UNIT FOUR
564
Clinical Skills and Care
with external respiration, supplemental oxygen increases the amount of available oxygen with each inhalation. Oxygen is not without its risks, however. Safety: Oxygen supports combustion, meaning that its presence will cause any fire to burn faster and hotter. Whenever oxygen is in use, you must ensure that safety precautions are followed: • Ensure that “No Smoking” signs are posted on the doors and above the bed. In hospitals, smoking is no longer allowed anywhere. However, in home health-care and some long-term care or assisted living facilities, smoking could still be an issue. In those settings, be sure the signs are in place and the restrictions on smoking are enforced. • Ensure that no open fl ames are in the same room as an oxygen source. In home health care, this refers to open- fl ame heaters, candles, and fi replaces. The oxygen source must be in another room away from any fl ame. • Check electrical devices such as electric razors to ensure that there are no frayed wires that could cause sparks, which could lead to a fi re. • Eliminate the possibility of static electricity, which could spark a fi re. Use cotton gowns and linens, not synthetics. • Avoid using petroleum-based products such as petroleum jelly on the lips of patients using supplemental oxygen. Use a water-soluble or non–petroleum-based product instead. Oxygen can cause toxicity in some situations. If a person breathes a high concentration of oxygen for long periods, it can cause central nervous system damage. If a high-liter fl ow of oxygen is given to patients with chronic lung dis- ease, it can cause severe respiratory problems. Remember that the patient’s stimulus to breathe is low oxygen in the blood rather than higher-than-normal carbon dioxide levels. During a severe exacerbation, such as an acute worsening of chronic lung disease, higher levels of oxygen may be used short term only to help get the patient through the crisis. If the patient receives supplemental oxygen at a liter fl ow above 2 to 3 L/min beyond the acute crisis, it can cause respiratory depression and even death. Safety: Always keep routine sup- plemental oxygen liter flow for patients with chronic obstruc- tive lung disease below 3 L/min unless otherwise ordered. OXYGEN DELIVERY. Supplemental oxygen can be delivered in a variety of ways. The health-care provider will order the speci fi c device. However, it is important for you to evalu- ate the effectiveness of such orders and to suggest a change if it is appropriate. It also is important for you to understand how oxygen is delivered by each device. For example, if a patient who is using a nasal cannula, which delivers oxygen via nasal prongs, is breathing mostly through their mouth, a mask may be more appropriate for oxygen delivery. Oxygen may be derived from different types of sources. For example, in the hospital setting, oxygen is piped in through the walls and accessed by inserting a fl owmeter into a valve. The oxygen then fl ows through tubing to the patient (Fig. 28.2). When the patient leaves the hospital room, a portable oxygen tank, called an E-cylinder, is used to
be mixed with saline. Safety: Follow orders carefully because failing to mix the medication as ordered could lead to an over- dose. Saline without medication may also be used to provide moisture to the airways in order to thin tenacious mucus. The compressed air travels through the liquid medication or saline, converting it into a fi ne mist that the patient inhales directly into the airways and lungs. A health-care provider’s order is required for all nebulizer treatments. Once you add the liquid medication, medication with saline, or saline alone to the cup, you will assemble the remaining apparatus for medication delivery. When the compressor is turned on, you will see vapor in the mask or from the spacer on the back side of the handheld mouth- piece. The patient then breathes the vapor in, slowly and deeply. If the patient is using the mouthpiece, they must close the lips around it and breathe in through the mouth and out through the nose. If the patient is unable to breathe in this manner during the nebulizer treatment, you will want to use the mask apparatus rather than the mouthpiece. The patient can then breathe in and out through the nose or mouth and still inhale the medication effectively. Skill 28.4 gives the steps for preparing a nebulizer and administering a nebu- lizer treatment. Chest Physical Therapy To help drain mucus from the lobes of the lungs, chest physi- cal therapy (CPT) may be ordered. This involves assisting the patient into different positions to encourage the drainage of mucus out of the lungs. It also involves using percussion to help loosen pooled mucus. In most hospitals, this will be per- formed by respiratory therapists. However, it is possible that in home health-care and long-term care settings, a licensed practical/vocational nurse might need to assist with CPT. Postural drainage refers to positioning the patient in ways to speci fi cally drain each lobe of the lungs. The right and left upper lobes are best drained with the patient in the orthopneic and high Fowler positions. To drain the middle lobes, place the bed in the Trendelenburg position and have the patient lie in the right lateral position and then the left lat- eral position. To drain the lower lobes, continue to keep the bed in the Trendelenburg position and assist the patient to lie in the left semi-prone and right semi-prone position and then to lie in the prone position. Keep in mind that not all patients who have respiratory illnesses can tolerate remaining in all of these positions. Percussion refers to cupping or clapping over the lung fi elds to loosen mucus and help it drain. This is done with the hands cupped, clapping against the rib cage, and pausing to let the patient cough as needed. Supplemental Oxygen When a patient is hypoxemic, the health-care provider orders supplemental oxygen. It is important to understand the purpose of this; remember that room air contains 21% oxygen, so it is always available as we breathe. However, in the presence of lung disease or other conditions that interfere
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