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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

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Oxygen Therapy Hypoxemialow levels of oxygen in the blood Hypoxiadecreased tissue oxygenation Goal of oxygen therapyto use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects

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Oxygen Intake and Oxygen Delivery

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Hazards and Complications of Oxygen Therapy Combustion Oxygen-induced hypoventilation Oxygen toxicity Absorption atelectasis Drying of mucous membranes Infection

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Low-Flow Oxygen Delivery Systems Nasal cannula Simple facemask

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Low-Flow Oxygen Delivery Systems (Contd) Partial rebreather mask Non-rebreather mask

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High-Flow Oxygen Delivery Systems Venturi mask Face tent Aerosol mask Tracheostomy collar T-Piece

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Venturi Mask

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T-Piece

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Noninvasive Positive-Pressure Ventilation Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation BiPAPmechanical 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. CPAPcontinuous positive airway pressure

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Continuous Positive Airway Pressure (CPAP)

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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.

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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

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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

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Oxygen Therapy

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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.

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Tracheostomy

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Interventions Preoperative care Operative procedures Postoperative careensure patent airway Possible complications assessment: Tube obstruction Tube dislodgmentaccidental decannulation

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Other Possible Complications Assess for: Pneumothorax Subcutaneous emphysema Bleeding Infection

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Tracheostomy Tubes Disposable or reusable Cuffed tube or tube without a cuff for airway maintenance Inner cannula disposable or reusable Fenestrated tube

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Tracheostomy Tubes

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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.

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Cuff Pressures

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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.

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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

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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

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Possible Complications of Suctioning Tissue trauma Infection of lungs by bacteria from the mouth Vagal stimulationstop suctioning immediately and oxygenate patient manually with 100% oxygen Bronchospasmmay require a bronchodilator

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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.

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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 hygieneavoid glycerin swabs or mouthwash that contains alcohol; assess mouth for ulcers, bacterial or fungal growth, or infections.

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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.

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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.

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Fenestrated Tracheostomy Tube

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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.

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NCLEX TIME

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Question 1 Nitrogen gas makes up what percentage of room air? A.10% B.21% C.49% D.79%

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Question 2 What is a possible outcome when oxygen delivery is combined with smoking? A.The oxygen will burn. B.An explosive effect will be produced. C.The combustion process will be supported and enhanced. D.The combustion process will be sped up.

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Question 3 What complication would the patient with a cuffed tracheostomy be at risk for developing? A.Tracheomalacia B.Pneumothorax C.Subcutaneous emphysema D.Tracheainnominate artery fistula

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Question 4 A patient who is hypoxemic also has chronic hypercarbia (increased Paco 2 levels). What is the appropriate flow of oxygen delivery for this patient? A.1 L/min via nasal cannula B.4 L/min via nasal cannula C.6 L/min via nasal cannula D.40% oxygen via Venturi mask

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Question 5 A patient experiences vagal stimulation during deep tracheal suctioning. The nurse would expect to see: A.Severe tachycardia B.Severe bradycardia C.Hypertension D.Bronchospasm