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Interventions for Clients Requiring Oxygen Therapy or Tracheostomy

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Title: Interventions for Clients Requiring Oxygen Therapy or Tracheostomy


1
Interventions for Clients Requiring Oxygen
Therapy or Tracheostomy
2
  • Therapeutic oxygen is used for both acute and
    chronic respiratory conditions associated with
    decreased blood and tissue oxygen levels as
    indicated by decreased partial pressure of
    arterial oxygen (PaO2) levels or by decreased
    arterial oxygen saturation (SaO2).
  • Conditions outside the respiratory system that
    increase oxygen demand, decrease oxygen-carrying
    capability of the blood, or decrease cardiac
    output also are indications for oxygen therapy.
    Such conditions include sepsis, fever, and
    decreased hemoglobin levels or poor hemoglobin
    quality

3
  • The goal of oxygen therapy is to use the lowest
    fraction of inspired oxygen (FiO2) to obtain the
    most acceptable oxygenation without causing the
    development of harmful side effects
  • The average client requires an oxygen flow of 2
    to 4 L/min via nasal cannula or up to 40 via
    Venturi mask.
  • The client who is hypoxemic and also has chronic
    hypercarbia (increased partial pressure of
    arterial carbon dioxide PaCO2 levels) requires
    lower levels of oxygen delivery, usually 1 to 2
    L/min via nasal cannula, to prevent decreased
    respiratory effort. (A low PaO2 level is this
    client's primary drive for breathing.

4
Hazards and Complications of Oxygen Therapy
  • Combustion
  • Oxygen-induced hypoventilation
  • The central chemoreceptors in the brain (medulla)
    are normally sensitive to increased Paco2 levels,
    which stimulate breathing and cause an increased
    respiratory rate. When the Paco2 increases over
    time to above 60 to 65 mm Hg, this normal
    mechanism shuts off. The central chemoreceptors
    lose their sensitivity to increased levels of
    Paco2 and no longer respond by increasing the
    rate and depth of respiration, a condition called
    CO2 narcosis. For these clients, the stimulus to
    breathe is a decreased arterial oxygen
    concentration as sensed by peripheral
    chemoreceptors found in the carotid sinus areas
    and aortic arch. When partial pressure of
    arterial oxygen (Pao2) levels drop (hypoxemia),
    these receptors signal the brain to increase the
    respiratory rate and depth the hypoxic drive to
    breathe.
  • The hypoxic drive occurs only in the presence of
    severely elevated PaCO2 levels (i.e., in the
    client who has hypoxemia and hypercarbia). When
    the client with low Pao2 levels and high Paco2
    levels receives oxygen therapy, the Pao2 level
    increases, removing the stimulation for
    breathing, and the client experiences respiratory
    depression. (The client being ventilated
    mechanically is not at risk for this
    complication.

5
Hazards and Complications of Oxygen Therapy
  • Oxygen toxicity
  • High concentrations of oxygen are avoided unless
    absolutely necessary. The addition of continuous
    positive airway pressure (CPAP) with an oxygen
    mask, bilevel positive airway pressure (Bi-PAP),
    or positive end-expiratory pressure (PEEP) on the
    mechanical ventilator may reduce the amount of
    oxygen needed. As soon as the client's clinical
    condition allows, the physician decreases the
    prescribed amount of oxygen
  • Absorption atelectasis
  • Nitrogen normally plays a large role in the
    maintenance of patent airways and alveoli. Making
    up 79 of room air, nitrogen prevents alveolar
    collapse. When high concentrations of oxygen are
    delivered, nitrogen is diluted, oxygen diffuses
    from the alveoli into the pulmonary circulation,
    and the alveoli collapse. Collapsed alveoli cause
    atelectasis (called absorption atelectasis),
    which is detected by auscultation
  • Drying of the mucous membranes
  • Infection

6
A bubble humidifier bottle used with oxygen
therapy
7
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8
Oxygen Delivery Systems
  • Oxygen delivery systems are classified according
    to the rate at which oxygen is delivered. There
    are two systems low-flow systems and high-flow
    systems.
  • Low-flow systems do not provide enough flow of
    oxygen to meet the total inspiratory effort of
    the client. Part of the tidal volume is supplied
    by inspiring room air. The total concentration of
    oxygen received depends on the respiratory rate
    and tidal volume.
  • In contrast, high-flow systems provide a flow
    rate that is adequate to meet the entire
    inspiratory effort and tidal volume of the client
    regardless of the respiratory pattern. High-flow
    systems are used for critically ill clients and
    when it is particularly important to know the
    precise concentration of oxygen being delivered.
  • If the client requires a mask but is able to eat,
    the nurse requests an order for a nasal cannula
    at an appropriate liter flow for mealtimes only.
    The mask is replaced after the meal is completed.
  • To increase mobility, up to 50 feet of connecting
    tubing can be used with proper connecting pieces.

9
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10
Low-flow oxygen delivery systems
  • NASAL CANNULA. The nasal cannula, or nasal
    prongs, is used at flow rates of 1 to 6 L/min.
    Approximate oxygen concentrations of 24 (at 1
    L/min) to 44 (at 6 L/min) can be achieved.
  • The nasal cannula is frequently used for chronic
    lung disease and for long-term maintenance of
    clients with other illnesses. The nurse places
    the nasal prongs in the nostrils, with the
    openings facing the client

11
Low-flow oxygen delivery systems
  • SIMPLE FACE MASK. A simple face mask is used to
    deliver oxygen concentrations of 40 to 60 for
    short-term oxygen therapy or in an emergency. A
    minimum flow rate of 5 L/min is needed to prevent
    the rebreathing of exhaled air. The nurse gives
    special attention to skin care and to the proper
    fitting of the mask so that inspired oxygen
    concentration is maintained

12
Low-flow oxygen delivery systems
  • PARTIAL REBREATHER MASK. A partial rebreather
    mask provides oxygen concentrations of 60 to
    75, with flow rates of 6 to 11 L/min. It
    consists of a mask with a reservoir bag but no
    flaps. The client first rebreathes one third of
    the exhaled tidal volume, which is high in
    oxygen, thus providing a high fraction of
    inspired oxygen (Fio2).
  • The nurse ensures that the bag remains slightly
    inflated at the end of inspiration otherwise,
    the client will not be getting the desired oxygen
    prescription. If needed, the nurse calls the
    respiratory therapist for assistance

13
Low-flow oxygen delivery systems
  • NON-REBREATHER MASK. A non-rebreather mask
    provides the highest concentration of the
    low-flow systems and can deliver an Fio2 greater
    than 90, depending on the client's breathing
    pattern. The non-rebreather mask is used most
    often with deteriorating respiratory status who
    might soon require intubation.
  • The non-rebreather mask has a one-way valve
    between the mask and the reservoir and two flaps
    over the exhalation ports. The valve allows the
    client to draw all needed oxygen from the
    reservoir bag, and the flaps prevent room air
    from entering through the exhalation ports.
    During exhalation, air leaves through these
    exhalation ports while the one-way valve prevents
    exhaled air from re-entering the reservoir bag.

14
High-flow oxygen delivery systems
  • VENTURI MASK. The Venturi mask (commonly called
    Venti mask) delivers the most accurate oxygen
    concentration. Its operation is based on a
    mechanism that pulls in a specific proportional
    amount of room air for each liter flow of oxygen.
    An adaptor is located between the bottom of the
    mask and the oxygen source. Adaptors with holes
    of different sizes allow only specific amounts of
    air to mix with the oxygen. Precise delivery of
    oxygen results. Each adaptor also specifies the
    flow rate to be used for example, to deliver 24
    of oxygen, the flow rate must be 4 L/min. Another
    type of Venturi mask has one adaptor with a dial
    that the nurse uses to select the amount of
    oxygen desired. Humidification is not necessary
    with the Venturi mask. The Venturi system is best
    for the client with chronic lung disease because
    it delivers a precise oxygen concentration

15
High-flow oxygen delivery systems
  • OTHER HIGH-FLOW SYSTEMS. The face tent, aerosol
    mask, tracheostomy collar, and T-piece are often
    used to administer high humidity. A dial on the
    humidification source regulates the oxygen
    concentration being delivered.
  • A face tent fits over the chin, with the top
    extending halfway across the face. The oxygen
    concentration varies, but the face tent, instead
    of a tight-fitting mask, is useful for facial
    trauma or burns.
  • An aerosol mask is used when high humidity is
    required after extubation or upper airway surgery
    or for thick secretions.
  • The tracheostomy collar can be used to deliver
    high humidity and the desired oxygen to the
    client with a tracheostomy.
  • A special adaptor, called the T-piece, can be
    used to deliver any desired Fio2 to the client
    with a tracheostomy, laryngectomy, or
    endotracheal tube. The flow rate is regulated so
    that the aerosol does not disappear on the
    exhalation side of the T-piece

16
A T-piece apparatus for attachment to an
endotracheal or tracheostomy tube.
Example of transtracheal oxygen delivery.
17
Noninvasive positive-pressure ventilation
  • Noninvasive positive-pressure ventilation (NPPV)
    is a newer technique using positive pressure to
    keep alveoli open and improve gas exchange
    without the need for airway intubation.
  • This type of ventilation can deliver oxygen or
    may just use room air. Essentially, a nasal mask
    or full-face mask delivery system allows
    mechanical delivery of either bilevel positive
    airway pressure (BiPAP) or continuous nasal
    positive airway pressure.
  • For BiPAP, a cycling machine delivers a set
    inspiratory positive airway pressure each time
    the client begins to inspire. As the client
    begins to exhale, the machine delivers a lower
    set end expiratory pressure. Together, these two
    pressures improve tidal volume.
  • Nasal continuous positive airway pressure
    delivers a set positive airway pressure
    continually throughout each cycle of inhalation
    and exhalation. The effect is to open collapsed
    alveoli. Clients who might benefit from this form
    of oxygen or air delivery include those with
    postoperative atelectasis or cardiac-induced
    pulmonary edema. This technique is also used for
    sleep apnea. The effect of this use is to hold
    open the upper airways

18
Transtracheal oxygen therapy
  • Transtracheal oxygen (TTO) is a long-term method
    of delivering oxygen directly into the lungs. The
    physician passes a small, flexible catheter into
    the trachea via a small incision with the use of
    local anesthesia.
  • TTO allows better compliance and avoids the
    irritation that nasal prongs cause. Clients also
    report it to be more cosmetically acceptable.
  • A TTO team provides formal client education,
    including the purpose of TTO and care of the
    catheter. The physician prescribes a TTO flow
    rate for rest and for activity and a flow rate
    for the nasal cannula, to be used when the TTO
    catheter is being cleaned. The average client
    will have a 55 reduction in required oxygen flow
    at rest and a 30 decrease with activity

19
Home care management
  • CRITERIA FOR HOME OXYGEN THERAPY
  • The client must be clinically stable and
    optimally treated before the need for home oxygen
    is considered.
  • For Medicare to cover the cost of continuous
    oxygen therapy, the client must have severe
    hypoxemia.
  • For reimbursement purposes, severe hypoxemia is
    generally defined as a partial pressure of
    arterial oxygen (Pao2) level of less than 55 mm
    Hg or an arterial oxygen saturation (Sao2) of
    less than 88 on room air and at rest.
  • The criteria are variable when hypoxemia is
    caused by cardiac rather than pulmonary problems,
    or when oxygen is needed only at night or with
    exercise

20
Home care management
  • CLIENT EDUCATION
  • After the need for home oxygen therapy is
    verified, the nurse begins a teaching plan about
    oxygen therapy. The client, with the nurse's
    assistance, selects a durable medical equipment
    (DME) company to deliver oxygen equipment and a
    community health nursing agency for follow-up
    care in the home. The physician re-evaluates the
    need for oxygen therapy approximately 6 months
    after discharge from the health care facility and
    yearly thereafter.
  • While providing discharge planning and teaching,
    the nurse is sensitive to the client's
    psychologic adjustment to oxygen therapy. The
    nurse encourages the client to share feelings and
    concerns. The client may be concerned about
    social acceptance and misconceptions of friends.
    The nurse helps him or her realize that
    compliance with oxygen therapy is important so
    that normal activities of daily living (ADLs) and
    events that bring enjoyment can be continued

21
TRACHEOSTOMY
  • Tracheotomy is the surgical incision into the
    trachea for the purpose of establishing an
    airway.
  • Tracheostomy is the (tracheal) stoma, or opening,
    that results from the tracheotomy. A tracheostomy
    can be performed as an emergency procedure or as
    a scheduled surgical procedure and can be
    temporary or permanent

Indications for tracheostomy
22
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23
Complications
  • Tube obstruction
  • Tube dislodgment or accidental decannulation
  • Pneumothorax
  • Subcutaneous emphysema
  • Bleeding
  • Infection

24
Tracheostomy tubes
  • Double-lumen tube
  • Single-lumen tube
  • Cuffed tube
  • Cuffless tube
  • Fenestrated tube
  • Cuffed fenestrated tube
  • Metal tracheostomy tube
  • Talking tracheostomy tube

25
Dual-lumen cuffed tracheostomy tube with
disposable inner cannula
26
Single-lumen cannula cuffed tracheostomy tube
27
Dual-lumen cannula cuffed fenestrated
tracheostomy tube
28
Care Issues for the Tracheostomy Client
  • Prevention of tissue damage
  • Cuff pressure can cause mucosal ischemia.
  • Use minimal leak technique and occlusive
    technique.
  • Check cuff pressure often.
  • Prevent tube friction and movement.
  • Prevent and treat malnutrition, hemodynamic
    instability, or hypoxia.

29
Air Warming and Humidification
  • The tracheostomy tube bypasses the nose and
    mouth, which normally humidify, warm, and filter
    the air.
  • Air must be humidified.
  • Maintain proper temperature.
  • Ensure adequate hydration.

30
Suctioning
  • Suctioning maintains a patent airway and promotes
    gas exchange.
  • Assess need for suctioning from the client who
    cannot cough adequately.
  • Suctioning is done through the nose or the mouth.
  • Suctioning can cause
  • Hypoxia (see causes to follow)
  • Tissue (mucosal) trauma
  • Infection
  • Vagal stimulation and bronchospasm
  • Cardiac dysrhythmias from hypoxia caused by
    suctioning

31
Causes of Hypoxia in the Tracheostomy
  • Ineffective oxygenation before, during, and after
    suctioning
  • Use of a catheter that is too large for the
    artificial airway
  • Prolonged suctioning time
  • Excessive suction pressure
  • Too frequent suctioning

32
Possible Complications of Suctioning
  • Tissue trauma
  • Infection of lungs by bacteria from the mouth
  • Vagal stimulation stop suctioning immediately
    and oxygenate client manually with 100 oxygen
  • Bronchospasm may require a bronchodilator

33
Tracheostomy Care
  • Assessment of the client
  • Secure tracheostomy tubes in place
  • Prevent accidental decannulation

34
Bronchial and Oral Hygiene
  • Turn and reposition every 1 to 2 hours, support
    out-of-bed activities, encourage early
    ambulation.
  • Coughing and deep breathing, chest percussion,
    vibration, and postural drainage promote
    pulmonary cure.
  • Oral hygieneavoid glycerine swabs or mouthwash
    that contains alcohol assess mouth for ulcers,
    bacterial or fungal growth, or infections.

35
Nutrition
  • Swallowing can be a major problem for the client
    with a tracheostomy tube in place.
  • If balloon is inflated, it can interfere with the
    passage of food through the esophagus.
  • Elevate head of bed for at least 30 minutes after
    client eats to prevent aspiration during
    swallowing.

36
Speech and Communication
  • Client can speak with a cuffless tube,
    fenestrated tube, or cuffed fenestrated tube that
    is capped or covered.
  • Client can write.
  • Phrase questions to client for yes or no
    answers.
  • A one-way valve that fits over the tube and
    replaces the need for finger occlusion can be
    used to assist with speech.

37
Weaning from a Tracheostomy Tube
  • Weaning is a gradual decrease in the tube size
    and ultimate removal of the tube.
  • Cuff is deflated as soon as the client can manage
    secretions and does not need assisted
    ventilation.
  • Change from a cuffed to an uncuffed tube.
  • Size of tube is decreased by capping use a
    smaller fenestrated tube.
  • Tracheostomy button has a potential danger of
    getting dislodged.
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