Common Interventions to Improve Oxygenation

QUICK LOOK AT THE CHAPTER AHEAD

Respiratory disorders interfere with the maintenance of airways, patterns of breathing, clearance of secretions, and exchange of gases. Treatments are required to maintain and enhance oxygenation. This chapter will review the following topics:

General health and policy issues for respiratory health
Improving physical mobility
Breathing and coughing exercises
Mobilizing secretions
Maintaining airway patency
Closed chest drainage
Oxygen therapy
Mechanical ventilation

CASE STUDY

Mr. J, a 47-year-old male, is at the emergency room with a 10-day history of flu-like symptoms: fever, aches, loss of appetite, a productive cough with yellowish green sputum, and increasing shortness of breath. His only significant past medical history is a 30-pack year of cigarette smoking. The physical exam reveals a slightly anxious, diaphoretic, pale, well-nourished man who is leaning forward on the bedside table. Vital signs: temperature—102.4°F, apical pulse (AP)—112 and regular, BP—148/86 on the right arm and 152/90 on the left, respiration rate (RR)—28 breaths per minute and slightly labored, and Sao₂ is 89% on room air. Lung sounds: scattered expiratory wheezing throughout both lung fields; crackles—anteriorly from the left sternal border fourth intercostal space (ICS) to the sixth ICS at the midaxillary line, and posteriorly from T5 down. Crackles decrease but do not disappear with coughing or deep breathing. The nurse practitioner examining the patient makes the decision to admit him and writes orders to initiate oxygen therapy via nasal cannula at 2 L/min.

Improving oxygenation involves promoting ventilation, assisting diffusion of gases, and facilitating the perfusion of oxygen throughout the body. In this chapter, nursing interventions and collaborative strategies to enhance oxygenation will be reviewed with a special focus on incorporating collaborative interventions into the patient’s nursing care. While some interventions to improve respiratory health are performed in the acute and intensive care settings, others may be incorporated into the patient’s care at home. Because every patient is unique, it is important to customize the interventions to the patient’s abilities, lifestyle, and to the underlying disease process.

GENERAL RESPIRATORY HEALTH AND POLICY

Promoting respiratory health begins with promoting healthy lifestyles. Respiratory health is maintained by exercise, clean air, and a competent cough reflex (see Table 4-1). Exercise is an important part of promoting respiratory and cardiovascular health. During exercise, ventilation
improves as the lungs expand more fully, and perfusion is enhanced by the increased cardiac output.

Table 4-1 Facilitating Respiratory Health

1. Exercise regularly—30 minutes, three to four times per week.

2. Do not smoke or use tobacco products.

3. Avoid secondhand smoke.

4. Support legislation to control and eliminate pollution.

5. Ensure adequate ventilation of wood stoves and furnaces.

6. Reduce exposure to noxious fumes at home and at work.

Part of promoting healthy ventilation is advocating for clean air in the environment, whether it is in the atmosphere or home and work environments. The quality of atmospheric air is often measured as the air quality index. Vulnerable people, such as those with respiratory disorders such as asthma or chronic obstructive pulmonary disease (COPD), should avoid going outside when the air quality index is poor. Of primary concern to healthcare providers are the risks associated with cigarette smoking. Nurses are in position to teach their patients and the community about the hazards of cigarette smoking. Of particular concern is the rising incidence of smoking in adolescence. Educational programs increasingly begin in grade schools to educate children about the dangers of smoking before adolescence. The risks associated with secondhand smoke should also be emphasized to adults so they can protect their children and limit their exposure to secondhand smoke.

Occupational hazards need to be evaluated in the nursing assessment. As described in Chapter 2, exposure to certain chemicals, asbestos, dust, and fumes at work puts patients at risk for respiratory problems. Policies at the local and federal levels are directed at reducing occupational exposure to hazardous materials, encouraging adequate ventilation in work sites, and requiring the use of protective apparatus.

When a patient’s health is compromised by age, lifestyle, surgery, or disease, respiratory functioning may be disrupted. Advanced interventions to improve oxygenation require a collaborative approach. Nurses, physicians, and respiratory therapists work together to enhance ventilation, diffusion, and oxygenation through a variety of approaches. In this chapter, the following strategies for improving oxygenation will be reviewed:

Improving physical mobility
Breathing and coughing exercises
Mobilizing secretions
Maintaining airway patency
Closed chest drainage
Oxygen therapy
Mechanical ventilation

IMPROVING PHYSICAL MOBILITY

When a patient’s ability to move is compromised, maintaining physical and respiratory functioning becomes an important nursing intervention. Pain, surgical incision, medications, and age may make it difficult for the patient to move and breath. Chest expansion and alveolar inflation are diminished during immobility and may result in atelectasis, inadequate gas exchange, or even pneumonia.

The best position for maximum chest expansion is upright. Encourage able patients to ambulate three times a day to enhance ventilation and maintain cardiovascular conditioning. Patients undergoing surgery should be ambulated postoperatively as soon as allowed by the surgeon and at least three times a day thereafter. Premedication of the postoperative patient with an analgesic (30 to 45 minutes before the activity) will improve mobility and depth of inhalation. For the bedridden patient, the semi-Fowler’s or high Fowler’s position allows maximum chest expansion. In the patient with chronic airflow limitation (CAL), the orthopnea position or tripod position may provide relief from dyspnea and enhance
ventilation. The tripod position involves having the patient sit at the bedside with a table in front of him or her, allowing for propping of the elbows on the table while compressing the lower chest.

If the patient is bedridden, he or she should be turned from side to side every 2 hours to improve chest expansion on the upward side and increased perfusion of the lung on the dependent side. Occasionally the prone position is used to improve oxygenation in ventilated patients who continue to deteriorate despite other interventions.

Patients with chronic respiratory disorders such as emphysema may have an impaired ability to oxygenate their blood and a decreased capacity to exert themselves. With less oxygen in the blood, less is available for the cells when activity increases the oxygen demands of the tissues. Deep breathing and coughing exercises (discussed later in this chapter) may be used to increase oxygenation and maintain airway patency.

Respiratory diseases such as emphysema or chronic bronchitis change the structure and the functioning of the respiratory tract. The diaphragm becomes flattened, reducing the ability of the chest to expand. Air becomes trapped in distal alveoli and the bases of the lungs. Air trapping causes a ventilation/perfusion (V/Q) mismatch with resultant hypoxemia. Even normal activities, such as walking and eating, can be exhausting to a patient with a chronic respiratory disorder. Nursing care for these patients includes teaching ways to reduce oxygen demand, such as:

Pace activities with rest periods.
Eat frequent, light meals to decrease metabolic demands and gastric fullness, which might press the diaphragm upward.
Avoid holding the breath during activities, which will further diminish the Po₂ and increase dyspnea.
Avoid the Valsalva maneuver, which increases intrathoracic pressure and decreases blood return into the thorax, resulting in dizziness.
Decrease temperature if febrile, as each degree (Fahrenheit) elevation results in a 7% increase in metabolic demand.
Use energy conservation exercises such as performing the work part of an activity during exhalation and using pursed-lip breathing during exertion.

Preoperative teaching is important in providing patients with information regarding the risks of developing respiratory problems postoperatively. General anesthesia, postoperative pain, immobility, and pain medications can alter normal ventilation and put patients at risk for atelectasis, pneumonia, thrombophlebitis, and pulmonary embolism. Interventions to improve ventilation, oxygenation, and mobility postoperatively include the following:

Encourage breathing exercises and incentive spirometry every 1 to 2 hours to maximize lung expansion.
Promote early ambulation and leg exercises to improve venous circulation.
Maintain airway patency with coughing to clear secretions and, if necessary, suctioning.
Administer pain medication prior to ambulation or chest physical therapy and use splinting to support surgical incisions.

BREATHING EXERCISES

Breathing exercises may help patients control breathing, improve ventilation, decrease anxiety, and increase activity levels. Some exercises are more suited to patients with chronic airflow limitations (CAL), and others are more useful with anxious patients or those with postoperative pain.

Diaphragmatic Breathing

Diaphragmatic breathing is indicated for patients with CAL or anxiety because it allows for slow, deep breaths. Slow deliberate breaths using the abdomen and chest muscles may slow the frequency of the ventilations and help the patient focus.

Place the patient in a sitting position on the side of the bed or in the semi- or high Fowler’s position.
Have the patient place one hand on his or her chest and the other on his or her upper abdomen above the umbilicus. Another method that may be useful is to place a light object (e.g., tissue box) on the patient’s abdomen so he or she can see abdominal movement during diaphragmatic breathing.
Teach the patient to inhale slowly through the nose, feeling the abdomen rise up under his hands but with little movement in the chest.
Instruct the patient to exhale through pursed lips using the abdominal muscles (see next section on pursed-lip breathing).
Assess the patient’s response (e.g., dizziness and lightheadedness may indicate hyperventilation and necessitate slowing the frequency of the ventilations).
Repeat for three breaths and rest for 1 minute.

Pursed-Lip Breathing

The pursed-lip breathing technique is especially useful in patients with diseases of chronic airway limitation because it slows the collapse of the small airways by maintaining a higher bronchiole pressure and prolonging expiration. It can also be used to control breathing in the dyspneic patient, to prevent holding the breath during activity (a common problem in patients with CAL), and to reduce air trapping in the alveoli.

Assist the patient into a sitting or high semi-Fowler’s position.
Instruct the patient to purse his or her lips as if to whistle with lips slightly open.
Have the patient inhale through the nose to a count of two and slowly exhale through pursed lips to a count of four or until he or she has completely exhaled.
Repeat this technique for 10 minutes, increasing the frequency to four to five times a day.

Incentive Spirometry

Incentive spirometry or sustained maximal inspiration devices (SMI) are tools that help maximize ventilation by increasing lung volume, flow, and alveolar inflation. The device measures respiratory volume and provides a visual stimulus via a colored, plastic float to induce the patient to breath deeply. Incentive spirometry can be combined with breathing exercises to maximize ventilation.

Incentive spirometers are usually plastic, disposable units that patients may take home after discharge from a facility. They are useful in patients who have the diminished ability to breathe deeply and during the postoperative period, especially after thoracic or abdominal surgery when deep inhalation may be limited by pain. During the postoperative period, general anesthesia, incisional pain, and narcotic medications all diminish alveolar inflation. The incentive spirometer provides visual cues of preoperative functioning and postoperative goals. The preoperative levels are marked on the spirometer and can be used to monitor recovery after surgery (see Figure 4-1). Flow incentive spirometers are useful for patients at low risk for developing postoperative atelectasis. Volume spirometers are useful with higher risk patients because they measure lung inflation more precisely.

MOBILIZING SECRETIONS

Clearing respiratory secretions promotes patent airways and easier ventilation of the lungs, and prevents mucus stasis. Secretions are easier to cough up if they are thin, rather than thick and tenacious. Therefore,
adequate fluid intake, humidification of inspired air, and possibly expectorant medication (e.g., guaifenesin) are important interventions in mobilizing secretions. Other medications that can be used before breathing exercises are inhaled bronchodilators such as albuterol or systemic bronchodilators such as theophylline (see Table 4-2). These medications allow the airways to relax and dilate so that the breathing and coughing exercises are more effective.

Figure 4-1 Incentive spirometer.

Patients with chronic respiratory disorders such as COPD and cystic fibrosis may require more aggressive interventions to remove mucous
from the respiratory passages. A mucus clearance device or a flutter can help patients mobilize secretions. This handheld device has a ball valve that vibrates when the patient exhales, causing vibrations to be transmitted in the airways and loosen secretions. The device is held by the patient with the stem parallel to the floor. The patient exhales with flattened cheeks followed by huffing (see next section on coughing and huffing) to remove the secretions.

Table 4-2 Instructions for Patients Taking Theophylline

1.	Take theophylline with food to reduce nausea and vomiting.
2.	Take it on a regular schedule to maintain steady blood levels of the drug.
3.	Report signs and symptoms, such as dizziness, nausea, and vomiting.
4.	Have theophylline blood levels measured periodically according to physician’s protocol.

Coughing

Coughing is the most effective and natural way to clear the airways. A good coughing technique allows for adequate mobilization and expulsion of pulmonary secretions. Normally a cough is an involuntary response, but it can be controlled consciously. In healthy patients, a cough begins with inhalation, followed by glottic closure, and then the rapid opening of the glottis and rapid expulsion of the air. Sometimes the air is expelled at speeds up to 100 miles per hour. In patients with some respiratory disorders, the normal cough reflex may be diminished or there may be excessive secretions. Three techniques that can be used to help patients clear secretions are cascade coughing, huff coughing (huffing), and quad coughing.

Cascade Coughing

Cascade coughing is a useful technique during the postoperative period with patients who have CAL or neuromuscular diseases or those who are bedridden. Cascade coughing allows the patient to increase chest expansion during inhalation and more forcefully expel secretions with coughing.

Have the patient in an upright position such as sitting or semi-Fowler’s position.
Teach the patient to inhale and exhale slowly and deeply.
Then, have the patient inhale deeply and exhale, closing his throat and using small coughs without inhaling again, pause, and then inhale again very slowly (to decrease the cough stimulus). If paroxysmal coughing starts, instruct the patient to use slow deep breaths or pursed-lip breathing until the coughing urge passes.
Rest and repeat for a total of three cycles.
Assess ability to expel secretions and/or auscultate the lungs.
Try to set up a regular coughing schedule for patients with CAL to keep airways patent.

Huff or Open Glottis Coughing

Huff or open glottis coughing (huffing) is a useful technique in patients with chronic airway limitation such as COPD.

Have the patient in the sitting or semi-Fowler’s position with arms crossed below the rib cage (hugging a pillow may be more comfortable).
Instruct the patient to inhale slowly, hold for 2 seconds, tighten the abdominal, leg, and gluteal muscles (to increase intrathoracic pressure), and then exhale in short huffs, actually saying the word huff.
Repeat and try to cough on exhalation.
Assess the patient’s response and ability to expel secretions.
Auscultate the lungs.

Quad Coughing

Quad coughing may assist patients with muscle weakness such as multiple sclerosis to expel secretions. Using a modified Heimlich maneuver, the patient places the heels of both hands between the umbilicus and the xiphoid process, pressing inward and upward during coughing or huffing to clear secretions.

Chest Physical Therapy

Chest physical therapy (CPT) is another method to mobilize secretions and maintain airway patency and alveolar expansion. It may be combined with other interventions such as incentive spirometry, inhaled bronchodilators, and suctioning. Outcomes of successful CPT include improved breath sounds, increased Pao2, expulsion of sputum, and improved airflow on spirometry.

Chest physical therapy is composed of three techniques that may be used individually or in combination. These techniques—percussion, vibration,
and postural drainage—are performed by respiratory therapists or nurses. Percussion is performed by applying cupped hands in a rhythmic sequence over a part or the entire lung. It is useful in patients with cystic fibrosis and bronchiectasis and may be combined with vibration. Using the percussion technique, a hollow sound is produced as the cupped hand creates an air pocket when applied to the chest wall. It is used to loosen secretions (see Figure 4-2). Percussion may be combined with postural drainage positions to optimize drainage of particular lung segments (see Figure 4-3). Percussion is contraindicated in patients with cardiac conditions, osteoporosis, pneumothorax, hemopneumothorax, or pleural effusion.

Vibration is another technique of loosening secretions that usually follows percussion. It involves the placement of both hands pressing and vibrating the rib cage over the affected lung. The arm and shoulder muscles contract isometrically, producing a small vibration that is transmitted through the patient’s chest wall and airways. This vibration
is thought to increase the turbulence of the air in the lung and to loosen secretions. Vibration is useful in patients with cystic fibrosis and bronchiectasis.

Figure 4-2 Hand position for vibration of the chest wall.

Figure 4-3 Lobes of the lungs.

Postural drainage involves positioning the patient in such a way as to allow gravity to drain particular segments of the lungs (see Figure 4-4). Several positions may not be tolerated by the patient because the head is lower than the torso. The positions can be adapted by raising the head of the bed so that the patient is comfortable and can breathe easily. Postural drainage may be contraindicated if the patient has cardiac conditions or
increased intracranial pressure. Particular positions can be combined with percussion and vibration to further mobilize secretions.

Figure 4-4 Postural drainage positions.

MAINTAINING A PATENT AIRWAY

In all patients, maintaining a patent airway is the most important intervention to improve oxygenation. Airway patency is especially important if the patient is unconscious, anesthetized, or obtunded. In these conditions, the airways may collapse and secretions may accumulate, impeding the passage of air into the lungs. For example, patients who are semiconscious after anesthesia may not be able to maintain a patent airway because the tongue falls back and may occlude the posterior oropharynx. Artificial airways may be placed to maintain patency of the airway, allow for suctioning of secretions, and permit mechanical ventilation. The most common types of artificial airways are oral airways, nasopharyngeal airways, endotracheal tubes, and tracheostomy tubes.

Oral airways are rigid, plastic devices (see Figure 4-5 and Table 4-3) used to maintain the normal structure of the oropharynx. They are used for short-term airway maintenance, such as in postanesthesia units while the patient recovers from anesthetic agents. Oral airways are curved to follow the normal anatomy of the oropharynx from the lips, over the tongue, and into the posterior oropharynx. The opening allows for air passage through as well as around the airway and permits suctioning of secretions in the
posterior oropharynx. Once the patient is alert enough to maintain the airway and clear secretions, the oral airway is removed as it can be very irritating.

Figure 4-5 Oral airway.

Table 4-3 Insertion of an Oral Airway

1.	Measure the oral airway along the patient’s jaw with the open end of the curve facing the patient’s neck to ensure that the airway is the correct size. The curve of the airway should follow the angle of the patient’s jawline.
2.	Check that dentures are removed and that there are no loose teeth before inserting the airway.
3.	Place the patient in the supine position and open the mouth using the “cross-finger technique,” using the thumb and forefinger on the upper and lower teeth to open the mouth.
4.	Gently put the airway in upside down until past the teeth and then rotate it over the tongue to follow the curve of the oropharynx.
5.	Tape the airway in place and position the patient on his side to prevent aspiration of secretions or vomitus.
6.	Suction at least hourly to remove secretions.
7.	Evaluate respiration and adequacy of the airway frequently.

Nasal or nasopharyngeal airways are soft rubber or latex tubes that are placed through one nares into the pharynx. They are used for short-term
airway maintenance if the oral route is not amenable due to surgery or loose teeth (see Table 4-4).

Endotracheal tubes (ET) are long tubes that are placed from the nose or mouth, past the glottis, and into the trachea. Endotracheal tubes are used in the following clinical situations:

Oral or nasal airways cannot maintain a patent airway.
Effective suctioning cannot be performed with other airways.
There has been trauma to the upper airways.
The patient needs assisted or mechanical ventilation.

Endotracheal tubes (ET) are long (240 to 360 mm in length) and 5 to 10 mm in internal diameter. Patients are intubated via the mouth or nose. Most ET tubes have a cuff at the distal end, which can be inflated with air via an external catheter to create a seal between the tube and the patient’s trachea. The seal may be complete with “no leak” or incomplete with a “minimal leak” or “minimal occlusive pressure.” The difference between these two depends on the patient’s ventilatory requirements. The no-leak seal ensures that all air exchange takes place only through the tube. This is especially important when positive end-expiratory pressure (PEEP) is used in mechanical ventilation or if a feeding tube is in place (see Figure 4-6). The no-leak seal also prevents aspiration of secretions or gastric contents.

Other conditions may allow for a minimal-leak seal to exist between the trachea and the cuff when the patient’s condition does not require
complete ventilatory support. The minimal-leak seal also minimizes damage to the tracheal wall, such as irritation and necrosis, because microcirculation in the trachea is preserved. The cuff is inflated using a cufflator, and the pressure is measured. The normal pressure in the cuff is approximately 25 mmHg. The amount of leak around the endotracheal tube cuff can also be auscultated by placing the stethoscope on the patient’s trachea and slowly inflating the cuff or balloon with air. When there is no sound during the highest pressure phase of the ventilatory cycle, then there is no leak. When only a small rush of air is heard at peak inspiratory pressure, then there is a minimal leak. A minimal leak around the endotracheal tube cuff is acceptable if there is no significant volume loss on exhalation.

Table 4-4 Insertion of a Nasal Airway

1.	Measure the nasal airway following along the patient’s cheek, starting at the nose and down the cheek past the jaw to ensure the tube is long enough to maintain an airway past the posterior oropharynx. The tube should be slightly wider than the patient’s nares.
2.	Using a water-soluble gel, lubricate the distal end of the airway.
3.	Hyperextend the patient’s neck, if allowable, and gently insert the airway in the nares. If any resistance is felt, stop and try the other nares.
4.	Assess adequacy of respiration and air exchange and suction as necessary.
5.	Examine the posterior oropharynx to ensure the tube is present and tape is in place.

Figure 4-6 Positive end-expiratory pressure (PEEP).

Patients with endotracheal tubes are cared for in the intensive care setting and require a great deal of nursing care. Because their ability to maintain an airway, mobilize secretions, and oxygenate adequately are all compromised, the team must work together to ensure the best outcome for the patient. Nurses, physicians, and respiratory therapists are all part of the team that plans the appropriate interventions for intubated patients.

Tracheostomy tubes, another type of airway, are placed through a surgically created opening in the trachea (see Figure 4-7). A tracheostomy stoma is created either electively or emergently between the third or fourth ring of the trachea. It is created after total laryngectomy for cancers of the vocal cords or larynx. It may also be created if the patient has a severe airway obstruction, difficulty expelling pulmonary secretions
(as in some chronic airway diseases), as part of the care of a patient who requires long-term ventilation, or as a means of delivering oxygen to the distal tracheobronchial tree.

Figure 4-7 Tracheostomy tube.

Tracheostomy tubes are inserted through the tracheostomy stoma and down into the trachea. They are made of two types of materials: plastic and metal. Metal tubes are used less frequently because the plastic has been found to be less irritating to the trachea. Metal tubes may be composed of an outer and inner cannula. The outer cannula is inserted into the trachea with a soft-ended guide called an obturator. The obturator is removed once the catheter is in place and an inner cannula is inserted. The inner cannula is removable for cleaning of dried secretions.

The tracheostomy tube may be either cuffed (having a balloon at the inner end, which may be inflated) or uncuffed (no balloon cuff or a metal cuff). The outer cannula of a metal tube or the outer portion of a plastic tube has a wider flange that allows the tube to be anchored and secured with sutures or taped around the neck. Fenestrated tracheostomy tubes have an opening in the outer cannula that when plugged allows the patient to phonate or speak. Otherwise, when a tracheostomy tube is in place, the patient cannot speak.

Tracheostomies require careful care to maintain the airway and prevent complications. Because the tube is a direct opening into the lower respiratory tract, all the protective mechanisms of the upper airways have been bypassed. Air is no longer filtered, warmed, or humidified. The ability to cough effectively is diminished because it is difficult to build up sufficient intrathoracic pressure with an opening in the trachea. Bacteria can easily access the lungs, and patients are at risk for infection.

Nursing Care of the Patient with a Tracheostomy

To maintain the airway in patients with tracheostomies, nursing care involves humidifying and warming the inspired air and suctioning the secretions (see Table 4-5). A tracheostomy collar is a specially designed oxygen delivery mask that fits over the tracheostomy to deliver humidified air or oxygen. Sterile water is always used when humidifying inspired air.

The tracheostomy site and tube also require careful cleaning to prevent infection of the respiratory tract. The tracheostomy stoma needs to be cleaned daily and more often if there are signs of infection (i.e., redness, drainage, or swelling). If an inner cannula is present, then it should be cleaned every 8 hours (see Table 4-6). Complications of tracheostomy tubes include both immediate problems and long-term risks. Postoperatively, patients with newly created tracheostomies are at risk for hemorrhage, pneumomediastinum (air in the mediastinum), subcutaneous emphysema (air in the tissues around the tracheostomy), and tracheoesophageal (T-E) fistula. T-E fistula can occur at any time after tracheostomy creation. Tracheoesophageal fistulas may develop because of necrosis of the posterior wall of the larynx from prolonged pressure (from the cuff) or malposition of the tube. Long-term problems include dislodgment of the tube, expelled tubes, and infection. Patients with permanent tracheostomies need to observe for signs of infection (fever, painful cough, increased sputum, and chest pain) and notify their healthcare providers.

Table 4-5 Suctioning a Tracheostomy Tube

1.	Assess the patient’s breath sounds and breathing patterns. Loud, noisy respiration, an increased respiratory rate, crackles, wheezes, or rhonchi on auscultation may indicate the need for suctioning or the patient himself may request it.
2.	Prepare the needed equipment and always have suctioning equipment in the room of a patient with a tracheostomy (some prepackaged suctioning kits are available):
	• Sterile and nonsterile gloves
	• Sterile saline or water and a container for it
	• Manual resuscitation bag
	• Suction catheters
	• Syringe (5 mL)
	• Suction machine (at 60 to 80 mm suction) or wall suction
3.	Wash your hands.
4.	Explain the procedure to the patient. Be calm and reassuring because the patient may be concerned about choking and being unable to communicate.
5.	Ventilate the patient with 100% oxygen using the manual resuscitation bag for five breaths. If there are superficial secretions, suction them first before manually inflating the lungs.
6.	Fill the container with saline or sterile water.
7.	Place a sterile glove on the dominant hand that will hold the sterile catheter and a nonsterile glove on the nondominant hand that will control the suction.
8.	Insert the sterile catheter into the tracheostomy and down into the bronchus about 6 to 12 inches or until resistance is felt. (Do not use suction during insertion.)
9.	Withdraw the catheter slowly, rotating it and applying suction only intermittently so as not to damage the airway walls. (Suction for no more than 10 seconds.)
10.	Return the tracheostomy collar (oxygen), and assess the patient’s status. If the patient requires more suctioning, wait at least 2 minutes before performing it again.
11.	Clear the suction catheter when finished by suctioning with sterile water or saline from the container until the tubing is clear. Discard the suction catheter.
12.	Document the color, type, amount, consistency, and any odor of the secretions.

Table 4-6 Care of the Tracheostomy Site

1.	Gather the needed equipment or a prepackaged kit. Supplies include:
	• Sterile hydrogen peroxide
	• Sterile saline
	• Sterile plastic forceps or swabs
	• Sterile tracheostomy dressing
	• Sterile bowl for soaking inner cannula if present
2.	Explain to the patient what you are going to do.
3.	Suction the patient as described in Table 4-5 before removing the cannula.
4.	Use gloves to remove and discard the old tracheostomy dressing. Assess the drainage on the dressing and the site.
5.	Pour sterile saline into one bowl and sterile hydrogen peroxide into the other bowl.
6.	Put on sterile gloves.
7.	Hold the tracheostomy tube with one hand to keep it from moving (which could stimulate coughing) and use the other hand to gently clean around the tube with sterile saline (or half-strength saline and peroxide depending on the institution’s guidelines).
8.	Soak the inner cannula, if present, in the peroxide for 1 minute and rinse it in the saline. Allow it to drip dry on the sterile field or gauze.
9.	If you are changing the tapes that anchor the tube (usually done every 48 hours or more often if soiled), have another nurse help you keep the tube secure while changing them. Check the tension on the ties frequently to make sure that they are not too tight. They should be snug enough to prevent slippage but loose enough to allow circulation.
10.	Keep a spare tracheostomy tube with its obturator of the patient’s size taped over his bed at all times in case the tube should become dislodged during cleaning.

CLOSED CHEST DRAINAGE

Many disease processes and surgeries can result in the accumulation of air and fluid in the pleural space. Irritation of the pleural lining from malignancy or infection can produce fluid. For example, a thoracotomy
for lung cancer may produce excess fluid accumulation in the pleural cavity, preventing lung re-expansion.

The pleural space is a potential space where the pressure is subatmospheric (lower than atmospheric pressure), allowing the lungs to remain expanded. When the pleural space is opened, air rushes into the pleural space and the lung collapses. Increased pressure in the pleural space can result in complete collapse of the lung on the affected side and shifting of the mediastinal contents to the opposite side of the chest. This dangerous and life-threatening condition, a mediastinal shift, may kink the great vessels in the thoracic cavity, compromising cardiac and respiratory function and requiring immediate treatment.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Tags: Quick Look Nursing: Oxygenation

Oct 17, 2016 | Posted by drzezo in NURSING | Comments Off

Nurse Key

Fastest Nurse Insight Engine

Common Interventions to Improve Oxygenation

Related

Stay updated, free articles. Join our Telegram channel

Full access? Get Clinical Tree

Nurse Key

Fastest Nurse Insight Engine

Common Interventions to Improve Oxygenation

Share this:

Related

Related posts:

Stay updated, free articles. Join our Telegram channel

Full access? Get Clinical Tree