Respiratory Care

Modalities
Learning Objectives:
• Describe the nursing management for
patients receiving oxygen therapy,
intermittent positive-pressure
breathing, mini-nebulizer therapy,
incentive spirometry, chest
physiotherapy, and breathing
retraining.
• Describe the patient education and
home care considerations for patients
receiving oxygen therapy.
• Describe the nursing care for a patient
with an endotracheal tube and for a
patient with a tracheostomy.
Oxygen Therapy
Administration of oxygen at greater than 21% to
provide adequate transport of oxygen in the blood
while:

Decreasing the work of breathing and reducing

stress on the myocardium

Hypoxemia: a decrease in the arterial oxygen

tension in the blood

Hypoxia: a decrease in oxygen supply to the tissues

and cells that can also be caused by problems
outside the respiratory system
Severe hypoxia can be life threatening
Oxygen Toxicity
• May occur when too high a concentration of
oxygen (greater than 50%) is administered for an
extended period
• Symptoms include substernal discomfort,
paresthesias, dyspnea, restlessness, fatigue,
malaise, progressive respiratory difficulty,
refractory hypoxemia, alveolar atelectasis, and
alveolar infiltrates on x-ray
• Prevention:
• Use lowest effective concentrations of oxygen
• PEEP or CPAP prevent or reverse atelectasis
and allow lower oxygen percentages to be
used
Oxygen Administration
• Cylinder, piped-in, concentrator
• Classified as low flow or high flow
• Devices
• Nasal cannula
• Oropharyngeal catheter
• Masks
• Transtracheal catheter
Nasal Canula and
Face Mask
Nasal Canula
Nasal
Canula • Low flow device
• Most common device used
for mild hypoxia
• Can be set between 1 and
6 LPM (24% to 40% FiO2)
• FiO2 increases approximately
4% with each liter of O2
Simple Face
Mask
Simple Face
Mask • Low flow device
• Can be set between 5 and
10LPM (35-55% FiO2)
• Useful when moderate
amount of O2 needed
 Non-
Rebreather
Face Mask
 Non- • Low flow device with high FiO2
Rebreather • Uses a reservoir bag to
deliver a higher
Face Mask concentration of O2
• One way valve prevents patient
from inhaling expired air
• Can be set between 10 and 15 LPM
(80 to 95% O2)
• Useful in severely hypoxic
patients who are ventilating
well
Venturi Mask
Venturi • High flow device
Mask • Allows precise measurement of
O2 delivered
• Utilizes different sized ports to
change amount of FiO2 (24% to
50%)
• Useful in COPD patients
where precise O2
prescription is crucial
Question
#1 Is the following statement true or
false?

The primary oxygen administration

method for a patient with COPD is
a nasal cannula
False
Answer to
The primary oxygen administration Question
method for a patient with COPD is
a Venturi mask, not a nasal cannula #1
Incentive Spirometry
• Two types: volume or flow
• Device encourages patient to inhale slowly and
deeply to maximize lung inflation and alveoli
expansion
• Used to prevent or treat atelectasis
• Indications: post surgery
• Nursing care
• Positioning of patient, encourage use, set
realistic goals, and record outcomes
• Patient education
 Incentive
Spirometry
Question
#2 Is the following statement true or false?

The patient should be encouraged to

use an incentive spirometer
approximately 10 breaths per hour
between treatments while awake
 True
Answer to
The patient should be
Question encouraged to use an incentive
#2 spirometer approximately 10
breaths per hour between
treatments while awake
Mini
Nebulizer
Therapy
Mini- Nebulizer Therapy
• Handheld apparatus that disperses a
moisturizing agent or medication into the
lungs
• Indication
• Difficulty in clearing secretions, reduced vital
capacity, and unsuccessful with simpler methods
• Nursing care:
• Instruct patient to take slow, deep breaths
through the mouth and hold a few seconds
• Encourage patient to cough
• Monitor effectiveness of therapy
Chest Physiotherapy
Postural Drainage
• Allows force of gravity to assist in
removal of Bronchial Secretions to
drain from the affected bronchioles
to the bronchi and trachea and are
removed by coughing
• Used to prevent or relieve
bronchial obstruction caused by
accumulation of secretions
• Because the patient usually sits in
an upright position, secretions are
likely to accumulate in the lower
parts of the lungs
Chest Percussion and Vibration
• Chest percussion is carried out by
cupping the hands and lightly striking the
chest wall in a rhythmic fashion over the
lung segment to be drained
• Vibration is the technique of applying
manual compression and tremor to the
chest wall during the exhalation phase of
respiration
• An inflatable HFCWO vest may be used
to provide chest therapy
 Nursing Interventions
• State physician’s prescription for oxygen
and the manner in which it is to be used

Home • Indicate when a humidifier should be

used
• Identify signs and symptoms indicating
Oxygen the need for change in oxygen therapy
• Demonstrate correct adjustment of
prescribed flow rate
• Describe how to clean and when to
replace oxygen tubing
 • Acute upper airway obstruction
may be caused by food particles,
vomitus, blood clots, or anything
Emergency that obstructs the larynx or trachea
Management of • Rapid observations:
Upper Airway • Inspection
Obstruction • Palpation
• Auscultation
• As soon as it is identified, nurse
takes emergency measures
Endotracheal Intubation
• Provides patent airway,
access for mechanical
ventilation, facilitates
removal of secretions
• Passing an endotracheal
tube through mouth into
the trachea
Endotracheal
Tube
 1. Check symmetry of chest expansion.
• Auscultate breath sounds of anterior and lateral chest
bilaterally.
• Obtain order for chest x-ray to verify proper tube placement.
Nursing • Check cuff pressure every 8–12 hours.
Management • Monitor for signs and symptoms of aspiration.

for 2. Ensure high humidity; a visible mist should appear in the T-piece
or ventilator tubing.
Endotracheal 3. Administer oxygen concentration as prescribed by physician.

Tube 4. Secure the tube to the patient’s face with tape, and mark the
proximal end for position maintenance.
• Prevent kinking.
• Insert an oral airway or mouth device to prevent the patient
from biting and obstructing the tube.
 5. Use sterile suction technique and airway care to
prevent contamination and infection.
6. Continue to reposition patient every 2 hours and as
Nursing needed to
Management prevent atelectasis and to optimize lung expansion.
for 7. Provide oral hygiene and suction the oropharynx
whenever
Endotracheal necessary.
Tube 8. Monitor the patient’s oxygen level using a pulse
oximeter.
9. Keep NPO or give only ice chips for next few hours.
10. Provide mouth care.
Tracheostomy
• Surgical procedure in which an
opening is made into the
trachea

• The indwelling tube inserted

into the trachea is called a
tracheostomy tube.
 1. Check symmetry of chest expansion.
• Auscultate breath sounds of anterior and lateral chest

Nursing bilaterally.
• Obtain order for chest x-ray to verify proper tube
Management placement.
for • Check cuff pressure every 8–12 hours.

Tracheostom • Monitor for signs and symptoms of aspiration.

2. Ensure high humidity; a visible mist should appear in
y the T-piece
or ventilator tubing.
3. Administer oxygen concentration as prescribed by
physician.
 4. Secure the tube to the patient’s face with tape, and mark the
proximal end for position maintenance.
• Cut proximal end of tube if it is longer than 7.5 cm (3 inches)
Nursing to prevent kinking.
Management • Insert an oral airway or mouth device to prevent the patient

for from biting and obstructing the tube.

5. Use sterile suction technique and airway care to prevent
Tracheostom iatrogenic

y contamination and infection.

6. Continue to reposition patient every 2 hours and as needed to
prevent atelectasis and to optimize lung expansion.
7. Provide oral hygiene and suction the oropharynx whenever
necessary.
Mechanica
l Ventilator
 • Method of positive-pressure ventilation
that can be given via facemasks that
cover the nose and mouth, nasal masks,
or other oral or nasal devices such as the
Noninvasive nasal pillow
• Eliminates need for endotracheal
Positive- intubation or tracheostomy
Pressure • Continuous positive airway pressure
Ventilation (CPAP)
• Bilevel positive airway pressure (BiPAP)
• Indications: respiratory arrest, serious
dysrhythmias, cognitive impairment,
head/facial trauma
Assessment
• Systematic assessment of all body
Nursing
systems: Process:
• In-depth respiratory assessment
including all indicators of
The
oxygenation status Patient
• Neurologic status
• Effective coping and emotional
Receiving
needs Mechanical
• Comfort level and ability to
communicate needs
Ventilation
 Goals include:
• Maintenance of patent airway
Nursing • Optimal gas exchange
Process: • Absence of trauma or infection
• Attainment of optimal mobility
Planning • Adjustment to nonverbal
methods of communication
• Successful coping measures
 Nursing Diagnoses
Impaired Ineffective Impaired
Risk for
Gas Airway Physical
Trauma
Exchange Clearance Mobility

Impaired Verbal Defensive Powerlessness

Communication Coping
Collaborative
Problems/Potentia •Ventilator problems
l Complications •Alterations in cardiac function
•Barotrauma (trauma to the
alveoli) and Pneumothorax
•Pulmonary infection and
sepsis
•Delirium
Nursing Enhancing gas exchange

Intervention Promoting effective airway

s clearance
Preventing trauma and infection

optimal level of
Promoting
mobility
Promoting
optimal
communication
Promoting coping ability
 Careful use of analgesics to relieve
pain without suppressing respiratory
drive
Enhancing Frequent repositioning to diminish
Gas the pulmonary effects of immobility
Exchange: Monitor for
Intervention adequate fluid
Assess peripheral edema
I&O and daily weights
balance:
s
Administer medications to
control primary disease
 Assess lung sounds at least every 2
to 4 hours

Measures to clear airway:

Effective suctioning, CPT, position changes,
Airway promote increased mobility

Clearance:
Humidification of airway
Intervention

Administer medications
 Trauma and
Infection Infection Control Measures

Interventions: Tube Care

Cuff Management

Oral Care

Elevation of Head of the Bed

 Other Interventions
ROM and Communication Stress reduction
immobility methods techniques

Interventions Include in care: family teaching,

to promote and the emotional and coping
coping support of the family
 •Alterations in cardiac
function
Monitor and
Manage •Barotrauma and
Potential pneumothorax
Complications
•Pulmonary infection
•Delirium
 Process of withdrawal of
dependence upon the ventilator

Weaning
Weaning
Three stages:
• Patient is gradually removed from
the ventilator
• Then from either the endotracheal
or tracheostomy tube
• And finally, from oxygen

Successful weaning is a
collaborative process
 Criteria for
Weaning
Weaning weaning

Patient
preparation

Methods of
weaning
Thoracic
• Procedures to relieve conditions:
Surgery
• Lung abscesses
• Lung cancer
• Cysts
• Benign tumors
• Emphysema
Preoperative
Improving
Management Assessment
and airway
diagnosis clearance

Educating
Relieving
the
anxiety
patient
Postoperative Management
Vital signs
Careful
checked Oxygen positioning
frequently

Medication Mechanical Chest

for pain ventilation drainage
 Monitoring respiratory and cardiovascular status

Improving gas exchange and breathing

Postoperative Improving airway clearance
Nursing
Management- Relieving pain and discomfort
Thoracic Promoting mobility and shoulder
Surgery exercises
Maintaining fluid volume and nutrition
Monitoring and managing potential
complications
 Chest drainage systems have:
Chest
• A suction source
Tube • A collection chamber for pleural drainage
• And a mechanism to prevent air from
Drainag reentering the chest with inhalation

e Used in removal of air and fluid from the

pleural space and re-expansion of the lungs

System Wet (water seal) or dry suction

control
1 Way
Bottle
System
2 Way
Bottle
System
3 Way
Bottle
System
Preoperative
Improving
Management Assessment
and airway
diagnosis clearance

Educating
Relieving
the
anxiety
patient
 Monitoring respiratory and cardiovascular status

Improving gas exchange and breathing

Postoperative Improving airway clearance
Nursing
Management- Relieving pain and discomfort
Thoracic Promoting mobility and shoulder
Surgery exercises
Maintaining fluid volume and nutrition
Monitoring and managing potential
complications