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Nurseinfo.in provides free Nursing Notes, Nursing Procedures, Medical MCQs, Nursing Calculators, Care Plans and exam preparation resources for BSc Nursing, GNM, P.B. BSc and MSc Nursing students. Browse subject-wise notes, previous year questions and study materials based on the latest nursing syllabus.
TRACHEOSTOMY SUCTIONING – Definition,
Purpose, Equipment, Preliminary Assessment and Procedure
DEFINITION
Tracheostomy
is an artificial airway which requires being maintained secretion free, thereby
insuring adequate ventilation for the patient
PURPOSE
To clear secretions from the
artificial airway or tracheobronchial tree
To maintain the patency of the
tracheostomy tube
To ensure maximum ventilation of the
patient
To reduce maximum ventilation of the
patient
To reduce the risk of respiratory
infection
EQUIPMENT
A clean tray
Sterile suction catheters size 14, 16
adult, 10, 12 pediatric with thumb control
Sterile gloves
Sterile towel
Sterile container and water or normal
saline for flushing the catheter and tubing
Normal saline for installation
Sterile syringe 2 ml, 5 ml
Resuscitation bag with reservoir
connected to 100% oxygen source. Add positive end expiratory pressure valve to
exhalation valve on resuscitation bag in an amount equal to that on the
ventilator or (PAP, CPAP device)
Receptacle for disposables
Suction apparatus, e.g. portable
machine or wall suction set at 80 to 120 mm Hg
PRELIMINARY ASSESSMENT
Check physician’s order, progress
notes and nursing care plan
Explain the procedure to the patient.
Include instructions on how to splint the surgical incision as coughing will be
induced during the procedure
Ensure the patient’s privacy
Position the patient in suitable
position
Monitor heart rate, respiration rate
and type and arterial blood pressure. If blood gases are ordered, know baseline
values
Collect and assemble equipment. Check
function of suction and resuscitation bag connected to 100% oxygen source
Wash and dry hands
Procedure
Open sterile towel and place in bib
like fashion on patient’s chest
Open sterile gloves and place on
sterile field
If the patient is attached to
ventilator test to ensure that disconnection of ventilator may be with one hand
Fill the sterile container with
sterile water
Open the end of the pack containing
the suction catheter and connect it to the tubing of the suction machine
Using the contaminated hand
disconnect the patient from the ventilator CPAP device or other oxygen source
Ventilate and oxygenate the patient
with the resuscitator bag 5 to 6 times
In the spontaneously breathing
patient coordinate ventilation with patients own respiratory effort
Slide the cover off the catheter and
rinse it through with sterile water/saline to lubricate it
Insert the catheter into the
tracheostomy as for as possible without applying suction
Apply suction and quickly rotate the
catheter while it is being withdrawn
Limit suction time 10 to 15 seconds.
Discontinue if heart rate decreases by 20 beats per minute or if cardiac ectopy
is observed
Ventilate the patient between suction
with 4-5 manual ventilation
Sterile normal saline 2 to 3 ml may
be instilled into the airway followed by manual ventilation then suction
Rinse catheter between suctioning.
Procedure with sterile water/saline
Continue procedure as necessary to a
maximum of 4 suction passes
Give the patient 6 to 8 ‘sigh’
breaths with the bag
Return the patient to the ventilator
or apply CPAP or other oxygen delivery device
Suck oral secretions from the
oropharynx above the artificial cuff
Deliver tracheostomy care as required
If patient is not an respiratory
assistance apply filter or humidifier as indicated
Check vital signs
Leave the patient as comfortable as
possible
Clear and clean equipment
Wash and dry hands
Document the procedure including
patient’s response in appropriate nursing notes
TRACHEOSTOMY SUCTIONING – Definition, Purpose, Equipment, Preliminary Assessment and Procedure
TRACHEOSTOMY CARE – Definition, Use
of Tracheostomies, Parts of the Tracheostomy, Indications for Tracheostomy,
Complications of Tracheostomy, Care of the Tracheostomy Patient and Cleansing
the Inner Cannula
DEFINITION
A
tracheostomy is an incision into the trachea the 2nd, 3rd,
or 4th tracheal ring
USE OF TRACHEOSTOMIES
To facilitate prolonged artificial
ventilation
To bypass serious upper respiratory
obstructions
To prevent aspiration of blood,
secretions or food into the lungs
To provide easier access to the lower
airways than that is possible through nose or mouth
PARTS OF THE TRACHEOSTOMY TUBE
Outer tube or outer cannula
The inner tube or inner cannula
The obturator or pilot. It is used as
a guide to the outer tube
INDICATIONS FOR TRACHEOSTOMY
Apnea
Respiratory obstruction
Circulatory arrest
Exsanguinating hemorrhage
Carcinoma of the larynx
Diphtheria, Ludwig’s angina
Head injury, neck injury or chest
injuries
Respiratory failure
Fracture of the larynx or trachea
In case of foreign body in
hypopharynx or larynx
Patient with severe burns, especially
around hand, neck, and face
Patients who have had thyroidectomy
or radical neck resection
Patients with neurological disorders,
drug overdose, bulbar paralysis, or cerebrovascular accidents
Patients with severe pulmonary edema
Patients with severe emphysema
Weak, feeble patients
Canine biting
COMPLICATIONS OF TRACHEOSTOMY
Subcutaneous emphysema
Pneumothorax
Mediastinal emphysema
Obstruction of tracheostomy tube
Respiratory insufficiency
Displacement of the tube from its
position on the tracheal turner
Hemorrhage
Pulmonary infection
Atelectasis
Tracheoesophageal fistula
Tracheomalacia
Constant
pressure exerted by the cuff causes tracheal dilation and erosion
Signs and
Symptoms
An increased amount of air is
required in the cuff to maintain the seal
A large tracheostomy tube is required
to prevent air leak at the stone
Food particles are seen is tracheal
secretions
The client does not receive the set
tidal volume of the ventilator
Management
No special
management is needed unless bleeding occurs
Prevention
Use and uncuffed tube as soon as
possible
Monitor cuff pressure and air volumes
closely and detect changes
Tracheal
Stenosis
Narrowed
tracheal lumen is due to scar formation from irritation of tracheal mucosa by
the cuff
Signs and
Symptoms
Stenosis
usually is seen after the cuff is deflated or the tracheostomy tube is removed.
The client has increased coughing, inability to expectorate secretions or
difficulty in breathing or talking
Management
Tracheal
dilation or surgical intervention is used
Prevention
Prevent pulling of and traction on
the tracheostomy tube
Properly secure the tube in the
midline position
Maintain proper cuff pressure
Minimize oronasal intubation time
Tracheoesophageal
fistula (TEF)
Excessive
cuff pressure causes erosion of the posterior wall of the trachea. A hole is
created between the trachea and the anterior esophagus. The client at highest
risk also has a nasogastric tube present
Signs and
Symptoms
Manually administer oxygen by mask to
prevent hypoxemia
A small soft feeding tube is used
instead of a nasogastric tube for tube feedings
A gastrostomy or jejunostomy may be
performed
Monitor the client with a nasogastric
tube closely; assess for TEF and aspiration
Prevention
Maintain cuff pressure
Monitor the amount of air needed for
inflation and detect changes
Progress to a deflated cuff or
cuffless tube as soon as possible
Trachea-innominate
artery fistula
A
malpositioned tube causes its distal tip to push against the lateral wall of
the tracheostomy. Continued pressure causes necrosis and erosion of the
innominate artery. This is a medical emergency
Signs and
Symptoms
The tracheostomy
tube pulsates in synchrony with the heartbeat. There is heavy bleeding from the
stoma. This is a life-threatening complication
Management
Remove the tracheostomy tube
immediately
Apply direct pressure to the
innominate artery at the stoma site
Prepare the client for immediate
surgical repair
Prevention
Use correct tube size and maintain
tube in midline position
Prevent pulling or tugging on the
tracheostomy tube immediately notify the physician of the pulsating tube
CARE OF THE TRACHEOSTOMY PATIENT
Maintain an open airway. Suction and
clean the tube as indicated. Prevent aspiration, e.g. of water, solutions, etc.
through the tracheostomy. Keep materials which may occlude the tracheostomy,
away from the opening, e.g. clothing, bedsheets
Observe the patient carefully for
indication of respiratory difficulty, e.g. noisy respirators, restlessness,
cyanosis, intercostals and substernal retraction, alternations in respiratory
rate, labored respiration
Practice asepsis. Strict aseptic
technique should be followed while suctioning, cleaning and dressing the wound
Observe for complications of
tracheostomy. If the airway is obstructed, do suctioning, if the tracheostomy
outer tube has come out, put the tracheal dilator inside and inform the doctor.
Never try to push a blown out tracheostomy tube back into its place. Tracheal
dilator and tracheal hook, sterile, should be present near the patient all the
time
Ensure maximal humidification of the
inspired air and approximately warm inspired air. Sterile wet gauze covering
the tracheostomy will help in humidification
Provide adequate hydration to help
liquefy pulmonary secretions. At least 3,000 ml of intravenous fluids are
ordered daily if adequate oral intake is not possible
Maintain fluid and electrolyte
balance. Keep an accurate intake and output chart
Be gentle. The tracheal mucosa is
easily traumatized during suctioning
Keep the necessary articles like
extra sterile inner tracheostomy tube, tracheal dilator, tape, Vaseline, gauze,
sterile gauze pieces, suction nozzles, sterile water and suction apparatus
nearby
Prevent pressure and trauma to the
tracheobronchial tree. If a cuffed tube is being used, see that the cuff is
deflated, as ordered, to relieve pressure periodically on the tracheal wall
Periodically inspect the tracheostomy
for trauma or infection
Ensure use of a fresh tracheostomy
tube as needed. Clean the inner cannula of mucus and encrustations as
indicated. The inner tube is changed by nurses and outer tube by doctors
Change the dressings and tracheostomy
tube as necessary
Provide appropriate skin care. Keep
skin clean and dry
Provide adequate nourishment
Provide frequent mouth care to
minimize possible infection. Plenty of water should be given orally
Administer medications as ordered.
Narcotics and sedatives are usually avoided. To minimize apprehension, only
mild tranquilizers are given
For long-term cases, the patient and
his relatives are taught how to take care of the tube
Alleviate the patient’s apprehension
by closely observing him, providing care in a calm but efficient manner and
helping him communicate by providing a call bell
The suction
procedure is as follows:
Auscultate the chest before and after
suctioning
Wash hands and use sterile gloves
Place a sterile towel across the
patient’s chest just below the tracheostomy tube
Clean the skin around the tube and
the adaptors with a recommended antiseptic
Select the catheter, attach it to the
suction apparatus and lubricate it with sterile normal saline, gently insert
into the tracheostomy tube and do the suctioning. It should not be continued
more than 5 seconds at a time
After suctioning, discard the
catheter and gloves and also the saline. Note the amount and the character of
the secretions aspirated
Wash hands after completion of the
procedure
Cleansing
the Inner Cannula
It is
changed every 2 to 4 hour, but in some cases, only twice. It can be cleaned
with cold water and soap and also with hydrogen peroxide solution. After
cleaning, it can be sterilized and can be used again. Do not leave the inner
cannula out for longer than 5 to 10 m while removing or cleaning it
If left out for
longer periods, secretions and crust begin to form in the outer cannula, making
it difficult to reinsert the inner cannula
The
following conditions should be reported to the doctor if they occur during the
postoperative period:
Tube displacement
Indications of shock, hemorrhage,
respiratory insufficiency and hypoxia
Respiratory obstruction
Excessive restlessness or
apprehension
Cyanosis, in case of cyanosis, oxygen
should be given
Rhinorrhea
Development of tracheoesophageal
fistula
TRACHEOSTOMY CARE – Definition, Use of Tracheostomies, Parts of the Tracheostomy, Indications for Tracheostomy, Complications of Tracheostomy, Care of the Tracheostomy Patient and Cleansing the Inner Cannula
SUCTIONING TECHNIQUE – Types,
Orotracheal and Nasotracheal and Tracheal Suctioning
Suctioning
is the process of sucking. The removal of gas or fluid from a cavity or rather
container by means of reduced pressure
Suctioning
done: when a patient is unable to clear respiratory tract secretion with
coughing, the nurse must use suctioning to clear the airways
TYPES
Oropharyngeal and nasopharyngeal
suctioning
Orotracheal and nasotracheal
suctioning
OROPHARYNGEAL AND NASOPHARYNGEAL
The oropharynx extends behind the
mouth from the soft palate above the level of the hyoid bone and contains the
tensil. The nasopharynx is located
behind the nose and extends to the level of soft palate
This suctioning is used when the
patient is able to cough effectively but is unable to clears secretions by
expectorating or swallowing
OROTRACHEAL AND NASOTRACHEAL
It is
necessary when the client with pulmonary secretion is unable to cough and does
not have an artificial airway present
TRACHEAL SUCTIONING
Tracheal
suctioning is accomplished through an artificial airway such as an endotracheal
tube or tracheostomy tube.
EQUIPMENT
Laryngoscope with curved on straight
blade and working light sources
Endotracheal tube with low pressure
cuff and adapter to connect to ventilator style to guide the endotracheal tube
Oral airway
10 ml syringe
Suction sources
Suction catheter
Sterile towel
Gloves
Face shield
End trail CO2 detector
Resuscitation and mask connected to O2
source
PROCEDURE
Preparation
Phase
Assess the
patient’s heart rate, level of consciousness and respiratory status
Performance
Phase
Remove the patient dental bridgework
and plates
Remove headboard of bed
Prepare equipment
Aspirate stomach contents if nasogastric
tube is in place.
If time allows inform the patient of
impending inability to talk and discuss alternative means of communication
If the patient is confused, it may be
necessary to apply soft wrist restraints
Put on gloves and face shield
During oral intubations if cervical
spine is not injured place patients head in a “sniffing” position
Spray the back of the patient’s
throat with anesthesia spray if time is available
Ventilate and oxygenate the patient
with the resuscitation bag and mask before intubations
Hold the handle of the laryngoscope
in the left hand and hold the patients mouth open with the right hand by
placing crossed hungers on the teeth
Insert the curve blade of the
laryngoscope along the right side of the tongue, push the tongue to the left
and use right thumb and index finger to pull patient lower lip away from lower
teeth
Lift the laryngoscopes forward to
expose the epiglottis
Lift the laryngoscopes forward to 45
degree angle to expose glottis and visualize vocal cords
As the epiglottis is lift forwards,
the vertical opening of the larynx between the vocal cords will come into view
Once the vocal cord is visualized,
insert the tube into the right corner of the mouth and pass the tube while
keeping vocal cords in constant view
Gently push the tube through the
triangular space formed by the vocal cords and back wall of trachea
Stop insertion just after the tube
cuff had disappeared from view beyond the cords
Withdraw laryngoscope while holding
endotracheal tube, attach bag to ET tube, and ventilate the patient
Inflate cuff with the minimal amount of
air required to occlude the trachea
Insert a bite block if necessary
Ascertain expansion of both sides of
the chest by observation and auscultation of breath sound
Record distance from proximal end of
tube to the point where the tube reaches the teeth
Secure tube to the patient’s face
with adhesive tape or apply a commercially available endotracheal tube
stabilization device
Obtain chest X-ray to verify tube
position
SUCTIONING TECHNIQUE – Types, Orotracheal and Nasotracheal and Tracheal Suctioning
Sputum
culture are obtained to aid with diagnosis and treatment decisions in patients
with suspected pneumonia tuberculosis, or there infectious diseases of the
lower airway. A microbiology laboratory cultures and incubates the specimen to
identify any pathogenic microorganisms. Sputum is obtained for cytology to
search for abnormal cells that might indicate cancer or a precancerous
condition of the lungs or airway. In either case, it is important to obtain a
specimen that has been coughed up and expectorated from the lower airways, with
minimal contamination by oral and pharyngeal secretions. The patient must be
asked to cough deeply and the specimen is collected in a sterile container
PURPOSE
Sputum collection for suspected
cancer for tuberculosis may be required for three consecutive mornings
To provide a specimen to determine
the presence and type of microorganisms in the oropharynx
GENERAL INSTRUCTIONS
The specimens should be brought to
the office as soon as possible to avoid deterioration of the material
Most diagnostic specimens are
obtained early in the morning when the greatest volume of secretions has had a
chance to accumulate
If the sputum specimen is not
possible to collect, specimen may also be collected after respiratory
treatments or therapy
It is vitally important that the
patient understand that the specimen must be collected from the lung field and
not from the mouth
Pathogen must be collected from sits
of concern with a twisting motion for maximum collection. Touching other areas
will alter the substances on the swab
CLIENT PREPARATION
Inform about the difference between
saliva and sputum may need to be explained on the client’s level of
understanding
Before the sputum collection,
encourage the client to increase fluid intake to decrease the viscosity
(thickness) of the secretions
The client may be weak from illness,
and thick mucus will be hard to bring up, causing the client to be even more
exhausted. A cool mist humidifier may help also
EQUIPMENT
Tongue blade (depressor)
Sterile specimen container
Sterile swab (if one is not supplied
with the specimen container)
Complete laboratory request slip
PROCEDURE
Wash hands
Arrange the equipment and supply
Explain the procedure to the client
Put the gloves and face mask or
shield
Carefully remove the sterile swab
from the container
Have the patient say AHHH as you
press on the midpoint of the tongue depressor
Swab the area of concern on the
mucous membranes, especially the tonsillar area, the crypts, and anterior and
posterior pharynx. Turn the swab to expose all its surfaces. Avoid touching
areas other than those suspected of infection
Maintain the tongue depressor
position while withdrawing the swab
Follow the instructions on the
specimen container for transferring the swab. Some require that the wooden swab
stick to broken after dropping into the culture; others may have a special swab
that is contaminated within the container and is secured when the container is
sealed
Properly dispose of the equipment and
supplies, remove gloves and wash your hands
Route the specimen or store it
appropriately until routing can be completed
ENDOTRACHEAL INTUBATION – Definition,
Purpose, Assessment Phase, Precautions, Planning Phase, Client/Family Teaching
and Equipment Used
DEFINITION
Endotracheal
intubation is assisting in passing of a slender hollow tube into trachea
through nose or mouth to facilitate artificial ventilation and resuscitation,
using aseptic technique
PURPOSE
To treat acute respiratory failure,
persistent hypoxemia, persistent rise in pCO2
To maintain patient airway
To ensure adequate oxygenation in
fracture of cervical vertebrae, spinal cord injury
To provide ventilatory assistance
when indicated
Objective:
to insert an endotracheal tube into the trachea to provide a patient airway for
ventilatory support or to manage secretions
ASSESSMENT PHASE
Does the client require intubations?
Why are intubations being considered?
Based on time consideration and on
the condition of the client. Should nasal or oral intubations be attempted?
Will the client need mechanical
ventilation after intubations?
PRECAUTIONS
Avoid damage to the client’s teeth
and soft tissue, which can be caused by improper use of the laryngoscope and
tubes or by unnecessary force during the procedure
Ensure the availability of a oxygen
source. Ventilate the client with a manual resuscitator using 100 percent
oxygen if intubation cannot be accomplished within a reasonable period
Have suction equipment setup and
operable at the client’s bedside before performing the procedure
Avoid bronchial intubations by
correctly positioning the endotracheal tube above the level of the carina
Be alert for signs of esophageal
intubations. These signs include abdominal distention, belching and lack of
breath sounds in the lung fields after intubations
PLANNING PHASE
Endotracheal tubes with low pressure
cuffs in various sizes (most common sizes for adult client range from 5 to 9 mm
inside diameter)
Laryngoscope handle and several sizes
of both curved and straight blades
Topical anesthetic spray and sedative
Water-soluble anesthetic lubricating
jelly
Flexible stylet
Forceps
10 ml syringe
Oral airway or bite block
Tape, benzoin tincture and alcohol
swabs
Suction equipment
Manual resuscitator with oxygen
source
CLIENT/FAMILY TEACHING
If the client is conscious, explain
the need for endotracheal intubations and explain the procedure
Explain sensations that may be
experienced during the procedure
Explain the need for endotracheal
intubations and explain the procedure to the family
EQUIPMENT USED FOR ENDOTRACHEAL INTUBATION: IMPLEMENTATION PHASE
Ensure that client is properly
oxygenated using manual resuscitator with 100% oxygen
Administer medications as ordered
Check equipment
Use syringe to inflate tube cuff. Check for uniform inflation and leaks
before use
Check laryngoscope batteries and light by attaching proper sized blade
If using stylet, lubricate entire
length and insert into endotracheal tube. Make sure tip of stylet does not
extend beyond tip of endotracheal tube
Remove client’s dentures or partial
plates if applicable
Hyperextend client’s neck or place
client’s head in brandy sniffing position
Open client’s mouth using crossed
finger technique if necessary. Spray posterior pharynx with topical anesthetic.
Suction mouth and pharynx if necessary
Hold laryngoscope in left hand.
Insert blade into right side of client’s mouth, moving to center of mouth to
displace tongue
Advance blade until epiglottis is
visualized. If straight blade is used, advance blade past epiglottis. If curved
blade is used, position tip of blade anterior to epiglottis in the vallecula
Lift laryngoscope to a 45 degree
angle. Do not use the teeth a pivot
If oral intubations will be used,
insert endotracheal tube through mouth into larynx between vocal cords
Advance tube until cuff disappears
behind vocal cords. If nasal intubations will be used, insert endotracheal tube
through nares into the pharynx. Forceps may now be used to guide tube between
vocal cords and into larynx. Advance tube until cuff disappears behind vocal
cords
Holding tube in place, removes
stylet, if used, and inflate cuff
Ventilate client with manual resuscitator
and 100% oxygen. Auscultate chest during ventilation. Suction endotracheal tube
is necessary
Secure tube with adhesive tape.
Before applying tape, wipe client’s cheeks with alcohol and benzoin
Obtain chest film
Connect client to oxygen using Briggs
adapter or to mechanical ventilator
Check cuff inflation using
pneumometer. Pressure should not exceed 25 cm. record pressure and volume of
air required to maintain seal
ENDOTRACHEAL INTUBATION – Definition, Purpose, Assessment Phase, Precautions, Planning Phase, Client/Family Teaching and Equipment Used
To remove
either an oral or nasal endotracheal tube after it has been determined that the
client can breathe without assistance and that secretions can be removed
without an airway in place
ASSESSMENT PHASE
Can the client ABC value be
maintained without assisted ventilation?
Has the client’s underlying condition
improved to the point at which an artificial airway is no longer required?
Does the client have spontaneous
respirations without the assistance of a ventilator?
Will the client require supplemental
oxygen after extubation?
Are secretions a problem? Will the
client be able to cough and clear secretions after the endotracheal tube is
removed?
PRECAUTIONS
Extubations should only be attempted
after the client is well-rested, especially in clients who have been intubated
for long periods. Extubation may be more successful in the morning than in the
late afternoon or evening
Never remove an endotracheal tube
unless the personnel who are trained to reintubate are present. If respiratory
failure follows extubation, a patient airway must be re-established
A suction setup with sterile
catheters and gloves must be present during the extubation process to remove
secretions in the client’s airway
PLANNING PHASE
Sterile suction catheter
Sterile gloves
Scissors
Water-soluble lubricant
Vacuum source lubricant
Unit dose container of sterile normal
saline or 6 ml syringe filled with normal saline stethoscope
Aerosol setup with supplemental
oxygen
Emergency airway box
Manual resuscitator with mask
Laryngoscope and blades
Endotracheal tubes
CLIENT/FAMILY TEACHING
Discuss the procedure for removing
the endotracheal tube
Describe the suctioning process that
will be used concurrently with the extubation procedure
Encourage the client to cough and
breathe deeply, after the endotracheal tube is removed. Describe the benefits
of coughing and deep breathing and explain why these procedures will reduce the
risk of reintubations
IMPLEMENTATION PHASE
Elevate head of bed to semi-Fowler’s
position or as high as client can tolerate
Assemble equipment for suctioning as
prescribed in previous section on blind endotracheal suctioning
Assemble equipment to give
supplemental oxygen after endotracheal tube is removed
Remove tape or other means of
securing tube in place
Using sterile technique, suction secretions
from the endotracheal tube
Increase client’s FiO2
Insert syringe into one way valve in
pilot balloon and be prepared to deflate cuff
Instruct client to breathe deeply.
Reinsert suction catheter 1 to 2 inches below end of endotracheal tube, deflate
cuff and apply suction while endotracheal tube is removed
Supplemental oxygen and aerosol
should be administered to client as needed
Tracheostomy tubes are removed in
approximately same way as endotracheal tubes are. More attention is given to
stoma after tracheostomy tube is removed. Sterile dressing should be applied to
stoma after tube is removed. Permanent closure to stoma usually occurs within
few days of extubation
After reoxygenation, encourage client
to cough and breathe deeply. Suction oropharynx
Correctly dispose of tubes, catheters
and gloves
Belated
Nursing Care
Encourage client to cough and deep
breathly
Suction is needed to remove
secretions from oropharynx and trachea
Caution: do not leave client
unattended. Observe for any signs of respiratory failure and airway obstruction
CHEST X-RAY (Purpose, Indications,
Normal Findings, Standard Positions Used, Portable Chest X-ray, Lateral View,
Lateral Decubitus Position, Oblique Position, Lordotic Position and Nursing
Considerations)
Chest X-ray
can help in the diagnosis of the large variety of pulmonary problems, including
pneumonia, lung cancer, emphysema, pulmonary edema, and many others. When
performed in a radiology department, usually two view are ordered; a posterior
to anterior view and lateral view. This gives a radiologist a more
three-dimension perspective of the chest X-ray may also be taken of the sinuses
in cases of sinusitis
PURPOSE
Chest X-ray studies done as part of
routine screening procedures
To detect or identify the pulmonary
diseases
To monitor the status of respiratory
disorders and abnormalities (e.g. pleural diffusion, atelectasis and
tuberculosis cavities lesions)
To confirm endotracheal or
tracheotomy tube placement
To detect traumatic chest injuries
after any major accidents
INDICATIONS
Chest X-ray is used to identify
abnormalities in chest structures and lung tissue for diagnosis and injuries of
the lungs and to monitor treatment
Chest films may reveal abnormalities
when there are no physical signs or symptoms of pulmonary disease
Chest films show the bony structures
(e.g. ribs, sternum, clavicles, scapulae, and upper portion of the humerus)
NORMAL FINDINGS
The vertebral column is visible
vertically through the middle of the thorax. The two hemidiaphragm normally
appear rounded, smooth and sharply defined, with the right hemidiaphragm
slightly elevated above the left
The junction of the rib cage and the
diaphragm, called the costophrenic angle is normally clear visible and angled
Heart tissue is dense and appears
white but less intensely white then bony structures. The heart shadow is
normally clearly outlined and extends primarily onto the left side of the
thorax and occupies no more than one third of the chest width
Close observation shows the trachea
in the upper middle chest almost superimposed over the cervical and thoracic
vertebrae. The trachea bifurcates at the level of the forth thoracic vertebra
into the right and left main stem bronchi
The pulmonary blood vessels, bronchi
and lymph nodes are located in the hilum on both the right and left sides of
the midthorax
Lung tissue appears black on X-ray
film. Vascular lung structures are visible as white, thin, wispy strings
fanning out from the hilum
STANDARD POSITIONS USED
Adult chest X-ray studies are taken
with the clients standing or sitting facing the X-ray film, with the chest and
shoulder in direct contact with the film cassette
The shoulders are rotated forward to
pull the scapulae away from the lung field
The X-ray cathode penetrates from the
posterior. This position is called posteroanterior (PA) position
The radiograph is usually taken at
pull inspiration, which causes the diaphragm to move downwards
Radiographs taken on expiration are
sometimes requested for demonstrating the degree of diaphragm movement or for
assisting in the assessment and diagnosis of pneumothorax
PORTABLE CHEST X-RAY
For clients unable to be transported
to the radiology department, portable chest radiography may be taken
Portable radiographs are usually
taken with the film placed behind the client, and the X-ray beam penetrates
from the front of the chest anterioposterior (AP) position
Because the X-ray beam enters from
the anterior chest, the heart will appear larger than it reality is and larger
than on a PA view
LATERAL VIEW
It usually accompanies a standard PA
view. It is taken from either the right or left side of the chest
The arms are raised above the head,
and the side of the chest is placed against the film
The lateral view allows better
visualization of the heart and diaphragm dome
When used in conjunction with a PA
film, a lateral position gives a three-dimension view, allowing more specific
identification of an abnormality’s location
LATERAL DECUBITUS POSITION
This position may be used when it is
necessary to determine whether opaque areas on the pleura are due to solid or
liquid media
This view is taken with the client
lying on either the right or left side, depending on which side of the chest is
being assessed
In a left lateral decubitus position,
the client is lying on the left side. The term decubitus refers to a lying down
position
OBLIQUE POSITION
This position is used to see behind
and around underlying structures. The shoulders are rotated either to the right
or left of the film
By turning the client, the angle at
which the X-ray beam passes through the chest is shifted
In a right oblique position, the
right side is closest to the film. The view may be taken from either an
anterior or posterior position
LORDOTIC POSITION
This position is useful if clearer
visualization of the upper lung fields is needed
This angle of the X-ray cathode is
lowered and the beam directed at an upward angle
This angle removes the clavicles and
first and second ribs from the field of vision
NURSING CONSIDERATION
Explain to the client that this test
detects or monitor the progress of respiratory distress
Explain the client, who will perform
the procedure, where and when it will be done, and that it takes only minutes
Inform that the client must wear a
gown without snaps but may keep his pants, socks and shoes on
Instruct the client, to remove all
jewelry from his neck and chest
Inform the client, that this
procedure is performed in radiology department; the client will stand or sit in
front of a machine
Inform that the client is asked to
take a deep breath and to hold it for a few seconds while the X-ray is taken
Reassure him that the amount of
radiation exposure is minimal. Faculty personnel will leave the area when the
technician takes the X-ray because they are potentially exposed to radiation
many times a day
If the client is incubated, make sure
that no one disconnects the tubes during the procedure
Care should be taken for female
clients of childbearing age
CHEST X-RAY (Purpose, Indications, Normal Findings, Standard Positions Used, Portable Chest X-ray, Lateral View, Lateral Decubitus Position, Oblique Position, Lordotic Position and Nursing Considerations)
POSTURAL DRAINAGE – Definition, Purpose, Equipment, General Instructions, Procedure
DEFINITION
Drainage of
secretion from lung segments by gravity utilizing specific positioning
techniques
PURPOSE
To drain lung secretion before and
after surgery
To aid for easy breathing in
bronchial or lobar pneumonia, lung abscess
To treat patient with, e.g.
bronchiectasis, chronic bronchitis and cystic fibrosis
To assist patient who are unable to
cough and bring out sputum, via. Unconscious, debilitated, quadriplegic patient
EQUIPMENT
Pillows: 3:4
Sputum cup
Tissue paper
Sputum measuring glass
GENERAL INSTRUCTIONS
Perform postural drainage for
patient on empty stomach before meals
Avoid postural drainage for patient
with hemoptysis
PROCEDURE
Explain purpose an procedure to
patient
Locate affected lung with help of
X-rays, auscultation and percussion
Administer bronchodilators before
procedure
Give steam inhalation to patient after
obtaining doctor’s written order
Position patient according to lung
segment to be drained
Postural
drainage techniques:
Upper lobes:
Upper segments: place patient in high Fowler’s position in chair or bed
Anterior segments: place patient in semi-Fowler’s position in chair or
bed
Posterior segments: place patient in Fowler’s position in chair or bed,
provide a cardiac table
Lateral segments: place patient in lateral position elevated to about 45
degree celcius, first to one side and then to other side. When out of bed ask
patient to lean on arm, resting on chair or table for support.
Right middle
lobes
Anterior segment (right side): place
patient flat on left side with a pillow under chest. Right shoulder and body
are kept forward
Posterior
segment: place patient in prone with chest and abdomen elevated
Lower lobes
Anterior segments: place patient in supine,
Trendelenburg with hips elevated with pillows, so that hips are higher than
shoulders
Posterior
segments: place patient prone, Trendelenburg or hips elevated with pillows so
that hips are higher than shoulders
Lateral
segments: place patient in right side lying
Trendelenburg
for left lung and left side lying Trendelenburg for right lung or hips elevated
with pillows to keep hips higher than shoulders
Perform chest percussions and
vibrations on areas to be drained
Encourage patient to cough out
secretions and collect in sputum container
Do suctioning if coughing is not
possible
Make patient comfortable and ask to
rest flat for ten to fifteen minutes before allowing sitting or getting out of
bed
Dispose sputum container in
infectious waste container. Replace articles
Document, time, amount and color of
sputum drained, response of patient to therapy
POSTURAL DRAINAGE – Definition, Purpose, Equipment, General Instructions, Procedure
Nebulization
therapy is to liquefy and remove retained secretions from the respiratory
tract. A nebulizer is a device that produces a stable aerosol of fluid and/or
drug particles.
PURPOSE
To relieve respiratory insufficiency
due to bronchospasm
To correct the underlying respiratory
disorders responsible for bronchospasm
To liquefy and remove retained thick
secretion from the lower respiratory tract
To reduce inflammatory and allergic
responses the upper respiratory tract
To correct humidify deficit resulting
from inspired air by passing the upper airway during the use of mechanical
ventilators in critically ill and post-surgical patients
TYPES
Jet nebulizers
Ultrasonic nebulizer
JET MEDICATION NEBULIZER
A jet
medications nebulizers utilize a high velocity gas flew to generate practice
from the prescribed solution either O2 of compressed air powers the
nebulae.
EQUIPMENT
O2 cylinder/wall O2
outlet of flew metals
A clean tray with O2
nipple adapted to bit the connection tubing
Nebulizer kit consent of: (face
mask/mouth piece)
Nebulized jet and nebulizer cap O2 supply tubing
Physician orders
Prescribed nebulizer solution
The 0.9% NaCl ampoules as diluent if
prescribed
A 5 ml syringe with needle
Disposable spectrum cup
Box of disposable leisters
PROCEDURE
Unscrew the nebulizer jar and instill
the prescribed dose of solutions
Rescrew cap on nebulizer jar
Connect one end of the O2
tubing to the nebulizer and attach the other end of the supply tubing to the O2 flew maters
Place the patient in a comfortable
sitting on semi-Fowler’s positions
Adjust the O2 to flow rate
5 to 6 units per minute or until a fine must appears
Place the mask snugly over the
patients face to cover the nose, mouth and chin and adjust the elastic sharp
around the patients
Instruct the patient to take deep
breath, repeat hold breath briefly this exhale unit all the medications is
nebulized
Observe expansion of the patient
chest during therapy
Observe the patient. Though out the
procedure and give constant reassurance
Thin oil the O2 when all
the solution has vaporized and remove the face mask
Encourages the patient to length
after several deep breaths
Assist the patient to a comfortable
position and wipe off the moisture from the face to face with towel or
disposable tissue
Dismantle the nebulizes kit and
decontaminate in both soapy water
ULTRASONIC NEBULIZER
The
ultrasonic nebulizer utilizes fluid contained in two chambers, which is rapidly
vibrated, causing the fluid to breathe into small particles.
It works on
the principles that high adequacy sound waves can break up water into aerosol
particles by means of two transducers
EQUIPMENT
Ultrasonic equalizers and
manufacturers instruction
Circulating set-up
Disposable aerosol mask
Sterile water
Physicians writes codes
Prescribed solution
Disposable sputum cup
Box of disposable tissue
PROCEDURE
Fill ultrasonic chamber, and the
prescribed solution to the appropriate lay with sterile water
Assemble circulating according to
manufacture instructions and plug the cord into an electrical outlet
Turn on the machine and adjust the
selling until the described amount of mist is obtained
Position the client, in a comfortable
sitting or semi-Fowler’s positions
Place the mask singly over the
patient to cover the base
Observe the patient, for any adverse
reaction to the treatment
Encourage the patient to partially
cough and expectorate any secretions loosed during the treatment
Turn off the machine and discontinue
the procedure
Remove the facemasks and
decontaminate in hot soapy water
Wash and dry mask bands
PRELIMINARY
ASSESSMENT
Check the general condition of the
patient
Check the doctor’s orders
Check the correct position of the
patient
Check the articles available in the
patient unit
COMPLICATIONS
Combustion
CO2 necessaries
O2 toxicity
Absorption atelectasis
Infection
Chronic O2 therapy it home
POSTURAL DRAINAGE
DEFINITION
Drainage of
secretion from lung segments by gravity utilizing specific positioning
techniques
PURPOSE
To drain lung secretion before and
after surgery
To aid for easy breathing in
bronchial or lobar pneumonia, lung abscess
To treat patient with, e.g.
bronchiectasis, chronic bronchitis and cystic fibrosis
To assist patient who are unable to
cough and bring out sputum, via. Unconscious, debilitated, quadriplegic patient
EQUIPMENT
Pillows: 3:4
Sputum cup
Tissue paper
Sputum measuring glass
GENERAL INSTRUCTIONS
Perform postural drainage for
patient on empty stomach before meals
Avoid postural drainage for patient
with hemoptysis
PROCEDURE
Explain purpose an procedure to
patient
Locate affected lung with help of
X-rays, auscultation and percussion
Administer bronchodilators before
procedure
Give steam inhalation to patient after
obtaining doctor’s written order
Position patient according to lung
segment to be drained
Postural
drainage techniques:
Upper lobes:
Upper segments: place patient in high Fowler’s position in chair or bed
Anterior segments: place patient in semi-Fowler’s position in chair or
bed
Posterior segments: place patient in Fowler’s position in chair or bed,
provide a cardiac table
Lateral segments: place patient in lateral position elevated to about 45
degree celcius, first to one side and then to other side. When out of bed ask
patient to lean on arm, resting on chair or table for support.
Right middle
lobes
Anterior segment (right side): place
patient flat on left side with a pillow under chest. Right shoulder and body
are kept forward
Posterior
segment: place patient in prone with chest and abdomen elevated
Lower lobes
Anterior segments: place patient in supine,
Trendelenburg with hips elevated with pillows, so that hips are higher than
shoulders
Posterior
segments: place patient prone, Trendelenburg or hips elevated with pillows so
that hips are higher than shoulders
Lateral
segments: place patient in right side lying
Trendelenburg
for left lung and left side lying Trendelenburg for right lung or hips elevated
with pillows to keep hips higher than shoulders
Perform chest percussions and
vibrations on areas to be drained
Encourage patient to cough out
secretions and collect in sputum container
Do suctioning if coughing is not
possible
Make patient comfortable and ask to
rest flat for ten to fifteen minutes before allowing sitting or getting out of
bed
Dispose sputum container in
infectious waste container. Replace articles
Document, time, amount and color of
sputum drained, response of patient to therapy
ARTIFICIAL AIRWAY MANAGEMENT –
Definition, Indications, Endotracheal Route of Insertion, Tube Types, General
Instructions, Equipment, Preparation of the Patient and the Environment,
Procedure, After Care and Complications
DEFINITION
An artificial
airway is a tube that is inserted at the mouth or nose or level of the second
or third tracheal ring to permit mechanical ventilation and facilitate
secretion removal. The distal end of the tube is located in the trachea below
the vocal cords.
INDICATIONS
Acute respiratory failure, central
nervous system (CNS) depression, neuromuscular disease, pulmonary disease,
chest wall injury
Upper airway obstruction
Anticipated upper airway obstruction
from edema or soft tissue swelling due to head and neck trauma, some
postoperative head and neck procedures involving the airway facial or airway
burns, decreased level of consciousness
Aspiration prophylaxis
Fractured cervical vertebrae with
spinal cord injury requiring ventilator assistance
ENDOTRACHEAL ROUTE OF INSERTION
Tube can be
inserted through nose or mouth. A cuff is always located at the distal end of
the tube.
Orotracheal: insertion of an oral
tube is technically easier, since it is done under direct visualization.
Disadvantages are increased oral secretions, decreased patient comfort,
difficulty with stabilization, and inability of the patient to use lip movement
as a communication.
Nasotracheal: may be more comfortable
to the patient and is easier to stabilize. Disadvantages are that blind
insertion is required, possible development of pressure necrosis of the nasal
airway, sinusitis and otitis media
TUBE TYPES
Vary according to length and inner
diameter in millimeters
Vary according to cuff, most are high
volume, low pressure with self-sealing inflation valves or the cuff may be foam
rubber (foam cuff)
Vary according to composition and
cuff type synthetic Teflon, nylon, polyvinyl chloride, polyethylene or
silastic. May or may not have inner cannula.
Usually are cuffed.
Tubes with high volume, low pressure
cuff self-sealing inflation valves and with or without inner cannula
Pressure limiting cuffs
Polyurethane foam filled cuffs
Speaking tracheotomy tube
Fenestrated
Usual sizes for adult are 6.0, 7.0,
8.0, and 9.0 mm
GENERAL INSTRUCTIONS
Physical
Management
Ensure adequate ventilation and
oxygenation through the use of mechanical ventilation, continuous positive
airway pressure (CPAP) device, Briggs T-piece adapter
Provide adequate humidity, since the
natural humidifying pathway of the oropharynx is bypassed. Clear airway of
secretions as needed with suctioning
Use aseptic technique when entering
the artificial airway. The artificial airway is sterile below the level of the
vocal cords
Frequently assess the patient’s need
for ventilator assistance
Elevate the patient to a
semi-Fowler’s or sitting position, when possible, since these positions
resulting improved lung compliance. The patient’s position however, should be
changed at least every 2 hours, to ensure ventilation of all lung segments and
prevention of secretion stagnation. Position changes are also necessary to
avoid skin breakdown
Nutrition endotube: recognizes that
the tube holds open the epiglottis. Therefore, only the inflated cuff prevents
the aspiration of oropharyngeal contents into the lungs. The patient must not
receive oral feeding. Nutrition must take the form of external tube feedings.
Be aware of the complications and
damage that inflated cuffs may have on the tracheal mucosa. Endotracheal tube
cuffs should be inflated continuously and deflated only during intubations,
extubations, and tube repositioning. The internal cuff pressure should be
checked every 2 hours
External tube site care endotube: patients
with endotracheal tubes have mouth care every shift, or a frequently as needed.
Oral secretions tend to stagnate and risk oral infection is increased. An oral
endotracheal tube may also stimulate an increase in the production of oral
secretions. The tube must be secured at all times and the ventilator, CPAP or
T-piece tubing supported so that traction is not applied to the tube
Have available at all times all the
patient’s bedside a resuscitation bag, oxygen bag source and mask to ventilate
the patient in the event of accidental removal anticipate your course of action
in such an event
Endotracheal tube: know the location
and assembly of reintubation equipment. Know the method of contact personnel
capable of reintubation
PSYCHOLOGICAL CARE OF THE PATIENT
Recognize that the patient is usually
apprehensive particularly about choking inability to communicate verbally,
being unable to remove secretions, difficulty in breathing, or mechanical
failure
Explain the function of the equipment
carefully
Inform the patient and his family
that he will not be able to speak while the tube is in place being a
tracheostomy tube
EQUIPMENT
Laryngoscope with curved or straight
blade and working light source
Endotracheal tube with low pressure
cuff and adapter to connect tube to ventilator or resuscitation bag
Stylet to guide the endotracheal tube
Oral airway or bite block to keep the
patient from biting into and occluding the endotracheal tube
Adhesive tape or tube fixation system
Sterile anesthetic lubricant jelly
Syringe
Suction source
Suction catheter and tonsil suction
Resuscitation bag and mask connected
to oxygen source
Anesthetic spray
PREPARATION OF THE PATIENT AND THE ENVIRONMENT
Suction endotracheal tube
Suction oropharyngeal airway above
the endotracheal cuff as thoroughly as possible
Loosen tape or endotracheal tube
securing device
Extubate the patient
Ask the patient to take as deep as a breath as possible
At peak inspiration deflate the cuff completely and pull the tube out in
the direction of the curve
Once the tube is fully removed, ask
the patient to cough or exhale forcefully to remove secretions. Then suction
the back of the patient’s airway with the tonsil suction
Evaluate immediately for any signs of
airway obstruction, stridor or difficult breathing. If the patient develops any
of the above problems, attempt to ventilate the patient with the resuscitation
bag and mask and prepare for reintubation
Administer oxygen as directed
AFTER CARE
Observe patient closely
post-extubation for any signs and symptoms of airway obstruction or respiratory
insufficiency
Observe character of voice
COMPLICATIONS
Mechanical
Cuff leaks
Cuff herniation
Tube obstruction
Tube displacement
Inadvertent extubation
Right main stem intubation
Laryngeal
and Tracheal
Sore throat
Hoarse voice
Glottic edema
Ulceration of tracheal mucosa
Vocal cord ulceration, granuloma, or
polyps
Vocal cord paralysis
Laryngotracheal web: formation of a
web fibrin and cellular debris initiated by neuro tissue at the glottic or
subglottic level
Post-extubation tracheal stenosis
Formation of tracheoesophageal
fistula
ARTIFICIAL AIRWAY MANAGEMENT – Definition, Indications, Endotracheal Route of Insertion, Tube Types, General Instructions, Equipment, Preparation of the Patient and the Environment, Procedure, After Care and Complications
