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DavisPlus, located at http://davisplus.fadavis.com. OXYGENATION STATUS. When beginning to assess the pa- tient’s oxygenation status, determine the patient’s orientation to time, place, and person. Note restlessness and unusual irritability or confusion. Even minor changes can indicate hypoxia. Safety: Remember that changes in level of conscious- ness can indicate decreased oxygen reaching the brain. OXYGEN SATURATION. Determine oxygen saturation using a pulse oximeter. (Refer to Chapter 17 for the procedure for using pulse oximetry.) The pulse oximeter is used to measure the oxygen saturation of capillary blood (SaO 2 ). The normal range for SAO 2 is 95% to 100%. In healthy people, a satura- tion of 94% or below is cause for concern. Safety: Remember that nail polish, especially a dark color, and artificial nails will cause inaccurate pulse oximetry results. Remove nail polish or use an alternative site such as the earlobe or forehead. You can check a patient’s oxygen saturation without a health-care provider’s order. Be alert to subtle signs and symptoms of hypoxemia, and check the oxygen saturation when indicated.
TEXT STEP #1 Build a solid foundation.
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Clinical Skills and Care
Clinical Skills and Care Critical Thinking Connections at the beginning of every chapter help connect what you read to what you will see and do in the clinical setting. The diaphragm and the intercostals are the muscles re- quired for breathing to occur. When the diaphragm contracts in response to stimulus from the phrenic nerves, it moves downward, which increases the size of the chest cavity. In- tercostal muscles then contract, moving the ribs up and out, which also enlarges the chest cavity from side to side and from front to back. When the chest cavity size increases, it causes the lungs to expand. The pressure within the lungs then drops below atmospheric pressure, or becomes negative pressure. This causes a sort of vacuum; air is pulled into the lungs until the pressure in the lungs equals the pressure out- side of the body. The term used to describe this is inhalation, also known as inspiration. and carbon dioxide move across the alveolar cell membranes and the cell membranes of the capillaries surrounding the alveoli by the process of diffusion. This process occurs involuntarily, meaning that no con- scious thought is given to it. It is important to understand the mechanics of how breathing occurs so that you can grasp the treatments for respiratory disorders affecting those mechan- ics, such as chest tubes, endotracheal tubes, and mechanical ventilation. Sample Documentation Regulation of Respiration Nerves and a chemical control mechanism both contribute to the regulation of respirations. The respiratory center is in the medulla, located in the brainstem. This brain function automatically controls inhalation by sending impulses to the phrenic nerve, which causes contraction of the diaphragm and intercostal muscles. As these muscles relax, again in response to nerve stimu- lus, the size of the chest cavity decreases. The ribs come in- ward, the diaphragm rises upward, and the lungs are then compressed, forcing the air to go out. This is referred to as exhalation, also known as expiration. Chemical regulation of respirations is influenced by chemoreceptors located in the carotid and aortic bodies and in the medulla of the brain. When these chemoreceptors de- tect a decrease in the oxygen level of the blood or a change in blood pH, they send a message to the medulla, which in turn causes an increase in the rate and depth of respirations. When carbon dioxide increases above normal amounts, it causes the blood to become more acidic. The chemorecep- tors respond by sending the message to the medulla, which in turn causes the respiratory rate to increase to “blow off” or remove excess carbon dioxide, returning the blood pH to normal levels. (See Chapter 29 for more information about acid-base balance and the role of the lungs in maintaining blood pH.) Rising carbon dioxide levels that in turn cause the blood to become more acidic provide the brain’s stimulus to breathe.
SKILLS—cont’d
28.4 Administering a Nebulizer Treatment 28.5 Administering Supplemental Oxygen 28.6 Performing Nasopharyngeal and Oropharyngeal Suctioning 28.7 Performing Endotracheal and Tracheostomy Suctioning 28.8 Performing Tracheostomy Care 28.9 Maintaining Chest Tubes
KNOWLEDGE CONNECTION What areas will you inspect when assessing a patient with impaired oxygenation? When you palpate, what two evalu- ations are you making? How can you tell if the patient is becoming hypoxic or hypoxemic?
Knowledge Connection boxes check your understanding of the material you just read.
CRITICAL THINKING CONNECTION Clinical Assignment
588 You are assigned to care for a hospitalized patient tomorrow in clinical who has a tracheostomy. He was injured in a car accident and was on a ventilator for several weeks. He is breathing on his own now, but he still has the tracheostomy in place. In addition, he has recently developed pneumonia in his right lung. He has a large amount of secretions and requires suctioning every 2 to 3 hours. The tracheostomy will have to be
UNIT FOUR
Skill 28.9 (continued) 10. Ensure that Vaseline and gauze 4 × 4s are at the bedside in case of air leakage or other emergency. Follow your facility’s policy for appropriate action to take if the chest tube is dislodged. 11. Assess output in the collection chamber. Be aware of the color and amount draining each hour. Safety: Notify the phy- sician immediately if the drainage changes to a bright red color or is greater than 100 mL/hr. 12. Assess for air leaks in the drainage system. Remember that wet suction will bubble gently in the suction chamber. If the patient has a pneumothorax, expect to see air in the water- seal chamber and tidaling in the chamber. As the pneu- mothorax resolves and the lung reinflates, the air in the water-seal chamber and the tidaling in the chamber will cease. 13. Mark output for your shift on the writable surface of the col- lection chamber. Mark the level of the output and then write the date, time, and your initials. Calculate drainage out- put for your shift by subtracting the amount in the drainage chamber when you started your shift from the amount in the chamber at the end of your shift. 14. Assist the patient to a comfortable position and reassure them regarding the chest tubes. Encourage the patient to change position, cough, and deep breathe every 2 hours to help re-expand the lung and remove drainage from the chest cavity. 15. Follow the Ending Implementation Steps located on the inside back cover.
Evaluation Steps 1. Evaluate the effectiveness of the chest tubes. Is the patient breathing with less difficulty? Is the suction set correctly? Is the water seal at 2 cm of water? Are there signs of escaping pneumothorax? Are there any signs of additional air leaks? 2. Evaluate the patient’s response to the procedure. Is the patient resting comfortably? Is pain medication needed for the incision site? Is the patient complaining of any other problems? 3. Evaluate the insertion site dressings. If there is a hemothorax, is the dressing dry and intact? Does it need to be reinforced or changed? Follow your facility’s policy for changing the dress- ing to the chest tube insertion site.
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cleaned on your shift and a new inner cannula put in place. He has humidified oxygen at 4 L/min via a tracheostomy collar. Critical Thinking Questions: 1. Why is a tracheostomy done? 2. How does a tracheostomy work? 3. How will you suction it? 4. How will you clean it and replace the inner cannula? 5. What is a tracheostomy collar?
Older Adult Connection Teaching Older Adults Have a caregiver or family member present during teaching, if possible. Allow plenty of time for teaching so that the patient does not feel rushed. Be alert to cues that the older patient does not understand the teaching. They may put you off, saying, “I’ll do it later” or “I already read it.” This may occur because the patient is confused or does not understand but does not want to say so. Be very patient with older adult learners. Use plenty of repetition without getting frustrated. 10/12/28 1825 Dr. Chapman inserted one chest tube for hemothorax. Attached to Pleuravac drainage system with wet suction at –20 cm. Water seal established with 2 cm water. Chest tube draining mod amt of dark red fluid, less than 100 mL/hr. All connections double-taped. Drsg at insertion site clean, dry, and intact. Resting quietly in bed in semi-Fowler’s position eating ice chips. States he “can breathe better” after chest tube insertion. Requests pain med for incisional pain. _________________________________________________________________________ ___________________________________________________ Nurse’s signature and credentials Settings Connection: Home Health Home Health Referral for Teaching Patients who are to be discharged from the hospital but need more teaching can be referred to home health care for follow-up teaching. This requires a health-care provider’s order. Be alert to the need to ask for a referral for more teaching. A home health-care follow-up often can prevent rehospitalization if the patient has not mastered information needed for self-care. your patient and made him a little short of breath. How- ever, once you had suctioned his tracheostomy several times, he could breathe considerably better and mouthed “thank you.” After that, you weren’t afraid to suction him. His tracheostomy collar stayed in place pretty well, and you were able to replace his inner cannula the first day with your instructor’s guidance. By the second day, you were feeling far more confident about all of his care. By the third day of clinicals, you were showing other students how to suction him.
It can be alarming to see a patient struggle to breathe or to have to assist a patient who must be suctioned to be able to breathe. As the patient becomes more anxious, it is easy for your anxiety to increase as well. This chapter will help you prepare to care for patients who have respiratory problems, assisting them to improve oxygenation and breathe more easily.
Geriatric content throughout familiarizes you with this important patient demographic.
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CRITICAL THINKING CONNECTIONS: POST CONFERENCE
Critical Thinking Connections: Post Conference boxes at the end of every chapter provide answers to the questions posed by the Critical Thinking Connections. NORMAL OXYGENATION
You were really worried when you walked into your patient’s room the first morning and saw him with his tra- cheostomy, sounding all bubbly and coughing frequently. He pointed to the tracheostomy and mouthed the word “suction.”Without much time to think, you grabbed a suc- tion catheter and glove kit and set up quickly but with- out contaminating your sterile field or sterile supplies. You remembered as you suctioned to hold your own breath and not suction for longer than 10 seconds. It was obvious to you that the suctioning procedure tired Key Points • Muscles, nerves, and chemicals all play a role in causing and controlling respirations. • Impaired oxygenation may be the result of hypoxia or
The term airway refers to the path that air takes as it enters and exits the lungs. The normal pathway is through the nos- trils into the pharynx, into the trachea, and then to either the right or the left bronchus, which branches into the bronchi- oles that terminate into the alveoli. When this pathway is un- blocked and air is moving freely, it is referred to as a patent airway. The Mechanics of Breathing When the airway is patent, air is inhaled and follows the path- way to the alveoli, where oxygen is absorbed into the blood and carbon dioxide leaves the blood to be exhaled. Oxygen
• Give
• WORD • BUILDING • inhalation: in – in + hala – breath + tion – action exhalation: ex – out + hala – breath + tion – action
• Crepitus indicates air under the skin, or subcutaneous emphysema, and the source of the leaking air must be found and treated.
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