chapter 30
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Chapter 30. Care of Patients Requiring Oxygen Therapy or Tracheostomy. Mrs. Marion Kreisel MSN, RN NU230 Adult Health 2 Fall 2011. Oxygen Therapy. Hypoxemia — low levels of oxygen in the blood Hypoxia — decreased tissue oxygenation - PowerPoint PPT PresentationTRANSCRIPT
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Chapter 30
Care of Patients Requiring Oxygen Therapy or Tracheostomy
Mrs. Marion Kreisel MSN, RNNU230 Adult Health 2Fall 2011
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Oxygen Therapy• Hypoxemia—low levels of oxygen in the
blood• Hypoxia—decreased tissue oxygenation• Goal of oxygen therapy—to use the lowest
fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects
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Oxygen Intake and Oxygen Delivery
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Hazards and Complications of Oxygen Therapy
• Combustion• Oxygen-induced hypoventilation• Oxygen toxicity• Absorption atelectasis• Drying of mucous membranes• Infection
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Low-Flow Oxygen Delivery Systems
• Nasal cannula Simple facemask
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Low-Flow Oxygen Delivery Systems (Cont’d)• Partial rebreather mask Non-rebreather mask
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High-Flow Oxygen Delivery Systems• Venturi mask • Face tent• Aerosol mask• Tracheostomy collar• T-Piece
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Venturi Mask
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T-Piece
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Noninvasive Positive-Pressure Ventilation
• Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation
• BiPAP—mechanical delivery of set positive inspiratory pressure each time the patient begins to inspire; as the patient begins to exhale, the machine delivers a lower set end-expiratory pressure, together improving tidal volume.
• CPAP—continuous positive airway pressure
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Continuous Positive Airway Pressure (CPAP)
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Continuous Nasal Positive Airway Pressure
• Technique delivers a set positive airway pressure throughout each cycle of inhalation and exhalation.
• Effect is to open collapsed alveoli.• Patients who may benefit include those
with atelectasis after surgery or cardiac-induced pulmonary edema; it may be used for sleep apnea. Assess pt for improved sleep. If not make sure patient is using the CPAP on a regular basis.
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Transtracheal Oxygen Delivery• Used for long-term delivery of oxygen
directly into the lungs• Avoids the irritation that nasal prongs
cause and is more comfortable• Flow rate prescribed for rest and for
activity
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Home Oxygen Therapy• Criteria for home oxygen therapy
equipment• Patient education for use:
• Compressed gas in a tank or cylinder• Liquid oxygen in a reservoir• Oxygen concentrator
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Oxygen Therapy
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Tracheostomy• Tracheotomy is the surgical incision into
the trachea for the purpose of establishing an airway.
• Tracheostomy is the stoma, or opening, that results from the procedure of a tracheotomy.
• Procedure may be temporary or permanent.
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Tracheostomy
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Interventions • Preoperative care• Operative procedures• Postoperative care—ensure patent airway• Possible complications assessment:
• Tube obstruction• Tube dislodgment—accidental
decannulation
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Other Possible Complications Assess for:
• Pneumothorax• Subcutaneous emphysema• Bleeding• Infection
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Tracheostomy Tubes• Disposable or reusable• Cuffed tube or tube without a cuff for
airway maintenance• Inner cannula disposable or reusable• Fenestrated tube
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Tracheostomy Tubes
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Tracheostomy Tubes
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Care Issues for the Tracheostomy Patient
• Prevention of tissue damage:• Cuff pressure can cause mucosal
ischemia.• Use minimal leak technique and
occlusive technique.• Check cuff pressure often.• Prevent tube friction and movement.• Prevent and treat malnutrition,
hemodynamic instability, or hypoxia.
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Cuff Pressures
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Air Warming and Humidification• The tracheostomy tube bypasses the nose
and mouth, which normally humidify, warm, and filter the air.
• Air must be humidified.• Maintain proper temperature.• Ensure adequate hydration.
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Suctioning • Suctioning maintains a patent airway and
promotes gas exchange.• Assess need for suctioning from the
patient who cannot cough adequately.• Suctioning is done through the nose or the
mouth.• Suctioning can cause:
• Hypoxia (see causes to follow)• Tissue (mucosal) trauma• Infection• Vagal stimulation and bronchospasm• Cardiac dysrhythmias from hypoxia
caused by suctioning
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Causes of Hypoxia in the Tracheostomy
• Ineffective oxygenation before, during, and after suctioning
• Use of a catheter that is too large for the artificial airway
• Prolonged suctioning time• Excessive suction pressure• Too frequent suctioning
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Possible Complications of Suctioning• Tissue trauma• Infection of lungs by bacteria from the
mouth• Vagal stimulation—stop suctioning
immediately and oxygenate patient manually with 100% oxygen
• Bronchospasm—may require a bronchodilator
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Tracheostomy Care• Assessment of the patient.• Secure tracheostomy tubes in place.• Prevent accidental decannulation.• Patient may shower as long as they are
careful not to get water into the stoma.
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Bronchial and Oral Hygiene• Turn and reposition every 1 to 2 hr,
support out-of-bed activities, encourage early ambulation.
• Coughing and deep breathing, chest percussion, vibration, and postural drainage promote pulmonary cure.
• Oral hygiene—avoid glycerin swabs or mouthwash that contains alcohol; assess mouth for ulcers, bacterial or fungal growth, or infections.
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Nutrition • Swallowing can be a major problem for the
patient with a tracheostomy tube in place.• If the balloon is inflated, it can interfere
with the passage of food through the esophagus.
• Elevate the head of bed for at least 30 minutes after the patient eats to prevent aspiration during swallowing.
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Speech and Communication• Patient can speak with a cuffless tube,
fenestrated tube, or cuffed fenestrated tube that is capped or covered.
• Patient can write.• Phrase questions to patient for “yes” or
“no” answers.• A one-way valve that fits over the tube and
replaces the need for finger occlusion can be used to assist with speech.
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Fenestrated Tracheostomy Tube
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Weaning from a Tracheostomy Tube• Weaning is a gradual decrease in the tube
size and ultimate removal of the tube.• Cuff is deflated as soon as the patient can
manage secretions and does not need assisted ventilation.
• Change from a cuffed to an uncuffed tube. • Size of tube is decreased by capping; use
a smaller fenestrated tube.• Tracheostomy button has a potential
danger of getting dislodged.
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NCLEX TIME
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Question 1
Nitrogen gas makes up what percentage of room air?
A. 10%B. 21%C. 49%D. 79%
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Question 2
What is a possible outcome when oxygen delivery is
combined with smoking?
A. The oxygen will burn.B. An explosive effect will be produced. C. The combustion process will be
supported and enhanced. D. The combustion process will be sped up.
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Question 3
What complication would the patient with a cuffed
tracheostomy be at risk for developing?
A. TracheomalaciaB. PneumothoraxC. Subcutaneous emphysema D. Trachea–innominate artery fistula
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Question 4
A patient who is hypoxemic also has chronic hypercarbia (increased Paco2 levels). What is
the appropriate flow of oxygen delivery for this
patient?
A. 1 L/min via nasal cannulaB. 4 L/min via nasal cannulaC. 6 L/min via nasal cannulaD. 40% oxygen via Venturi mask
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Question 5
A patient experiences vagal stimulation during deep
tracheal suctioning. The nurse would expect to see:
A. Severe tachycardiaB. Severe bradycardiaC. HypertensionD. Bronchospasm