Learning Supplement
Respiratory Assistive Devices and Oxygen Therapy
Introduction
Normally, adequate ventilation in an individual is maintained by frequent changes
of position, ambulation, and exercise. When individuals become ill, however, their
respiratory functions may be inhibited, for such reasons as pain and immobility.
Shallow respirations inhibit both diaphragmatic excursion and lung expansion.
The result of inadequate chest expansion is stasis and pooling of respiratory
secretions, which ultimately harbor microorganisms and promote infection.
ASSESSMENT
Nurses must assess respiratory function and oxygenation to formulate a plan of
care.
Assessment Of Oxygen Saturation / Pulse Oximetry
Pulse oximetry is a non-invasive method of measuring the oxygen saturation of
hemoglobin in the blood. A sensing device is clipped to an area with pulsating arterial
blood such as a finger, toe or earlobe. With this device, a photoelectrical detector
records the amounts of light transmitted or reflected by deoxygenated versus
oxygenated hemoglobin picking up light signals registered by the pulsations.
Pulse oximetry is a useful for monitoring oxygen level. Arterial saturation
measured with the pulse oximeter is reliable because it has a close correlation with
the saturations obtained from the blood gases.
Normal saturation is 95% - 100%. A saturation below these values indicate
oxygenation problems. A saturation below 70% is critical, life-threatening and
requires immediate attention.
Procedure
 Clean the patient finger with an alcohol swab, and remover any nail polish or
artificial nails.
 Clip the sensor to the finger or toe. If the peripheral circulation is poor, then
clip to the earlobe.
 Follow manufacturer’s directions for use.
 Read values and record.
NURSING DIAGNOSIS
Common nursing diagnosis related to the individual experiencing a problem with
oxygenation include:
1. Ineffective airway clearance related to:
2. Ineffective breathing pattern related to:
3. Impaired gas exchange related to:
GOALS
The patient will:
1.
2.
3.
INTERVENTIONS / UTILIZATION OF RESPIRATORY ASSISTIVE DEVICES
The purpose of using respiratory assistive devices is to:
 Loosen respiratory secretions
 Improve pulmonary ventilation
 Counteract the effects of anesthesia and / or hypoventilaton
 Facilitate respiratory gaseous exchange
 Expand collapsed alveoli
 Prevents atelectasis (collapse of the alveoli)
1. Positioning
The semi-fowler’s or fowler’s position allows maximum chest expansion in bedridden patients. Some patients may use the orthopneic position in which the
patient sits up in bed and leans over the overbed table with a pillow for support.
This is helpful for patients with chronic lung problems. The main advantage of
using the orthopneic position instead of high fowlers position is that the
abdominal organs are not pressing on the diaphragm. Also the patient in the
orthopneic position can press the lower part of the chest against the table to help
in exhaling.
2. Turning, Deep Breathing and Coughing (TCDB)
The nurse encourages the patient to turn from side to side frequently so that
alternate sides of the chest are permitted maximum expansion. Turning also
assists with redistribution of pulmonary blood flow and ventilation and preventing
pooling of secretions. If a patient is immobile, the nurse is responsible for
placing the patient on a turning schedule (ex. Every 2 hours).
The nurse can facilitate respiratory functioning by encouraging deep breathing
exercises and coughing to remove secretions. Breathing exercises are commonly
indicated for patients with chronic obstructive lung disorders or patients
recovering from surgery. When teaching the patient about breathing exercises
ask the patient to:
 Concentrate on expanding the upper chest forward and upward while
inhaling deeply to aerate lobes of the lungs.
 Hold the breath for 3 to 4 seconds to promote aeration of alveoli
 Exhale passively and slowly through the mouth or nose.
Coughing clears the tracheobronchial tree of secretions. Many patients are afraid
to cough because of fear of pain. Other patients are unable to cough due to the
effects of disease or medication. Ineffective coughing may significantly increase a
patient’s energy expenditure as they work to clear their airways.
It is important to assist the patient with effective coughing. To assist the patient
with coughing, position the patient in a sitting position. Instruct the patient to
splint the abdomen or chest with pillows or hands. Have the patient take three
deep breaths and then at the end of the third breath, have the patient bend
forward and cough on exhalation.
Repeat this deep breathing and coughing every 2 hours.
3. Incentive Spirometer
An incentive spirometer measures the flow of air inhaled through a mouthpiece.
The patient is offered an incentive to improve inhalation.
The patient should be assisted in an upright sitting position in bed or in a chair.
This position promotes maximum ventilation. The patient holding the spirometer
exhales normally, seals the lips around the mouthpiece and takes a slow, deep
breath to elevate the ball in the cylinder. The cylinder is calibrated and the
patient is encouraged to increase the depth of their inspiration to meet certain
measurements on the cylinder. The deep ventilation from using the incentive
spirometer may loosen secretions and coughing afterwards can facilitate their
removal.
4. Percussion and Postural Drainage (PVD)
Percussion is forceful striking of the skin with cupped hands. The fingers and
thumb are held together and flexed slightly to form a cup. Percussion over
congested lung areas can mechanically dislodge tenacious secretions from the
bronchial walls.
Postural drainage is the drainage, by gravity, of secretions from various lung
segments. Secretions that remain in the lungs or respiratory airways promote
bacterial growth and infection. The patient is placed in a variety of positions to
drain specific affected areas of the lungs.
These treatments, usually by respiratory therapy, are done two or three times
daily depending on the degree of lung congestion.
5. Oxygen Therapy
Oxygen therapy is indicated for patients who have hypoxemia (decreased oxygen
in the blood) or reduced lung diffusion of oxygen through the respiratory
membrane or heart conditions leading to inadequate transport of oxygen.
Hypoxemia may be assessed by noting the following signs and symptoms:
 Tachycardia
 Mental confusion
 Restlessness
 Tachypnea (increased respiratory rate)
 Air hunger
 Sweating
 Cyanosis
Oxygen therapy is prescribed for treatment of hypoxemia. The physician will
order the specific concentration, method, and liter flow per minute.
Safety Precautions
Although oxygen by itself will not burn, it supports combustion. Oxygen safety
precautions in the past included signs, such as, “no smoking, oxygen in use.”
In today’s world hospitals and sometimes campuses, are “smoke-free.” The nurse,
however, should instruct patients and visitors about the hazards of smoking with
oxygen in use.
Oxygen Delivery
How supplied:
Oxygen is supplied in two ways: by cylinders and from wall outlets. The small
cylinders are used for ambulatory patients and emergency situations.
Humidification:
Oxygen administered from a cylinder or wall-outlet unit is dry. The dry oxygen
dehydrates the respiratory mucus membranes. Humidification is necessary as an
adjunct of oxygen therapy. Humidifiers prevent mucous membranes from drying
and becoming irritated and loosen secretions for easier expectoration.
Flow Meter:
A flow meter regulates the amount of oxygen delivered. It is calibrated in liters
per minute. The nurse can regulate the flow meter to the prescribed level. Turn
the knob which allows air flow to elevate a ball so that it is centered on the line of
the desired liter flow.
Devices:
1. Nasal cannula – most common inexpensive low-flow device used to
administer oxygen. It consists of a rubber or plastic tube that extends around
the face, with curved prongs that fit into the nostrils. The cannula is often
held in place by an elastic band or an extension of the tubing. The nasal
cannula does not interfere with eating or talking. It is relatively comfortable,
permits freedom of movement, and is well tolerated by the patient. The usual
flow rate with this is device is 2 L/min.
2. Face mask – cover the patient’s nose and mouth and may be used for oxygen
inhalation. They are made of plastic and mold to fit the face. They are held in
place by adjustable elastic bands. There are a variety of types of face masks
prescribed for specific purposes.
 Simple face mask – used for low-flow oxygen delivery. Delivers oxygen
concentrations from 40% - 60% with liter flows of 5-8 liters / minute.
 Partial rebreather mask – low-flow oxygen delivery. Delivers oxygen
concentrations from 60% - 90% at liter flows of 6 – 10 liters / minute.
 Non-rebreather mask – low-flow oxygen delivery. Delivers the highest
oxygen concentration possible that is 95% - 100% with liter flows of 10 –
15 liters / minute.
 Venturi mask – high-flow oxygen delivery. Used with COPD patients and
deliver oxygen concentration of various concentrations.