Pulse oximetry and oxygen therapy

• A pulse oximeter is a device with a sensor probe that attaches securely to the fingertip, toe, bridge of nose, earlobe, or forehead with a clip or band.

• A pulse oximeter measures pulse saturation (SpO₂) via a wave of infrared light that measures light absorption by oxygenated and deoxygenated hemoglobin in arterial blood. SpO₂ reliably reflects the percent of saturation of hemoglobin (SaO₂) when the SaO₂ is greater than 70%.

• Oxygen is a tasteless and colorless gas that accounts for 21% of atmospheric air.

• Oxygen flow rates vary to maintain an SpO₂ of 95% to 100% using the lowest amount of oxygen to achieve the goal without risking complications.

• The fraction of inspired oxygen (FiO₂) is the percentage of oxygen the client receives.

Pulse oximetry

Noninvasive measurement of the oxygen saturation of the blood for monitoring respiratory status when assessment findings include any of the following:

• Increased work of breathing

• Wheezing

• Coughing

• Cyanosis

• Changes in respiratory rate or rhythm

• Adventitious breath sounds

• Restlessness, irritability, confusion

• Dyspnea

• Orthopnea

Considerations

Interventions for Readings Less than 90% (Indicating Hypoxemia)

• Confirm probe placement.

• Confirm that the oxygen delivery system is functioning and that the client is receiving the prescribed oxygen levels.

• Place the client in semi-Fowler’s or Fowler’s position to promote chest expansion and to maximize ventilation.

• Encourage deep breathing.

• Remain with the client and provide emotional support to decrease anxiety.

Interpretation of Findings

• The expected reference range is 95% to 100%. Acceptable levels range from 91% to 100%. Some illness states can allow for 85% to 89%. Readings less than 90% reflect hypoxemia.

• Values can be slightly lower for older adult clients and clients who have dark skin.

• Additional reasons for low readings include hypothermia, poor peripheral blood flow, too much light (sun, infrared lamps), low hemoglobin levels, jaundice, movement, edema, metal studs in nails, and nail polish.

Oxygen therapy

Oxygen is a therapeutic gas that treats hypoxemia (low levels of arterial oxygen). Administering and adjusting it requires a prescription.

Indications

Manifestations of Hypoxia

Early

• Tachypnea

• Tachycardia

• Restlessness, anxiety, confusion

• Pale skin, mucous membranes

• Elevated blood pressure

• Use of accessory muscles, nasal flaring, adventitious lung sounds​​​​​​​

Late

• Stupor

• Cyanotic skin, mucous membranes

• Bradypnea

• Bradycardia

• Hypotension

• Cardiac dysrhythmias

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia?

Select all that apply.

A

Restlessness

B

Tachypnea

C

Bradycardia

D

Confusion

E

Hypertension

Submit

Considerations

Nursing Actions

• ​​​​​​​Monitor respiratory rate and pattern, level of consciousness, SpO₂, and arterial blood gases (ABGs).

• Provide oxygen therapy at the lowest liter flow that will correct hypoxia.

• Make sure the mask creates a secure seal over the nose and mouth.

• Assess/monitor hypoxia and hypercarbia (elevated levels of CO₂): restlessness, hypertension, and headache.

• Auscultate the lungs for breath sounds and adventitious sounds (crackles and wheezes).

• Assess/monitor oxygenation status with pulse oximetry and ABGs.

• Promote oral hygiene.

• Encourage turning, coughing, deep breathing, and the use of incentive spirometry and suctioning.

• Promote rest and decrease environmental stimuli.

• Provide emotional support.

• Assess nutritional status. Provide supplements.

• Assess skin integrity. Provide moisture and pressure-relief devices.

• Assess and document the response to oxygen therapy.

• Titrate oxygen to maintain the recommended oxygen saturation.

• Discontinue supplemental oxygen gradually.

• Monitor for respiratory depression (decreased respiratory rate and level of consciousness).

• Low-flow oxygen delivery systems deliver varying amounts of oxygen based on the delivery method and the client’s breathing pattern.

Nasal Cannula

Simple Mask

Venturi Mask

Non-Rebreather Mask

Face Tent

Low-Flow Oxygen Delivery Systems

Nasal Cannula

Tubing with two small prongs for insertion into the nares

Fraction of inspired oxygen: Delivers an FiO₂ of 24% to 44% at a flow rate of 1 to 6 L/min.

Advantages

• A cannula is a safe, simple, and easy-to-apply method.

• A cannula is comfortable and well-tolerated.

• The client is able to eat, talk, and ambulate.

Disadvantages

• The FiO₂ varies with the flow rate, and the rate and depth of the client’s breathing.

• Extended use can lead to skin breakdown and dry mucous membranes.

• Tubing is easily dislodged.​​​​​​​

Nursing Actions

• Assess the patency of the nares.

• Ensure that the prongs fit in the nares properly.

• Use water-soluble gel to prevent dry nares.

• Provide humidification for flow rates of 4 L/min and greater.

Simple Face Mask

Covers the client’s nose and mouth

Fraction of Inspired Oxygen

• It delivers an FiO₂ of 35% to 60% at flow rates of 5 to 10 L/min.

• The minimum flow rate is 5 L/min to ensure flushing of CO₂ from the mask.

Advantages

• A face mask is easy to apply and can be more comfortable than a nasal cannula.

• It is a simple delivery method.

• It is more comfortable than a nasal cannula.

• It provides humidified oxygen.

Disadvantages

• Flow rates less than 5 L/min can result in rebreathing of CO₂.

• Clients who have anxiety or claustrophobia do not tolerate it well.

• Eating, drinking, and talking are impaired.

• Moisture and pressure can collect under the mask and cause skin breakdown.

• Face masks pose a greater risk of aspiration.

Nursing Actions

• Assess proper fit to ensure a secure seal over the nose and mouth.

• Make sure the client wears a nasal cannula during meals.

• Use with caution for clients who have a high risk of aspiration or airway obstruction.

• Monitor for skin breakdown.

Partial Rebreather Mask

Covers the client’s nose and mouth

Fraction of inspired oxygen: Delivers an FiO₂ of 60% to 90% at flow rates of 10 to 15 L/min.

Advantages

• The mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to ⅓ of exhaled air together with room air.

• Allows easier humidification of oxygen.

Disadvantages

• Complete deflation of the reservoir bag during inspiration causes CO₂ buildup.

• The FiO₂ varies with the client’s breathing pattern.

• Clients who have anxiety or claustrophobia do not tolerate it well.

• Eating, drinking, and talking are impaired.

• The bag can twist or kink easily.

Nursing Actions

• Keep the reservoir bag from deflating by adjusting the oxygen flow rate to keep the reservoir bag ⅓ to ½ full on inspiration.

• Assess proper fit to ensure a secure seal over nose and mouth. Assess for skin breakdown beneath the edges of the mask and bridge of the nose.

• Make sure the client uses a nasal cannula during meals.

• Use with caution for clients who have a high risk of aspiration or airway obstruction.

Non-rebreather Mask​​​​​​​

Covers the client’s nose and mouth

Fraction of inspired oxygen: Delivers an FiO₂ of 80% to 95% at flow rates of 10 to 15 L/min to keep the reservoir bag ⅔ full during inspiration and expiration.

Advantages

• It delivers the highest O₂ concentration possible (except for intubation).

• A one-way valve situated between the mask and reservoir allows the client to inhale maximum O₂ from the reservoir bag. The two exhalation ports have flaps covering them that prevent room air from entering the mask.

Disadvantages

• The valve and flap on the mask must be intact and functional during each breath.

• It is poorly tolerated by clients who have anxiety or claustrophobia.

• Eating, drinking, and talking are impaired.

• Use with caution for clients who have a high risk of aspiration or airway obstruction.

Nursing Actions

• Perform an hourly assessment of the valve and flap.

• Assess proper fit to ensure a secure seal over the nose and mouth. Assess for skin breakdown beneath the edges of the mask and bridge of nose.

• Make sure the client uses a nasal cannula during meals.

High-Flow Oxygen Delivery Systems

Venturi Mask

Covers the client’s nose and mouth

Fraction of inspired oxygen: Delivers an FiO₂ of 24% to 60% at flow rates of 4 to 15 L/min via different size adapters, which allows specific amounts of air to mix with oxygen.

Advantages

• It delivers the most precise oxygen concentration with humidity added.

• Best for clients who have chronic lung disease.

Disadvantages

• Use is expensive.

• Eating, drinking, and talking are impaired.

• The mask and added humidity can lead to skin breakdown.

Nursing Actions

• Assess frequently to ensure an accurate flow rate.

• Assess proper fit to ensure a secure seal over the nose and mouth. Assess for skin breakdown beneath the edges of the mask, particularly on the nares.

• Make sure the tubing is free of kinks.

• Ensure that the client wears a nasal cannula during meals.

Aerosol Mask

Face tent: fits loosely around the face and neck

Tracheostomy collar: a small mask that covers the surgically created opening of the trachea

Fraction of Inspired Oxygen

• Delivers an FiO₂ of 24% to 100% at flow rates of at least 10 L/min.

• Provides high humidification with oxygen delivery.

Advantages

• Use with clients who do not tolerate masks well.

• Useful for clients who have facial trauma, burns, and thick secretions.

Disadvantages: High humidification requires frequent monitoring.

Nursing Actions

• Empty condensation from the tubing often.

• Ensure adequate water in the humidification canister.

• Ensure that the aerosol mist leaves from the vents during inspiration and expiration

• Make sure the tubing does not pull on the tracheostomy.

Complications

Oxygen Toxicity

Oxygen toxicity can result from high concentrations of oxygen (typically greater than 50%), long durations of oxygen therapy (typically more than 24 to 48 hr), and the severity of lung disease.

Manifestations: Nonproductive cough, substernal pain, nausea, vomiting, fatigue, dyspnea, restlessness, paresthesias

Nursing Actions

• Use the lowest level of oxygen necessary to maintain an adequate SpO₂.

• Monitor ABGs and notify the provider if SpO₂ levels are outside the expected reference range.

• Decrease the FiO₂ as the client’s SpO₂ improves.

Oxygen-induced Hypoventilation

Clients who have conditions that cause alveolar hypoventilation can be sensitive to the administration of oxygen.

Nursing Actions

• Monitor respiratory rate and pattern, level of consciousness, behavior, and SpO₂.

• Provide oxygen therapy at the lowest liter flow rate that manages hypoxemia.

• If the client tolerates it, use a Venturi mask to deliver precise oxygen levels.

• Notify the provider of impending respiratory depression (a decreased respiratory rate and a decreased level of consciousness).

Combustion

Oxygen is combustible.

Nursing Actions

• Post “No Smoking” or “Oxygen in Use” signs to alert others of the fire hazard.

• Know where to find the closest fire extinguisher.

• Educate about the fire hazard of smoking with oxygen use.

• Have clients wear a cotton gown because synthetic or wool fabrics can generate static electricity.

• Ensure that all electric devices (razors, hearing aids, radios) are working well.

• Make sure all electric machinery (monitors, suction machines) is grounded.

• Do not use volatile, flammable materials (alcohol, acetone) near clients receiving oxygen.

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions?

Select all that apply.

A

​​​​​​Apply petroleum jelly around and inside the nares.

B

Remove the nasal cannula during mealtimes.

C

Check the position of the cannula frequently.

D

Report any nausea or difficulty breathing.

E

Post "No Smoking" signs in prominent locations.

Submit

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse’s priority?

A

Increase the oxygen flow.

B

Assist the client to Fowler's position.

C

Promote removal of pulmonary secretions.

D

Obtain a specimen for arterial blood gases.

Submit

Airway clearance

Mucosal secretion buildup or aspiration of emesis can obstruct a client’s airway.

• Adequate hydration and coughing help the client maintain airway patency.

• Nursing interventions that mobilize secretions and maintain airway patency include assistance with coughing, hydration, positioning, humidification, nebulizer therapy, chest physiotherapy, and suctioning.

• These interventions promote adequate gas exchange and lung expansion.

Indications

Clients at risk for developing airway compromise: infants, clients who have neuromuscular disorders, clients who are quadriplegic, clients who have cystic fibrosis

Indications that clients need help maintaining airway clearance: hypoxia (restlessness, irritability, tachypnea, tachycardia, cyanosis, decreased level of consciousness, decreased SpO₂ levels), adventitious breath sounds, visible secretions, absence of spontaneous cough

Considerations

• Humidification of oxygen moistens the airways, which loosens and mobilizes pulmonary secretions.

• Nebulization breaks up medications (bronchodilators, mucolytic agents) into minute particles that disperse throughout the respiratory tract and improves clearance of pulmonary secretions.

• Chest physiotherapy involves the use of chest percussion, vibration, and postural drainage to help mobilize secretions. Chest percussion and vibration facilitate movement of secretions into the central airways. For postural drainage, one or more positions allow gravity to assist with the removal of secretions from specific areas of the lung.

• Early-morning postural drainage mobilizes secretions that have accumulated through the night.

Nursing Actions

• Whenever possible, encourage coughing. Coughing is more effective than artificial suctioning at moving secretions into the upper trachea and laryngopharynx.

• Suction orally, nasally, or endotracheally, not routinely but only when clients need it.

• Maintain surgical asepsis when performing any form of tracheal suctioning to avoid bacterial contamination of the airway.

Sputum specimen collection

Collection of sputum for analysis

Indications

• For cytology to identify aberrant cells or cancer

• For culture and sensitivity to grow and identify micro-organisms and the antibiotics effective against them

• To identify acid-fast bacilli (AFB) to diagnose tuberculosis (requires three consecutive morning samples)

Considerations

Nursing Actions

• Obtain specimens early in the morning.

• Wait 1 to 2 hr after the client eats to obtain a specimen to decrease the likelihood of emesis or aspiration.

• Perform chest physiotherapy to help mobilize secretions.

• Use a sterile specimen container, a label, a laboratory requisition slip, a biohazard bag for delivery of the specimen to the laboratory, clean gloves, and a mask and goggles if necessary.

• Use a container with a preservative to obtain a specimen for cytology.

• Use a sterile container for routine cultures and AFB testing.

• Collect sputum specimens by suctioning during coughing.

• If a client cannot cough effectively and expectorate sputum into the container, collect the specimen by endotracheal suctioning.

• Older adult clients have a weak cough reflex and decreased muscle strength, making it difficult for them to expectorate. They can require suctioning for sputum specimen collection.

Interpretation of Findings

• Presence of micro-organisms indicating infection

• Presence of cancer cells

Chest physiotherapy

• The use of a set of techniques that loosen respiratory secretions and move them into the central airways where coughing or suctioning can remove them

• For clients who have thick secretions and are unable to clear their airways

• Contraindicated for clients who are pregnant; have a rib, chest, head, or neck injury; have increased intracranial pressure; have had recent abdominal surgery; have a pulmonary embolism; or have bleeding disorders or osteoporosis

Percussion: the use of cupped hands to clap rhythmically on the chest to break up secretions

Vibration: the use of a shaking movement during exhalation to help remove secretions

Postural drainage: the use of various positions to allow secretions to drain by gravity

Considerations

Nursing Actions

• Schedule treatments 1 hr before or 2 hr after meals, and at bedtime to decrease the likelihood of vomiting or aspirating.

• Administer a bronchodilator medication or nebulizer treatment 30 min to 1 hr prior to postural drainage.

• Offer the client an emesis basin and facial tissues.

• Apply manual percussion to the chest wall using cupped hands or a specific device.

• Place hands on the affected area, tense hand and arm muscles, and move the heel of the hands to create vibrations as the client exhales. Have the client cough after each set of vibrations.

• Have the client remain in each position for 10 to 15 min to allow time for percussion, vibration, and postural drainage.

• Discontinue the procedure if the client reports faintness or dizziness.

• Note that older adult clients have decreased respiratory muscle strength and chest wall compliance, which puts them at risk for aspiration. They require more frequent position changes and other interventions to promote mobility of secretions.

Positioning: Ensure proper positioning to promote drainage of specific areas of the lungs.

• Both lobes in general: high Fowler’s

• Apical segments of both lobes: sitting on the side of the bed

• Right upper lobe, anterior segment: supine with head elevation

• Right upper lobe, posterior segment: on the left side with a pillow under the right side of the chest

• Right middle lobe, anterior segment: three-quarters supine with dependent lung in Trendelenburg

• Right middle lobe, posterior segment: prone with thorax and abdomen elevation

• Right lower lobe, lateral segment: on the left side in Trendelenburg

• Left upper lobe, anterior segment: supine with head elevation

• Left upper lobe, posterior segment: on the right side with a pillow under the left side of the chest

• Left lower lobe, lateral segment: on the right side in Trendelenburg

• Both lower lobes, anterior segments: supine in Trendelenburg

• Both lower lobes, posterior segments: prone in Trendelenburg

Suctioning

Suction orally, nasally, or endotracheally when clients have early signs of hypoxemia (restlessness, confusion, tachypnea, tachycardia, decreased SpO₂ levels, adventitious breath sounds, audible or visible secretions, cyanosis, and absence of spontaneous cough).

Tracheal Suctioning

Considerations

Nursing Actions

• Don the required personal protective equipment.

• Assist the client to high-Fowler’s or Fowler’s position for suctioning if possible.

• Encourage the client to breathe deeply and cough in an attempt to clear the secretions without artificial suction.

• Obtain baseline breath sounds and vital signs, including SaO₂ by pulse oximeter. Can monitor SaO₂ continually during the procedure.

• For oropharyngeal suctioning, use a Yankauer or tonsil-tipped rigid suction catheter and move the catheter around the mouth, gum line, and pharynx.

• For nasopharyngeal and nasotracheal suctioning, use a flexible catheter and lubricate the distal 6 to 8 cm (2 to 3 in) with water-soluble lubricant.

• For endotracheal suctioning, use a suction catheter. The catheter should not exceed one half of the internal diameter of the endotracheal tube to prevent hypoxia. The nurse should use no larger than a 16 French suction catheter when suctioning an 8 mm endotracheal tube or tracheostomy tube. Hyperoxygenate the client using a bag-valve-mask (BVM) or specialized ventilator function with an FiO₂ of 100%.

• Use medical asepsis for suctioning the mouth.

• Use surgical asepsis for all other types of suctioning.

• Use suction pressure no higher than 120 to 150 mm Hg.

• Limit each suction attempt to no longer than 10 to 15 seconds to avoid hypoxemia and the vagal response. Repeat suctioning if needed. Limit total suctioning time to 5 min.

Additional Guidelines for Nasopharyngeal and Nasotracheal Suctioning

• Insert the catheter into the naris during inhalation.

• Do not apply suction while inserting the catheter.

• Follow the natural course of the naris and slightly slant the catheter downward while advancing it.

• Advance the catheter 15 to 20 cm (6 to 8 in).

• Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds.

• Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger.

• Do not perform more than two passes with the catheter. Allow at least 1 min between passes for ventilation and oxygenation.

Additional Guidelines for Endotracheal Suctioning

• Remove the bag or ventilator from the tracheostomy or endotracheal tube and insert the catheter into the lumen of the airway. Advance the catheter until resistance is met. The catheter should reach the level of the carina (location of bifurcation into the mainstem bronchi).

• Pull the catheter back 1 cm (0.4 in) prior to applying suction to prevent mucosal damage.

• Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds.

• Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger.

• Reattach the BVM or ventilator and administer 100% oxygen.

• Rinse catheter and suction tubing with sterile saline until clear.

• Do not reuse the suction catheter for subsequent suctioning sessions.​​​​​​​

A nurse is preparing to perform endotracheal suctioning for a client. Please place the following actions in the proper order.

​​Remove the bag or ventilator from the tracheostomy or endotracheal tube and insert the catheter into the lumen of the airway. Advance the catheter until resistance is met. The catheter should reach the level of the carina (location of bifurcation into the mainstem bronchi).

Don the required personal protective equipment.

Reattach the BVM or ventilator and administer 100% oxygen.

Assist the client to high-Fowler’s or Fowler’s position for suctioning if possible.

Pull the catheter back 1 cm (0.4 in) prior to applying suction.

Apply suction intermittently by covering and releasing the suction port with the thumb for 10-15 seconds.

Rinse catheter and suction tubing with sterile saline until clear.

Encourage the client to breathe deeply and cough in an attempt to clear the secretions without artificial suction.

Artificial airways and tracheostomy care

A tracheotomy is a sterile surgical incision into the trachea through the skin and muscles for the purpose of establishing an airway.

• A tracheotomy can be an emergency or a scheduled surgical procedure; it can be temporary or permanent.

• A tracheostomy is the stoma/opening that results from a tracheotomy to provide and secure a patent airway.

• Artificial airways can be placed orotracheally, nasotracheally, or through a tracheostomy to assist with respiration.

• Tracheostomy tubes vary in their composition (plastic, steel, silicone), number of parts, size (long vs. short), and shape (50° to 90° angles).

• There is no standard tracheostomy sizing system. However, the diameter of the tracheostomy tube must be smaller than the trachea.

• The outside cannula has a flange or neck plate that sits against the skin of the neck and has holes on each side for attaching ties around the neck to stabilize the tracheostomy tube.

• Airflow in and out of a tracheostomy without air leakage (a cuffed tracheostomy tube) bypasses the vocal cords, resulting in an inability to produce sound or speech.

• Uncuffed tubes and fenestrated tubes, in place or capped, allow speech. Clients who have a cuffed tube can be off mechanical ventilation, can breathe around the tube, and can use a specific valve to allow for speech. The cuff is deflated and the valve occludes the opening.

• Indications for a tracheostomy include acute or chronic upper airway obstruction, edema, anaphylaxis, burns, trauma, head/neck surgery, copious secretions, obstructive sleep apnea refractory to conventional therapy, and the need for long-term mechanical ventilation or reconstruction after laryngeal trauma or laryngeal cancer surgery.

Artificial Airway Tube Types

Single-lumen (Cannula)

• Long, single-cannula tube

• For clients who have long or thick necks

Nursing Actions: Do not use with clients who have excessive secretions. 

Double-lumen (Cannula)

• An outer cannula fits into the stoma and keeps the airway open.

• An inner cannula fits snugly into the outer cannula and locks into place.

• An obturator is a thin, solid tube the provider places inside the tracheostomy and uses as a guide for inserting the outer cannula, and removes immediately after outer cannula insertion.

• This device allows removing, cleaning, reusing, discarding, and replacing the inner cannula with a disposable inner cannula.

• It is useful for clients who have excessive secretions.

Cuffed Tube

It has a balloon that inflates around the outside of the distal segment of the tube to protect the lower airway by producing a seal between the upper and lower airway.

​​​​​​​Nursing Actions

• A cuffed tube permits mechanical ventilation.

• A cuffed tube prevents aspiration of oropharyngeal secretions.

• Cuffs do not hold the tube in place.

• Cuff pressures must be monitored to prevent tracheal tissue necrosis.

• The client is unable to speak.

• Children do not require a cuffed tube.

Cuffless Tube

It has no balloon and is for clients who have long-term airway-management needs.

Nursing Actions

• The client must be at low risk for aspiration.

• Cuffless tubes are not for clients receiving mechanical ventilation.

• This device allows the client to speak.

Fenestrated Tube with a Cuff

• It has one large or multiple openings (fenestrations) in the posterior wall of the outer cannula with a balloon around the outside of the distal segment of the tube.

• It also has an inner cannula.

Nursing Actions

• This device allows for mechanical ventilation.

• Removing the inner cannula allows the fenestrations to permit air to flow through the openings.

• This device allows the client to speak.

Fenestrated Tube without a Cuff

• It has one larger or multiple openings (fenestrations) in the posterior wall of the outer cannula with no balloon.

• It also has an inner cannula.

Nursing Actions

• The holes in the tube help wean the client from the tracheostomy.

• Removing the inner cannula allows the fenestrations to permit air to flow through the openings.

• This device allows the client to speak.

Considerations

Nursing Actions

• Keep the following at the bedside: two extra tracheostomy tubes (one the client’s size and one size smaller, in case of accidental decannulation), the obturator for the existing tube, an oxygen source, suction catheters and a suction source, and a BVM.

• Provide methods to communicate with staff (paper and pen, dry-erase board).

• Provide an emergency call system and a call light.

• Provide adequate humidification and hydration to thin secretions and reduce the risk of mucous plugs.

• Give oral care every 2 hr.

• Provide tracheostomy care every 8 hr to reduce the risk of infection and skin breakdown.

  • Suction the tracheostomy tube, if necessary, using sterile suctioning supplies.

  • Apply the oxygen source loosely if the client’s SpO₂ decreases during the procedure.

  • Use surgical asepsis to remove and clean the inner cannula (with the facility-approved solution). Use a new inner cannula if it is disposable.

  • Remove soiled dressings and excess secretions.

  • Clean the stoma site and then the tracheostomy plate.

  • Place a fresh split-gauze tracheostomy dressing of nonraveling material under and around the tracheostomy holder and plate.

  • Replace tracheostomy ties if they are wet or soiled. Secure the new ties before removing the soiled ones to prevent accidental decannulation.

  • If a knot is needed, tie a square knot that is visible on the side of the neck. Check that one or two fingers fit between the tie and the neck.

• Change nondisposable tracheostomy tubes every 6 to 8 weeks or per protocol.

• Reposition the client every 2 hr to prevent atelectasis and pneumonia.

• Minimize dust in the room. Do not shake bedding.

• If the client is permitted to eat, position them upright and tip the chin to the chest to enable swallowing. Assess for aspiration.

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?

Select all that apply.

A

Apply the oxygen source loosely if the SpO2 decreases during the procedure.

B

Use surgical asepsis to remove and clean the inner cannula.

C

Clean the outer cannula surfaces in a circular motion from the stoma site outward.

D

Replace the tracheostomy ties with new ties.

E

Cut a slit in gauze squares to place beneath the tube holder.

Submit

Complications

Accidental Decannulation

Accidental decannulation within the first 72 hr after surgery is an emergency because the tracheostomy tract has not matured, and replacement can be difficult.

Ventilate the client with a BVM. Call for assistance.

Nursing Actions

• Always keep the tracheostomy obturator and two spare tracheostomy tubes at the bedside.

• If unable to replace the tracheostomy tube, administer oxygen through the stoma. If unable to administer oxygen through the stoma, occlude the stoma and administer oxygen through the nose and mouth, except for clients who have had a laryngectomy.

If accidental decannulation occurs after the first 72 hr

• Immediately hyperextend the neck and with the obturator inserted into the tracheostomy tube, quickly and gently replace the tube, and remove the obturator.

• Secure the tube.

• Assess tube placement by auscultating for bilateral breath sounds.

Damage to the Trachea

Tracheal stenosis: Narrowing of the tracheal lumen due to scar formation resulting from irritation of the tracheal mucosa from the tracheal tube cuff.

Nursing Actions

• Keep the cuff pressure between 14 and 20 mm Hg.

• Check the cuff pressure at least once every 8 hr.

• Keep the tube in the midline position and prevent pulling or traction on the tracheostomy tube.

Tracheal wall necrosis: Tissue damage that results when the pressure of the inflated cuff impairs blood flow to the tracheal wall.