Oxygen Therapy

- Oxygen therapy is the medical administration of supplemental oxygen is considered to

be a process similar to that of administering medications and requires similar nursing
intervention.
- Determining the effectiveness of oxygen therapy involves several measures, including
checking vital signs and peripheral blood oxygen saturation (pulse oximetry).
- Oxygen therapy is prescribed by the healthcare provider who orders concentration,
method of delivery, and depending on the method, liter flow per minute (L/m).
- The order may also call for the nurse to titrate the oxygen to achieve a desired saturation
level as measured by pulse oximetry.
- Oxygen is supplied in 2 ways, by portable systems (cylinder or tanks) or from wall
outlets.
- Portable oxygen delivery systems are available to increase the client's independence.
- Oxygen administered from a cylinder or wall-outlet system is dry. Dry gasses dehydrate
respiratory mucous membranes.
- Humidifying devices that add water vapor to inspired air is an essential accessory of
oxygen therapy, particularly flows over 4L/min.
- These devices provide 20-40% humidity
- A humidifier bottle is attached below the flow meter gauge. Humidifiers prevent mucous
membranes from drying and becoming irritated and loosen secretions for easier
expectoration.
- Oxygen cylinders need to be handled and stored with caution and strapped securely in
wheeled transport devices or stands to prevent possible falls and outlet breakages.
- A regulator that releases oxygen at a safe level and at a desirable rate must be attached
before the oxygen supply is used.
To use an oxygen wall-outlet system, carry out these steps:
- Attach the flow meter to the wall outlet, exerting firm. pressure. The flow meter should be
in the off position.
- Fill the humidifier bottle with distilled or tap water per agency protocol. This can be done
before coming to the bedside. Some humidifier bottles prefilled by the manufacturer.
- Attach the humidifier bottle to the base of the flow meter (if indicated).
- Attach the prescribed oxygen tubing and delivery device to the humidifier.
- Regulate the flow meter to the prescribed level. The line for the prescribed flow rate
(e.g., 2 L/min) should be in the middle of the ball of the flow meter.
Oxygen Therapy Safety Precautions

- For home oxygen use or when the facility permits smoking.

- Place cautionary signs reading "No Smoking: Oxygen in Use" on the client's door, at the
foot or head of the bed, and on the oxygen equipment.
- Instruct the client and visitors about the hazard of smoking with oxygen in use.
- Make sure that electric devices (such as razors, hearing aids, radios, televisions, and
heating pads) are in good working order to prevent the occurrence of shod-circuit
sparks.
 - Avoid materials that generate static electricity, such as woolen blankets and synthetic
fabrics. Cotton blankets should be used, and clients and caregivers should be advised to
wear cotton fabrics.
- Avoid the use of volatile, flammable materials, such as oils, greases, alcohol, ether, and
acetone (e.g., nail polish remover), near clients receiving oxygen.
- Be sure that electronic monitoring equipment, suction machines, and portable diagnostic
machines are all electrically grounded.
- Make known the location of fire extinguishers, and make sure personnel are trained in
their use.
Oxygen Delivery Systems
- Low-flow and high-flow systems are available to deliver oxygen to the client.
- Low-flow systems deliver oxygen via small-bore tubing.
- High-flow systems supply all the oxygen required during ventilation in precise amounts,
regardless of the client's respirations. The high-flow system used to deliver a precise and
consistent Fi02 is the Venturi mask with large-bore tubing.
Cannula
- The nasal cannula (nasal prongs) is the most common and inexpensive device used to
administer oxygen. The nasal cannula is easy to apply, comfortable, permits some
freedom of movement, and is well tolerated by the client.
- It delivers a relatively low concentration of oxygen (24 % to 45%) at flow rates of 2 to 6
L/min.
- Styles of reservoir cannulas; mustache reservoir nasal cannula and the pendant
reservoir nasal cannula.
Face Mask
- Face Mask Face masks that cover the client's nose and mouth may be used for oxygen
inhalation. Most masks are made of clear, pliable plastic that can be molded to fit the
face. They are held to the client's head with elastic bands. Some have a metal clip that
can be bent over the bridge of the nose for a snug fit.
- Exhalation ports on the sides of the mask allow exhaled carbon dioxide to escape.
A variety of oxygen mask are marketed:
- The simple face mask delivers oxygen concentrations from 35% to 65% at liter flows of
8 to 12 L /min, respectively
- The partial rebreather mask delivers oxygen concentrations of 40% to 60% at liter
flows of 6 to 10 L /min, respectively.
- The nonrebreather mask delivers the highest oxygen concentration possible -60% to
100% —by means other than intubation or mechanical ventilation, at liter flows of 6 to 15
L/min.
- The Venturi mask delivers oxygen concentrations varying from 24% to 40% or 50% at
liter flows of 4 to 10 L/min. The Venturi mask has wide-bore tubing and color-coded jet
adapters that correspond to a precise oxygen concentration and liter flow. For example,
in some cases, a blue adapter delivers a 24% concentration of oxygen at 4 L/min, and a
green adapter delivers a 35% concentration of oxygen at 8 L/min.
- Face tents can replace oxygen masks when masks are poorly tolerated by clients. Face
tents provide varying concentrations of oxygen, for example, 28% to 100% concentration
 of oxygen at 8 to 12 L/min. It is convenient for providing humidification and oxygenation;
however, oxygen concentration cannot be controlled.
- A transtracheal catheter is placed through a surgically created tract in the lower neck
directly into the trachea. Once the tract has matured (healed), the client removes and
cleans the catheter two to four times per day. Oxygen applied to the catheter at greater
than 1 L/min should be humidified, and high flow rates, as much as 15 to 20 L /min, can
be administered.
- In certain circumstances clients require mechanical assistance to maintain adequate
breathing. This assistance may be accomplished by the use of noninvasive positive
pressure ventilation (NPPV), delivery of air or oxygen under pressure without the need
for an invasive tube such as endotracheal tube or tracheostomy tube.

Administering Oxygen by Cannula, Face Mask, or Face Tent

PURPOSES
Cannula
- To deliver a relatively low concentration of oxygen when only minimal O2 is required
- To allow uninterrupted delivery of oxygen while the clients ingests food or fluids
Face Mask
- To provide moderate O2 support and a higher concentration of oxygen and/or humidity
than is provided by cannula
- To provide a high flow of O2 when attached to a Venturi system
Face Tent
- To provide high humidity
- To provide oxygen when a mask is poorly tolerated

EQUIPMENT
Cannula
- Oxygen supply with a flow meter and adapter
- Humidifier with distilled water or tap water according to agency protocol
- Nasal cannula and tubing
- Tape (optional)
- Padding for elastic band

Face Mask
- Oxygen supply with a flow meter and adapter
- Humidifier with distilled water or tap water according to agency protocol
- Prescribed face mask of the appropriate size
- Padding for elastic band
Face Tent
- Oxygen supply with a flow meter and adapter
- Humidifier with distilled water or tap water according to agency protocol
- Face tent of the appropriate size
 TRACHEOSTOMY
Is an opening into the trachea through the neck a tube is usually inserted through this
opening and an artificial airway is created.

Performed in 2 techniques:
THE PERCUTANEOUS INSERTION
can be done at the bedside in a critical care unit.
THE TRADITIONAL OPEN SURGICAL METHOD
is done in an operating room where a surgical incision is made in the trachea just below
the larynx.
A curved tracheostomy tube is inserted to extend through the stoma in the trachea.
When a patient has a tracheostomy in place, care should be done by the nurse:
1. Maintain patency of the tube
2. Reduce the risk of the infection.
3. Suction and clean every 1-2 hrs. (suction only as needed because it may lower the
vital signs of the patient)
4. Sterile technique should be used when providing tracheostomy care in order to
prevent infection. (after stoma has healed, you may use clean gloves for tracheostomy
care)

Tracheostomy Care
● The nurse provides tracheostomy care for the client with a new or recent tracheostomy
to maintain patency of the tube and reduce the risk of infection.
● There is no defined standard technique or sequence of steps for the process.
Purpose
● Maintain airway patency
● Maintain cleanliness
● Prevent infection at the tracheostomy site
● Facilitate healing and prevent skin excoriation around the tracheostomy incision
● Promote comfort

Equipment
● Sterile disposable tracheostomy cleaning kit
● Disposable inner cannula (if applicable)
● Towel/Drape
● Sterile suction catheter kit
● Sterile normal Saline
● Sterile gloves
● Clean gloves
● Moisture-proof bag
● Commercially prepared sterile tracheostomy dressing or 4x4 gauze dressing
● Velcro collar
● Clean scissors
Implementation
1. Introduce yourself and verify the patient’s identity.
2. Ensure that infection-control procedures are in place (i.e. hand hygiene).
3. Ensure the patient’s privacy.
4. Prepare the patient and your equipment.
 Help the patient to a Semi-Fowler’s or Fowler’s position.
 Open the tracheostomy kit or sterile basins.
 Pour the soaking solution and sterile normal saline into separate containers.
 Establish the sterile field.
 Open other sterile supplies as needed, such as sterile applicators, suction kit, and
tracheostomy dressing.
5. If needed, suction the tracheostomy tube.
a. Put on a pair of sterile gloves.
b. Suction the full length of the tracheostomy tube to remove secretions and reinforce the
airway.
c. Rinse the suction catheter, wrap the catheter around your hand, and peel the glove off
so that it turns inside out over the catheter.
d. Unlock the inner cannula with the gloved hand.
i. Remove it by gently pulling toward you in with its curvature.
ii. Place it in the soaking solution.
e. Remove the soiled tracheostomy dressing.
i. Place the dressing in your gloved hand and peel the glove off so that it turns inside
out over the dressing.
ii. Discard the glove and the dressing.
6. Clean the inner cannula.
a. Clean the inner cannula thoroughly using a pipe cleaner moistened with sterile normal
saline.
b. Then rinse using sterile normal saline.
c. (if the patient has disposable inner cannula, simply replace the cannula and dispose
the soiled ones. Usually a disposable cannula can be used for at least 2 days)
d. Tap the cannula against the inside edge of the sterile saline container. Use pipe
cleaners folded to clean the inside. DO NOT DRY THE OUTSIDE.
Rationale: This removes excess liquid from the cannula and prevents possible
aspiration by the client, while leaving a film of moisture on the outer surface to lubricate
the cannula for reinsertion.
7. Replace the inner cannula and secure it.
8. Clean the incision site as well as the tube flange.
a. Clean the incision site using sterile applicators or gauze dressings that have been
moistened with normal saline.
b. Hydrogen peroxide may be used. Thoroughly rinse the cleaned area using gauze
squares moistened with sterile normal saline. Rationale: hydrogen peroxide can be
irritating and can inhibit the healing process.
c. Then clean the flange of the tube
d. Then dry patient’s skin using a dry gauze
 9. Apply a sterile dressing.
a. Never use cotton-filled gauze squares or cut the 4×4 gauze. Rationale: Cotton
lint or gauze fibers can be aspirated by the client, potentially creating a tracheal
abscess.
b. When applying the dressing make sure that is supported.
● Rationale: Excessive movement can irritate trachea.
10. Change the tracheostomy ties.
a. Twill tape is inexpensive and available; however, it’s easily soiled and can trap moisture
that often leads to skin irritation.]
b. Velcro ties are wider, more comfortable, and cause fewer abrasions.
11. Tape and pad the tie knot.
12. Check the tightness of the ties.
a. Should be two fingers wide
13. Document relevant information. Record suctioning, tracheostomy care, and the dressing
change. Proper tracheostomy care is vital for the health and safety of the patient. As a
nurse, you will be responsible for maintaining airway patency, preventing infection at the
tracheostomy site, facilitating the healing process, and promoting patient comfort. These
crucial steps can help prevent trach risks or complications

OROPHARYNGEAL, NASOPHARYNGEAL, NASOTRACHEAL SUCTIONING

Artificial airways are inserted to maintain a patent air passage for clients whose airways have
become obstructed. A patent airway is necessary so that air can flow to and from the lungs.
Four of the more common types of airways are Oropharyngeal, Nasopharyngeal,
endotracheal and tracheostomy

Oropharyngeal and Nasopharyngeal airways are used to keep upper air passages open
when secretions or the tongue may obstruct them. (e.g. a client who is sedated, semicomatose,
or has alternated level of consciousness). These airways are easy to insert and have a low risk
of complications. Sizes vary and should be appropriate to the size and age of the client. The
nasopharyngeal airway should be well lubricated with water soluble gel prior to inserting. The
oropharyngeal airway may be lubricated with water or saline, if necessary.

Oropharyngeal airways stimulate the gag reflex and are only used for clients with altered
levels of consciousness with no gag reflex (e.g., because of general anasthesia, overdose, or
head injury) To insert airway:

● Place client in a supine or semi-fowler’s position.

● Apply clean gloves
● Hold the lubricated airway by the outer flange, with the distal end pointing up or curved
upward.
● Open the client’s mouth and insert the airway along the top of the tongue.
 ● When the distal end of the airway reaches the soft palate at the back of the mouth,
rotate the airway 180 degrees downward, and slip past the uvula into the oral pharynx.
● If not contraindicated, place the client on a side lying position or witht the head turned to
the side to allow secretions to drain out of the mouth.
● The oropharynx may be suctioned as needed by inserting the suction catheter along the
way.
● Remove and discard gloves.
● Perform hand hygiene.
● Do not tape the airway in place; remove it when the client begins to cough or gag.
● Provide mouth care atleast every 2-4 hours, keeping suction available at the bed side.
● As appropriate for the client’s condition, remove the airway every 8hours to assess the
mouth and provide oral care. Reinsert the airway immediately.

Nasopharyngeal airways - are tolerated better by alert clients because the nasal airways do
not cause the client to gag. They are inserted through the nares, terminating in the oropharynx.
When inserting, use the largest nostril, use water-soluble lubricant, and insert with the curve of
the tube toward the mouth. Advance with the tube gently, straight in, following the floor of the
nose. When caring for a client with a nasopharyngeal airway, provide frequent oral and nares
care, reinserting the airway in the other nares every 8 hours or as ordered to prevent necrosis
of the mucosa.

Endotracheal tubes (EETs) - are most commonly inserted in clients who have had general
anasthetics or for those in emergency situations where mechanical ventilation is required. An
EET is inserted by an anesthesiologist, primary care provider, certified registered nurse
anesthetist (CRNA), or respiratory therapist with specialized education. It is inserted through the
mouth or the nose and into the trachea using a laryngoscope as a guide. The tube terminates
just superior (above) the bifurcation pf the trachea into the bronchi. The tube may have an air-
filled cuff to prevent leakage around it. Because and EET passes through the epiglottis and
glottis, the client is unable to speak while it is in place.

Nasopharyngeal airway in place Oropharyngeal airway in place

 Endotracheal tube (EET)

SUCTIONING OF AN UNCONSCIOUS CLIENT

What equipment do you need?

• Yankauer
• Light source
• Personal protective equipment (PPE)

2. Set to required pressure – usually up to 115mmHg for adults, 100mmHG for

children.

Safe oral suctioning technique

Only carry out oral suction if you are trained to do so
1. Prepare equipment, ensure unit is charged if using via battery.
2. Set to required pressure – usually up to 115mmHg for adults, 100mmHG for
children.
3. Explain the procedure to the individual and obtain consent if possible from the person to carry
on.
4. Position individual correctly – where possible ensure in upright position
5. Ensure good lighting is available, use of a pen torch may be required.
6. Wash hands and put on PPE.
7. Check suction pressure by placing thumb over the end of the tubing.
8. Insert Yankauer gently into the mouth until it reaches the inside pouch of the cheek, (some
suction units require you to place your finger over a hole) and apply suction.
9. Use suction for a short amount of time – no longer than 10 seconds.
10. Remain in the oral cavity where Yankauer is visible, do not suction beyond the
tonsils.
11. During suctioning keep a close eye on the person’s facial expression and stop at any signs
of distress.
12. Repeat as necessary, turn off the suction when finished.
13. The Yankauer and tubing is single use so should be disposed of after a single
procedure.
14. Remove gloves and wash hands.
15. Documents that you have carried out the procedure in nursing notes.

CHEST PHYSIOTHERAPY
- A type of therapy composed of several techniques that is used to help clear mucus from the
lungs.
- Airway clearance technique (ACT) to drain the lungs, and may include percussion
(clapping), vibration, deep breathing, and huffing or coughing.
- CPT is often a treatment option for many respiratory conditions, such as bronchiectasis and
chronic obstructive pulmonary disease (COPD). A recent study also showed CPT as a
successful approach in COVID-19 to help reduce or prevent the need for artificial ventilator
treatment.

Why do people perform chest physiotherapy?

- People perform CPT to loosen and expel excess mucus that can build up in the lungs
from a range of respiratory conditions, such as cystic fibrosis.

What are the different types of chest physiotherapy?

- Early methods of CPT required the assistance of another person. This and the fact that it
is a labor intensive procedure often made it difficult for some people to undergo it
regularly. Recent developments have led to self-administered alternatives to
conventional CPT.

Types:
1. Conventional CPT
- With conventional CPT, you get into various positions to drain excess
mucus from the different lobes of the lungs. Each position is specifically
designed so that one of the five lobes of the lungs is facing downward.
This enables gravity to help clear the mucus.
2. Active Cycle of breathing technique
- Is typically divided into three phases. Each phase has different breathing
techniques that are use to help clear mucus from the lungs.
- Phase ones is used to help relax the airways, phase two is to get some
air behind the mucus and helps clear it; lasty, phase three that helps you
force the mucus out of your lungs.
3. Autogenic Drainage
 - This technique uses various speeds of breathing to move mucus through
your lungs.
- Autogenic drainage can take a lot of practice. It is only recommended for
people over the age of 8 years old.
4. Positive Expiratory Pressure
- Type of a therapy that uses extra, or collateral airways to get behind the
mucus and get air into your lungs.
5. High Frequency Chest wall oscillation
- High-frequency chest wall oscillation - or the vest, as it is sometimes
known, uses an inflatable vest attached to a machine. The machine then
vibrates at a high frequency, mechanically performing CPT which help
loosen the mucus.
- Around every 5 minutes, it is necessary to stop the machine to cough or
huff in order to expel the loosened mucus.

Postural drainage
- a c component of pulmonary hygiene. It consists of drainage, positioning, and turning
and is sometimes accompanied by chest percussion and vibration. It improves secretion
clearance and oxygenation positioning of the patient during this type of therapy.With
postural drainage, the person lies or sits in various positions so the part of the lung to be
drained is as high as possible. That part of the lung is then drained using percussion,
vibration, and gravity.
- When the person with CF is in one of the positions, the caregiver can clap on the
person’s chest wall. This is usually done for three to five minutes and is sometimes
followed by vibration over the same area for approximately 15 seconds (or during five
exhalations). The person is then encouraged to cough or huff forcefully to get the mucus
out of the lungs.
Clapping (percussion)

- by the caregiver on the chest wall over the part of the lung to be drained helps move the
mucus into the larger airways. The hand is cupped as if to hold water but with the palm
facing down (as shown in the figure below). The cupped hand curves to the chest wall
and traps a cushion of air to soften the clapping.
-
Percussion is done forcefully and with a steady beat. Each beat should have a hollow sound.
Most of the movement is in the wrist with the arm relaxed, making percussion less tiring to do. If
the hand is cupped properly, percussion should not be painful or sting.

Special attention must be taken to not clap over the:

- Spine
- Breastbone
- Stomach
- Lower ribs or back (to prevent injury to the spleen on the left, the liver on the right and
the kidneys in the lower back)

Different devices may be used in place of the traditional cupped palm method for percussion.
Ask your CF doctor or respiratory therapist to recommend one that may work best for you.

Vibration

Vibration is a technique that gently shakes the mucus so it can move into the larger airways.
The caregiver places a firm hand on the chest wall over the part of the lung being drained and
tenses the muscles of the arm and shoulder to create a fine shaking motion. Then, the caregiver
applies a light pressure over the area being vibrated. (The caregiver may also place one hand
over the other, then press the top and bottom hand into each other to vibrate.)

Vibration is done with the flattened hand, not the cupped hand. Exhalation should be as slow
and as complete as possible.

Deep breathing
Deep breathing moves the loosened mucus and may lead to coughing. Breathing with the
diaphragm (belly breathing or lower chest breathing) is used to help the person take deeper
breaths and get the air into the lower lungs. The belly moves outward when the person breathes
in and sinks in when he or she breathes out. Your CF respiratory or physical therapist can help
you learn more about this type of breathing.

Pillows may be used for added comfort. If the person tires easily, the order of the positions can
be varied, but all areas of the chest should be percussed or clapped.

Controlled Coughing
This technique helps break down thick mucus and then helps expel the mucus.

Here's how to do it:

● Sit on a chair with both feet on the floor.

● Take a slow, deep breath through your nose. Hold for 2
counts.
● Lean forward slightly.
● Cough twice—2 short coughs.
● Relax for a few seconds.

Repeat the steps as needed.

Turning

Like postural drainage, this technique uses the natural force of gravity to help loosen and move
mucus from the lungs. It involves turning a patient from side to side to expand the lungs and
promote drainage.
Chest Physiotherapy - Infants Newborn to 12 Months
Percussor Cups
● Never percuss over bare skin. Make sure the child
is wearing a t-shirt or onesie.
● Hold the percussor between your fingers and firmly
pat over 6 areas of the child's chest and back for 2
to 4 minutes.
● Do the patting in a regular rhythm.
● Percussion, done properly, does not hurt.

Positioning

● Position your child so that the part of the lung to be drained is higher than any other part
of the lung.

It is important for you to be in a comfortable position because this makes the treatment more
effective and easier for both you and your child. You may use a pillow to make your child more
comfortable.

● Place your child on your lap.

● Always have your child's knees and hips bent to help him or her relax and to make
coughing easier.
● Pictures 1 through 6 below show how chest physiotherapy is done.
 INCENTIVE SPIROMETRY

- An incentive spirometer is a handheld medical device that measures the volume of your
breath. It helps your lungs recover after surgery or lung illness, keeping them active and
free of fluid.
- is a device that will expand your lungs by helping you to breathe more deeply and fully.
- It is referred to as sustained maximum inspiration devices measuring the flow of air
inhaled through the mouthpiece. It is used:
1. Improve pulmonary ventilation
2. Counteract the effects of anesthesia or hypoventilation
3. Loosen respiratory secretion
4. Facilitate respiratory gaseous exchange
 5. Expand collapse alveoli.
- Encourages voluntary deep breathing by providing visual feedback to clients about
inspiratory volume and it promotes deep breathing and prevents atelectasis in post-
operative clients. (General anesthesia is a common cause of atelectasis. It changes your
regular pattern of breathing and affects the exchange of lung gasses, which can cause
the air sacs (alveoli) to deflate. Nearly everyone who has major surgery develops some
amount of atelectasis. It often occurs after heart bypass surgery.)

Parts of spirometer

Types of spirometry

1. Flow Oriented Spirometer

- impose more work of breathing, and increase muscular activity of the upper chest
- The flow – incentive spirometer (Triflo) consists of a mouthpiece and corrugated
tubing connected to a manifold composed of three flow tubes containing light
weight plastic balls. The patient inhales through the mouth piece thereby creating
a negative pressure within the tubes. This causes them to rise. The number of
balls and the level to which they rise depends on the magnitude of the flow
achieved. At lower flows, the first ball rises to a level that depends on the
magnitude of flow. As the inspiratory flow increases, the second ball rises,
followed by the third ball
2. Volume oriented spirometer
- impose less work of breathing and improve diaphragmatic activity
- In a recent study it was observed that the volume incentive spirometry has
resulted in early recovery of both pulmonary function and diaphragm movement
in patients who undergone laparoscopic abdominal surgery
- The volume-incentive spirometer (Coach 2 device) enables the patient to inhale
air through a mouthpiece and corrugated tubing which is attached to a plastic
bellows. The volume of air displaced is indicated on a scale located on the device
enclosure. After the patient has achieved the maximum volume, the individual is
instructed to hold this volume constant for 3 to 5 seconds
HOW TO USE THE INCENTIVE SPIROMETER

When you’re using your incentive spirometer, make sure to breathe through your mouth. If you
breathe through your nose, the incentive spirometer won’t work properly. You can hold your
nose if you have trouble.

If you feel dizzy at any time, stop and rest. Try again at a later time.

To use your incentive spirometer, follow the steps below.

1. Sit upright in a chair or in bed. Hold the incentive spirometer at eye level.
○ If you had surgery on your chest or abdomen (belly), hug or hold a pillow to help
splint or brace your incision (surgical cut) while you’re using the incentive
spirometer. This will help decrease pain at your incision.
2. Put the mouthpiece in your mouth and close your lips tightly around it. Slowly breathe
out (exhale) completely.
3. Breathe in (inhale) slowly through your mouth as deeply as you can. As you take the
breath, you will see the piston rise inside the large column. While the piston rises, the
indicator on the right should move upwards. It should stay in between the 2 arrows (see
Figure 1).
4. Try to get the piston as high as you can, while keeping the indicator between the arrows.
○ If the indicator doesn’t stay between the arrows, you’re breathing either too fast
or too slow.
5. When you get it as high as you can, hold your breath for 10 seconds, or as long as
possible. While you’re holding your breath, the piston will slowly fall to the base of the
spirometer.
6. Once the piston reaches the bottom of the spirometer, breathe out slowly through your
mouth. Rest for a few seconds.
 7. Repeat 10 times. Try to get the piston to the same level with each breath.
8. After each set of 10 breaths, try to cough, holding a pillow over your incision, as needed.
Coughing will help loosen or clear any mucus in your lungs.
9. Put the marker at the level the piston reached on your incentive spirometer. This will be
your goal next time.
NEBULIZATION

Nebulizer
- a piece of medical equipment that a person with asthma or another respiratory condition
can use to administer medication directly and quickly to the lungs.
- turns liquid medicine into a very fine mist that a person can inhale through a face mask
or mouthpiece. Taking medicine this way allows it to go straight into the lungs and the
respiratory system where it is needed.
Who needs nebulization?
● Asthma
● Chronic Obstructive Pulmonary Disease (COPD)
● Cystic Fibrosis
● Bronchiectasis
● And other respiratory diseases as prescribed by doctors
Parts of nebulizer

3 main parts of your nebulizer:

- Compressor - a power source that compresses room air which then breaks the
liquid medication into tiny droplets (an aerosol) which can be breathed in.
- Nebulizer chamber - a plastic cylinder which holds the medication and is attached
to the compressor by a plastic tube.
- Mouthpiece or face mask - attaches to the nebulizer chamber and is placed on the
face or between the teeth allowing the medication to be breathed into the lungs.

PROCEDURE
1. Wash your hands properly.
2. Check the medication
3. Gather the equipments
4. Make the patient sit in an upright position.
5. Check the breath sounds, pulse rates and respiratory status.
6. Explain the breathing process to the patient during the therapy.
7. Then connect the hose of the nebulizer to an air compressor.
8. Then fill the medicine cup with the required medication and appropriate saline
solution as prescribed by a doctor.
9. Connect the hose and mouthpiece or breathing mask to the medicine cup.
10. Now place the mouthpiece firmly in between your lips, if using a breathing mask
attach the mask properly.
11. Then inhale the mist being sprayed on with the slow deep breaths.
 NURSE RESPONSIBILITY

As part of their duty of care to patients, nurses must ensure that oxygenation is optimized at the
pulmonary and cellular levels. This necessitates understanding of respiratory and cardiac
physiology, as well as the selection of suitable supplemental oxygen treatment, equipment and
delivery methods. It is the nurse's responsibility to assess, monitor and educate clients.

Assessment and Monitoring

● Assess for signs of hypoxia; e.g., confusion, difficulty speaking, tachycardia,
dyspnea, pallor, cyanosis, increased rate and depth of respirations, accessory
muscle use, SpO2 less than 92%
● Verify oxygen delivery device, flow rate, humidification, target oxygen saturation.
● Nasal cannula, face mask: ensure proper fit, adjust for comfort.
● Check tubing for twists, kinks, attached to device and oxygen source.
● Monitor response to supplemental oxygen; report worsening oxygenation status
- Oxygen saturation
- Vital signs
- Lung sounds
- Skin for color changes
- Level of consciousness
● Monitor pressure points for skin breakdown; provide skin care, padding as
needed

Client Education
● Purpose of oxygen therapy
● Oxygen set-up, pulse oximetry
● Offer emotional support and reassurance for claustrophobia
● Home oxygen therapy
○ How to wear the delivery device and operate the machinery
○ Wash nasal cannula in warm soapy water at least once each week;
replace it every two to four weeks
○ Supplemental oxygen is a medication; administer their oxygen at the
prescribed rate, not to discontinue therapy abruptly
○ Increasing their fluid intake can help reduce dryness of mucous
membranes
○ Safety measures
■ Keep the oxygen at least five feet away from any heat source
■ Avoid using equipment that could emit a spark
■ Avoid wearing synthetic clothing due to static electricity
■ Avoid use of flammable liquids
■ No smoking
■ Fire extinguisher readily available
Pulse Oximeter
 1. Complete pre-procedure protocol
2. Assess for signs and symptoms of alterations in oxygen saturation.
3. Assess for factors that influence measurement of SpO2
4. Determine the most appropriate patient-specific site (e.g., finger, earlobe, bridge of nose,
forehead) for sensor probe placement by measuring refill time
● If capillary refill time is less than 2 seconds, select alternative site:
a. Site must have adequate local circulation and be free of moisture.
b. a finger free of nail polish or acrylic is preferred.
c. If a patient has tremors or is likely to move, use earlobes or forehead.
d. If a patient's finger is too large for the clip-on probe, as may be the
case with obesity or edema, the clip-on probe may not fit properly,
obtaining a disposable (tape-on) probe.
5. Bring equipment to the bedside and perform hand hygiene
6. Attach sensors to monitoring sites. If using a finger, remove fingernail polish from the
digit with acetone or polish remover.
7. Instruct patient that clip on probe will feel like a clothespin on the finger but will not hurt
8. Once the sensor is in place, turn on the oximeter by activating power. Observe pulse
waveform/intensity display and audible beep. Correlate oximeter pulse rate with
patient’s radial pulse rate.
9. Leave sensor in place 10 to 30 seconds or until oximeter readout reaches constant value
and pulse display reaches full strength during each cardiac cycle. Inform the patient that
the oximeter alarm will sound if the sensor falls off or the patient moves it. Read SpO2
value on digital display.
10. Discuss findings with patient and perform hand hygiene
11. Compare SpO2 reading with the patient's previous baseline and acceptable SpO2
values. This allows the nurse to assess changes in patient’s condition and presence of
respiratory alteration.
12. 12. Complete post procedural protocol.

Resuscitation Bag
1. High flow oxygen (eg. 15 L/min) is attached to the system and it’s attached to a mask or
tube
2. Properly position patient and provide appropriate mask size
3. Please over mouth and nose
4. Tight fit
5. Open airway using two hands thumbs down technique (with an assistant bagging in
preference to do the less affected one handed C-E grip to ensure air patency a (one
person technique versus two person technique)
6. The bag is used to deliver oxygen to spontaneously breathing patient or the bag
compressed to manually ventilate them via mask or tube

Chest Tube and Drainage System

1. Monitor and maintain the patency and integrity of drainage system
 2. Assess the client’s vital signs, oxygen saturation, cardiovascular status and respiratory
status.
3. Observe the dressing site at least every 4 hours. Inspect the dressing for excessive and
abnormal drainage, such as bleeding or foul smelling discharge.
4. Determine the level of discomfort with and without activity and medicate the client for
pain if indicated.
5. Encourage deep-breathing exercises and coughing every 2 hours (this may be
contraindicated in clients who have had a lung removed)
6. Reposition the client every 2 hours, when the client is lying on the affected side, place
the rolled towels beside the tubing. (Rationale: frequent position changes promote
drainage, prevent complications and provide comfort). Rolled towels prevent occlusion of
the chest tube by the client’s weight.
7. Assist the client with range-of-motion exercises of the affected shoulder three times per
day to maintain joint mobility.
8. Ensure that the connections are surely taped and that the chest tube is secured to the
client’s chest wall.
9. Keep the collection device below the client’s chest level.
10. Frequent check the water-seal and suction control chambers
11. Assess the drainage in the tubing and collection chamber. The drainage is measured at
regularly scheduled times (check agency policy)
12. Avoid aggressive chest tube manipulation (e.g., milking or stripping the tube)
13. Frequently check the water-seal and suction control chambers.
14. Assess the drainage in the tubing and collection chamber. The drainage is measured at
regularly scheduled times (check agency policy).
15. Avoid aggressive chest tube manipulation (e.g., milking or stripping the tube). Avoid
clamping the chest tube because this increases the risk of a tension pneumothorax.
16. If the tube becomes disconnected from the collecting system, submerge the end in 2.5
cm (1 in.) of sterile saline or water to maintain the seal.
17. If the chest tube is inadvertently pulled out, the wound should be immediately covered
with a dry sterile dressing.

(For patients with chest tubes)

1. Monitor and maintain the patency and integrity of the drainage system.
2. Assess the client's vital signs, oxygen saturation, cardiovascular status, and respiratory
status.
3. Observe the dressing site at least every 4 hours. Inspect the dressing for excessive and
abnormal drainage, such as bleeding or foul smelling discharge.
4. Determine level of discomfort with and without activity and medicate the client for pain if
indicated.
5. Encourage deep-breathing exercises and coughing every 2 hours (this may be
contraindicated in clients who have had a lung removed).
6. Reposition the client every 2 hours.
7. Assist the client with range-of-motion exercises of the affected shoulder three times per
day to maintain joint mobility.
8. Ensure that the connections are securely taped and that the chest tube is secured to the
client's chest wall.
9. Keep the collection device below the client's chest level.
10. Frequent check the water-seal and suction control chambers
11. Assess the drainage in the tubing and collection chamber. The drainage is measured at
regularly scheduled times (check agency policy)
12. Avoid aggressive chest tube manipulation (e.g., milking or stripping the tube)
13. Avoid clamping the chest tube because this increases the risk of a tension
pneumothorax.
14. If the tube becomes disconnected from the collecting system, submerge the end in 2.5
cm (1 in.) of sterile saline or water to maintain the seal.
15. If the chest tube is inadvertently pulled out, the wound should be immediately covered
with a dry sterile dressing.