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Oxygenation summary Ch 41
Nursing Process Ii (Broward College)
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OXYGENATION
Respiratory function is necessary for life. Oxygen is a basic human need.
Respiration is the exchange of O2 and CO2 during cellular metabolism
Blood is oxygenated through the mechanisms of ventilation, perfusion, transport of respiratory gases.
The cardiovascular system provides the transport mechanisms to distribute oxygen to cells and tissues
of the body.
Ventilation = air moving in and out (inspiration/expiration)
Diffusion = the exchange of gases from one area to another by concentration gradient
Perfusion = movement of oxygenated blood to tissues and deoxygenated blood to lungs
The alveoli are also responsible for production of a substance known as Surfactant (phospholipid), and it
maintains the surface tension, prevents the lung from collapsing. E.g: premature babies often wind up on
a ventilator, one of the reasons they must be ventilated is that their lungs aren’t mature enough to
produce the Surfactant, as a result their lungs collapse. So, they need the Surfactant to keep the lung
open. Pts with resp diseases have decreased surfactant production and develop atelectasis (collapse of
alveoli).
Normal respiratory functioning depends on several factors:
1) Physiological
Resp diseases: asthma, COPD, tracheal edema – increase airway resistance, O2 delivered to alveoli
decreases.
COPD (Chronic Obstructive Pulmonary Disease). It’s a group of debilitating, progressive, and potentially
fatal lung diseases that have in common increased resistance to air movement. There’s prolongation of
the expiratory phase (Exhale), and there’s a LOSS of elasticity of the lungs (which means they won’t reexpand/collapse as well). It includes Emphysema, Chronic Obstructive Bronchitis, Chronic Bronchitis,
Pneumatic Bronchitis. People with COPD breathe in shallow, exhausting, rapid pattern.
A person with Scoliosis/ kyphosis/ fractured ribs lead to decreased compliance of lungs (ability to expand);
Anemia and inhalation of toxic substances decrease the oxygen-carrying capacity of blood by reducing the
amount of available hemoglobin to transport O2. cardiac disorders.
Hypovolemia- decreased circulating blood volume leads to hypoxia to body tissues.
Pregnancy- enlarged uterus pushes the abdominal contents upward causing dyspnea
Obesity – lungs do not expand fully, and lower lobes retain pulmonary secretions.
Increased metabolic rate – wound healing, exercise, fever cause increase of metabolic activity because
body is using energy for building new tissues.
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2) Developmental
Infants – healthy full-term infants tend to have lower infection rate because of mother’s antibodies.
Infection rate increases in infants 3-6 m.o. More upper respiratory tract infections, but in most cases
they are not dangerous. Also, infants are at higher risk of airway obstructions (kids like to put objects in
mouth), as their airways are anatomically smaller
School age children- risk of respiratory infection due to exposure to cigarette/vape smoking
Young and middle-age adults – unhealthy diet, lack of exercise, smoking, OTC meds
Older adults- changes of body such as vascular stiffening, atherosclerotic plaques, calcification of
airways, reduction of cilia. As people get older there’s a normal drop in the PaO₂ and the SaO₂
3) Lifestyle
Nutrition. A patient with chronic lung disease often requires a diet higher in calories and smaller
portions, more frequent meals A diet with a moderate amount of carbs is recommended to prevent an
increase in CO2 production.
Poor nutrition can lead to anemia, and poor oxygen carrying capacity as a result.
Dehydration- can lead to thickening of pulmonary secretions. Fluid overload may lead to vascular
congestion in pts with heart, lungs, and kidney diseases.
Exercise. People who exercise 150 min per week have lower heart rate, BP, increased blood flow,
greater O2 extraction
Smoking/Secondhand smoke -nicotine causes vasoconstriction, decreases blood flow to peripheral
vessels. Smoking gives you carbon monoxide to ride around on your hemoglobin, destroys the cilia and
eventually destroys that mucociliary clearance. That’s the reason why smokers cough.
Substance abuse. Alcohol depresses resp center, reduces depth of respiration. Opioid causes resp
depression.
Stress – increases metabolic demand and affects pt health. Stressors can cause hyperventilation, asthma.
4) Environmental
There’s a high correlation between air pollution and cancer. E.g. asbestosis – a disease developed due to
exposure to asbestos, creates restrictive lung diseases, interstitial fibrosis, cancer.
CAPNOGRAPHY- provides instant info about pt ventilation, how effectively CO2 leaves the body,
produced by cellular metabolism, and how effectively it is transported through vascular system.
Alveoli
- Alveoli is where the actual gas exchange occurs.
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- The blood that comes in from the Pulmonary Artery is Unoxygenated . It’s the ONLY artery in the body
that carries Unoxygentaed blood. It gives off CO₂, picks up O₂, O₂ goes into Pulmonary Vein, which is the
only vein in the body that carries Oxygenated blood.
VENTILATION & RESPIRATION
External Respiration: The exchange of gases at the Alveolar level. At the terminal alveoli and the
capillary margin. When that membrane gets diseased like with too much O₂, it thickens, and that
can interfere with the exchange of gases at the Alveolar Level.
Internal Respiration: Occurs at the Cellular Level; also a process of diffusion.
Ventilation has 2 Phases: (Inhalation & Exhalation)
INHALATION phase is active, it requires muscle work, muscular strength and movement to move air into
the lungs.
EXHALATION is passive. The muscles relax and the air goes out of the lungs.
- The respiratory center in the medulla and the brainstem are what control it.
- The respiratory effort is stimulated by an ↑ concentration of CO₂ and H⁺
- Hypoxia – will stimulate the respiratory effort as well. Stimulation of the medulla by CO₂ and H⁺, causes
us to breathe more rapidly and deeply. We blow off the waste products in CO₂, which also helps us get rid
of the H⁺, and then we would breathe less deeply and less rapidly.
Principles of Respiration
- All cells require oxygen, the body can’t store it.
Oxygen is all around you, but sometimes it’s not as dense. Oxygen is always 21% of the air, but we get
more oxygen taking a breath at sea level vs. on top of a mountain b/c the air is less dense, and you don’t
get as much oxygen in a breath. And that’s important to know for our pts, b/c they may need supplemental
O₂ as they adjust to environment.
- Air passages must be Patent for respiration to occur.
The MOST common obstruction to an airway is:
- TONGUE. Pt falls unconscious, the tongue goes back, and obstructs the airway. That’s why when
you did CPR pay attention to how to position the head, chin, etc.
- Foreign bodies
- Others. E.g. tumors, edema, thick Secretions (all things that can plug the airway).
- Dyspnea (it’s Subjective). What we can see is Labored breathing and the pt struggling to breathe
- Pulmonary embolus
Adequate food intake and hydration is important for effective breathing.
OXYGEN
Oxygen has to move around; it moves around the blood in two ways:
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Some of it is dissolved in Plasma, but O₂ isn’t very soluble, and a whole lot of it doesn’t dissolve.
1) PaO₂ - Partial Pressure (PaO₂). It’s one of the key values
2) SaO₂ - The MOST of it, is carried as Oxyhemoglobin. Hemoglobin has a strong affinity for O₂. We
measure it with a Pulse Oximetry (the O₂ Saturation, Pulse Ox, O₂ Sat, etc.)
Oxygen Saturation is affected by Temperature, pH, and by PaCO₂.
- When the SaO₂ DROPS to 90; the PaO₂ ↓ to 60. The pts has a resp. failure, and they’ll be hauling out
the vent and determining whether they should be intubated.
- When the SaO₂ DROPS to 60; the PaO₂ would be 30. That isn’t compatible with life. Pt will need a
ventilator or die.
VENTILATION PROBLEMS
HYPOXEMIA = LOW O₂ in the blood.
- In Hypoxemia; if the PaO₂ is less than 60, and the SaO₂ is less than 90, it leads to Anaerobic Metabolism
(metabolism that will be occurring in the absence of O₂). When that happens, you’re going to get Lactic
Acid production as a byproduct of that anaerobic metabolism. The Lactic Acid that’s produced from
Anaerobic Metabolism, leads to an Acidosis. It shifts the pH value of the blood.
- In Hypoxemia; one of the things it’s going to cause is Hyperventilation. When our O₂ level ↓, the pt will
breathe more deeply and more rapidly, so they’ll have hyperventilation.
- When we have Hyperventilation, our body is picking up on the Hypoxemia, we’re going to breathe deeper
and more rapid; we’re going to blow off the CO₂, and when we do that, it will raise the pH level of the
blood. The reason why that happens is CO₂ combines in the blood with water, and it makes Carbonic Acid.
When we blow off CO₂, it breaks down that bond, and it leaves water. So, by breathing rapidly and fast,
and getting rid of a bunch of CO₂, we get rid of one kind of acid, which takes care of an overabundance of
the Lactic Acid. And the body equalizes itself.
Normally the first sign of Hypoxemia is Altered Thought Process as they’re not getting enough O₂
anywhere, including the brain. They start to get Anxious and Restless. If pt used to be ok, and now he is
confused, anxious, and restless - check are their SaO₂, and assess them for Hypoxemia. They’ll start to feel
Dyspnic; labored breathing, they’re trying to get more air; body’s trying to compensate for low O₂ level by
breathing in more. Vital signs: HR↑ (heart is trying to pump the O₂ fast); Resp Rate↑; BP ↑.
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- Pt will get a Narrowing/Lowering of the Pulse Pressure. Diastolic Pressure will ↑MORE than the
Systolic Pressure. So, maybe they were 120/80 (pulse pressure = 40), and now they’re 130/95 (pulse
pressure = 35)
- Cyanosis is a LATE sign. Do not wait for your pt’s to have Cyanosis before you intervene. Blue color is
TOO LATE. We know peripheral cyanosis is not a big deal (we can get that in the classroom when it’s
cold), but CENTRAL cyanosis needs immediate actions.
NURSING interventions
History:
Risk factors, family history of lung cancer, CVD, allergies
Physical examination:
Clubbing of nails. Clubbed nails often occur in pts with chronic oxygen deficiency, such as cystic fibrosis
and congenital heart defects.
Chest wall- rounded in COPD
Elevation of clavicles at rest – labored breathing
RR greater than 35 breaths/min – metabolic acidosis (Kussmaul respiration)
Auscultation:
Wheezing – musical sounds- narrowed airways- asthma, acute bronchitis, pneumonia
Crackles – discontinuous sounds of different pitch-resp passages are not cleared – pneumonia,
emphysema, chronic bronchitis
Rhonchi – deeper sound in pitch than crackles- presence of thick secretions and muscle spasms
in the airway- asthma, pneumonia.
INDEPENDENT interventions:
POSITIONING
•
•
•
45 degrees semi-fowler for lung expansion
side position with a good lung down when pt has unilateral lung disease
affected lung down in hemorrhage/ pulmonary abscess
COUGHING TECHNIQUES
Before pts go into surgery, we should teach them coughing techniques when they come back :Turn,
Cough, and Deep Breath. “TCDB”.
It’s going to hurt, so: 1) Medicate them ahead of time; have them push their PCA pump. 2) Give them
a pillow to push up against the incision.
•
Directed coughing permits a pt to remove secretions from both upper and lower airways. We tell
pt to take deep breath, a breath that is sufficient enough to move bottom of rib cage. That sounds
easy for us, but if you’ve had abdominal surgery, taking a really deep breath is very hard.
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It is recommended for people who are immobile, who just had a surgery, and are getting narcotics
for their pain.
•
Double Cough Technique (For COPD pts)
We ask them to take a really deep breath, exhale half, and then cough. That way you can get some
of the effects of the cough, without collapsing more alveoli.
•
Huff Cough- It’s for clearing larger airways. Pt takes a deep breath, keeps it for 2-3 sec, forcefully
exhales saying the word “HUFF” when they cough.
•
Cascade Cough. Pt takes a deep breath, hold it for 1-2 seconds, then open mouth and perform
series of coughs throughout exhalation. For pts with large amount of sputum
•
Then there’s a QUAD Cough. This is for spinal cord injury pts and pts without abdominal muscle
control. We DO NOT do this as a matter of routine. This is a DEPENDENT intervention. Need a
physician’s order, and special training. This technique involves putting pressure under the
diaphragm on the abdomen to create pressure at that precise moment of the cough to force it
out, like the Heimlich maneuver.
•
Diaphragmic breathing – encourages deep breathing to increase air to the lower lungs. Helps to
decrease dyspnea for short period of time in pts with COPD.
✓ Pts with pulmonary diseases, upper and lower resp tract infections – cough q2h while awake
✓ Pts with large amount of sputum q1h while awake
✓ Post op pts – deep breathing and coughing q2-4h while awake (do not forget support devices for
incisions)
✓ - If a pt has a cough and it’s dry/hacking, and nothing comes up, it is NON-PRODUCTIVE
(fatiguing, irritating, annoying)
✓ - If the cough brings stuff up, it’s PRODUCTIVE.
✓ - As a nurse, if a pt has a PRODUCTIVE COUGH, one of the most important interventions is GOOD
MOUTH CARE. Mucus coming out of the lungs, gets in the mouth, mixes with that bacteria in
there, and grows stuff, when we tell the pt to take a nice, deep breath. Where are all those
germs going? Down into the lungs. It’s always important to have a clean mouth, but if a pt has a
resp infection, and is coughing up stuff, it’s even more important.
✓ - COUGH SUPPRESANTS suppress cough reflex. The BEST one known is CODEINE. If we have a pt
who had surgery, and we give them a narcotic for their pain, it will suppress the cough as well as
fix the pain. So the secretions that have built up during surgery will lay in the chest.
✓ CODEINE is the preferred high end cough suppressant. It can cause secretions to be retained in
the lungs.
✓ NIGHTTIME NYQUIL - suppresses your cough reflex. Pt lies there, let all the secretions
accumulate overnight; bacteria grows. And now pt actually may have Pneumonia. So when
you’re giving someone Nyquil, is it a dry, non-productive, irritating, annoying cough – then OK. If
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✓
✓
✓
✓
it’s a PRODUCTIVE COUGH, then DON’T GIVE IT to suppress it so they can get a good night’s
sleep, b/c you’re keeping the secretions down there.
EXPECTORANTS
- The BEST ONE is WATER. Adequate fluid intake is considered to be the most effective
expectorant. If normal is 1,5-2 L/day is normal; if someone is really congested we want them to
take 2-3 L/day.
- Milk products can thicken secretions, so it’s better to avoid them.
- Drugs help as well, but you can’t liquefy the secretions without having the fluid pulling it out.
Have to have the fluid for the drug to work.
DEPENDENT interventions.
Diagnostic tests- ABG, pulmonary function tests, MRI, bronchoscopy, etc.
Some tests could be painful. Nurse should reduce pt’s anxiety by explaining the procedure and telling a
pt what to expect. Pain management 30-60 min prior the procedure.
CHEST PHYSIOTHERAPY
External chest wall manipulation using:
•
•
•
Percussion – rhythmically clapping on chest wall with cupping hands. Contraindicated in pts with
bleeding disorders, osteoporosis, fractured ribs
Vibration – gentle shaking during exhalation to shake secretions into larger airways
High frequency chest wall compression – inflatable vest attached to an air-pulse generator,
beneficial in pts with neuromuscular diseases.
POSTURAL DRAINAGE
•
Draining secretions from segments of lungs and bronchi to trachea
AMBULATION – immobility is a major factor in developing atelectasis, ventilator associated pneumonia
(VAP), functional limitations, including muscle weakness and fatigue. Early ambulation is beneficial, even
if a pt is on invasive mechanical ventilation.
POSITIONING- 45-degree Semi-Fowler’s position is the most effective one to promote lung expansion
and reduce from the abdomen on a diaphragm. Good lung down to promote perfusion, unless pt is
hemorrhaging or has pulmonary abscess.
INCENTIVE SPIROMETER
Encourages voluntary deep breathing by providing visual feedback to the pt about inspiratory volume.
Prevents or treats atelectasis in postop pts. 5-10 breaths are recommended per session every hour while
awake. Keep in mind, if somebody just had surgery, those 10 breaths may not happen one after the other.
You might have to space them out
SUCTIONING
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It is used when pt are unable to clear resp secretions by coughing or other less invasive procedures. In
most cases use STERILE technique because oropharynx and trachea are considered sterile. When
suctioning you apply negative pressure during withdrawal of catheter and never on insertion. Perform
tracheal suctioning before pharyngeal sanctioning whenever possible. The mouth and pharynx contain
more bacteria than the trachea.
ARTIFICIAL AIRWAYS
It is for pts with decreased level of consciousness or airway obstruction. E.g. catheter inserted through
the rib cage into pleural space to remove air, fluids or blood. Chest tubes are common after chest
surgery and chest trauma; used for treatment of pneumothorax (collection of air in pleural space) or
hemothorax (collection of blood). Removal of chest tubes requires patient preparation. The most
frequent sensations include burning, pain, and apple in sensation. Make sure that the patient is giving
pain medication at least 30 minutes before removal.
OXYGEN THERAPY
Purpose = To provide supplemental oxygen. Oxygen is a drug. You need an order for it.
Health education:
PROMOTING NUTRITION
- People who are having trouble breathing don’t want to take the time to eat. - We need to give them
special mouth care. - Breathing burns up calories; and a person needs 700 additional calories a day just
to break even for the work of breathing. Problems - They don’t want to eat, b/c they’re too busy
concentrating on breathing. - When you put food in the stomach, it puts pressure on the diaphragm that
now makes it harder to breathe. - When you’re eating you have to chew and swallow, which requires
quitting breathing – but their whole thing is breathing. So it’s hard to chew and swallow and breathe at
the same time. So what can we do to help them? - Small portions, - Frequent feedings & Easy to handle
food. Patients with COPD require increased calories intake and small portions.
- Schedule their breathing treatment a little before the meal so they’re at their best respiratory effort Make sure they have their mouth care after their treatment (b/c if you have all that gunk in your mouth,
your appetite will be disrupted as well)
DANGERS
1) Atelectasis – if we give person 100% oxygen and we maintain that, it washes all the Nitrogen out of
the alveoli. When we take a breath, we get 21% Oxygen, 78% Nitrogen, and 1% Other Gases. What the
Nitrogen does is it holds the alveoli open while the oxygen diffuses into the blood, and the CO₂ diffuses
out. If we give pt 100% oxygen, and 100% diffuses in the blood, there’s nothing left to keep the alveoli
open. You get Atelectasis.
2) Retrolental fibroplasia – a problem with blindness in infants (premature infants). It’s High O₂ levels.
We used to think you couldn’t run the O₂ above 40%. Now what research is showing is an SaO₂ of 8595% is what’s working for these babies. They’re questioning whether it’s the oxygen that does the
damage to the kids, or if it’s the CO₂ levels. It causes Retrolental Fibroplasia, which is blindness forever.
3) Oxygen Induced Carbon Dioxide Narcosis – It’s a thing with COPD pts. We said the main stimulant to
breathe is CO₂ and High H⁺ (pH in the blood) content. With a COPD pt when they’re retaining CO₂ is they
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build up these high levels of CO₂, they’ll levels of PaCO₂ of 55-60 (way high) and their medulliary
center/respiratory center ceases to respond to the stimulus. And now the only thing that makes them
breathe is a LOW oxygen level. SO if we take one of these pts and put them on an O₂ device, and we run
their O₂ level up above borderline failure. If we put it on and give them normal oxygenation, they have
no reason to breathe, and they won’t. So, you want to keep their PaO₂ between 60-80. That’s why they
say for COPD pts, “we’re running the Naso O₂ at 1- 2 L per minute.
4) Oxygen Toxicity – If you give someone too much oxygen for too long, you get oxygen toxicity. There’s
a thickening of the alveolar membranes, and the oxygen and CO₂ exchange is not going to work too
good.
Oxygen Physical Danger
It’s not a flammable gas, but supports combustion
- To prevent fire, we need to have no open flames in the pt’s room.
- 10 feet from open flames.
- Nobody can smoke with O₂ in use.
- Electrical equipment needs to be spark free.
- Avoid oils in the area
- Make sure safety for oxygen is followed for transported patients
- Anticipate needs for oxygen if you’re going to transport the pt.
- Need to know policy in hospital.
OXYGEN DELIVERY SYSTEMS
LOW FLOW
1. Nasal cannula - 2 L of 28% oxygen and we can run all the way up to 6 L and 44% oxygen - Used for
mild resp distress, hypoxia, pts without nasal obstructions (if we’re putting prongs in the nose obviously,
we can’t have nasal obstructions, it’s not for mouth breathers. Recommended flow rate is 1-6 L. Be alert
for skin breakdown and drying of mucosa.
2. Simple face mask - There’s no little bag on it, clear plastic - Has exhalation ports on the side, covers
the nose and mouth - We can give 40-60% oxygen - For short term therapy; use cautiously if pt at risk for
vomiting b/c if they can’t get mask off, they’ll breathe it - Flow rate: 5-8 mL - Need a humidifier to use
with it: worry about keeping face dry underneath. Needs to fit tight, and it’s claustrophobic.
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3. Trach collar - Like a mask, but it just fits over the
tracheostomy. It’ll have a hole in it for suctioning, and
humidified air (it has to be heated, humidified, and
cleaned) to go into the side. Keep in mind, anytime you
put the moisture up against a pt’s skin, it’s going to be
wet, uncomfortable, the skin could get mascerated.
4. Partial rebreather / Rebreather - Plastic mask with a reservoir - For the partial rebreather, the pt
rebreathes about a 1/3 of their exhaled air. Now
you know the air you exhale contains oxygen,
otherwise CPR wouldn’t work. So when they
breathe their exhaled air, that ↑ the O₂
consumption, and you can get up to about 95%
Oxygen on this up to about 10 L.
- Used for short term, heart disease, lung disease
- Little valves can be taken off/ put on and adjust
to go between rebreather and nonrebreather.
HIGH FLOW
1. High flow nasal cannula – heated and humidified oxygen
2. Non-rebreather: We leave the two rubber discs
on and it traps all the oxygen inside, you can deliver
up to 100% oxygen of you’re running up to 15 L. We
use this on pts with code, shock, ER pts
- We would NOT put this on a COPD pt. A
consideration is maybe the pt is confused and they
pull oxygen off the wall, there is nothing going in
there. If the oxygen becomes disconnected, it’s like
putting a plastic bag over their head. There’s only a
tiny hole to allow the CO₂ to escape. So the pt’s
going to smother. So a pt who is on a Non Rebreather mask, has to be under supervision.
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2. Venturi Mask
It has a dial. It tells you 3L/minute of oxygen, you set the
dial here. You can get 24% oxygen accurately. Sometimes
instead of a dial, they have different little plastic pieces
you can put in and it tells you the Liter flow and the
resulting percentage of oxygen.
- Could we use this mask on a COPD pt? YES! b/c we can
control it at the low flow. We can also use it for high flow,
but we can control it at the low flow.
For ALL of these devices we need to give:
- Frequent hygiene, Good Mouth Care, Good Nasal Hygiene
- You NEED to watch out for where the Elastic goes up over the ears. People can get Decubiti up there
from the pressure of the elastic.
RESTORATIVE AND CONTINUING CARE
Resp muscle training: repetitive breathing
Breathing exercises: pursed-lip breathing, diaphragmic breathing
Home O2 therapy
NURSING CARE ASSESSMENT: You need to assess resp status. Breath sounds, Resp rate and depth, for
sputum, Blood gases, past Rx history as far as lung diseases (especially COPD), we’re going to watch for
clinical signs of Hypoxia, need to verify physician’s order for oxygen – make sure we get the right method,
pulse oxygen – if less than 93, need to intervene. However, sometimes just have the pt take a few deep
breaths is enough.
NURSE & ASSISSTIVE PERSONEL
The nurse is responsible for assessing the patient’s
respiratory system and the response to oxygen therapy.
The skill of artificial airways suctioning of newly inserted
artificial airways
The skill of administering home oxygen equipment
ETT CARE
The skill of applying and nasal cannula, oxygen mask can be
delegated to assistive personnel
Oral pharyngeal and well-established tracheostomy tube
suctioning can be delegated.
The skill of artificial airways suctioning of newly inserted
artificial airways cannot be delegated to assistive
personnel.
The skill of administering home oxygen equipment cannot be
delegated to assistive personnel.
The skill of performing ETT care cannot be delegated to
assistive personnel assistive personnel. AP can ONLY assist
the nurse.
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The nurse directs the assistive personnel about proper
positioning, ambulating in transferring patient was just
drainage, reporting changes in vital signs and complains,
danger of any disconnection of drainage system.
The skill of chest tube management cannot be delegated to
assistive personnel.
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