MS LAB Week c.

Mask Simple = 5-8 L (40-60%)

Respiratory System Skills and
Nursing Consideration
2. High Flow
Oxygen Therapy
Goal:
- Provide adequate transport of O2 in the
blood while decreasing the work of
breathing and reducing stress on the
myocardium
Complications:
- Oxygen toxicity - 21% inhaled O2 (if more
it damages the lung lining tissues and air
sacs)
- Coughing irritation of the large airways,
damage to the lung tissues may cause fluid
leakage into the air sacs, accompanied by
increasingly severe shortness of breath
- Bert's Effect - perioral and hand twitching –
early
- Smith's effect - pulmonary toxicity - damage
pulmonary epithelium and destroys
surfactant
- Suppression of ventilation
d. Mask Partial Rebreather = 6-10 L
(60-90%)
e. Mask, Nonrebreather = 10-15 L (80-
100%
a. Transtracheal = ¼ - 4 L/min (60-
100%)
b. Venturi = 4 – 10 L/min (24%) =
color coded jet adapter = BLUE 4 L,
40%, 50% à <35% 8 L GREEN
c. Mask, aerosol = 8 – 10 L/min (30-
100%)
d. Tracheostomy collar = 8 – 10 L/min
(30 – 100%)
e. T-piece = 8 – 10 L/min (30 – 100%)
f. Face Tent = 8 – 10 L/min (30 –
100%)

Measures to Promote Adequate Respiratory

Function
1. Adequate oxygen supply from the
environment
2. Deep breathing and coughing exercises
3. Chest physiotherapy (PD, percussion,
vibration)
4. Bronchial Hygiene measures:
- Steam Inhalation - for 15 to 20 minutes
- Others - Aerosol, Medimist
- Oro and Nasopharyngeal Suctioning
- Incentive Spirometry
Oxygen Therapy: Methods of Administration
1. Low Flow
a. Nasal Cannula = 1-2 L (23%-30%),
6L (42%)
b. Oropharyngeal catheter 1-6 L (23-
42%)
Tracheostomy collar – may be only opened through
Cricoidotomy
Partial Rebreather mask – merong reservoir
wherein kapag huminga ang patient, dun pwede
pumunta ang CO2 (CO2 is a stimulant). Dito rin
pumupunta ang oxygen, and there is possible
mixing of carbon dioxide and oxygen to your
patient.
Partial Non-rebreather mask – totally isolated; big
help to prevent residual volume na mawala
ENDOTRACHEAL TUBE
Nursing Considerations: OXYGEN THERAPY
- Administer O2 in the lowest possible
concentration just to relieve hypoxemia
(normal O2sat = > 94%)
- Neonates – too much oxygen can cause
blindness
- O2 supports combustion (ex. Silk,
smoking, oil base)
- Check ABG before O2 therapy (if
necessary)
- Check for Allen’s test: for blood flow
- Assess signs/symptoms of hypoxia
(nailbeds, capillary refill, cyanosis, mucous
membrane)
- Blanche test – 2 – 5 seconds refill
- Consider Endotracheal Tube (ETT)/
Tracheostomy Tube (TT) insertion if O2
therapy will be given in a long period of
time
- Patients might be able to experience
complications like: dryness of the
mucosa
- COPD patient must receive 2 – 3 L of O2
only to prevent cessation of breathing
(hypoxic drive)
- COPD – loss of functional recoil in the
lungs; have more oxygen trapped in the
lungs
- Proper positioning is always Fowler’s
position = promote good lung expansion
- Check the content of the tank. Open the
regulator (hissing sound) to remove tiny
particles.
- If hissing sound occurs during O2 therapy
suspect kinking of the tube
- Kinking – may naipit or obstruction;
- Refill the container of the humidifier with
tap (any clean) water.
- Possible complications include:
aspiration of fluid, and possibly,
difficulty of breathing
- Insertion of airway catheter through the
mouth or nose into the trachea (above the
bifurcation of the trachea)
- Attach to mechanical ventilation machine
and to deliver high pressure O2
- 20 – 25 mm Hg (pressure of the cuff)
- “The cuff when inflated, prevents the
dislodging of tube”
Laryngoscope – For insertion of ETT;
observation and assessment of the larynx
Pediatrics – If epiglottitis (inflammation of
epiglottis) occurs, it is a big no no for child to
stay in the house. The child should be admitted,
 because the epiglottis will be totally closed
(especially when tongue depressor is used)
causing total obstruction of the airway.
• Hyperextend the patient to align passage
way for easier insertion of tube
Nursing Considerations: ENDOTRACHEAL
TUBE: Immediately after Intubation
- Check symmetry of chest expansion
- Auscultate breath sounds (5-point
auscultation)
- Chest x-ray – confirmed (inflate cuff)
– 5 – 10 cc of air
- Check cuff PRESSURE every 8 – 12
hours (20-25 mmHg)
- Monitor signs/symptoms of aspiration
- Oral or nasal care every 2 – 4 hours
§ Patients may experience
drooling
- Suction then administer oxygen
- Secure the tube to the patient’s face with
tape and mark the proximal end for position
- Mark will be the hint if bumababa pa
ang tube below the bifurcation area (if
di na makita ang mark, baka pumunta
na sa left or right bronchus ang tube)
- PetCO2 = 35 – 45 mmHg (continuous
waveform capnography) – correct ETT
placement
- You can see presence of Respiratory
Acidosis/Alkalosis
Care of Patient Following Intubation (that the
nurse should be continually doing)
- Reposition patient every 2 hours
- Provide oral hygiene and suction the
oropharynx whenever necessary
- Reposition the tube at the opposite side per 8
hour shift (to prevent irritation to the oral
mucosa)
Nursing Considerations: Endotracheal Tube
- Done when patient is awake
Extubation (Removal of Endotracheal Tube)
- Explain procedure
- Have self-inflating bag and mask
- Why? Patients may experience
difficulty of breathing after removal.
Self-inflating bags help patients to be
adapted to transfer/modifications
- Suction, remove tape, deflate cuff
- To prevent destruction of trachea
- Give 100% O2 for a few breaths, then
suction
- Have the patient inhale
- At peak inspiration, remove tube
- Sasabayan ang pagremove ng tube
habang nageexpire
Care of Patient Following Extubation:
- Give humidified O2 by face mask, high
fowler’s position
- Use of face mask help the patient adapt
to the external environment after ETT
use
- Monitor RR, quality of chest rise (stridor,
color change, LOC)
- NPO or give ice chips
- Oral care
- Teach coughing and breathing exercises
- GAG reflex – before
feeding/eating/drinking
- Two kinds of reflexes that remain in
the patient (until the day they die):
Cough and Gag reflex
TRACHEOSTOMY TUBE
- Surgical insertion of hollow tube of rubber,
metal, or plastic in trachea for long-term
airway support
- Auscultate after insertion to check if the tube
is in the right place
- Positioned between the 2nd and 3rd tracheal
rings
- After the trachea is exposed, cuffed trach
tube is inserted
- Cuff 15 – 25 mmHg (types: cuffed,
uncuffed, fenestrated)
- Obturator should always be at bedside
- Obturator – instrument that we are
using to insert in the cannula to check
the patency, obstructions.
- Clean inner cannula with sterile saline
solution
- Use absorbable type of gauze not moist
type of gauze (moist type creates
bacterial growth)
- Inner cannula is the one that should be
cleaned regularly (common cause of
infections)
- Clean incision site with ½ solution of
hydrogen peroxide
- One to two fingers under the ties
- Not too loose, not too tight
§ Too loose = dislodge of
cannula
§ Too tight = choking
1 -2 Fingers should be inserted underneath
Nursing Consideration: TRACHEOSTOMY TUBE
- Maintenance of patency
- Adequate humidification
- Wound care and sterile tracheal suctioning
and cleaning of the materials
(Eto yung time na nag-ingay si Lacsa)
- Assess breath sounds every 2 hours to verify
needs of suctioning and TURN every 2
hours
- Perform oral care (toothbrush, swabs, and
antiseptic mouthwash or hydrogen peroxide
diluted with water)
- Maintain semi-fowler’s or sitting position
whenever possible
- If accidentally removed: get retention
sutures to grasp and spread opening
Must be at Bedside:
- Extra set of trach tube
- For replacement
- Suction machine
- Dilator clamp and obturator
Tracheostomy Care:
Disposable Inner Cannula
1. Gather supplies to the bedside, then place
client in semi-Fowler’s position, if not
contraindicated, to promote lung expansion
and oxygenation and prevent aspiration of
secretions
2. Don personal protective equipment (mask,
goggles, and clean gloves) to maintain
universal precautions. Auscultate lungs and
suction secretions if necessary
 3. Remove soiled dressing and also remove
clean gloves
4. Don sterile gloves: remove old disposable
cannula and replace with a new one. While
stabilizing the back plate with the
nondominant hand, unlock (unclip) the old
cannula with the dominant hand; remove
gently by pulling it out in line with its
curvature; pick up the new cannula, touching
only the outer looking portion (to prevent
contamination and maintain asepsis); insert;
and lock (clip) into place.
5. Clean around stoma with sterile water or
saline, dry, and replace sterile gauze pad to
remove dried secretions, and dry around
stoma well to limit the growth of
microorganisms. Some tracheostomy tubes
are sutured in place and do not require a
dressing. If secretions are copious, apply a
dressing.
Interventions both used when doing ET Tube and
Tracheostomy Tube:
- Monitor patients by auscultation with the
presence of breath sounds
- Suctioning as much as possible to prevent
retained secretions that may lead to
pneumonia
- Always assess patient for any signs of
hypoxemia and cyanosis
- Evaluate the effectiveness of Oxygenation
by checking nail beds, mucous membranes
Questions:
Measures to Promote Adequate Respiratory
Function
1. A male client abruptly sits up in
bed, reports having difficulty
breathing and has an arterial
oxygen saturation of 88%. Which
mode of oxygen delivery would
most likely reverse the
manifestations?
a. Simple mask
b. Non-rebreather mask
c. Face tent
d. Nasal cannula
Answer: B. Non-rebreather mask
A non-rebreather mask can deliver
levels of the fraction of inspired oxygen
(FiO2) as high as 100%. Other mode s
simple mask, face tent, and nasal cannula
deliver lower levels of FiO2
FiO2 is a fraction of the amount of oxygen
a patient is inhaling produced by an
oxygen device
2. After the client had tolerated the
weaning process, the physician
ordered the removal of the
endotracheal tube and will be
shifted into a nasal cannula. Which
of the following findings after the
removal requires immediate
intervention by the physician?
a. Sore throat
b. Hoarseness of the voice
c. Coughing out blood
d. Neck discomfort
Answer: C. coughing out blood
A sign of a tracheal or esophageal
perforation which prevents oxygen from
reaching the lungs and can result in
internal bleeding. This life-threatening
side-effect of being intubated requires
immediate medical intervention. Options
A, B, and D are normal and that the client
should limit talking if this occurs.
 1. Adequate oxygen supply from the
environment
2. Deep breathing and coughing exercises
3. Chest physiotherapy (PD, percussion, and
vibration)
4. Bronchial Hygiene measures:
a. Steam Inhalation – for 15 to 20
minutes
b. Others: Aerosol (Pedia), Medimist
(Adult)
c. Oro and Nasopharyngeal Suctioning
5. Incentive Spirometry
Deep Breathing Exercise:
1. Assist client to Fowler’s or sitting position
2. Have client place hands palm down, with
middle fingers touching, along lower border
of rib cage
3. Instruct client to place hands along lower
ribcage to feel diaphragm movement
- Palpable movements of the muscles in
the ribs is the helpful to determine the
patient is breathing
4. Ask client to inhale slowly through the nose,
feeling middle fingers separate. Hold breath
for 2 or 3 seconds
5. Encourage client to inhale slowly and deeply
through the nose, holding breath for 2 to 3
seconds
6. Have client exhale slowly through the
mouth. Repeat three to five times (every 2 –
3 hours)
7. Document procedure
Coughing Exercise
1. Assist the client to Fowler’s or sitting
position
2. If sputum is present, have client take a deep
breath, hold for 3 seconds, and cough deeply
two or three times. Stand to the client’s side
to ensure the cough is not directed at you.
Client must cough deeply, not just clear the
throat
3. If the client has an abdominal or chest
incision that will cause pain during
coughing, instruct the patient to hold a
pillow firmly over the incision (splinting)
when coughing
4. Instruct, reinforce, and supervise deep-
breathing and coughing exercises every 2 to
3 hours postoperatively
5. Document procedure
CHEST PHYSIOTHERAPY
- Done to remove bronchial secretions,
improve ventilation, and increase efficiency
of respiratory muscles; patients breathe more
freely and to get more oxygen into the body
- Includes:
- Postural Drainage – positioned for
drainage through gravity (maintain
position 10-15 minutes)
- Chest percussion and vibration
Postural Drainage
- Know the diagnosis
- Sudden movements or change in
positions may cause complications
- Auscultate lungs before and after
- Postural drainage can be performed 2 – 4
times a day
- Before meals
- baka sumuka kapag after meals
- Bronchodilators or saline solution can be
nebulized before the procedure
- Patient should remain in position 10 – 15
minutes
- Suction and or cough out
- Note the amount, color, viscosity of sputum
- Assess patient’s color and pulse
- Oral hygiene after
Anterior Upper lobes: use of gravity: bababa ang Posterior Middle Lobes (Both)
secretions para maexpectorate

Posterior Upper Lobes

Anterior Right Lower lobe

Anterior Middle Lobes – supine

Posterior Lower Lobes

CHEST VIBRATION
- Vibrate as patient EXHALES
- Place hands firmly over the chest wall one
over the other, arms and shoulders straight,
vibrate BACK and FORTH RAPIDLY
 - 3 – 4 vibrations - STOP TREATMENT:
o Increased pain
o Increased shortness of breath
o Weakness
o Lightheadedness
o Hemoptysis
- Rest 5-10 minutes

Bronchial Hygiene Measures

- Steam inhalation - for 15 to 20 minutes
- Others: Aerosol (Pedia), Medimist (Adult)–
CHESS PERCUSSION nebulization
- Performed 3 – 5 minutes for thick secretions - Oropharyngeal and Nasopharyngeal
o CUP-SHAPED HANDS Suctioning
- DO NOT PERCUSS: Suctioning: Oropharyngeal and Nasopharyngeal
o chest draining tubes - Determine need for suctioning:
o sternum o Retained secretions
o spine o Difficulty breathing
o liver - Explain, Assemble, Handwashing
o kidneys - Position: Semi-Fowler's (conscious); Left
o spleen lateral (Unconscious)
o breasts o Left-lateral position prevents
o Caution: Percussion in elderly aspiration
(sensitive sila) - Place towel or waterproof pad across
patient's chest
- Turn suction to appropriate pressure
- wall unit
o Adult: 100 to 120 cm Hg
o Child: 95 to 110 cm Hg
o Infant: 50 to 95 cm Hg
- Portable unit
o Adult: 10 to 15 cm Hg
o Child: 5 to 10 cm Hg
o Infant: 2 to 5 cm Hg
- Vital capacity of younger people is lesser
than adults, thus lesser pressure needed for
Nursing Considerations: Chest Physiotherapy suctioning
Findings: A need for suctioning includes:
- Patient should be comfortable, no - decreased oxygen saturation
constrictive clothing, empty stomach - altered mental status (irritability and
- Upper area first lethargy
- Give medications for pain - increased heart rate
- Before CPT, splint any incisions through - increased RR
pillows - increased work of breathing (flared nostrils)
- Adventitious breath sounds
 - Pallor, mottled or cyanotic skin coloring
Suction catheters vary in sizes:
- Adults - From 12 to 18
- Children - From 8 to 10
- Infant - From 5 to 8
Nursing Considerations
- Perform hand hygiene and don clear gloves
- Insertion depth - tip of nose to ear lobe →
nasopharynx
- Insertion depth: edge of mouth to ear lobe
→ oropharynx
- Do it Before meals; 2-3 hours
o To prevent nausea and vomiting
o Para hindi mawalan ng appetite
- Auscultate - hyperoxygenate à suction à
hyperoxygenate à auscultate
Steps:
1. Place client in semi-Fowler's position
2. Hyperoxygenate (100% O2) before and after
3. Gently insert catheter with suction off by
leaving the vent on the Y-connector open.
NEVER apply suction as catheter is
introduced
4. Apply intermittent suction while rotating the
suction catheter while withdrawing (5-10)
seconds
o How? By closing or opening the
suction
5. Flush the catheter with saline
6. If repeated, 30 - 60 seconds
7. Auscultate then document
8. Offer oral hygiene after suctioning
Question:
A nurse is suctioning fluids from a female
client through an endotracheal tube. During the
suctioning procedure, the nurse notes on the
monitor that the heart rate is decreasing. Which of
the following is the appropriate nursing
intervention?
a. Continue to suction
b. Notify the physician immediately
c. Stop the procedure and
reoxygenate the client
d. Ensure that the suction is limited
to 15 seconds
Answer: C. Stop the procedure and reoxygenate
the client.
During suctioning, the nurse should monitor the
client closely for side effects, including
hypoxemia, cardiac irregularities such as a
decrease in heart rate resulting from vagal
stimulation, mucosal trauma, hypotension, and
paroxysmal coughing. If side effects develop,
especially cardiac irregularities, the procedure is
stopped, and the client is reoxygenated
Incentive Spirometry (Sustained Maximal
Inspiration)
- Method of deep breathing that provides
visual feedback to encourage the patient to
inhale slowly and deeply to maximize lung
inflation to assist expansion of the lungs
post-op and to prevent collapse of lung
- A spirometer is an apparatus for easuring the
volume of air inspired and expired by the
lungs
- Indications: Post-op surgery
- Minimum of 10 sustained voluntary
inflation maneuvers per session
- use incentive spirometer q hour while awake
- during inspiration: ball will move upward