Chapter 21 Respiratory Care

Question 1

What are the different flow rates and oxygen percentages of an orpharyngeal catheter?

Answer 1

1-6L

23-42%

Question 2

What arethe pros and consof an oropharyngeal catheter?

Answer 2

Pros: inexpensive, no tracheostomy needed

Cons: Nasal mucosa irritation, frequent changes of catheter to alternating nostrils

Question 3

What are the flow rates and oxygen percentages of a simple mask?

Answer 3

6-8L

40-60%

Question 4

What arethe pros and cons of asimple mask?

Answer 4

Pros: simple touse, inexpensive

Cons: variable FiO2, poor fitting, must remove to eat

Question 5

What are the flow rates and oxygen percentages of a partial rebreathing mask?

Answer 5

8-11L

50-75%

Question 6

What are the advantages and disadvantages of a partial rebreathing mask?

Answer 6

Pros: Moderate O2 concentration

Cons: Warm, poorly fitting, must remove to eat

Question 7

What are the flow rates and oxygen percentages of a nonrebreathermask?

Answer 7

12L

80-100%

Question 8

What are the pros and cons of a nonrebreather mask?

Answer 8

Pros: High O2 concentration

Cons: poorly fitting, must remove to eat

Question 9

What are the flow rates and oxygen percentages of a transtracheal catheter?

Answer 9

1/4-4

60-100%

Question 10

What are the pros and cons of a transtracheal catheter?

Answer 10

Pros: more comfortable, concealed by clothing, less liters per minute required than a nasal

Cons: requires regular and frequent cleaning, requires a surgical intervention (inserted directly into trachea)

Question 11

What are the flow rates and oxygen percentages for a venturi mask?

Answer 11

4-6L 24,26,28%

6-8L 30,35,40%

Question 12

What are the pros and cons of a venturi-mask?

Answer 12

Pros: provides low levels of supplemental O2 at a very precise rate

Cons: must remove to eat

Question 13

What are the flow rates and oxygen percentages for a tracheostomy collar, T-piece, face tent, and aerosol mask?

What do all of these devices have in common?

Answer 13

8-10L

30-100%

They are all used with a nebulizer (aerosol) device.

Question 14

What are the pros and cons of an aerosol mask?

Answer 14

Pros: good humidity, accurate FiO2

Cons: uncomfortable for some

Question 15

What are the pros and cons of a tracheostomy collar?

Answer 15

Pros: good humidity, comfortable, fairly accurate FiO2

Cons: none listed in chart

Question 16

What are the pros and cons of a t-piece?

Answer 16

Pros: good humidity, comfortable, faily accurate FiO2

Cons: heavy with the tubing

Question 17

What are the pros and cons of a face tent?

Answer 17

Pros: good humidity, fairly accurate FiO2

Cons: bulky and cumbersome

Question 18

Is oxygen therapy used to help patients go beyond their baseline arterial oxygen pressure?

Explain your reasoning for this answer.

Answer 18

NO, oxygen therapy is used to get patients back to baseline arterial oxygen pressure, which is 60-95 mmHg.

At these pressure levels, hemoglobin is 80-98% saturated with oxygen, therefore higher FiO2 rates like those with supplemental oxygen dont significantly increase the amount of oxygen in the blood if going past baseline, and it may be harmful.

Question 19

When can oxygen toxicity possibly occur?

What causes oxgen toxicity?

Answer 19

When a high concentration of oxygen (greater than 50%) is given for a long period of time (longer than 48 hours)

Oxygen toxicity is caused by a build-up of oxygen free radicals, which are by-products of cell metabolism. These free radicals can damage and kill cells.

Question 20

What are some signs and symptoms of oxygen toxicity?

Answer 20

Substernal discomfrt, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory dificulty, refractory hypoxemia, alveolar atelectasis, alveolar infiltrates evident of chest x-rays.

Question 21

What are some preventative techniques for oxygen toxicity?

Answer 21

Antioxidant (vitamin E, C, and beta-carotene) rich diet or supplementation (for those with poor appetite or are unable to eat), use oxygen only as prescribed, if high concentrations are necessary minimize duration and reduce concentration as soo as possible

Question 22

What is PEEP?

Describe “best PEEP”.

Answer 22

positive end-expiratory pressure, this may be used with oxygen therapy to reverse or prevent microatelectasis. This allows lower oxygen concentrations to be used on patient, which may help prevent oxygen toxicity. CPAP may also be used in this way.

Best PEEP is the PEEP that allows the best oxygenation without hemodynamic compromise (can effect preload).

Question 23

What drives a COPDer to breath rather than a non COPDer?

Answer 23

Low levels of oxygen (hypoxic) drive a COPDer to breath rather than a high level of CO2 (hypercarbic).

Question 24

What is supression of ventilation in regards to oxygen therapy in COPD patients?

Answer 24

If high concentrations of oxygen are administered to COPD patients the increase in arterial oxygen levels may cause the patients rspiratory drive to decrease or go out completely, This hypoventilation can lead to respiratory failure and death caused by carbon dioxide narcosis and acidosis.

Question 25

How do you prevent suppression of ventilation and COPDers?

Answer 25

administer low flow rates of oxygen (1-2L/min) and closely monitor the respiratory rate and oxygen saturation (pulse oximetry)

Question 26

Other than oxygen toxicity and ventiation supression, what are sme other complications of oxygen therapy?

Answer 26

Oxygen supports combustion, no smoking signs need to be placed when oxygen is in use in facilities that arent smoke free.

There is also a risk of bacterial cross-infection, tubing needs to be changed according to infection control policy and the type of oxygen delivery equipment.

Question 27

What is mini-nebulizer therapy?

Answer 27

A handheld apparatus that disperses a moisturizing agent or medication into particles that are delivered to the lungs as the patient inhales. Usually the nebulizer is air driven, but it can be oxygen drive.

Question 28

How do you know that thenebulizer is functioning properly?

Answer 28

A visible mist must be available for the patient to swallow.

Question 29

What are some indications for nebulizer therapy?

Answer 29

difficulty in clearing secretions

reduced vital capacity with ineffective deep breathing and coughing

unsuccessful trials of other, more simple and less costly methods of clearing respiratory secretions, delivering aerosol, or expanding the lungs

These are frequently used for patients with COPD for inhaled medications

Commonly used in the home for long-term care

Question 30

In order to properly use a small volume nebulizer the patient must be able to take a deep breath, describe diaphragmatic breathing which is a technique to help a patient prepare for mini-nebulizer treatments.

Answer 30

Goal: to use and strengthen the diaphragm during breathing

Steps:

1. place once hand on the abdomen (just below ribs), and the other hand on the middle of the chest to increase he awareness of the position ofthe diaphragm and its function in breathing
2. Breathe in slowly and deeply thorugh the nose, letting the abdomen protrude as far as possible.
3. Breathe out through pursed lips while tightening (contracting) the abdominal muscles.
4. Press firmly inward andupward on the abdomen while breathing out.
5. Repeat for 1 minute; follow with a rest period of 2 minutes.
6. Gradually increase the duration up to 5 minutes, several times a day (before meals and at bedtime)

Question 31

Describe pursed lip breathing.

Answer 31

Goal: To prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance.

Steps:

1. Inhaled through the nose while slowly counting to 3 (the amount of time needed to say “smell a rose??????”).
2. Exhale slowly andevenly against pursed lips whiled tightening the abdominal muscles (pursing lips increase intratracheal pressure; exhaling through the mouth offers less resistance to expired air)
3. Count to 7 slowly while prolonging expiration through pursed lips (the amount of time to say “blow out the candle????????”)
4. While walking: Inhale through nose while taking 2 steps, exhale through pursed lips while walking 4 or 5 steps.

Question 32

What are some general therapeutic instruction for breathing?

Answer 32

Breath slowly and rhythmically to exhale completely and empty the lungs completely

Inhale through the nose to filter, humidify, and warm the air before it enter the lungs

If you feel out of breath, breath more slowly by prolonging exhalation time

Keep the air moist with a humidifier

Question 33

Other than the proper breathing techniques that help the client get a deep breath, what are some other nurse management priorities for mini-nebulizer theapy?

Answer 33

Ask the patient to cough to assess the effectiveness of the therapy.

Instruct the patient and family about the purpose of the treatment, equipment setup, medication additive, and proper cleaning and storage of the equipment.

Question 34

What is chest physiotherapy?

Answer 34

Chest physiotherapy includes postural drainage, chest percussion and vibration, and breathing retraining. Another important part of CPT is teaching the client about effective coughing.

Goal: To remove bronchial secretions, improve ventilation, and increase efficiency of the respiratory muscles.

Question 35

What is postural drainage?

Answer 35

Postural drainage allows the force of gravity to assist in the removal of bronchial secretions. The secretions drain from the affected bronchioles into the bronchi and trachea, which are then removed by coughing and suctioning.

Middle and lower lobes are cleared better with the head down, while the upper lobes are cleared better with the patients head up.

Becuase the patient is mostly upright, secretions are likely to accumulate in the lower lobes.

Bronchodilators or mucolytics may be administered before postural drainage to improve the drainage process.

Question 36

Describe nursing management of patients undergoing postural drainage.

Answer 36

Always keep in mind the medical diagnosis and the lobes involved, cardiac status, and any structural deformities of chest wall of spine.

Listen to the chest to identify areas that need drained before procedure, and listen after as well to confirm effectiveness of the procedure, teach the same thing for patients family at home.

For home use, objects may need to be used to help patient assume the correct position, such as pillows, cushions, or cardboard boxes.

Performed 2-4 times daily, before meals (prevents n/v and aspiration), and at bedtime.

Positions start with draining lower lobes then move to upper lobes.

Question 37

Describe nursing management of patients undergoing postural drainage CONT…

Answer 37

Make the patient as comfortable AS POSSIBLE in each postition

emesis basin, sputum cup, and paper tissues

10-15 minutes in each position breath slow in nose out mouth (pursed lips)

If a position cant be tolerated, the nurse may help the patient assume a modfied position

Make sure to tell the patient to cough and remove secretions when changing positions, if patient cant cough suction may be used, if suction is needed at home be sure to teach proper technique for use and care of equipment

Chest percussion and vibration may be needed to loosen mucous plugs and secretions that adhere to the bronchioles and bronchi.

Oxygen may be needed during this procedure

If the sputum is foul smelling the procedure may be performed in a private room away ftom other patients and family members. There are doederizers to counteract smell, but the aerosol can cause bronchospasm and irritation so it should be used cautiously and sparingly.

Question 38

What does the nurse do after postural drainage is finished?

Answer 38

note the amount, color, viscosity, and character of sputum.

Evaluation of skin color and pulse for the first few procedures.

Brushing teeth and mout wash before resting is considered refreshing after the procedure.

Question 39

What is chest percussion and vibration (CPT)?

Answer 39

This is the use of percussion or vibration against the chest to loosen up thick secretions in the respiratory tract.

Vibration is usually accomplished by use of a HFCWO vest (high-frequency-chest-wall-oscillation vest)

Hydration, coughing, and clearing sputum can help minimize secretions.

Percussion - cupping of hands and lightly striking chest wall in rhythmic fashion over area that needs to be drained, alternately flex and extend wrists so that chest is cupped and clapped in painless manner.

Vibration - manual compression and tremor of chest wall during exhalation

Question 40

Describe nursing management of chest percussion.

Answer 40

Percussion: a soft cloth or towel may beplaced over the skin to help with irritation from contact.

Percussion alternating with vibration is performed for 3-5 minutes for each position.

Diaphragmatic breathing to promote relaxation

Question 41

Where and when should chest percussion NOT be used or be used cautiously?

Answer 41

Where to avoid: chest tubes, sternum, spine, liver, kidneys, spleen, or breasts (in women).

Who to be cautious of: chest percussion in older adults (osteoperosis and risk for rib fracture)

Question 42

Describe the nursing management of chest vibration.

Answer 42

After three or four vibrations the patient is encuraged to cough.

The number of cycles performed is dependent on client response and tolerance.

Evaluate breath sounds before and after

HFCWO vest, inflatable vest uses air pulses to compress chest wall 8-18 times/second

Vest therapy is usually much more tolerated and preferred than manual CPT and is considered equally as effective, although the patients specific needs and preferences still need to be considered.

There are also vibropercussion mattresses that may rotate the torso up to 45 degrees

Flutter valve for patients with CF (looks like pipe with cap over bowl) to help decrease viscocity of mucous

Question 43

What are some nursing considerations for patients receiving chest percussion and vibration?

Answer 43

Make sure the client is conmfortable, not wearingt restrictive clothing, has not just eaten.

GIve medication for pain and splint any incisionsand provide pillows for support.

For HFCWO the patient may be in whatever position and may even be participating in light activity within the length of the hose

STOP HFCWO: if client experiences increase pain, SOB, weakness, lightheadedness, hemoptysis

Therapy is indicated until the patient has normal respirations, can mobilize secretions, normal breath sounds, and chest x-rays come back normal

Question 44

What is breathing retraining?

Answer 44

exercises and breathing practices that are designed to achieve more efficient and controlled ventilation and to decrease the work of breathing. This is especially indicated in patients with COPD and dyspnea (slow, relaxed, rhythmic). These techniques include diaphragmatic and pursed-lip breathing.

Breathing exercises may require additional oxygen, emphysema like changes may occur as part of the natural aging process in the lungs, this means that breathing exercises are appropriate for all older adult patients, whether hospitalized or not, sedentary, even without primary lung disease.

Question 45

What are some nursing management techniques for breathing retraining?

Answer 45

Slow and rhythmic breathing in a relaxed manner, empty the lungs completely,always inhale through nose.

If SOB, patient should focus on length of exhalation, this will avoid increase in SOB and panic

Adequate dietary intake promotes gas exchange and increase energy levels, no small frequent snacks, ready-prep meals and favorite foods being available helps encourage nutrient consumption

Rest beforeand after meals to conserve energy

Gas-producing foods should be avoided: beans, legumes, broccoli, cabbage, and brussel sprouts, these produce gastric distress

Question 46

What positions of postural drainage drain which part of the lungs?

Answer 46

REVIEW CHART 21-3

Question 47

What are some patient education points on self-care using oxygen therapy?

Answer 47

Gas and liquid forms come in portable devices so patient can leave home while using

humidity must be provided while oxygen is used (except with portable devices) to counteract dry, irritating effects of oxygen on the airway

REVIEW CHART 21-2 on page 498

Question 48

What are the purposes of an ET tube?

Answer 48

Intubation provides a patent airway while the patient is experiencing respiratory distress that cant be treated with simpler methods and is the method of choice in emergency care.

It is a means of providing an airway for:

• patients that cant maintain an airway on their own (comatose, UAO)
• patients needing mechanical ventilation
• suctioning of secretions from the pulmonary tree

Question 49

What are some complications that can occur with use of an ET tube?

Answer 49

Trachial bleeding, ischemia, and pressure necrosis can occur with too much pressure of the cuff of the tube. Pressure should be maintained between 15-20 mmHg.

Aspiration pneumonia can occur is pressure of the cuff is not high enough.

Cough reflex is depressed due to glottic closure and secretions are usually thicker because of the bypass of warming and humidifying effect of upper airway.

Swallow reflex is supressed becuase of the mechanical trauma and disuse, this inceases the risk for aspiration or microaspiration which can lead to VAP (ventilator associated pneumonia)

Ulceration and stricture of the larnyx or trachea may develop.

Patient has great concern for inability to talk or communicate needs.

Unintentional or premature removal of tube can be life-threatening, this occurs usually during nursing care of by the patient (this can cause laryngeal swelling, hypoxemia, bradycardia, or death).

Question 50

Describe nursing management of patients with ET tubes.

Answer 50

Routine deflation is NOT recommended because of increase risk for aspiration and hypoxia.

Oxygen should be warm and humidified ALWAYS

No longer than 14-21 days, a tracheostomy should be considered after this time to decrease trachial trauma and irritation, prevent vocal cord parlysis, and decrease the work of breathing.

ENSURE TO TELL FAMILY THE IMPORTANCE OF TUBE AND THE DANGERS OF REMOVAL.

Ensure to obtain baseline function and conduct an ongoing assessment of the patient to make sure care is effective.

Comfort measures: opioids and sedation can improve tolerance to tube. Also one-to-one interaction or television can help distract.

Restraints are not needed: If the patient cannot move arms or hand, or is a/o and cooperative to follow directions to where it is highly unlikely that they wil remove tube themselves.

Soft wrist restraints may be required if patient is at risk for self-removal. Rationale for restraints needs to be documented and told to family members. LIMITED TO NO LONGER THAN 24 HOURS. Closely monitor patient to ensure safety and prevent harm.

REVIEW CHART 21-7 P. 505