Fundamentals of Nursing

Implementation

There are interventions for promoting and maintaining adequate oxygenation across the continuum of care. As a nurse, you will be responsible for independent interventions such as positioning, coughing techniques, and health education for disease prevention. In addition, you will provide physician-initiated interventions such as oxygen therapy, lung inflation techniques, and chest physiotherapy.

Health Promotion

Maintaining the patient’s optimal level of health is important in reducing the number and/or severity of respiratory symptoms. Prevention of respiratory infections is foremost in maintaining optimal health. Providing cardiopulmonary-related health information (Box 40-6) is an important nursing responsibility.

Box 40-6 Patient Teaching

Prevention of Respiratory Infections

Objective

• The patient will be able to verbalize the methods to reduce the risk factors for respiratory infection and the steps needed to adopt health promotion behaviors.

Teaching Strategies

• Establish rapport with the patient and maintain eye contact as long as it is culturally acceptable.

• Teach the importance of not smoking. Refer to smoking cessation programs and discuss appropriate medication to support smoking cessation from the primary health provider.

• If a patient does not smoke, teach the importance of avoiding secondhand smoke and areas of high air pollution.

• Inform patient about other risk factors for pulmonary disease such as diabetes, obesity, and lack of physical inactivity.

• Teach how to implement a balanced diet low in fat, sodium, and carbohydrates. Provide sample menus.

• Discuss the benefits of exercising 30 to 60 minutes a day and help patient develop an exercise program suited to lifestyle.

• Teach patient about the importance of getting annual influenza vaccines and the pneumovax vaccine. If younger than 65 at the time of the primary vaccination, a one-time revaccination is recommended within 5 years (CDC, 2011).

• Teach the importance of handwashing during flu and cold season.

• Inform patient of signs of respiratory infection that should be reported to health care provider such as increased coughing, shortness of breath, change of color of sputum, fever, and fatigue.

Evaluation

• Ask patient to verbalize what they learned about smoking cessation, secondhand smoke, diet and exercise.

• Ask patient to describe in simple terms the symptoms of respiratory infection and when to call the health care provider.

• Have patient tell you how he or she plans to prevent exposure to respiratory infections.

• Ask if patient has any other questions or need for additional information or referrals.

Vaccinations: Annual flu vaccines are recommended for all people 6 months and older. Patients with chronic illnesses (heart, lung, kidney, or immunocompromised), infants, older adults, and pregnant women can get very sick; thus they should be immunized. Close contacts of infants under 6 months should also be immunized. Anyone who had the 2009 H1N1 (pandemic) vaccine or who actually had the pandemic flu in 2009 should get the 2010-2011 vaccine because it provides protection against A/H1N1 and two other flu viruses. The vaccine is also recommended for people in close or frequent contact with anyone in the high-risk groups. It is effective in reducing the severity of illness and the risk of serious complications and death (CDC, 2010c).

Researchers do not fully understand the value of vaccination in immune-compromised patients. HIV-positive patients receive the flu vaccine; however, they often require a second vaccine to gain protection. People with a known hypersensitivity to eggs or other components of the vaccine should not be vaccinated. Adults with an acute febrile illness should schedule the vaccination after they have recovered. The vaccines are formulated annually based on worldwide surveillance data. The live, attenuated nasal spray vaccine is given to people from 2 through 49 years of age if they are not pregnant or do not have certain long-term health problems such as asthma; heart, lung or kidney disease; diabetes; or anemia. The inactivated flu shot should be given to these individuals and those 50 and older (CDC, 2010c).

Pneumococcal vaccine (PCV13) is routinely given to infants in a series of four doses and is recommended for patients at increased risk of developing pneumonia. This includes all adults over 65 years of age, those with chronic illnesses or who are immunocompromised (such as HIV/AIDS), any adult who smokes or has asthma, and those living in special environments such as nursing homes or long-term care facilities (CDC, 2010d, 2011).

Healthy Lifestyle: Identification and elimination of risk factors for cardiopulmonary disease are important parts of primary care. Encourage patients to eat a healthy low-fat, high-fiber diet; monitor their cholesterol, triglyceride, high-density lipoprotein (HDL), and low-density lipoprotein (LDL) levels; reduce stress; exercise; and maintain a body weight in proportion to their height. Eliminating cigarettes and other tobacco, reducing pollutants, monitoring air quality, and adequately hydrating are additional healthy behaviors. Encourage patients to examine their habits and make appropriate changes.

Exercise is a key factor in promoting and maintaining a healthy heart and lungs. Encourage patients to exercise at least 3 to 4 times a week for 30 to 60 minutes. Aerobic exercise is necessary to improve lung and heart function and strengthen muscles. Walking is an efficient way to achieve a good aerobic workout. Many shopping malls have programs allowing people to walk in the enclosed mall before the shops open. During the hot summer months teach patients to limit activities to early in the day or late in the evening, when temperatures are lower. Teach patients how to maintain adequate hydration and sodium intake, especially if they are taking diuretics.

Patients with cardiopulmonary alterations need to minimize their risk for infection, especially during the winter months. Teach them to avoid large, crowded places; keep their mouth and nose covered; and be sure to dress warmly, including a scarf, hat, and gloves. This is especially important during the peak of the flu season.

Patients with known cardiac disease and those with multiple risk factors are cautioned to avoid exertion in cold weather. Shoveling snow is especially risky and often precipitates a cardiac event. Other activities such as hanging holiday lights and decorations in the extreme cold can precipitate chest pain and bronchospasm.

Environmental Pollutants: Avoiding exposure to secondhand smoke is essential to maintaining optimal cardiopulmonary function. Most businesses and restaurants now ban smoking or have separate areas designated as smoking areas. If patients are exposed to secondhand smoke in their home environments, counseling and support for all family members are necessary to assist the smoker in successful smoking cessation or alterations in behavior patterns such as smoking outside.

Consider if a patient is exposed to chemicals and pollutants in the work environment. Farmers, painters, carpenters, and others benefit from the use of particulate filter masks to reduce the inhalation of particles.

Acute Care

Patients with acute pulmonary illnesses require nursing interventions directed toward halting the pathological process (e.g., respiratory tract infection); shortening the duration and severity of the illness (e.g., hospitalization with pneumonia); and preventing complications from the illness or treatments (e.g., hospital-acquired infection resulting from invasive procedures).

Dyspnea Management: Dyspnea is difficult to measure and treat. Health care providers will individualize treatments for each patient and usually implement more than one therapy. Treatment of the underlying process causing dyspnea is then followed with other therapies (e.g., pharmacological measures, oxygen therapy, physical techniques, and psychosocial techniques). Pharmacological agents include bronchodilators, inhaled steroids, mucolytics, and low-dose antianxiety medications. Oxygen therapy reduces dyspnea associated with exercise and hypoxemia. Physical techniques such as cardiopulmonary reconditioning (e.g., exercise, breathing techniques, and cough control), relaxation techniques, biofeedback, and meditation are also beneficial.

Airway Maintenance: The airway is patent when the trachea, bronchi, and large airways are free from obstructions. Airway maintenance requires adequate hydration to prevent thick, tenacious secretions. Proper coughing techniques remove secretions and keep the airway open. A variety of interventions such as suctioning, chest physiotherapy, and nebulizer therapy assist patients in managing alterations in airway clearance.

Mobilization of Pulmonary Secretions: The ability of a patient to mobilize pulmonary secretions makes the difference between a short-term illness and a long recovery involving complications. Nursing interventions promoting removal of pulmonary secretions assist in achieving and maintaining a clear airway and help to promote lung expansion and gas exchange.

Hydration: Maintenance of adequate systemic hydration keeps mucociliary clearance normal. In patients with adequate hydration, pulmonary secretions are thin, white, watery, and easily removable with minimal coughing. Excessive coughing to clear thick, tenacious secretions is fatiguing and energy depleting. The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 mL/day unless contraindicated by cardiac or renal status. The color, consistency, and ease of mucus expectoration determine adequacy of hydration.

Humidification: Humidification is the process of adding water to gas. Temperature is the most important factor affecting the amount of water vapor a gas can hold. Relative humidity is the percentage of water in the gas. Air or oxygen with a high relative humidity keeps the airways moist and loosens and mobilizes pulmonary secretions. Humidification is necessary for patients receiving oxygen therapy at greater than 4 L/min (check agency protocol). It might be necessary to add humidification at lower oxygen concentrations if the environment is dry and arid. Bubbling oxygen through water adds humidity to the oxygen delivered to the upper airways (see Skill 40-4).

An oxygen hood is used for infants, and a humidity tent is used for children with illnesses such as croup and tracheitis to liquefy secretions and help reduce fever (Hockenberry and Wilson, 2011). The nebulizer at the top of the humidity tent remains filled with water to prevent nonhumidified air or oxygen from entering the tent. Air in the humidity tent sometimes becomes cool and falls below 20° C (68° F), causing the child to become chilled. Children in humidity tents require frequent changes of clothing and bed linen to remain warm and dry.

Nebulization: Nebulization adds moisture or medications to inspired air by mixing particles of varying sizes with the air. Aerosolization suspends the maximum number of water drops or particles of the desired size in inspired air. The moisture added through nebulization improves clearance of pulmonary secretions. Nebulization is used for administration of bronchodilators and mucolytic agents.

When the thin layer of fluid supporting the mucous layer over the cilia dries, the cilia are damaged and unable to adequately clear the airway. Humidification through nebulization enhances mucociliary clearance, the natural mechanism of the body for removing mucus and cellular debris from the respiratory tract.

Coughing and Deep-Breathing Techniques: Coughing is effective for maintaining a patent airway. Directed coughing is a deliberate maneuver that is effective when spontaneous coughing is not adequate (AARC, 1993). Directed coughing permits a patient to remove secretions from both the upper and lower airways. The normal series of events in the cough mechanism are deep inhalation, closure of the glottis, active contraction of the expiratory muscles, and glottis opening. Deep inhalation increases the lung volume and airway diameter, allowing the air to pass through partially obstructing mucus plugs or other foreign matter. Contraction of the expiratory muscles against the closed glottis causes a high intrathoracic pressure to develop. When the glottis opens, a large flow of air is expelled at a high speed, providing momentum for mucus to move to the upper airways where the patient can expectorate or swallow it.

Diaphragmatic breathing/belly breathing is a technique that encourages deep breathing to increase air to the lower lungs. The belly moves out when breathing in and sinks in when breathing out (CFF, 2005). Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. This is especially important if the airway of the alveoli is plugged with mucus. The neighboring alveoli can share the air distribution through the pores of Kohn (McCance and Huether, 2010).

Evaluate the effectiveness of coughing by sputum expectoration, the patient’s report of swallowed sputum, or clearing of adventitious sounds by auscultation. Encourage patients with chronic pulmonary diseases, upper respiratory tract infections, and lower respiratory tract infections to deep breathe and cough at least every 2 hours while awake. Encourage patients with a large amount of sputum to cough every hour while awake and then awaken them at night in order to cough every 2 to 3 hours. This is necessary until the acute phase of mucus production has ended. After surgery it is recommended that directed cough be performed every 2 to 4 hours while awake to prevent accumulation of secretions. Offer postoperative patients support devices (folded blanket, pillow, or palmed hands) to splint an abdominal or thoracic incision to minimize pain during directed coughing. Cough is a source of droplet transmission of pulmonary pathogens; thus the health care provider should follow Standard Precautions. Coughing techniques include deep breathing and coughing for the postoperative patient, cascade, huff, and quad coughing (AARC, 1993).

With the cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then he or she opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum.

The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. With practice he or she inhales more air and is able to progress to the cascade cough.

The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough.

Chest Physiotherapy: Chest physiotherapy (CPT) is a group of therapies for mobilizing pulmonary secretions. These therapies include postural drainage, chest percussion, and vibration. CPT is followed by productive coughing or suctioning of a patient who has a decreased ability to cough. It is recommended for patients who produce greater than 30 mL of sputum per day or have evidence of atelectasis on chest x-ray examination. The procedure is safe for infants and young children; however, at times conditions and diseases unique to children contraindicate it. CPT is for a select group of patients. Box 40-7 describes the guidelines to determine if CPT is indicated.

Box 40-7 Guidelines for Chest Physiotherapy

Nursing and respiratory therapy collaborate with the health care provider to determine if chest physiotherapy (CPT) is best for the patient. The following guidelines help in physical assessment and subsequent decision making:

• Know a patient’s normal range of vital signs. Conditions requiring CPT such as atelectasis and pneumonia affect vital signs. The degree of change is related to the level of hypoxia, overall cardiopulmonary status, and tolerance to activity.

• Conduct a respiratory assessment to confirm need for CPT, including sputum production, effectiveness of cough, history of pulmonary problems successfully relieved with CPT, abnormal lung sounds, documented conditions such as atelectasis, pneumonia, and changes in oxygenation status.

• Know the patient’s medications. Certain medications, particularly diuretics and antihypertensives, cause fluid and hemodynamic changes. These decrease a patient’s tolerance to positional changes and postural drainage. Long-term steroid use increases a patient’s risk of pathological rib fractures and often contraindicates vibration.

• Know the patient’s medical history. Certain conditions such as increased intracranial pressure, spinal cord injuries, and abdominal aneurysm resection contraindicate the positional changes of postural drainage. Thoracic trauma or surgery contraindicates percussion and vibration.

• Know the patient’s level of cognitive function. Participation in controlled coughing techniques requires him or her to follow instructions. Congenital or acquired cognitive limitations alter a patient’s ability to learn and participate in these techniques.

• Be aware of the patient’s exercise tolerance. CPT maneuvers are fatiguing. When a patient is not used to physical activity, initial tolerance to the maneuvers is often decreased. However, with gradual increases in activity and planned CPT, patient tolerance for the procedure improves.

Postural drainage is a component of pulmonary hygiene; it consists of drainage, positioning, and turning and is sometimes accompanied by chest percussion and vibration (CFF, 2005). It improves secretion clearance and oxygenation. Positioning includes most lung segments (Table 40-6) and helps to drain secretions from specific segments of the lungs and bronchi into the trachea. Some patients do not require postural drainage of all lung segments, and clinical assessment is crucial in identifying specific lung segments requiring it. For example, patients with left lower lobe atelectasis require postural drainage of only the affected region, whereas a child with cystic fibrosis often requires postural drainage of all lung segments.

TABLE 40-6

Positions for Postural Drainage

Chest percussion involves rhythmically clapping on the chest wall over the area being drained to force secretions into larger airways for expectoration. Position the hand so the fingers and thumb touch and the hands are cupped. The cupping makes the hand conform to the chest wall while trapping a cushion of air to soften the intensity of the clapping. The procedure should produce a hollow sound and should not be painful (CFF, 2005). Perform chest percussion by vigorously striking the chest wall alternately with cupped hands (Fig. 40-9). Perform percussion over a single layer of clothing, not over buttons, snaps, or zippers. The single layer of clothing prevents slapping the patient’s skin. Thicker or multiple layers of material dampen the vibrations.

FIG. 40-9 Chest wall percussion, alternating hand clapping against patient’s chest wall.

Percussion is contraindicated in patients with bleeding disorders, osteoporosis, or fractured ribs. Avoid percussion over burns, open wounds, or skin infections of the thorax. Take caution to percuss the lung fields under the ribs and not the over the spine, breastbone, stomach or lower back or trauma can occur to the spleen, liver, or kidneys (CFF, 2005).

Vibration is a gentle, shaking pressure applied to the chest wall to shake secretions into larger airways. Place a flattened hand or two hands (pressing top and bottom hand into each other to vibrate) firmly on the chest wall over the appropriate segment and tense the muscles of the arm to provide a shaking motion. Have the patient exhale as slowly as possible during the vibration. This technique increases the velocity and turbulence of exhaled air, facilitating secretion removal. Vibration increases the exhalation of trapped air, shakes mucus loose, and induces a cough (CFF, 2005).

Suctioning Techniques: Suctioning is necessary when patients are unable to clear respiratory secretions from the airways by coughing or other less invasive procedures. Suctioning techniques include oropharyngeal and nasopharyngeal suctioning, orotracheal and nasotracheal suctioning, and suctioning an artificial airway.

In most cases use sterile technique for suctioning because the oropharynx and trachea are considered sterile. The mouth is considered clean; therefore you suction oral secretions after suctioning the oropharynx and trachea. In the home setting a “clean” versus “sterile” technique is used because the patient is not exposed to pathogens common to health care settings; however, appropriate measures for disinfecting equipment should be taught (AARC, 2004).

Each type of suctioning requires the use of a round-tipped, flexible catheter with holes on the sides and end of the catheter. When suctioning, you apply negative pressures (not greater than 150 mm Hg) during withdrawal of the catheter, never on insertion. Patient assessment determines the frequency of suctioning. It is indicated when audible on auscultation (rhonchi, gurgling breath sounds, diminished breath sounds) or visible secretions are present after other methods to remove airway secretions have failed. You may also use suctioning to obtain a sputum specimen for culture or cytology if the patient is not able to cough productively. Too-frequent suctioning puts patients at risk for development of hypoxemia, hypotension, arrhythmias, and possible trauma to the mucosa of the lungs (AARC, 2004).

Oropharyngeal and Nasopharyngeal Suctioning: Oropharyngeal or nasopharyngeal suctioning is used when the patient is able to cough effectively but unable to clear secretions by expectorating. Apply suction after a patient has coughed (Skill 40-1 on pp. 855-861). Once the pulmonary secretions decrease and a patient is less fatigued, he or she is then able to expectorate or swallow the mucus, and suctioning is no longer necessary.

Orotracheal and Nasotracheal Suctioning: Orotracheal or nasotracheal suctioning is necessary when a patient with pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway present (see Skill 40-1). You pass a sterile catheter through the mouth or nose into the trachea. The nose is the preferred route because stimulation of the gag reflex is minimal. The procedure is similar to nasopharyngeal suctioning, but you advance the catheter tip farther into the patient’s trachea. The entire procedure from catheter passage to its removal is done quickly, lasting no longer than 15 seconds (AARC, 2004). Unless in respiratory distress, allow the patient to rest between passes of the catheter. If the patient is using supplemental oxygen, replace the oxygen cannula or mask during rest periods.

Tracheal Suctioning: You perform tracheal suctioning through an artificial airway such as an endotracheal (ET) or tracheostomy tube. The size of a catheter should be as small as possible but large enough to remove secretions. Recommendation is about half the internal diameter of the ET tube (Pedersen et al., 2009). Never apply suction pressure while inserting the catheter to avoid traumatizing the lung mucosa. Once you insert a catheter the necessary distance, maintain suction pressure between 120 and 150 mm Hg (AARC, 2004) as you withdraw. Apply suction intermittently only while withdrawing the catheter. Rotating the catheter enhances removal of secretions that have adhered to the sides of the ET tube.

The practice of normal saline instillation (NSI) into artificial airways to improve secretion removal is inconclusive. Clinical studies comparing the results of suctioning following NSI with standard suctioning have not shown any clinical or significant results (Box 40-8). There are anecdotal results supporting the theory that NSI stimulates patients to cough and as a result the airway secretions are loosened and dislodged. However, the practice of NSI has the potential of causing detrimental effects such as increased heart rate and blood pressure and an increased risk of respiratory infection (Kuriakose, 2008).

Box 40-8 Evidence-Based Practice

The Effectiveness of Instilling Normal Saline into Artificial Airways Before Suctioning

PICO Question: In patients with artificial airways, does instilling normal saline into artificial airways before suctioning increase the output of mucus?

Evidence Summary

The practice of instilling normal saline before suctioning artificial airways to dilute and loosen secretions has been questioned by researchers. Several meta-analysis studies report more harmful effects from normal saline instillation than benefits. One of the complications found was significant decreased oxygenation saturation in patients receiving normal saline instillation compared to patients who did not. The saline group actually took 5 minutes to return to baseline SaO₂ after suctioning (Halm and Krisko-Hagel, 2008; Kuriakose, 2008; Rauen et al., 2008).

Another complication reported was increased dyspnea in people over 60 years if they had saline instilled (Kuriakose, 2008; Pedersen et al., 2009). Along with dyspnea, patients reported anxiety, dread, and increased pain when saline was used (Halm and Krisko-Hagel, 2008).

Increased colonization of the lower respiratory tract after 48 hours was found to be five times higher in patients receiving saline. It was thought that the saline actually dislodged colonies and dispersed them to the lower airways (Halm and Krisko-Hagel, 2008; Kuriakose, 2008).

Studies looking at the amount of sputum yield after suctioning following saline instillation showed that the amount obtained was not clinically important. It was even found that the saline was rapidly absorbed and did not really mix with the secretions (Halm and Krisko-Hagel, 2008). The problem with the yield studies was how to quantify the amount removed (Rauen et al., 2008).

The evidence of adverse effects of instilling saline both physically and psychologically supports not using saline instillation before suctioning. However, change in practice is a challenge since surveys have found that 2 to 3 times as many respiratory therapists report that they continue to use saline before suctioning compared to nurses (Halm and Krisko-Hagel, 2008; Rauen et al., 2008). However, surveys of nursing practice report that 24% to 33% of nurses still use saline (Rauen et al., 2008). What may help change practice is the American Association of Respiratory Care guideline for endotracheal suctioning of mechanically ventilated patients with artificial airways (2010a), which states that normal saline should not be used before suctioning on a routine basis.

Application to Nursing Practice

• Normal saline and mucus do not appear to mix so it does not thin or mobilize secretions. It would be better to increase humidification by improving systemic hydration either orally or by intravenous infusion.

• Use humidification with oxygen and refer to respiratory therapy for appropriate nebulizer treatments to disperse the humidification more uniformly.

• Increase ambulation and mobility even in intensive care units to help mobilize secretions.

• Use chest physiotherapy to help mobilize secretions.

• Use positioning such as “good lung down” to facilitate oxygenation and elevation of head of bed to at least 45 degrees. Turn critically ill patients more frequently than every 2 hours.

The two current methods of suctioning are the open and closed methods. Open suctioning involves using a new sterile catheter for each suction session (Pedersen et al., 2009). Wear sterile gloves and follow Standard Precautions during the suction procedure. Closed suctioning involves using a reusable sterile suction catheter that is encased in a plastic sheath to protect it between suction sessions (Fig. 40-10). Closed suctioning is most often used on patients who require mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the risk of oxygen desaturation. Although sterile gloves are not used in this procedure, nonsterile gloves are recommended to prevent contact with splashes from body fluids (Box 40-9).

Box 40-9 Procedural Guidelines

Closed (In-Line) Suction Catheter

Delegation Considerations

Airway suctioning with a closed (in-line) suction catheter cannot be routinely delegated to nursing assistive personnel (NAP). This procedure may be delegated when suctioning a patient with a permanent tracheostomy is necessary (follow agency policy). The nurse is responsible for the patient’s cardiopulmonary assessment and evaluation. The nurse informs the NAP about:

• Any individualized aspects of patient care that pertain to suctioning (e.g., position, duration of suction, pressure settings).

• The expected quality, quantity, and color of secretions and to immediately report any changes to the nurse.

• Patient’s anticipated response to suction and to immediately report to the nurse changes in vital signs, complaints of pain, changes in respiratory status, mental status, or increased restlessness

Equipment

Closed system or in-line suction catheter; suction machine, 6 feet of connecting tubing, clean gloves (optional), face shield, goggles (optional) or mask (optional), saline vial or syringe (for rinsing tubing), clean towel, pulse oximeter and stethoscope

1. Identify the patient using two identifiers (e.g., name and birth date or name and account number) according to facility policy. Compare identifiers with information on the patient’s medical record.

2. Perform assessment as in Skill 40-1.

3. Explain the procedure to patient and the importance of coughing during the suctioning procedure.

4. Assist patient with assuming a position of comfort usually semi-or high-Fowler’s position. Place towel across patient’s chest.

5. Perform hand hygiene, apply face shield and clean gloves, and attach suction. Note: If risk for splash is present or patient is on respiratory precautions, mask and goggles may be needed.

a. In some settings a respiratory therapist attaches the catheter to the closed ventilator circuit. If catheter is not already in place, open closed-suction catheter package using aseptic technique, attach catheter to ventilator circuit by removing swivel adapter, and place catheter apparatus on endotracheal or tracheostomy tube. Connect Y on mechanical ventilator circuit to closed-suction catheter with flex tubing (see Fig. 40-10).

b. Connect one end of connecting tubing to suction machine and the other to the end of a closed system or in-line suction catheter, if not already done. Turn suction device on and set vacuum regulator to appropriate negative pressure (see manufacturer directions). Many closed-system suction catheters require slightly higher suction; consult manufacturer guidelines.

6. Hyperinflate and/or hyperoxygenate patient with bag-valve mask or manual breathing mechanism on mechanical ventilator according to institution protocol and clinical status (usually 100% oxygen).

7. Unlock suction-control mechanism if required by manufacturer. Open saline port and attach saline syringe or vial.

8. Pick up suction catheter enclosed in plastic sleeve with dominant hand.

CLINICAL DECISION: The instillation of normal saline into the airway before closed in-line suctioning may not be appropriate for all patients and needs further investigation. Normal saline instillation in conjunction with artificial airway suctioning may lead to the dispersion of microorganisms into the lower respiratory tract (Kuriakose, 2008).

9. Insert catheter; use a repeating maneuver of pushing catheter and sliding (or pulling) plastic sleeve back between thumb and forefinger until you feel resistance or patient coughs.

10. Encourage patient to cough and apply suction by squeezing on suction-control mechanism while withdrawing catheter. It is difficult to apply intermittent pulses of suction and nearly impossible to rotate the catheter compared with a standard catheter. Be sure to withdraw catheter completely into plastic sheath so it does not obstruct airflow (AARC, 2004).

11. Reassess cardiopulmonary status, including pulse oximetry, to determine need for subsequent suctioning or complications. Repeat Steps 5 through 9 one to two more times to clear secretions. Allow adequate time (at least 1 full minute) between suction passes for ventilation and reoxygenation (AARC, 2004).

12. When airway is clear, withdraw catheter completely into sheath. Be sure that colored indicator line on catheter is visible in the sheath. Squeeze vial or push syringe while applying suction to rinse the inner lumen of catheter. Use at least 5 to 10 mL of saline to rinse the catheter until it is clear of retained secretions, which cause bacterial growth and increase the risk of infection (AARC, 2004). Lock suction mechanism, if applicable, and turn off suction.

13. If patient requires oral or nasal suctioning, perform Skill 40-1 with separate standard suction catheter.

14. Reposition patient.

15. Remove gloves and face shield, discard into appropriate receptacle, and perform hand hygiene.

16. Compare patient’s respiratory assessment with evaluation findings after suctioning and observe airway secretions.

FIG. 40-10 Ballard tracheal care, closed suction catheter.

Artificial Airways: An artificial airway is for a patient with a decreased level of consciousness or airway obstruction and aids in removal of tracheobronchial secretions. The presence of an artificial airway places a patient at high risk for infection and airway injury. Use clean technique for oral airways, but use sterile technique in caring for and maintaining endotracheal and tracheal airways to prevent health care–associated infections (HAIs). Artificial airways need to stay in the correct position to prevent airway damage (Skill 40-2 on pp. 861-869).

Oral Airway: The oral airway, the simplest type of artificial airway, prevents obstruction of the trachea by displacement of the tongue into the oropharynx (Fig. 40-11). The oral airway extends from the teeth to the oropharynx, maintaining the tongue in the normal position. Use the correct-size airway. Determine the proper oral airway size by measuring the distance from the corner of the mouth to the angle of the jaw just below the ear. The length is equal to the distance from the flange of the airway to the tip. If the airway is too small, the tongue does not stay in the anterior portion of the mouth; if the airway is too large, it forces the tongue toward the epiglottis and obstructs the airway.

FIG. 40-11 Artificial oral airways.

Insert the airway by turning the curve of the airway toward the cheek and placing it over the tongue. When the airway is in the oropharynx, turn it so the opening points downward. Correctly placed, the airway moves the tongue forward away from the oropharynx, and the flange (i.e., the flat portion of the airway) rests against the patient’s teeth. Incorrect insertion merely forces the tongue back into the oropharynx.

Endotracheal and Tracheal Airway: An endotracheal (ET) tube is a short-term artificial airway to administer mechanical ventilation, relieve upper airway obstruction, protect against aspiration, or clear secretions. A physician or specially trained clinician inserts the ET tube. The tube is passed through the patient’s mouth, past the pharynx, and into the trachea (Fig. 40-12). It is generally removed within 14 days; however, it is sometimes used for a longer period of time if the patient is still showing progress toward weaning from mechanical ventilation and extubation.

FIG. 40-12 Endotracheal tube inserted into trachea. Cuff inflated to maintain position. (From Nellcor Puritan Bennett: Hi-Lo Evac endotracheal tube with evacuation lumen, http://www.nellcor.com/_Catalog/PDF/Product/Hi-LoEvac.pdf. Accessed August 2, 2011).

If a patient requires long-term assistance from an artificial airway, a tracheostomy is considered. A surgical incision is made into the trachea, and a short artificial airway (a tracheostomy tube) is inserted. Most tracheostomies have a small plastic inner tube that fits inside a larger one (the inner cannula). The most common complication of a tracheostomy tube is partial or total airway obstruction caused by buildup of respiratory secretions. If this occurs, the inner tube can be removed and cleaned or replaced with a temporary spare inner tube that should be kept at the patient’s bedside. Keep tracheal dilators at the bedside to have available for emergency tube replacement or reinsertion. Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. Tracheostomy suctioning should be done as often as necessary to clear secretions. The majority of patients with a tracheostomy tube cannot speak because the tube is inserted below the vocal cords. It is important to use written or nonverbal communication (lip reading) strategies to help patients communicate. Be sure to assess patients for anxiety caused by the inability to speak (Higgins, 2009). Care and cleaning of the tracheostomy tube is discussed in Skill 40-2.

Maintenance and Promotion of Lung Expansion: Nursing interventions to maintain or promote lung expansion include noninvasive techniques such as ambulation, positioning, incentive spirometry, and noninvasive ventilation. Invasive medical interventions such as chest tube insertion and management assist in restoring lung expansion.

Ambulation: Immobility is a major factor in developing atelectasis, ventilator-associated pneumonia (VAP), and functional limitations. The research has shown that, after 1 week of bed rest, muscle strength declines by as much as 20%, which results in an increased oxygen demand, weakened respiratory muscles, and a decline of functional status. Early ambulation studies indicate that the therapeutic benefits of activity include an increase in general strength and lung expansion. Even the patient who requires mechanical ventilation benefits by an early mobility program. Such mobility programs should include input from both respiratory and physical therapists in the treatment plan (Perme and Chandrashekar, 2009). Progressive mobilization from dangling the legs to standing and then walking is safe for intubated patients (Rauen et al., 2008).

Positioning: The healthy, completely mobile person maintains adequate ventilation and oxygenation by frequent position changes during daily activities. However, when a person’s illness or injury restricts mobility, the risk for respiratory impairment is increased. Frequent changes of position are simple and cost-effective methods for reducing stasis of pulmonary secretions and decreased chest wall expansion, both of which increase the risk of pneumonia. Research has shown that turning critically ill patients every 2 hours is not often enough to prevent pneumonia (Rauen et al., 2008).

The 45-degree semi-Fowler’s is the most effective position to promote lung expansion and reduce pressure from the abdomen on the diaphragm. When a patient is in this position, be sure that he or she does not slide down in bed, which can reduce lung expansion. A patient with unilateral lung disease such as pneumothorax, atelectasis, pneumonia, thoracotomy, and trauma of one lung should be positioned in a manner to promote perfusion of the healthy lung and improve oxygenation. In most cases, position the patient with the good lung down (Rauen et al., 2008). In the presence of pulmonary abscess or hemorrhage, position the patient with the affected lung down to prevent drainage toward the healthy lung. For bilateral lung disease the best position depends on the severity of the disease.

Incentive Spirometry: Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It promotes deep breathing and prevents or treats atelectasis in the postoperative patient. There is solid evidence to support the use of lung expansion with incentive spirometry in preventing postoperative pulmonary complications following abdominal surgery (Lawrence et al., 2006).

Flow-oriented incentive spirometers consist of one or more plastic chambers that contain freely moving colored balls. A patient inhales slowly and with an even flow to elevate the balls and keep them floating as long as possible to ensure a maximally sustained inhalation.

Volume-oriented incentive spirometry devices have a bellows that is raised to a predetermined volume by an inhaled breath (Fig. 40-13). An achievement light or counter is used to provide feedback. Some devices are constructed so the light does not turn on unless the bellows is held at a minimum desired volume for a specified period to enhance lung expansion (see Chapter 50).

FIG. 40-13 Volume-oriented incentive spirometer.

Incentive spirometry encourages patients to use visual feedback to maximally inflate their lungs and sustain that inflation (Basoglu et al., 2005). A postoperative inspiratory capacity one half to three fourths of the preoperative volume is acceptable because of postoperative pain. The AARC guidelines (2011) recommend 5 to 10 breaths per session every hour while awake. Administration of pain medications before incentive spirometry helps a patient achieve deep breathing by reducing pain and splinting.

Noninvasive Ventilation: Noninvasive positive-pressure ventilation (NPPV) is used to prevent using invasive artificial airways (ET tube or tracheostomy) in patients with acute respiratory failure, cardiogenic pulmonary edema, or exacerbation of COPD. It has also been used following extubation of an ET tube (Agarwal et al., 2007). The purpose of NPPV is to maintain a positive airway pressure and improve alveolar ventilation. This prevents or treats atelectasis by inflating the alveoli, reducing pulmonary edema by forcing fluid out of the lungs back into circulation, and improving oxygenation in those with sleep apnea. Ventilatory support is achieved using a variety of modes, including continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP).

CPAP treats patients with obstructive sleep apnea, patients with heart failure, and preterm infants with underdeveloped lungs. In obstructive sleep apnea, airways collapse, causing shallow or absent breathing. Any air moving past the obstruction results in loud snoring. An overnight sleep study may be needed to determine the correct settings for a CPAP machine (see Chapter 42). Equipment includes a mask (Fig. 40-14) that fits over the nose or both nose and mouth and a CPAP machine that delivers air to the mask (National Heart Lung and Blood Institute, 2010). The smallest mask with the proper fit is the most effective. Because straps hold the mask in place, it is important to assess for excess pressure on the patient’s face or nose that could cause skin breakdown or necrosis. The mask should have enough slack to allow one to two fingers between the straps and the face (Soo Hoo, 2010). However, it must also be tight enough to form a tight seal on the face so the air does not escape. With higher pressures escape of some air may be avoidable.

FIG. 40-14 CPAP mask

The most common mode of support is BiPAP that provides both inspiratory positive airway pressure (IPAP) and expiratory airway pressure (EPAP), also known as positive end-expiratory pressure (PEEP). The difference between these two pressures indicates the amount of pressure support a patient needs (Soo Hoo, 2010). During inhalation the positive pressure increases the patient’s tidal volume and alveolar ventilation. The pressure support decreases when the patient exhales, allowing for easier exhalation.

Complications of noninvasive ventilation include facial and nasal injury and skin breakdown, dry mucous membranes and thick secretions, and aspiration of gastric contents if vomiting occurs during ventilation. Complications avoided by noninvasive ventilation are VAP, sinusitis, and effects of large-dose sedative agents. Use of noninvasive ventilation results in shorter intensive care unit (ICU) and hospital stays (Soo Hoo, 2010). Perform good oral hygiene every few hours while a patient is on BiPAP to relieve dryness.

Chest Tubes: A chest tube (Fig. 40-15) is a catheter inserted through the thorax to remove air and fluids from the pleural space, to prevent air or fluid from reentering the pleural space, or to reestablish normal intrapleural and intrapulmonic pressures (Roman and Mercado, 2006). Chest tubes are common after chest surgery and chest trauma and are used for treatment of pneumothorax or hemothorax to promote lung reexpansion (Skill 40-3 on pp. 869-873).

FIG. 40-15 Chest tube placement.

A pneumothorax is a collection of air in the pleural space. The loss of negative intrapleural pressure causes the lung to collapse. There are a variety of causes for a pneumothorax. A secondary pneumothorax can occur as a result of chest trauma (e.g., stabbing, gunshot wound, or rib fracture from striking the chest against the steering wheel in an automobile accident). Other causes of secondary pneumothorax are the rupture of an emphysematous bleb on the surface of the lung (the destruction caused by emphysema), tearing of the pleura from an invasive procedure such as surgery, insertion of a subclavian IV line, and mechanical ventilation, including PEEP. Spontaneous (primary) pneumothorax is a genetic condition that occurs unexpectedly in healthy individuals who develop blisterlike formations (blebs) on the visceral pleura, usually on the apex of the lungs. The blebs can rupture during sleep or exercise (McCance and Huether, 2010). A patient with a pneumothorax usually feels pain as atmospheric air irritates the parietal pleura. The pain is sharp and pleuritic and worsens on inspiration. Dyspnea is common and worsens as the size of the pneumothorax increases.

A hemothorax is an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleura, usually as a result of trauma. It produces a counter pressure and prevents the lung from full expansion. A rupture of small blood vessels from inflammatory processes such as pneumonia or TB can cause a hemothorax. In addition to pain and dyspnea, signs and symptoms of shock develop if blood loss is severe.

A variety of chest tubes are available to drain air or excess fluid from the pleural space to relieve respiratory distress. A small-bore chest tube (12 to 20 Fr) is used to remove a small amount of air, and a larger-bore chest tube is used to remove large amounts of fluid or blood and large amounts of air (Coughlin and Parchinsky, 2006).

After a chest tube is inserted, it is attached to a drainage system. A traditional chest drainage unit (CDU) has three chambers for collection, water seal, and suction control. This unit can drain a large amount of both fluid and air (Coughlin and Parchinsky, 2006). Mobile systems rely on gravity, not suction, for drainage. In selected patients these mobile drains reduce the length of time needed for the chest tube, improve ambulation, and decrease the length of time in the hospital (Carroll, 2005). Nonventilated patients and patients who had thoracoscopic lung surgery or minimally invasive cardiac surgery do well with these mobile chest drains. They are lighter and smaller; thus patients are able to move more easily. As a result this reduces the risks of deep vein thrombosis and pulmonary embolism.

The simplest closed drainage system is the single chamber unit. The chamber serves as a fluid collector and a water seal. During normal respiration the fluid in the chamber ascends with inspiration and descends with expiration. A single chamber is used for smaller amounts of drainage such as an empyema (i.e., a collection of infected fluid or pus in the pleural space).

The use of two chambers permits any fluid to flow into the collection chamber as air flows into the water-seal chamber. Fluctuations in the water-seal tube are still anticipated. Two chambers allow for more accurate measurement of chest drainage and are used when larger amounts of drainage are expected.

When a volume of air or fluid needs to be evacuated with controlled suction, all three chambers are used. Mark the suction control with centimeter readings to adjust the amount of suction. Usually 15 to 20 cm of water is used for adults (Roman and Mercado, 2006). This means that the chamber is filled with sterile water to the 15- or 20-cm water level.

There is a new dry chest drainage system that does not use water in the suction chamber. An automatic control valve (ACV) is located inside the regulator and continuously balances the force of the suction with the atmospheres. As a result, the ACV responds and adjusts to changes in patient air leaks and fluctuations in suction source vacuum to deliver accurate suction. Set the pressure between −10 cm H₂O and −40 cm H₂O (Roman and Mercado, 2006). Regardless of the system used, the principles of patient management are the same.

Special Considerations: Keep a chest tube system closed and below the chest (see Skill 40-3). The tube should be secured to the chest wall. Watch for slow, steady bubbling in the suction-control chamber and keep it filled with sterile water at the prescribed level. Make sure that the water-seal chamber is filled to the manufacturer-specified level and watch for fluctuation (tidaling) of the fluid level to ensure that the chest tube and system are working. A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately. Mark the level on the outside of the collection chambers every shift. Report any unexpected cloudy or bloody drainage. Do not let the tubing kink or loop, and ideally it should lie horizontally across the bed or chair before dropping vertically into the drainage device. Encourage your patient to cough, deep breath, and use the incentive spirometer. Make sure that he or she is frequently repositioned and ambulated if not contraindicated. Routinely assess respiratory rate, breath sounds, SpO₂ levels, and the insertion site for subcutaneous emphysema (Rushing, 2007).

Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Air pressure builds in the pleural space, collapsing the lung and creating a life-threatening event. A chest tube is only clamped when replacing the chest drainage system, assessing for an air leak, or during removal (Rushing, 2007).

Chest tubes are not routinely stripped or milked to move clots or increase chest tube drainage (Rushing, 2007). Stripping or milking chest tubes is based on nursing assessment (see Skill 40-3). Stripping is when the thumb and forefinger are used to compress the chest tube and the other hand is used to pull the tube away from the chest wall. Milking is squeezing, twisting, or kneading the tube to create a burst of suction to move clots. The excessive pressure caused by milking can lead to damaged tissue being trapped in the eyelets of the chest tube, resulting in increased bleeding (Halm, 2007).

Handle the chest drainage unit carefully and maintain the drainage device below the patient’s chest. If the tubing disconnects from the drainage unit, instruct the patient to exhale as much as possible and to cough. This maneuver rids the pleural space of as much air as possible. Temporarily reestablish a water seal by immersing the open end of the chest tube into a container of sterile water (Roman and Mercado, 2006).

Removal of chest tubes requires patient preparation. The most frequent sensations reported by patients during chest tube removal include burning, pain, and a pulling sensation. Make sure that the patient is given pain medication at least 30 minutes before removal. The nurse assists the health care provider in removing the chest tube and monitors the dressing placed over the insertion site and the patient’s respiratory status after tube removal.

Maintenance and Promotion of Oxygenation: Promotion of lung expansion, mobilization of secretions, and maintenance of a patent airway assist patients in meeting their oxygenation needs. However, some patients also require oxygen therapy to keep a healthy level of tissue oxygenation.

Oxygen Therapy: Oxygen therapy is widely available and used in a variety of settings to relieve or prevent tissue hypoxia. The goal of oxygen therapy (AARC, 2007) is to prevent or relieve hypoxia by delivering oxygen at concentrations greater than ambient air (21%). Oxygen is a medical gas and should be used in accordance with federal, state, and local regulations. It has dangerous side effects such as oxygen toxicity. The dosage or concentration of oxygen is monitored continuously. Routinely check the health care provider’s orders to verify that the patient is receiving the prescribed oxygen concentration. The six rights of medication administration also pertain to oxygen administration (see Chapter 31).

Safety Precautions: Oxygen is a highly combustible gas. Although it does not burn spontaneously or cause an explosion, it can easily cause a fire in a patient’s room if it contacts a spark from an open flame or electrical equipment. With increasing use of home oxygen therapy, patients and health care professionals need to be aware of the dangers of combustion. Chapter 27 describes steps to take in case of fire.

Promote oxygen safety by the following measures:

• Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider’s order. Distribution must be in accordance with federal, state, and local regulations (AARC, 2007).

• Place an “Oxygen in Use” sign on the patient’s door and in the patient’s room. If using oxygen at home, place a sign on the door of the house. No smoking should be allowed on the premises.

• Keep oxygen-delivery systems 10 feet from any open flames.

• Determine that all electrical equipment in the room is functioning correctly and properly grounded (see Chapter 27). An electrical spark in the presence of oxygen can result in a serious fire.

• When using oxygen cylinders, secure them so they do not fall over. Store them upright and either chained or secured in appropriate holders.

• Check the oxygen level of portable tanks before transporting a patient to ensure that there is enough oxygen in the tank.

Supply of Oxygen: Oxygen is supplied to a patient’s bedside either by oxygen tanks or through a permanent wall-piped system. Oxygen tanks are transported on wide-based carriers that allow the tank to be placed upright at the bedside. Regulators control the amount of oxygen delivered. One common type is an upright flowmeter with a flow adjustment valve at the top. A second type is a cylinder indicator with a flow adjustment handle. In the home setting oxygen therapy is also supplied in a variety of methods, including oxygen concentrators and refillable cylinders (AARC, 2007).

In the hospital or home oxygen tanks are delivered with the regulator in place. In the hospital the respiratory care department usually connects the regulator to the oxygen source. Home care vendors are usually responsible for connecting the oxygen tank to the regulator for home use.

Methods of Oxygen Delivery: The nasal cannula and oxygen masks are the most common devices to deliver oxygen to patients.

Nasal Cannula: A nasal cannula is a simple, comfortable device used for precise oxygen delivery (Skill 40-4 on pp. 873-875). The two nasal prongs are slightly curved and inserted in a patient’s nostrils. To keep the nasal prongs in place, fit the attached tubing over the patient’s ears and secure it under the chin using the sliding connector. Be alert for skin breakdown over the ears and in the nostrils from too tight an application. Attach the nasal cannula to a humidified oxygen source with a flow rate up to 6 L/min (24% to 40% oxygen). Flow rates equal to or greater than 4 L/min have a drying effect on the mucosa and thus need to be humidified (AARC, 2007). Know which flow rate produces a given percentage of inspired oxygen concentration (FIO₂) (Table 40-7).

TABLE 40-7

Approximate FIO₂ with Different Oxygen-Delivery Devices

FIO₂, Fraction of inspired oxygen concentration.

Oxygen Masks: An oxygen mask is a plastic device that fits snugly over the mouth and nose and is secured in place with a strap. It delivers oxygen as the patient breathes through either the mouth or nose by way of a plastic tubing at the base of the mask that is attached to an oxygen source. An adjustable elastic band is attached to either side of the mask that slides over the head to above the ears to hold the mask in place. There are two primary types of oxygen masks: those delivering low concentrations of oxygen and those delivering high concentrations.

The simple face mask (Fig. 40-16) is used for short-term oxygen therapy. It fits loosely and delivers oxygen concentrations from 35% to 50% FIO₂. The mask is contraindicated for patients with carbon dioxide retention because retention can be worsened. Flow rates should be 5 L or more to avoid rebreathing exhaled carbon dioxide retained in the mask. Be alert to skin breakdown under the mask with long-term use (AARC, 2002).

FIG. 40-16 Simple face mask.

A plastic face mask with a reservoir bag (Fig. 40-17) is capable of delivering higher concentrations of oxygen. A partial rebreather mask is a simple mask with a reservoir bag that should be at least one third to one half full on inspiration and delivers from 40% to 70% FIO₂ with a flow rate of 6 to 10 L/min. When used as a nonrebreather mask, a similar face mask has one-way valves that prevent exhaled air from returning to the reservoir bag. The flow rate should be a minimum of 10 L/min and deliver FIO₂ of 60% to 80% (AARC, 2002). Frequently inspect the reservoir bag to make sure that it is inflated. If it is deflated, the patient is breathing large amounts of exhaled carbon dioxide. High-flow oxygen systems should be humidified (AARC, 2007).

FIG. 40-17 Plastic face mask with reservoir bag.

The Venturi mask (Fig. 40-18) delivers higher oxygen concentrations of 24% to 60% with oxygen flow rates of 4 to 12 L/min, depending on the flow-control meter selected.

FIG. 40-18 Venturi mask.

Home Oxygen Therapy: Indications for home oxygen therapy include an arterial partial pressure (PaO₂) of 55 mm Hg or less or an arterial oxygen saturation (SaO₂) of 88% or less on room air at rest, on exertion, or with exercise. Home oxygen therapy is administered via nasal cannula or face mask. Patients with permanent tracheostomies use either a T tube or tracheostomy collar (AARC, 2007). Home oxygen therapy has beneficial effects for patients with chronic cardiopulmonary diseases. This therapy improves patients’ exercise tolerance and fatigue levels and in some situations assists in the management of dyspnea.

There are three types of oxygen delivery systems: compressed gas cylinders, liquid oxygen, and oxygen concentrators. Before placing a certain delivery system in a home, assess the advantages and disadvantages (Table 40-8) of each type, along with the patient’s needs and community resources. In the home the major consideration is the oxygen-delivery source.

TABLE 40-8

Home Oxygen Systems

Data from AARC: Clinical practice guideline—2007 revision and update, Cleveland Clinic Foundation: Home oxygen therapy, 2010b, from http://www.cchs.net/health/health-info/docs/2400/2412.asp?index=8707. Accessed September 14, 2010.

Patients and their family caregivers need extensive teaching to be able to manage oxygen therapy efficiently and safely (Skill 40-5 on pp. 875-878). Teach the patient and family about home oxygen delivery (i.e., oxygen safety, regulation of the amount of oxygen, and how to use the prescribed home oxygen-delivery system) to ensure their ability to maintain the oxygen-delivery system. The home health nurse coordinates the efforts of the patient and family, home respiratory therapist, and home oxygen equipment vendor. The social worker usually assists initially with arranging for the home care nurse and oxygen vendor.

Restoration of Cardiopulmonary Functioning: If a patient’s hypoxia is severe and prolonged, cardiac arrest results. A cardiac arrest is a sudden cessation of cardiac output and circulation. When this occurs, oxygen is not delivered to tissues, carbon dioxide is not transported from tissues, tissue metabolism becomes anaerobic, and metabolic and respiratory acidosis occurs. Permanent heart, brain, and other tissue damage occur within 4 to 6 minutes.

Cardiopulmonary Resuscitation: During cardiac arrest there is an absence of pulse and respiration. The American Heart Association continues to research cardiac arrest treatment and outcomes. The 2010 Consensus Conference reviewed the most current and comprehensive resuscitation literature/research to develop the 2010 AHA Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC), thus simplifying the basic life support (BLS) steps (AHA, 2010b).

The previous ABC (establish an Airway, initiate Breathing, and maintain Circulation) of cardiopulmonary resuscitation (CPR) is changed to CAB (Chest compression, Airway, Breathing) for adults and pediatric patients (excluding newborns). In adults (the majority of cardiac arrests) the critical initial elements found to be essential for survival were chest compressions and early defibrillation. In the previous ABC sequence, establishing an airway first delays chest compressions. Now ventilation is done after the first cycle of 30 chest compressions. Another issue is that bystander CPR may increase if those not comfortable with doing ventilations would at least perform chest compression. For most adults with out-of-the-hospital arrest, hands-only CPR by bystanders has had similar outcomes to conventional CPR. A lone health care provider who sees an adult in cardiac arrest should activate the emergency response system, get and use an automatic external defibrillator (AED) if available, and give CPR. Defibrillation by AED (Box 40-10) is needed to stop an abnormal heart rhythm, and AEDs are now available in public places such as schools, airports, and workplaces (AHA, 2006a, 2010b).

Box 40-10 Automated External Defibrillator

• An automated external defibrillator (AED) is a device used to administer an electrical shock through the chest wall to the heart to stop the abnormal rhythm and restore a normal heart rhythm.

• Built-in computers assess patient’s heart rhythm and determine if defibrillation is necessary. New technology has made them user friendly with audio and visual cues telling users what to do when using them (AHA, 2010b).

• The AED analyzes the patient’s heart rhythm and determines if a shock is needed. It delivers a shock to the patient after announcing, “Everyone stand clear of patient.” A shock is only delivered if the patient needs it.

• Lay rescuer AED programs train lay personnel (security guards, police, and firefighters) on the use of the AED (AHA, 2006b, 2010b).

• The AED is used to strengthen the chain of survival. Every minute of a sudden cardiac arrest without defibrillation decreases the survival rate by 7% to 10% (AHA, 2010b).

• For witnessed ventricular fibrillation, early cardiopulmonary resuscitation with defibrillation within the first 3 to 5 minutes can result in greater than 50% long-term survival (AHA, 2010a).

Restorative and Continuing Care

Restorative and continuing care emphasizes cardiopulmonary reconditioning as a structured rehabilitation program. Cardiopulmonary rehabilitation helps patients achieve and maintain an optimal level of health through controlled physical exercise, nutrition counseling, relaxation and stress-management techniques, and prescribed medications and oxygen. As physical reconditioning occurs, a patient’s complaints of dyspnea, chest pain, fatigue, and activity intolerance decrease. In addition, the patient’s anxiety, depression, or somatic concerns often decrease. The patient and the rehabilitation team define the goals of rehabilitation.

Respiratory Muscle Training: Respiratory muscle training improves muscle strength and endurance, resulting in improved activity tolerance. Respiratory muscle training prevents respiratory failure in patients with COPD. One method for respiratory muscle training is the incentive spirometer resistive breathing device (ISRBD). Patients achieve resistive breathing by placing a resistive breathing device into a volume-dependent incentive spirometer. Patients achieve muscle training when they use the ISRBD on a scheduled routine (e.g., twice a day for 15 minutes or 4 times a day for 15 minutes).

Breathing Exercises: Breathing exercises include techniques to improve ventilation and oxygenation. The three basic techniques are deep-breathing and coughing exercises, pursed-lip breathing, and diaphragmatic breathing. Deep-breathing and coughing exercises, previously discussed, are routine interventions used by postoperative patients (see Chapter 50).

Pursed-Lip Breathing: Pursed-lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, instruct the patient to take a deep breath and exhale slowly through pursed lips as if blowing through a straw. Have him or her blow through a straw into a glass of water to learn the technique. Patients need to gain control of the exhalation phase so it is longer than inhalation. The patient is usually able to perfect this technique by counting the inhalation time and gradually increasing the count during exhalation. In studies using pulse oximetry as a feedback tool, patients are able to demonstrate an increase in their arterial oxygen saturation during pursed-lip breathing (AARC, 1993).

Diaphragmatic Breathing: Diaphragmatic breathing is useful for patients with pulmonary disease, postoperative patients, and women in labor to promote relaxation and provide pain control. The exercise improves efficiency of breathing by decreasing air trapping and reducing the WOB.

Diaphragmatic breathing is more difficult than other breathing methods because it requires a patient to relax intercostal and accessory respiratory muscles while taking deep inspirations, which takes practice. The patient places one hand flat below the breastbone (upper hand) and the other hand (lower hand) flat on the abdomen. Ask him or her to inhale slowly, making the abdomen push out (as the diaphragm flattens, the abdomen should extend out) and moving the lower hand outward. When the patient exhales, the abdomen goes in (the diaphragm ascends and pushes on lungs to help expel trapped air). The patient practices these exercises initially in the supine position and then while sitting and standing. The exercise is often used with the pursed-lip breathing technique.

Safety Guidelines for Nursing Skills

Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate the patient’s priorities of care and preferences, and use the best evidence when making decisions about your patient’s care. When performing the skills in this chapter, remember the following points to ensure safe, individualized patient care.

• Patients with sudden changes in their vital signs, level of consciousness, or behavior are possibly experiencing profound hypoxia (McCance and Huether, 2010).

• Perform tracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. If a large amount of oral secretions is present before beginning the procedure, suction mouth with separate oral suction device.

• Use caution when suctioning patients with a head injury. The suction procedure causes elevations in intracranial pressure (ICP). Reduce this risk by presuctioning hyperventilation, which results in hypocarbia, which in turn induces vasoconstriction, thereby reducing the risk of increased ICP. It is recommended that you limit the introduction of the catheter to 2 times with each suctioning procedure (Gholamzadeh and Javadi, 2009).

• The routine use of NSI into the airway before ET and tracheostomy suctioning is not recommended. Normal saline is not effective in thinning secretions or improving removal. Use of NSI is associated with the adverse effects of excessive coughing, bronchospasm, spread of organisms to the lower respiratory tract, and decreased oxygen saturation (AARC, 2010b).

• Check your institutional policy before stripping or milking chest tubes. Nursing assessment determines if these procedures are necessary. These procedures can cause excessive pressure that has the potential to damage tissue trapped in the eyelets of the chest tube and cause increased bleeding.

• The most serious tracheostomy complication is airway obstruction, which can result in cardiac arrest. Most tracheostomy tubes are designed with a small plastic inner tube that sits inside the larger one. If the airway becomes occluded, the smaller one can be removed and replaced with a temporary spare. It is important to always have a spare at the bedside for emergency replacement (Higgins, 2009).

• Patients with COPD who are breathing spontaneously should never receive high levels of oxygen therapy because it results in a decreased stimulus to breathe. Do not administer oxygen more than 2 L/min unless a health care provider’s order is obtained (AARC, 2007).

Skill 40-1 Suctioning

Unexpected Outcomes and Related Interventions:

1. Worsening cardiopulmonary status

• Limit length of suctioning.

• Determine need for presuctioning hyperoxygenation and hyperinflation.

• Determine need for more frequent suctioning, possibly shorter duration.

• Notify health care provider of changes.

2. Return of bloody secretions

• Determine amount of suction pressure used and adjust accordingly.

• Evaluate suctioning frequency and reduce if appropriate.

• Determine other factors that lead to bloody secretions (e.g., prolonged bleeding time).

• Provide more frequent oral hygiene.

3. Unable to pass suction catheter through first naris attempted

• Try other naris or oral route.

• Insert nasal airway, especially if suctioning through patient naris frequently.

• Guide catheter along naris floor to avoid turbinates.

• If obstruction is mucus, apply suction to relieve obstruction but do not apply suction to mucosa. If you think obstruction is a blood clot, consult health care provider.

• Increase lubrication of catheter.

Recording and Reporting:

• Record amount, consistency, color, and odor of secretions.

• Record patient’s response to procedure.

• Record and report patient’s presuctioning and postsuctioning cardiopulmonary status.

Home Care Considerations:

• Adhere to best practices for infection control while weighing cost-effectiveness in the presence of a chronic situation. If a patient has an established tracheostomy or requires long-term nasotracheal suctioning and infection is not present, clean suction technique is appropriate.

• Although most patients with airway clearance problems at home have a tracheostomy, some also require nasal pharyngeal suctioning. Catheters are often used for a 24-hour period and then cleaned and disinfected; or they are cleaned with soapy water after each use and discarded after 24 hours.

• Stress to family caregivers the importance of brief intervals of applying suction pressure. Instruct those performing suction to hold their breath during the application of negative suction pressure to help them remember to not suction too long.

• Instruct patient to clean and disinfect or change the secretion collection container every 24 hours according to home care or institutional protocol.

• Teach patient and family how to practice infection-control measures when emptying the suction container jar. These secretions are emptied in the toilet but have a splash risk. Instruct caregiver to apply mask (shield if available) and gloves and bring the jar as close to the toilet bowel as possible to decrease the risk of splash.

Skill 40-2 Care of an Artificial Airway

Unexpected Outcomes and Related Interventions:

1. Unexpected extubation of ET tube

• Call for assistance while remaining with patient.

• Assist respirations with bag-valve mask as needed.

• Assess patient for airway patency, spontaneous breathing, and vital signs.

• Prepare for reintubation.

2. Accidental decannulation of tracheostomy tube

• Call for assistance while remaining with patient.

• Replace old tracheostomy tube with new spare tube of same size and kind kept at the bedside. Some experienced nurses or respiratory therapists may be able to quickly reinsert tracheostomy tube (Higgins, 2009).

• Same-size ET tube can be inserted in stoma in an emergency.

• Be prepared to manually ventilate patient who develops respiratory distress.

3. Movement of ET tube

• Repeat taping or securing procedure.

• In very active patients without facial injury who are at risk for self-extubation, consider applying a second piece of tape around back of head.

4. Pressure area around tracheostomy tube

• Increase frequency of tracheostomy care. Keep dressing under faceplate at all times.

• Consider using double dressing or applying hydrocolloid or stoma adhesive dressing around stoma.

Recording and Reporting:

• Record respiratory assessment measures before and after care.

• Record ET tube care: depth of ET tube, frequency and extent of care, patient tolerance of procedure, and special care of any unexpected outcomes related to presence of the tube.

• Record tracheostomy care: type and size of tracheostomy tube, frequency and extent of care, patient tolerance of procedure, and special care of any unexpected outcomes related to presence of the tube.

Home Care Considerations Tracheostomy Only (Cleveland Clinic, 2010a):

• Instruct family caregivers in how to obtain supplies. Routine tracheostomy care should be done at least once a day after discharge from hospital. At home clean technique is used with nonsterile gloves.

• Immediately after tracheostomy insertion, patients must communicate with others by writing or use of computer.

• Instruct caregivers in signs and symptoms of respiratory distress, tube dysfunction, and respiratory and stoma infections. Call health care provider if patient feels pain or discomfort longer than a week after insertion, if breathing does not improve after usual method of clearing secretions, or if secretions become thick or mucus plugs are present.

• When outside, use tracheostomy covers to protect from dust or cold air.

• Never remove the outer cannula unless instructed by health care provider to do so.

Skill 40-3 Care of Patients With Chest Tubes

Unexpected Outcomes and Related Interventions:

1. Air leak unrelated to patient respirations

• Assess all connections between patient and drainage system to find source and tighten any loose connections (Coughlin and Parchinsky, 2006).

• If air leak persists, notify health care provider to change drainage system.

2. Tension pneumothorax present

• Determine that chest tubes are not clamped, kinked, or occluded. Obstructed chest tubes trap air in intrapleural space when air leak originates within patient and can cause a tension pneumothorax.

• Notify patient’s health care provider immediately.

• Prepare immediately for another chest tube insertion; obtain a flutter (Heimlich) valve or large-gauge needle for short-term emergency release of air in intrapleural space; have emergency equipment (e.g., oxygen, code cart) near patient.

3. Continuous bubbling in water-seal chamber, indicating that leak is between patient and water seal

• Tighten loose connections between patient and water-seal system.

• Check agency policy and, if instructed, cross-clamp chest tube closer to patient’s chest using hemostat clamps. If bubbling stops, the air leak is inside patient’s thorax or at chest tube insertion site.

• Unclamp chest tube.

• Reinforce dressing.

• Notify health care provider.

Recording and Reporting:

• Record and report patency of chest tube; presence, type, and amount of drainage; presence of fluctuations; patient’s vital signs; chest dressing status; amount of suction and/or water seal; and patient’s level of comfort.

Home Care Considerations:

• Patients with chronic conditions (e.g., uncomplicated pneumothorax, effusions, empyema) that require long-term chest tube may be discharged with smaller mobile drains. These systems do not have a suction-control chamber and use a mechanical one-way valve instead of a water-seal chamber.

• Instruct patient in how to ambulate and remain active with a mobile chest tube drainage system.

• Provide patient with information as to when to contact health care professionals regarding changes in health status or drainage system (e.g., chest pain, breathlessness, change in drainage).

Skill 40-4 Applying a Nasal Cannula or Oxygen Mask

Unexpected Outcomes and Related Interventions

1. Patient experiences continued hypoxia.

• Check that oxygen-delivery device is patent, not kinked, and attached to oxygen flowmeter.

• Check oxygen level set on flowmeter; determine if delivered amount is consistent with health care provider’s order.

• Obtain orders for follow-up pulse oximetry monitoring or ABG assessment.

• Consider measures to improve airway patency, coughing techniques, and oropharyngeal suctioning.

• Notify health care provider.

2. Dry nasal and upper airway mucosa or epistaxis.

• If oxygen flow rate is greater than 4 L/min, determine need for humidification.

• Assess patient’s fluid status and increase fluids if appropriate.

• Provide frequent oral care.

• Obtain health care provider’s order for use of sterile nasal saline intermittently.

3. Skin irritation or breakdown (e.g., at ears, bridge of nose, nares, other pressure areas).

• Adjust tightness of elastic strap to looser level.

• Provide good hygiene and skin care around the ears.

• Use soft, woven 4 × 4s as nonabrasive pad between elastic and ears.

• Reposition elastic strap frequently.

Recording and Reporting

• Record and report type of oxygen-delivery device and liter flow in medical record; document patient and family education.

• Record respiratory assessment findings; patient response to oxygen therapy, and any adverse reactions or side effects.

• Report any unexpected outcomes to health care provider or nurse in charge.

Skill 40-5 Using Home Oxygen Equipment

Unexpected Outcomes and Related Interventions:

1. Patient reports no oxygen flow.

• Check tank pressure gauge. If level of oxygen is low, refill tank if portable or provide alternate source of oxygen such as concentrator.

• Notify home oxygen supplier of need for refill.

• Reassure patient and family.

2. Patient or family caregiver is unable to fill portable liquid oxygen from main source.

• Check to see that portable tank is connected correctly.

• Determine if valve is frozen.

• Contact home oxygen supplier for service visit.

• Provide alternate oxygen source if necessary.

Recording and Reporting:

• Record teaching plan and patient’s and family caregiver’s ability to safely use home oxygen equipment; report type of home oxygen equipment to be used, patient’s and family’s understanding of how to use equipment, knowledge of safety guidelines and unexpected outcomes, and ability to return demonstrate proper use of oxygen-delivery device.

Assessment Activities	Findings/Defining Characteristics*
Ask Mr. Edwards how long he has had this cough.	He replies, “I have a morning cough every day, but this cough is different. It started about a week ago. It is worse when I lie flat.”
Ask Mr. Edwards what is different about this cough.	He replies, “My ribs are getting sore. It is difficult to cough up anything, my mouth is dry, and I have become more fatigued.”
Observe Mr. Edwards’ skin and mucous membranes.	Skin and mucous membranes are dry.
Auscultate lung fields.	Abnormal lung sounds (crackles) are heard in lower lobes bilaterally.
Ask Mr. Edwards to produce a sputum sample.	Sputum is thick and discolored yellow to yellow-green.

Goals	Expected Outcomes (NOC)†
	Respiratory Status: Airway Patency
Mr. Edwards will be able to effectively clear secretions by discharge.	Lung sounds will be clear in 48 hours.
	Mr. Edwards will notice increased ease in coughing within 48 hours.
	Sputum will be thin and white within 3 days.
	Respiratory rate will be within 12 to 20 breaths/min in 48 hours.
Mr. Edwards will increase oral hydration within 48 hours.	Mr. Edwards will drink 2500 mL of water or preferred liquids every 24 hours starting today. Mr. Edwards will verbalize that his mouth is not dry in 48 hours.

Interventions (NIC)‡	Rationale
Airway Management
Position Mr. Edwards with head elevated 30-45 degrees.	An upright angle allows for thoracic expansion; lying flat allows abdominal organs to push up against the diaphragm, compromising inspiration. This allows for a more normal respiratory rate (Lawrence et al., 2006).
Ambulate in room or hall as tolerated at least 2 times a day. If unable to ambulate, reposition from side to side every 2 hours or more.	Body movement helps mobilize secretions (Perme and Chandrashekar, 2009).
Have Mr. Edwards deep breathe and cough every 2 hours. Teach him to take a deep breath, hold it for several seconds, open his mouth, tighten his abdominal muscles, and cough 2 to 3 times with his mouth open.	Retained secretions predispose patient to atelectasis and pneumonia. Controlled coughing that uses the diaphragmatic muscles make the cough more effective in removing mucus (AARC, 1993).
Administer 2 L/min of oxygen as ordered per nasal cannula if SpO₂ less than 90%.	This dependent nursing intervention will relieve hypoxia.
Increase fluids to 2500 mL in 24 hours if not contraindicated by cardiac or renal status. Offer fluids Mr. Edwards prefers.	Fluids help to liquefy secretions and promote ease of removal. Fluids relieve oral mucosa and skin dryness.

Nursing Actions	Patient Response/Finding	Achievement of Outcome
Auscultate the chest.	Mr. Edwards reports that he has not heard any rattling in his chest.	Lung sounds are normal.
Ask Mr. Edwards if he can deep breathe and cough and measure SpO₂.	Mr. Edwards reports that it is easier to cough up his secretions. SpO₂ is 95%.	Airway clears with coughing. SpO₂ is within normal levels.
Observe sputum.	Mr. Edwards states, “My sputum is thinner and white now.”	Sputum is thin and white.
Monitor respiratory rate.	Mr. Edwards says that it is easier to breathe.	Rate is between 12 and 20 breaths/min.
Assess Mr. Edwards’ level of hydration (skin turgor, condition of mucosa).	Mucous membranes are moist. Fluid intake in previous 24 hours was 2600 mL.	Oral membranes are pink and moist. Minimum fluid intake of 2500 mL was achieved.

Teamwork and Collaboration

Implementation

Health Promotion

Acute Care

Restorative and Continuing Care

Evaluation

Through the Patient’s Eyes

Patient Outcomes

Safety Guidelines for Nursing Skills

Skill 40-1 Suctioning

Skill 40-2 Care of an Artificial Airway

Skill 40-3 Care of Patients With Chest Tubes

Skill 40-4 Applying a Nasal Cannula or Oxygen Mask

Unexpected Outcomes and Related Interventions

Recording and Reporting

Skill 40-5 Using Home Oxygen Equipment

Key Points

Preparing for Clinical Practice

Are You Ready to Test Your Nursing Knowledge?

References

Research References