1. ★ breathing retraining
1) Clients with a respiratory disorder should be positioned with the head of the bed elevated.
2) pursed-lip breathing
- exercises to decrease the use of the accessory muscles of breathing, to decrease fatigue, and to promote CO2 elimination
- The client should exhale three times longer than inhalation, by blowing through pursed lips.
3) diaphragmatic breathing
- exercises to decrease the use of the accessory muscles of breathing to decrease fatigue, and to promote CO2 elimination
- The client should inhale slowly through the nose. The client should place a hand over the abdomen while inhaling. The abdomen should expand with inhalation and contract during exhalation.
4) huff coughing
- This is an effective coughing technique that conserves energy, reduces fatigue, facilitates mobilization of secretions, and expectorate secretion.
- Sit and lean forward. The client should take three or four deep breaths using pursed-lip and diaphragmatic breathing. And hold breathe for 2 to 3 seconds. Leaning slightly forward, the client should cough, sounding like a huff, three or four times during exhalation. the client may need to splint the thorax or abdomen to achieve a maximum cough.
2. CPT (Chest PhysioTherapy)
- Percussion, vibration, and postural drainage techniques are performed over the thorax to loosen secretions in the affected area of the lungs and move them into more central airways. Affected lung이 위로 가도록 함.
- Administer the bronchodilator, if prescribed, 15 minutes before the procedure. Perform CPT in the morning on arising, 1 hour before meals, or 2 to 3 hours after meals. (2 to 4 / day) Place a layer of material (gown or pajamas) between the hands or percussion device and the client’s skin. Position the client for postural drainage based on assessment. Percuss the area for 1 to 2 minutes. Vibrate the same area while the client exhales four or five deep breaths. Maintain the position for 5 to 20 minutes after the procedures. Dispose of sputum properly. Provide mouth care after the procedure.
3. incentive spirometry
- Instruct the client to assume a sitting or upright position. Instruct the client to place the mouth tightly around the mouthpiece of the device. Instruct the client to inhale slowly to raise and maintain the flow rate indicator between the 600 and 900 marks. Instruct the client to hold the breath for 5 seconds and then to exhale through pursed lips. Instruct the client to repeat this process 10 times every hour.
1) nasal cannula (nasal prongs)
- 1 to 6 L/min oxygen flow for the oxygen concentration of 24 to 44%
- Easily tolerated. Can dislodge easily. Assess nasal mucosa and skin integrity.
2) simple face mask
- 5 to 8 L/min oxygen flow for the oxygen concentration of 40 to 60%
- Can be warm and confining. Interferes with eating and talking. Ensure that mask fits securely over the nose and mouth. Provide skincare to the area covered by the mask. Monitor for risk of aspiration from the inability of the client to clear mouth, I.e., if vomiting occurs. Provide emotional support to decrease anxiety in the client who feels claustrophobic.
3) partial rebreather mask (mask with reservoir bag)
- 6 to 15 L/min oxygen flow for the oxygen concentration of 70 to 90%
- Make sure the reservoir bag does not twist or kink. Adjust the flow rate to keep the reservoir bag two-thirds full during inspiration. The deflation of the bag results in decreased oxygen delivered and rebreathing of exhaled air.
4) non-rebreather mask
- 6 to 15 L/min oxygen flow for the oxygen concentration of 60 to 100%
- Make sure the reservoir bag does not twist or kink. Adjust the flow rate to keep the reservoir bag inflated. Ensure that the valves and flaps are intact and functional during each breath (Valves should open during expiration and close during inhalation).
- T-piece can be used to deliver any desired FiO2 to a client with a tracheostomy, laryngectomy, or endotracheal tube.
- Empty condensation forms the tubing to prevent the client from being ravaged with water and to promote an adequate oxygen flow rate. Keep the exhalation port in the T-piece open and uncovered. Position the T-piece so that it does not pull on the tracheostomy or endotracheal tube and cause erosion of the skin at the tracheostomy insertion site.
6) face tent
- The face tent provides 8 to 12 L/min and the FiO2 varies due to environmental loss.
5. respiratory suctioning
- Sterile technique
- Explain the procedure to the client. Assist the client in an upright position. Perform hand hygiene and don protective garb. Prepare suctioning equipment and turn on the suction. Hyperoxygenate the client. Insert the catheter without suction applied. Once inserted, apply suction intermittently while rotating and withdrawing the catheter. Hyperoxygenate the client. Listen to breath sounds. Document the procedure, client response, and effectiveness.
- ★ Once the nurse has assessed the client, the nurse would explain the procedure. The client is assisted in a sitting upright position such as semi-Fowler’s with the head hyperextended (unless contraindicated). The nurse next performs hand hygiene (hand hygiene is also performed before positioning the client) and applies appropriate protective garb, using aseptic technique. The nurse prepares the needed suctioning equipment, turns on the suction device, and sets it to the appropriate pressure. The nurse hyperoxygenates the client with a resuscitation bag, increasing the oxygen flow rate, or asking the client to take deep breaths. The nurse next lubricates the catheter with sterile water or water-soluble lubricant (per agency procedure), inserts the catheter without the application of suction, and then applies intermittent suction for up to 10 seconds while rotating and withdrawing the catheter. After suctioning, the nurse hyperoxygenates the client and encourages the client to take deep breaths if possible. During the procedure, the nurse monitors the client for toleration of the procedure and the presence of complications. Finally, the nurse listens to breathe sounds to assist in determining the effectiveness and documents of the procedure, the client’s response, and effectiveness.
- 성인의 경우 catheter는 12 ∼ 14 Fr (no more than half)
- 1 회당 10초 넘기지 않기, 1 ∼2분 간격으로 총 3 ∼4회, 총 5분
- 압력 100∼120mmHg for 성인, 50∼75mmHg for 소아
- ET tube 시 25∼30cm 삽입, Advanced until resistance is felt and retracted 1cm before applying suction
6. ET tube (EndoTracheal tubes)
- ET tubes are indicated when the client needs mechanical ventilation.
|① orotracheal tubes||– Inserted through the mouth. Allows the use of a larger diameter tube and reduces the work of breathing.
– An oral airway may be needed to keep the client from biting on the tube.
|② nasotracheal tubes||– Inserted through the nostril. It is more comfortable for the client, and the client is unable to manipulate the tube with the tongue.|
- intubation: Placement is confirmed by chest x-ray film. The correct placement is 1 to 2 cm above the carina. Assess placement by auscultating both sides of the chest while manually ventilating with a resuscitation bag (Ambu bag). Perform auscultation over the stomach to rule out esophageal intubation. Secure the tube with adhesive tape immediately after intubation.
- routine care: Suction the tube only when needed. Prevent dislodgment and pulling or tugging on the tube. The oral tube needs to be moved to the opposite side of the mouth daily to prevent pressure and necrosis of the lip and mouth area. Moving the tube to the opposite side of the mouth should be done by two HCPs. Assess the pilot balloon to ensure that the cuff is inflated. Maintain cuff inflation, which creates a seal and allows complete mechanical control of respiration. Monitor cuff pressures at least every 8 hours per agency procedure to ensure that they do not exceed 20 mmHg. A resuscitation bag needs to be kept at the bedside of a client with an endotracheal tube or a tracheostomy tube at all times. HOB 30°. 관에 차 있는 습기는 제거할 것. Inflate when at risk of aspiration and deflate when no risk of aspiration.
- extubation: Hyperoxygenate the client and suction the ET tube and the oral cavity. Place the client in a semi-Fowler’s position. Deflate the cuff. Have the client inhale and, at peak inspiration, remove the tube, suctioning the airway through the tube while pulling it out. After removal, instruct the client to cough and deep breathe to assist in removing accumulated secretions in the throat. Apply oxygen therapy, as prescribed. Monitor for respiratory difficulty. Inform the client that hoarseness or a sore throat is normal and that the client should limit talking if it occurs. 하지만 stridor가 들리면 upper respiratory obstruction 이므로 우선 순위에 해당됨.
- A tracheostomy is an opening made surgically directly into the trachea to establish an airway. A T-tube is inserted into the opening and the tube attaches to the mechanical ventilator or another type of oxygen delivery device. If the client requires an artificial airway for longer than 10 to 14 days, a tracheostomy may be created to avoid mucosal and vocal cord damage that can be caused by the endotracheal tube.
- Monitor ABGs and pulse oximetry. Monitor for bleeding, difficulty with breathing, absence of breath sounds, and crepitus, which are indications of hemorrhage or pneumothorax. Assess the stoma and secretions for blood or purulent drainage. Maintain a semi-Fowler’s to high-Fowler’s position. Suction fluids as needed. If the client is allowed to eat, sit the client up for meals and ensure that the cuff is inflated for meals and for 1 hour after meals to prevent aspiration. Monitor cuff pressures as prescribed. Follow the HCP’s prescriptions and agency policy for cleaning the tracheostomy site and inner cannula. Usually, half-strength hydrogen peroxide is used. Obtain assistance in changing tracheostomy ties. After placing the new ties, cut and remove the old ties holding the tracheostomy in place. A resuscitation bag needs to be kept at the bedside of a client with an endotracheal tube or a tracheostomy tube at all times. An obturator, clamps, and a spare tracheostomy tube or the same size at the bedside. Never insert a plug (cap) into a tracheostomy tube until the cuff is deflated and the inner cannula is removed.
- Clean around every shift. Sterile technique.
- ① Suction. ② Remove old dressing. ③ 주변 소독. ④ new tie. ⑤ old tie 제거.
- 삽입 후 72 시간 이내인데 t-tube 제거되었을 경우 call team. 삽입 후 72 시간 이후 t-tube 제거되었을 경우 just insert.
8. chest tube ★
- The chest tube drainage system returns negative pressure to the intrapleural space. The system is used to remove abnormal accumulations of air and fluids from the pleural space.
- ★ drainage bottle (collection chamber): Monitor drainage. Notify the HCP if drainage is more than 70 to 100mL/hour or if drainage becomes bright red or increases suddenly. Mark the chest tube drainage in the collection chamber at 1 to 4 hours intervals, using a piece of tape.
- ★ water seal bottle: Water in the water seal chamber oscillates. Moves up as the client inhales and moves down as the client exhales. Fluctuation in the water seal chamber stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has re-expanded. If the client has a known pneumothorax, intermittent bubbling in the water seal chamber is expected as air is drained from the chest, but continuous bubbling indicates an air leak in the system. 물 높이: 2 cm
- ★ suction control bottle : Gentle and continuous bubbling should be noted in the suction control chamber. 물 높이: 20 cm
- An occlusive sterile dressing is maintained at the insertion site. Ensure that all connections are secure. Keep the drainage system below the level of the chest and the tubes free of kinks, dependent loops, or other obstructions. Tube를 bed frame 에 걸지 않는다. Do not strip or milk a chest tube unless specifically directed to do so by an HCP and if agency policy allows it. Never clamp a chest tube without a written prescription from the HCP. Also, determine agency policy for clamping a chest tube. If the system needs to be changed, keep a clamp and a sterile occlusive dressing at the bedside at all times. If the drainage system cracks or breaks, insert the chest tube into a bottle of sterile water, remove the cracked or broken system, and replace it with a new system. If the chest tube is pulled out of the chest accidentally, pinch the skin opening together, apply an occlusive sterile dressing (petroleum gauze), cover the dressing with overlapping pieces of 2-inch tape, and call the HCP immediately. Encourage coughing and deep breathing. Change the client’s position frequently to promote drainage and ventilation.