates respiratory rate and depth within normal ranges. DOCUMENTATION Guidelines Document your assessment before and after intervention. Document the amount of oxygen applied, the patient’s respiratory rate, oxygen saturation, and lung sounds. Sample Documentation 9/17/12 1300 Oxygen via nasal cannula applied at 2 L/min. Humidification in place. Pulse oximeter before placing oxygen 92%; after oxygen at 2 L/min 98%. Respirations even and unlabored. Chest rises symmetrically. No nasal flaring or retractions noted. Lung sounds clear and equal all lobes. —C. Bausler, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Patient was fine on oxygen delivered by nasal cannula but now is cyanotic, and the pulse oximeter reading is less than 93%: Check to see that the oxygen tubing is still connected to the flow meter and the flow meter is still on the previous setting. Someone may have stepped on the tubing, pulling it from the flow meter, or the oxygen may have accidentally been turned off. Assess lung sounds to note any changes. Areas over ear or back of head are reddened: Ensure that areas are adequately padded and that tubing is not pulled too tight. If available, a skin care team may be able to offer some suggestions. When dozing, patient begins to breathe through the mouth: Temporarily place the nasal cannula near the mouth. If this does not raise the pulse oximeter reading, you may need to obtain an order to switch the patient to a mask while sleeping. SPECIAL CONSIDERATIONS Home Care Considerations 14-4 Oxygen administration may need to be continued in the home setting. Portable oxygen concentrators are used most frequently. Caregivers require instruction concerning safety precautions with oxygen use and need to understand the rationale for the specific liter flow of oxygen. To prevent fires and injuries, take the following precautions: Avoid open flames. Place “No Smoking” signs in conspicuous places in the patient’s home. Instruct the patient and visitors about the hazard of smoking when oxygen is in use. Check to see that electrical equipment used in the room is in good working order and emits no sparks. Avoid using oils in the area. Oil can ignite spontaneously in the presence of oxygen. Administering Oxygen by Mask When a patient requires a higher concentration of oxygen than a nasal cannula can deliver (6 L or 44% oxygen concentration), use an oxygen mask. (See Table 14-1 in Skill 14-3 for a comparison of different types of oxygen delivery systems.) Fit the mask carefully to the patient’s face to avoid leakage of oxygen. The mask should be comfortably snug, but not tight against the face. Disposable and reusable face masks are available. The most commonly used types of masks are the simple facemask, the partial rebreather mask, the nonrebreather mask, and the Venturi mask. Figure 1 illustrates different types of oxygen masks. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 716 Aptara 716 UNIT II 14-4 Promoting Healthy Physiologic Responses Administering Oxygen by Mask A B continued C E D FIGURE 1. Types of oxygen masks. (A) Venturi mask. (B) Nonrebreather mask. (C) Partial rebreather mask. (D) Simple face mask. (E) High-flow oxygen face mask and bottle. EQUIPMENT Flow meter connected to oxygen supply Humidifier with sterile distilled water, if necessary, for the type of mask prescribed Face mask, specified by physician Gauze to pad elastic band (optional) PPE, as indicated LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 717 Aptara 717 CHAPTER 14 Oxygenation ASSESSMENT Assess patient’s oxygen saturation level before starting oxygen therapy to provide a baseline for determining the effectiveness of therapy. Assess patient’s respiratory status, including respiratory rate and depth and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Many other nursing diagnoses may be appropriate, possibly including: Risk for Activity Intolerance Excess Fluid Volume Decreased Cardiac Output OUTCOME IDENTIFICATION AND PLANNING The expected outcome is that the patient exhibits an oxygen saturation level within acceptable parameters. Other outcomes that may be appropriate include the following: the patient will remain free of signs and symptoms of respiratory distress; and respiratory status, including respiratory rate and depth, will be in the normal range for the patient’s age. IMPLEMENTATION ACTION 1. Bring necessary equipment to the bedside stand or overbed table. R AT I O N A L E Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. This ensures the patient’s privacy. 5. Explain what you are going to do and the reason for doing it to the patient. Review safety precautions necessary when oxygen is in use. Place “No Smoking” signs in appropriate areas. Explanation relieves anxiety and facilitates cooperation. Oxygen supports combustion; a small spark could cause a fire. 6. Attach face mask to oxygen source (with humidification, if appropriate, for the specific mask) (Figure 2). Start the flow of oxygen at the specified rate. For a mask with a reservoir, be sure to allow oxygen to fill the bag (Figure 3) before proceeding to the next step. Oxygen forced through a water reservoir is humidified before it is delivered to the patient, thus preventing dehydration of the mucous membranes. A reservoir bag must be inflated with oxygen because the bag is the oxygen supply source for the patient. 7. Position face mask over the patient’s nose and mouth (Figure 4). Adjust the elastic strap so that the mask fits snugly but comfortably on the face (Figure 5). Adjust the flow rate to the prescribed rate (Figure 6). A loose or poorly fitting mask will result in oxygen loss and decreased therapeutic value. Masks may cause a feeling of suffocation, and the patient needs frequent attention and reassurance. 8. If the patient reports irritation or redness is noted, use gauze pads under the elastic strap at pressure points to reduce irritation to ears and scalp. Pads reduce irritation and pressure and protect the skin. 9. Reassess patient’s respiratory status, including respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, or dyspnea. This helps assess the effectiveness of oxygen therapy. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 718 Aptara 718 UNIT II 14-4 Promoting Healthy Physiologic Responses Administering Oxygen by Mask ACTION continued R AT I O N A L E FIGURE 2. Connecting face mask to oxygen source. FIGURE 3. Allowing oxygen to fill the bag. FIGURE 4. Applying face mask over nose and mouth. FIGURE 5. Adjusting elastic straps. 10. Remove PPE, if used. Perform hand hygiene. 11. Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously. Do not use powder around the mask. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The tight-fitting mask and moisture from condensation can irritate the skin on the face. There is a danger of inhaling powder if it is placed on the mask. LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 719 Aptara CHAPTER 14 Oxygenation 719 FIGURE 6. Adjusting flow rate. EVALUATION The expected outcome is met when the patient exhibits an oxygen saturation level within acceptable parameters. In addition, the patient demonstrates an absence of respiratory distress and accessory muscle use and exhibits respiratory rate and depth within normal parameters. DOCUMENTATION Guidelines Sample Documentation Document type of mask used, amount of oxygen used, oxygen saturation level, lung sounds, and rate/pattern of respirations. Document your assessment before and after intervention. 9/22/12 Patient reports feeling short of breath. Skin pale, respirations 30 breaths per minute and labored. Lung sounds decreased throughout. Oxygen saturation via pulse oximeter 88%. Findings reported to Dr. Lu. Oxygen via nonrebreather face mask applied at 12 L/min as ordered. Patient’s skin is pink after O2 applied. Oxygen saturation increased to 98%. Respirations even and unlabored. Chest rises symmetrically. Respiratory rate 18 breaths per minute. Lungs remain with decreased breath sounds throughout. Patient denies dyspnea. —C. Bausler, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Patient was previously fine but now is cyanotic, and the pulse oximeter reading is less than 93%: Check to see that the oxygen tubing is still connected to the flow meter and the flow meter is still on the previous setting. Someone may have stepped on the tubing, pulling it from the flow meter, or the oxygen may have accidentally been turned off. Assess lung sounds for any changes. Areas over ear or back of head are reddened: Ensure that areas are adequately padded and that tubing is not pulled too tight. If available, a skin-care team may be able to offer some suggestions. SPECIAL CONSIDERATIONS Different types of face masks are available for use. (Refer to Table 14-1 in Skill 14-3 for more information.) It’s important to ensure the mask fits snugly around the patient’s face. If it is loose, it will not effectively deliver the right amount of oxygen. The mask must be removed for the patient to eat, drink, and take medications. Obtain an order for oxygen via nasal cannula for use during meal times and limit the amount of times the mask is removed to maintain adequate oxygenation. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 720 Aptara 720 UNIT II 14-4 Promoting Healthy Physiologic Responses Administering Oxygen by Mask continued Skill Variation Using an Oxygen Hood Oxygen hoods are generally used to deliver oxygen to infants. They can supply an oxygen concentration up to 80% to 90%. Use of oxygen hoods enable the oxygen percentage to be measured more accurately and make appropriate humidification possible (Pease, 2006). The oxygen hood is placed over the infant’s head and shoulders, and allows easy access to the chest and lower body. The hoods are made of hard plastic or vinyl with a metal frame. Assessment of an infant should include assessment of skin color. A pale or cyanotic patient may not be receiving sufficient oxygen. Assessment should also include assessing the patient for any signs of respiratory distress, such as nasal flaring, grunting, or retractions; oxygen-depleted patients often exhibit these signs. Additional equipment required includes the oxygen hood, oxygen analyzer, and a humidification device. 1. Bring necessary equipment to the bedside stand or overbed table. 2. Perform hand hygiene and put on PPE, if indicated. FIGURE A. Placing oxygen hood over infant. 3. Identify the patient. 4. Close curtains around bed and close the door to the room, if possible. 5. Explain what you are going to do and the reason for doing it to the patient and parents/guardians. Review safety precautions necessary when oxygen is in use. 6. Calibrate the oxygen analyzer according to manufacturer’s directions. 7. Place hood on crib. Connect humidifier to oxygen source in the wall. Connect the oxygen tubing to the hood. Adjust flow rate as ordered by physician. Check that oxygen is flowing into the hood. 10. If using the soft vinyl hood, roll small blankets or towels and place around edges where the hood meets crib (if needed) to keep oxygen concentration at desired level. Do not block hole in top of hood if present. If using a vinyl hood, the vent hole covering may need to be removed. 11. Instruct family members not to raise edges of the hood. 12. Reassess patient’s respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, grunting, retractions, or dyspnea. 13. Remove PPE, if used. Perform hand hygiene. 8. Turn analyzer on. Place oxygen analyzer probe in hood. 9. Adjust oxygen flow, as necessary, based on sensor readings. Once oxygen levels reach the prescribed amount, place hood over patient’s head (Figure A). The hood should not rub against the infant’s neck, chin, or shoulder. 14. Frequently check bedding and patient’s head for moisture. Change linen and dry the patient’s skin, as needed, to keep the patient dry. 15. Monitor the patient’s body temperature at regular intervals. 721 CHAPTER 14 Oxygenation 14-5 Using an Oxygen Tent Oxygen tents are often used in children who will not leave a face mask or nasal cannula in place. The oxygen tent gives the patient freedom to move in the bed or crib while humidified oxygen is being delivered; however, it is difficult to keep the tent closed, because the child may want contact with his or her parents. It is also difficult to maintain a consistent level of oxygen and to deliver oxygen at a rate higher than 30% to 50%. Frequent assessment of the child’s pajamas and bedding is necessary because the humidification quickly creates moisture, leading to damp clothing and linens, and, possibly, hypothermia. EQUIPMENT ASSESSMENT Assess the patient’s lung sounds. Secretions may cause the patient’s oxygen demand to increase. Assess the oxygen saturation level. The physician will usually order a baseline for the pulse oximeter (i.e., deliver oxygen to keep pulse oximetry greater than 95%). Assess skin color. A pale or cyanotic patient may not be receiving sufficient oxygen. Assess patient for any signs of respiratory distress, such as nasal flaring, grunting, or retractions; oxygen-depleted patients often exhibit these signs. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Many other nursing diagnoses may be appropriate, possibly including: Risk for Activity Intolerance Excess Fluid Volume Decreased Cardiac Output Risk for Impaired Skin Integrity OUTCOME IDENTIFICATION AND PLANNING The expected outcome is that the patient exhibits an oxygen saturation level within acceptable parameters. Other outcomes that may be appropriate include the following: patient will remain free of signs and symptoms of respiratory distress; respiratory status, including respiratory rate and depth, will be in the normal range for the patient’s age; and patient’s skin will be pink, dry, and without evidence of breakdown. Oxygen source Oxygen tent Humidifier compatible with tent Oxygen analyzer Small blankets for blanket rolls PPE, as indicated IMPLEMENTATION ACTION 1. Bring necessary equipment to the bedside stand or overbed table. R AT I O N A L E Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. This ensures the patient’s privacy. 5. Explain what you are going to do and the reason for doing it to the patient and parents/guardians. Review safety precautions necessary when oxygen is in use. Explanation relieves anxiety and facilitates cooperation. Oxygen supports combustion; a small spark could cause a fire. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 722 Aptara 722 UNIT II 14-5 Promoting Healthy Physiologic Responses Using an Oxygen Tent ACTION continued R AT I O N A L E 6. Calibrate the oxygen analyzer according to manufacturer’s directions. Ensures accurate readings and appropriate adjustments to therapy. 7. Place tent over crib or bed. Connect the humidifier to the oxygen source in the wall and connect the tent tubing to the humidifier. Adjust flow rate as ordered by physician. Check that oxygen is flowing into tent. Oxygen forced through a water reservoir is humidified before it is delivered to the patient, thus preventing dehydration of the mucous membranes. 8. Turn analyzer on. Place oxygen analyzer probe in tent, out of patient’s reach. The analyzer will give an accurate reading of the concentration of oxygen in the crib or bed. 9. Adjust oxygen as necessary, based on sensor readings (Figure 1). Once oxygen levels reach the prescribed amount, place patient in the tent (Figure 2). Patient will receive oxygen once placed in the tent. 10. Roll small blankets like a jelly roll and tuck tent edges under blanket rolls, as necessary (Figure 3). The blanket helps keep the edges of the tent flap from coming up and letting oxygen out. FIGURE 1. Adjusting oxygen flow. FIGURE 2. Placing patient in the tent. FIGURE 3. Tucking edges under blanket rolls. CHAPTER 14 Oxygenation ACTION 723 R AT I O N A L E 11. Encourage patient and family members to keep tent flap closed. Every time the tent flap is opened, oxygen is released. 12. Reassess patient’s respiratory status, including respiratory rate, effort, and lung sounds. Note any signs of respiratory distress, such as tachypnea, nasal flaring, use of accessory muscles, grunting, retractions, or dyspnea. This assesses the effectiveness of oxygen therapy. 13. Remove PPE, if used. Perform hand hygiene. 14. Frequently check bedding and patient’s pajamas for moisture. Change as needed to keep the patient dry. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The large amount of humidification delivered in an oxygen tent quickly makes cloth moist, which would be uncomfortable for the patient and may affect temperature regulation. The expected outcome is met when the patient exhibits an oxygen saturation level within acceptable parameters. In addition, the patient remains free of dyspnea, nasal flaring, grunting, or use of accessory muscles when breathing; and respirations remain in normal range for age. DOCUMENTATION Guidelines Document amount of oxygen applied, respiratory rate, oxygen saturation level, and your assessment before and after intervention. Sample Documentation 9/17/12 Patient noted to have nasal flaring and grunting. Lung sounds clear and equal. Pulse oximeter reading 92%. Patient placed in oxygen tent at 45% per standing order. Pulse oximeter reading increased to 98% after placing in tent. Respirations even, unlabored, and symmetric. No nasal flaring or retractions noted. Lung sounds clear and equal all lobes. —C. Bausler, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS 14-6 Child refuses to stay in tent: Parent may play games in tent with child if this will help child to stay in tent. Alternative methods of oxygen delivery may need to be considered if child still refuses to stay in tent. It is difficult to maintain an oxygen level above 40% in the tent: Ensure that the flap is closed and edges of the tent are tucked under blanket. Check oxygen delivery unit to ensure that the rate has not been changed. Encourage patient to leave flaps closed. If still a problem, analyzer may need to be replaced or recalibrated. Suctioning the Nasopharyngeal and Oropharyngeal Airways Suctioning of the pharynx is indicated to maintain a patent airway and to remove saliva, pulmonary secretions, blood, vomitus, or foreign material from the pharynx. Suctioning helps a patient who cannot successfully clear his or her airway by coughing and expectorating. When performing suctioning, position yourself on the appropriate side of the patient. If you are right-handed, stand on the patient’s right side; if left-handed, stand on the patient’s left side. This allows for comfortable use of the dominant hand to manipulate the suction catheter. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 724 Aptara 724 UNIT II Promoting Healthy Physiologic Responses 14-6 Suctioning the Nasopharyngeal and Oropharyngeal Airways continued EQUIPMENT Portable or wall suction unit with tubing A commercially prepared suction kit with an appropriate size catheter or Sterile suction catheter with Y-port in the appropriate size (Adult: 10F to 16F) Sterile disposable container Sterile gloves Sterile water or saline Towel or waterproof pad Goggles and mask or face shield Disposable, clean gloves Water-soluble lubricant Additional PPE, as indicated ASSESSMENT Assess lung sounds. Patients who need to be suctioned may have wheezes, crackles, or gurgling present. Assess oxygenation saturation level. Oxygen saturation usually decreases when a patient needs to be suctioned. Assess respiratory status, including respiratory rate and depth. Patients may become tachypneic when they need to be suctioned. Assess the patient for signs of respiratory distress, such as nasal flaring, retractions, or grunting. Assess effectiveness of coughing and expectoration. Patients with an ineffective cough and who are unable to expectorate secretions may need to be suctioned. Assess for history of deviated septum, nasal polyps, nasal obstruction, nasal injury, epistaxis (nasal bleeding), or nasal swelling. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Ineffective Airway Clearance Ineffective Breathing Pattern Impaired Gas Exchange Risk for Aspiration OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve is that the patient will exhibit improved breath sounds and a clear, patent airway. Other outcomes that may be appropriate include the following: patient will exhibit an oxygen saturation level within acceptable parameters; patient will demonstrate a respiratory rate and depth within age-acceptable range; and patient will remain free of any signs of respiratory distress, including retractions, nasal flaring, or grunting. IMPLEMENTATION ACTION 1. Bring necessary equipment to the bedside stand or overbed table. R AT I O N A L E Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. This ensures the patient’s privacy. 5. Determine the need for suctioning. Verify the suction order in the patient’s chart, if necessary. For a postoperative patient, administer pain medication before suctioning. To minimize trauma to airway mucosa, suctioning should be done only when secretions have accumulated or adventitious breath sounds are audible. Some facilities require an order for nasoand oropharyngeal suctioning. Suctioning stimulates coughing, which is painful for patients with surgical incisions. LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 725 Aptara CHAPTER 14 Oxygenation ACTION 725 R AT I O N A L E 6. Explain what you are going to do and the reason for suctioning to the patient, even if the patient does not appear to be alert. Reassure the patient you will interrupt procedure if he or she indicates respiratory difficulty. Explanation alleviates fears. Even if the patient appears unconscious, explain what is happening. Any procedure that compromises respiration is frightening for the patient. 7. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Lower side rail closest to you. If patient is conscious, place him or her in a semi-Fowler’s position. If patient is unconscious, place him or her in the lateral position, facing you. Move the bedside table close to your work area and raise it to waist height. Having the bed at the proper height prevents back and muscle strain. A sitting position helps the patient to cough and makes breathing easier. Gravity also facilitates catheter insertion. The lateral position prevents the airway from becoming obstructed and promotes drainage of secretions. The bedside table provides a work surface and helps maintain sterility of objects on the work surface. 8. Place towel or waterproof pad across the patient’s chest. This protects bed linens. 9. Adjust suction to appropriate pressure (Figure 1). Higher pressures can cause excessive trauma, hypoxemia, and atelectasis. For a wall unit for an adult: 100–120 mm Hg (Roman, 2005); neonates: 60–80 mm Hg; infants: 80–100 mm Hg; children: 80–100 mm Hg; adolescents: 80–120 mm Hg (Ireton, 2007). For a portable unit for an adult: 10–15 cm Hg; neonates: 6–8 cm Hg; infants: 8–10 cm Hg; children: 8–10 cm Hg; adolescents: 8–10 cm Hg. Put on a disposable, clean glove and occlude the end of the connecting tubing to check suction pressure. Place the connecting tubing in a convenient location. FIGURE 1. Adjusting wall suction. 10. Open sterile suction package using aseptic technique. The open wrapper or container becomes a sterile field to hold other supplies. Carefully remove the sterile container, touching only the outside surface. Set it up on the work surface and pour sterile saline into it. Sterile normal saline or water is used to lubricate the outside of the catheter, minimizing irritation of mucosa during introduction. It is also used to clear the catheter between suction attempts. 11. Place a small amount of water-soluble lubricant on the sterile field, taking care to avoid touching the sterile field with the lubricant package. Lubricant facilitates passage of the catheter and reduces trauma to mucous membranes. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 726 Aptara 726 UNIT II 14-6 Promoting Healthy Physiologic Responses Suctioning the Nasopharyngeal and Oropharyngeal Airways continued ACTION R AT I O N A L E 12. Increase the patient’s supplemental oxygen level or apply supplemental oxygen per facility policy or primary care provider order. Suctioning removes air from the patient’s airway and can cause hypoxemia. Hyperoxygenation can help prevent suctioninduced hypoxemia. 13. Put on face shield or goggles and mask. Put on sterile gloves. The dominant hand will manipulate the catheter and must remain sterile. The nondominant hand is considered clean rather than sterile and will control the suction valve (Y-port) on the catheter. Handling the sterile catheter using a sterile glove helps prevent introducing organisms into the respiratory tract; the clean glove protects the nurse from microorganisms. 14. With dominant gloved hand, pick up sterile catheter. Pick up the connecting tubing with the nondominant hand and connect the tubing and suction catheter (Figure 2). Sterility of the suction catheter is maintained. 15. Moisten the catheter by dipping it into the container of sterile saline (Figure 3). Occlude Y-tube to check suction. Lubricating the inside of the catheter with saline helps move secretions in the catheter. Checking suction ensures equipment is working properly. FIGURE 2. Connecting catheter to tubing. FIGURE 3. Dipping catheter into sterile saline. 16. Encourage the patient to take several deep breaths. Suctioning removes air from the patient’s airway and can cause hypoxemia. Hyperventilation can help prevent suction-induced hypoxemia. 17. Apply lubricant to the first 2 to 3 inches of the catheter, using the lubricant that was placed on the sterile field. 18. Remove the oxygen delivery device, if appropriate. Do not apply suction as the catheter is inserted. Hold the catheter between your thumb and forefinger. 19. Insert the catheter: a. For nasopharyngeal suctioning, gently insert catheter through the naris and along the floor of the nostril toward the trachea (Figure 4). Roll the catheter between your fingers to help advance it. Advance the catheter approximately 5 to 6 to reach the pharynx. b. For oropharyngeal suctioning, insert catheter through the mouth, along the side of the mouth toward the trachea. Advance the catheter 3 to 4 to reach the pharynx. (For nasotracheal suctioning, see the accompanying Skill Variation display.) Lubricant facilitates passage of the catheter and reduces trauma to mucous membranes. Using suction while inserting the catheter can cause trauma to the mucosa and remove oxygen from the respiratory tract. Correct distance for insertion ensures proper placement of the catheter. The general guideline for determining insertion distance for nasopharyngeal suctioning for an individual patient is to estimate the distance from the patient’s earlobe to the nose. LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 727 Aptara CHAPTER 14 Oxygenation ACTION 727 R AT I O N A L E FIGURE 4. Inserting catheter into naris. 20. Apply suction by intermittently occluding the Y-port on the catheter with the thumb of your nondominant hand and gently rotating the catheter as it is being withdrawn (Figure 5). Do not suction for more than 10 to 15 seconds at a time. Turning the catheter as it is withdrawn minimizes trauma to the mucosa. Suctioning for longer than 10 to 15 seconds robs the respiratory tract of oxygen, which may result in hypoxemia. Suctioning too quickly may be ineffective at clearing all secretions. 21. Replace the oxygen delivery device using your nondominant hand, if appropriate, and have the patient take several deep breaths. Suctioning removes air from the patient’s airway and can cause hypoxemia. Hyperventilation can help prevent suction-induced hypoxemia. 22. Flush catheter with saline (Figure 6). Assess effectiveness of suctioning and repeat, as needed, and according to patient’s tolerance. Wrap the suction catheter around your dominant hand between attempts. Flushing clears catheter and lubricates it for next insertion. Reassessment determines the need for additional suctioning. Wrapping prevents inadvertent contamination of catheter. FIGURE 5. Suctioning nasopharynx. FIGURE 6. Rinsing catheter. 23. Allow at least a 30-second to 1-minute interval if additional suctioning is needed. No more than three suction passes should be made per suctioning episode. Alternate the nares, unless contraindicated, if repeated suctioning is required. Do not force the catheter through the nares. Encourage the patient to cough and deep breathe between suctioning. Suction the oropharynx after suctioning the nasopharynx. The interval allows for reventilation and reoxygenation of airways. Excessive suction passes contribute to complications. Alternating nares reduces trauma. Suctioning the oropharynx after the nasopharynx clears the mouth of secretions. More microorganisms are usually present in the mouth, so it is suctioned last to prevent transmission of contaminants. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 728 Aptara 728 UNIT II 14-6 Promoting Healthy Physiologic Responses Suctioning the Nasopharyngeal and Oropharyngeal Airways continued ACTION R AT I O N A L E 24. When suctioning is completed, remove gloves from dominant hand over the coiled catheter, pulling them off inside out. Remove glove from nondominant hand and dispose of gloves, catheter, and container with solution in the appropriate receptacle. Assist patient to a comfortable position. Raise bed rail and place bed in the lowest position. 25. Turn off suction. Remove supplemental oxygen placed for suctioning, if appropriate. Remove face shield or goggles and mask. Perform hand hygiene. This technique reduces transmission of microorganisms. Proper positioning with raised side rails and proper bed height provide for patient comfort and safety. Proper removal of PPE and hand hygiene reduces risk of transmission of microorganisms. 26. Offer oral hygiene after suctioning. Respiratory secretions that are allowed to accumulate in the mouth are irritating to mucous membranes and unpleasant for the patient. 27. Reassess patient’s respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds. This assesses effectiveness of suctioning and the presence of complications. 28. Remove additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcome is met when the patient exhibits improved breath sounds and a clear and patent airway. In addition, the oxygen saturation level is within acceptable parameters, and the patient does not exhibit signs or symptoms of respiratory distress or complications. DOCUMENTATION Guidelines Sample Documentation Document the time of suctioning, your before and after intervention assessments, reason for suctioning, route used, and the characteristics and amount of secretions. 9/17/12 1440 Patient with gurgling on inspiration and weak cough; unable to clear secretions. Lungs with sonorous wheezes in upper airways. Nasopharyngeal suction completed with 12F catheter. Large amount of thick, yellow secretions obtained. After suctioning, lung sounds clear in all lobes, respirations 18 breaths per min, no gurgling noted. —C. Bausler, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS The catheter or sterile glove touches an unsterile surface: Stop the procedure. If the gloved hand is still sterile, call for assistance and have someone open another catheter or remove the gloves and start the procedure over. Patient vomits during suctioning: If the patient gags or becomes nauseated, remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, change catheters, because it is probably contaminated. Turn patient to the side and elevate the head of the bed to prevent aspiration. Secretions appear to be stomach contents: Ask the patient to extend the neck slightly. This helps to prevent the tube from passing into the esophagus. Epistaxis is noted with continued suctioning: Notify physician and anticipate the need for a nasal trumpet. (See Skill Variation14-7: Inserting a Nasopharyngeal Airway.) The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning. SPECIAL CONSIDERATIONS Infant and Child Considerations For infants, use a 5F to 6F catheter. For children, use a 6F to 10F catheter. LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 729 Aptara CHAPTER 14 Oxygenation 729 Skill Variation Nasotracheal Suctioning Nasotracheal suctioning is indicated to maintain a patent airway and remove saliva, pulmonary secretions, blood, vomitus, or foreign material from the trachea. Tracheal suctioning can lead to hypoxemia, cardiac dysrhythmias, trauma, atelectasis, infection, bleeding, and pain. It is imperative to be diligent in maintaining aseptic technique and following facility guidelines and procedures to prevent potential hazards. When performing suctioning, position yourself on the appropriate side of the patient. If you are right-handed, stand on the patient’s right side; if left-handed, stand on the patient’s left side. This allows for comfortable use of the dominant hand to manipulate the suction catheter. To perform nasotracheal suctioning: 1. Perform hand hygiene. Put on PPE, as indicated. 2. Identify the patient. 3. Determine the need for suctioning. For a postoperative patient, administer pain medication before suctioning. 4. Explain to the patient what you are going to do and the reason for doing it, even if the patient does not appear to be alert. 5. Adjust bed to a comfortable working position. Lower the side rail closest to you. If the patient is conscious, place him or her in a semi-Fowler’s position. If the patient is unconscious, place him or her in the lateral position, facing you. Move the overbed table close to your work area and raise to waist height. 6. Place a towel or waterproof pad across the patient’s chest. 7. Turn suction to appropriate pressure. Put on a disposable, clean glove and occlude the end of the connecting tubing to check suction pressure. Place the connecting tubing in a convenient location. 8. Open sterile suction package using aseptic technique. The open wrapper becomes a sterile field to hold other supplies. Carefully remove the sterile container, touching only the outside surface. Set it up on the work surface and pour sterile saline into it. 9. Place a small amount of water-soluble lubricant on the sterile field, taking care to avoid touching the sterile field with the lubricant package. 10. Increase the patient’s supplemental oxygen level or apply supplemental oxygen per facility policy or physician order. 11. Put on face shield or goggles and mask. Put on sterile gloves. The dominant hand will manipulate the catheter and must remain sterile. The nondominant hand is considered clean rather than sterile and will control the suction valve. 12. With dominant gloved hand, pick up the sterile catheter. Pick up the connecting tubing with the nondominant hand and connect the tubing and suction catheter. 13. Moisten the catheter by dipping it into the container of sterile saline. Occlude the Y-tube to check suction. 14. Encourage the patient to take several deep breaths. 15. Apply lubricant to the first 2 to 3 inches of the catheter, using the lubricant that was placed on the sterile field. 16. Remove the oxygen-delivery device, if appropriate. Do not apply suction as the catheter is inserted. Hold the catheter in your thumb and forefinger. Gently insert the catheter through the naris and along the floor of the nostril toward the trachea. Roll the catheter between your fingers to help advance it. Advance the catheter approximately 8 to 9 inches to reach the trachea. Resistance should not be met. If resistance is met, the carina or tracheal mucosa has been hit. Withdraw the catheter at least 12 inches before applying suction. 17. Apply suction by intermittently occluding the Y-port on the catheter with the thumb of your nondominant hand, and gently rotating the catheter as it is being withdrawn. Do not suction for more than 10 to 15 seconds at a time. 18. Replace the oxygen-delivery device using your nondominant hand and have the patient take several deep breaths. 19. Flush the catheter with saline. Assess effectiveness of suctioning and repeat, as needed, and according to patient’s tolerance. Wrap the suction catheter around your dominant hand between attempts. 20. Allow at least a 30-second to 1-minute interval if additional suctioning is needed. No more than three suction passes should be made per suctioning episode. Alternate the nares, unless contraindicated, if repeated suctioning is required. Do not force catheter through the nares. Encourage the patient to cough and deep breathe between suctioning. Suction the oropharynx after suctioning the trachea. 21. When suctioning is completed, remove glove from dominant hand over the coiled catheter, pulling it off inside-out. Remove glove from nondominant hand and dispose of gloves, catheter, and container with solution in the appropriate receptacle. Remove face shield or goggles and mask. Perform hand hygiene. 22. Turn off suction. Remove supplemental oxygen placed for suctioning, if appropriate. Assist patient to a comfortable position. 23. Offer oral hygiene after suctioning. 24. Reassess patient’s respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds. 25. Remove additional PPE, if used. Perform hand hygiene. 26. Document the time of suctioning, your before and after intervention assessments, the reason for suctioning, route used, and the characteristics and amount of secretions. 730 UNIT II Promoting Healthy Physiologic Responses 14-7 Inserting an Oropharyngeal Airway An oropharyngeal airway is a semicircular tube of plastic or rubber inserted into the back of the pharynx through the mouth in a patient who is breathing spontaneously. The oropharyngeal airway can help protect the airway of an unconscious patient by preventing the tongue from falling back against the posterior pharynx and blocking it. Once the patient regains consciousness, the oropharyngeal airway is removed. Tape is not used to hold the airway in place because the patient should be able to expel the airway once he or she becomes alert. The nurse can insert this device at the bedside with little to no trauma to the unconscious patient. Oropharyngeal airways may also be used to aid in ventilation during a code situation and to facilitate suctioning an unconscious or semiconscious patient. Alternately, airway support may be provided with a nasopharyngeal airway. Nasopharyngeal airways, frequently referred to as nasal trumpets, are curved, soft rubber or plastic tubes inserted into the back of the pharynx through the nose in patients who are breathing spontaneously. (Refer to the accompanying Skill Variation.) EQUIPMENT ASSESSMENT Assess patient’s level of consciousness and ability to protect the airway. Assess amount and consistency of oral secretions. Auscultate lung sounds. If the tongue is occluding the airway, lung sounds may be diminished. Assess for loose teeth or recent oral surgery, which may contraindicate the use of an oropharyngeal airway. NURSING DIAGNOSIS Determine related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Aspiration Risk for Injury Ineffective Airway Clearance Other nursing diagnoses may require the use of this skill. OUTCOME IDENTIFICATION AND PLANNING The expected outcome is that the patient will sustain a patent airway. Another outcome that may be appropriate includes the following: the patient remains free of aspiration and injury. Oropharyngeal airway of appropriate size Disposable gloves Suction equipment Goggles or face shield (optional) Flashlight (optional) Additional PPE, as indicated IMPLEMENTATION ACTION 1. Bring necessary equipment to the bedside stand or overbed table. R AT I O N A L E Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. This ensures the patient’s privacy. 5. Explain to the patient what you are going to do and the reason for doing it, even though the patient does not appear to be alert. Explanation alleviates fears. Even though a patient appears unconscious, the nurse should explain what is happening. LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 731 Aptara 731 CHAPTER 14 Oxygenation ACTION R AT I O N A L E 6. Put on disposable gloves; put on goggles or face shield, as indicated. Gloves and other PPE prevent contact with contaminants and body fluids. 7. Measure the oropharyngeal airway for correct size (Figure 1). Measure the oropharyngeal airway by holding the airway on the side of the patient’s face. The airway should reach from the opening of the mouth to the back angle of the jaw. Correct size ensures correct insertion and fit, allowing for conformation of the airway to the curvature of the palate. 8. Check mouth for any loose teeth, dentures, or other foreign material. Remove dentures or material if present. Prevents aspiration or swallowing of objects. During insertion, the airway may push any foreign objects in the mouth to the back of the throat. 9. Position patient in semi-Fowler’s position. This position facilitates airway insertion and helps prevent the tongue from moving back against the posterior pharynx. 10. Suction patient, if necessary. This removes excess secretions and helps maintain patent airway. 11. Open patient’s mouth by using your thumb and index finger to gently pry teeth apart. Insert the airway with the curved tip pointing up toward the roof of the mouth (Figure 2). This is done to advance the tip of the airway past the tongue, toward the back of the throat. FIGURE 1. Measuring for oropharyngeal airway. FIGURE 2. Sliding in the airway. 12. Slide the airway across the tongue to the back of the mouth. Rotate the airway 180 degrees as it passes the uvula (Figure 3). The tip should point down and the curvature should follow the contour of the roof of the mouth. A flashlight can be used to confirm the position of the airway with the curve fitting over the tongue. This is done to shift the tongue anteriorly, thereby allowing the patient to breathe through and around the airway. 13. Ensure accurate placement and adequate ventilation by auscultating breath sounds (Figure 4). If the airway is placed correctly, lung sounds should be audible and equal in all lobes. 14. Position patient on his or her side when airway is in place. This position helps keep the tongue out of the posterior pharynx area and helps to prevent aspiration if the unconscious patient should vomit. 15. Remove gloves and additional PPE, if used. Perform hand hygiene. 16. Remove the airway for a brief period every 4 hours, or according to facility policy. Assess mouth, provide mouth care, and clean the airway according to facility policy before reinserting it. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Tissue irritation and ulceration can result from prolonged use of an airway. Mouth care provides moisture to mucous membranes and helps maintain tissue integrity. (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 732 Aptara 732 UNIT II 14-7 Promoting Healthy Physiologic Responses Inserting an Oropharyngeal Airway FIGURE 3. Rotating the airway. EVALUATION continued FIGURE 4. Auscultating breath sounds. The expected outcome is met when the patient exhibits a patent airway with oxygen saturation levels greater than 95%. In addition, the patient remains free of injury and aspiration. DOCUMENTATION Guidelines Sample Documentation Document the placement of the airway, airway size, removal/cleaning, assessment before and after intervention, and oxygen saturation level. 9/22/12 1210 Patient noted to have gurgling with respirations, tongue back in posterior pharynx. Difficult to suction oropharynx. Size 4 oropharyngeal airway inserted. Patient placed on left side. Lung sounds clear and equal all lobes. Pulse oximeter 98% on room air. —C. Bausler, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS The patient awakens: Remove the oral airway once the patient is awake because it may be uncomfortable and cause vomiting. Conscious patients can usually protect their airway. The tongue is sliding back into the posterior pharynx, causing respiratory difficulties: Put on disposable gloves and remove the airway. Make sure the airway is the appropriate size for the patient. Patient vomits as oropharyngeal airway is inserted: Quickly position patient onto his or her side to prevent aspiration. Remove oral airway. Suction mouth if needed. SPECIAL CONSIDERATIONS Wearing gloves, remove the airway briefly every 4 hours to provide mouth care. Assess the mouth and tongue for tissue irritation, tooth damage, bleeding, and ulceration. Ensure that the lips and tongue are not between the teeth and the airway to prevent injury. When reinserting the oropharyngeal airway, attempt to insert it on the other side of the mouth. This helps to prevent the tongue and mouth from irritation. Suction secretions, as needed, by manipulating around and through the oropharyngeal airway. LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 733 Aptara CHAPTER 14 Oxygenation 733 Skill Variation Inserting a Nasopharyngeal Airway Nasopharyngeal airways, frequently referred to as nasal trumpets, are curved, soft rubber or plastic tubes inserted into the back of the pharynx through the nose in patients who are breathing spontaneously. The nasal trumpet provides a route from the nares to the pharynx to help maintain a patent airway. These airways may be indicated if the teeth are clenched, the tongue is enlarged, or the patient needs frequent nasopharyngeal suctioning. The appropriate size range for a nasal trumpet for adolescents to adults is 24F to 36F. Additional assessments include assessing for the presence of nasal conditions, such as a deviated septum or recent nasal or oral surgery, and increased risk for bleeding, such as anticoagulant therapy, which would contraindicate the use of a nasopharyngeal airway. 1. Bring necessary equipment to the bedside stand or overbed table. airway should reach from the tragus of the ear to the nostril plus 1 inch. The diameter should be slightly smaller than the diameter of the nostril. 8. Adjust bed to a comfortable working level, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Lower side rail closest to you. If the patient is awake and alert, position supine in semi-Fowler’s position. If the patient is not conscious or alert, position in a sidelying position. 9. Suction patient, if necessary. 10. Lubricate the nasopharyngeal airway generously with the water-soluble lubricant, covering the airway from the tip to the guard rim (Figure B). 2. Perform hand hygiene and put on PPE, if indicated. 3. Identify the patient. 4. Close curtains around bed and close the door to the room, if possible. 5. Explain what you are going to do and the reason you are doing it to the patient, even if the patient does not appear to be alert. 6. Put on disposable gloves. If the patient is coughing or has copious secretions, wear a mask and goggles also. FIGURE B. Lubricating nasopharyngeal airway. 7. Measure the nasopharyngeal airway for correct size (Figure A). Measure the nasopharyngeal airway length by holding the airway on the side of the patient’s face. The 11. Gently insert the airway into the naris (Figure C), narrow end first, until the rim is touching the naris (Figure D). If resistance is met, stop and try the other naris. FIGURE A. Measuring the nasopharyngeal airway. FIGURE C. Inserting nasopharyngeal airway. (continued) 734 UNIT II 14-7 Promoting Healthy Physiologic Responses Inserting an Oropharyngeal Airway Skill Variation Inserting a Nasopharyngeal Airway continued continued 12. Check placement by closing the patient’s mouth and placing your fingers in front of the tube opening to check for air movement. Assess the pharynx to visualize the tip of the airway behind the uvula. Assess the nose for blanching or stretching of the skin. 13. Remove gloves and raise the bed rail. Place bed in the lowest position. Remove additional PPE, if used. Perform hand hygiene. FIGURE D. Nasopharyngeal airway inserted. 14-8 14. Remove the airway, clean in warm soapy water, and place in other naris at least every 8 hours, or according to facility policy. If the patient coughs or gags on insertion, the nasal trumpet may be too long. Assess the pharynx. The tip of the airway should be visualized behind the uvula. Suctioning an Endotracheal Tube: Open System The purpose of suctioning is to maintain a patent airway and remove pulmonary secretions, blood, vomitus, or foreign material from the airway. When suctioning via an endotracheal tube, the goal is to remove secretions that are not accessible to cilia bypassed by the tube itself. Remember, tracheal suctioning can lead to hypoxemia, cardiac dysrhythmias, trauma, atelectasis, infection, bleeding, and pain, so it is imperative to be diligent in maintaining aseptic technique and following facility guidelines and procedures to prevent potential hazards. Frequency of suctioning is based on clinical assessment. Because suctioning removes secretions not accessible to bypassed cilia, recommendation is to insert the catheter only as far as the end of the endotracheal tube. Catheter contact and suction can cause tracheal mucosal damage, loss of cilia, edema, and fibrosis, and increase the risk of infection and bleeding for the patient. Insertion of the suction catheter to a predetermined distance, no more than 1 cm past the length of the endotracheal tube, avoids contact with the trachea and carina, reducing the effects of tracheal mucosal damage (Ireton, 2007; Pate, 2004; Pate & Zapata, 2002). Box 14-1 discusses several methods for determining appropriate suction catheter depth. Some consider open system suctioning to be the most efficient way to suction the endotracheal tube, arguing that there are no limitations to the movement of the suction catheter while suctioning. However, the nurse may unknowingly contaminate an open system during the procedure. In addition, with the open system, the patient must be removed from the ventilator during suctioning. See the two Evidence for Practice displays below that focus on open versus closed endotracheal suctioning systems. LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 735 Aptara 735 CHAPTER 14 Oxygenation BOX 14-1 METHODS TO DETERMINE SUCTION CATHETER DEPTH Open Suction System Method 1 (Endotracheal Tubes) Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align. Insert the suction catheter no further than an additional 1 cm. Method 2 (Endotracheal Tubes) Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Document the determined length at the bedside or on the plan of care, according to facility policy. Method 3 (Endotracheal and Tracheostomy Tubes) Note the length of catheter used to reach the end of the tube. Document the determined length at the bedside or on the plan of care. Alternately, mark the distance on the suction catheter with permanent ink or tape and place the catheter at the bedside for reference. Refer to facility policy. Closed Suction System (Endotracheal and Tracheostomy Tubes) Combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm. Advance the catheter until the appropriate length can be seen through the catheter sheath or window. Document the depth of the catheter at the bedside or on the plan of care. Using a spare endotracheal or tracheostomy tube of the same size as being used for the patient, insert the suction catheter to the end of the tube. (Adapted from Pate, M., & Zapata, T.. Ask the experts: How deeply should I go when I suction an endotracheal tube or tracheostomy tube? Critical Care Nurse, 22, 130–131, with permission.) EQUIPMENT Portable or wall suction unit with tubing A commercially prepared suction kit with an appropriate size catheter (see General Considerations) or Sterile suction catheter with Y-port in the appropriate size Sterile, disposable container Sterile gloves Towel or waterproof pad Goggles and mask or face shield Additional PPE, as indicated Disposable, clean glove Resuscitation bag connected to 100% oxygen Assistant (optional) ASSESSMENT Assess lung sounds. Patients who need to be suctioned may have wheezes, crackles, or gurgling present. Assess oxygenation saturation level. Oxygen saturation usually decreases when a patient needs to be suctioned. Assess respiratory status, including respiratory rate and depth. Patients may become tachypneic when they need to be suctioned. Assess patient for signs of respiratory distress, such as nasal flaring, retractions, or grunting. Additional indications for suctioning via an endotracheal tube include secretions in the tube, acute respiratory distress, and frequent or sustained coughing. Also assess for pain and the potential to cause pain during the intervention. Perform individualized pain management in response to the patient’s needs (Arroyo-Novoa, et al., 2007). If patient has had abdominal surgery or other procedures, administer pain medication before suctioning. Assess appropriate suction catheter depth. Refer to Box 14-1. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Ineffective Airway Clearance Risk for Infection Risk for Aspiration Impaired Gas Exchange (continued) LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 736 Aptara 736 UNIT II Promoting Healthy Physiologic Responses 14-8 Suctioning an Endotracheal Tube: Open System OUTCOME IDENTIFICATION AND PLANNING continued The expected outcome is that the patient will exhibit improved breath sounds and a clear, patent airway. Other outcomes that may be appropriate include the following: patient will exhibit an oxygen saturation level within acceptable parameters; patient will demonstrate a respiratory rate and depth within age-acceptable range; and patient will remain free of any signs of respiratory distress. IMPLEMENTATION ACTION 1. Bring necessary equipment to the bedside stand or overbed table. R AT I O N A L E Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. This ensures the patient’s privacy. 5. Determine the need for suctioning. Verify the suction order in the patient’s chart. Assess for pain or the potential to cause pain. Administer pain medication, as prescribed, before suctioning. To minimize trauma to airway mucosa, suctioning should be done only when secretions have accumulated or adventitious breath sounds are audible. Suctioning can cause moderate to severe pain for patients. Individualized pain management is imperative (Arroyo-Novoa, et al., 2007). Suctioning stimulates coughing, which is painful for patients with surgical incisions. 6. Explain what you are going to do and the reason for doing it to the patient, even if the patient does not appear to be alert. Reassure the patient you will interrupt the procedure if he or she indicates respiratory difficulty. Explanation alleviates fears. Even if the patient appears unconscious, the nurse should explain what is happening. Any procedure that compromises respiration is frightening for the patient. 7. Adjust bed to comfortable working position, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Lower side rail closest to you. If patient is conscious, place him or her in a semi-Fowler’s position. If patient is unconscious, place him or her in the lateral position, facing you. Move the overbed table close to your work area and raise it to waist height. Having the bed at the proper height prevents back and muscle strain. A sitting position helps the patient to cough and makes breathing easier. Gravity also facilitates catheter insertion. The lateral position prevents the airway from becoming obstructed and promotes drainage of secretions. The overbed table provides work surface and maintains sterility of objects on work surface. 8. Place towel or waterproof pad across patient’s chest. This protects bed linens and the patient. 9. Turn suction to appropriate pressure. Higher pressures can cause excessive trauma, hypoxemia, and atelectasis. For a wall unit for an adult: 100–120 mm Hg (Roman, 2005); neonates: 60–80 mm Hg; infants: 80–100 mm Hg; children: 80–100 mm Hg; adolescents: 80–120 mm Hg (Ireton, 2007). For a portable unit for an adult: 10–15 cm Hg; neonates: 6–8 cm Hg; infants 8–10 cm Hg; children 8–10 cm Hg; adolescents: 8–10 cm Hg. 10. Put on a disposable, clean glove and occlude the end of the connecting tubing to check suction pressure. Place the connecting tubing in a convenient location. Place the resuscitation bag connected to oxygen within convenient reach, if using. Glove prevents contact with blood and body fluids. Checking pressure ensures equipment is working properly. Allows for an organized approach to procedure. LWBK545_C14_p700-778.qxd 8/6/10 10:47 PM Page 737 Aptara CHAPTER 14 Oxygenation ACTION 737 R AT I O N A L E 11. Open sterile suction package using aseptic technique. The open wrapper becomes a sterile field to hold other supplies. Carefully remove the sterile container, touching only the outside surface. Set it up on the work surface and pour sterile saline into it. Sterile normal saline or water is used to lubricate the outside of the catheter, minimizing irritation of mucosa during introduction. It is also used to clear the catheter between suction attempts. 12. Put on face shiel