Fundamentals of Nursing Exam Study Outline

Chapter 41 – Oxygenation PPT: Wk 11.1 Oxygenation (7 questions)  Factors Affecting Oxygenation: CNS Alterations – p. 877; PPT slide 5 (notes) • Three steps are involved in the process of oxygenation: ventilation, perfusion, and diffusion. • Ventilation requires coordination of the muscular and elastic properties of the lung and thorax. The major inspiratory muscle of respiration is the diaphragm. It is innervated by the phrenic nerve, which exits the spinal cord at the fourth cervical vertebra. • Perfusion relates to the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs. • Diffusion is responsible for moving the respiratory gases from one area to another by concentration gradients. For the exchange of respiratory gases to occur, the organs, nerves, and muscles of respiration need to be intact; and the central nervous system needs to be able to regulate the respiratory cycle.  C. Artificial Airway (Tracheostomy or Endotracheal) Suctioning – p. 911, 912; PPT slide 33 (notes) • 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 of an artificial airway (discussed on a later slide). • 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. • Oropharyngeal and Nasopharyngeal Suctioning  Apply suction after a patient has coughed. • 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 • 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 entire procedure from catheter passage to its removal is done quickly, lasting no longer than 10 seconds. • Tracheal Suctioning • 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 endotracheal (ET) tube (AARC, 2010a). 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, 2010a) 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. • You will learn various suctioning techniques in the nursing skills lab. • You will differentiate between when to use sterile and when to use clean techniques. If you suction the patient too much, he or she can be at risk for hypoxemia, hypotension, dysrhythmias, and trauma to the mucosa of the lungs.  Coughing & Deep Breathing Techniques – p. 892; PPT slide 31 (notes) • Coughing is effective for maintaining a patent airway. Directed coughing is a deliberate maneuver that is effective when spontaneous coughing is not adequate. Fundamentals of Nursing Exam Study Outline Fundamentals of Nursing Exam #4 Study Outline • With the cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then the patient 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 the patient 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. • Diaphragmatic breathing/belly breathing is a technique that encourages deep breathing to increase air to the lower lungs. • Chest physiotherapy is a group of therapies used to mobilize pulmonary secretions. These include postural drainage, chest percussion, and vibration. You will want to work collaboratively with respiratory therapists when using these techniques  Relevant Nursing Diagnosis: issues with oxygenation – p. 886, 888; PPT slide 28   Chest Tubes: Special consideration – p. 899; Unexpected outcomes & related interventions – p. 926; PPT slide 41 (notes) • 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. • Chest tubes are common after chest surgery and chest trauma and are used for treatment of pneumothorax or hemothorax to promote lung reexpansion. • [Review Skill 41-3, Care of Patients with Chest Tubes.] • 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. • 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. • The simplest closed drainage system is the single chamber unit. The chamber serves as a fluid collector and a water seal.  Activity intolerance  Decreased cardiac output  Fatigue  Impaired gas exchange  Impaired verbal communication  Ineffective airway clear  Risk for aspiration   Ineffective breathing pattern  Ineffective health main Fundamentals of Nursing Exam #4 Study Outline • 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 (Carroll, 2015). This means that the chamber is filled with sterile water to the 15- or 20-cm water level. • Keep a chest tube system closed and below the chest. • 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. • 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. • 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. • Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. • Chest tubes are not routinely stripped or milked to move clots or increase chest tube drainage. • Handle the chest drainage unit carefully and maintain the drainage device below the patient’s chest. • 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. Tracheostomy Obturator – p. 921; PPT slide 36 (notes) • 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. 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 invasive mechanical ventilation and extubation. • 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.