O2 Therapy, ETTs & Chest Tubes

Question 1

S/S of O2 toxicity

Answer 1

dyspnea
nonproductive cough
chest pain beneath sternum
GI upset
crackles on auscultation (due to lack of nitrogen to keep alveoli open)

Question 2

FiO2 delivered: nasal cannula

Answer 2

24% @ 1L / min (add 4% for each add'l L)
28% @ 2L / min
32% @ 3 L / min
36% @ 4 L / min [begin humidifying]
40% @ 5 L / min
44% @ 6 L / min

Question 3

FiO2 delivered: simple face mask

Answer 3

Must be set at minimum of 5L / min to flush mask of CO2

• 40% @ 5 L/min
• 45-50% @ 6 L/min
• 55-60% @ 8 L/min

Question 4

FiO2 delivered: Partial Rebreather Mask

Answer 4

60-75% at 6-11 L/min

- reservoir bag must be 2/3 full during inspiration & expiration

Question 5

FiO2 delivered: non-rebreather mask

Answer 5

80-95% @ a flow rate high enough to maintain reservoir bag 2/3 full

Question 6

Venturi mask (Venti)

Answer 6

• considered high-flow O2 delivery
  24-50% FiO2 @ 4-10 L/min
• delivers most accurate O2 level w/o intubation
• no humidity needed

Question 7

High-flow O2 delivery systems

Answer 7

1. face tent
2. aerosol mask
3. tracheostomy collar
4. T-collar

Question 8

Assist-control (AC)

Answer 8

who: weak and critically ill

provides most ventilator support

Question 9

O2 toxicity - when

Answer 9

O2 level > 50% for 24-48 hours may damage lungs

Monitor ABGs - if PaO2 > 90 mmHg = notify provider

Question 10

Oxygen induced Hypercarbia - s/s

Answer 10

COPD patients at risk
ABGs = acidic (retaining CO2)
Patient will be hypoventilating (shallow breath)
Monitor K+ = increases w/acidosis
s/s = deceased RR, decreased LOC

Question 11

nursing interventions for intubation

Answer 11

Document:

1. tube size
2. cuff pressure
3. lung sounds & movement
4. position @ lips/teeth

Question 12

cuff pressure monitoring

Answer 12

1. cuff inflation – inject air until no leak is heard at peak inspiration
   * disadvantage - generates higher cuff pressures (tracheal necrosis)
   * advantage - less risk for aspiration/better seal
2. every shift
3. pressure = 20-25 mmHg

Question 13

ETT troubleshooting: DOPEY

Answer 13

Displaced: esophagus, R mainstem
Obstructed: secretions, blood, kink
Pneumothorax
Equipment: malfunction, O2, ETT, ventilator
You: your approach, technique: missing something?

Question 14

Endotracheal suctioning - when?

Answer 14

coughing
secretions in airway
respiratory distress
rhonchi on auscultation
increased PIP on ventilator
decreased SsO2 or PaO2

Question 15

suctioning technique

Answer 15

1. sterile procedure
2. Suction no greater than 120-150
3. duration of each pass: 5-10
4. # of passes: 3 or less
5. apply suction only during w/drawal
6. hyperoxygenate before AND after
7. suction prior to paralytics

Question 16

signs of too much suctioning/complications

Answer 16

• hypoxemia
• atelectasis
• bronchospasm
• dysrhythmias (bradycardia, PVC)
• decreased BP
• airway trauma
• pneumonia

Question 17

Extubation procedure

Answer 17

1. thoroughly suction trachea, oropharynx, and nasopharynx
2. elevate HOB, hyperoxygenate, auscultate
3. tell pt to take deep breath - at peak inspiration, deflate cuff & remove tube rapidly
4. tell pt to cough; suction as pt coughs
5. give pt NC or facemask = usually 10% higher than was on ETT
6. encourage voice rest - will be hoarse for awhile
7. use spirometer

Question 18

after extubation - monitor for?

Answer 18

• stay in pt’s room/don’t leave unattended!
• respiratory distress or s/s of airway occlusion
• monitor SaO2, BP, pulse and patient effort
• Semi-Fowler’s position

Question 19

post-extubation complications

Answer 19

• hoarseness/vocal cord paralysis
• sore throat
• dysphagia
• tracheal stenosis
• laryngeal incompetence
• laryngospasm - MEDICAL EMERGENCY

Question 20

chest tube drainage systems

Answer 20

Three bottle system

1. drainage chamber
2. water-seal chamger
3. suction control chamber

Question 21

CT drainage chamber

Answer 21

collection chamber

• easy measurement
• recording of time
• date/amt of drainage

Question 22

CT water-seal chamber

Answer 22

• maintain 2 cm sterile water (pressure)
• if bubbling in water-seal chamber
  = air leak (air drainage from pt)
• air leak monitor = approx degree of air leak from chest cavity (1-low, 7-high)

Question 23

CT air leak

Answer 23

• continuous bubbling in water seal chamber
• clamp CT close to dressing
  = if bubbling stops = air leak is at site of CT insertion or w/in chest (ASSESS INSERTION SITE AND CT POSITION)
  = if bubbling continues = air leak is between clamp and drainage system (REPLACE DRAINAGE SYSTEM AND TUBING)

Question 24

CT: tidaling

Answer 24

fluctuation in water-seal

• during inspiration: fluid level goes UP
• during expiration: fluid level goes DOWN

If absent: occluded CT or lungs fully expanded (good!)

• *mechanical vent: reversed
• during inspiration: fluid level goes DOWN
• during expiration: fluid level goes UP

**mediastinal chest tube: NO TIDALING

Question 25

CT - suction control chamber

Answer 25

WET SUCTION CONTROL - fill sterile water to 20 cm (-20 cm H2O suction pressure) - NORMAL: gentle bubbling when connected DRY SUCTION CONTROL - higher suction pressures - set suction control on dial (-20 cm H2O) - orange float will appear - NORMAL: no bubbling

Question 26

CT - clamp the tube?

Answer 26

NO - could cause tension pneumothorax May clamp if: 1. assessing for an air leak 2. prior to removing CT 3. pleurodesis

Question 27

NI for Chest Tubes

Answer 27

- assess breath sounds Q4H - reposition pt. who reports a "buring" pain in the chest - avoid kinks in tubing - keep system lower than chest level - check and document drainage - amt, color, characteristics NOTIFY MD IF: - O2 sats < 90% - drainage is >70 ml/hr OR STOP - tube falls out of chest (cover w/sterile dressing) - tube disconnects from drainage system (place end of tube in sterile water)