2. Oxygenation Skills By Mary Knutson, RN

3. The Nursing Process: Start with Assessment:  Subjective/objective data Nursing Diagnosis  Identify problems Planning  Goals/interventions Implementation Evaluation

4. Focused Respiratory Assessment: Look for signs of dyspnea/hypoxia Look for signs of dyspnea/hypoxia Ask about cough/sputum/breathing Ask about cough/sputum/breathing Monitor vital signs, O 2 saturation Monitor vital signs, O 2 saturation Observe and auscultate chest Observe and auscultate chest Utilize respiratory and pain interventions ordered by physician Utilize respiratory and pain interventions ordered by physician Evaluate effectiveness of interventions Evaluate effectiveness of interventions

5. Interventions to Improve Oxygenation: Comfort and reassure patient Comfort and reassure patient Promote relaxation and cooperation Promote relaxation and cooperation Non-pharmacological interventions Non-pharmacological interventions Pharmacological interventions Pharmacological interventions

6. General Comfort and Positioning: Elevate Head of Bed or use sitting position Elevate Head of Bed or use sitting position Maintain adequate fluids and nutrition Maintain adequate fluids and nutrition Position patient as comfortably as possible Position patient as comfortably as possible Provide effective pain management Provide effective pain management

7. Non-pharmacologic Interventions: Incentive Spirometer Incentive Spirometer Coughing and deep breathing Coughing and deep breathing Hydration of secretions Hydration of secretions Postural drainage Postural drainage Chest physiotherapy Chest physiotherapy Involve family, considering culture and beliefs Involve family, considering culture and beliefs

8. Patient Teaching: Coughing and Deep Breathing Coughing and Deep Breathing Incentive Spirometry Incentive Spirometry Prepare surgical patients for pain assessments Prepare surgical patients for pain assessments Anticipatory Guidance Anticipatory Guidance

9. Pharmacologic Interventions: Expectorants, Mucolytics Expectorants, Mucolytics Antitussives/Cough suppressants Antitussives/Cough suppressants Bronchodilators (inhalers or nebulizers) Bronchodilators (inhalers or nebulizers) Pain medication (especially surgical patients) Pain medication (especially surgical patients) Medications for chronic respiratory conditions Medications for chronic respiratory conditions

10. Oxygen Therapy: Use nasal cannulas, catheters, masks Use nasal cannulas, catheters, masks Wall oxygen, tanks, or concentrators Wall oxygen, tanks, or concentrators Control liters per minute with flowmeter and O2 concentration FiO 2 Control liters per minute with flowmeter and O2 concentration FiO 2 Hyper-oxygenate patients prior to suctioning Hyper-oxygenate patients prior to suctioning Use lower flow rates if patient is a CO 2 retainer Use lower flow rates if patient is a CO 2 retainer

11. Artificial Airways: Nasal Airway Nasal Airway Oral Airway Oral Airway Endotracheal tube Endotracheal tube Tracheostomy Tracheostomy Be sure to keep the openings clear- potential for obstruction exists

12. Suctioning Skills: Oral Suctioning Oral Suctioning Tracheostomy Suctioning Tracheostomy Suctioning  Use of Ambu bag  Care of tracheostomy Suctioning of ET (Endotracheal) tube Suctioning of ET (Endotracheal) tube  Inline suctioning of ventilator patient Suction only as needed, not on a routine basis.

13. Catheter Selection: Choose catheter size based on airway size and sputum thickness Choose catheter size based on airway size and sputum thickness  Adult size is usually 12-16 Fr.  Pediatric size is usually 8-10 Fr.  Newborn size is usually 6-8 Fr.

14. Vacuum Pressure Selection:  Wall Unit suction:  Adult:100 to 120 mm Hg  Child:95 to 110 mm Hg  Infant:50 mm Hg  Portable Suction Unit:  Adult:10 to 15 mm Hg  Child:5 to 10 mm Hg  Infant:2 to 5 mm Hg

15. Additional Assessments and Interventions: Arterial Blood Gases Arterial Blood Gases Postural Drainage Postural Drainage Chest P.T. (Physiotherapy) Chest P.T. (Physiotherapy) Thoracentesis Thoracentesis Chest Tube Chest Tube CPAP or BiPAP CPAP or BiPAP Mechanical Ventilation Mechanical Ventilation

16. Chest Tubes: Assist with insertion and removal Assist with insertion and removal Monitor respiratory status/drainage Monitor respiratory status/drainage Check for secure, occlusive dressing Check for secure, occlusive dressing Maintain functioning gravity drainage system with no loops or kinks Maintain functioning gravity drainage system with no loops or kinks Keep 2 clamps at bedside in case the unit needs changing Keep 2 clamps at bedside in case the unit needs changing

17. Thoracentesis: Explain procedure/obtain signed permit Explain procedure/obtain signed permit Position patient/observe for reactions Position patient/observe for reactions  Patient sitting on edge of bed with elbows propped  If unable, lie on unaffected side, raising hand of affected side Prepare lab specimen, evaluate and document patient’s response Prepare lab specimen, evaluate and document patient’s response

18. Pre-skill Organization: Wash hands Wash hands Introduce yourself Introduce yourself Observe the patient and the situation Observe the patient and the situation Listen to patient and answer questions Listen to patient and answer questions Explain what you will be doing Explain what you will be doing Assemble equipment Assemble equipment

19. Skill Completion: Keep patient comfortable as possible Keep patient comfortable as possible Check oxygenation and administer oxygen as prescribed/needed Check oxygenation and administer oxygen as prescribed/needed Evaluate results of intervention and how the patient tolerated the procedure Evaluate results of intervention and how the patient tolerated the procedure Wash hands Wash hands Finish documentation Finish documentation

20. Assessment Variables: Concurrent illness or chronic illnesses Concurrent illness or chronic illnesses Type of airway Type of airway Dementia, sensory impairment, or inability to express needs Dementia, sensory impairment, or inability to express needs Age Age  Pediatric patients  Frail, elderly patients

21. Pediatric Oxygenation Blood oxygen drops quickly Different sizes and types of oxygen equipment Use developmentally appropriate language Teach parents about equipment, CPR, support services and safety factors

22. Respiratory Care of Elderly Patients Physiological changes in lungs and chest Physiological changes in lungs and chest Less productive coughing Less productive coughing Drier mucus membranes Drier mucus membranes Respiratory problems limit independence Respiratory problems limit independence Increased risk for pneumonia and other respiratory diseases Increased risk for pneumonia and other respiratory diseases

23. Critical Thinking: 3 year old boy with a tracheostomy had O 2 saturation of 85%. Oxygen was started and then 89% sats. He was anxious, with resp. rate of 38. There were no abnormal lung sounds. The tubing was not kinked or blocked with water, and the oxygen was flowing. What would you do next if you suspected a mucus plug in trach? 3 year old boy with a tracheostomy had O 2 saturation of 85%. Oxygen was started and then 89% sats. He was anxious, with resp. rate of 38. There were no abnormal lung sounds. The tubing was not kinked or blocked with water, and the oxygen was flowing. What would you do next if you suspected a mucus plug in trach?

24. Critical Thinking: You began a focused respiratory assessment on your elderly patient. You have completed the Vital Signs, but have not listened to the lungs yet. She became dyspneic, cyanotic, and had loud, audible crackles from excess secretions. Do you complete your assessment, or begin suctioning? You began a focused respiratory assessment on your elderly patient. You have completed the Vital Signs, but have not listened to the lungs yet. She became dyspneic, cyanotic, and had loud, audible crackles from excess secretions. Do you complete your assessment, or begin suctioning?

25. Respiratory Blended Skill: Your patient is a 77 year old woman with asthma exacerbation, pneumonia, HTN, Diabetes Mellitus II, and GERD Your patient is a 77 year old woman with asthma exacerbation, pneumonia, HTN, Diabetes Mellitus II, and GERD  Do focused respiratory assessment  Effective Communication  Interventions to promote oxygenation  Evaluation and Documentation

26. Reflection: There is a lot more to the ABC’s than you thought!  Airway  Breathing  Circulation Understanding oxygenation skills gives you more of the foundation you need for excellent patient care This presentation was created in 2004.