Module 11
Mr. Y. is first day post-op following open heart surgery. HCP’s orders: 1. Turn, cough, deep breath q2h 2. Incentive spirometer q2h while awake 3. O 2 per nasal cannula at 2 l/min 4. Pulse oximetry continuous. 5. Up to chair tomorrow a.m.
How does performing breathing exercises support Mr. Y’s respiratory function?
Because Mr. Y. has an incision in his chest, it is uncomfortable for him to breathe normally. He is hypoventilating. Which type of breathing would be appropriate to teach Mr. Y? Explain how you would teach him. Explain why you did not choose pursed-lip breathing ro abdominal breathing.
Mr. Y’s doctor ordered him to turn q 2h.
What is the rationale for having a patient utilize voluntary coughing?
Mr. Y is suppose to use an incentive spirometer q2h while awake. What is the purpose of him using this device?
Place mouthpiece in mouth with lips tightly around the mouthpiece Inhale with slow deep breath to raise the flow rate indicator. Continue inhaling to try to raise the piston to the prescribed volume level. (Tell patient like sucking on straw) Exhale completely through nose if possible or mouth. Do this several times every 1-2 hours.
Inspiration Inhale like sucking on straw
Which of the following patients would the nurse expect incentive spirometer to be used? Choose all that apply. a.First day post- operative abdominal surgery patient b.16 year old with fracture of leg in hospital for casting c.24 y/o woman in post partum unit who had vaginal delivery yesterday d.45 y/o woman on bedrest for past 4 days e.A 62 y/o diabetic patient admitted for wound care treatment of leg ulcers What did you base your decision making?
Any of the patients who had possibility of stasis of secretions in the lungs is a candidate for use of an incentive spirometer.
Rationale: *gravity assists in lung expansion *reduces pressure from the abdomen on the diaphragm Semi-fowlersOrthopneic
Activation of cough reflex Reduce pain Increase ventilatory compensation Drainage of areas of the lungs Maintaining a patent airway
Stimulates respirations while walking Upright position allows for lung expansion.
Measures the flow of air inhaled through a mouthpiece. Purpose: ◦ Encourages deep breathing by providing visual feedback about their inspiratory ability so they can improve their own breathing efforts.
Place mouthpiece in mouth with lips tightly around the mouthpiece Inhale with slow deep breath to raise the flow rate indicator. Continue inhaling to try to raise the piston to the prescribed volume level. (Tell patient like sucking on straw) Exhale completely through nose if possible or mouth. Do this several times every 1-2 hours.
Inspiration Inhale like sucking on straw
Which of the following patients would the nurse expect incentive spirometer to be used? Choose all that apply. a.First day post- operative abdominal surgery patient b.16 year old with fracture of leg in hospital for casting c.24 y/o woman in post partum unit who had vaginal delivery yesterday d.45 y/o woman on bedrest for past 4 days e.A 62 y/o diabetic patient admitted for wound care treatment of leg ulcers What did you base your decision making?
Any of the patients who had possibility of stasis of secretions in the lungs is a candidate for use of an incentive spirometer.
Postural DrainagePercussion Vibration
Drainage of secretions by gravity from various segments of the lung
Percussion- forceful striking of the skin with cupped hands to mechanically dislodge tenacious secretions from bronchi Vibration is a technique in which the chest wall is set in motion by oscillating movements of the hands.
Indicated for patients who have hypoxemia or inadequate transport of oxygen
Mental Confusion Restlessness Tachypnea Tachycardia Air Hunger Sweating Cyanosis
Specific concentration Method Liter flow per minute
Place “No Smoking Oxygen in Use” sign on the door, at head of bed, and on the oxygen equipment Instruct patient / visitors about precautions Make sure electrical devices are in good working order to prevent sparks Avoid materials that generate static electricity Ground equipment Make known location / use fire extinguishers
Low-flow High-flow
Low-flow Devices: 1.Nasal Cannula – tube that extends around the face with curved prongs that fit into the nostrils. Comfortable Allows patient to eat, drink, talk Check skin – around ears and nostrils for irritation. Need to clean nares and if drying occurs, add humidification. Pad area over ears with gauze or cotton balls
Low-flow devices 2. Face Mask Simple Partial rebreather mask Nursing Care Assess skin around ears and where the elastic or mask compress the skin Can cause anxiety in patients and give feeling of confinement or claustrophobia. Use of humidification may be needed to prevent drying.
High-flow devices ◦ Venturi Mask - the device delivers oxygen at a precise oxygen concentration and can be set to meet specific needs of the patient.
Humidification ◦ Necessary to prevent mucous membranes from drying and becoming irritated and loosen secretions for easier expectoration
Flow Meter: ◦ Regulates the amount of oxygen being delivered ◦ Calibrated in liters per minute ◦ Can be regulated by nurses by turning knob to elevate ball within chamber
Pulse oximetry is a non-invasive way of measuring oxygen saturation of hemoglobin in the blood Normal saturation is 95% - 100% Levels below indicate oxygenation problems.. A saturation below 70% is critical, life-threatening and requires immediate attention.
A sensing device is clipped to an area with pulsating arterial blood such as a finger, toe or earlobe. With this device, a photoelectrical detector records the amounts of light transmitted or reflected by deoxygenated versus oxygenated hemoglobin picking up light signals registered by the pulsations.
Assess for best location Prepare the site Attach the sensor Follow manufacturer’s directions for use. Read values and document. Notify doctor of low levels
The nurse assesses the pulse oximetry of a patient with known respiratory problems and obtains a reading of 88%. What would the nurse do?