Pulse Oximetry Pulse oximetry is a non-invasive way of measuring oxygen saturation of hemoglobin in the blood Normal saturation is 95% - 100% Levels below indicate oxygenation problems.. A saturation below 70% is critical, life-threatening and requires immediate attention.
Pulse Oximetry A sensing device is clipped to an area with pulsating arterial blood such as a finger, toe or earlobe. With this device, a photoelectrical detector records the amounts of light transmitted or reflected by deoxygenated versus oxygenated hemoglobin picking up light signals registered by the pulsations.
Procedure Assess for best location Prepare the site Attach the sensor Follow manufacturer’s directions for use. Read values and document. Notify doctor of low levels
Nursing Diagnosis Ineffective airway clearance related to: Ineffective breathing pattern related to: Impaired gas exchange related to: Goals The patient will: 1. 2. 3.
Positioning Rationale: *gravity assists in lung expansion *reduces pressure from the abdomen on the diaphragm Semi-fowlersOrthopneic
Benefits gained from Positioning Activation of cough reflex Reduce pain Increase ventilatory compensation Drainage of areas of the lungs Maintaining a patent airway
Ambulation Stimulates respirations while walking Upright position allows for lung expansion.
Incentive Spirometry Measures the flow of air inhaled through a mouthpiece. Purpose: Encourages deep breathing by providing visual feedback about their inspiratory ability so they can improve their own breathing efforts.
Patient Teaching Place mouthpiece in mouth with lips tightly around the mouthpiece Inhale with slow deep breath to raise the flow rate indicator. Continue inhaling to try to raise the piston to the prescribed volume level. (Tell patient like sucking on straw) Exhale completely through nose if possible or mouth. Do this several times every 1-2 hours.
What is the key point when instructing a patient in the use of an incentive spirometer ?
Answer: Inspiration Inhale like sucking on straw
Turning Purpose: Permits maximum expansion of both sides of the chest Assists with redistribution of pulmonary blood flow and ventilation and preventing pooling of secretions.
Turning Turn patient every 2 hours Some patients are on a turning schedule Rt. side supine Lf. side supine
Reduces the risks of Stasis of Pulmonary Secretions Increases chest Wall expansion Answer:
Breathing Techniques Pursed-lip breathing - technique of mouth breathing that creates slight resistance to exhalation, thereby prolonging exhalation and preventing airway collapse by maintaining positive airway pressure. Diaphragmatic breathing - technique to reduce the respiratory rate, increase tidal volume, and reduce residual capacity in which the patient consciously uses the diaphragm and abdominal muscles during respirations.
Deep Breathing and Controlled Coughing When teaching the patient about breathing exercises ask the patient to: Concentrate on expanding the upper chest forward and upward while inhaling deeply to aerate lobes of the lungs. Hold the breath for 3 to 4 seconds to promote aeration of alveoli Exhale passively and slowly through the mouth or nose.
Cough What is the rationale for having a patient cough?
Answer: Permits patient to remove secretions from both upper and lower airways
Teaching a Patient to Cough Splint abdomen Take 3 deep breaths In-2-3-4 Out 2-3-4 On third deep breath, COUGH on expiration
Postural Drainage Drainage of secretions by gravity from various segments of the lung
Percussion and Vibration Percussion- forceful striking of the skin with cupped hands to mechanically dislodge tenacious secretions from bronchi Vibration is a technique in which the chest wall is set in motion by oscillating movements of the hands.
Indicated for patients who have hypoxemia or inadequate transport of oxygen
Signs and Symptoms of Hypoxemia Tachycardia Mental Confusion Restlessness Tachypnea Air Hunger Sweating Cyanosis
Doctor’s Order Needed Specific concentration Method Liter flow per minute
Safety Precautions Place “No Smoking Oxygen in Use” sign on the door, at head of bed, and on the oxygen equipment Instruct patient / visitors about precautions Make sure electrical devices are in good working order to prevent sparks Avoid materials that generate static electricity Ground equipment Make known location / use fire extinguishers
Oxygen Delivery Low-flow Devices: 1. Nasal Cannula – tube that extends around the face with curved prongs that fit into the nostrils. Check skin / nostrils for irritation. 2. Face Mask Simple Partial rebreather mask
Oxygen Devices High-flow devices Venturi Mask - the device delivers oxygen at a precise oxygen concentration and can be set to meet specific needs of the patient.
Oxygen Delivery Humidification Necessary to prevent mucous membranes from drying and becoming irritated and loosen secretions for easier expectoration
Oxygen Delivery Flow Meter: Regulates the amount of oxygen being delivered Calibrated in liters per minute Can be regulated by nurses by turning knob to elevate ball within chamber