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suctioning

suctioning

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Published by khem0205

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Published by: khem0205 on Apr 17, 2010
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02/22/2014

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 a.s.b.0205
Respiratory System
 
I.
 
Review of Anatomy and Physiology
y
 
 N
ose ± filters impurities, humidifies andwarms the air 
y
 
 N
asal cavity ± passageway of air 
y
 
Paranasal sinuses ± lightens the weight of theskull; resonating chambers of speech
y
 
T
urbinates (Conchae) ± warms and humidifiesair; contains nerves that detect odors andinitiates
 sneezing reflex
(C
 N1
)
y
 
Pharynx ± serves as passageway of food,water, air 
y
 
E
 piglottis ± flap-like cover during theswallowing to avoid foreign objects fromgetting into the lungs
y
 
L
arynx ± voice box; initiates the
cou
 gh reflex
 
y
 
T
rachea ± has cricoids process; enclosesthyroid and parathyroid gland
y
 
L
ungs ± inspiration and respiration site
y
 
M
ediastinum ± allow fu
 
ll expansion of thelungs
y
 
B
ronchia
y
 
M
ainstream bronchi
y
 
L
obar bronchi
y
 
S
egmental bronchi
y
 
S
ubsegmental bronchi ± keep moisture inlungs and prevents excessive liquidaccumulation
y
 
B
ronchioles
y
 
T
erminal bronchioles
y
 
Respiratory bronchioles ± serves astransitional passageway to the alveoli
y
 
Alveoli ± site of gas exchange
o
 
T
ype
1
± made-up of epithelial cellsthat provide structure
o
 
T
ype 2 ± metabolically active cellsthat produce surfactant
o
 
T
ype 3 ± macrophages that engulfsforeign bodiesII.
 
Functions of Respiratory
S
ystem
1
. Oxygen transport2. Respiration3. Ventilation4. Perfusion5. Diffusion6. Gas exchange7. Acid-base balanceIII.
 
B
reathing
E
xercisesPurposes:
1
.
 
Promote maximal alveolar inflation2.
 
Promote muscle relaxation3.
 
Relieves anxiety4.
 
E
liminate ineffective uncoordinated patternsof respiration and slow down respiratory rate5.
 
Decrease work of breathingInstructions:
1
.
 
B
reathe slowly and rhythmically, and emptylungs completely2.
 
Inhale through the nose and exhale through themouth3.
 
Keep air moist with humidifier 
T
echniques:
1
.
 
Diaphragmatic
B
reathing
y
 
strengthens diaphragm during breathing
y
 
indicated to client with pulmonarydisease, COPD, postoperative, paincontrol2.
 
Pursed-lip
B
reathing
y
 
same with diaphragmatic breathing
y
 
 prolonged exhalation time
y
 
increase airway pressure during expirationthus reducing amount of trap air in thelungsIV.
 
Coughing
E
xercisePurposes:
1
.
 
Remove secretions in the lungs2.
 
Active contraction of expiratory muscles3.
 
Opens glottis to provide momentum onexpectoration
T
echniques:
1
.
 
Cascade
y
 
to clear large amount of sputum2.
 
Huff 
y
 
to stimulate natural cough reflex
y
 
effective in clearing central airways3.
 
Quad
y
 
most brutal
 
 a.s.b.0205
y
 
contraindicated to those with involuntarycontrolV.
 
Chest Physiotherapy
y
 
Group of therapies used in combination tomobilize pulmonary secretions
y
 
Includes postural drainage, chest vibration,and chest percussion
y
 
Generally indicated to client who can produce productive cough (30m
L
)
y
 
Contraindications:
o
 
 patients with trauma in chests
o
 
conditions or diseases related tochildhood
o
 
those with spinal injury
o
 
those who are mentally challenged
y
 
 N
ursing Considerations:
o
 
assess vital signs
o
 
know medications used by the patient
o
 
client¶s tolerance to position
o
 
assess energy level of patientVI.
 
Incentive
S
 pirometry (
S
ustained
M
aximalInspiration)
y
 
method of encouraging voluntary deep breathing by providing visual feedback onclient about their inspiratory volume
y
 
 prevent and treat atelectasis
y
 
 promote maximal lung inflationVII.
 
Oxygen
T
herapy
y
 
Administration of oxygen greater than what isfound in the environment
y
 
Indications:
o
 
Change in client¶s respiratory rate and pattern
o
 
Hypoxemia
o
 
Hypoxia
y
 
Complications:
o
 
Oxygen toxicity which causesuppression of ventilation
o
 
Potential source of infection
o
 
S
upports combustions
y
 
 N
ursing Consideration:
o
 
 N
o smoking sign
o
 
Orient visitors/relatives about precaution
o
 
Assess all electrical equipments
o
 
L
ocate all close fire extinguishers
o
 
Orient client and relatives about fire procedure and evacuation area
o
 
U
se cotton instead of synthetic fiber for linens and clothing
o
 
Do not use alcohol in cleaning theoxygen tank 
o
 
S
oil is the most effective fireextinguisher VIII.
 
S
uctioning
y
 
aspiration of secretions through a catheter connected to a suctioning machine or wallsuction outlet
y
 
Purposes:
o
 
to remove secretions
o
 
facilitate ventilation
o
 
obtain secretions for diagnostic procedures
o
 
to prevent infection
y
 
Assessment Parameters:
o
 
signs and symptoms of restlessness
o
 
gurgling sounds during respiration
o
 
adventitious breath sounds uponauscultation
o
 
change in skin color 
o
 
change in respiratory rate and pattern
o
 
change in pulse rate and rhythm
y
 
Principles:
o
 
M
aintain sterile technique
o
 
Dominant hand is always sterile; other hand is clean
o
 
E
ntire suctioning procedure shouldonly last less than 2 minutes
o
 
S
uctioning attempt should only last
1
0-
1
5 seconds
o
 
Hyperoxygenate patient before andafter each suctioning attempt
o
 
Insert catheter during inhalation
o
 
S
uction patient intermittently
o
 
Allow 30 seconds interval in betweensuctioning attempt
o
 
U
se separate suction catheter for eachairway to be suctioned
o
 
Do not apply suction upon insertionof catheter 
y
 
E
quipments:
o
 
S
uction catheter 
 
Adults: French
1
2-
18
 
 
 a.s.b.0205
 
Children: French
8
-
1
0
 
Infants: French 5-
8
 
o
 
S
uction machine
o
 
Ovum forceps
o
 
 N
SS
solution/sterile water 
o
 
T
owel
o
 
2 sterile basin
o
 
2 sterile gloves
o
 
S
tethoscope
o
 
Penlight
y
 
Procedure:
1
.
 
Verify doctor¶s order a.
 
S
ize of catheter  b.
 
T
ype of solutionc.
 
Airway to be suctionedd.
 
Pressure to be used2.
 
Go to patient¶s room3.
 
E
stablish rapport4.
 
Assess need for suctioning5.
 
Assess patency of nares6.
 
Wash hands7.
 
Prepare equipments
8
.
 
Provide comfort, privacy, and safety to client9.
 
Position clientConscious: sitting, semi/high fowler¶s
U
nconscious: side lying
1
0.
 
Put towel
11
.
 
Open sterile equipments and attach to whereclosest to the client
1
2.
 
Indicate date and time opened
1
3.
 
Open sterile basin
1
4.
 
Put
 N
SS
solution/sterile water 
18
inches above basin
1
5.
 
T
est suction machine
1
6.
 
Don gloving
1
7.
 
Hyperoxygenate client
18
.
 
Ask client to inhale deeply then insert catheter 
1
9.
 
S
uction20.
 
Reassess clienta.
 
S
ecretions on mouth or nose? b.
 
How do you feel right now?2
1
.
 
After care22.
 
Hand wash23.
 
Documentationa.
 
U
ntoward reaction of client during the procedure b.
 
Characteristic of secretionc.
 
Duration of suctioningIX.
 
T
racheostomy Care
y
 
care given to patient with tracheostomy tube
y
 
Purposes:
o
 
M
aintain airway patency
o
 
M
aintain cleanliness and preventinfection
o
 
T
o clean stoma and promote healing
o
 
T
o provide comfort
y
 
Assessment Parameters:
o
 
Respiration status
o
 
Characteristic and amount of secretions
o
 
Presence of drainage
 
Palpate nape of client
 
L
ook at tracheostomy site
o
 
Appearance of stoma
o
 
If pilot balloon is inflated
y
 
Principles:
o
 
M
aintain sterile technique
o
 
Pilot balloon should be inflated
y
 
E
quipments:
o
 
 N
SS
solution
o
 
Hydrogen peroxide
o
 
T
owel
o
 
2 4´x4´ gauze
o
 
S
terile gloves
o
 
T
emporary canula
o
 
T
rachesotomy brush
o
 
2 medicine glass
o
 
2 basin
o
 
T
racheostomy tie (should not beelastic)
o
 
Cotton applicators
y
 
Procedure
1
.
 
Verify doctor¶s order a.
 
S
olution to be used2.
 
E
stablish rapport3.
 
Assess respiratory rate and pattern4.
 
Prepare equipmentsPortable
U
nit Wall
S
uction OutletAdult
1
0-
1
5 mmHg
1
00-
1
20 mmHgChildren 5-
1
0 mmHg 95-
11
0 mmHgInfant 2-5 mmHg 50-95 mmHg

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