Section IV. SPECIAL NURSING MANAGEMENT
a. Unless contraindicated, coughing is encouraged in order to clear mucous secretions from the trachea and bronchi. If secretions are allowed to accumulate, they block the air passages and prevent air from reaching lung tissue. Effective coughing, deep breathing, and change of position are all measures that help to promote complete aeration of lung tissue in bedridden, debilitated, and postoperative patients. When
coughing is prescribed, teach and assist the patient to cough effectively. It can often be a painful experience, and the patient may try to suppress the cough, give a small "hacking" cough, or merely clear his throat. The patient can cough most effectively in the sitting position.
b. Using good body mechanics assist the patient to sit upright in bed or in a stable straight-backed chair. If the patient is unable to sit up, assist him to a supine position and raise the head of the bed if permissible. Provide tissue and an emesis basin for the expectorated secretions. Instruct the patient to inhale deeply, cough on exhalation, and expectorate the coughed-up secretions into the tissue or basin. Repeat the procedure several times in order to clear the air passages. Assist the patient into a comfortable position and document the results of the procedure.
a. Percussion, a method of tapping massage, is done to mobilize secretions, to aid in expansion of lung tissue, and to promote efficient use of respiratory muscles.
b. Prior to administering percussion, review the patient's chart to determine the reason or purpose for the treatment. Familiarize yourself with the patient's diagnosis and condition. Discuss the procedure with the patient and assemble the necessary equipment.
(1) Suction equipment, if necessary, to remove secretions that cannot be expectorated.
(4) Toothpaste, toothbrush, basin.
(5) Pillows to help support the patient in the desired position.
When administering percussion, it is necessary to observe the following precautions:
a. Avoid fatiguing the patient by modifying positions according to the patient's tolerance.
b. Avoid performing percussion immediately before or within one hour after meals to avoid nausea, vomiting, and aspiration.
c. Avoid percussing over the spine, liver, kidneys, or spleen to avoid injury.
d. Avoid percussing over a female patient's breasts.
e. Place a towel over the bare skin or percuss over the patient's clothing. Do not percuss over buttons, snaps, or zippers.
f. Remove rings or any other jewelry that might scratch or bruise the patient.
a. Prior to the start of the treatment, auscultate the patient's lungs to locate the areas of congestion. Position the patient in the posture that best facilitates drainage of the areas to be percussed. Instruct the patient to breathe slowly and deeply to promote relaxation.
b. Hold your hands in a cupped shape with the fingers flexed and the thumbs pressed tightly against the index fingers.
c. Using a tapping or clapping movement of your cupped hands against the torso, percuss the selected area in a rhythmic manner. A hollow sound indicates correct performance of the technique. Percuss each area one to two minutes.
d. After completion of percussion, instruct the patient to breathe deeply and cough to remove loosened secretions.
e. Auscultate the patient's lungs to evaluate the effectiveness of the treatment.
a. An incentive spirometer is a device that stimulates the patient to achieve maximum voluntary lung expansion. The purpose of the device is to help the patient achieve deeper inspirations.
b. In performing the exercise, the patient places his lips securely over the mouthpiece of the spirometer and inhales as deeply as possible. At maximum inflation there should be a slight pause, and the patient then relaxes and exhales.
c. The spirometer is normally equipped with a visual reinforcement device for patient encouragement. For example, a light may come on at maximum inspiration or the patient may watch a plastic ball rise to the top of a chamber during inspiration.
d. The patient should be encouraged to cough and expectorate any secretions loosened by the deep breathing.
a. Oxygen is a colorless, tasteless, odorless gas that is slightly heavier than air. Oxygen may be delivered by various administrative devices. The method of delivery
selected depends upon the condition of the patient, the concentration of oxygen required, and the preference of the physician. The following equipment will be necessary:
(1) Oxygen source (O2 tank o piped-in wall outlet)
(2) A cylinder regulator (O2 tank) or a flow meter (wall O2)\
(4) Sterile or distilled water.
(5) Administration device.
b. Administration devices include:
(1) A nasal cannula is a rubber or plastic tube with short curved prongs that extend into the nostrils about 1/4 to 1/2 inch. The cannula is held in place with an elastic band that fits around the patient's head. It is used to administer low to medium concentrations of oxygen. A flow rate of 2-6 liters/minute should provide an oxygen concentration of 25-35 percent. Start the oxygen flow prior to inserting the prongs into the patient's nostrils.
(2) A venturi mask is a facemask designed to deliver precisely controlled oxygen concentrations by providing oxygen mixed with room air. A fixed flow of oxygen is mixed with a flow of air to produce a constant oxygen concentration regardless of rate of breathing. Masks are designed to provide 24 percent, 28 percent, 31 percent, 35 percent, 40 percent, and 50 percent oxygen concentrations. The mask should be assembled according to the manufacturer's instructions for the oxygen concentration prescribed by the physician. Start the oxygen flow at the specified flow rate and adjust the mask over the patient's nose and mouth.
(3) A simple facemask is designed to provide low to medium oxygen concentration using liter flow rates of 2-8 liters/minute. Simple masks come in many sizes and configurations. Follow the manufacturer's instructions for use of the mask. Always begin the oxygen flow prior to placing the mask over the patient's nose and mouth.
(4) Re-breathing masks are designed for inhalation of moderately high concentrations of oxygen from a reservoir bag. A partial re-breathing mask has perforations on both sides of the mask that serves as exhalation ports. Inspired oxygen concentrations of 50-60 percent can be achieved. The non-re-breathing mask differs from the partial re-breathing mask in that it has a one-way valve between the mask and the reservoir bag that ensures that the patient receives only 100 percent oxygen from the reservoir bag. The mask has two flapper valves over the exhalation ports that allow the patient to exhale, but prevent inhalation of room air that would dilute the oxygen concentration.
(5) A T-tube is a device that connects directly to an endotracheal or tracheostomy tube to deliver humidified oxygen. Connecting tubing runs from the T-tube to the humidification device, which is connected to the oxygen source.
c. Safety precautions associated with the use of oxygen include:
(1) Post "Oxygen" and "No Smoking" signs wherever oxygen is stored or in use. Oxygen supports combustion, so things that burn slowly in normal air will burn violently or explosively in the presence of increased oxygen.
(2) Inform the patient and visitors of requirement for no smoking and no open flames. Enforce this rule.
(3) Ensure that oil or grease isnít used around the oxygen fittings, as petroleum-based products will burn.
(4) Ensure that all electrical equipment is properly grounded and in good
(5) Avoid the use of static-generating materials such as nylon and wool. This applies to uniforms, pajamas, and bedding.
(6) If an oxygen tank is used, secure it away from doors and high traffic areas to reduce the possibility of the cylinder being knocked over and the valve being damaged.
(7) When transporting an oxygen cylinder, strap it to the carrier. An unsecured cylinder may drop or fall, causing injury to patients or staff, and damaging equipment, walls, and flooring. If the valve should break, the sudden release of the high pressure could cause the cylinder to become a high velocity missile. A full oxygen cylinder has enough force to penetrate a concrete wall.
a. The nose, mouth, and throat may be cleared of mucus, vomitus, blood, or other material by a procedure called suctioning.
(1) Material that accumulates in the mouth and throat can usually be expectorated. Mucus accumulations in the nostrils can be removed by blowing the nose. If the patient is unable to cough, expectorate, or otherwise clear the upper air passages effectively, there is a danger that the accumulated material may be aspirated into the lower air passages (trachea, bronchi, and lungs).
(2) These suctioning procedures may be carried out using medical asepsis (clean technique) since the nostrils, mouth, and throats are not sterile areas. In specific cases, such as isolation, sterile technique may be required.
b. Wash your hands and assemble the necessary equipment. Set it up at the patient's bedside.
(1) Set up the suction apparatus (portable suction machine or in-wall suction) and connect a sufficient length of tubing to reach easily from the suction source to the patient.
(2) Place a container of water (or normal saline solution), 4x4 gauze squares, an emesis basin, and tissues on the bedside table.
(3) Select the appropriate size catheter (14 or 16 French for adults, 10 or 12 French for children) and attach it to the suction tubing. If the catheter does not have a thumb control suction valve, attach it to the tubing with a Y-connector.
(4) Turn on the suction apparatus and check the suction and the patency of the tubing by aspirating some of the water through the catheter. Do this by inserting the free end of the catheter into the container of water. Apply suction by placing your thumb over the suction control (thumb control valve or Y-connector).
c. Suction of the nasopharynx and nostrils:
(1) Moisten the catheter in the water.
(2) With suction diverted, insert the catheter gently through a nostril to the back of the throat (about 3-5 inches).
Note: If an obstruction is met, or if the patient's cough reflex is stimulated, remove the catheter and wait a moment before reinserting.
(3) Apply suction and slowly remove the catheter, using a rotating motion. Remember: You are suctioning oxygen as well as secretions, so suction for only 5-10 seconds at a time.
(4) Clear the catheter by aspirating some water through it. Thick secretions adhering to the outer surface of the catheter should be removed with moistened gauze.
(5) Repeat the procedure through the other nostril.
d. Suction of the oropharynx and mouth:
(1) Moisten the catheter in the water.
(2) With suction diverted, insert the catheter gently into the mouth toward the back of the throat. Note: If gag or cough reflexes are stimulated, remove the catheter and wait until gagging or coughing subsides before reinserting.
(3) Apply suction and rotate the catheter to suction the secretions. Suction for only 5-10 seconds at a time. Do not push the catheter in and out against the wall of the throat as this may injure the mucous membrane.
(4) Withdraw the catheter and clear it by aspirating water through it. Thick secretions adhering to the outer surface of the catheter should be removed with moistened gauze.
(5) Repeat the procedure, suctioning around the teeth and gums and under the tongue if secretions have accumulated in these areas.
(6) For suctioning of the mouth, a firm metal suction tip may be used instead of a soft catheter. One such tip is the Yankauer. Care must be taken when using a rigid suction tip to avoid injury to the oral mucosa.
e. Bulb syringe suctioning is used to clear secretions from the nose and mouth of infants.
(1) Grasp the bulb syringe firmly and squeeze the bulb to expel the air.
(2) Very gently, insert the tip into the mouth or nostril of the infant, taking care not to injure the delicate mucosa.
(3) Release the pressure on the bulb. As the air returns into the bulb, it creates a sucking action that will withdraw the secretions.
(4) When the bulb has inflated, remove the tip from the infant's mouth or nose. Dispose of the secretions into a basin or piece of gauze by squeezing the bulb, forcing out the air and secretions.
(5) Repeat the procedure as necessary.
(6) Rinse the syringe as necessary and at the end of the procedure. Squeeze the bulb, insert the tip into a basin of water, and release the bulb to aspirate the water. Remove the tip from the basin and squeeze the bulb to expel the water.
a. The procedures for endotracheal (within the trachea) suctioning are similar to those used for naso and oropharyngeal suctioning with two major differences.
(1) Endotracheal suctioning, unlike naso- and oropharyngeal suctioning, is done as an aseptic, or sterile, procedure.
(2) Suctioning the trachea interferes greatly with oxygenation. A high suction pressure and a lengthy suctioning time will greatly decrease the amount of
oxygen in the alveoli. If the patient is old or greatly debilitated, suctioning has the potential to set off cardiac arrhythmias.
b. Wash your hands, then assemble and set up the suction equipment.
(1) Check the suction and the tubing by aspirating water through the connecting tubing.
(2) On the bedside table, place an open package of 4x4 gauze, a sterile suction catheter, a suction set or sterile basin, a container of sterile water or normal saline, and sterile gloves.
(3) Set up the suction set or sterile basin. Fill the sterile container with the sterile water or normal saline.
c. Using aseptic technique, open the catheter package just enough to expose the connecting end and connect the catheter to the suction tubing. Don the sterile gloves. Using aseptic technique, remove the catheter from the package and hold it in your dominant hand. Test the catheter by aspirating some of the sterile solution.
d. Pick up a piece of the gauze with your non-dominant hand and grasp the patient's tongue. Gently pull the tongue out of the mouth. This will provide a view of the oropharynx and at the same time raise the epiglottis to permit easier insertion of the catheter into the trachea. As an alternative method, the catheter may be introduced through the nose.
e. As the patient inhales, introduce the catheter (with suction diverted) toward the posterior of the mouth and down the throat into the trachea. The patient will probably cough at this point. If coughing brings up sufficient secretions to clear the air passages, the procedure may be discontinued at this point. If not, relax the tongue a bit and instruct the patient to breathe normally.
f. Apply suction and gently rotate the catheter to aspirate secretions. Remember to suction for only 5-10 seconds at a time. Withdraw the catheter and rinse between suctioning by aspirating sterile solution. This will keep the catheter moist and free of secretions that may block the lumen.
g. Repeat the procedure until the secretions have been cleared. Remember that frequent catheter introductions irritate the tracheal mucosa, so suction thoroughly to avoid repeated insertions.
h. Observe the patient closely for changes in color or respiration, disorientation, or agitation. These could be signs of anoxia. Listen to the patient's breath sounds, which should become quieter as secretions are removed.
a. An endotracheal tube may be inserted through the nose or mouth into the trachea. This procedure is normally done by a physician or a nurse anesthetist. Endotracheal intubation may be done during surgery to facilitate anesthesia and control respirations, to bypass an upper airway obstruction, or to permit connection of the patient to a resuscitation bag or mechanical ventilator.
b. Endotrachial (ET) tubes generally have an inflatable cuff, which holds the tube in place in the trachea and prevents aspiration of upper respiratory tract secretions into the lower respiratory tract. The cuff must be deflated periodically to prevent injury to the trachea.
c. If intubation is necessary for an extended period of time, a tracheotomy is performed and the patient is intubated with a tracheostomy tube. This surgical procedure will be discussed in section VI.
a. When a patient is unable to maintain appropriate levels of arterial oxygen and carbon dioxide by normal breathing, some sort of mechanical assistance becomes necessary. A mechanical ventilator is a positive pressure-breathing device that maintains respirations automatically. Ventilators may be used for complete or partial control of a patient's respirations.
b. Mechanical ventilators are used in three modes of operation: assist, control, and assist-control. Determination is made by the physician according to the needs of the patient.
(1) Control mode is used for the patient whose respiratory drive is absent or excessive. The ventilator initiates breathes at a pre-set rate and will not respond to any patient attempts to initiate a breath.
(2) Assist mode is used for the patient who is able to make an inspiratory effort, but is unable to inhale an adequate amount of air. The patient initiates each breath and the ventilator then augments the breath to achieve a preset volume of air.
(3) Assist-control mode is used for the patient who has an erratic respiratory pattern. The ventilator will function in assist mode as long as the patient maintains an adequate respiratory rate. If the patient's respiratory rate falls below a preset level, the machine will switch to control mode and initiate breaths. The ventilator will switch from assist to control as determined by the needs of the patient.
c. The ventilator settings are determined by the physician.
(1) Tidal volume--The amount of air delivered for each inhalation.
(2) Respiratory rate--The number of breathes per minute.
(3) Minute volume--The amount of air delivered each minute (tidal volume multiplied by respiratory rate).
(4) Oxygen concentration--Percentage of oxygen mixed with room air.
d. Management of the ventilator and the ventilator patient is normally done by a physician, a respiratory therapist, and specially trained professional nurses. Paraprofessional nursing personnel assigned to patient care areas where ventilator patients are managed will receive special training in the principles of mechanical ventilation.