Chapter 39. Oxygenation. Procedures Checklist ADMINISTERING OXYGEN. Procedure 39.2: Administering Oxygen by Cannula, Face Mask, or Face Tent

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1 Chapter 39 Oxygenation Procedures Checklist ADMINISTERING OXYGEN Procedure 39.2: Administering Oxygen by Cannula, Face Mask, or Face Tent Performed Preparation Yes No Mastered Comments 1. Assess: Skin and mucous membrane colour note whether cyanosis is present Breathing patterns Chest movements Chest wall configuration Lung sounds Presence of clinical signs of hypoxemia Presence of clinical signs of hypercarbia Presence of clinical signs of oxygen toxicity 2. Determine: The order for oxygen, including the administering device and the litre flow rate (l/min), or the percentage of oxygen The levels of oxygen (PO 2 ) and carbon dioxide (PaCO 2 ) in the client s arterial blood Whether the client has COPD Vital signs, especially pulse rate and quality, and respiratory rate, rhythm, and depth Results of diagnostic studies Hemoglobin, hematocrit, complete blood count Arterial blood gases Pulmonary function tests The need for oxygen therapy; verify the order for the therapy Perform a respiratory assessment to develop baseline data, if not already available 3. Assemble equipment and supplies: Cannula Oxygen supply with a flow meter and adapter Humidifier with distilled water or tap water, according to agency

2 protocol Nasal cannula and tubing Tape Padding for the 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 the 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 4. Assist the client to a semi-fowler s position, if possible. 5. Explain that oxygen is not dangerous when safety precautions are observed. Inform the client and support people about the safety precautions connected with oxygen use. Procedure 1. Explain to the client what you are going to do, why it is necessary, and how he can cooperate. 2. Wash hands and observe other appropriate infection control procedures. 3. Provide for client privacy. 4. Set up the oxygen equipment and the humidifier. Attach the flow meter to the wall outlet or tank. The flow meter should be in the OFF position. If needed, fill the humidifier bottle. Attach the humidifier bottle to the base of the flow meter. Attach the prescribed oxygen tubing and delivery device to the humidifier. 5. Turn on the oxygen at the prescribed rate, and ensure proper functioning. Check that the oxygen is flowing freely through the tubing. There should be no kinks in the tubing, and the connections should be airtight. There should be bubbles in the humidifier as the oxygen flows through. You should feel the oxygen at the outlets of the cannula, mask, or tent.

3 Set the oxygen at the flow rate ordered. 6. Apply the appropriate oxygen delivery device. Cannula Put the cannula over the client s face, with the outlet prongs fitting into the nares and the elastic band around the head. If the cannula will not stay in place, tape it at the sides of the face. Pad the tubing and band over the ears and cheekbones as needed. Face Mask Guide the mask toward the client s face, and apply it from the nose downward. Fit the mask to the contours of the client s face. Secure the elastic band around the client s head so that the mask is comfortable but snug. Pad the band behind the ears and over bony prominences. Face Tent Place the tent over the client s face, and secure the ties around the head. 7. Assess the client regularly. Assess the client s vital signs, level of anxiety, colour, and ease of respirations, and provide support while the client adjusts to the device. Assess the client in minutes, depending on the client s condition, and regularly thereafter. Assess the client regularly for clinical signs of hypoxia, tachycardia, confusion, dyspnea, restlessness, and cyanosis. Review arterial blood gas results if they are available. Nasal Cannula Assess the client s nares for encrustations and irritation. Apply a water-soluble lubricant as required to soothe the mucous membranes. Face Mask or Tent Inspect the facial skin frequently for dampness or chafing, and dry and treat it as needed. 8. Inspect the equipment on a regular basis. Check the litre flow and the level of water in the humidifier in 30 minutes and whenever providing care to the client.

4 Make sure that safety precautions are being followed. 9. Document findings in the client record.

5 TRACHEOSTOMY CARE Procedure 39.3: Providing Tracheostomy Care Performed Preparation Yes No Mastered Comments 1. Assess: Respiratory status, including ease of breathing, rate, rhythm, depth, and lung sounds Pulse rate Character and amount of secretions from tracheostomy site Presence of drainage on tracheostomy dressing or ties Appearance of incision 2. Assemble equipment and supplies: Sterile disposable tracheostomy cleaning kit or supplies Towel or drape to protect bed linens Sterile suction catheter kit Hydrogen peroxide and sterile normal saline Sterile gloves (2 pairs) Clean gloves Moisture-proof bag Commercially prepared sterile tracheostomy dressing or sterile 4" x 4" gauze dressing Cotton twill ties Clean scissors Procedure 1. Explain to the client what you are going to do, why it is necessary, and how he can cooperate. Provide for a means of communication, such as eye blinking or raising a finger, to indicate pain or distress. 2. Wash hands and observe other appropriate infection control procedures. 3. Provide for client privacy. 4. Prepare the client and the equipment. Assist the client to a semi-fowler s or Fowler s position. Open the tracheostomy kit or sterile basins. Pour hydrogen peroxide and sterile normal saline into separate containers. Establish a sterile field.

6 Open other sterile supplies as needed, including sterile applicators, suction kit, and tracheostomy dressing. 5. Suction the tracheostomy tube. Put a clean glove on your nondominant hand and a sterile glove on your dominant hand (or put on a pair of sterile gloves). Suction the full length of the tracheostomy tube to remove secretions and ensure a patent airway. Rinse the suction catheter and wrap the catheter around your hand, and peel the glove off so that it turns inside out over the catheter. Using the gloved hand, unlock the inner cannula (if present) and remove it by gently pulling it out toward you in line with its curvature. Place the inner cannula in the hydrogen peroxide solution. Remove the soiled tracheostomy dressing. Place the soiled dressing in your gloved hand and peel the glove off so that it turns inside out over the dressing. Discard the glove and the dressing. Put on sterile gloves. Keep your dominant hand sterile during the procedure. 6. Clean the inner cannula. Remove the inner cannula from the soaking solution. Clean the lumen and entire inner cannula thoroughly, using the brush or pipe cleaners moistened with sterile normal saline. Inspect the cannula for cleanliness by holding it at eye level and looking through it into the light. Rinse the inner cannula thoroughly in the sterile normal saline. After rinsing, gently tap the cannula against the inside edge of the sterile saline container. Use a pipe cleaner folded in half to dry only the inside of the cannula; do not dry the outside. Using sterile technique, suction the outer cannula. 7. Replace the inner cannula, securing it in place. Insert the inner cannula by grasping the outer flange and inserting the cannula in the direction of its curvature.

7 Lock the cannula in place by turning the lock (if present) into position to secure the flange of the inner cannula to the outer cannula. 8. Clean the incision site and tube flange. Using sterile applicators or gauze dressings moistened with normal saline, clean the incision site. Handle the sterile supplies with your dominant hand. Use each applicator or gauze dressing only once and then discard. Hydrogen peroxide may be used to remove crusty secretions. Thoroughly rinse the cleaned area, using gauze squares moistened with sterile normal saline. Clean the flange of the tube in the same manner. Thoroughly dry the client s skin and tube flanges with dry gauze squares. 9. Apply a sterile dressing. Use a commercially prepared tracheostomy dressing of nonravelling material, or open and refold a 4" x 4" gauze dressing into a V shape. Place the dressing under the flange of the tracheostomy tube. While applying the dressing, ensure that the tracheostomy tube is securely supported. 10. Change the tracheostomy ties. Two-Strip Method Cut two unequal strips of twill tape, one approximately 25 cm (10 in) long and the other about 50 cm (20 in) long. Cut a 1 cm (0.5 in) lengthwise slit approximately 2.5 cm (1 in) from one end of each strip. To do this, fold the end of the tape back onto itself about 2.5 cm (1 in), then cut a slit in the middle of the tape from its folded edge. Leaving the old ties in place, thread the slit end of one clean tape through the eye of the tracheostomy flange from the bottom side; then thread the long end of the tape through the slit, pulling it tight until it is securely fastened to the flange.

8 If the old ties are very soiled, or if it is difficult to thread new ties onto the tracheostomy flange with the old ties in place, have an assistant put on a sterile glove and hold the tracheostomy in place while you replace the ties. Repeat the process for the second tie. Ask the client to flex his neck. Slip the longer tape under the client s neck, place two fingers between the tape and the client s neck, and tie the tapes together at the side of the neck. Tie the ends of the tapes, using square knots. Cut off any long ends, leaving approximately 1 2 cm ( in). Once the clean ties are secured, remove the soiled ties and discard. One-Strip Method Cut a length of twill tape 2.5 times the length needed to go around the client s neck from one tube flange to the other. Thread one end of the tape into the slot on one side of the flange. Bring both ends of the tape together, and take them around the client s neck, keeping them flat and untwisted. Thread the end of the tape next to the client s neck through the slot from the back to the front. Have the client flex his neck. Tie the loose ends with a square knot at the side of the client s neck, allowing for slack by placing two fingers under the ties, as with the two-strip method. Cut off long ends. 11. Tape and pad the tie knot. Place a folded 4" x 4" gauze square under the tie knot, and apply tape over the knot. 12. Check the tightness of the ties. Frequently check the tightness of the tracheostomy ties and position of the tracheostomy tube. 13. Document all relevant information. Record suctioning, tracheostomy care, and the dressing change, noting your assessments.

9 Variation: Using a Disposable Inner Cannula Procedure Check policy for frequency of changing inner cannula. Open new cannula package. Using a gloved hand, unlock the current inner cannula (if present) and remove it by gently pulling it out toward you in line with its curvature. Check the cannula for amount and type of secretions, and discard properly. Pick up the new inner cannula, touching only the outer locking portion. Insert the new inner cannula into the tracheostomy. Lock the cannula in place by turning the lock (if present).

10 SUCTIONING Procedure 39.4: Suctioning Oropharyngeal and Nasopharyngeal Cavities Performed Preparation Yes No Mastered Comments 1. Assess for clinical signs indicating the need for suctioning: Restlessness Gurgling sounds during respiration Adventitious breath sounds when the chest is auscultated Change in mental status Skin colour Rate and pattern of respirations Pulse rate and rhythm 2. Assemble equipment and supplies: Towel or moisture-resistant pad Portable or wall suction machine with tubing and collection receptacle Sterile disposable container for fluids Sterile normal saline or water Sterile gloves Goggles or face shield, if appropriate Sterile suction catheter kit Water-soluble lubricant (for nasopharyngeal suctioning) Y-connector Sterile gauzes Moisture-resistant disposal bag Sputum trap, if specimen is to be collected Procedure 1. Explain to the client what you are going to do, why it is necessary, and how she can cooperate. 2. Wash hands and observe other appropriate infection control procedures. 3. Provide for client privacy. 4. Prepare the client. Position a conscious person who has a functional gag reflex in the semi- Fowler s position, with the head turned to one side for oral suctioning or with the neck hyperextended for nasal suctioning. Position an unconscious client in the lateral position, facing you. Place the towel or moisture-resistant pad over the pillow or under the chin.

11 5. Prepare the equipment. Set the pressure on the suction gauge, and turn on the suction. Open the lubricant (if performing nasopharyngeal suctioning). Open the sterile suction package: Set up the cup or container, touching only the outside. Pour sterile water or saline into the container. Put on the sterile gloves, or put on a non-sterile glove on the nondominant hand and then a sterile glove on the dominant hand. With your sterile gloved hand, pick up the catheter, and attach it to the suction unit. 6. Make an approximate measure of the depth for the insertion of the catheter, and test the equipment. Measure the distance between the tip of the client s nose and the earlobe. Mark the position on the tube with the fingers of the sterile gloved hand. Test the pressure of the suction and the patency of the catheter by applying your sterile gloved finger or thumb to the port or open branch of the Y-connector (the suction control) to create suction. 7. Lubricate and introduce the catheter. For nasopharyngeal suction, lubricate the catheter tip with sterile water, saline, or water-soluble lubricant; for oropharyngeal suction, moisten the tip with sterile water or saline. For Oropharyngeal Suction Pull the tongue forward, if necessary, using gauze. Do not apply suction during insertion. Advance the catheter about cm (4 6 in) along one side of the mouth into the oropharynx. For Nasopharyngeal Suction Without applying suction, insert the catheter the premeasured or recommended distance into either naris and advance it along the floor of the nasal cavity. Never force the catheter against an obstruction. If one nostril is obstructed, try the other. 8. Perform suctioning. Apply your finger to the suction control port to start suction, and gently rotate the catheter.

12 Apply suction for 5 10 seconds while slowly withdrawing the catheter, then remove your finger from the control and remove the catheter. A suction attempt should last only seconds. During this time, the catheter is inserted, the suction applied and discontinued, and the catheter removed. It may be necessary during oropharyngeal suctioning to apply suction to secretions that collect in the vestibule of the mouth and beneath the tongue. 9. Clean the catheter, and repeat suctioning as above. Wipe off the catheter with sterile gauze if it is thickly coated with secretions. Dispose of the used gauze in a moisture-resistant bag. Flush the catheter with sterile water or saline. Relubricate the catheter, and repeat suctioning until the air passage is clear. Allow 20- to 30-second intervals between each suction, and limit suctioning to 5 minutes in total. Alternate nares for repeat suctioning. Encourage the client to breathe deeply and to cough between suctions. 10. Obtain a specimen, if required. Use a sputum trap as follows. Attach the suction catheter to the tubing of the sputum trap. Attach the suction tubing to the sputum trap air vent. Suction the client s nasopharynx or oropharynx. The sputum trap will collect the mucus during suctioning. Remove the catheter from the client. Disconnect the sputum trap tubing from the suction catheter. Remove the suction tubing from the trap air vent. Connect the tubing of the sputum trap to the air vent. Connect the suction catheter to the tubing. Flush the catheter to remove secretions from the tubing. 11. Promote client comfort. Offer to assist the client with oral or nasal hygiene. Assist the client to a position that facilitates breathing.

13 12. Dispose of equipment and ensure availability for the next suction. Dispose of the catheter, gloves, water, and waste container. Wrap the catheter around your sterile gloved hand and hold the catheter as the glove is removed over it for disposal. Rinse the suction tubing as needed by inserting the end of the tubing into the used water container. Empty and rinse the suction collection container as needed or indicated by protocol. Change the suction tubing and container daily. Ensure that supplies are available for the next suctioning. 13. Assess the effectiveness of suctioning. Auscultate the client s breath sounds to ensure they are clear of secretions. Observe skin colour, dyspnea, and level of anxiety. 14. Document relevant data. Record the procedure: The amount, consistency, colour, and odour of sputum The client s breathing status before and after the procedure

14 Procedure 39.5: Suctioning a Tracheostomy or Endotracheal Tube Performed Preparation Yes No Mastered Comments 1. Assess: Client for the presence of congestion on auscultation of the thorax Note the client s ability or inability to remove the secretions through coughing 2. Determine: If the client has been suctioned previously; if so, review the documentation of the procedure 3. Assemble equipment and supplies: Resuscitation bag (Ambu bag) connected to 100 percent oxygen Sterile towel (optional) Equipment for suctioning (see Procedure 39-4) Goggles and mask, if necessary Gown (if necessary) Sterile gloves Moisture-resistant bag Procedure 1. Explain to the client what you are going to do, why it is necessary, and how he can cooperate. 2. Wash hands and observe other appropriate infection control procedures. 3. Provide for client privacy. 4. Prepare the client. If not contraindicated because of health, place the client in the semi- Fowler s position. If necessary, provide analgesia before suctioning. 5. Prepare the equipment. Attach the resuscitation apparatus to the oxygen source. Adjust the oxygen flow to 100 percent flush. Open the sterile supplies in readiness for use. Place the sterile towel, if used, across the client s chest below the tracheostomy. Turn on the suction, and set the pressure in accordance with agency policy. Put on goggles, mask, and gown, if necessary. Put on sterile gloves.

15 Holding the catheter in the dominant hand and the connector in the nondominant hand, attach the suction catheter to the suction tubing. 6. Flush and lubricate the catheter. Using the dominant hand, place the catheter tip in the sterile saline solution. Using the thumb of the nondominant hand, occlude the thumb control, and suction a small amount of the sterile solution through the catheter. 7. If the client does not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning. Summon an assistant, if one is available, for this step. Using your nondominant hand, turn on the oxygen to l/min. If the client is receiving oxygen, disconnect the oxygen source from the tracheostomy tube using your nondominant hand. Attach the resuscitator to the tracheostomy or endotracheal tube. Compress the Ambu bag 3 5 times, as the client inhales. Observe the rise and fall of the client s chest to assess the adequacy of each ventilation. Remove the resuscitation device and place it on the bed or the client s chest, with the connector facing up. Variation: Hyperventilation Using the Ventilator Procedure If the client is on a ventilator, use the ventilator for hyperventilation and hyperoxygenation. 8. If the client has copious secretions, do not hyperventilate with a resuscitator. Instead: Keep the regular oxygen delivery device on and increase the litre flow or adjust the FiO 2 to 100 percent for several breaths before suctioning. 9. Quickly but gently insert the catheter without applying any suction. With your nondominant thumb off the suction port, quickly but gently insert the catheter into the trachea through the tracheostomy tube.

16 Insert the catheter about 12.5 cm (5 in) for adults, less for children, or until the client coughs or you feel resistance. To prevent damaging the mucous membranes at the bifurcation, withdraw the catheter about 1 2 cm ( in) before applying suction. 10. Perform suctioning. Apply intermittent suction for 5 10 seconds by placing the nondominant thumb over the thumb port. Rotate the catheter by rolling it between your thumb and forefinger while slowly withdrawing it. Withdraw the catheter completely, and release the suction. Hyperventilate the client. Then suction again. 11. Reassess the client s oxygenation status and repeat suctioning. Observe the client s respirations and skin colour. Check the client s pulse, if necessary, using your nondominant hand. Encourage the client to breathe deeply and to cough between suctions. Allow 2 3 minutes between suctions when possible. Flush the catheter, and repeat suctioning until the air passage is clear and the breathing is relatively effortless and quiet. After each suction, pick up the resuscitation bag with your nondominant hand and ventilate the client with no more than three breaths. 12. Dispose of equipment and ensure availability for the next suction. Flush the catheter and suction tubing. Turn off the suction, and disconnect the catheter from the suction tubing. Wrap the catheter around your sterile hand, and peel the glove off so that it turns inside out over the catheter. Discard the glove and the catheter in the moisture-resistant bag. Replenish the sterile fluid and supplies so that the suction is ready for use again. 13. Provide for client comfort and safety.

17 Assist the client to a comfortable, safe position that aids breathing. If the person is conscious, a semi-fowler s position is frequently indicated. If the person is unconscious, the Sims position aids in the drainage of secretions from the mouth. 14. Document relevant data. Record the suctioning, including the amount and description of suction returns, and any other relevant assessments. Variation: Closed Airway/Tracheal Suction System (In-Line Catheter) Procedure If a catheter is not attached, put on clean gloves, aseptically open a new closed catheter set, and attach the ventilator connection on the T piece to the ventilator tubing. Attach the client connection to the endotracheal tube or tracheostomy. Attach one end of the suction connecting tubing to the suction connection port of the closed system, and the other end of the connecting tubing to the suction device. Turn suction on, occlude or kink tubing, and depress suction control valve (on closed catheter system) to set suction to the appropriate level. Release the suction control valve. Use the ventilator to hyperoxygenate and hyperinflate the client s lungs. Unlock suction control mechanism, if required by the manufacturer. Advance the suction catheter enclosed in plastic sheath with dominant hand. Steady the T piece with the nondominant hand. Depress the suction control valve and apply suction for no more than 10 seconds, and gently withdraw the catheter. Repeat as needed, remembering to provide hyperoxygenation and hyperinflation as needed. When done suctioning, withdraw the catheter into its sleeve and close the access valve, if appropriate. Flush the catheter by instilling normal saline into the irrigation port and applying suction. Repeat until the catheter is clear. Close the irrigation port and close the suction valve.

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19 Procedure 39.6: Applying a Sequential Compression Device Performed Preparation Yes No Mastered Comments 1. Assess for baseline data: Cardiovascular status, including heart rate and rhythm, peripheral pulses, and capillary refill Colour and temperature of extremities Movement and sensation of feet and lower extremities Homans sign 2. Determine: Physician s order for type of sequential compression device sleeve 3. Assemble equipment and supplies: Measuring tape Antiemboli stockings Sequential compression device (SCD), including disposable sleeves, air pump, and tubing Procedure 1. Explain to the client what you are going to do, why it is necessary, and how she can cooperate. 2. Wash hands and observe other appropriate infection control procedures. 3. Provide for client privacy. 4. Prepare the client. Place the client in a dorsal recumbent or semi-fowler s position. Measure the client s legs as recommended by the manufacturer if a thigh-length sleeve is required. Apply antiemboli stockings. Make sure there are no wrinkles or folds in the stockings. 5. Apply the sequential compression sleeves. Place a sleeve under each leg with the opening at the knee. Wrap the sleeve securely around the leg, securing the Velcro. Allow two fingers to fit between the leg and the sleeve. 6. Connect the sleeves to the control unit and adjust the pressure as needed.

20 Connect the tubing to the sleeves and control unit, ensuring that arrows on the plug and the connector are in alignment and that the tubing is not kinked or twisted. Turn on the control unit and adjust the alarms and pressures as needed. The sleeve-cooling control and alarm should be on; ankle pressure is usually set at mm Hg. 7. Document the procedure. Record baseline assessment data and application of the SCD. Note control unit settings. Assess and document skin integrity and neurovascular status at least every 8 hours while the SCD is in place.