chap.30 med surg
Content
Ignatavicius: Medical-Surgical Nursing, 6th Edition
Chapter 30: Care of Patients Requiring Oxygen Therapy or Tracheostomy Key Points – Print Chapter 30 discusses the nursing assessment and management of patients with oxygen therapy or a tracheostomy procedure. We will begin with a review of oxygen therapy. • Oxygen is a gas essential for life and a drug used for hypoxemia and hypoxia. • The oxygen content of atmospheric air is about 21%. Oxygen therapy is prescribed when the oxygen needs of the patient cannot be met by room air alone. • The goal of oxygen therapy is to use the lowest fraction of inspired oxygen to have an acceptable blood oxygen level without causing harmful side effects. • Arterial blood gas analysis is the best measure for determining the need for oxygen therapy and for evaluating its effects, although oxygen need can also be determined by noninvasive monitoring, such as pulse oximetry. • Monitor the rate and depth of respiration at least every hour for any patient with hypercarbia and CO2 narcosis who is receiving oxygen by mask or nasal cannula. • Use aspiration precautions for any patient with an altered level of consciousness or who has an endotracheal tube. • Assess the skin under the mask and under the plastic tubing every shift for patients receiving oxygen by mask and assess the skin of the nares and under the elastic band every shift for patients receiving oxygen by nasal cannula. • Patients with oxygen therapy may require nursing diagnoses for anxiety and acute confusion related to hypoxemia and risk for impaired spontaneous ventilation. • Oxygen therapy presents certain hazards and complications including: o A risk of combustion o Oxygen induced hypoventilation in patients whose main respiratory drive is hypoxia o Oxygen toxicity related to the oxygen concentration delivered o Duration of oxygen therapy o Degree of lung disease o Absorption atelectasis from dilution of nitrogen levels and alveolar collapse o Infection resulting from nebulizers or other delivery equipment Now we will review oxygen delivery systems. • The type of delivery system used depends on: o Required oxygen concentration o Delivery system concentration o Importance of accuracy and control of the oxygen concentration o Patient comfort, expense, required humidity, and patient mobility • Oxygen delivery systems are classified by the rate of oxygen delivery as low-flow and high-
Copyright © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
• • •
• • • • •
flow systems. Low-flow delivery systems include nasal cannula, simple face mask, partial rebreather mask, and non-rebreather mask which are inexpensive, easy to use, and fairly comfortable. In low-flow systems, the oxygen delivered is variable and depends on the patient’s breathing pattern since room air dilution occurs. High-flow systems include the Venturi mask, aerosol mask, face tent, tracheostomy collar, and T-piece which deliver accurate oxygen levels that meet the patient’s oxygen needs when properly fitted. A high-flow system delivers oxygen concentrations from 24% to 100% at 8 to 15 L/min. Noninvasive positive-pressure ventilation is a technique using positive pressure to keep alveoli open and improve gas exchange without the need for airway intubation, using oxygen or just room air. Transtracheal oxygen is a long-term method of delivering oxygen directly into the lungs through a small, flexible catheter passed into the trachea via a small incision. The patient must be stable and optimally treated before home oxygen is considered. The nurse or respiratory therapist teaches the patient about the equipment needed for home oxygen therapy, including the oxygen source, delivery devices, humidity sources, and safety aspects of using and maintaining the equipment. Home oxygen therapy is provided in one of three ways: via an oxygen concentrator, compressed gas in a tank or a cylinder, or liquid oxygen in a reservoir.
REVIEW Your patient is hypoxic, demonstrating confusion, gasping, nasal flaring and oxygen saturation of 81% and is ordered oxygen therapy of 50% FiO2. Which delivery system would be appropriate? A. Nasal cannula B. Partial rebreather mask C. Venturi mask D. Simple face mask Some patients require tracheotomy for adequate ventilation management. • Tracheotomy is the surgical incision into the trachea to create an airway. • Tracheostomy is the stoma or opening that results from the tracheotomy. • A tracheotomy can be an emergency procedure or a scheduled surgery. • Tracheostomies can be temporary or permanent. • Some indications for tracheostomy include acute airway obstruction, need for airway protection, laryngeal trauma, radiation to structures in the neck, and airway involvement during head or neck surgery. • Nursing diagnoses and collaborative problems for patients requiring tracheostomy include impaired gas exchange, impaired verbal communication, imbalanced nutrition, risk for infection, impaired oral mucous membranes, impaired self-concept, and impaired social interaction. • Immediately after surgery, care is focused on ensuring a patent airway. • Confirm the presence of bilateral breath sounds and conduct a thorough respiratory assessment at least every 2 hours.
Key Points – Print • • • •
303
Assess the patient for complications from the procedure such as tube obstruction, tube dislodgement and accidental decannulation, pneumothorax, subcutaneous emphysema, bleeding, and infection. Use a manual resuscitation bag to ventilate the patient if the tracheostomy tube has dislodged or a power failure occurs. The type of tracheostomy tube chosen depends on the specific needs of the patient. Ensure that a tracheostomy tube of the same type, including an obturator, and patient size plus one size smaller is at the bedside at all times, along with a tracheostomy insertion tray. Ensure that tracheostomy suction equipment is at the bedside at all times.
Care of the patient with a tracheostomy is an important nursing function. • Assess the new tracheostomy stoma site at least once per shift for purulent drainage, redness, pain, and swelling as indicators of infection. • Tissue damage can occur where the inflated cuff presses against the tracheal mucosa. Keep the cuff pressure between 14 and 20 mm Hg to prevent tissue injury. • Secure new tracheostomy ties or tube holders in place before removing the soiled ones to prevent accidental decannulation. • The tracheostomy tube bypasses the nose and mouth, which normally humidify, warm, and filter the air. Tracheal damage can occur and thick, dried secretions can occlude the airways. To prevent complications, humidify the air as prescribed. • Suctioning maintains a patent airway and promotes gas exchange by removing secretions from the patient who cannot cough adequately. • Suctioning is needed when audible or noisy secretions, crackles or wheezes on auscultation, restlessness, increased pulse or respiratory rates, or mucus in the artificial airway is present. • Hypoxia can be caused by ineffective oxygenation before, during, and after suctioning, use of a catheter that is too large, prolonged suctioning time, excessive suction pressure, and too frequent suctioning. • Prevent hypoxia by hyperoxygenating the patient with 100% oxygen before suctioning. • In the hospital, use sterile technique for suctioning and for all suctioning equipment, including suction catheters, gloves, and saline or water to prevent infection. • Suction the mouth after suctioning the artificial airway and never use oral suction equipment for suctioning an artificial airway. • Provide meticulous oral care at least every four hours. • Vagal stimulation and bronchospasm are possible during suctioning resulting in severe bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias. Stop suctioning immediately and oxygenate with 100% oxygen. • Tracheostomy care keeps the tube free of secretions, maintains a patent airway, and provides wound care. • Bronchial hygiene, which promotes a patent airway and prevents infection, includes turning and repositioning the patient every 1 to 2 hours, supporting out-of-bed activities, and encouraging ambulation. • Since swallowing may be a problem, instruct the patient to keep the head of the bed elevated for at least 30 minutes after eating. • The patient can speak when there is a cuffless tube or when a fenestrated tracheostomy tube is in place and capped or covered.
Copyright © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
• • • • • • • • • • • • •
The inability to talk is a major stressor for the patient. Until natural speech is feasible, teach the patient and family about other communication methods. Acknowledge the patient’s frustration with communication and allow time for communication. The patient may have a change in body image because of deformity, stoma or artificial airway, speech changes, method of eating, or difficulty with speech. Help the patient set realistic goals, starting with involvement in self-care. Weaning the patient from a tracheostomy tube entails a gradual decrease in the tube size and ultimate removal of the tube. A device used for transition from tracheostomy to natural breathing is a button which maintains stoma patency and assists spontaneous breathing. By the time of discharge from the hospital, the patient should be able to provide self-care, including tracheostomy care, nutritional care, suctioning, and communication. Instruct the patient to use a shower shield over the tracheostomy tube when bathing to prevent water from entering the airway. Teach the patient to cover the airway to protect it during the day, filter the air entering the stoma, keep humidity in the airway, and enhance appearance. Teach the patient to increase humidity in the home and instruct him or her to instill normal saline into the artificial airway 10 to 15 times a day, as prescribed. Tell the patient to continue using the method of communication that began in the hospital and to wear a medical alert bracelet. The health care team assesses specific discharge needs and makes referrals to home care. Self-managing tracheostomy care and oxygen therapy can be difficult for the older patient who has vision problems or difficulty with upper arm movement.
REVIEW Of the following interventions for patients with a tracheostomy, which is the highest priority? A. Assist patient to reduce stress with alternative communication methods. B. Teach patients and families correct aseptic technique for home suctioning. C. Maintain a patent airway with adequate air exchange. D. Provide tracheostomy wound care once per shift to prevent infection.
Chapter 30: Care of Patients Requiring Oxygen Therapy or Tracheostomy Key Points – Print Chapter 30 discusses the nursing assessment and management of patients with oxygen therapy or a tracheostomy procedure. We will begin with a review of oxygen therapy. • Oxygen is a gas essential for life and a drug used for hypoxemia and hypoxia. • The oxygen content of atmospheric air is about 21%. Oxygen therapy is prescribed when the oxygen needs of the patient cannot be met by room air alone. • The goal of oxygen therapy is to use the lowest fraction of inspired oxygen to have an acceptable blood oxygen level without causing harmful side effects. • Arterial blood gas analysis is the best measure for determining the need for oxygen therapy and for evaluating its effects, although oxygen need can also be determined by noninvasive monitoring, such as pulse oximetry. • Monitor the rate and depth of respiration at least every hour for any patient with hypercarbia and CO2 narcosis who is receiving oxygen by mask or nasal cannula. • Use aspiration precautions for any patient with an altered level of consciousness or who has an endotracheal tube. • Assess the skin under the mask and under the plastic tubing every shift for patients receiving oxygen by mask and assess the skin of the nares and under the elastic band every shift for patients receiving oxygen by nasal cannula. • Patients with oxygen therapy may require nursing diagnoses for anxiety and acute confusion related to hypoxemia and risk for impaired spontaneous ventilation. • Oxygen therapy presents certain hazards and complications including: o A risk of combustion o Oxygen induced hypoventilation in patients whose main respiratory drive is hypoxia o Oxygen toxicity related to the oxygen concentration delivered o Duration of oxygen therapy o Degree of lung disease o Absorption atelectasis from dilution of nitrogen levels and alveolar collapse o Infection resulting from nebulizers or other delivery equipment Now we will review oxygen delivery systems. • The type of delivery system used depends on: o Required oxygen concentration o Delivery system concentration o Importance of accuracy and control of the oxygen concentration o Patient comfort, expense, required humidity, and patient mobility • Oxygen delivery systems are classified by the rate of oxygen delivery as low-flow and high-
Copyright © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
• • •
• • • • •
flow systems. Low-flow delivery systems include nasal cannula, simple face mask, partial rebreather mask, and non-rebreather mask which are inexpensive, easy to use, and fairly comfortable. In low-flow systems, the oxygen delivered is variable and depends on the patient’s breathing pattern since room air dilution occurs. High-flow systems include the Venturi mask, aerosol mask, face tent, tracheostomy collar, and T-piece which deliver accurate oxygen levels that meet the patient’s oxygen needs when properly fitted. A high-flow system delivers oxygen concentrations from 24% to 100% at 8 to 15 L/min. Noninvasive positive-pressure ventilation is a technique using positive pressure to keep alveoli open and improve gas exchange without the need for airway intubation, using oxygen or just room air. Transtracheal oxygen is a long-term method of delivering oxygen directly into the lungs through a small, flexible catheter passed into the trachea via a small incision. The patient must be stable and optimally treated before home oxygen is considered. The nurse or respiratory therapist teaches the patient about the equipment needed for home oxygen therapy, including the oxygen source, delivery devices, humidity sources, and safety aspects of using and maintaining the equipment. Home oxygen therapy is provided in one of three ways: via an oxygen concentrator, compressed gas in a tank or a cylinder, or liquid oxygen in a reservoir.
REVIEW Your patient is hypoxic, demonstrating confusion, gasping, nasal flaring and oxygen saturation of 81% and is ordered oxygen therapy of 50% FiO2. Which delivery system would be appropriate? A. Nasal cannula B. Partial rebreather mask C. Venturi mask D. Simple face mask Some patients require tracheotomy for adequate ventilation management. • Tracheotomy is the surgical incision into the trachea to create an airway. • Tracheostomy is the stoma or opening that results from the tracheotomy. • A tracheotomy can be an emergency procedure or a scheduled surgery. • Tracheostomies can be temporary or permanent. • Some indications for tracheostomy include acute airway obstruction, need for airway protection, laryngeal trauma, radiation to structures in the neck, and airway involvement during head or neck surgery. • Nursing diagnoses and collaborative problems for patients requiring tracheostomy include impaired gas exchange, impaired verbal communication, imbalanced nutrition, risk for infection, impaired oral mucous membranes, impaired self-concept, and impaired social interaction. • Immediately after surgery, care is focused on ensuring a patent airway. • Confirm the presence of bilateral breath sounds and conduct a thorough respiratory assessment at least every 2 hours.
Key Points – Print • • • •
303
Assess the patient for complications from the procedure such as tube obstruction, tube dislodgement and accidental decannulation, pneumothorax, subcutaneous emphysema, bleeding, and infection. Use a manual resuscitation bag to ventilate the patient if the tracheostomy tube has dislodged or a power failure occurs. The type of tracheostomy tube chosen depends on the specific needs of the patient. Ensure that a tracheostomy tube of the same type, including an obturator, and patient size plus one size smaller is at the bedside at all times, along with a tracheostomy insertion tray. Ensure that tracheostomy suction equipment is at the bedside at all times.
Care of the patient with a tracheostomy is an important nursing function. • Assess the new tracheostomy stoma site at least once per shift for purulent drainage, redness, pain, and swelling as indicators of infection. • Tissue damage can occur where the inflated cuff presses against the tracheal mucosa. Keep the cuff pressure between 14 and 20 mm Hg to prevent tissue injury. • Secure new tracheostomy ties or tube holders in place before removing the soiled ones to prevent accidental decannulation. • The tracheostomy tube bypasses the nose and mouth, which normally humidify, warm, and filter the air. Tracheal damage can occur and thick, dried secretions can occlude the airways. To prevent complications, humidify the air as prescribed. • Suctioning maintains a patent airway and promotes gas exchange by removing secretions from the patient who cannot cough adequately. • Suctioning is needed when audible or noisy secretions, crackles or wheezes on auscultation, restlessness, increased pulse or respiratory rates, or mucus in the artificial airway is present. • Hypoxia can be caused by ineffective oxygenation before, during, and after suctioning, use of a catheter that is too large, prolonged suctioning time, excessive suction pressure, and too frequent suctioning. • Prevent hypoxia by hyperoxygenating the patient with 100% oxygen before suctioning. • In the hospital, use sterile technique for suctioning and for all suctioning equipment, including suction catheters, gloves, and saline or water to prevent infection. • Suction the mouth after suctioning the artificial airway and never use oral suction equipment for suctioning an artificial airway. • Provide meticulous oral care at least every four hours. • Vagal stimulation and bronchospasm are possible during suctioning resulting in severe bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias. Stop suctioning immediately and oxygenate with 100% oxygen. • Tracheostomy care keeps the tube free of secretions, maintains a patent airway, and provides wound care. • Bronchial hygiene, which promotes a patent airway and prevents infection, includes turning and repositioning the patient every 1 to 2 hours, supporting out-of-bed activities, and encouraging ambulation. • Since swallowing may be a problem, instruct the patient to keep the head of the bed elevated for at least 30 minutes after eating. • The patient can speak when there is a cuffless tube or when a fenestrated tracheostomy tube is in place and capped or covered.
Copyright © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
• • • • • • • • • • • • •
The inability to talk is a major stressor for the patient. Until natural speech is feasible, teach the patient and family about other communication methods. Acknowledge the patient’s frustration with communication and allow time for communication. The patient may have a change in body image because of deformity, stoma or artificial airway, speech changes, method of eating, or difficulty with speech. Help the patient set realistic goals, starting with involvement in self-care. Weaning the patient from a tracheostomy tube entails a gradual decrease in the tube size and ultimate removal of the tube. A device used for transition from tracheostomy to natural breathing is a button which maintains stoma patency and assists spontaneous breathing. By the time of discharge from the hospital, the patient should be able to provide self-care, including tracheostomy care, nutritional care, suctioning, and communication. Instruct the patient to use a shower shield over the tracheostomy tube when bathing to prevent water from entering the airway. Teach the patient to cover the airway to protect it during the day, filter the air entering the stoma, keep humidity in the airway, and enhance appearance. Teach the patient to increase humidity in the home and instruct him or her to instill normal saline into the artificial airway 10 to 15 times a day, as prescribed. Tell the patient to continue using the method of communication that began in the hospital and to wear a medical alert bracelet. The health care team assesses specific discharge needs and makes referrals to home care. Self-managing tracheostomy care and oxygen therapy can be difficult for the older patient who has vision problems or difficulty with upper arm movement.
REVIEW Of the following interventions for patients with a tracheostomy, which is the highest priority? A. Assist patient to reduce stress with alternative communication methods. B. Teach patients and families correct aseptic technique for home suctioning. C. Maintain a patent airway with adequate air exchange. D. Provide tracheostomy wound care once per shift to prevent infection.
