Lesson 9: Patient Care (3)

Question 1

The body’s need for oxygen

Answer 1

• every cell in the body needs a constant supply of oxygen to work properly

Question 2

Pathway for oxygen (respiratory system)

Answer 2

• oxygen enters the body when a person inhales
• upon inhalation, the air is brought into the lungs
• the oxygen moves into the lungs, then into the bronchus, and finally into the alveoli
• oxygen meets with the cardiovascular system entering the pulmonary venules which take oxygen-rich blood from the lungs to the heart

Question 3

Pathway for oxygen (cardiovascular system)

Answer 3

• from the heart, the arterial system takes the blood to all cells of the body

Question 4

Pathway for oxygen (cellular level)

Answer 4

• in the cells, the metabolic reactions use the oxygen creating metabolic waste, carbon dioxide
• carbon dioxide exits the blood into the venous system and eventually out through the lungs during exhalation

Question 5

What protein in red blood cells carry the oxygen to the body’s cells and tissues?

Answer 5

Hemoglobin

Question 6

List the possible reasons as to why a patient might not be getting sufficient oxygen into the blood.

Answer 6

1. There is insufficient oxygen in the air the patient is breathing
2. The patient’s breathing is not sufficient to bring in enough oxygen into the body to meet the body’s needs
3. The lungs do not work sufficiently to allow oxygen to move from the incoming air into the blood; This could be a lung problem or a nervous system problem
4. There is insufficient blood to move a sufficient amount of blood to the cells
5. There is insufficient or blocked hemoglobin to carry a sufficient amount of blood to the cells

Question 7

Hypoxia

Answer 7

A state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis
- results from hypoxemia

Question 8

Hypoxemia

Answer 8

Inadequate oxygen delivery to the tissues because of low blood supply or low oxygen content in the blood

Question 9

Signs and symptoms of hypoxia

Answer 9

1. Apprehension, anxiety, restlessness
2. Decreased ability to concentrate
3. Decreased level of consciousness
4. Increased fatigue
5. Vertigo
6. Behavioral changes
7. Increased pulse rate
   
   • as hypoxia advances, slow pulse rate or bradycardia, occurs which in turn results in additional decreased oxygen saturation
8. Increased rate and depth of respiration
   
   • as hypoxia progresses, respirations become shallow and slower as apnea develops
9. Elevated blood pressure
10. Cardiac dysrhythmias
    
    • abnormal rhythms of the heart
11. Pallor
    
    • pale appearance
12. Cyanosis
13. Digits clubbing
    
    • a deformity of the finger or to nails occurring with chronic hypoxia
14. Dyspnea
    
    • difficult or labored breathing

Question 10

What is necessary for the patient’s body to do before the provider orders oxygen?

Answer 10

The patient must have sufficient oxygen in the blood stream AND it must be consistent
- the body cannot store up oxygen and it cannot catch up if oxygen is insufficient for a long time

Question 11

In addition to physical examination, the physician will perform which five tests to determine the patient’s blood oxygen?

Answer 11

Oximetry, arterial blood gas measurement, sleep oxygen tests, rest/walking tests, high altitude tests

Question 12

Signs and symptoms of poor oxygen saturation

Answer 12

1. Difficulty catching breath
2. Bluish color in nails, face, or lips
3. Racing pulse
4. Tightness or pain in chest
5. A cough that gets worse over time
6. General feeling of discomfort and restlessness

Question 13

Who starts oxygen therapy?

Answer 13

A licensed physician must order the oxygen therapy, and the respiratory therapist, CRT/RRT, nurse, EMT in the field, or any other licensed healthcare provider may start it

Question 14

Respiratory care department

Answer 14

Most hospitals and residential facilities have a staff of respiratory therapists who assume the responsibility of administering oxygen and delivering treatments designed to improve a patient’s ventilation and oxygenation

Question 15

Policies related to oxygen administration

Answer 15

• Oxygen therapy must be ordered by a healthcare provider. Oxygen is considered to be a drug; therefore, it must be treated as prescribing of a drug. The physician will order the rate and method of administration
• Oxygen therapy must be closely monitored by the nurse to ensure proper administration and safety of the patient. Since oxygen is considered to be a drug, it should be administered as a drug by qualified nursing staff
• A PCT’s role may be to monitor a patient on oxygen. Under the supervision of the nursing staff, a PCT my be asked to assist in oxygen administration.
• Oxygen administration requires the critical thinking skills of a qualified nurse. The nurse is responsible for ensuring the oxygen is administered in the correct manner, with the correct equipment, in the correct flow rate. The nurse is also responsible for monitoring the patient;s response to oxygen therapy.
• Correct placement and adjustment of oxygen devices may be may be delegated to unlicensed assistive personnel such as PCT
• The care provider must be instructed about the possible complications and outcomes associated with oxygen delivery
• Care providers must report any complications or changes in the patient to the nurse immediately

Question 16

The normal blood oxygen level is:

Answer 16

92 - 100%

Question 17

True or False: Any care provider can give a patient oxygen if it is deemed necessary for a patient’s well-being.

Answer 17

False

Question 18

Patient positioning

Answer 18

This can impact their ability to breathe.
- side-lying position may be the best positon to pace a patient if their is something obstructing their airways
- This must be approved by a provider and nursing staff

Question 19

Preparation for the patient’s coughing and breathing exercises

Answer 19

1. Verify with the nurse the procedure to be performed
2. Introduce yourself to the patient including your name and title or role
3. Properly identify the patient by checking his or her identification bracelet and requesting that the patient state his or her name, date of birth, or both. Use the facility’s protocol for identifying patients.
4. Explain the procedure to the patient. Do this in a way that the patient understands. Advise the patient of anything that might be uncomfortable related to the procedure. Allow time for the patient to ask questions. If you cannot answer a question, contact your nurse.
5. Determine the need for and provide patient education before and during the procedure. Notify the nurse of any additional educational needs.
6. Perform hand hygiene and don clean gloves according to your facility policy and guildines from the Centers of Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA).
7. Assemble the equipment. Close the door or pull the privacy curtain around the patient’s bed. Raise the bed to a comfortable working height and lower the side rail on the side nearest to you. Position and drape the patient as necessary.

Question 20

Procedure to assist the patient with coughing and deep breathing exercises

Answer 20

1. Assist the patient into a semi-Fowler’s position, sitting on the side of the bed, or standing position. Upright positions facilitate diaphragmatic movement.
2. Stand or sit facing the patient to observe you so they understand how to perform the breathing exercise.
3. Instruct the patient to place the palms of hands across from each other, down and along lower borders of their anterior rib cage. Instruct the patient to place the tips of the fingertips lightly together.
4. Show the patient how to take slow, deep breaths, nhaling through the nose and pushing the abdomen against the hands. Have the patient feel the middle fingers separate during inhalation. Explain to the patient that they will feel normal downward movement of the diaphragm while inhaling and that the abdominal organs will move down and the chest wall will expand.
5. Tell the patient to avoid using their chest and shoulders while inhaling.
6. Repeat the complete breathing exercises three to five times or as instructed by your nurse supervisor or physician.
7. Encourage the patient to practice this exercise by taking 10 slow, deep breaths every hour while awake.

Question 21

Performing coughing exercises

Answer 21

1. If the patient has a surgical incision on either the throat or the abdomen, teach the patient to place a pillow or bath blanket over the incision area and place hands over the pillow to splint the incision. The patient should press gently against the incisional area for splinting and support.
2. Demonstrate the coughing exercise. Instrcut the patient to take two slow, deep beaths, inhaling through the nose and exhaling through the mouth.
3. Show the patient how to inhale deeply a third time and hold the breath for a count of three, The patient should cough fully for two or three coughs without inhaling between coughs. Tell the patient to try to push all of the air out of the lungs.
4. Make sure the patient understands the difference between clearing the throat and coughing. The patient should cough rather than clearing the throat.
5. Ask the patient to practice the coughing exercise two or three time every two hours while awake.
6. Instruct the patient to look at the sputum, or mucus, each time for consistency, odor, amount and color changes. The patient should report any changes to you or the nurse.
7. Return the patient to bed or to a place where they are comfortable. Properly remove your drugs. Properly perform hand hygiene.

Question 22

incentive spirometer

Answer 22

This is a device used to help the patient keep the lungs healthy and helps patients learn how to take slow, deep breaths.
- A patient’s provider may recommend that a patient use this after surgery or when you have a lung illness, like pneumonia

Question 23

Parts of an incentive spirometer

Answer 23

1. marker/indicator: the provider may indicate the breathing goals for the patient
2. piston: this rises inside the device and measures the volume of the inspired air
3. coach indicator: use the coach indicator to guide the breathing. Slow down breathing goes above the marked area. Speed up the breathing if the indicator does not reach the marked area, The goal is to keep the ball between the arrows.
4. mouthpiece: the lips should form a tight seal around the mouthpiece. Disinfect the mouthpiece before and after each use.
5. flexible tubing: the flexible tubing connects the mouthpiece to the spirometer
6. handle: the patient should keep a firm grip on the handle and position the device so they can see the indicators
7. volume measurement: total volume of the breath is measured in millimeters

Question 24

Using an incentive spirometer

Answer 24

1. As with deep breathing and coughing exercises, perform hand hygiene and don gloves, introduced yourself to the patient, and properly identify the patient. Explain what you are going to do and why using the device is helpful
2. If possible and approved by the nursing staff, assist the patient in sitting up or in a semi-Fowler’s position. Give the spirometer to the patient and show them how to old the device.
3. Show the patient how to place the mouthpiece of the spirometer in his or her mouth. Make sure they have formed a good seal over the mouthpiece with their lips.
4. Instruct the patient to breath out (exhale) normally and then to breathe in (inhale) slowly. Show them how the small ball inside the spirometer rises as they breathe in. The goal is to get this pice to rise as high as possible. The provider may place a marker on the device to indicate how high the ball should be moved indicating the breathing goal.
5. Explain that the goal should be to make sure the ball or disk stays in the middle of the chamber while breathing. If the patient breathes in too fast, the ball will shoot to the top. If the patient breathes in too slowly, the ball will stay at the bottom.
6. The patient should hold their breath for 3 to 5 seconds. Then, they should slowly exhale.
7. The patient should take 10 to 15 breaths using the spirometer every 1 to 2 hours or as often as instructed by the physician.

Question 25

Tips for the incentive spirometer

Answer 25

• If the patirnt has a surgical incision in the chest or abdomen, it may be helpful to hold a pillow tightly while inhaling to ease discomfort
• Encourage the patient to not be discouraged if they can not make the breathing goal indicated by the provider. Breathing will improve with practice and as the body heals
• If the patient begins to feel dizzy or lightheaded, remove the mouthpiece from the patient’s mouth and instruct them to take some normal breaths. When the dizziness clears, continue with the incentive spirometer.

Question 26

Parts of an oxygen wall unit and flow regulator

Answer 26

1. oxygen wall outlet: most hopsital and similar healthcare facilities have a wall outlet for oxygen. These are colored green. There may be other types of outlets in the vicinity, such as a vacuum or medical air.
2. oxygen regulator: the nurse or respiratory therapist will attach the regulator to the wall oxygen outlet
3. humidifier: if using a high flow, a humidifier is commonly attached to the flow meter to help avoid the drying of the patient’s mucosa in the mouth and nose
4. tubing: the tubing is attached to either the humidifier or directly to the flow regulator if a humidifier is not used.
5. on/off knob: typically, turning the knob to the right(clockwise) turns the oxygen off and turning to the left (counterclockwise) turns to the oxygen on. The knob is usually marked with on and off notations.
6. measurement ball: the patient should keep a firm grip on the handle and position the device so they can see the indicators.

Question 27

nasal cannula

Answer 27

This is a simple, two-pronged plastic device used to deliver low concentrations of oxygen; It is a long slender tube that runs from the oxygen tank to the small plastic prongs that fit into the resident’s nostrils.
- The two prongs that project from the end of the nasal cannula thing are placed about 1/2 inch into the resident’s nostrils after oxygen has been turned on
- Do not use petroleum jelly (Vaseline) as a lubricant to prevent irritation of nares.
- Producing a water-soluble lubricant is necessary.
- This method supplies oxygen at low concentrations (22 - 30%) at flow rates of 1 to 5 liters per minute
- Major concerns associated with use of nasal cannula when the oxygen administration flow rate os above 8 liters per minute are
1. the resident has a tendency to swallow air
2. the nasal or pharyngeal passage becomes irritated
- Instrcut the resident to breath through the nose
- Inspect the nares for irritation as well as behind the ears where skin breakdown can occur from continuous contact with the tubes delivering the oxygen
- Monitor the liter flow to ensure the physician’s order is followed and the flow has not been changed/increased by the resident or a visitor (unqualified individuals)
- It allows the patient to eat and talk normally
- Used for all age groups
- One way to administer oxygen to the patient

Question 28

Parts of the nasal cannula

Answer 28

1. prongs: the prongs are inserted into the patient’s nostrils (nasal openings)
2. tubing: the tubing is looped over the nasal ears
3. toggle or slide: the toggle is adjusted to helps secure the cannula on the patient
4. tubing: the tubing is typically long to allow for easy connection to an oxygen tank or to the wall unit in hospital
5. flow regulator connection: this end connect to the oxygen flow regulator on the wall or on an oxygen tank

Question 29

oxygen mask

Answer 29

Masks are typically used when igher oxygen concentrations are needed
- Another method of administering oxygen

Question 30

Parts of a venturi mask

Answer 30

1. mask: the mask covers the patient’s nose and mouth
2. exhalation ports: the holes on the sides of the mask allow the patient to exhale
3. metal nose piece: the metal piece at the top of the mask helps seal the mask over the nose
4. strap: the strap is placed onto the patient’s head to help secure the mask in place
5. oxygen inlets or inhalation port: this moves oxygen from the oxygen source into the mask
6. tubing: the tubing is attached to the oxygen source. It is usually very long to allow the patient to move without hindering the oxygen flow.
7. Venturi barrel: this compartment provides a predetermined and fixed concentration of oxygen so that the patient;s respiratory pattern does not affect the concentration of oxygen

Question 31

Rebreather mask

Answer 31

This is designed so that the patient inhales some of the exhaled carbon dioxide to stimulate breathing

Question 32

Parts of a rebreather mask

Answer 32

1. mask: the mask covers the patient’s nose and mouth
2. exhalation ports: the holes on the sides of the mask allow the patient to exhale
3. metal nose piece: the metal piece at the top of the mask to help seal the mask over the nose
4. strap: the strap is placed onto the patient’s head to help secure the mask in place
5. oxygen inlets or inhalation port: this moves oxygen from the oxygen source into the mask
6. reservoir: the reservoir saves one-third of a person’s exhaled air, while the rest of the air gets out via side ports covered with a one-way valve. This allows the person to re-breath some of the carbon dioxide. This acts as a way to stimulate breathing.

Question 33

oxygen cylinders

Answer 33

Patients in home health care often require oxygen and may use an oxygen cylinder
- Oxygen cylinders and equipment are delivered by a medical oxygen company
- Oxygen must be ordered by the physician
- Oxygen cylinders are green

Question 34

oxygen concentrators

Answer 34

A medical device that gives a patient extra oxygen; it pulls air in the room and filters out the nitrogen concentrating oxygen
- A physician may order a patient to use supplemental oxygen at home when the patient’s condition causes oxygen levels to dip too low for good health
- A humidifier may be added, not to dry out the patient’s membranes
- Some allow the patient to be very mobile and are battery operated

Question 35

Conditions requiring oxygen concentrators

Answer 35

asthma
lung cancer
COPD
flu
COVID-19

Question 36

Oxygen administration (1 - 9)

Answer 36

1. Verify with the nurse the procedure to be done. Introduce yourself to the patient, including your name and title or role.
2. Identify the patient by checking his or her identification bracelet and requesting that the patient state his or her name or both date, or both. Follow the identification protocols established by your facility.
3. Explain that you are administering oxygen therapy and why this is important in a way that the patient can understand. Allow time for the patient to ask questions. If you cannot answer a question or if the patient is asking a medical question, refer this to the provider or your nurse supervisor. Never answer medical questions.
4. Determine the need for patient education before the procedure. Educate the patient as needed. Notify the nurse if additional education is needed.
5. Perform hand hygiene and don clean gloves according to your facility’s protocol. Assemble equipment.
6. Close the door or pull the privacy curtain around the bed. Raise the bed to a c comfortable working height. Lower the side rail on the side nearest to you. Position the patient as necessary.
7. Explain the necessary precautions during oxygen therapy. Remind the patient that their visitors should also follow these precautions.
8. Ausculate lung sounds and observe for signs and symptoms of hypoxia or respiratory distress. Review laboratory reports of arterial blood gas levels. Determine the need to suction any secretions obstructing the airway. Notify the nurse if this is necessary.
9. Fill the humidifier container to the designated level. Humidify oxygen if the flow rate is greater than 4 L/min. Use only sterile water in the humidifier.

Question 37

Oxygen administration (10 - 18)

Answer 37

10. Attach the flowmeter to the humidifier. Insert the flow meter into the proper oxygen source. This may be a central oxygen outlet in the hospital room on the wall, a portable oxygen cylinder, r an oxygen concentrator. Verify that water is bubbling in the humidifier. If a humidifier is not being used, verify that oxygen is coming out of the tubing.
11. Administer te oxygen therapy using a mask or a nasal cannula as ordered by the provider. Attach the mask or nasal cannula tubing to the flow meter. Adjust the flow meter to 6 to 10 L/min to flush the tubing. Then adjust the flow rate to the prescribed amount. Place he mask or nasal on the patient properly.
12. For a nasal cannula, place padding between the strap and ears, if needed. Use lamb’s wool, gauzde, or cotton balls. Ensure the cannula tubing is long enough to all for patient movement. Regularly evaluate the cannula for obstruction.
13. Regularly evaluate the patient;s external nasal area, nares, and superior surface of both ears for skin impairment every 6 - 8 hours. Clena skin with cotton-tipped applicator as needed. Apply a water-soluble lubricant to the nares as needed, Maintain the solution in the humidifier container at appropriate level at all times.
14. For an oxygen mask, ensure the mask fits snuggly over the patient;s nose and mouth. There are several types of oxygen masks depending on the patient’s needs. Adjust the flow rate to the prescribed rate. Pad the patient’s skin under the elastic straps as needed.
15. Evaluate the skin under the mask every 2 - 4 hours. Clean and dry the skin as needed. Maintain the solution in the humidifier container at the appropriate level at all times.
16. When you have placed the nasal cannula or mask onto the patient, assist the patient to a comfortable position. Raise side rails of the bed and lower the bed to the lowest position.
17. Remove gloves and all protective barriers and dispose of properly. Remove and dispose of soiled supplies and equipment according to facility policies.
18. Report any unexpected outcomes to the supervising nurse. Document with following information: Date, time, method of oxygen delivery, evaluation of respiratory status, response to oxygen therapy, changes in healthcare orovider’s orders, adverse reactions to oxygen therapy.

Question 38

tracheostomy

Answer 38

This is an artificial opening made by a surgical incision into the trachea.
- It is created for patients who cannot breath independently or who experience apnea or who have some type of respiratory obstruction.
- It provides an open airway for the patient
- A tracheostomy tube is inserted into the opening and secured with tape wrapped around the patient’s neck
- Sterile guaze is them placed around the opening in the neck under the plastic rims fo the outer tube to protect the skin during the healing process of the wound

Question 39

Transtracheal oxygen delivery

Answer 39

A tracheal catheter is inserted directly into the trachea between the second and third tracheal cartilages
- It does no interfere with eating, drinking, or talking as the traditional tracheostomy tube does
Oxygen is delivered through the entire respiratory cycle to include both inhalation and exhalation
- No oxygen is lost to the atmosphere and it may be possible to decrease the flow rate for some patients, so this method is more economical
- This also allows patients to use portable oxygen delivery systems longer between refills
- Humidification is unnecessary

Question 40

Endotracheal tube

Answer 40

Another way to create an artificial airway.
- This is a procedure (intubation) in which the physician places a breathing tube into the mouth and down the throat to provide oxygen via a machine because the patient cannot maintain their airway on their own because of illness or anesthesia.
- A person cannot go home when intubated.

Question 41

Caring for a tracheostomy

Answer 41

A PCT may be asked to assit in the care of a tracheostomy. Important care considerations include:
1. Evaluating the patient frequently for excess secretions and perform suction as needed.
2. Providing constant airway humidification
3. Changing all respiratory therapy equipment every 8 hours
4. Removing water that condenses in the equipment tubing
5. Providing frequent mouth care
6. Mainting nutritional levels via parenteral or enteral nourishment methods for those with enotracheal tubes
7. Patients with a tracheostomy may drink fluids and eat food in some cases. Follow the faciltiy’s policies. The patient must have a specific type of tracheostomy tube to eat.
8. Turning and reposiitoning the patient every 2 hours to help with maximal ventilation and lung expansion
9. Keeping spare tracheostomy tubing at the bedside in case of malfunctioning tube
10. Encouraging family and friends to talk to the patient
11. Keeping a call light within the patient’s reach

Question 42

Procedure for caring for a tracheostomy

Answer 42

1. Verify with the nurse the procedure to be done. Introduce yourself to the patient, including your name and title or role
2. Identify the patient by checking his or her identification bracelet and requesting that the patient state his or her name or birth date, or both. Follow the identification protocols established by your facility.
3. Explain that you are caring for the patient’s tracheostomy and why this is important in a way that the patient can understand. Allow time for the patient to ask questions. If you cannot answer a question or ifthe patient is asking a medical question, refer this to the provider or your nurse supervisor. Never answer medical questions.
4. Determine the need for patient education before the procedure. Educate the patient as needed. Notify the nurse if additional education is needed.
5. Perform hand hygiene and don clean gloves according to your facility’s protocol. Assemble the equipment.
6. Close the door or pull the privacy curtain around the bed. Raise the bed to a comfortable working height. Lower the side rail on the side nearest to you. Position the patient in the semi-Fowler’s position. Check the patient’s tracheostomy for exudate, edema, and respiratory construction. Notify the nurse if needed.
7. Provide paper and pencil or a communication board for the patient so you can communicate with the patient during the tracheostomy care.
8. Position yourself at the head of the bed facing the patient. Always face the patient while cleaning and suctioning.
9. Auscultate lung sounds.

Question 43

Suctioning for a Tracheostomy (10 - 18)

Answer 43

10. Place a towel or prepackaged drape under the tracheostomy and across the patient’s chest.
11. Perform hand hygiene. Perpare the equipment and supplies on an over-the-bed table. Check the suction equipment and machine.
12. Open the suction catheter kit while maintaining sterility of all the contents. Leave the tip in its wrapper. Don sterile gloves. Open the basin fr the strile saline. Attach the end of the suction catheter to the suction machine tubing. Pick up the tubing from the machine with the nondominant hand. Fanfold or wrap the suction catheter around the dominant hand.
13. Use the nondominant hand to pour rinsing solution (sterile normal saline) into the basin. Turn on the suction machine with the nondominant hand.
14. Preoxygenate the patient by having the patient take several deep breaths. If the patient is receiving oygen, wait to remove the oxygen delivery system until just before suctioning. Suction the tracheal cannula.
15. Place your thumb over the suction control vent and place the tip of the suction catheter in the container of sterile rinse solution. WIthdraw the sterile rinsing solution through the catheter by placing your thumb over the suction control.
16. Remove your thumb from the suction control and advance the catheter until resistance is met. Then, withdraw the catheter approximately 1 cm. Apply intermittent suction by placing your thumb on and off the sucton control. Gently rotate the catheter as it is withdrawn. Suction for a maximum of 10 seconds at a time (never longer.)
17. Rinse the catheter wth sterile solution by suctioning the solution through it. Repeat as needed. Allow the patient to rest between each suctioning effort. If the patient was receiving oxygen, reapply it at the prescribed rate between each suctioning episode.
18. Turn off the suction and disposes of the catheter appropriately. Perform hand hygiene and auscultate lung sounds. Asisit the patient to a comfortable position and place needed items within reach. Remove PPE and perform hand hygiene. Document the procedure.

Question 44

Aftercare for suctioning tracheostomy (1 - 9)

Answer 44

1. If you are only caring for the tracheostomy, without suctioning, follow the pervious steps 1 - 9. Check the patient;s tracheostomy for sanguineous exudate, edema, and respiratory obstruction.
2. Perform suctioning if needed BEFORE performing tracheostomy care.
3. Place the patient in semi-Fowler’s position. Perform hand hygiene and position yourself at the head of the hed. Don a clean glove on your nondominant hand.
4. Remove the old dressing from around the tracheostomy stoma and discard it in an appropriate waste receptacle.
5. Prepare the equipment and supplies on an over-the-bed table. Open the tracheostomy cleaning kit with aeseptic technique. Apply one sterile glove to the dominant hand. Sterile gloves are typically packed in the basin.
6. Separate the basins with the dominant hand. Use the nondominant hand to pour cleansing solution (hydrogen peroxide) in one basin and the rinsing solution (sterile saline) in another basin. Some facilities may also use a third solution of half hydrogen peroxide and half normal saline to clean around the tracheostomy stoma. Follow your facility’s protocol.
7. With the nondominant had, unlock and remove the inner cannula. Place it in the hydrogen peroxide cleaning solution. Never remove the out cannula. If the outer annular is expelled by the patient, hofl the tracheostomy bag open and call for assistance. There should always be a sterile packaged hemostst and an extra sterile tracheostomy set available at the bedside.
8. Apply the second sterile glove or apply a new pair of sterile gloves if the old ones were contaminated.
9. Clean the inner cannula. Use a brush to clean inside and outside of the inner cannula. Place the inner cannula in the sterile normal saline solution. Pipe cleaners may be used to dry the inside of the inner cannula. Inspect the inner and outer areas of the inner cannula and remove any excess liquid. Insert the inner cannula and lock it into place.

Question 45

Aftercare for suctioning tracheostomy (10 - 18)

Answer 45

10. Clean the skin aorund the tracheostomy and the tabs of the outer cannula with hydrogen peroxide (or the half-and-half solution, if this is the policy of the facility) and cotton swabs. Always clean away from the opening. Use wipes that are free of lint.
11. If necessary, rinse the cleaning solution from the skin using a sterile 4x4 gauze. Place a dry, sterile dressing around the tracheostomy faceplate.
12. Change the cotton tapes holding the tracheostomy in place, if necessary. Thread the clean tie through the opening of the flange of the outer cannula alongside the old tie. You may need assistance. If you have help, untie one side of the cotton tape from the outer cannula and replace it with a clean one while the assistant stabilizes the tracheostomy tube.
13. Bring the clean tape under the back of the patient’s neck. If you do not have assistance, thread the tie through the opening in the opposite flange of the outer cannula alongside the old tie. If you have assistance, just remove the other side from the outer cannula and replace it with clean tape.
14. Tie the ends of the clean cotton tapes together in a knot at the side of the neck
15. Ausculate the lung sounds
16. Provide mouth care
17. Assist the patient into a comfortable position and place the needed items within reach. Raise side rails and lower the bed to its lowest position.
18. Remove PPE and perform hand hygiene. Document the procedure.

Question 46

Measuring oxygen saturation with an oximeter

Answer 46

An oximeter is used to asses a patient’s oxygen saturation. This is referred to as pulse oximetry (SpO2).
- This is an noninvasive measurement of arterial blood oxygen saturation, or the percent to which hemoglobin in the blood is bound with oxygen.

Question 47

Non-sealing mask O2 administration

Answer 47

This uses a long slender plastic tube that extends from the oxygen tank to a plastic mask shaped like a cup.
- This type of mask is advantageous fr residents who are unable to breathe solely through their nose
- Some makss have a metal clip that can be bent over the bridge of the resident’s now to secure the mask snugly
- The use of this must be ordered by a physician
- A major concern with the use of a face-mask is pressure and moisture accumulation on the resident’s face; report any redness or discoloration to the resident’s facial skin
- Monitor the liter flow to ensure the physician’s order is followed and the flow has not been changed/increased by the resident or a visitor (unqualified individual)
- Refer to facility policies and procedures addressing the frequency of mask/tubing change
- When not in use, the mask should be placed in a plastic bag for storage to prevent contamination.

Question 48

pulse oximeter

Answer 48

This is a probe with an LED connected by a cable to an oximeter.
- Uses two sensors and a light source to determine what percentage of oxygen is in the blood
- Each sensor detects for a different color of light.
- Oxygenated blood is a brighter shade of red than unoxygenated blood.
The device measures the difference between the two to determine the percentage of oxygen saturation
- The probe for the oximeter must be placed on a pulsing vascular bed
- It uses arterial blood for its reading.
- The device also
- The normal SpOidentifies pulse rate and displays pulse beats
- Most appropriate location for the probe is either the nail bed or earlobe
2 in a healthy individual is greater than 95%.
- An SpO2 less than 90% is considered to be a clinical emergency
- The pulse oximeter may be portable or may be connected to the vital sign monitor.

Question 49

Assessing oxygen saturation

Answer 49

1. Identify the factor that influences measurement of SpO2. These include oxygen therapy, respirator therapy, treatments, hemoglobin level, hypotension, temperature, and some medications.
2. Review the patient’s record for the healthcare provider’s order. Dtermine the pervious baseline SpO2 from the patient record, if available. Follow the facility’s procedure for measuring oxygen saturation.
3. Determine the most appropriate patient-specific site for probe placement. It may be the finger, earlobe, bridge of the nose, or forehead. Do this by measuring capillary refill. If capillary refill if greater than 2 seconds, select an alternative site. The site must be also free of moisture. It is best if the fingernails is free of polish or any crylic nail. Use the earlobe or orehead if the patient has tremors. You may need a tape-on probe.
4. Position the patient comfortably. Instruct the patient to breathe normally. Support the lower arm, if the finger is being used. If a finger is being used, remove the fingernail polish from the digit with acetone or polish remover.
5. Attach the sensor to the site. The clip on probe should not hurt, but should feel like a clothespin on the finger. Turn on the oximeter by activating the power.
6. Observe the pulse waveform/intensity display and audible beep. Correlate the oximeter oulse rate by taking the patient’s radial pulse. Leave the sensor in place until the oximeter readout reaches a constant value and the pulse display reaches full strength during each cardiac cycle. Tell the patient that an alarm will sound if the probe falls off.
7. If you are told to monitor SpO2 continuously, verify the SpO2 alarm limits are preset at a low of 85% and a high of 100%. Determine the limits for SpO2 and pulse rate as indicated by the patient’s condition. Verify that the alarms are on. Assess the skin integrity under the probe every 2 hours.
8. If you are to monitor the SpO2 intermittently or spot check it, remove the probe and turn the oximeter off after you have made the measurement. Store the sensor in an appropriate location.
9. Compare the measurement SpO2 with the patient’s previous baseline and acceptable SpO2 if indicated by the nurse. NOte use of oxygen therapy, which can affect the oxygen saturation.

Question 50

Safety precautions for oxygen use

Answer 50

1. No smoking! Oxygen is highly flammable. There should be no smoking in the room or area where people are using oxygen. Place “No Smoking” signs or “Oxygen in Use” signs (preferably both) in the patient’s room where they can be easily seen. This applies to home care. Certiainly the patient should not smoke oxygen. The other family members and visitors must not smoke either.
2. Avoid using electrical appliances. Electrical appliances like razors, electric blankets, hair dryers, and heating pads should not be used n the area where oxyen is being administered.
3. Secure oxygen delivery systems. When portable oxygen delivery systems are being used, such as a large tank or concentrator, they should be secured to prevent them from falling or tipping over. Oxygen tanks are heavy and can cause serious injury. Make sure that concentrators are placed in such a way that the patient does not trip over the device or the tubing.
4. Locate oxygen cylinders properly. Do no place oxygen cylinders near sources of heat such as radiators, stoves, fireplaces, lamps, heaters, etc.
5. Selest clothing carefully. Avoid clothing, linens, bedding, blankets, etc. that is not fire resistant.
6. Inspect electrical equipment. Inspect electrical equipment in the area to ensure it is functioning properly. All electrical equipment should be grounded with a 3-prong plug. This is especially important for the oxygen concentrator. Check the cords to ensure they are not frayed, tangled, or cluttered. Never overload a circuit.
7. Know the fire and evacuation procedures. Know the fire procedures for the facility, including how to safely evacuate and where the free extinguishers are located. In a home environment, you may need to create a fire and evacuation plan. Periodically inspect fire extinguishers to ensure that have not expired. Ensure that the fire/smoke alarms are functioning properly.
8. Follow the provider’s order. Always administer oxygen by the method and rate ordered by the healthcare provider. If you think that something should be changes, notify your nurse supervisor.
9. Avoid flammable products. Avoid products such as petroleum jelly, when oxygen is being administered. This also includes keeping grease or oils, alcohol, and flammable liquids out of the area far away from the oxygen.

Question 50

Oxygen therapy devices

Answer 50

Pulse oximetry, nasal cannula, non-sealing mask