FUNDAMENTALS OF NURSING DAY 2

RESPIRATORY PROCEDURES
ELIMINATION
FEEDING
Oxygen Therapy
Factors affecting Respiratory Function
Age  Health Status
 Environment  Medications
 Lifestyle  Stress

Oxygen Safety Tips
 Do NOT use oxygen around open flames, such as matches, cigarette lighters, candles or
cigarettes.
 Do NOT use oxygen around other sources of heat, such as electric or gas heaters and/or stoves.
 If you are using supplemental oxygen, avoid using lotions or creams containing petroleum — the
combustion of flammable products containing petroleum can also be supported by the presence
of oxygen.
 Store oxygen cylinders safely in a secure, upright position in an approved place for storage.
 Turn oxygen supply valves off when not in use.
 Pay close attention to the safety instructions recommended by your oxygen supply company,
regarding safe usage and storage of supplemental oxygen.
Nasal Cannula
 Most common and inexpensive device used to administer oxygen.
 The nasal cannula is easy to apply and does not interfere with the client’s ability to eat or talk.
 It delivers low concentration of oxygen at flow rates of 2-6 L per minute. (24-45%)
Facemask
 Delivers oxygen concentration from 40-60% at liter flows of 5-8 liters per minute.
 This mask is only meant for patients who are able to breathe on their own, but who may require a
higher oxygen concentration than the 21% concentration found in ambient air/minute.
Partial Rebreather Mask
 Delivers oxygen concentration 60-90% at liter flows of 6-10LPM
 The partial rebreather is a breathing set that recycles exhaled air and mixes that with a breathing
gas containing oxygen. This reduces the amount of breathing gas needed
The exhaled air is filtered through a carbon dioxide scrubber containing a soda lime absorbent.
The cleaned air then reenters the line and is mixed with the breathing gas.
Non-Rebreather Mask
 Delivers the highest oxygen concentration about 95-100%
 One way valve on the mask and between the reservoir bag and the mask prevent the room air
and the clients exhaled air from entering the bag so only the oxygen in the bag is inspired
Venturi mask
 Delivers oxygen concentration varying from 24%-40% or 50% at liter flows of 4-10lpm
 The venturi mask has a wide bore tubing and color coded jet adapters that correspond to a
precise oxygen concentration and liter flow.
 The color of the device reflects the delivered oxygen concentration, for example: blue = 24%
(4lpm); yellow = 28%; white = 31%; green = 35%(8lpm); pink = 40%; orange = 50%
Face tent
 Can replace oxygen mask when masks are poorly tolerated by clients
 It provides varying concentrations of oxygen at 4-8LPM

Nasal Cannula- Assess client’s nares for encrustations and irritation. Apply water soluble lubricant.
 Assess the top of the client’s ears for any signs of irritation. Place padding with a gauze pad.
Face Mask or Tent- Inspect the facial skin frequently for dampness.
  The mask should mold to the face, so that very little oxygen escapes into the eyes or around
cheeks and chin.

Suctioning is aspirating secretions through a catheter connected to a suction machine or wall suction
outlet.
Suction catheters
Open tipped – effective for removing thick mucous plugs
Whistle tipped- less irritating to respiratory tissues
Oral suction tube/ Yankauer device- suction the oral cavity
Size:
Adult Fr. 12-18
Children Fr. 8-10
Infant- Fr. 5-8
POSITION:
CONSCIOUS: SEMI – FOWLER’S
Mouth – face turned to side 4-6 inches
Nose- neck hyperextended 5 inches
UNCONSCIOUS: LATERAL

PRESSURE OF THE SUCTION EQUIPMENT

WALL UNIT PORTABLE UNIT
Adult 100 – 120 mmHg Adult 10 -15 mmHg
Child 95 - 110 Child 5 - 10
Infant 50 -95 Infant 2-5

Perform Suctioning
Apply suction for 5-10 seconds (maximum of 15 seconds)
Allow sufficient time between each suction for ventilation and oxygenation. Limit suctioning to 5 minutes in
total. Encourage to breathe deeply and to cough between suctions

Tracheostomy – is a surgical opening in the trachea (windpipe) to make breathing easier. The
opening is called a stoma. A tracheostomy tube is inserted in it to keep it open.

Suctioning a Tracheostomy or Endotracheal tube

Position: Semi- fowlers
- The outer diameter of the suction catheter should not exceed one half the internal diameter of
the tracheostomy so that hypoxia can be prevented
- Hyperoxygenation can be done with a manual resuscitating bag (3-5 times) or through the
ventilator by increasing the flow before and between suction attempts.
- Insert catheters about 5 inches or until client coughs or you feel resistance.

Chest Physiotherapy
 Is the removal of excess secretions (also called mucus, phlegm, sputum) from inside the lungs,
by physical means.
 It is used to assist a cough, re-educate breathing muscles and to try to improve ventilation of the
lungs.

Prophylactic
 Chest physiotherapy is usually indicated in smokers, in those with abnormal lung function pre
operative.
 Pre operative respiratory muscle training in high-risk abdominal and thoracic surgery.
 Post operative assistance in clearing secretions in high-risk abdominal and thoracic surgery.
POSTURAL DRAINAGE
  This uses gravity and correct positioning to bring the secretions into the throat where it is easier
to remove them.
 The lungs are divided into segments called lobes and at times, certain lobes can be more
affected than others.
 If the bottom lobes have more secretions, then the child/adult will be tipped head down.
 If one lung is more affected than the other, then they will be positioned on the opposite side.
 When tipping the child over pillows to get them 'head down', the pillows should be placed under
the pelvis, NOT under the chest.
 In babies, it may be more usual for the upper lobes to be affected and then the baby will be
propped in sitting position to try and clear some of the secretions.
Percussion
 This involves a form of 'patting' the chest to vibrate the lungs and help the secretions move.
 It is not hitting! 'Vibrations' and 'patting' do what they say, to try and clear the airways
 Assisted coughing is a very important adjunct to chest physiotherapy and when done well is
effective and comfortable.
 It assists the work of the diaphragm to increase the cough pressure and try and force the
secretions out.
 Chest physiotherapy should never be done straight after a meal or drink.
 For a meal wait one hour and after a drink wait ½ hour.
 Chest physiotherapy should be done when secretions need removing and this may be once a day
or it may be 4-5 times a day.
 It is often useful to do physio first thing in the morning before getting out of bed.
 The chest will have been relaxed at night and the secretions may be easier to remove.
Vibration
 Is the technique of applying manual compression and tremor to the chest wall during the
exhalation phase of respiration. This helps to increase the velocity of the air expired from the
small airways, thus freeing the mucus. After three or four vibrations, the pt. is encouraged to
cough, using the abdominal muscles.

Drainage or Removal of Secretion- coughing or suctioning

- Provide mouth care
- Auscultate the client lungs, compare findings to the baseline data and document the amount,
color and character of expectorated secretions

The sequence for PVD is usually Positioning, Percussion, Vibration and Drainage of secretion

Micturition, Voiding and Urination- refer to the process of emptying the urinary bladder.
Urine collects in the bladder until pressure stimulates special sensory nerve endings in the bladder wall
called stretch receptors. This occurs when adult bladder contains 250-450 ml of urine, for children 50-200
ml.

Altered Urine Production

Polyuria- production of large amount of urine by the kidneys, more than 100ml/ hr or 2500/day
Oliguria- less than 30 ml/ hr or less than 500 ml/day
Anuria- 0-10 ml/ hr

Altered Urinary Elimination

Urinary Frequency- voiding at frequent intervals that is more than 4-6 times/ day
Nocturia- voiding 2 or more times at night
Dysuria- voiding that is either painful or difficult
Hesitancy- delay or difficulty in initiating voiding
Enuresis- involuntary urination in children beyond the age when voluntary bladder control is normally
acquired usually 4-5 years of age
URINARY INCONTINENCE
- Involuntary urination
Total incontinence- continuous or unpredictable loss of urine
Stress incontinence- leakage of less than 50 ml urine due to increase intra abdominal pressure
Reflex incontinence- involuntary loss of urine occurring at predictable intervals when specific bladder
volume is reached.

URINARY RETENTION
- Emptying of the bladder is impaired urine accumulates and the bladder becomes overdistended

Managing Urinary Retention

Provide privacy
Increase fluids
Serve bedpan/ urinal
Listen to sound of running water
Pour warm water over the perineum

Flaccid bladder (weak, soft, and lax bladder muscles) - may use manual pressure on the bladder to
promote bladder emptying known as Crede’s maneuver.
- May give Cholinergic drug such as Bethanechol Chloride

URINARY CATHETERIZATION
- Introduction of urinary catheter into the urinary bladder.
- Most common cause of Hospital Acquired Infections

Single Catheterization) - straight catheter

- Spot urine specimen is required and for temporary decompression
Retention Catheterization- 2 way Foley catheter
- If the bladder must remain empty, or for continuous urine measurement
Continuous Bladder Irrigation- 3 way Foley catheter
- Sterile irrigating fluid will flow into the bladder through the 3 rd lumen then fluid exists the bladder
through the drainage lumen along with the urine.

Purposes:
To relieve discomfort due to bladder distention
To assess the amount of residual urine if the bladder empties incompletely
To obtain a sterile urine specimen
Irrigate the bladder
To empty the bladder completely prior to surgery

Position- Female supine with knees flexed, feet about 2 feet apart and hips slightly externally rotated
Male- supine, thighs slightly abducted or apart

Establish adequate lighting- stand on the client’s right if you are right-handed, on the client’s left if you are
left-handed

Size Lubricate Length of Insertion

Female Fr 12-14 1-2 inches 3-4 inches
Male Fr 16-18 6-7 inches 6-9 inches

Things to Remember:
- Test the balloon
- Lubricate and ask client to take a slow deep breath and insert the catheter as the client exhales.
- Advance catheter 2 inches further after the urine begins to flow.
 - If the catheter accidentally slips the vagina the catheter may be left in place until the new catheter
is inserted
- Remove the straight catheter when urine stops to flow.
- For an indwelling catheter, secure the catheter tubing to the inner thigh for female clients or the
upper thigh/ abdomen for male clients
- Do not pull the catheter while the balloon is inflated

Remove Indwelling Catheter

- Few days before removal, the catheter may be clamped for specified periods of time (2-4 hours)
then released to allow the bladder to empty.
- Check agency policy regarding bladder training procedures.
- Expect voiding during the first 6-8 hours

DEFECATION- it is the expulsion of feces from the rectum

Fecal Elimination Problems

Constipation may be defined as fewer than 3 bowel movements per week. This infers the passage of dry,
hard stool or the passage of no stool
- Increase fluid intake, high fiber diet
- Establish regular pattern of defecation
- Minimize stress and adequate activity
- Laxatives

Fecal Impaction is a mass or collection of hardened feces in the folds of the rectum. It can be recognized
by the passage of liquid fecal seepage and no normal stool
- Manual extraction
- Increase fluid intake, Activity and exercise

Diarrhea refers to the passage of liquid feces and an increased frequency of defecation.
- Replace fluids and electrolytes
- Good perianal care
- Rest to reduce peristalsis

Flatulence is the presence of excessive gas in the intestine

- Avoid gas forming foods
- Warm fluids to increase peristalsis
- Early ambulation post op

Bowel/ Fecal Incontinence is the loss of voluntary ability to control fecal and gaseous discharges through
the anal sphincter. The incontinence may occur at specific times such as after meals or may occur
irregularly.
- Surgery- repair of the anal sphincter or bowel diversion

Enema
- A solution introduced into the rectum and large intestine. The action is to distend the intestine and
sometimes to irritate the intestinal mucosa.

Size of Rectal Tube

Adult Fr. 22-32
Child Fr. 14-18
Infant Fr. 12

Classification of Enema
 1. Cleansing Enema
Purpose: Prevent escape of feces during surgery
Prepare intestine for certain diagnostic test
Remove feces in instances of constipation or impaction
Solutions: Hypertonic- Fleet phosphate enema
Hypotonic solution- tap water
Isotonic solution- normal saline, soapsuds enema
High enema (12-18inches) is given to cleanse as much of the colon as possible.
Position: left lateral position- dorsal recumbent position- right lateral position
Low enema (12 inches) used to clean the rectum and sigmoid colon
Position- left lateral position
2. Carminative Enema
Purpose: To expel flatus
3. Retention Enema
Purpose: Introduces oil or medication into the rectum and sigmoid colon
Liquid is retained for long period of time (1-3hours)
Antibiotic enemas are used to treat infection locally
Anthelmintic enemas kill helminthes such as worms and intestinal parasites
4. Return flow enema
Purpose: use occasionally to expel flatus
This is repeated 5-6 timesuntil the flatus is expelled and abdominal distention is relieved

Colostomy
Indication:
Temporary- Bowel inflammation, Bowel infection, Bowel injury
Permanent- Cancer

Anatomic Locations:
Ileostomy- produces fecal liquid fecal drainage, cannot be regulated, odor is minimal
Ascending colostomy- drainage is liquid and cannot be regulated, odor is a problem
Transverse colostomy- produces malodorous , mushy drainage
Descending colostomy- semi- formed
Sigmoidostomy- formed and firmed, can be regulated
Foods to avoid:
- Foods that can cause gas and odor
- Foods that can cause diarrhea
- Foods that are hard to digest

Purpose of Colostomy Care

1. To assess and care for peristomal skin
2. To collect stool for assessment of the amount and type of output
3. To minimize odors for the clients comfort and self- esteem

Stoma color: should appear red

Pale- indicates anemia
Bluish- impaired blood circulation
Stoma size and shape: protrude slightly from the abdomen and swollen, but swelling decreases over 2-3
weeks up to 6 weeks
Failure of swelling to recede- indicates blockage
Stomal bleeding: slight bleeding initially when stoma is touched is normal

Position: Lying in bed, sitting or standing position

Things to remember:
Empty the content of a drainable pouch to prevent spillage of stool
Use warm water, mild soap (optional) and washcloth to clean the skin and stoma
Assess the stoma and peristomal skin
Cut out the traced stoma pattern to make an opening in the skin barrier. Make the opening no more than
1/8 or ¼ inch larger than the stoma

PREPARED BY:
MISCHELL Q. TIONGSON RN, MAN