Bedside Clinic
Content
Kristian Rey Jalagat Oxygen therapy – is the administration of oxygen as a therapeutic modality. It is prescribed by the physician, who specifies the concentration, method of delivery, and liter flow per minute. Additional Benefits of Oxygen Therapy: Increased clarity Relieves nausea Can prevent heart failure in people with severe lung disease Allows the bodies organs to carry out normal functions
Long-Term Benefits of Oxygen Therapy: Prolongs life by reducing heart strain Decreases shortness of breath Makes exercise more tolerable Results in fewer days of hospitalization
Oxygen Delivery Systems 1. Nasal Cannula Also called nasal prongs. Is the most common inexpensive device used to administer oxygen. It is easy to apply and does not interfere with the client’s ability to eat or talk. It delivers a relatively low concentration of oxygen which is 24% to 45% at flow rates of 2 to 6 liters per minute.
2. Face Mask It cover the client’s nose and mouth may be used for oxygen inhalation. Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape.
Types of Face Masks: 1. Simple Face Mask - Delivers oxygen concentrations from 40% to 60% at liter flows of 5 to 8 liters per minute, respectively. 2. Partial Rebreather Mask – Delivers oxygen concentration of 60% to 90% at liter flows of 6 to 10 liters per minute, respectively. 3. Non Rebreather Mask – Delivers the highest oxygen concentration possible 95% to 100% – by means other than intubation or mechanical ventilation, at liter flows of 10 to 15 liters per minute. 4. Venturi Mask – Delivers oxygen concentrations varying from 24% to 40% or 50% at liter flows of 4 to 10 liters per minute.
3.Face Tent It can replace oxygen masks when masks are poorly tolerated by clients. It provide varying concentrations of oxygen such as 30% to 50% concentration of oxygen at 4 to 8 liters per minute.
4. Transtracheal Oxygen Delivery It may be used for oxygen-dependent clients. The client requires less oxygen (0.5 to 2 liters per minute) because all of the low delivered enters the lungs.
Oxygen Therapy Safety Precautions: 1. For home oxygen use or when the facility permits smoking, teach family members and roommates to smoke only outside or in provided smoking rooms away from the client. 2. Place cautionary signs reading “No Smoking: Oxygen in use” on the clients door, at the foot or head of the bed, and on the oxygen equipment. 3. Instruct the client and visitors about the hazard of smoking with oxygen use. 4. Make sure that electric devices (such as razors, hearing aids, radios, televisions, and hearing pads) are in good working order to prevent the occurrence of short-circuit sparks. 5. Avoids materials that generate static electricity, such as woolen blankets and synthetic fabrics. Cotton blankets should be used , and client and caregivers should be advised to wear cotton fabrics. 6. Avoid the use of volatile, flammable materials such as oils, greases, alcohol, ether, and acetone(e.g. nail polish remover), near clients receiving oxygen. 7. Ground electric monitoring equipment, suction machines and portable diagnostic machines. 8. Make known the location of the fire extinguishers, and make sure personnel are trained in their use
ADMINISTERING OXYGEN BY MASK 1. Explain procedure to patient and review safety precautions necessary when oxygen is in use. Place No Smoking signs in appropriate areas. 2. Perform hand hygiene. 3. Attach face mask to oxygen setup with humidification. Start flow of oxygen to fill bag before placing mask over patient’s nose and mouth. 4. Position face mask over patient’s nose and mouth. Adjust it with the elastic strap so mask fits snugly but comfortable on face. 5. Use gauze pads to reduce irrigation on patient’s ears and scalp. 6. Perform hand hygiene. 7. Remove mask and dry skin every 2 to 3 hours if oxygen is running continuously. Do not powder around mask. 8. Assess and chart patient’s response to therapy. ADMINISTERING OXYGEN BY NASAL CANNULA 1. Explain procedure to patient and review safety precautions necessary when oxygen is in use. Place No Smoking sign in appropriate areas. 2. Perform hand hygiene. 3. Connect nasal cannula to oxygen setup with humidification, if one is in use. Adjust flow rate as ordered by physician. Check the oxygen is flowing out of prongs. 4. Place the prongs in patient’s nostrils. Adjust according to type of equipment: a. Over and behind each ear with adjuster comfortably under chin or b. Around patient’s head. 5. Use gauze pads at ear beneath tubing as necessary. 6. Encourage patient to breathe through nose with mouth closed. 7. Perform hand hygiene. 8. Assess and chart patient’s response to therapy. 9. Remove and clean cannula and assess nares at least every 8 hours or according to agency recommendations. Check nares for evidence of irrigation or bleeding.
Bag valve mask
A disposable BVM Resuscitator A bag valve mask (also known as a BVM or Ambu bag) is a handheld device used to provide positive pressure ventilation to a patient who is not breathing or who is breathing inadequately. The device is a normal part of a resuscitation kit for trained professionals, such as ambulance crew. The BVM is frequently used in hospitals, and is an essential part of a crash cart. The device is used extensively in the operating room to ventilate an anaesthetised patient in the minutes before a mechanical ventilator is attached. The device is self-filling with air, although additional oxygen (O2) can be added. Use of the BVM to ventilate a patient is frequently called "bagging" [1] the patient. Bagging is regularly necessary in medical emergencies when the patient's breathing is insufficient (respiratory failure) or has ceased completely (respiratory arrest). The BVM resuscitator is used in order to manually provide mechanical ventilation in preference to mouth-to-mouth resuscitation (either direct or through an adjunct such as a pocket mask). Components The Ambu Resuscitator bag or BVM, this version shows is a hybrid MkIII body, Mark IV head and with an old obsolete latex inflatable seal on the mask. The part labelled 1 is a flexible mask designed to seal to the patient's face, and the part labelled 3 is a self-filling bag, i.e. re-fills as an action of the elastic re-coil of the bag after compression. The BVM consists of a flexible air chamber, about the size of a football ball, attached to a face mask via a shutter valve. When the air chamber or "bag" is squeezed, the device forces air through into the patient's lungs; when the bag is released, it self-inflates, drawing in ambient air or a low pressure oxygen flow supplied from a regulated cylinder, while the patient's lungs deflate to the air through the one way valve. Bag and valve combinations can also be attached to an alternate airway adjunct, such as an endotracheal tube or laryngeal mask airway. Often a small HME filter (Heat & Moisture exchanger, or humidifying / bacterial filter) is used. A bag valve mask can be used without being attached to an oxygen tank to provide air to the patient, often called "room air" in the U.S. Supplemental oxygen increases the partial pressure of oxygen inhaled, helping to increase perfusion in the patient. Most devices also have a reservoir which can fill with oxygen while the patient is exhaling (a process which happens [2] passively), in order to increase the amount of oxygen that can be delivered to the patient to nearly 100%. Bag valve masks come in different sizes to fit infants, children, and adults. Most types of the device are disposable and therefore single use, while others are designed to be cleaned and reused. Method of operation The BVM directs the gas inside it via a one-way valve when compressed by a rescuer; the gas is then delivered through a mask and into the patient's trachea, bronchus and into the lungs. In order to be effective, a bag valve mask must deliver between 500 and 800 milliliters of air to the patient's lungs, but if oxygen is provided through the tubing and if the patient's chest rises with each inhalation (indicating that adequate amounts of air are reaching the lungs), 400 to 600 [1] ml may still be adequate. Squeezing the bag once every 5 seconds for an adult or once every 3 seconds for an infant or [3] child provides an adequate respiratory rate (12 respirations per minute in an adult and 20 per minute in a child or infant). Professional rescuers are taught to ensure that the mask portion of the BVM is properly sealed around the patient's face (that is, to ensure proper "mask seal"); otherwise, air escapes from the mask and is not pushed into the lungs. In order to maintain this protocol, some protocols use a method of ventilation involving two rescuers: one rescuer to hold the mask to [4] the patient's face with both hands and ensure a mask seal, while the other squeezes the bag. However, as most ambulances have only two members of crew, the other crew member is likely to be doing compressions in the case of CPR, or may be performing other interventions such as defibrillation or cannulation. In this case, or if no other options are available, the BVM can also be operated by a single rescuer who holds the mask to the patient's face with one hand, in the anaesthetists grip, and squeezes the bag with the other. When using a BVM, as with other methods of positive pressure ventilation, there is a risk of over-inflating the lungs. This can lead to pressure damage to the lungs themselves, and can also cause air to enter the stomach, causing gastric distention which can make it more difficult to inflate the lungs and which can cause the patient to vomit. This can be avoided by care on behalf of the rescuer. Alternatively, some models of BVM (usually Paediatric) are fitted with a valve
which prevents over inflation, by venting the pressure when a pre-set pressure is reached. Nevertheless, cricoid pressure should be applied whenever possible until the patient is intubated or until ventilations have ceased. An endotracheal tube (ETT) can be inserted by a trained practitioner and can substitute for the mask portion of the BVM. This provides a more secure fit and is easier to manage during emergency transport, since the ET tube is sealed with an inflatable cuff in the trachea, so that any regurgitation is less likely to enter the lungs. Such material can severely damage the lung tissue, and in the absence of an ET tube, could choke the patient by obstructing the airway. Inhalation of stomach contents can be fatal; the after effects can cause Mendelson's syndrome or aspiration pneumonia. Some rescuers may also choose to use a different form of resuscitation adjunt, such as an oropharyngeal airway or Laryngeal mask airway, which would be inserted and then used with the BVM. In a hospital, long-term mechanical ventilation is provided by using more complex devices such as an intensive care ventilator, rather than by a BVM, which requires at least one person to operate it constantly. A flow-restricted, oxygen-powered ventilation device (FROPVD) is similar to a BVM in that oxygen is pushed through a mask into the patient's lungs, but unlike a BVM, in the FROPVD the pressure needed to push air into the patient's lungs is generated by oxygen via a pressure regulator from a cylinder rather than by squeezing a bag.
Nebulizer Therapy
Nebulizer therapy aids bronchial hygiene by restoring and maintaining mucus blanket continuity, hydrating dried secretions, promoting secretion expectoration, humidifying inspired oxygen, and delivering drugs. It may be given through nebulizers that have a large or small volume, are ultrasonic, or are placed inside ventilator tubing. Large volume nebulizers such as Venturi Jet provide humidity for an artificial airway. Small volume nebulizer such as Mini Nebulizer is used to deliver drugs such as bronchodilators. Ultrasonic nebulizers are electrically driven and use high-frequency vibrations to break up surface water into particles; resultant dense mist can penetrate smaller airways, hydrate secretions, and induce coughing. In line nebulizers are used to deliver drugs to patients being mechanically ventilated. Equipment For ultrasonic nebulizer For a small-volume nebulizer Untrasonic gas delivery device Pressurized gas source Large bore oxygen tubing Flowmeter Nebulizer couplet compartment Oxygen tubing For a large-volume nebulizer Nebulizer cup Pressurized gas source Mouthpiece or mask Flowmeter Normal saline solution Large-bore oxygen Prescribed drug Nebulizer bottle For an in-line nebulizer Sterile distilled water Pressurized gas source Heater Flowmeter Inline thermometer Nebulizer cup Normal saline solution Prescribed drug Preparation of Equipment For an ultrasonic nebulizer Fill the couplet compartment to the indicated level. For a large-volume nebulizer Fill with distilled water to the indicated level Avoid using normal saline solution, to prevent corrosion Add a heating device if ordered Ensure delivery of the prescribed oxygen percentage For a small-volume nebulizer Draw up the drug, inject it into the nebulizer cup, and add the prescribed amount of normal saline solution, or water. Attach the mouth piece, mask, or other gas delivery device. For an in-line nebulizer Draw up the drug and diluents, remove the nebulizer cup, quickly inject the drug, then replace the cup. If using an intermittent positive-pressure breathing machine, attach the mouthpiece and mask to the machine.
Procedure Reinforce the explanation of the procedure to the patient Wash hands Take the patient’s vital signs and monitor his respiratory status. Place the patient in a sitting or high fowler’s position
For an ultrasonic nebulizer Give an inhaled bronchodilator to prevent bronchospasm Turn the machine on and check the outflow port for proper misting Monitor the patient for adverse reactions Watch for labored respirations Take the patients vital signs and monitor his respiratory status. Encourage the patient to cough and expectorate, or suction him as needed. For a small volume nebulizer Attach the flow meter to the gas source Attach the nebulizer to the flowmeter and adjust the flow to at least 10L Check the outflow port to ensure adequate misting Remain with the patient during treatment Encourage the patient to cough and expectorate Change the nebulizer cup and tubing according to your facility’s policy.
For a large volume nebulizer Attach the delivery device to the patient Encourage the patient to cough and expectorate, or suction him as needed Check the water level in the nebulizer and refill it, as indicated When refilling a reusable container, discard the old water Change the nebulizer unit and tubing according to hospital policy. If the nebulizer is heated, tell the patient to report discomfort. For an in-line nebulizer Turn on the machine and check for proper misting Remain with the patient during treatment Take the patient’s vital signs and monitor him for adverse reactions
Encourage the patient to cough, and suction excess secretions as necessary. Monitor the patient’s respiratory status to evaluate the effectiveness of therapy.
Nursing Interventions 1. The efficacy of aerosol therapy, what type of fluids to use, the types of drugs that can be delivered, and the effectiveness of therapy, haven’t been established. 2. Monitor for overhydration, especially in the patient with a delicate fluid balance. 3. Carefully monitor for adequate flow if oxygen is being delivered at the same time. 4. Encourage the patient to take slow, even breaths to derive maximum benefit. Complications Mucosa irritation, bronshospasm, dyspnea, airway burns, infection and adverse drug reactions.
Pulse Oximetry
Used to noninvasively monitor arterial oxygen saturation. A photo detector slipped over the finger measures transmitted light as it passes through the vascular bed, detects the relative amount of color absorbed by arterial blood, and calculates exact mixed venous oxygen saturation without interference from surrounding venous blood, skin, connective tissue, or bone.
Turn on the power switch. If the device is working properly, a beep will sound, a display will light momentarily, and the pulse search light will flash. After four to six heartbeats the pulse amplitude indicator will begin tracking the pulse. Rotate the sensor site according to the manufacturer’s instructions. Clean the probe per facility policy between patients or, if disposable, discard.
Nursing Interventions 1. Some machines have a pleth wave. A steady, level, even wave form ensures that the numerical reading is accurate. 2. The pulse rate on the oximeter should correspond to the patient’s actual pulse. If it doesn’t, monitor the patient, check the oximeter, and reposition the probe. 3. Factors that interfere with accuracy include: o Elevated carboxyhemoglobin or methemoglobin levels o Lipid emulsions and dyes o Excessive light o Excessive patient movement o Hypothermia o Hypotension o Vasoconstriction o Medications such as dapsone, vasopressors. 4. Use the bridge of the nose if the patient has compromised circulation in his extremities. 5. If an automatic blood pressure cuff is used on the same extremity as the saturation probe is placed, the cuff will interfere with oxygen saturation readings during inflation. 6. If the light is a problem, cover the probes. 7. If patient movement is the problem, move the probe or select a different probe. 8. Notify the physician of any significant change in the patient’s condition.
Equipment
Oximeter Sensor probe Alcohol pads Nail polish remover, if necessary
Preparation of Equipment
Review the manufacturer’s instruction for assembly.
Procedure
Reinforce the explanation of the procedure to the patient.
Using a finger probe
Select a finger (usually index finger) on the patient’s nondominant hand, if possible for placement of the probe. Remove fake fingernail and nail polish from the test finger. Place the transducer (photoprotector) probe over the patient’s finger so the light beams and sensor oppose each other. Trim long fingernails or position the probe perpendicular to the finger. Position the patient’s hand at heart level.
Long-Term Benefits of Oxygen Therapy: Prolongs life by reducing heart strain Decreases shortness of breath Makes exercise more tolerable Results in fewer days of hospitalization
Oxygen Delivery Systems 1. Nasal Cannula Also called nasal prongs. Is the most common inexpensive device used to administer oxygen. It is easy to apply and does not interfere with the client’s ability to eat or talk. It delivers a relatively low concentration of oxygen which is 24% to 45% at flow rates of 2 to 6 liters per minute.
2. Face Mask It cover the client’s nose and mouth may be used for oxygen inhalation. Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape.
Types of Face Masks: 1. Simple Face Mask - Delivers oxygen concentrations from 40% to 60% at liter flows of 5 to 8 liters per minute, respectively. 2. Partial Rebreather Mask – Delivers oxygen concentration of 60% to 90% at liter flows of 6 to 10 liters per minute, respectively. 3. Non Rebreather Mask – Delivers the highest oxygen concentration possible 95% to 100% – by means other than intubation or mechanical ventilation, at liter flows of 10 to 15 liters per minute. 4. Venturi Mask – Delivers oxygen concentrations varying from 24% to 40% or 50% at liter flows of 4 to 10 liters per minute.
3.Face Tent It can replace oxygen masks when masks are poorly tolerated by clients. It provide varying concentrations of oxygen such as 30% to 50% concentration of oxygen at 4 to 8 liters per minute.
4. Transtracheal Oxygen Delivery It may be used for oxygen-dependent clients. The client requires less oxygen (0.5 to 2 liters per minute) because all of the low delivered enters the lungs.
Oxygen Therapy Safety Precautions: 1. For home oxygen use or when the facility permits smoking, teach family members and roommates to smoke only outside or in provided smoking rooms away from the client. 2. Place cautionary signs reading “No Smoking: Oxygen in use” on the clients door, at the foot or head of the bed, and on the oxygen equipment. 3. Instruct the client and visitors about the hazard of smoking with oxygen use. 4. Make sure that electric devices (such as razors, hearing aids, radios, televisions, and hearing pads) are in good working order to prevent the occurrence of short-circuit sparks. 5. Avoids materials that generate static electricity, such as woolen blankets and synthetic fabrics. Cotton blankets should be used , and client and caregivers should be advised to wear cotton fabrics. 6. Avoid the use of volatile, flammable materials such as oils, greases, alcohol, ether, and acetone(e.g. nail polish remover), near clients receiving oxygen. 7. Ground electric monitoring equipment, suction machines and portable diagnostic machines. 8. Make known the location of the fire extinguishers, and make sure personnel are trained in their use
ADMINISTERING OXYGEN BY MASK 1. Explain procedure to patient and review safety precautions necessary when oxygen is in use. Place No Smoking signs in appropriate areas. 2. Perform hand hygiene. 3. Attach face mask to oxygen setup with humidification. Start flow of oxygen to fill bag before placing mask over patient’s nose and mouth. 4. Position face mask over patient’s nose and mouth. Adjust it with the elastic strap so mask fits snugly but comfortable on face. 5. Use gauze pads to reduce irrigation on patient’s ears and scalp. 6. Perform hand hygiene. 7. Remove mask and dry skin every 2 to 3 hours if oxygen is running continuously. Do not powder around mask. 8. Assess and chart patient’s response to therapy. ADMINISTERING OXYGEN BY NASAL CANNULA 1. Explain procedure to patient and review safety precautions necessary when oxygen is in use. Place No Smoking sign in appropriate areas. 2. Perform hand hygiene. 3. Connect nasal cannula to oxygen setup with humidification, if one is in use. Adjust flow rate as ordered by physician. Check the oxygen is flowing out of prongs. 4. Place the prongs in patient’s nostrils. Adjust according to type of equipment: a. Over and behind each ear with adjuster comfortably under chin or b. Around patient’s head. 5. Use gauze pads at ear beneath tubing as necessary. 6. Encourage patient to breathe through nose with mouth closed. 7. Perform hand hygiene. 8. Assess and chart patient’s response to therapy. 9. Remove and clean cannula and assess nares at least every 8 hours or according to agency recommendations. Check nares for evidence of irrigation or bleeding.
Bag valve mask
A disposable BVM Resuscitator A bag valve mask (also known as a BVM or Ambu bag) is a handheld device used to provide positive pressure ventilation to a patient who is not breathing or who is breathing inadequately. The device is a normal part of a resuscitation kit for trained professionals, such as ambulance crew. The BVM is frequently used in hospitals, and is an essential part of a crash cart. The device is used extensively in the operating room to ventilate an anaesthetised patient in the minutes before a mechanical ventilator is attached. The device is self-filling with air, although additional oxygen (O2) can be added. Use of the BVM to ventilate a patient is frequently called "bagging" [1] the patient. Bagging is regularly necessary in medical emergencies when the patient's breathing is insufficient (respiratory failure) or has ceased completely (respiratory arrest). The BVM resuscitator is used in order to manually provide mechanical ventilation in preference to mouth-to-mouth resuscitation (either direct or through an adjunct such as a pocket mask). Components The Ambu Resuscitator bag or BVM, this version shows is a hybrid MkIII body, Mark IV head and with an old obsolete latex inflatable seal on the mask. The part labelled 1 is a flexible mask designed to seal to the patient's face, and the part labelled 3 is a self-filling bag, i.e. re-fills as an action of the elastic re-coil of the bag after compression. The BVM consists of a flexible air chamber, about the size of a football ball, attached to a face mask via a shutter valve. When the air chamber or "bag" is squeezed, the device forces air through into the patient's lungs; when the bag is released, it self-inflates, drawing in ambient air or a low pressure oxygen flow supplied from a regulated cylinder, while the patient's lungs deflate to the air through the one way valve. Bag and valve combinations can also be attached to an alternate airway adjunct, such as an endotracheal tube or laryngeal mask airway. Often a small HME filter (Heat & Moisture exchanger, or humidifying / bacterial filter) is used. A bag valve mask can be used without being attached to an oxygen tank to provide air to the patient, often called "room air" in the U.S. Supplemental oxygen increases the partial pressure of oxygen inhaled, helping to increase perfusion in the patient. Most devices also have a reservoir which can fill with oxygen while the patient is exhaling (a process which happens [2] passively), in order to increase the amount of oxygen that can be delivered to the patient to nearly 100%. Bag valve masks come in different sizes to fit infants, children, and adults. Most types of the device are disposable and therefore single use, while others are designed to be cleaned and reused. Method of operation The BVM directs the gas inside it via a one-way valve when compressed by a rescuer; the gas is then delivered through a mask and into the patient's trachea, bronchus and into the lungs. In order to be effective, a bag valve mask must deliver between 500 and 800 milliliters of air to the patient's lungs, but if oxygen is provided through the tubing and if the patient's chest rises with each inhalation (indicating that adequate amounts of air are reaching the lungs), 400 to 600 [1] ml may still be adequate. Squeezing the bag once every 5 seconds for an adult or once every 3 seconds for an infant or [3] child provides an adequate respiratory rate (12 respirations per minute in an adult and 20 per minute in a child or infant). Professional rescuers are taught to ensure that the mask portion of the BVM is properly sealed around the patient's face (that is, to ensure proper "mask seal"); otherwise, air escapes from the mask and is not pushed into the lungs. In order to maintain this protocol, some protocols use a method of ventilation involving two rescuers: one rescuer to hold the mask to [4] the patient's face with both hands and ensure a mask seal, while the other squeezes the bag. However, as most ambulances have only two members of crew, the other crew member is likely to be doing compressions in the case of CPR, or may be performing other interventions such as defibrillation or cannulation. In this case, or if no other options are available, the BVM can also be operated by a single rescuer who holds the mask to the patient's face with one hand, in the anaesthetists grip, and squeezes the bag with the other. When using a BVM, as with other methods of positive pressure ventilation, there is a risk of over-inflating the lungs. This can lead to pressure damage to the lungs themselves, and can also cause air to enter the stomach, causing gastric distention which can make it more difficult to inflate the lungs and which can cause the patient to vomit. This can be avoided by care on behalf of the rescuer. Alternatively, some models of BVM (usually Paediatric) are fitted with a valve
which prevents over inflation, by venting the pressure when a pre-set pressure is reached. Nevertheless, cricoid pressure should be applied whenever possible until the patient is intubated or until ventilations have ceased. An endotracheal tube (ETT) can be inserted by a trained practitioner and can substitute for the mask portion of the BVM. This provides a more secure fit and is easier to manage during emergency transport, since the ET tube is sealed with an inflatable cuff in the trachea, so that any regurgitation is less likely to enter the lungs. Such material can severely damage the lung tissue, and in the absence of an ET tube, could choke the patient by obstructing the airway. Inhalation of stomach contents can be fatal; the after effects can cause Mendelson's syndrome or aspiration pneumonia. Some rescuers may also choose to use a different form of resuscitation adjunt, such as an oropharyngeal airway or Laryngeal mask airway, which would be inserted and then used with the BVM. In a hospital, long-term mechanical ventilation is provided by using more complex devices such as an intensive care ventilator, rather than by a BVM, which requires at least one person to operate it constantly. A flow-restricted, oxygen-powered ventilation device (FROPVD) is similar to a BVM in that oxygen is pushed through a mask into the patient's lungs, but unlike a BVM, in the FROPVD the pressure needed to push air into the patient's lungs is generated by oxygen via a pressure regulator from a cylinder rather than by squeezing a bag.
Nebulizer Therapy
Nebulizer therapy aids bronchial hygiene by restoring and maintaining mucus blanket continuity, hydrating dried secretions, promoting secretion expectoration, humidifying inspired oxygen, and delivering drugs. It may be given through nebulizers that have a large or small volume, are ultrasonic, or are placed inside ventilator tubing. Large volume nebulizers such as Venturi Jet provide humidity for an artificial airway. Small volume nebulizer such as Mini Nebulizer is used to deliver drugs such as bronchodilators. Ultrasonic nebulizers are electrically driven and use high-frequency vibrations to break up surface water into particles; resultant dense mist can penetrate smaller airways, hydrate secretions, and induce coughing. In line nebulizers are used to deliver drugs to patients being mechanically ventilated. Equipment For ultrasonic nebulizer For a small-volume nebulizer Untrasonic gas delivery device Pressurized gas source Large bore oxygen tubing Flowmeter Nebulizer couplet compartment Oxygen tubing For a large-volume nebulizer Nebulizer cup Pressurized gas source Mouthpiece or mask Flowmeter Normal saline solution Large-bore oxygen Prescribed drug Nebulizer bottle For an in-line nebulizer Sterile distilled water Pressurized gas source Heater Flowmeter Inline thermometer Nebulizer cup Normal saline solution Prescribed drug Preparation of Equipment For an ultrasonic nebulizer Fill the couplet compartment to the indicated level. For a large-volume nebulizer Fill with distilled water to the indicated level Avoid using normal saline solution, to prevent corrosion Add a heating device if ordered Ensure delivery of the prescribed oxygen percentage For a small-volume nebulizer Draw up the drug, inject it into the nebulizer cup, and add the prescribed amount of normal saline solution, or water. Attach the mouth piece, mask, or other gas delivery device. For an in-line nebulizer Draw up the drug and diluents, remove the nebulizer cup, quickly inject the drug, then replace the cup. If using an intermittent positive-pressure breathing machine, attach the mouthpiece and mask to the machine.
Procedure Reinforce the explanation of the procedure to the patient Wash hands Take the patient’s vital signs and monitor his respiratory status. Place the patient in a sitting or high fowler’s position
For an ultrasonic nebulizer Give an inhaled bronchodilator to prevent bronchospasm Turn the machine on and check the outflow port for proper misting Monitor the patient for adverse reactions Watch for labored respirations Take the patients vital signs and monitor his respiratory status. Encourage the patient to cough and expectorate, or suction him as needed. For a small volume nebulizer Attach the flow meter to the gas source Attach the nebulizer to the flowmeter and adjust the flow to at least 10L Check the outflow port to ensure adequate misting Remain with the patient during treatment Encourage the patient to cough and expectorate Change the nebulizer cup and tubing according to your facility’s policy.
For a large volume nebulizer Attach the delivery device to the patient Encourage the patient to cough and expectorate, or suction him as needed Check the water level in the nebulizer and refill it, as indicated When refilling a reusable container, discard the old water Change the nebulizer unit and tubing according to hospital policy. If the nebulizer is heated, tell the patient to report discomfort. For an in-line nebulizer Turn on the machine and check for proper misting Remain with the patient during treatment Take the patient’s vital signs and monitor him for adverse reactions
Encourage the patient to cough, and suction excess secretions as necessary. Monitor the patient’s respiratory status to evaluate the effectiveness of therapy.
Nursing Interventions 1. The efficacy of aerosol therapy, what type of fluids to use, the types of drugs that can be delivered, and the effectiveness of therapy, haven’t been established. 2. Monitor for overhydration, especially in the patient with a delicate fluid balance. 3. Carefully monitor for adequate flow if oxygen is being delivered at the same time. 4. Encourage the patient to take slow, even breaths to derive maximum benefit. Complications Mucosa irritation, bronshospasm, dyspnea, airway burns, infection and adverse drug reactions.
Pulse Oximetry
Used to noninvasively monitor arterial oxygen saturation. A photo detector slipped over the finger measures transmitted light as it passes through the vascular bed, detects the relative amount of color absorbed by arterial blood, and calculates exact mixed venous oxygen saturation without interference from surrounding venous blood, skin, connective tissue, or bone.
Turn on the power switch. If the device is working properly, a beep will sound, a display will light momentarily, and the pulse search light will flash. After four to six heartbeats the pulse amplitude indicator will begin tracking the pulse. Rotate the sensor site according to the manufacturer’s instructions. Clean the probe per facility policy between patients or, if disposable, discard.
Nursing Interventions 1. Some machines have a pleth wave. A steady, level, even wave form ensures that the numerical reading is accurate. 2. The pulse rate on the oximeter should correspond to the patient’s actual pulse. If it doesn’t, monitor the patient, check the oximeter, and reposition the probe. 3. Factors that interfere with accuracy include: o Elevated carboxyhemoglobin or methemoglobin levels o Lipid emulsions and dyes o Excessive light o Excessive patient movement o Hypothermia o Hypotension o Vasoconstriction o Medications such as dapsone, vasopressors. 4. Use the bridge of the nose if the patient has compromised circulation in his extremities. 5. If an automatic blood pressure cuff is used on the same extremity as the saturation probe is placed, the cuff will interfere with oxygen saturation readings during inflation. 6. If the light is a problem, cover the probes. 7. If patient movement is the problem, move the probe or select a different probe. 8. Notify the physician of any significant change in the patient’s condition.
Equipment
Oximeter Sensor probe Alcohol pads Nail polish remover, if necessary
Preparation of Equipment
Review the manufacturer’s instruction for assembly.
Procedure
Reinforce the explanation of the procedure to the patient.
Using a finger probe
Select a finger (usually index finger) on the patient’s nondominant hand, if possible for placement of the probe. Remove fake fingernail and nail polish from the test finger. Place the transducer (photoprotector) probe over the patient’s finger so the light beams and sensor oppose each other. Trim long fingernails or position the probe perpendicular to the finger. Position the patient’s hand at heart level.
