ABG’s

Abnormal Respiratory Assessment

Findings
Case Studies
Diagnostic Tests
Respiratory Modalities
 Pulmonary assessment

What types of patients are at risk for

pulmonary disease?

What occupations & behaviors increase the

risk of pulmonary disease?

Weight, neck size and history of OSA?

 Cough
Most common symptom of respiratory dz

Nonproductive cough: usually not a bacterial or

viral problem

White & clear sputum is usually not bacterial

Mucoid and blood streaked = viral

 Sputum
Rusty, green or yellow: Bacterial

Pink & Frothy: p. edema

Bloody: Cancer, lung abscess, TB, p.

embolus

Large amounts of bloody clots: p.

infarction
 Chest Pain
Have patient stop any strenuous activity, sit
down

Place oxygen on the patient & assess the

pain, take vs & O2 sat

What would make you think it is pleuritic in

nature?
 Pleurisy
Abrupt onset at the site of inflammation

Well localized

Cutting, sharp pain

Increases with cough, breathing & sneezing

Splinting may decrease the pain

 Inspection
Peripheral cyanosis is unreliable:

WHY?

Vasoconstriction from the cold

Dependent extremity
Reduced blood flow
Elevated hemoglobin levels
Peripheral cyanosis
 Thoracic Configuration
Abnormal chest configuration tells you:

1. Patient has other underlying health issues

2. Patient is at greater risk of developing

pulmonary complications

3. Care with high levels of O2 in these patients!!

 Respirations
A very sensitive indicator of patient’s
condition

Tachypnea: hypoxia, pain, anxiety, fear,

fever, metabolic acidosis

Bradypnea: drugs, respiratory center

depression, metabolic alkalosis, loss of
hypoxic drive in patients who are chronic
CO2 retainers
 Respirations
Shallow: pain, ascites, pregnancy,
abdominal distention, depressed
respiratory center

Deep: DKA, sleep, neurological disorders

Irregular: metabolic or neurological

disorders
 Dyspnea

SOB

Paroxysmal nocturnal dyspnea (PND)

Orthopnea

Are they SOB at rest, talking, walking or

running?
 Work Of Breathing (WOB)
When does dyspnea occur (Running, rest)?

What accessory muscles does the patient

use?
Abdominal
Sternoclaidomastoids
Intercostals

Nasal flaring? Pursed lips?

 Neck & Teeth
Neck size > 17”

Top overbite =
underdeveloped
chin/mandible
 Trachea Midline
Occurs in pleural effusion, atelectasis,
pneumo/hemothorax

Important to assess in ventilator, COPD and

trauma patients

& great vessels are shifting also

 Palpation
Tactile fremitus: “99” vibration should be felt
over entire chest but greatest in the major
airways

in pneumonia

with airway obstruction/blockage

 Pain & tenderness
Assess when pt c/o CP, especially if it
increases on inspiration

Palpate gently

May indicate rib fractures in trauma pts

 Crepitus
Crackling sensation that occurs when air enters
the soft tissue of the chest

Indicates subcutaneous emphysema

Pneumothorax

If patient has a chest tube, remove dressing to

assure the tube is in the patient, re-dress and
then mark with ink around the crepitus, alert md
 Adventitious Lung Sounds
Crackles – inspiratory – fluid filled alveoli

Rhonchi – continuous – fluid in the larger airways- often clears

with cough & suctioning

Wheeze – inspiratory +/or expiratory – indicates

bronchoconstriction

Stridor - is a high pitched sound resulting from turbulent air flow in

the upper airway.
 Stridor
Inspiratory: laryngeal problem

Expiratory: lower airway problem

Both I & E: tracheal problem

Can be d/t: airway obstruction from epiglottitis, foreign

body, or layngeal tumor

Stridor is a 911 emergency!

Tx with nebulized racemic adrenaline or nebulized Cocaine

dexamethasone (Decadron)
inhaled Heliox (70% helium, 30% oxygen)
 Auscultation
Pleural friction rub: heard best on
inspiration, have patient hold breath to r/o
pericardial rub

Diminished throughout: shallow

respirations d/t pain, obesity, ascites, etc

Absent breath sounds: pneumothorax,

atelectasis, pleural effusion
 Oxygen Saturation
What is O2 saturation?

Is it always reliable?

What factors can affect it?

Can a patient be 100% saturated and still be

in trouble?
 Pulse oximetry
Used to assess trends. nl > 92%, with
anemia > 94%

Does not replace ABG’s

Unreliable in vasoconstriction, anemia,

polycythemia

Will drop with hypotension

 Oxygen Saturation
Dependent upon Hemoglobin levels

Hgb = O2 Sat

Hgb = O2 Sat

HIGH SATURATION DOES NOT MEAN

WELL OXYGENATED !!!!!
 Pulse Oximetry
You must know your
patient’s
hemoglobin level to
evaluate O2 sats !!!!!

And the amount of

O2 the patient is
receiving
 Arterial Blood Gases
Normal ABG’s:

pH = 7.35 – 7.45 PaCO2 = 35-45

HCO3 = 22 – 26 PaO2 = 80-100

You MUST know the % O2 the patient is on to

evaluate ABG’s !!!!!
 Respiratory
Determined by PaCO2 levels (normal =35-
45)

Hyperventilation ( RR) blows off CO2

thus lowering it (c/w respiratory
alkalosis)

Hypoventilation ( RR) causes CO2 to

be retained, thus increasing CO2 levels
(c/w respiratory acidosis)
 Metabolic
Bicarb = HCO3 = the metabolic component
(normal levels = 22-26)

Too much HCO3 or too little acid is c/w

metabolic alkalosis

Too little HCO3 or too much acid is c/w

metabolic acidosis
 Acid-base Imbalances

Uncompensated

Partially Compensated

Compensated
 Uncompensated
1. pH is abnormal

2. PaCO2 OR HCO3 abnormal

Example:
pH = 7.30, PaCO2 = 50, HCO3 = 26
 Partially Compensated

pH, PaCO2 & HCO3 are all abnormal

Example:
pH = 7.34, PaCO2 = 48, HCO3 = 30
 Compensated ABG
1. pH is normal

2. CO2 & HCO3 are abnormal

Example
pH 7.35, PaCO2 = 33, HCO3 = 20
 ROME
If the problem is respiratory, the pH and PaCO2
will go in opposite directions of each other

ie: Respiratory acidosis: pH = 7.29

PaCO2 = 58

Respiratory alkalosis: pH = 7.54

PaCO2 = 30
 ROME
If the problem is metabolic, the pH and HCO3 will go in
the same (equal) direction

ie Metabolic acidosis: pH = 7.31

HCO3 = 19

Metabolic alkalosis: pH = 7.51

HCO3 = 32
 Case Study One
History of Present Illness:

31 y/o female presents with c/o n,v,abdominal

pain.

Began 9 pm last evening.

No alleviating or aggravating factors

She has not had her insulin in several days

because “she can’t afford it”.
 Case Study One
Past Medical History: IDDM

Past Surgical History: None

Allergies: NKDA

Current Medications: Lantus insulin

 Case Study One
Vital Signs: T = 96.6

P = 119

RR = 40,

BP = 92/42

O2 Sat = 100% RA Pain = 8/10

 Case Study
Focused Assessment:

Abdomen:

Non-distended, soft with decreased BS x 4

Tender to palpation in the epigastric region and right

upper quadrant without rigidity, rebound or guarding.

No flank ecchymosis.
 Case Study One
What is the following Acid- pH 6.91
base imbalance?
PaCO2 29.2

PaO2 140
Why has it occurred?
HCO3 31.8
Is it compensated, partially
compensated or Hgb 13
uncompensated?
O2 Sat on 97%
28%
 Case Study One
Na 131 *

What is her anion K 6.8 *

Gap? Cl 98
CO2 5*

How does it affect Anion Gap

Treatment?
BUN 22 *
Cr 1.4 *
What treatment do
Gl 546 *
you expect her to
Ca 7.8 * (Albumin 4. 9)
receive?
PO4 1.4 *
Mg 1.7 *
 Anion Gap
Na – (Cl + CO2) = Anion gap

131 – (98 + 5) =

131 – 103 = 28

Anion gap is > 12

 Treatment
IVF

Insulin

NaHCO3
 What electrolyte imbalance is
due to the acid-base imbalance?

Acidosis increases serum ______

H+ in ___ out
Serum
Cell Serum
 Is she truly Hypocalcemic?
Her albumin level is WNL, however:

Acidosis increases ionized ______ and decreases serum ______.

H+ on serum____ off & it

Albumin
becomes ionized
_____
 Hypocalcemic?
When her acidosis is corrected, H+ will jump
off the albumin and ionized calcium will jump
on thus,

H+ Ionized Ca
Albumin

Increasing serum _____.

 HCO3 & CO2
Venous CO2 represents the arterial HCO3

Clinically, the venous CO2 value has little direct use

but when venous CO2 content is abnormal,

it should alert the clinician to the need for obtaining arterial blood
gas and pH values.
 Other Causes
Cardiac Arrest

Hypoperfusion

Renal Failure

Diarrhea

Starvation
 Compensatory Mechanisms
Rapid respirations (Kussmal’s)

Decreased PaCO2

Urine pH will decrease to < 6

Hyperkalemia & increased ionized Ca++

How quickly
will O2
be released
from Hgb
molecule ?
 O2 Dissociation
O2 will _____ off the hemoglobin molecule
in times of need such as:

Exercise Acidosis Fever

Increased CO2
 Possible Nursing Diagnoses
Decreased cardiac output

Risk for impaired sensory/perception

Risk for injury

Risk for fluid volume deficit

 Case Study 2
A 64 year old male

long flight from California to Ohio.

complaining of sudden onset of chest pain and

SOB

extremely anxious and afraid he is “going to die”.

also complaining of lightheadedness and

numbness and tingling in his extremities.
 Case Study 2
T = 99.2, HR = 121, RR = pH 7.51
38, BP = 156/88
PCO2 22
O2 Sat = 81%,
pain = 7/10
PO2 52
Hgb = 17
HCO3 26
Why is he anxious?
Activity level? O2 Sat 81% on
NRM
 Case Study 2
What is the initial concern and treatment for
a client with c/o CP and SOB?

What is this client’s Acid-base imbalance?

Is it compensated, partially compenstated

or uncompensated?

What medical problem do you suspect?

 Case Study 2
Why is the client c/o numbness and tingling?

H+ ions Albumin ionized

Ca
 Case Study 2
What other electrolyte problems may he
have and why?

H+ __
out Cell in
 Case Study 2

What treatment will this client require?

What other conditions can cause this acid-base

imbalance?
 Hemoglobin & O2 Sats
What effect will his Hgb of 17 have on his
O2 Saturations?
Cells = % Saturated with O2
 Possible Nursing Diagnoses
Impaired sensory/perception related to
neurological deficits
Impaired thought processes related to
altered cerebral functioning
Ineffective breathing pattern related to
hyperventilation
Risk for injury related to weakness, tetany
and seizures
 Case Study 3
54 year old male

2 PPD smoker with sleep apnea

Very anxious and SOB

Paramedics insert an IV catheter, place the client

on a 100% non-rebreather mask (NRM)

Upon arrival to the ED, he is no longer anxious but

appears sleepy.
 Case Study 3
T = 100.3, HR = 102, RR = 8, BP = 146/88
O2 Sat = 99%, pain = 0/10
pH 7.31
pCO2 92
pO2 131

HCO3 32
Hgb 17
O2Sat 99% on 100%
NRM
 Case Study 3
1. What is this client’s acid-base imbalance
and why did it occur?

2. How does a client with hypoxia act?

Hypercapnia?

3. Why would pulse oximetry be of limited

use in determining this client’s problem?

4. What actions should be taken?

 Case Study 3
Vasodilation: warm flushed skin, H/A, BP,
HR, papilledema

CO2 Narcosis: ALOC, drowsiness

progressing to coma, seizures

Acidosis: dysrhythmias, decreased CO

 Case Study 3
What other conditions can cause this problem?
COPD CNS depressants

Chest wall abnormalities

Pneumonia Atelectasis

Respiratory muscle weakness

Underventilation
 Possible Nursing Diagnoses
Ineffective breathing pattern: hypoventilation
Impaired gas exchange: alveolar
hypoventilation
Impaired sensory perception: acid-base
alterations
Anxiety: breathlessness
Risk for injury: ALOC
Risk for decreased cardiac output:
dysrhythmias
 Case Study 4
Mrs. C undergoes an open cholecystectomy

NGT to low wall suction with large amounts

of drainage.
pH 7.51
pCO2 46
pO2 96
HCO3 35
Hgb 9*
O2Sat 99% on RA
 Case Study 4
What is her acid-base imbalance and why has it
occurred?

What other electrolyte imbalance does she

probably have and how will this imbalance
contribute to her problem?

What type of fluid should the nurse flush an NGT

to LWS and why?

What is the best treatment to increase this client’s

peristalsis?
 Diffusion
H2O

K+ K+

Stomach
 Anemia
Falsely increases O2 saturations

Look for s/s hypoxia as O2 sats are unreliable in

anemia & polycythemia:

restlessness

confusion

dysrhythmias
 Other causes
Vomiting

Diuretic therapy

Hypokalemia

Licorice

Excessive antacids or mineralocorticoids (ie.

aldosterone)
 Clinical Manifestations
Compensatory: RR & urine pH > 6

CNS: Muscle cramps, hyperreflexia, tetany,

paresthesias, seizures

GI: anorexia, nausea, vomiting, paralytic

ileus
 Nursing Diagnoses
Deficient fluid volume: GI loss
Decreased CO: FVD & altered conduction
d/t hypokalemia & alkalosis
Knowledge deficit: potassium-wasting
diuretics & antacids
Risk for impaired gas exchange:
hypoventilation
Risk for injury: FVD
 Questions
Interventions to correct respiratory acidosis
would first include:

1. Administering morphine sulfate IVP

2. Giving sodium bicarbonate IV push
3. Increasing supplemental O2 levels
4. Correcting the cause of hypoventilation
 Question
Which of the following can cause a
respiratory alkalosis?

1. Oversedation
2. Heart rate < 60 bpm
3. Intractable pain
4. High PaO2
 Question
Which of the following ABG findings indicate
the presence of acute uncompensated
respiratory acidosis?

1. PCO2 increased, HCO3 normal

2. PCO2 decreased, HCO3 normal
3. PCO2 increased, HCO3 increased
4. PCO2 decreased, HCO3 decreased
 Question
Which of the following ABG findings is most
consistent with a metabolic acidosis?

1. Increased PCO2
2. Decreased PCO2
3. Increased HCO3
4. Decreased HCO3
 Question
ABG’s on a client with pneumonia indicate
the client is in respiratory acidosis. In
order to best improve this acid-base
imbalance, the nurse implements which of
the following interventions?

Select all that apply.

 Answers
1. Restrict oral fluid intake to H2O only

2. Ambulate client in the hall twice a shift

3. Assist the client to cough & deep breathe

4. Give a non-opiate pain med prn for intercostal

muscle pain

5. Give Magnesium rider IVPB

 CXR
Used to determine lung pathology & line
placement to r/o pneumothorax

Portable CXR can be done in emergency

conditions, pts with Chest tubes, etc

For excellent tutorials on diagnostic tests:

http://www.nlm.nih.gov/medlineplus/tutorials/
Normal
CXR
Acute
MVR
Right
pneumo
CHF
Pre-
tx
RML
Pneumonia
Lg Right
Pleural
effusion
Right
Hemo-
thorax
ARDS
CT Chest: w/wo contrast
 CT Scans
NPO 4 hours prior if possible*

Assess Patient’s ability to cooperate & lie

flat for the procedure

May require IV contrast

Be alert to allergies & pts with HTN & DM

Bronchoscopy: Tumor
 Pre-procedure
Obtain signed consent

Postural drainage

Sedation if ordered
 Patient Teaching
Pre-procedure:
NPO 6-12 hr
Hold anticoagulants, anti-plt meds*
Alert MD to any allergies, pregnancy

Procedure:
Local anesthetic & sedation
Slow, deep breaths
Make high pitched sounds to pass larynx
Takes 30-60 minutes
Bx
 Patient Teaching
Post-procedure:
Someone else drives home
Rest the remainder of the day
Lozenges & warm salt water for soreness
Drink H2O first & carefully

Call MD if:
SOB
T > 100.4 x 24 hr
> 2 Tbsp blood
 Complications
Aspiration: Check gag reflex PTA any foods or liquids

Bleeding

Infection

Bronchial perforation

Bronchospasm (Ambu) or laryngospasm (Solumedrol)

Pneumothorax - air becomes trapped in the pleural space

causing the lung to collapse
 Post-bronchoscopy Nursing
Actions
Instruct the client NOT to swallow oral
secretions
Save expectorated sputum and observe for
frank bleeding
NPO until gag reflex returns
Observe for subcutaneous emphysema &
dyspnea
Apply ice collar to reduce throat discomfort
Angiography: Pulmonary
Embolus
Pulmonary Function Studies
Thoracentesis
 Pre-procedure Actions
Obtain signed consent

PT, PTT & CXR

Position in high-fowlers or sitting up on the edge of

the bed with feet supported on a chair.

Lean over table

If unable to sit up, turn on the unaffected side

 Complications

Bleeding (vitals, ck site)

Infection

Pneumothorax (Ck BBS, CXR)

 Post Thoracentesis
Obtain VS & auscultate BBS

Evaluate for signs of shock, especially if > 1 liter of fluid

removed

Assess for pain, cyanosis, increased RR & WOB, pallor

Obtain PCXR

Note color, characteristics and amount of fluid removed,

patient tolerance and post procedure condition & record
Respiratory Treatments

Pulmonary Medications
&
Oxygen
 Pulmonary Medications
Bronchodilators

Relieves bronchospasm
Increases HR & CO
Increases O2 demand
Diuretic effect

SE: Nervousness, anxiety, arrhythmias

Hold if severely tachycardic
 Evaluating the effectiveness of
bronchodilators
RR, WOB, wheezing, restlessness

Improved ABG’s

BBS
 Diuretics: Lasix
Decreases edema in CHF, renal failure, P.
edema
Decreases preload ( CVP)
Decreases BP

SE: Hypokalemia, metabolic alkalosis, BP,

Polycythemia, DVT, thirst, tachycardia,
hyperglycemia, increased BUN
 Lasix
Usually 10-40 mg but can be much higher

Comes supplied 40 mg in 4 mL or 100 mg in

10 mL

Administer slowly to avoid ototoxicity

How many mL’s will you draw up to

administer 20 mg?
 Evaluating the effectiveness of
diuretic therapy
HR, RR, BP, CVP, PAP, PCWP, edema,
JVD, crackles, SOB, WOB

No further S3

UOP, O2 Saturation, PaO2

Make sure you know how to calculate I & O’s,

change weights to mL’s or Liters

1 kilogram = 1 liter 1 lb = approximately 500 mL

 Nursing Precautions
ALWAYS obtain BP & K before giving

Hold if SBP < 100, (CVP <8 call MD PTA)

Hold if K < 3.5 (< 4.0 if no K ordered) Watch

trends

Consider foley cath, give in am, Call MD if

no UOP
 Anticoagulation therapy
Used in the treatment & prevention of P. embolus
d/t immobility, arrhythmias, DIC, heart surgery,
stroke, MI, dialysis and cardio-pulmonary bypass
pump

Heparin, Lovenox, Coumadin

Lovenox has decreased risk of bleeding

Make sure you know how to titrate & administer

heparin
 Anticoagulation
Usually start with heparin continuous IV
infusion for immediate anticoagulation
evaluated by monitoring PTT levels

Then start coumadin monitoring PT/INR

levels

Wean off heparin as PT increases

 Nursing Precautions
Monitor coag studies prior to treatment & as
needed (ie. Before invasive procedures)

Hemoccult stool, emesis & NGT drainage

Protect from injury, Anti-ulcer meds

Hold pressure to all lab sticks. Hold medication

& call MD prior to invasive procedures
 Remember
Drug Lab Value Antidote

Coumadin PT Vitamin K
Blood Product/FFP
Heparin PTT Protamine Sulfate
Platelets*** Blood Product/FFP
Lovenox Platelets Protamine Sulfate
Blood Product/Plts
 Morphine Sulfate
The single most effective drug in the treatment of
pulmonary edema

Decreases anxiety
Venous dilator ( preload)
Arterial dilator( afterload)
Decreases O2 demands
Bronchodilates
 Nursing Precautions
Hold med or give with extreme caution if
SBP < 90 mmHg

Hold if RR < 12

Antidote is Narcan

Evaluate effectiveness
 Sodium Bicarbonate
Usually given for Metabolic Acidotic States

Doseage determined by ABG’s

1 amp = 50 mEq’s of NaHCO3

Flush before and after administering

 Digoxin (Lanoxin)
Contractility  CO

HR  SV

Therapeutic level = 0.5 – 2.0

Monitor serum blood levels. > 2.0 is toxic

Increased risk of toxicity with hypokalemia

S/S toxicity = Brady-tachy syndrome, green halos,

nausea & vomiting
 Digoxin
Given loading dose IV initially (0.5 mg)

Later 0.125 – 0.25 mg

Supplied 0.5 mg in 2 mL

Calculate how many mL’s will you give if you

need to administer 0.125 mg
 Question

Why do you need to take an apical heart

rate when administering digoxin OR when
the heart rate is irregular?

What will you do if the patient’s K+ level is <

3.5 or < 4.0 with lasix administration?
 Question
What if a patient has order for lasix but does not
have an order for potassium?

Renal function is WNL

Labs:

Day 1 Day 2 Today

K = 5.4 K = 4.8 K = 3.7
Steroids: Solucortef/Solumedrol
Given to reduce inflammation

Glucose, Na & H2O retention, risk of GI

bleeding

Causes immunosuppression ( WBC counts &

fever are not always seen with infection) You
need to look for other s/s of infection)

Must be weaned to prevent Adrenal Insufficiency

 Steroids
Available in different strengths

125 mg in 2 mL

Need to administer 90 mg.

How many mL’s will you administer?

 Nursing Precautions
Monitor glucose levels

Hemoccult stools/gastric secretions

Daily weights

Observe for s/s infection

Anti-ulcer medication
 Vasodilator therapy
Nitroglycerin or Ace Inhibitors (“pril”)

NTG decreases preload > afterload Work of

Tx: ACS & CHF

Ace inhibitors decrease afterload by causing

arterial dilation thus increases CO  decreasing
pulmonary congestion and LVHF
 Nursing Precautions
Obtain BP prior to administering

Standard of Practice is to hold meds that

decrease BP if the SBP is < 100

You will need a physician’s order to

administer these medications if the SBP is
< 100 mmHg
 Antibiotics

Often given board-spectrum ATB until organism

is identified or infection is r/o

At risk for infection d/t: steroids, decreased

immune response, debilitated health & cross
contamination from health care providers

Obtain cultures first if possible & note allergies

Monitor serum drug levels if appropriate (Call MD if

< or > than therapeutic PTA)
Gram Stain will tell if organism is
+ or -
Gram + vs Gram -
C & S: MRSA Vancomycin = S
 Oxygen
Is considered a drug

Anything > 4 L/m via NC should be humidified

>60 % O2 over 36 hours or 100% over 24 hours can result in

O2 toxicity

Can result in Acute Respiratory Distress Syndrome (ARDS)

 Nursing Precautions
Give the lowest amount of O2 necessary to
maintain a normal PaO2 or O2 Sat

S/S O2 toxicity: tickling in the throat, cough,

burning of the trachea/bronchus (early)
DOE, n, v, h/a (late)

Monitor for improvement or tolerance to

weaning
 Weaning
Describes the process of allowing the
patient to breath with less oxygen

Greater success with weaning if well

nourished and has normal PO4 levels
 Weaning
Should begin in early hours of the day

Explain procedure to patient

Sit them up in bed

Monitor patient closely for signs of

intolerance to weaning
 Readiness Criteria
Hemodynamically stable

SaO2 > 92% on 40% FiO2 or less

CXR, ABG’s, lytes WNL for patient

Hematocrit > 25%

Stop weaning & obtain ABG’s if:
RR > 35 bpm, HR > 20% higher than baseline,
SBP > 180 mmHg or < 90 mmHg

SaO2 < 90% (higher if anemic)

Rapid, shallow respirations, increased use of

accessory muscles, nasal flarring

Labored breathing, anxiety, restlessness,

diaphoresis, arrhythmias
 Rule of Thumb

If a client becomes unstable after you have

adjusted something…..

Return the client to the last settings where

they were stable.
 Oxygen Therapy

Nasal cannula (NC)

Venimask (VM)
Partial Nonrebreather (PNRM)
Nonrebreather (NRM)
BiPAP & CPAP
Endotracheal tube (ETT)
Tracheostomy tube (Trach)
Trach collar (TC)
 Nasal Cannula (NC) Estimation of FIO2
can be made by the formula (Liter Flow x 4)+20=
FIO2
Effective
Simple
Delivers 24-44%
at 4-6 liters/min

Difficult to keep
In place unless
Pt is very
Cooperative
Requires humidification
If > 4 L/m
 Venturi Mask (VM)
Effective
24-40 % O2

Masks & nasal

cannulas
can cause
skin breakdown
 Face Mask
Delivers 35-60%

About 1/3 of exhaled

air is rebreathed

Reservoir contains
mostly O2 from
previous
inhalation
 Non-rebreathing Mask
Has 1 way valve
prevents client from
exhaling back into
bag

Delivers 100%
O2 at flow
rate of 10-12
L/min
 Noninvasive Positive-Pressure
Ventilation
NPPV

Can use nasal or full face

Improves alveolar ventilation

Decreases WOB
Preserves the ability to swallow speak &
cough normally
Bi-pap vs C-PAP
 BiPAP vs CPAP
Bi-level positive airway pressure: delivers a
higher pressure on inspiration than
exhalation. Can be used to ventilate pt

Continuous positive airway pressure: delivers

the same pressure during inspiration &
expiration which helps re-expand and
stabilize the alveoli. The pt must have
spontaneous respirations.
 Swallow Precautions
a. oral motor weakness/facial droop/decreased sensation

b. food/liquid leaking from mouth, inability to control oral

secretions or pocketing of food

c. dysarthria (slurred speech), wet" vocal quality (gurgle) or

coughing or choking during fluid intake or during meals

d. feeding tube

e. history of aspiration pneumonia or of dysphagia

f. decrease LOC or recent anesthetic

 Airway Maintenance
Never give anything by mouth to a person
who has ALOC or questionable swallow
reflex

Anyone with the potential for dysphagia

should have suction set up at the bedside

Unless contra-indicated elevate the HOB

 Airway Maintenance
Check residuals for tube feedings and hold
per policy

Maintain peristalsis

Obtain swallow study when needed

 Airway Maintenance
Oral Airway
Use in unconscious patients only

1. Use tongue blade to depress tongue

and insert directly into mouth

2. Position curved end toward the roof of

the mouth and rotate 180 degrees

Suctioning Equipment
Airway Maintenance: Suctioning
Hyper- oxygenate with 100% O2 for 2” to
prevent hypoxia

Insert catheter as far as possible without

applying suction

Apply intermittent suction while withdrawing

& rotating catheter over less than 10
seconds
 Warning

Always observe heart monitor when suctioning for:

Arrhythmias: PVC’s (hypoxia)

Bradycardia (vagal stimulation)
O2 saturation

Stop suctioning and give 100% O2, if prolonged

then treat with DOC
 Other Nursing Interventions

Mouth care Q 1-2 hours in NPO patients & q

shift in others: Pneumonia

Empty H2O from oxygen tubing:

Pseudomonas Pneumonia

Remember pulmonary hygiene, force fluids* &

early/frequent ambulation
 Postural Drainage Positions:

Lower lobes: anterior basal segment

Postural Drainage Positions:

Lower lobes: superior segments

 Postural Drainage Positions:

Lower lobes: lateral basal segment

 Postural Drainage Positions:

Upper lobes: anterior segment

 Postural Drainage Positions:
Upper lobes: posterior segments
Postural Drainage Positions:
Upper lobes: apical segment
Percussion and Vibration
High-Frequency Chest Wall Oscillation
Vest
 Chest (Thorocotomy) Tubes
Used to restore negative intrathoracic
pressure or to remove drainage

Anterior CT: remove air and are inserted at

the 2nd ICS, MCL

Posterior CT: remove fluid and are inserted

in the 5th or 6th ICS, mid axilla
 Chest tubes: Components
Collection receptacle

Water seal

Suction

Air leaks in the system will show up as

bubbling in the water seal chamber
 Insertion
Check PT, PTT, Plts
Explain procedure
Gather equipment
Informed consent & pain med*
Place in semi or high fowler’s
Support patient emotionally
Once MD inserts tube, hold connecting tubing & tape
connections and to floor
Connect to suction if required, Assist with dressing
PCXR, resp assessment
Tape connections and tape to floor
 Document
Cardio-pulmonary assessments before & after CT
insertion

CT size & insertion site, amount of suction*

Drainage, amount, color

Tolerance & meds given

Results of CXR
 Nursing Report
Information you want to give to the on-
coming nurse:

1. Left or right, anterior or posterior

2. H2O seal vs suction, how much?
3. Drainage, amount, color, or
4. Air leak? How much? Is MD aware?
5. Respiratory assessment, CXR
 Assessments Q 4 hours
& lungs

Insertion site for crepitus/infection/oscillation

in tubing with breathing, cough

Dressing c/d/I, amount of suction, air leaks

No dependent loops or occlusions

Color, character & amount of drainage

 Dressing
Dressing should be dry and intact

If crepitus is present, mark with pen around crepitus

then remove dressing and check to see if any of the
drainage eyelets have been pulled out of the pleural
space.

If no eyelets are visible redress & call MD

If eyelets, call MD for repositioning of tube
 Nursing Care
Maintain sterile water, 4x4’s, tape, occlusive dressing &
clamps at bedside

CDB q 2 hours

Pain meds & splinting

Turn q 2 hours

ROM to affected arm & shoulder q 4 hrs (Frozen

shoulder)
Technique for Supporting Incision
While a Patient Coughs
Arm and Shoulder Exercises
 I&O
Record q shift* (Q 1 hr post op) mark on the
pleuravac the time

Notify MD if excessive output

Position affects drainage, don’t be surprised

if there is an increase in drainage when
the patient sits up the first time (Posterior
tubes)
Sudden cessation of drainage, or
lack of movement of fluid = Clots
postoperatively
Can cause tension pneumothorax (thoracotomy tube) or
cardiac tampanode (mediastinal tube)

Reposition the patient

If you can see the clot, straighten & raise the tubing to
facilitate drainage

Milk the tube gently to remove the clot

“Stripping” the tube = increase intra-thoracic pressure and

should be done ONLY if blood clotting is leading to
pleural/cardiac tampanode. It requires and MD order
 Bubbling = Air Leak
Check all connections

Clamp BRIEFLY starting at the patient: if bubbling

stops, the pleural space is leaking air or there is
a leak at the insertion site: this bubbling is
usually intermittent, varying with respirations

Should resolve as lung expands

Reinforce dressing, if still bubbling, call MD

 Bubbling = air leak
Constant bubbling = air leak in the system

Check all connections

Disconnect from suction

Use padded hemostats to check the system

 Padded Hemostats
If bubbling persists, clamp briefly along
the tubing starting at the patient and
working your way to the water seal

Bubbling will stop when you clamp

between the air leak and water seal

If you still can’t find the leak – change the

chest drainage unit (CDU)
 Other problems
CDU is knocked over: clamp briefly and change
the CDU

CT is pulled out:
Cover with dry, sterile dressing
If you hear air leaking, tape on 3 sides only
Have someone else call MD stat & get equipment
to insert new CT
Watch for tension pneumothorax
 Other problems
CT becomes disconnected from the CDU:

Submerge the CT in 1 inch of sterile NaCL

or H2O in a sterile container until a new
CDU can be set up

There should be a bottle of sterile water, 4 x

4’s, tape and padded hemostats in any
room with a CT tube
 The only time you clamp
To assess for leaks
Stimulate chest tube removal
To change out the CDU
Connect or disconnect an in-line
autotransfusion bag

Only briefly !!! Prolonged clamping can lead

to tension pneumothorax
 Precautions
Assure there are no kinks or dependent
loops in tubing

Never raise the CDU over the chest level of

the patient

Order daily PORTABLE CXR

 Precautions
Stop suction QS to assess fluid level in the
water seal chamber. Add sterile H2O if
necessary

Medicate for pain prior to discontinuing CT

Observe tolerance to removal of suction,

discontinuation of CT
 Criteria for CT removal
One day after cessation of air leak

Drainage of less than 50-100 mL day

1-3 days post Cardiac surgery

2-6 days post pulmonary surgery

Obliteration of empyema cavity

Serosanguineous drainage around the CT
insertion site
Incentive Spirometry
 Incentive Spirometry
Exhale slowly
Place mouthpiece between teeth and close
the lips
Take in a slow deep breath and hold for 5
seconds
Remove spirometer and exhale
Relax for a while
Perform 10 times per hour while awake