1. Specific Methods of Respiratory Management Respiratory Module

2. Deep Breathing & Coughing Airway clearance – Nrs Dx Ineffective airway clearance –  fluids

3. Breathing Exercises Goal –  work of breathing –  efficiency Diaphragmatic breathing Pursed-lip breathing

4. Breathing Exercises Diaphragmatic breathing – Gen info Diaphragm – muscle Practice – Procedure Place 1 hand on abdomen and other on chest Push out abd during I Chest move very little

5. Breathing Exercises Pursed-lip Breathing – Gen info Used when SOB Keep airway open during E   CO2 excretion With diaphragmatic breathing Counting   anxiety

6. Breathing Exercises Pursed-lip Breathing – Procedure I – slowly through nose – Count 2 E – Through pursed lips – Count 4

7. Positioning Conserve energy Max lung expansion Pt specific – Fowlers – Chair – leaning forward Good lung down

8. Oxygen therapy Goal – Provide adequate transport of O2 –  work –  stress to myocardium Need for O2 based on – ABG’s – Clinical assessment

9. Oxygen therapy Cautions on O2 tx – Med! Except in emergency need MD Rx Give O2 only to bring the pt back to baseline – ***COPD – WHY?

10. Oxygen therapy COPD & O2 – Normal - CO2 indicator to breath – COPD – O2 indicator to breath d/t  CO2 levels “burned” medulla sensor for CO2 – Medulla uses O2 to initiate breath

11. COPD & O2 COPD +  O2   Resp   PaCO2  Carbon dioxide narcosis & acidosis  Deathmosis

12. Oxygen therapy Precautions – Catalyst for combustion – “No smoking” sign – Tanks  missiles – No friction toys

13. Oxygen Side effects O2  Hyper or hypo ventilation? – Hypoventilation  – Atelectasis

14. Oxygen toxicity O2 overdose  O2 concentration > 48 hrs “r/t the destruction and  of surfactant “the formation of a hyaline membrane lining the lung “and the development of pulmonary edema that is not cardiac in origin”

15. Oxygen Toxicity S&S Sub-sternal distress Chest pain Dry cough Paresthesia Dyspnea – Progressive Restlessness * PaO2 > 100mmHg

16. Oxygen Toxicity Prevention  FiO2 P.E.E.P. – Positive, End, Expiratory, Pressure C.P.A.P. – Continuous positive airway pressure

17. Method of O2 Administration Nasal Cannula Flow rate – 1-6 L/min FiO2 – 20-40% Nrs – Talk & eat – Comfort – Nose breather

18. Method of O2 Administration Simple Mask Flow rate – 6-10 L/min FiO2 – 40-60% Nrs – Higher flow rate

19. Method of O2 Administration Partial Re-breather Mask (Reservoir) Flow rate – 6-10 L/min FiO2 – 60-100% Nrs – Uses reservoir to capture some exhaled gas for rebreathing – Vents allow room air to mix with O2

20. Method of O2 Administration Non-rebreather Mask Flow rate – 6-10 L/min FiO2 – 70-100%

21. Method of O2 Administration Nrs – Side vents closed – Reservoir vent closed for I, open for E – Reservoir bag stores O2 for I but does not allow E air in – Reservoir never collapse to <½

22. Method of O2 Administration Venturi Flow rate – 4-8 % FiO2 – 20-40% Nrs. – Precise % of O2 – i.e. COPD

23. Which one of the following conditions could lead to an inaccurate pulse oximetry reading if the sensor is attached to the clients ear? A.Artificial nails B.Vasodilation C.Hypothermia D.Movement of the head

24. Nebulizer Mist Treatment Deliver Moisture OR medication directly into the lungs Topical –  systemic S/E Indications: – Must be able to deep breath

25. Nebulizer Mist Treatment Meds: Bronchodilators – Albuteral (ventolin) Corticosteroids Mucolytic agents – Acetylcysteine Antibiotics

26. Metered Dose Inhaler Admin. Topical meds directly into the lungs  systemic S/E Meds: – Corticosteroids – Bronchodilators – Mast cell inhibitors

27. Metered Dose Inhaler Procedure Canister into unit correctly Shake gently Hold inhaler – breath out slowly (not into inhaler)

28. Metered Dose Inhaler Place mouthpiece into your mouth Close lips around it Tilt head back Keep tongue out of way Press top of the canister firmly & breath in through your mouth

29. Metered Dose Inhaler Remove inhaler from mouth Hold breath for several seconds Breath out slowly

30. Metered Dose Inhaler Rinse your mouth afterward to help reduce unwanted side effects

31. Incentive Spirometry Device enc. Deep breath Prevent & tx Atelectasis Procedure – Inhale!

32. Chest physiotherapy Goal – Remove bronchial secretions –  ventilation –  efficiency of respiration

33. Chest physiotherapy Postural drainage Help move secretion deep w/in lungs Used when pt has weak or ineffective cough (& retaining secretions) Client is placed in various positions to drain lungs – 15 min each position

34. Chest physiotherapy Nrs. Management Auscultate /a & /p Pt comfort Assess for: –  pain – SOB – Weakness – Lightheadedness – Hemoptysis

35. Chest physiotherapy Percussion Cupped hands strike the chest repeatedly  sound waves loosen secretions Vibration Vibrations using hands or vibratos to loosen secretions

36. Chest physiotherapy Percussion& vibration  after meals  over: – Chest tubes – Sternum – Spine – Kidneys – Spleen – Breasts Caution with elderly

37. Chest Drainage Tubes Continuous chest drainage Insertion of one or more chest tube by MD Into the pleural space Drain fluid or air

38. Chest Drainage Tubes Indications Air in pleural space Pneumothorax Pleural effusion Penetrating chest injury Chest surgery

39. Chest Drainage Tubes Upper, anterior chest (2 nd & 4 th intercostal space)  – Remove air Lower lateral chest (8 th or 9 th intercostal space)  – Remove fluid

40. Chest Drainage Tubes MD inserts Nrs connects system and secures all connections Vaseline gauze and sterile occlusive dressing at insertion site to prevent leakage

41. Chest Drainage Tubes 2 padded clamps at bedside Clamps only used if: – Chest system accidentally disconnected – Changing drainage system – Trial period before removal

42. Chest Drainage Tubes Tubes never clamped for more than few min  Prevents air from escaping  Buildup of air in pleural space  Pneumothorax

43. Chest Drainage Tubes 3-bottle system 1.Water seal bottle 2.Suction bottle 3.Drainage bottle

44. Chest Drainage Tubes Water seal When pt E  Air trapped in the pleural space travels through chest tube to the water seal bottle  Bubble up and out of the bottle

45. Chest Drainage Tubes Water seal Water acts as a seal – allows air to escape, prevents air from getting back in Bubbles with E – Normal Constant bubbling – Abnormal – leak – Check for leaks

46. Chest Drainage Tubes Water Seal Water level fluctuates –  I –  E Tidaling – Normal When lung is reinflated  – Tidaling stops If tidaling stops: – Lung reinflated – Tubing kinked – Tubing occluded

47. Chest Drainage Tubes Suction Bottle Suction sometimes used to speed up lung reinflation Amt of suction is dependent of the level of H2O in the bottle, not the amt of suction set on the machine

48. Chest Drainage Tubes Suction Bottle Suction level order by MD – -20cm Water Turn suction machine on enough to cause gentle bubbling – Normal

49. Chest Drainage Tubes Suction bottle Vigorous bubbling  water evaporation  change amt of suction – Turn down suction No bubbling – Kink in system – Suction disconnected

50. Chest Drainage Tubes Drainage bottle Collect fluid from pleural space Fluid d/t – Pleural effusion – Chest trauma – Surgery

51. Chest Drainage Tubes Drainage bottle Fluid is not emptied to measure – Mark line q shift Date Time Amt. – Add to I&O Sudden  in fluid, or very bloody  – Notify MD

52. Chest Drainage Tubes Nrs. Care Must always be kept upright Always below level of chest Notify MD if: –  Dyspnea – Drainage chamber full

53. Chest Drainage Tubes Transporting Transport w/ pt Ask MD if suction Ok to be off while transporting – Leave open to air Do not clamp to transport

54. Chest Drainage Tubes Nrs management  rate, effort, SOB, symmetry, pain Auscultate lung sounds – Absent/decreased  normal as inflate  Drsg intact, drainage Palpate insertion site for crepitus  tubing for kinks, connections

55. Chest Drainage Tubes No depended loops System below level of chest  system for cracks or leaks  water seal for – H2O level – Tidaling – Bubbling w/ E

56. Chest Drainage Tubes  suction control bottle – Gentle bubbling – H2O level  and mark amount of drainage

57. Chest Drainage Tubes Stripping Slide fingers down the tube Milking Gently squeezing tube w/out sliding MD order only!

58. Chest Drainage Tubes Accidental removal Drainage tube disconnected from system: – Clamp immediately – Reconnect system – Unclamp Drainage tube pulled out of patient: – Cover site with Vaseline gauze/ occlusive drsg – Notify MD

59. Chest Drainage Tubes Removal of tube MD removes Place Vaseline gauze & sterile occlusive dressing over site Assess: – Crepitus – Resp status – Dressing site

60. Question? You notice that the water seal on a pt chest tube rises and falls with each breath. What does this mean? A.There is a leak in the system B.Tubing is kinked C.Too much suction D.Too little suction E.Lung reinflated F.Normal occurrence

61. Question? You notice constant bubbling in the water seal bottle of a chest tube drainage system. What does this mean? A.There is a leak in the system B.Tubing is kinked C.Too much suction D.Too little suction E.Lung reinflated F.Normal occurrence

62. Question? You notice vigorous bubbling in the suction bottle of a chest tube drainage system. What does this mean? A.There is a leak in the system B.Tubing is kinked C.Too much suction D.Too little suction E.Lung reinflated F.Normal occurrence

63. Question? You notice constant bubbling in the suction bottle of a chest tube drainage system. What does this mean? A.There is a leak in the system B.Tubing is kinked C.Too much suction D.Too little suction E.Lung reinflated F.Normal occurrence

64. Question? You notice no bubbling in the suction bottle of a chest tube drainage system. What does this mean? A.There is a leak in the system B.Tubing is kinked C.Too much suction D.Too little suction E.Lung reinflated F.Normal occurrence

65. Question? While tuning a patient, the chest tube accidentally is pulled out of the patients chest. What should you do first? A.Clamp the tube B.Open the site with stoma openers C.Cover the site with occlusive dressing D.Re insert the tube E.Call the MD

66. Tracheostomy Tracheotomy: – Surgical opening through the base of the neck into the trachea Tracheostomy: – Permanent and has a tube inserted into the opening to maintain patency

67. Tracheostomy Reasons for Trach – Laryngeal CA – Airway obstruction – Trauma – Tumor – Difficulty clearing airway – Prolonged mechanical Ventilation

68. Tracheostomy Pt breaths through this opening, bypassing the upper airways Semi-fowler position post-op Cuff management – Usually 20-25mmHg

69. Tracheostomy If trach pulled out – Tracheal dilator to keep stoma open until MD arrives and reinsert tube

70. Suctioning General Info: Frightening & uncomfortable Leads to Hypoxia Leads to Vagal stim  – Bradycardia  – Cardiac arrest 

71. Suctioning Not do PRN Enc cough Hold own breath

72. Suctioning Oropharyngeal (clean) or nasopharyngeal (sterile) suctioning procedure Gather equipment Explain Connect cath to suction tubing, keep cath. inside sterile sleeve Turn on suction to level specified by facility (80-120 mmHg)

73. Suctioning Pour saline into sterile container Put on sterile gloves Suction small amt of saline into catheter to rinse and test suction Have pt take several breaths

74. Suctioning With thumb control uncovered, insert cath. through mouth/nose into pharynx until resistance is met or pt coughs Slowly withdraw cath, suction intermittently while rotating < 15 sec

75. Suctioning Allow pt to rest Repeat 2 more time if needed If trach – DO NOT instill sterile saline into trach If trach – hyperventilate before suctioning

76. Intubation Endotracheal tube (ET) – Mouth - trachea Most also mech ventilated Damages vocal cords & surrounding tissue – Only short term Long term  – Tracheostomy

77. Mechanical Ventilators General Info Provide ventilation to pt unable to breath effectively on own Use + pressure to push O2 air in via ET or Trach tube

78. Mechanical Ventilators Indication for use Cont.  in PaO2 Cont.  PaCo2 Persistent Acidosis

79. Mechanical Ventilators Nrs Management Advance directives Assess/monitor pt Setting per order Respond to alarms Tubing free of water Airway clear Manual resuscitation bag at bedside

80. Mechanical Ventilators Ventilator modes FiO2 – Fraction of inspired oxygen – Concentration of O2 Tidal Volume – Amt of air delivered with ea. Breath

81. Mechanical Ventilators Rate – Frequency of breaths I:E – Inspiration to expiration ratio – 1:3 I-1 sec E-3 sec

82. Mechanical Ventilators AC – Assist control mode – Delivers breath ea time pt begins to inhale – If pt  breath, delivers preset minimum # of breaths

83. Mechanical Ventilators SIMV – Synchronized Intermittent mandatory ventilation – Pt breaths on own, but delivers minimum # breaths

84. Mechanical Ventilators Pressure support (PS) – Provided + pressure on I to  work of breathing

85. Mechanical Ventilators Continuous positive airway pressure (CPAP) – + pressure on I & E to  work of breathing in spontaneously breathing pt

86. Mechanical Ventilators Positive End Expiratory Pressure (PEEP) – Provides + pressure on E to keep small airways open – Prevent Atelectasis – If too high  pneumothorax