333 oxygenation interventions/therapy Flashcards
nursing diagnoses related to oxygenation
ineffective airway clearance (thick secretions), risk for aspiration (cough), impaired gas exchange (chronic lung disease, infections), activity intolerance
long term preventative measures
vaccines, healthy lifestyles, environmental & occupational exposures
Dyspnea mgt
(difficult to treat), treat underlying condition, oxygen therapy, pharm treatment
when might someone not be able to maintain their airway
choking, recent anesthesia, overdose of pain meds, if pt is slumped over
managing pulmonary secretions
mobilize , hydrate, humidification, nebulization, meds
what does deep breathing do
increases air to the lower lobes of the lungs
how often should we encourage pt’s to cough when experiencing lung conditions/upper res problems
every 2 hours (we learned 1 last block)
cascade cough + considerations when teaching / what pts are best for them
he patient takes a slow, deep breath, holds it for 1 to 2 seconds, then opens the mouth and performs a series of coughs throughout exhalation / for pts with large amounts of sputum like CF pts
huff cough + considerations when teaching / what pts are best for them
The patient inhales deeply and then holds the breath for 2 to 3 seconds. While forcefully 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 / weaker pts like those w/ COPD
quad cough + considerations when teaching / what pts are best for them
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 / for patients without abdominal muscle control, such as those with spinal cord injuries
what is nursings best defense
turn, cough, deep breathe
chest physiotherapy goal
mobilize pulmonary secretions (this is after other interventions do not work, need HCP order)
chest physiotherapy activities
postural drainage, chest percussions, chest vibration **follow these activities w/ coughing & deep breathing
what pt indicates chest physiotherapy
pt’s w/ thick secretions, low effectiveness of cough, hx of pulmonary problems successfully relieved by CPT, abnormal lung sounds, conditions such as atelectasis, pneumonia, vital signs or change in O status
what pts are contraindicated for chest physiotherapy
pregnant, rib/chest injuries, increased intracranial pressure, recent abdominal/thoracic surgery, bleeding disorders, osteoporosis
postural drainage
lay on unaffected side to promote drainage of one particular lobe, usually transdelenburg is best **ex: infiltration seen on right lower lobe, lay pt on left side in transdelenbury
suctioning
sterile orotracheal & nasotracheal common, it is extremely uncomfortable and stimulates extreme coughing (should be less than 10 secs)
goal of oxygen therapy
prevent or relieve hypoxia
what is room FiO2
21%
fraction of inspired O2
% of O2 in inspired air
what is the exception to give O2 without an order
emergency situation & your pt is destating
can O2 be delegated to a CNA
yes -> CNA’s can apply nasal cannulas and oxygen masks **nurse must assess res system, response to therapy, setup, & adjustment responses
Nasal Cannula
-FiO2: 1-6L/min, 24-44%
-safe & well tolerated
-can lead to skin breakdown, tubing dislodges easily
-use humification if greater than 4L of flow
Simple Face Mask
-FiO2: 6-12L/min, 35-50%
-best for short periods (transport)
-not great for claustrophobic pts, skin breakdown, higher risk of aspiration
-assess for fit, watch for aspiration
-contraindicated for pt’s retaining CO2 (COPD)
Partial Rebreather Mask
-FiO2: 6-11L/min, 60-75%
-used for short period of dyspnea or other increased oxygen needs
-pt rebreathe up to 1/3 of exhaled air, helps w/ humidification
-keep reservoir bag partially inflated
-watch for aspiration & hourly assessment of masks
Non breather mask
-FiO2: 10-15L/min, 80-95%
-best for pts in critical need of oxygen (steps before intubation)
-one way valve allows for client to inhale max O2 con & two exhalation ports that restrict exhaled air from being rebreathed
-watch for aspiration & hourly assessment of masks
Venturi Mask
-FiO2: 4-12L/min, 24-60%
-provides the ability to deliver precise oxygen concentration w/ humidity
-not preferable for long periods of time
-used for pts who need highly regulated O2 cons (chronic lung disease)
face tent (aerosol mask)
-fits loosely around face & neck
-24-100% O2
-provides relatively high humidity
-seen a lot in post opt
High flow nasal cannula
-80-100L/min O2
-forces the air down, pressurized
-usually for ICU pts
-caution if pt is eating
nasal cannula w/ ETCO2 monitor
flat goes over the mouth and we can obtain a CO2 reading
when should humidification be used
always when greater than 4 lpm or g reater than 24 hrs of supplemental oxygen
oxygen toxicity: general
pleuritic chest pain, chest heaviness, coughing and dyspnea, muscle twitching, nausea/GI upset
oxygen toxicity: eyes
-loss of visual field
-near sightedness
-cataract formation
-bleeding
-fibrosis
oxygen toxicity: muscular
twitching
oxygen toxicity: CNS
seizures
oxygen toxicity: respiratory
jerky breathing, irritation, coughing, pain, SOB, tracheobronchitis, acute respiratory distress syndrome
complications of oxygen therapy
-drying effects of respiratory mucous membrane
-oxygen toxicity
-skin breakdown
