Adult ATI: Airway Management Ch. 53

what does managing compromise include
-respiratory assessment
-measuring vital signs: O2 sats via pulse oximetry
-administration of oxygen
what does administering oxygen do for pts
helps maintain adequate cellular oxygenation for clients who have many acute and chronic respiratory problems or are at risk for hypoxia
what kind of pt’s need to be administered oxygen
-pt’s who have acute/chronic respiratory problems
(hypoxemia, cystic fibrosis, asthma)

=pt’s who are at risk for developing hypoxia
(resp. illness, circulatory impairment)

what is a nursing priority with airway management
maintaining a patent airway
what is involved with maintaining a patent airway
-mobilizing secretions
-suctioning airways
-managing artificial airways (endotracheal tubes, tracheostomy tubes)

promotes adequate gas exchange and lung expansion

pulse oximeter
a device with a sensor probe that attaches securely to the fingertip, toe, bridge of nose, earlobe, or forehead with a clip or band
what does a pulse oximeter do
measure pulse saturation (SPo2) via a wabe of infrared light that measures light absorption by oxygenated and deoxygenated hemoglobin in arterial blood
what does SPO2 reflect
the percent of saturation of hemoglobin (SaO2)

when the SaO2 is greater than 70 percent

how much of the atmospheric air is oxygen
21 percent
oxygen rates vary to maintain…
an SpO2 of 95-100 using the lowest amount of oxygen to achieve the goal without risking complications
FiO2 Fraction of inspired air
the percentage of oxygen the client recieves
what findings during your assessment would cause you to need the pulse oximetry
-increased work of breathing
-wheezing
-coughing
-cyanosis
-changes in respiratory rate or rhythm
-adventitious breath sounds
-restlessness, irritability, confusion
what are some interventions that can be done if you have a pulse oximetry reading of less than 90% (indicating hypoxemia)
–confirm probe placement

-confirm that o2 delivery system is functioning and that client is receiving the prescribed o2 levels

-place the client in semi-fowler’s or fowler’s position to promote chest expansion and to maximize ventilation

-encourage deep breathing

-remain with the client and provide emotional support to decrease anxiety

what is an acceptable range of the pulse ox.
91-100 percent

some illnesses states can allow from 85-89 percent

readings of less than 90 reflect hypoxemia

what reasons may cause a low pulse ox reading
older adults
clients who have darker skin
hypothermia
poor peripheral blood flow
too much light
low hemoglobin levels
jaundice
movement
edema
nail polish
what is oxygen therapy used for
treating hypoxemia (low levels of arterial oxygen)
early manifestations of hypoxemia
-tachypenia
tachycardia
restlessness
anxiety
confusion
pale skin and mucous membranes
elevated blood pressure
use of accessory muscles, nasal flaring, tracheal tugging, adventitious lung sounds
what are late manifestations of hypoxemia
stupor
cyanotic skin, mucous membranes
bradypnea
bradycardia
hypotension
cardiac dysrhythmias
what are nursing actions that need to be considered with giving oxygen therapy
-monitor respiratory rate and pattern

-minitor level of conciousness

-monitor SpO2 and ABG

-provide ox. therapy at lower liter flow that will correct hypoxemia

– make sure mask is placed on face correctly

– assess/monitor for hypoxemia/hypercarbia (restlessness, hypertension, headache)

-listen to lungs for breath sounds

-assess/monitor pulse ox

-promote oral hygiene

-encourage turning, coughing, deep breathing and use of incentive spirometry and suctioning

-assess and document the response to ox therapy

-monitor for res. depression (decreased resp. rate and level of conciousness)

what rate of flow is a nasal canula
low flow
nasal canula
nasal canula
tubing with two small prongs fro insertion into the nares
what is the fraction of inspired oxygen for the nasal cannula
FIO2: 24%-44%
flow rate: 1-6 L/min
what are the advantages of a nasal cannula
safe
simple
easy to apply
comfortable
well tolerated
client able to eat, talk, ambulate
what are the disadvantages of a nasal cannula
FiO2 varies with the flow rate, and rate and depth of clients breathing

extended use can lead to skin breakdown and dry mucous membranes

tubing is easily dislodged

what are some nursing actions to consider with the nasal cannula
-assess patency of nares

-ensure that the prongs fit in nares properly

-use water soluble gel to prevent dry nares

– provide humidification for flow rates of 4L/min and greater

what rate of flow should you provide humidification
4 L/min or greater
Simple Face Mask
Simple Face Mask
covers clients nose and mouth
what is the fraction of inspired ox with the simple face mask
FiO2: 40-60 percent
Flow rate: 5 L/min to ensure flushing of CO2 from mask
what rate of flow is a simple face mask
low flow
what are the advantages of a simple face mask
-easy to pply
-more comfy
-simple delivery method
-provides humified ox
disadvantages of a simple face mask
-flow rate less that 5L/min can result in rebreathing of CO2

-clients who have anxiety or claustrophobia do not tolerate it well

-eating, drinking and talking are impaired

-moisture and pressure can collect under mask and cause skin breakdowns

nursing actions for a simple face mask
-assess for proper fit to ensure a secure seal over the nose and mouth

-make sure client wears a nasal cannula during meals

-use with caution for clients who have a high risk of aspiration or airway obstruction

-look for skin breakdown

what rate of flow is a partial rebreather mask
low flow
partial rebreather mask
partial rebreather mask
covers pt’s nose and mouth
what is the fraction of inspired ox for a partial rebreather mask
FiO2: 40-70 percent
Flow rate: 6-10 L/min
what are the advantages of a partial rebreather mask
the mask has a reservoir bag attached with no valve which allows the client to rebreath up to 1/3 of exhaled air together with room air
disadvantages of partial rebreather
-complete deflation of reservoir bag during inspiration causes CO2 buildup

– the FiO2 varies with clients breathing pattern

– clients who have anxiety or claustrophobia do not tolerate it well

– eating, drinking and talking impaired

nursing actions with a partial rebreather mask
-keep bag from deflating by adjusting oxygen flow rate to keep bad 1/3 to 1/2 full on inspiration

-asses fit to ensure a secure seal over nose and mouth

-look at skin for breakdown

-use with caution for pt’s who have risk of aspiration/obstruction

rate of flow for a nonbreather mask
low flow
nonrebreather mask
nonrebreather mask
what is the FiO2 and flow rate for a nonrebreather mask
FiO2: 60-100 percent
Rate: 10-15 L/min to keep bag 2/3 full during inspiration and expiration
advantages of a nonrebreather mask
-delivers highest O2 concentration possible (Except for intubation)

– a one way valve situated between mask and reservoir allows client to inhale max o2 from reservoir bag. the two exhalation ports have flaps covering that that prevent room from entering the mask

disadvantages of non rebreather mask
-valve and flap on mask by be intact and functional during each breath

-poorly tolerated by clients who anxiety/claustrophobia

-eating, drinking, talking impaired

-caution with pt with high risk of aspiration and obstruction of airway

nursing actions of non rebreather mask
-hourly assessment of valve and flap

-asses pfit

-assess for skin breakdown

-use nasal canula durring meals

low flow oxygen delivery systems
-nasal cannula
-simple face mask
-partial rebreather
-nonrebreather mask
high flow oxygen delivery systems
venturi mask
aerosol mask
venturi mask
venturi mask
what is the fraction of inspired oxygen and rate of flow for the venturi mask
FiO2: 24-100 percent
Rate: 4-12 l/min via diff. size adapters, which allow specific amounts of air to mix with oxygen
advantages of venturi mask
-delivers the most precise oxygen concentration

-humidification not required

-best for clients who have chronic lung disease

disadvantages of venturi mask
-use is expensive

-eating, drinking, talking impaired

nursing actions when using venturi mask
-assess frequently to ensure an accurate flow rate

-assess proper fit

– assess for skin breakdown

-make sure tubing is free of kinks

-make sure pt’s use nasal cannula sdu

flow rate of a aerosol mask
high flow
aerosol mask
aerosol mask
aka a face tent
tracheostomy collar
tracheostomy collar
small mask that covers the surgically created opening of the trachea
what is the fraction of inspired ox for the aerosol mask
FiO2: 24-100%
rate: at least 10 L/mn

provides high humidification with ox delivery

advantages of aerosol mask
-used with pt who do not tolerate masks well

-useful for clients who have facial trauma, burns and thick secretions

disadvantages of aerosol masks
-high humidification requires frequent monitoring
nursing actions with aerosol makss
-empty condensation from tubing often

-ensure adequate water in the humidification canister

-ensure aerosol must leaves from vents during inspiration and expiration

-make sure tubing does not pull on tracheostomy

complications of oxygen therapy
-oxygen toxicity
-oxygen induced hypoventilation
-combustion
what can oxygen toxicity result from
high concentrations of oxygen (greater than 50 percent)

long durations of oxygen therapy (more than 24-48 hours)

severity of lung disease

manifestations of oxygen toxicity
nonproductive cough
substernal pain
nasal stuffiness
nausea
vomiting
fatigue
headache
sore throat
hypoventilation
nursing actions with oxygen toxicity
-use lowest level of oxygen necessary to maintain an adequate SPO2

-monitor ABG’s and notify provider if SPO2 levels are outside expected reference range

-decrease FiO2 as the clients SPO2 improves

what clients can oxygen induced hypoventilation happen in
those that have conditions that cause alveolar hypoventilation

can be sensitive to admin of oxygen

nursing actions with oxygen induced hypoventilation
-monitor respiration rate, pattern, level of conciousness, and SpO2

-provide oxygen therapy at the lowest liter flow rate that manages hypoxemia,

-if they can tolerate it use a venturi mask to deliver precise oxygen levels

-notify provider if impending respiratory depression such as a decreased rep. rate and a decreased LOC

what are nursing actions that can be done to prevent combustion with use of oxygen
-post no smoking or oxygen in use signes to alert others of a fire hazard

-know where to find closest fire extinguisher

– educate about the fire hazard of smoking with oxygen use

-have clients ear a cotton gown because synthetic or wool fabrics can generate static electricity

– ensure that all electric devices are working well

-make sure all electric machinery are grounded

-do not use volatile flammable materials near clients receiving oxygen

what are nursing interventions that mobilize secretions and maintain airway patency

what do these interventions do for the pt

-assistance with coughing
-hydration
-positioning
-humidification
-nebulizer therapy
-chest physiotherapy
-suctioning

-they promote adequate gas exchange and lung expansion

what is at risk for developing airway compromise
infants
clients who have a neuromuscular disorders
quadriplegic
cystic fibrosis pt’s
indications that clients need help maintaining airway clearance
-hypoxemia

-restlessness

-irritability

-tachypnea

-tachycardia

-cyanosis

-decreased levels of conciousness

-adventitious breath sounds

-visible secretions

-absence of spontaneous cough

what does humidification do for preventing obstruction of airways
humidified oxygen moistens the airways which loosens and mobilizes pulmonary secretions
what does nebulization do for ensuring airway clearance
breaks up medications (bronchodilators, mucolytic agents) into minute particles that disperse throughout the resp. tract and improves clearance of pulmonary secretion
what is chest physiotherapy
the use of chest percussion, vibration , and postural drainage to help mobilize secretion
what does chest percussion and vibration do for airway clearance
it facilitates movement of secretions into the central airways
what does postural drainage to for airway clearance
one or more positions allow gravity to assist with the removal of secretions form specific areas of the lung
what does early morning postural drainage to for airway clearance
it mobilizes secretions that have accumulated through the night
how should the nurse collect sputum specimens
by suctioning during coughing
whenever possible what should a nurse instruct the pt to do to collect a specimen or help airway clearance

why?

-encourage coughing

-coughing is more effective that artificial suctioning at moving secretions into upper trachea and laryngopharynx

what should the nurse do to avoid bacterial contamination when ensuring airway clearance and collecting a sputum specimen
maintain surgical asepsis when performing any form of tracheal suctioning
what is sputum specimen collection used for
-cytology to id aberrant cell or cancer

-for culture and sensitivity to grow and id micro-organisms and the antibiotics effective against them

-to id acid fast bacillus to diagnose TB (requires three consecutive morning samples)

when should you collect specimens for sputim
in the morning
if the pt eats when should you collect a sputum specimen and why
wait 1 to 2 hours after they eat to decrease the likelihood of emesis or aspiration
what kind of container should you use to collect a sputum specimen for cytology
a container with a preservitive
what kind of container would you use for a routine and AFB sputum specimen collection
a sterile container
how would you collect a sputum specimen if the client cannot cough effectively and expectorate sputum into the container
collect the specimen by endotracheal suctioning
when would chesty physiotherapy be contraindicated
-pregnant
-have a rib, head, chest or neck injury
-have increased intracranial pressure
-recent abdominal surgery
-have pulmonary embolism
-have bleeding disorders
-have osteoporosis
percussion
the use of cupped hands to clap rhythmically on the chest to break up secretions
vibrations
the use of shaking movements during exhalation to help remove secretions
postural drainage
the use of various positions to allow secretions to drain by gravity
when should you schedule chesty physiotherapy if the pt has eaten
1 to 2 hours after eating and at bedtime to decrease the likelihood of vomiting or aspirating
what should you do 30 min to 1 hour before postural drainage
administer a bronchodilator meds or a nebeulizer
how do you create vibrations to mobilize secretions in the chest
-place hands on the affected area
-tense hand and arm muscles
-move the heal of the hands to create vibrations as the client exhales
-have the client cough after each set of vibrations
how long should each pt remain in each position during chest physiotherapy
10 to 15 min to allow time for percussion, vibration, and postural drainage
when should you discontinue chest physiotherapy
faintness or dizziness
what should you encourage pt’s to do when you are suctioning
breath deeply and cough in an attempt to clear the secretions with artificial suctioning
what should you use for oropharyngeal suctioning
a yankauer or tonsil tipped rigid suction catheter and move it around the mouth gum line and pharynx
what do you use for nasopharyngeal suctioning and nasotracheal suctioning
use a flexible catheter and lubricate the distal 6 to 8 cm with water soluble lubricant
what do you use for endotracheal suctioning
suction catheter
should not exceed one half of the internal diameter of the endotracheal tube to prevent hypoxia
chest physiotherapy positions
chest physiotherapy positions
the nurse should use what size ffrench suction cathetar when suctioning a 8mm endotracheal and tracheostomy tube
16 frech
how long should you limit each suction attempt
10-15 secs to avoid hypoxia and the vagal response
use suction pressure no higher than
120-150 mmHg
limit total suction time to
5 min
when should you insert the cathetar for nasopharyngeal or nastracheal suctioning
during inhalation
do not apply while inserting
how far do you advanse the nasal suctioning cathetar
the top of the nose to the base of the earloabe
when do you apply suctioning nasaly
only while withdrawing the catheter and rotating it with the thumb and forefinger
how many passes do you do with nasopharangyl or nasotracheal suctioning
no more than wo passes
allow at least one min between passes for ventilation and oxygenation
how far do you insert a endotracheal suctioning cathetar
until resistance is met
then pull back 1 cm prior to apply suction to prevent mucosal damage
how should you suction with endotracheal suctioning
intermittently by covering and releasing suction port with the thumb for 10 to 15 secs
when do you apply suction when endotracheal suctiong
only while withdrawing the catheter and rotating it with forefinger and thumb