Exam 5 sherpath
Cautions
Oxygen therapy is a type of medication administration - Follow all rights of medication administration. High oxygen levels can be toxic and damage lungs. Oxygen is flammable; keep away from open flames. Ensure oxygen signage is prominently displayed to indicate that oxygen is in use. In patients with chronic obstructive pulmonary disease (COPD), low-flow oxygen delivery is used (2 L/min or less). Humidification is recommended for any oxygen delivery system.
Poorly-Stated Goal
"He will quit smoking." Rationale: The goal tells who (he) and what (will quit smoking), but does not specify who "he" is. The goal is measurable because the patient is either actively smoking or is no longer smoking. However, it is more realistic to write smaller goals around each step leading up to complete smoking cessation. There is no time frame stated in this goal.
Better-Stated Goal
"The patient will reduce his smoking in the next six months." Rationale: The goal specifies "the patient," but reducing smoking is not specific. How much will he reduce smoking? By one cigarette per day? Half of a pack per week? The goal specifies "in the next six months." The nurse must consider whether this is a realistic goal for the patient. Will someone be able to follow-up on this goal to evaluate success?
Simple face masks do not have
reservoir bags. Allows room air to be inspired with the oxygen delivered Every increase of 1 L/min of oxygen relates to approximately a 5% increase in oxygen concentration delivered. Examples include: 5 L/min = 40% 6 L/min = 45% 7 L/min = 50% 8 L/min = 55% higher than 8 L/min = 60%
Coughing/Deep breathing
A breathing technique that combines controlled coughing with deep breathing to maintain lung expansion, and prevent atelectasis and pneumonia. Patient takes a series of deep breaths, holding each breath for 3 to 5 seconds, and then releases the breath with a series of coughs. The nurse, often as part of preoperative teaching, instructs the patient on the technique and the patient practices. The patient performs the technique with encouragement from the nurse.
Insertion of a pharyngeal airway may be considered for a patient for which reasons?
A decreased level of consciousness Decreased or loss of consciousness are often the reasons for insertion of a pharyngeal airway. Frequent suctioning needs Frequent suctioning needs is an excellent reason to consider use of a pharyngeal tube. Loss of muscle tone Loss of muscle tone is one indication for insertion of a pharyngeal tube.
Complaints of fatigue, dropping oxygen saturation with walking
Activity intolerance
Which device would the nurse apply to a patient who has arrived in the emergency department unconscious and in respiratory arrest (is not breathing)? Venturi mask Ambu bag Nasal cannula CPAP device
Ambu bag The bag-valve-mask (BVM) device, also known as an Ambu bag, uses a one-way valve to support, ventilate, and oxygenate a patient in respiratory arrest.
Anxiety related to difficulty in breathing, as evidenced by irritability and verbalization of nervousness about health status.
An example of patient assessment data that would support this nursing diagnosis: Patient diagnosed with a cold History of COPD States "I am anxious and worried that I will have to be hospitalized if the cold gets bad. My lungs don't bounce back anymore and if I get sick it gets bad." Acute pain related to damage to the heart muscle, as evidenced by pain rating at 7 out of 10, increased respiratory rate and diaphoresis. An example of patient assessment data that support this nursing diagnosis: Patient diagnosed with an acute myocardial infarction Diaphoretic and respiratory rate 36 breaths/min Complains of nausea and difficulty in breathing
Activity intolerance related to low oxygen levels and the need for more oxygen with activity, as evidenced by complaints of fatigue dropping O2 saturation levels with activity, and slow gait.
An example of patient assessment data that would support this nursing diagnosis: Patient diagnosed with chronic bronchitis SpO2 92% at rest and 84% after walking 20 feet Respiratory rate of 36 breaths/min after exercise Can't walk more than 20 feet without sitting down to rest Ineffective breathing pattern related to ineffective movement of air in and out of the lungs, as evidenced by difficulty in breathing with activity and at rest and use of pursed-lip breathing. An example of patient assessment data that would support this nursing diagnosis: Patient sitting up straight on side of bed with pursed-lip breathing Decreased breath sounds bilaterally to lower lobes Speech in short 1-2 word sentences
Impaired gas exchange related to the destruction of alveolar walls, as evidenced by SpO2 of 90% and patient complaint of an inability to breathe.
An example of patient assessment data that would support this nursing diagnosis: Patient diagnosed with emphysema SpO2 90% Adventitious breath sounds bilaterally Respiratory rate 26 breaths/min and shallow Speaks in short sentences
Ineffective airway clearance related to bronchoconstriction, increased production of mucus, as evidenced by thick sputum, prolonged coughing incidents, adventitious breath sounds, and complaint of dyspnea.
An example of patient assessment data that would support this nursing diagnosis: Patient diagnosed with pneumonia Decreased bilateral breath sounds in lower lungs Cough with thick, green sputum Ineffective peripheral tissue perfusion related to decreased oxygen levels in the blood, as evidenced by fatigue with exercise and cyanosis. An example of patient assessment data that support this nursing diagnosis: Patient sitting in wheelchair with oxygen in place Report of fatigue with ambulation SpO2 with oxygen 92%, without oxygen 82%
There are many drug classes that are used to treat cardiovascular diseases
Antiarrhythmics Suppress abnormal rhythms of the heart Treat or prevent tachyarrhythmias including ventricular tachycardia and fibrillation Results in: Return to normal heart rate and rhythm Assessments: Heart rate and rhythm Diuretics Promote the increased flow of urine and reduce excess water in the body Results in: A decrease in blood pressure A decrease in edema A decrease in weight Assessments: Daily weights, Intake and output Antiarrhythmics Suppress abnormal rhythms of the heart Treat or prevent tachyarrhythmias including ventricular tachycardia and fibrillation Results in: Return to normal heart rate and rhythm Assessments: Heart rate and rhythm Anticoagulants Prevent clot formation Results in: Decreased incidence of thrombi and emboli (e.g., pulmonary emboli) Assessments:Bleeding, Compliance with regimen
Many medications are available to treat cardiovascular diseases. Classifications commonly used include:
Antihypertensives -- Ordered to reduce blood pressure Includes a large group of drugs, such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists, beta-blockers, and calcium channel blockers Diuretics -- Often prescribed to treat heart failure or edema Antiarrhythmics -- May be given to patients with arrhythmias or heart failure to slow the heart rate and increase cardiac output. Anticoagulants -- Used to stop the development of blood clots with atrial fibrillation by preventing clot development in the atrium and prevent venous thrombo embolism (VTE) in acutely ill patients
Irritability, verbalization of nervousness
Anxiety
When developing nursing diagnoses for a patient with oxygenation and perfusion problems, selection and individualization of nursing diagnoses is dependent on what nursing activity?
Appropriate data clustering Chunking the patient's assessment findings is a crucial step in identifying problems and developing diagnoses. Accurate and thorough data collection A lower than normal SpO2 (oxygen saturation) percent is related to a problem of gas exchange at the alveolar level. Selecting interventions that meet patient needs Interventions cannot be determined until nursing diagnoses have been written. Evaluating patient goals Goal evaluation occurs after interventions to evaluate whether the problem has been resolved. It occurs as the end stage of the nursing process. Planning patient care Planning patient care cannot occur until the nursing diagnoses are written.
Here are some important nursing considerations related to suctioning:
Assess the need for suctioning and monitor patient's tolerance to suctioning during and after procedure, with special focus on the cardiac and respiratory status. A patient should not be suctioned unless necessary to reduce trauma to the airway. Tracheostomy and nasotracheal or nasopharyngeal suctioning of a patient may not be delegated to a UAP; however oral and oropharyngeal suctioning may be performed by a specially trained UAP, according to facility policy and procedures. Gather all necessary supplies and equipment; have them readily available at the bedside before beginning procedure. Maintain a high level of awareness of the patient's comfort and status throughout the suctioning procedure, especially when performing tracheal suctioning. Meticulously follow proper suctioning techniques to avoid potential complications.
The nurse writes "Ineffective airway clearance" as the beginning of a nursing diagnosis. Based on Ms. Kelley's data, what should be written in the "related to" to portion of the statement? Select all that apply. Bronchoconstriction Increased production of mucus Adventitious breath sounds (expiratory wheezes) Diminished breath sounds bilaterally Asthma
Bronchoconstriction Constriction of the bronchi can make airway clearance difficult. Increased production of mucus Thick mucoid bronchial secretions make airway clearance difficult. Not: Adventitious breath sounds (expiratory wheezes) This is supportive patient evidence that belongs "as evidenced by" portion of the nursing diagnosis statement. Not: Diminished breath sounds bilaterally This is supportive patient evidence that belongs "as evidenced by" portion of the nursing diagnosis statement. Not: Asthma This is a medical diagnosis and is not included in the nursing diagnosis but is important supportive data.
Combines controlled coughing with deep breathing to maintain lung expansion
Coughing/Deep breathing
Non-rebreather masks
are a type of reservoir mask. One-way valve does not allow any exhaled air to enter the reservoir bag. Additional one way valves allow air to be exhaled through the mask, however no room air can be inhaled through the valves. Flow rates should be higher than 10 L/min to maintain bag inflation. Flow rates and percent oxygen values range from: 10 L/min to 15 L/min = 60% to 100% (10 L/min needed to maintain reservoir inflation)
Benefits
Increased daily function Improvements in oxygenation and mental status of patient Increased tolerance to activity
Medications are used to treat lung disease by:
Decreasing symptoms Improving the ability to exercise Decreasing the number of exacerbations Improving the patient's health status. The preferred route of pulmonary medications is inhalation. However, the medications can be administered orally and intravenously for serious conditions. Several classification of medications are used for treating pulmonary diseases.
Goals
Decreasing symptoms related to hypoxemia Decreasing the workload on the cardiovascular system Maintaining PaO2 of 60 mm Hg at rest (normal PaO2 is 80-100 mm Hg) Maintaining an oxygen saturation level of more than 90% (normal SpO2 is 96-100%)
Post procedure
Directly following the procedure the nurse sees to the comfort of the patient and documents the date, time, assessment, procedure and patient's response to the procedure. Care of the chest tube and chest tube system is the responsibility of the nurse and cannot be delegated to a UAP. The nurse routinely monitors and documents: Patient comfort Patency of the chest tube Chest tube dressing status Functioning of all drainage system chambers Volume and characteristics of drainage Correct placement of tubing Drainage system suction setting The nurse promptly reports significant drainage changes or drainage system malfunction to the provider.
Chest Tube
Drains fluid or blood (hemothorax) and excessive air (pneumothorax) from the pleural space Promotes optimal respiratory functioning Allows the nurse to monitor drainage to ensure optimal lung expansion Prevents complications
Based on evaluation of the different types of tubes used to maintain oxygenation, which one would a patient receiving general anesthesia require? Nasopharyngeal Tracheostomy Oropharyngeal Endotracheal
Endotracheal An endotracheal tube is used for delivering oxygen under pressure when ventilation must be totally controlled and in general anesthetic procedures.
Inserted through the mouth for positive pressure mechanical ventilation
Endotracheal tube
Prioritizing Nursing Diagnoses Related to Oxygenation and Perfusion
For patients with diseases of the cardiovascular and respiratory system, the highest priority nursing diagnosis will often be related to airway, breathing, and/or tissue perfusion. Although there may be multiple nursing diagnoses, the priority diagnosis is one that, if not addressed, will cause harm or present an increased threat to the patient. Once diagnoses are prioritized in the ABC order, the nurse will prioritize the rest in order of how they must be resolved. For example, Ineffective Airway Clearance would take priority over Impaired Gas Exchange. The nurse cannot resolve a problem in the alveoli if air is unable to effectively enter the airway.
Helps a patient reach a set inhalation volume
Incentive spirometry
When assessing a patient's respiratory system, which alteration may require supplemental oxygen therapy? Select all that apply. Increased respiratory rate Decreased heart rate Low oxygen saturation Cyanosis Elevated hemoglobin
Increased respiratory rate Increased respiratory (tachypnea) rate is a sign of hypoxia and the possible need for supplemental oxygen therapy. Low oxygen saturation Low oxygen saturation is a sign that suggests reduced blood oxygen levels (hypoxemia). Cyanosis Cyanosis results from decreased tissue oxygenation and may be an indication for supplemental oxygen therapy.
The nurse is admitting Ms. Kelley. How should the nurse prioritize Ms. Kelley's nursing diagnoses? Begin with the highest priority diagnosis first.
Ineffective airway clearance is the highest-priority nursing diagnosis for Ms. Kelley. Since asthma can cause ineffective airway clearance (via constriction of the bronchi, coughing, and viscous mucoid bronchial secretions), airway clearance problems must be resolved for air to move in and out of the airway properly. Once the airway is cleared, then impaired gas exchange at the alveolar level can be addressed. Ineffective peripheral tissue perfusion is a result of both ineffective airway clearance and impaired gas exchange. Once those two are resolved, perfusion to the periphery can be addressed. Ms. Kelley's diagnosis of acute pain as soon as the ABC priorities have been resolved. Ms. Kelley likely has activity intolerance for several reasons: anesthesia, pain, and fatigue related to respiratory distress, surgical incisions, and poor perfusion to her organs and tissues. Ms. Kelley can be encouraged to be more mobile once her oxygenation, perfusion, and pain are addressed. Lastly, Ms. Kelley's anxiety could be a result of all of the above diagnoses; if each is resolved, then her anxiety may lessen significantly.
Complaints of difficulty breathing, purse-lip breathing
Ineffective breathing pattern
Low oxygen saturation and arterial oxygen levels
Ineffective peripheral tissue perfusion
Oropharyngeal Tube
Inserted through the mouth with the airway going over the tongue Should be removed from the airway every 4 to 8 hours Secure the airway in place with a holder or tape
Nasopharyngeal Tube
Inserted through the nose Protects nares and provides a guide for catheter insertion in patients requiring frequent suctioning
Clinical Indications
Laboratory results indicating hypoxemia (low arterial oxygen, low hemoglobin oxygen saturation) Hypoxemia signs (Tachycardia -increased heart rate and Tachypnea - increased respiratory rate) Dyspnea (shortness of breath) Cyanosis (bluish discoloration of the skin) A feeling of distress
Assessment data and nursing diagnosis are used to arrive at measurable goal statements.
Listed here are examples of measurable goal statements for patients with decreased oxygenation. Patient will maintain SpO2 at 92% or greater by the end of the shift. Patient's lungs will be clear to auscultation within 24 hours. Patient will maintain SpO2 at 92% or greater with activity within 48 hours. Patient will report decreased fatigue during hospitalization. Patient's extremities will be pink and warm to touch after supplemental oxygen is applied. Patient will verbalize an increase in psychological and physical comfort within 8 hours. Patient's respirations will return to a range between 16 breaths/min and 20 breaths/min after pain medication is administered before cardiac catheterization. These statements are objective and provide parameters for measurement such as the time frame, medication, or intervention.
The goals are specific, with numeric parameters or other concrete criteria
Measurable
Chest Physiotherapy
Mobilizes secretions to clear the respiratory tract Improves ventilation and perfusion Normalizes the functional residual capacity of the lungs Actions with chest physiotherapy include: Postural drainage Coughing and deep breathing technique Incentive spirometry Performed with patients who: Are unable or reluctant to change body positions Experience poor oxygenation due to position (i.e. unilateral lung diseases) Have difficulty removing secretions (i.e. cystic fibrosis or bronchiectasis)
Ms. Kelley is a 47-year-old female admitted to the post-surgical unit following removal of her gallbladder. She has a history of hyperlipidemia (elevated serum lipids), depression, and asthma (lung disease that causes bronchoconstriction, coughing, and thick bronchial secretions).
Ms. Kelley's vital signs are T 37.9° C (100.2° F), P 112 and regular, R 24 shallow and labored, BP 142/88, and continuous pulse oximetry reading of 89% on 2 liters of oxygen via nasal cannula. The patient denies pain but states that her chest feels "heavy." Lung auscultation reveals adventitious breath sounds (expiratory wheezes) with diminished sounds bilaterally at the lung bases. The patient appears restless and slightly diaphoretic. She asks you, "Why does the machine keep beeping?" Her abdomen is flat but tender from the surgical puncture sites. Her dressings are clean, dry, and intact. Laboratory and diagnostic test results Complete blood count (CBC): white blood cells (WBCs): Slightly elevated Arterial blood gas (ABG): Abnormal values, including a low oxygen level Treatment orders Respiratory therapy for breathing treatments Oxygen via nasal cannula to keep SpO2 (hemoglobin saturation) greater than 92% Incentive spirometry 10 times an hour while awake Medication orders Albuterol inhaler 4 times a day (bronchodilator) Zocor 20 mg PO daily (antihyperlipidemic) Wellbutrin 300 mg PO daily (antidepressant)
Planning and Collaboration
Multidisciplinary data may be collected through a verbal report, observation, or from the medical record. It is important to include data from all disciplines so that nursing diagnoses are holistic, thereby addressing multiple patient needs. Some of these include nutrition, mobility, psychosocial, religious, and rehabilitative. Specific to oxygenation and perfusion, the nurse will often collaborate with respiratory therapists (RT), physical therapists (PT), and nutrition services. This is especially true if the patient has a chronic disease such as COPD or diminished heart function because patient management becomes complex, requiring services from multiple disciplines. Nursing or the other healthcare providers may provide interventions for a patient's needs, but the nurse is responsible for updating the care plan.
While caring for a patient with pneumonia, the nurse receives an order for a common low-flow system to deliver continuous oxygen at 2 L/min. The nurse anticipates using which system? Non-rebreather mask BiPAP Nasal cannula Ambu bag
Nasal cannula A nasal cannula is used as a low-flow system used to deliver a continuous flow of supplemental oxygen at 2L per minute.
Inserted in the patient's nose to facilitate ease of suctioning
Nasopharyngeal tube
Pharyngeal Airways
Nasopharyngeal tubes are measured from the ear tragus to the nostril, plus 1 inch. Lubricate the airway before attempting insertion and insert gently. If resistance is encountered, try the other nostril. Remove the airway every 8 to 24 hours (or as required by institution policy), alternating nares. Secure the airway in place with a holder or tape. Attempting to place an oropharyngeal tube into an awake patient may result in gagging, vomiting, and possible aspiration. Therefore, it is important to fully assess the patient prior to attempting insertion. Other assessments include mucous membrane and respiratory status and inspect tube placement routinely (improper placement may result in inadequate ventilation). Document the reason for insertion of airway, oral care given, and the patient's tolerance of the airway.
Reservoir bag present; one-way valve prevents entry of exhaled air
Non-rebreather mask
What resources are used to develop individualized patient-centered goals? Select all that apply. Nursing diagnoses Standardized nursing process text resources Assessment data Facility policy and procedure documents
Nursing diagnoses Individualized goals are based on the nursing diagnoses developed for the patient. Assessment data Assessment data is the basis for development nursing diagnoses and individualized patient-centered goals.
Inserted in mouth; maintains airway; patient breathing w/o ventilatory help
Oropharyngeal tube
Reservoir bag present; room air is inspired with O2 delivered
Partial rebreather mask
Incentive spirometry (IS)
Patient attempts to reach a set inhalation volume using a special device called an incentive spirometer. It encourages deep breathing, maintains lung expansion, and helps to prevent atelectasis and pneumonia. A desired volume is preset on the IS device. While sitting upright, patient slowly inhales through a mouthpiece attached to the spirometer, holding the breath for 3 to 5 seconds and then exhales slowly.: The nurse, often as part of preoperative teaching, instructs the patient. The patient performs IS with encouragement from the nurse or UAP.
The goals are specifically written for the patient
Patient-centered
Tracheostomy Tube
Plastic polymer or metal tube that fits through a stoma in neck Most have an outer cannula with attached flange and a cuff and removable inner cannula Based on institutional policies, specific items are kept at the bedside in case of tracheostomy dislodgement: May include: BVM device, oxygen and suction equipment, extra inner and outer cannulas with obturators, extra tracheostomy care kit
Therapeutic positioning that facilitates gravity drainage from the lungs
Postural drainage
The patient must be able to attain the goals
Realistic
Suctioning
Removes mucus from the respiratory tract Assists the patient in clearing the airway Helps obtain specimens for ordered tests Prevents infections
Endotracheal Tube
Semi-rigid, curved tube with a cuff at the distal end Inflated cuff prevents aspiration of gastric contents into the lungs Placed through the mouth Sealed with a balloon at the end of the tube
No reservoir bag; 1 L/min increase O2 equal to 5% increase O2 concentration
Simple face mask
The nurse manager observes a nurse stripping the tubing of a chest tube on a patient who recently arrived in the unit following chest surgery. Based on the evidence, how should the nurse manager respond? Demonstrate the proper technique to be used with stripping to prevent injury. Take no action as long as the procedure is being performed correctly. Stop the procedure and inform the nurse that tube stripping is not to be performed. Assist the nurse by turning the patient to the side with the chest tube.
Stop the procedure and inform the nurse that tube stripping is not to be performed. Research has shown that stripping (milking) tubing on a chest tube to free a possible occlusion is not a safe practice and can result in damage to lung tissue, increase bleeding, or may alter pressures within the chest.
BiPAP (bilevel positive airway pressure)
Supplemental oxygen is not automatically provided with BiPAP. Use of supplemental oxygen therapy with BiPAP requires an additional oxygen order.
Non-Rebreather Mask (NRB)
The flow rate for non-breather masks must be at least 10 L/min to maintain reservoir inflation; however, the flow rate can range from 10 L/min to 15 L/min.
A new nurse who is being oriented to the unit is establishing patient-centered goals for Ms. Kelley. The nurse documents "The patient will ambulate." What goal writing criteria is it missing?
The goal should be time-limited. Goals need a time-limit for when evaluation occur. This statement is missing that final piece.
Realistic
The goals should be realistic. The patient must be able to attain the goals. Avoid goals that are too ambitious for the patient to achieve. Avoid a timeframe that is too short Be aware of barriers that must be overcome before the goal can be achieved
Measurable
The goals should be specific, with numeric parameters or other method of judging goal attainment. Example: "Patient will maintain SpO 2 at 92% or greater with activity within 48 hours." The numeric parameter of 92% or greater makes this goal measurable.
Patient-Centered
The goals should be specifically written for the patient, i.e., they should reflect patient rather than nurse's activities. Goal statements should begin with the patient. Example: " Patient's temperature will return to between 98.2° and 98.6° within 48 hr." The goal begins with reference to the patient, making it clear that this is a patient-centered goal.
Time-Limited
The goals should include a time for evaluation. In hospitalized patients, the evaluation may occur daily or within several days, whereas in homecare settings, evaluation may occur weekly. Example: "Patient's lungs will be clear to auscultation within 24 hours ." The 24-hour time limit informs the nurse exactly when to evaluate the patient's progress toward goal attainment.
Discharge teaching for a patient on anticoagulation therapy is crucial. The topics include:
The importance of compliance with the prescribed regimen Including periodic laboratory blood draws Dietary advice regarding controlling foods high in vitamin K Limiting green leafy vegetables Signs of adverse reactions to anticoagulants, such as bleeding Interactions with other medications
When inserting a nasopharyngeal tube, what guidelines will the student nurse need to remember?
The length is measured from tragus to nostril plus one inch. The correct way to measure is from the ear tragus to the nostril plus 1 inch. The airway is removed and changed at least every 24 hours. The airway is removed and changed every 8 to 24 hours along with alternating nares to prevent skin irritation. The airway is lubricated before attempting insertion and inserted gently to ease passage -If resistance is encountered, the other nostril is tried as force can cause tissue damage.
Before procedure
The nurse gathers supplies and explains the procedure to the patient.
During procedure
The nurse positions the patient and assures that the: tube is secured and patent dressing is secure drainage system is working properly
During the planning phase
The nurse uses the assessment data and nursing diagnoses to develop individualized goals. The goals are specific, both short- and long-term, and patient-centered. The nurse must prioritize which nursing diagnosis should receive the most attention. Next, measurable goals are developed which reflect expected outcomes. For example, for a patient with the nursing diagnosis of "impaired gas exchange" the nurse can plan that the patient "will maintain SpO2 at 92% or greater, by end of the shift." This is a specific goal with a measurable outcome. The nurse, at this point, will consider the orders received from the provider to determine the appropriate intervention to meet the goal.
The nurse is attempting to prioritize several nursing diagnoses written on a newly admitted patient with a cardiovascular disease. Which statement accurately reflects the basis by which the highest priority diagnosis is determined?
The priority diagnosis is one that, if not attended to, will cause harm or increased threat to the patient. The management of the airway is always a high priority in an asthma patient.
Postural drainage
Therapeutic positioning of a patient to use gravity for mobilization of secretions out of the lungs using positioning, percussion and vibration techniques Patient is placed in a series of specific positions that facilitate gravity drainage from a lung area. In each position, percussion and vibration are applied to the chest to loosen secretions. Patient is encouraged to take deep breaths and cough. In many facilities, physical therapy performs this; however, the nurse may do this if trained.
Purpose and Types of Artificial Airways
There are nonemergency and emergency situations when patients need assistance with maintaining a patent airway. When this occurs an artificial airway is prescribed. An artificial airway can be inserted in patients who may or may not be breathing on their own. There are two basic types of artificial airways—pharyngeal and tracheal. A pharyngeal airway extends only to the back of the oral cavity, opening the upper airway by pulling the tongue forward and away from the back of the throat. A tracheal airway extends beyond the pharynx, through the larynx and into the trachea, providing access to the lower airway.
A nursing student observes the insertion of a chest tube in a patient injured in a car crash. What should the student understand about the purpose of chest tubes? They provide oxygenation when respirations are impaired. They can be used for removal of excessive airway secretions. They drain blood and fluid to promote full lung expansion. They can keep the airway open when there is airway damage.
They drain blood and fluid to promote full lung expansion. Chest tubes drain fluid or blood from the pleural space so lungs can fully expand.
The goals include a time for evaluation
Time-limited
Inserted through trachea; provides ventilation when upper airway obstructed
Tracheostomy tube
Pharyngeal Airways
Useful for patients with: Decreased levels of consciousness Loss of muscle tone Frequent suctioning needs Two types of tubes: Nasopharyngeal Tube Oropharyngeal Tube
Tracheal Airways
Useful for patients with: Inability to breathe effectively Need for positive pressure mechanical ventilation Long-term airway patency problems Need for general anesthesia Blocked upper airway (tracheostomy tube) Two types of tubes: Endotracheal Tube Tracheostomy Tube
No reservoir bag; ensures accuracy of O2 concentration; uses adaptors/dials
Venturi mask
Oxygen Therapy
When a patient has documented or suspected hypoxemia (low arterial oxygen level), supplemental oxygen may be used as a therapy for supporting oxygenation and perfusion. Its use can be short-term or long-term dependent on the patient's diagnosis and oxygenation status. Devices used to deliver oxygen are categorized as low-flow systems, reservoir systems, and high-flow systems. The arterial blood gas (ABG) is the primary diagnostic laboratory test used for identifying hypoxemia. One ABG value, the partial pressure of oxygen in the arterial blood (PaO2), is a major indicator of oxygenation status. Pulse oximetry, which measures the hemoglobin saturation of oxygen (SpO2), is another important diagnostic test.
Oxygen Therapy Using Positive Air Pressure Application
When a patient is not able to maintain an open airway (e.g., obstructive sleep apnea), forced air (and oxygen, if ordered) may be administered through a mask over the nose or through nasal pillows at the nares, which keeps the airway open at all times. There are two types of positive air pressure devices that can be used to maintain a patent airway: Continuous positive airway pressure (CPAP), which provides the same pressure during both inhalation and exhalation Bilevel positive airway pressure (BiPAP), which provides continuous bilevel positive airway pressure using a higher pressure during inhalation and a lower pressure during exhalation Patient adherence to using CPAP devices varies between 50% and 80%. Dry nares, skin irritation, claustrophobia, perceived inability to breathe against air, noise of the apparatus may be barriers to compliance and need to be addressed. Patients complain about the rush of air pressure and tend to remove the mask during the night or not wear it at all. To increase compliance, nurses must provide education about the effectiveness of the device in treating and reducing the negative consequences of obstructive sleep apnea.
Characteristics of Patient-centered Goals
Writing goals can be a challenge in patients with oxygenation and perfusion problems because diseases of the respiratory and cardiovascular systems can permanently alter the anatomy and physiology of the organs. As a result, measurable parameters, such as blood pressure, heart pattern, and arterial blood gas values may become permanently altered. The nurse must be aware of the patient's altered baseline values so that realistic measures are used in each goal statement. SMART
Two major types of airway suction are:
Yankauer suction catheter - a rigid wand-like device used for oral or oropharyngeal suctioning Oral suction catheter - a small flexible tube used for all types of airway suctioning
Ms. Kelley is a 47-year-old patient who is admitted to your unit after gallbladder removal. Her significant respiratory history includes asthma, and she is currently experiencing slight respiratory distress. Her vital signs are T 37.9° C (100.2° F), P 112 and regular, R 24 shallow and labored, BP 142/88, and continuous pulse oximetry reading of 89% on 2 liters of oxygen via nasal cannula. You hear expiratory wheezes with diminished bilateral sounds at her lung bases. She has asked you why the pulse oximetry monitor is alarming. Her ABG reads pH 7.52, PCO2 31, PO2 83, HCO3 29 (abnormal values).
You have completed Ms. Kelley's admission, and have chosen two priority nursing diagnoses for her based on her physical assessment: Ineffective breathing pattern related to bronchospasm and respiratory muscle fatigue as evidenced by expiratory wheezes, tachypnea, shallow and labored respirations. Impaired gas exchange related to bronchospasm and alveolar damage as evidenced by hypoxemia, tachypnea, and oxygen saturation of 89% on 2 L of O2. Ms. Kelley has an order for a respiratory therapy consult and you have contacted the respiratory therapist.
The chest tube is
a flexible catheter that is inserted through the chest wall by the healthcare provider (HCP) to evacuate air or fluid. The tube is attached to a water-sealed chamber system that helps regulate the pleural pressure. Most systems are based on older three-bottle systems but are disposable self-contained plastic units. The three drainage system chambers are: Drainage collection chamber - accepts air and drainage from the patient Water-seal chamber - contains water to prevent air from backing up into patient's lung Suction control chamber - Usually contains water and is attached to a suction source to control amount of negative pressure being applied Many nurses were taught to "strip" or "milk" the tubing of a chest tube when there was a lack of drainage or an occlusion. Evidence shows, however, that this practice can result in pleural damage, increased bleeding, trauma, and impairment of left ventricular function due to increased intrathoracic pressure (Halm, 2007; Rushing, 2007). The practice of stripping or milking the tubing should therefore be avoided.
Partial rebreather masks
are a type of reservoir mask Allow some of the exhaled air to enter the reservoir. Rebreathing exhaled air, which contains carbon dioxide, acts as a stimulus for some patients, i.e. COPD. Flow rates and percentage oxygenation values are: 6 to 15 L/min = 70% to 90% (10 L/min needed to maintain reservoir inflation)
The bag-valve-mask (BVM) device
also known as an Ambu bag, uses a one-way valve to support, ventilate, and oxygenate a patient who needs ventilatory support. All emergency crash carts are supplied with a BVM unit. Only personnel who have been properly trained and certified in the use of the devices should administer ventilation using the BVM units. When possible, an oral airway is inserted and the BVM is attached to a high-flow oxygen source. When the BVM is attached to a mask, it is important to adequately seal the mask to the patient's face. If the patient is not intubated, it is necessary to maximize the amount of air moved into the lungs with each ventilation. The bag is compressed in a rhythmic fashion delivering an adequate level of oxygen and appropriate tidal volume for the size of the patient. While ventilating the patient, inspect for chest rise to determine if adequate ventilation is being delivered and reposition mask as needed to ensure adequate seal. The patient's oxygen saturation is monitored as an indication of the effectiveness of the therapy and adjustments are made to oxygen concentration and tidal volumes, as needed.
When writing nursing diagnoses
appropriate to meeting the needs of patients with problems of oxygenation and perfusion, the priorities are often related to the ABC issues—airway, breathing, and perfusion. Nursing diagnoses such as impaired gas exchange, ineffective airway clearance, and ineffective peripheral tissue perfusion reflect the ABC priorities. Goal statements are developed to evaluate whether the nursing diagnosis has been resolved. Goals can be short- or long-term but all should meet four criteria, including being realistic, patient-centered, measurable, and time-limited. In patients with chronic oxygenation and perfusion problems, the parameters used for measuring achievement of the goal may require adjustments due to permanent changes in the structure and function of the respiratory and cardiac systems, which can change the patient's baseline parameters.
Venturi masks
ensure accuracy of the oxygen concentration delivered. Often used with patients that retain CO2, such as COPD patients. Color-coded adaptors or a dial, with corresponding liters-per-minute setting listed, can be attached to the mask. The dial setting specifies the concentration of oxygen that will be delivered to the patient. To change the concentration, the nurse changes an adaptor inside the tubing or turns the dial to set to the desired percent oxygenation. Flow rates and percent oxygenation values range from: 4 to 12 L/min = 24% to 60%
Clinical research investigating best practice suctioning techniques
have proven beneficial to patients. Here is one example of research that has changed nursing practice. Current evidence shows that instilling normal saline into the airway to facilitate removal of secretions has no benefit because the saline does not mix with the secretions. Introduction of liquid into the respiratory tract can be emotionally disturbing and can produce harmful physiologic effects, such as decreasing oxygenation and lower respiratory tract infections. To aid in thinning and mobilization of secretions, airway humidification and adequate hydration should be initiated
Chest physiotherapy (CPT)
includes several techniques that aim to maintain or improve the patient's oxygenation status. Two of the techniques, coughing and deep breathing, and incentive spirometry (IS) are important for prevention of postoperative and immobility complications.
Nasal Cannula (NC)
is a commonly used low-flow system to deliver supplemental oxygen. It consists of a lightweight tube connected to an oxygen source, with a flowmeter. Humidification is recommended at all levels of therapy but especially at levels of 4 L/min and higher. Nasal cannulas are contraindicated for patients of any age with obstructed nasal passages. Increasing the oxygen flow rate alters the percentage of oxygen being breathed by the patient. As a rule of thumb, each liter raises the percentage of oxygen inspired by 4%, as shown in the table.
Correct positioning of all types of oxygen masks
is essential to assure delivery of the prescribed concentration of oxygen. There should be no large gaps or openings between the mask and skin. If the mask includes a reservoir bag, insure that the bag is filled before placing the mask on the patient. On placement of an oxygen mask the nurse evaluates the patient's tolerance to the mask and makes any adjustments to the fit. A focused respiratory assessment is conducted at 15 to 30 minutes after initiation of therapy and at regular intervals thereafter, based on the patient's changing status. The patient's response to the oxygen is evaluated (e.g., signs of reversal of hypoxemia, such as improving vital signs and oxygen saturation values). If improvement or further deterioration in the patient's condition is noted, the provider is promptly contacted and the plan of care is adjusted as needed.
Correct application of the nasal cannula
is essential to assure that the patient receives the optimal effects from the therapy. Encourage the patient to breathe through the nose and exhale through the mouth at a comfortable and natural rate. Monitor the patient for 15 to 30 minutes after starting the oxygen, and repeat assessments as needed, depending on the patient's status. Monitor the ears where the nasal cannula tubing rests and apply gauze or tubing covers as needed to prevent sores and protect the skin. Reassess the patient frequently for relief of hypoxemia signs and symptoms.
Airway Suctioning
is the application of negative pressure through a tube device to remove fluids from the patient's oral cavity or trachea. Nurses perform suctioning to clear the airway for patients who are unable to do so themselves or have an artificial airway. Common types of suctioning include tracheostomy, nasotracheal and nasopharyngeal, and oral and oropharyngeal.
There are many different types of drugs
like anticholinergics and bronchodilators, that are used to treat pulmonary disease. In general, these agents decrease symptoms, improve exercise ability, decreases disease flare-ups (exacerbations), and improve health status. Bronchodilators Effects: Oral: Increase the diameter of the bronchi and bronchioles Inhaled: Increase the diameter of the bronchi Results in: Decreased wheezing and improved oxygenation Anticholinergics Improve airway clearance Results in: Decreased wheezing, Improved oxygenation Corticosteroids Decrease inflammation Results in: Improved respiratory function Vaccines Provide protection against communicable disease Results in: Decreased incidence of influenza Decreased incidence of pneumonia Mucolytics Decrease the thickness of secretions Results in: Improved airway clearance Leukotriene Modifiers Decrease inflammation in the airways Results in: Improved respiratory function
Tracheal airways
require specific skills to manage safely and should not be handled without appropriate skills training. Assessments related to tracheal airways includes tube patency and placement, need for suctioning, and security of ties. In addition, the presence of the tip of tracheal airways in the lower airway, increases the patient's risk of infection. For this reason, the nurse should regularly assess for infection. Patients with a tracheostomy are assessed for the presence of subcutaneous emphysema around the stoma. Documentation needed after insertion of a tracheal airway includes the date, time, assessment, procedure, and patient's response to the procedure. Research findings regarding tracheostomy dressings suggest avoiding a dressing altogether, if possible. For excessive secretions, a special foam dressing is recommended to prevent the most adverse events
Nursing diagnoses for patients with decreased oxygenation and perfusion
should reflect the patient's precise health alterations. The specific manner in which any patient's illness manifests and progresses will have unique aspects based on individual patient factors such as age, general physical and mental health, and previous medical and surgical history. Individualizing a patient's nursing diagnosis requires accurate and thorough assessment data collection and appropriate data clustering. Failure to truly individualize the nursing diagnoses can lead to unnecessary or potentially harmful interventions.
Nursing care goals are
specific to each patient and reflect the desired measurable outcome for each nursing diagnosis. For example, the goals for patients with decreased oxygenation are designed to meet basic oxygen needs.
Ambu bag
uses a one-way valve to support, ventilate, and oxygenate a patient with high-flow oxygen who is unable to breathe without assistance.
