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Chapter 30. Care of Patients Requiring Oxygen Therapy or Tracheostomy. Mrs. Marion Kreisel MSN, RN NU230 Adult Health 2 Fall 2011. Oxygen Therapy. Hypoxemia — low levels of oxygen in the blood Hypoxia — decreased tissue oxygenation
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Chapter 30 Care of Patients Requiring Oxygen Therapy or Tracheostomy Mrs. Marion Kreisel MSN, RN NU230 Adult Health 2 Fall 2011
Oxygen Therapy • Hypoxemia—low levels of oxygen in the blood • Hypoxia—decreased tissue oxygenation • Goal of oxygen therapy—to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects
Hazards and Complications of Oxygen Therapy • Combustion • Oxygen-induced hypoventilation • Oxygen toxicity • Absorption atelectasis • Drying of mucous membranes • Infection
Low-Flow Oxygen Delivery Systems • Nasal cannula • Simple facemask
Low-Flow Oxygen Delivery Systems (Cont’d) • Partial rebreather mask • Non-rebreather mask
High-Flow Oxygen Delivery Systems • Venturi mask • Face tent • Aerosol mask • Tracheostomy collar • T-Piece
Noninvasive Positive-Pressure Ventilation • Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation • BiPAP—mechanical delivery of set positive inspiratory pressure each time the patient begins to inspire; as the patient begins to exhale, the machine delivers a lower set end-expiratory pressure, together improving tidal volume. • CPAP—continuous positive airway pressure
Continuous Nasal Positive Airway Pressure • Technique delivers a set positive airway pressure throughout each cycle of inhalation and exhalation. • Effect is to open collapsed alveoli. • Patients who may benefit include those with atelectasis after surgery or cardiac-induced pulmonary edema; it may be used for sleep apnea. Assess pt for improved sleep. If not make sure patient is using the CPAP on a regular basis.
Transtracheal Oxygen Delivery • Used for long-term delivery of oxygen directly into the lungs • Avoids the irritation that nasal prongs cause and is more comfortable • Flow rate prescribed for rest and for activity
Home Oxygen Therapy • Criteria for home oxygen therapy equipment • Patient education for use: • Compressed gas in a tank or cylinder • Liquid oxygen in a reservoir • Oxygen concentrator
Tracheostomy • Tracheotomy is the surgical incision into the trachea for the purpose of establishing an airway. • Tracheostomy is the stoma, or opening, that results from the procedure of a tracheotomy. • Procedure may be temporary or permanent.
Interventions • Preoperative care • Operative procedures • Postoperative care—ensure patent airway • Possible complications assessment: • Tube obstruction • Tube dislodgment—accidental decannulation
Other Possible Complications Assess for: • Pneumothorax • Subcutaneous emphysema • Bleeding • Infection
Tracheostomy Tubes • Disposable or reusable • Cuffed tube or tube without a cuff for airway maintenance • Inner cannula disposable or reusable • Fenestrated tube
Care Issues for the Tracheostomy Patient • Prevention of tissue damage: • Cuff pressure can cause mucosal ischemia. • Use minimal leak technique and occlusive technique. • Check cuff pressure often. • Prevent tube friction and movement. • Prevent and treat malnutrition, hemodynamic instability, or hypoxia.
Air Warming and Humidification • The tracheostomy tube bypasses the nose and mouth, which normally humidify, warm, and filter the air. • Air must be humidified. • Maintain proper temperature. • Ensure adequate hydration.
Suctioning • Suctioning maintains a patent airway and promotes gas exchange. • Assess need for suctioning from the patient who cannot cough adequately. • Suctioning is done through the nose or the mouth. • Suctioning can cause: • Hypoxia (see causes to follow) • Tissue (mucosal) trauma • Infection • Vagal stimulation and bronchospasm • Cardiac dysrhythmias from hypoxia caused by suctioning
Causes of Hypoxia in the Tracheostomy • Ineffective oxygenation before, during, and after suctioning • Use of a catheter that is too large for the artificial airway • Prolonged suctioning time • Excessive suction pressure • Too frequent suctioning
Possible Complications of Suctioning • Tissue trauma • Infection of lungs by bacteria from the mouth • Vagal stimulation—stop suctioning immediately and oxygenate patient manually with 100% oxygen • Bronchospasm—may require a bronchodilator
Tracheostomy Care • Assessment of the patient. • Secure tracheostomy tubes in place. • Prevent accidental decannulation. • Patient may shower as long as they are careful not to get water into the stoma.
Bronchial and Oral Hygiene • Turn and reposition every 1 to 2 hr, support out-of-bed activities, encourage early ambulation. • Coughing and deep breathing, chest percussion, vibration, and postural drainage promote pulmonary cure. • Oral hygiene—avoid glycerin swabs or mouthwash that contains alcohol; assess mouth for ulcers, bacterial or fungal growth, or infections.
Nutrition • Swallowing can be a major problem for the patient with a tracheostomy tube in place. • If the balloon is inflated, it can interfere with the passage of food through the esophagus. • Elevate the head of bed for at least 30 minutes after the patient eats to prevent aspiration during swallowing.
Speech and Communication • Patient can speak with a cuffless tube, fenestrated tube, or cuffed fenestrated tube that is capped or covered. • Patient can write. • Phrase questions to patient for “yes” or “no” answers. • A one-way valve that fits over the tube and replaces the need for finger occlusion can be used to assist with speech.
Weaning from a Tracheostomy Tube • Weaning is a gradual decrease in the tube size and ultimate removal of the tube. • Cuff is deflated as soon as the patient can manage secretions and does not need assisted ventilation. • Change from a cuffed to an uncuffed tube. • Size of tube is decreased by capping; use a smaller fenestrated tube. • Tracheostomy button has a potential danger of getting dislodged.
Question 1 Nitrogen gas makes up what percentage of room air? • 10% • 21% • 49% • 79%
Question 2 What is a possible outcome when oxygen delivery is combined with smoking? • The oxygen will burn. • An explosive effect will be produced. • The combustion process will be supported and enhanced. • The combustion process will be sped up.
Question 3 What complication would the patient with a cuffed tracheostomy be at risk for developing? • Tracheomalacia • Pneumothorax • Subcutaneous emphysema • Trachea–innominate artery fistula
Question 4 A patient who is hypoxemic also has chronic hypercarbia (increased Paco2 levels). What is the appropriate flow of oxygen delivery for this patient? • 1 L/min via nasal cannula • 4 L/min via nasal cannula • 6 L/min via nasal cannula • 40% oxygen via Venturi mask
Question 5 A patient experiences vagal stimulation during deep tracheal suctioning. The nurse would expect to see: • Severe tachycardia • Severe bradycardia • Hypertension • Bronchospasm