E Learning Notes: Administering Oxygen Therapy - Overview of The Skill

E LEARNING NOTES
Administering Oxygen Therapy - Overview of the Skill

Gloves and Administration of oxygen must be ordered by the physician or qualified
practitioner. Some areas will have protocols that govern oxygen therapy
and allow the nurse to begin therapy independently. Oxygen is a drug, so
medication administration criteria are followed in addition to the steps
unique to oxygen therapy. Clients unable to maintain adequate PO2 and O2
saturation levels on room air are candidates for oxygen therapy. An
adequate airway is essential to effectiveness of the treatment. It is best to
treat the hypoxia with the lowest oxygen dose possible. Some clients with
normal oxygen levels are also given oxygen if they are at risk for
complications related to hypoxia; for example, the myocardial infarction
client often receives oxygen therapy to prevent dysrhythmias.
The health care provider will order the oxygen delivery system and flow
rate, and the nurse will monitor response to the therapy. The dosage of
oxygen may be ordered as an FIO2 (fraction of inspired oxygen), which is
expressed as a percentage or as liters per minute (lpm). Respiratory
therapists may be available to assist in the administration and client
assessment of oxygen therapy.

Assessment: 1. Determine client history and acute and chronic health
problems. Clients with carbon dioxide retaining chronic
obstructive pulmonary disease (COPD) will need lower amounts
of oxygen so as not to obliterate their hypoxic respiratory
drive. They may already be on oxygen and need long-term
continuous therapy.
2. Assess the client's baseline respiratory signs, including airway,
respiratory pattern, rate, depth, and rhythm, noting indications of
increased work of breathing. This will help determine the client's
need for oxygen as well as response to the therapy.
3. Check the extremities and mucous membranes closely for
color. This gives some indication of oxygenation, although
problems with circulation and tissue perfusion can alter these
factors also.
4. Review arterial blood gas (ABG) and pulse oximetry results. These
are the most important determinants of the effectiveness of the
pulmonary system and determine the need for therapy as well
as changes in therapy.
5. Note lung sounds for rales/crackles. Secretions will interfere with
airway patency and diffusion of oxygen and carbon dioxide
across the alveolar-capillary bed.
6. Assess the nares, behind the earlobes, cheek, tracheostomy site, or
other places where oxygen tubing or equipment is in constant
contact with the skin to look for signs of skin irritation or
breakdown.

Diagnosis:  Impaired Gas Exchange
 Ineffective Breathing Pattern
 Risk for Injury
 Ineffective Airway Clearance
 Risk for Impaired Skin Integrity
 Activity Intolerance

Planning

Planning Needs: Equipment Needed (see Figures 7-1-1A, 7-1-1B, and 7-1-1C):
 Stethoscope
 Oxygen source-portable or in-line
 Oxygen flow meter
 Oxygen delivery device: nasal cannula, mask, tent, or T-tube with
adapter for artificial airway
 Oxygen tubing
 Pulse oximetry
 Humidifier and distilled or sterile water (not needed with low flow
rates per nasal cannula)

Expected 1. Oxygen levels will return to normal in blood and tissues as evident
Outcomes: by oxygen saturation ≥ 92%, skin color normal.
2. Respiratory rate, pattern, and depth will be within the normal range
for client.
3. The client will not develop any skin or tissue irritation or breakdown.
4. The client will demonstrate methods to clear secretions and
maintain optimal oxygenation.
5. Breathing efficiency and activity tolerance will be increased.
6. The client will understand the rationale for the therapy.

Client Education 1. Clearly explain to the client the reason for oxygen therapy.
Needed: 2. Help the client understand the importance of leaving the delivery
system on.
3. Use pictures to help clients understand their lungs and airway so
they will be more likely to cooperate with the therapy.
4. Make sure clients know what signs and symptoms to report that
indicate therapy is not effective and needs to be changed.
5. Reinforce safety issues-do not make clients overly afraid of a fire,
but make sure they understand that oxygen supports combustion.
6. Show clients methods to increase oxygenation such as pursed-lip
breathing, deep breathing, coughing, and changes in positioning.

Administering Oxygen Therapy - Implementation—Action/Rationale

Implementation ACTION RATIONALE
Action/Rational Nasal Cannula (see Figure 7-1-2)
e
1. Wash hands. 1. Reduces the transmission of
microorganisms.
2. Verify the health care provider's 2. Ensures correct dosage and
order. route.
3. Explain procedure and hazards 3. Increases compliance with
to the client. Remind clients procedures. Oxygen supports
who smoke of the reasons for combustion.
not smoking while O2 is in use.
4. If using humidity, fill humidifier 4. Prevents drying of the client's
to fill line with distilled water and airway and thins any secretions.
close container.
5. Attach humidifier to oxygen flow 5. Allows the oxygen to pass
meter. through the water and become
humidified.
6. Insert humidifier and flow meter 6. For access to oxygen. Many
into oxygen source in wall or institutions also have
portable unit. compressed air available from
outlets very similar in appearance
to oxygen outlets. Green always
stands for oxygen. Be sure to
plug the flow meter into the green
outlet.
7. Attach the oxygen tubing and 7. Rates above 6 liters/min are not
nasal cannula to the flow meter efficacious and can dry the nasal
and turn it on to the prescribed mucosa.
flow rate (1 to 5 liters/min).Use
extension tubing for ambulatory
clients so they can get up to go
to the bathroom (see Figure 7-
1-3).
8. Check for bubbling in the 8. Ensures proper functioning.
humidifier.
9. Place the nasal prongs in the 9. Keeps delivery system in place
client's nostrils. Secure the so client receives the amount of
cannula in place by adjusting oxygen ordered.
the tubing around the client's
ears and using the slip ring to
stabilize it under the client's
chin.
10. Check for proper flow rate every 10. Ensures that client receives
4 hours and when the client proper dose. The nasal cannula
returns from procedures. is a low flow system because it
administers oxygen while the
client also inspires room air. The
actual dose of oxygen received
by the client will vary depending
on the client's respiratory pattern.
The delivery rate may be
changed during procedures.
11. Assess client nostrils every 8 11. Dry membranes are more prone
hours. If the client complains of to breakdown by friction or
dryness or has signs of pressure from nasal cannula.
irritation, use sterile lubricant to
keep mucous membranes
moist. Add humidifier if not
already in place.
12. Monitor vital signs, oxygen 12. Detects any untoward effects
saturation, and client condition from therapy.
every 4 to 8 hours (or as
indicated or ordered) for signs
and symptoms of hypoxia.
13. Wean client from oxygen as 13. Oxygen is not without side effects
soon as possible using standard and should be used only as long
protocols. as needed. Problems with
reimbursement may develop if
criteria for therapy are not met.
Mask:Venturi (high flow device), simple mask (low flow), partial
rebreather mask, nonrebreather mask, and face tent
microorganisms.
15. Repeat Actions 2-6. 15. See Rationales 2-6.
16. Attach appropriately sized mask 16. Ensures proper fit; size needed is
(see Figure 7-1-4) or face tent based on the client's size.
to oxygen tubing and turn on Checks the oxygen source and
flow meter to prescribed flow primes the tubing and mask or
rate. The Venturi mask will have tent.
color-coded inserts that list the
flow rate necessary to obtain
the desired percentage of
oxygen. Allow the reservoir bag
of the nonrebreathing or partial
rebreathing mask to fill
completely. Figure 7-1-5 shows
several types of oxygen masks.
humidifier.
18. Place the mask or tent on the 18. Prevents loss of oxygen from the
client's face, fasten the elastic sides of the mask.
band around the client's ears
and tighten until the mask fits
snugly.
19. Check for proper flow rate every 19. Ensures that client is receiving
4 hours. the proper dose.
20. Ensure that the ports of the 20. Air must be entrained to mix
Venturi mask are not under room air and oxygen coming
covers or impeded by any other from source to ensure proper
source. oxygen percentage (FIO2).
21. Assess client's face and ears 21. Provides client comfort and
for pressure from the mask and prevents skin breakdown.
use padding as needed.
22. Wean client to nasal cannula 22. Oxygen is not without side
and then wean off oxygen per effects and should be used
protocol. only as long as needed. The
nasal cannula provides a
lower FIO2 than the mask.
Problems with reimbursement
may develop if criteria for
therapy are not met.
Oxygen via an Artificial Airway (tracheostomy or endotracheal tube)

microorganisms.
24. Verify the physician's or 24. Ensures correct dosage and time.
qualified practitioner's order.
25. Fill the humidifier with sterile 25. Avoids contamination of the
water and close the container. water.
26. Attach humidifier and warmer to 26. Humidification and warming of
the oxygen flow meter the air are essential with an
(see Figure 7-1-6). artificial airway because the
upper airway is bypassed by the
tube.
27. Attach the wide bore oxygen 27. Checks the oxygen source and
tubing and T-tube adapter or primes the tubing and adapter.
tracheostomy mask to the flow
meter and turn the meter to the
flow rate needed to achieve the
prescribed oxygen
concentration. An oxygen
analyzer may be used to check
the actual oxygen percentage
being delivered.
humidifier and a fine mist from
the adapter.
29. Attach the T-piece to the client's 29. Ensures that client will not
artificial airway or place the develop complications related to
mask over the client's airway. an interrupted oxygen supply.
Be sure the T-piece is firmly
attached to the airway
(see Figure 7-1-7).
30. Position tubing so that it is not 30. Provides for client comfort and
pulling client's airway. prevents dislodgment of the
artificial airway.
31. Check for proper flow rate and 31. Ensures that client is receiving
patency of the system every 1 proper dose.
to 2 hours depending on the
acuity of the client. Suction as
needed to maintain a patent
airway.
32. Monitor airway patency, vital 32. Detects response to or any
signs, oxygen saturation, and untoward effects from therapy.
for signs and symptoms of Determines whether tube is in
hypoxia every 2 hours, or more place.
frequently as necessary or as
ordered. Additionally, monitor
breath sounds and tube position
every 4 hours.
33. Wean client from therapy as 33. Prevents untoward effects of
ordered by physician or oxygen.
qualified practitioner. The client
will probably receive oxygen via
another route once the tube is
removed. Some clients have
tracheotomies permanently.
Administering Oxygen Therapy - Post-Skill

Evaluation:  Oxygen levels returned to normal in blood and tissues as
evident by oxygen saturation ≥ 92%; skin color normal for client.
 Respiratory rate, pattern, and depth are within the normal range.
 The client did not develop any skin or tissue irritation or
breakdown.
 Breathing efficiency and activity tolerance are increased.
 The client understands the rationale for the therapy.

Documentation: Nurses’ Notes

 Record O2 saturation and respiratory status.

 Note method of oxygen delivery and rate.
 Document client's assessment parameters and response to
treatment.
 Note and record changes in mental status.

Variations

Geriatric Variations:  Clients may pull at tubes; they need frequent reorientation and
explanation.

Pediatric  Clients may be frightened and pull off the O2 mask and increase
Variations: respiratory effort with crying. Try putting the mask on yourself
and make a game out of it so the child is less frightened.

Home Care  Oxygen may be provided by a high pressure cylinder, an
Variations: oxygen concentrator, or a liquid oxygen system. Spare tanks
and a backup power source are recommended. Compressed
oxygen gas in a cylinder is available in sizes H or K for large
stationary tanks and sizes D and E for travel and in the event of
a power failure. Portable carts and carrying shoulder cases are
also available. The company supplying the equipment will
usually have personnel that will help with the setup and specific
cleaning needs of the oxygen source.
 While any delivery system may be used in the home, nasal
cannulas and tracheostomy tents/masks are the most
commonly used. Home care clients may receive oxygen via a
Spofford Christopher Oxygen Optimizing Prosthesis
transtracheal system (SCOOP) catheter placed down into the
trachea via a small stoma. It is held in place by a bead chain
necklace and needs regular cleaning. Tubing, delivery system,
and humidifier container should be washed regularly every 2 to
7 days with soap and water, disinfected, and dried before reuse,
so an alternate setup should be available. Post safety
precautions in the home. Oxygen sources should be kept from
heating units, walls, drapes, and combustible substances such
as hair spray.

Long-Term Care  Long-term clients are more likely to develop skin irritation and
Variations: mucous membrane dryness from oxygen therapy. Padding may
be needed at friction sites. Humidity may be needed to reduce
dryness.
Administering Oxygen Therapy - Common Errors

Possible
The wrong flow rates are used.
Errors:

Prevention: Be sure to administer the flow rate ordered. Be aware of client history of lung
disease. Clients with lung disease cannot tolerate high flow rates of oxygen.

Possible The wrong delivery system is used.
Errors:

Prevention: Double-check the order. Assess the client's needs. Is the client a mouth
breather? Does the client have an artificial airway in place? Does the client
need humidified oxygen?

Possible The wrong client receives treatment.
Errors:

Prevention: Double-check the wristband, or ask the client to tell you his or her name.
Double-check written orders.

Nursing Tips:  Recognize which equipment to use; keep a chart on the unit that
gives information on flow rates and settings of different devices.
 Promote client comfort by adjusting tubing or padding so that clients
are more likely to leave oxygen therapy equipment on.
 Water will often collect in the corrugated tubing used for masks, T-
tubes, and tracheostomy tents, and creates pulls on the devices and
bubbling noises. Try to avoid dependent loops and empty the water
from the tubing into the appropriate container. Do not empty water
back into the humidifier container because this can cause
contamination of the humidifier.

Critical Thinking Skill

Introduction: Look at an example in which the nurse prevents potential cardiac arrest in a
client receiving oxygen via a tracheostomy.

Possible The client is receiving oxygen at 40% via a tracheostomy mask. The client's
Scenario: respirations are increased with intercostal retractions and tachycardia, and
are very flushed to cyanotic color. The nurse quickly checks to make sure the
oxygen is hooked up to the wall and connected to the client properly. The
oxygen source is attached correctly, but the humidification bottle is dry. There
are no visible secretions in the tracheostomy or T-tube adapter. When
assessing the client's breath sounds, she or he notices very diminished
sounds, and the client is in more and more distress. While calling for help, the
nurse tries to pass a suction catheter down the tracheostomy, but is unable to
pass the catheter or ventilate with a manual resuscitation bag (Ambu(r)-bag).
Finally, the nurse removes the inner cannula and finds a large, solid mucus
plug attached to the cannula. The client's respiratory distress subsides and
the cannula is cleaned and replaced.

Possible Cardiopulmonary arrest and death of the client resulting from an obstructed
Outcome: airway, could result.

Prevention: Ensure that clients with tracheostomies receive humidification to prevent
secretions from thickening and obstructing the airway.
Assisting a Client with Controlled Coughing and Deep Breathing - Overview of

the Skill

Overview: Teaching clients controlled, effective coughing techniques is essential
in the management of bronchial secretions. It should be taught to all
clients undergoing surgery and is essential for the management of
excessive respiratory secretions in clients with lung conditions from
acute to chronic. Secretions must be removed to prevent atelectasis
and pneumonia. Furthermore, immobility causes the pooling of
bronchial secretions in the gravity-dependent areas of the lungs and
blocks off small airways, and leads to trapping of secretions or closure
of these airways. As a result, less surface area of the lung is available
for ventilation, which leads to hypercapnia and hypoxemia. Deep,
controlled breathing reopens small airways, and coughing promotes
the removal of secretions.

Assessment: 1. Identify need for controlled coughing such as thick, tenacious
secretions; weak or ineffective cough; abnormal breath sounds; or
inability to take a deep breath because these conditions may
increase the client's risk for impaired respiratory function.
2. Assess breath sounds by auscultation throughout lung fields,
especially in dependent areas so comparison can be made to
baseline assessment after coughing and deep breathing.
3. Assess by percussion, if necessary, to verify ausculatory sounds.
4. Assess by tactile means for fremitis to verify presence of
secretions.
5. Assess the client for understanding, ability, and cooperation to
perform a controlled cough so the nurse can tailor client
education needs.

Diagnosis:  Ineffective Airway Clearance
 Altered Tissue Perfusion
 Deficient Knowledge regarding controlled coughing technique

Planning

Planning Equipment Needed (see Figure 7-2-1):
Needs:

 Tissues
 Water pitcher and glass
 Emesis basin
 Stethoscope
 Pillows for splinting the client's chest and abdomen
 Gloves

Expected 1. The client will be able to breathe deeply and clearly.
Outcomes: 2. The client will be able to use effective breathing techniques.
3. The client will be able to cough productively if secretions are present
on assessment.
4. The lung fields will be clear to auscultation; that is, there is absence
of atelectasis, or adventitious sounds (rales/crackles, or rhonchi).
5. The client's respiratory rate will be normal.
6. The client will have good skin color (for race) and mentation.

Client 1. Teach the client the rationale for effective deep breathing and
Education coughing.
Needed: 2. Show the client how to hold a pillow to the chest to support the chest
and abdominal muscles.
3. Instruct the caregiver how to assist the client with coughing and deep
breathing.
4. Teach the caregiver how to recognize changes in the client's
respiratory pattern.
5. Ask clients to turn their head away from the nurse when coughing.
6. Instruct clients to cover their mouth with tissue paper while coughing.
7. Tell the client to hold the inspiration for 1 to 2 seconds before
coughing for it to be effective.
8. Teach clients with lung disease to huff cough to clear central
airways: Take a slow, deep breath; hold it for 2 seconds; contract
expiratory muscles; and open mouth and say "huff" several times
while exhaling.
Assisting a Client with Controlled Coughing and Deep Breathing -

Implementation—Action/Rationale

Action/Rational 1. Wash hands. 1. Reduces the transmission of
e microorganisms.
2. Assess the client's pain status. 2. If pain is not controlled in clients
with abdominal or thoracic
surgery, they will not be able to
cooperate.
3. Explain the purpose and 3. Elicits client's cooperation.
importance of the procedure.
4. Help the client sit in a high 4. An upright posture allows for
Fowler's position if able. maximal lung expansion.
5. Auscultate lungs before 5. Allows nurse to know which areas
procedure (see Figure 7-2-2). of the lungs need more effective
coughing, deep breathing, and
repositioning.
6. Place the palms of your hands 6. Assesses effective expansion of
on the client's rib cage. chest.
7. Use pillow or folded towels to 7. Decreases pain with deep
splint the abdomen or chest if expansion in postoperative clients
client has had surgery and promotes effective deep
(see Figure 7-2-3). breathing and coughing.
8. Practice deep breathing with 8. Promotes loosening of secretions.
client:
 Repetition is necessary to
 Instruct the client to cough up secretions.
cover the mouth with
tissue (use mask, gloves,
and gown for staff as
needed).
 Take a deep breath in
and exhale slowly and
repeat 2 to 3 times.
 Repeat 10 times every 1
to 2 hours as needed.
9. Reassess lung fields after 9. Evaluation of procedure is

procedure. necessary to know whether
procedure should be repeated.
10 Assist the client to cough as 10 Even though deep inspirations
. follows: . may clear airways of clients with
atelectasis, coughing is essential
 Follow the procedure for to clear bronchial secretions,
deep breathing and have especially from lower airways.
the client hold breath for
1 to 2 seconds.  After a deep inspiration,
 Contract abdominal the force of the air will be
muscles, cough behind the mucus and
forcefully, and propel it upward. The force
expectorate secretions of the air after the deep
into tissue or basin as inspiration and the muscle
nurse splints incision contractions enable more
areas as appropriate effective coughing.
(see Figure 7-2-4).  The nurse can also use
 Splint the client's splinting at this time to
abdomen and chest as help with force of
he or she coughs by abdominal contraction.
pressing on lower chest
wall and abdomen with
your hands.
11 Repeat as necessary to clear 11 It is essential to clear airways to

. lung fields; however, be aware . prevent atelectasis and
that excessive coughing can pneumonia. If excessive coughing
irritate the trachea and bronchial happens, the client may cause
tree. Clients with chronic irritation and compromise
respiratory problems may need respiratory status.
to repeat the procedure at more
frequent intervals but with fewer
coughs with each procedure.
Adjunct therapy may be
necessary.
12 Observe for dizziness, shortness 12 May indicate hyperventilation.
. of breath, or other respiratory .
problems.
13 Dispose of all tissues and wash 13 Reduces the transmission of
. hands. . microorganisms.
Assisting a Client with Controlled Coughing and Deep Breathing - Post-Skill

Evaluation:  The client is able to breathe deeply and clearly.
 The client is able to use effective breathing techniques.
 The client is able to cough productively if secretions are present
on assessment.
 The lung fields are clear to auscultation, that is, there is
absence of atelectasis, rales/crackles, or rhonchi.
 The client's respiratory rate is normal.
 The client has good skin color and mentation.


 Record date and time of procedure.

 Include description of secretions and amount expectorated.
 Record results of auscultation before and after procedure.

Variations

Geriatric Variations:  Elderly clients may not effectively use deep breathing and may
need more instruction from the nurse.
 The tracheal tissue may be more fragile and at risk for bleeding
if coughing is too vigorous.
 Elderly clients may need more support during the procedure
such as help splinting the chest or abdomen with a pillow.

Pediatric  Crying may occur with coughing and pain after surgery and may
Variations: be appropriate in clearing airways of children.
 Children may benefit from hugging their favorite stuffed animal
instead of a pillow.
 Play therapy can be used in performing the procedure so it is
like a game.
 Children will need to have pain medication 30 minutes before
the procedure to help them cooperate.

Home Care  Long-term immobility will lead to increased secretions.
Variations:  Ask family members to assist with routine coughing and deep
breathing procedures.
 Assess the home for ventilation or air conditioning and the
client's reaction to the environment.
 Provide instruction on the proper disposal of secretions and
used tissues to decrease the risk of transmission of
microorganisms.

Long-Term Care  Immobility may lead to increased secretions.
Variations:  Encourage clients to walk in the halls.
 Increasing fluid intake will decrease viscosity of secretions.
Assisting a Client with Controlled Coughing and Deep Breathing - Common

Errors

Possible The client is not able to take a deep breath because you did not allow enough
Errors: time for pain control before starting the controlled breathing and coughing
procedure.

Prevention: Plan the pain medication dose for at least 30 minutes before the time of the
procedure. If not enough time was allowed for pain control, stop the breathing
exercise and allow the pain medication to take effect. Assess the client for
pain. Ask whether client is ready to do the deep breathing and coughing.
When client is ready, proceed.

Nursing Tips:  As clients take deep inspirations, breathe with them to help with
timing.
 Use gown, gloves, and mask with clients who have copious
secretions or clients who expectorate vigorously.
 Abdominal binders may be necessary for clients with major abdominal
surgery to avoid dehiscence.
 If clients complain of severe abdominal chest tube insetion site the
procedure, evaluate the wound site and pain status.


Introduction: If a client continues to have crackles and decreased breath sounds after
controlled breathing and coughing, there may be cardiovascular involvement.

Possible A 58-year-old smoker with a history of mild congestive heart failure has a
Scenario: hernia repair. After surgery he continues to have a moist cough and crackles
in the lower bases of the lungs.

Possible This client's nurse knows that the presence of fluid in the lungs may be
Outcome: related to pulmonary edema. He or she has the client cough to determine if
post-tusic rales are present. The nurse instructs him to change positions and
assesses whether the areas of crackles/rales or rhonchi change. They do
not. The nurse checks the client's weight and assesses for edema. He or she
listens for a third heart sound and reviews the intake and output information.
Finally, he or she checks vital signs and notifies the physician of signs and
symptoms indicative of congestive heart failure.

Prevention: Monitor fluid status and risk status of client each shift and be cognizant of any
early signs of change in cardiac and respiratory status.
Measuring Peak Expiratory Flow Rates - Overview of the Skill

Overview: A peak flow meter is a device that measures how well air moves out
of the lungs. Peak expiratory flow rate measures the rate of air
expired at the beginning of respiration, which correlates with the large
airway status. This test can be performed on children as young as 3
to 4 years old; other pulmonary function tests usually require more
maturity (i.e., more than 5 years of age). It is a simple measure of the
airflow and can determine how well one is breathing. If a client has a
breathing problem such as asthma, the physician or qualified
practitioner may recommend that the client use a peak flow meter.
The health care provider can provide a treatment plan that will tell
what actions to take when there is a change in the airflow. A written
record (peak flow monitoring chart) should be kept. Reviewing the
daily record can help the client and the health care provider check
closely on the asthma to provide the best treatment plan.
The peak flow meter should be used for the following:

1. When a client with asthma has an attack, the lungs are blocked and
air cannot move easily. Therefore, the peak flow meter will help
determine for a client with asthma how much the lungs are blocked.
2. The peak flow meter should be used when the client is experiencing
breathing problems to let the health care provider and client know
how serious the problem is and how well the asthma treatment is
working.
3. The peak flow meter can provide an objective measure of the
severity of the disease; response to treatment permits detection of
airway obstruction before wheezing can be heard through a
stethoscope or symptoms can be felt. Thus, the client can begin
treatment of episodes earlier and the likelihood of serious episodes
decreases.
4. During an asthma episode, the airways of the lungs begin to narrow
slowly. The use of a peak flow meter can help determine whether
there is a narrowing hours before symptoms of asthma appear. By
taking the medication(s) early (before the symptoms), the asthma
exacerbation can be stopped quickly and a serious episode avoided.

Assessment: 1. Take a complete history from the client, or a reliable informant, about
the signs and symptoms of the attack, and the frequency of the
attacks. Evaluates the frequency and severity of the episodes.
2. Ask about all medications the client takes on a regular basis, or as
needed, including over-the-counter drugs. If the client uses
medication frequently, regular measurement with a peak flow
meter may be required.
3. Assess the client's ability to cooperate with testing. A client who is
unable to reliably perform a spirometry or pulmonary function
test may not be able to provide an accurate peak flow meter
reading.

Diagnosis:  Ineffective Breathing Pattern
 Risk for Suffocation

Planning

Planning Equipment Needed:
Needs:

 Peak flow meter with mouthpiece (see Figures 7-6-1A and 7-6-1B)

 Peak flow record or chart
 Calculator

Expected 1. The client will use the peak flow monitor to monitor the course of
Outcomes: asthma and response to treatment using objective criteria to add or
decrease medication.
2. The client will detect early stages of airway obstruction.
3. The client will have an accurate perception of the severity of the
obstruction.
4. The client will accurately determine when emergency medication
care is needed.
5. The client will be able to distinguish between airway obstruction (e.g.,
asthma) and other causes of breathlessness (e.g., hyperventilation).
6. The effectiveness of client communication will be improved by
providing objective assessment of asthma severity.

Client 1. Show the client the peak flow meter. It has a mouthpiece with a
Education needle or pointer that corresponds to a particular number or reading.
Needed: 2. Describe the advantages of using a peak flow meter.
3. Explain how it works.
4. Demonstrate to the client the correct use of a peak flow meter.
5. Explain the peak flow zone system for using the peak flow meter to
manage asthma.
6. Calculate the client's three zones (green/yellow/red) based on
predicted values. "Predicted or usual" value is an average peak flow
value based on the peak flow reading of a large number of people
grouped by height and age. An individual peak flow reading may vary
widely and may be consistently higher or lower than such average
values. Therefore, each client will have his or her own "personal
best" value-the peak flow value established by the client during a 2 to
3 week period in which the client records peak flow measurements at
least two times a day. The personal best is the best number a client
has ever achieved with or without medications. Remind the client that
many clients have peak flow scores that are either higher or lower
than the predicted value. Emphasize that it is important to find the
client's true personal best in order to develop the best treatment to
manage asthma for the individual client.

Action/Rationale
1. Set up all the equipment needed 1. Promotes efficiency, thus gains
such as the peak flow meter with client's confidence in the nurse.
mouthpiece, record/ chart, and
calculator before going to the
client's room.
2. Identify the client and confirm 2. Promotes accuracy in teaching

the height, age, and gender of the use of a peak flow meter.
the client.
3. Explain and demonstrate the 3. Promotes client's compliance.

procedure to the client.
4. Have the client stand up or sit in 4. Expands the lungs to their

high Fowler's position with the maximum.
chin slightly up.
5. Show the client how to place the 5. Ensures accuracy in the reading.
indicator/pointer at the base of
the numbered scale.
6. Have the client take a deep 6. Maximizes expansion of the

breath through the mouth. lungs.
7. Teach the client to hold the peak 7. Promotes accuracy in the reading.
flow meter without touching the
pointer or needle.
8. Have the client place the peak 8. Promotes a good seal and reflects
flow meter in the mouth and the actual flow.
close the lips and teeth around
the mouthpiece without putting
the tongue inside the tube
(see Figure 7-6-2).
9. Have the client blow out as hard 9. Reflects the actual flow in the
and as fast as possible over a lungs.
period of about a second (not a
prolonged expiration).
10 Teach the client how to read the 10 Ensures accurate documentation

. number on the meter and where . of the results.
to record the number
(see Figure 7-6-3).
11 Show the client how to slide the 11 Permits choosing the best value
. pointer down to 0 and have the . among the three tries.
client repeat Actions 5-10 two
more times.
12 Allow the client to rest between 12 Ensures that each test is the
. attempts if necessary. . maximum possible value.
13 Write down the highest of the 13 The highest number is used to

. three numbers achieved on the . identify the client's best peak
client's chart/record. expiratory flow rate. Subsequent
rates are compared to the client's
best rate in order to identify the
client's zone.
14 Use the zone determination to 14 Zone determination provides an

. evaluate what course of . accurate, understandable
treatment should be followed. indicator of the course of
treatment to follow.
 A peak flow reading
between 80% and 100%  The green zone indicates
of the predicted value or that the asthma is under
personal best is the control.
green zone. The client  The yellow zone indicates
should continue using some increase in
the regular asthma inflammation and airway
medications. obstruction.
 A peak flow reading  The red zone indicates a
between 50% and 80% severe amount of
of the predicted value or inflammation and
personal best is the reactivity.
yellow zone. The client
should use the "as
needed" medication
ordered by the physician
or qualified practitioner.
The peak flow reading
should be checked again
10 minutes after
medication usage to
evaluate medication
effectiveness. If no
improvement is
observed, the client may
call the physician or
qualified practitioner, or
wait another 4 hours to
do another peak flow
reading and see whether
the value has gone up to
the green zone.
 A peak flow reading of
less than 50% of the
predicted value or
personal best is the red
zone. The client should
use the "as needed"
medication ordered and
call the health care
provider right away.
Measuring Peak Expiratory Flow Rates - Post-Skill Evaluation:
 The client uses the peak flow meter to monitor the course of asthma and response to
treatment, using objective criteria to increase or decrease the medication.
 The client can detect early stages of airway obstruction.
 The client has an accurate perception of the severity of the obstruction.
 The client accurately determines when emergency medical care is needed.
 The client is able to distinguish between airway obstruction (e.g., asthma) and other
causes of breathlessness (e.g., hyperventilation).
 The effectiveness of client communication is improved by providing objective
assessment of asthma severity.
Documentation:
Peak Flow Meter Record/Chart

 Record the best reading.

 Note any symptoms the client may have.
 Record any interventions required.

Medication Administration Record

 If a client will be given a treatment such as albuterol, document the amount, dosage,
manner, and time the medication was given.
Variations Geriatric Variations:
 Peak expiratory flow rate is based on age, height, and gender. The numbers usually
decrease in the geriatric age group compared with adults as a whole because lung
capacity decreases as people age.
 When using the peak flow meter, the client should be in a standing position if possible;
otherwise, an upright sitting position is preferred.
 Make sure that the client understands how to plot and interpret the numbers and zones.
 Have a sample/practice for better client compliance.
 Enlarged-print versions of charts will let the client see the readings/values more easily.
Pediatric Variations:
 It takes some maturity to use the peak flow meter and usually 3- to 4-year-olds can start
doing it.
 Some kids treat it as a game and have an incentive to do it correctly.
 Some nurses or parents instruct the client to do it just like blowing out birthday candles or
use a tissue paper, hold it about a foot away, and have the client blow as hard as possible
to move it.
 The nurse should convey the instructions so that the child can understand it at his or her
own level.
 Use colored graphs (green, yellow, and red) to let the child participate in the task.
Remind parents that they need to bring in the child's peak flow meter, including the
colored graphs, every time they come in for the recheck appointments.
 As the child grows taller, the predicted values should also increase. Therefore, regular
physician's visits should be kept.
Home Care Variations:
 Demonstrate to the client the correct use of a peak flow meter and have the client
practice. Correct the client's technique as needed. Write the instructions step-by-step.
 It is important to keep the peak flow meter clean and dust-free. The removable
mouthpiece can be cleaned by washing it in warm soapy water and then rinsing
thoroughly.
 Use the predicted peak flow value until the client's personal best value is determined.
Explain the difference between the predicted and personal best values as well as the zone
system in managing asthma.
 Calculate the client's three zones (green, yellow, and red) based on the predicted value.
Develop a schedule to establish the client's true personal best value. Emphasize that
identifying the client's personal best peak flow value by filling out the diary for 2 to 3
weeks will help ensure that the client receives the right amount and type of medication. It
may also lead to a reduction in the number and severity of asthma episodes. Instruct the
client to take peak flow readings every day for 2 to 3 weeks, morning and afternoon
before medication(s).
 Schedule a follow-up appointment to determine the true personal best score that will be
used instead of the predicted value. Remind the client to bring the sheets on the return
visit.
Long-Term Care Variations:
 Continue daily monitoring of peak flow if more data are needed to establish a pattern or if
the peak flow reading is consistently in the yellow or red zone.
 There are clients who are on daily medications such as inhaled corticosteroids and/or
long-acting beta-2 agonists, and these clients are also advised to check the peak flow rate
twice a day before the medications.
 Clients should bring their peak flow meter to the physician's or qualified practitioner's
office to check the accuracy of the unit and to review the proper use of the peak flow
meter as well as the charts to check client compliance.
 Use the colored peak flow diary to keep track of the peak flow readings.
 Clients should find the personal best peak flow number per instructions of the nurse and
follow the asthma control plan on the peak flow zone system as explained previously. A
decrease of 20% or greater of the client's personal best may mean the start of an asthma
episode. Indicate if any symptoms are present.

Measuring Peak Expiratory Flow Rates - Common Errors

Possible The client is getting very low values even though the client seems to be doing
Errors: well and is not having symptoms.

Prevention: Give proper instructions and a demonstration to the client prior to the test and
observe and correct the technique to get a reliable and accurate result.
Instruct the client not to put the tongue into the tube. The client should stand
up straight, take a deep breath, and blow as fast and as hard as possible in
just 1 second.

Possible An 8-year-old boy has a 3-year-old peak flow meter and the numbers are
Errors: always low.

Prevention: Change the peak flow meter about once a year. Make sure that the needle or
pointer works well. The metallic spring inside the peak flow meter might
develop some rust over time, thus skewing the results. There is a pediatric or
low range meter, which goes up to 300, and an adult or standard range
meter, which goes up to 800. However, if a client is in the pediatric age group
but can blow close to or as high as 300, the standard range peak flow meter
should be used.

Nursing Tips:  Demonstrate the technique and explain the purpose of using the peak
flow meter. Avoid using technical jargon when teaching the client or
the parent.
 Make sure the clients/parents are well informed before you let them
go home. Let the client demonstrate to you the technique in using the
peak flow meter.
 Practice plotting the numbers on the chart and give a sample scenario
to check whether the client understands the instructions. Ask the
client what to do based on the peak flow zoning system and asthma
action plan.
 Make sure the client's effort is valid and technique correct. The client
should stand up straight, take a deep breath, and blow into the
mouthpiece very hard and fast. The tongue should not be in the tube
while blowing. The nurse should distinguish between coughing and a
real blow.
 Be aware of the client's predicted value, which is based on height,
age, and gender. Find out the ranges or zones based on the predicted
value. Plot the numbers on the chart.
 The peak flow reading can be repeated 5 to 10 minutes after the
treatment is done (post-blow) to see whether the reading will go back
to the green zone. If the reading is still in the yellow or red zone, the
peak flow can be checked again after 4 hours to see whether the
numbers have improved (green zone). If not, another albuterol
treatment can be given, followed by another post blow in 5 to 10
minutes. If the reading continues to be in the yellow or red zone, the
health care provider should be consulted.


Introduction: It is important that the client understands the necessity of doing peak flow
readings and monitoring the results.

Possible A mother and a 7-year-old came to the clinic with the latter referred for an
Scenario: evaluation of asthma. The client was taught how to use the inhalers and peak
flow meter. The mother was uncooperative and thought that doing the peak
flow readings was just a waste of time and plotting the numbers was too
complicated.

Possible The client's mother calls a week later complaining that her daughter has
Outcome: some chest tightness and coughing. Now the peak flow reading is about 100
(lower limit of the yellow zone). The mother is not sure of the significance of
that number and does not know what to do next. She also does not know the
client's personal best. The peak flow measurement had only been taken once
because they "did not have time to do it."

Prevention: Explain the importance of peak flow monitoring. Demonstrate to the client the
correct way of using a peak flow meter and let the client demonstrate it to
you. Correct the client's technique if needed. Explain the peak flow zone
system to manage asthma. Have a practice and let the client/parent plot the
reading/value on the chart. Do a possible scenario, such as giving a value,
and then let them decide what to do next by using the asthma action plan.
Incentive Spirometry - Overview
Incentive spirometry assists the patient in deep breathing. An incentive

Overview: spirometer (IS) is most often used following abdominal or thoracic
surgery to help reduce the incidence of postoperative pulmonary
atelectasis. The use of an IS is especially important in patients with
underlying pulmonary diseases because of their risk for postoperative
pneumonia. Postoperative deep breathing and coughing have been
shown to be as effective as using an IS when performed frequently.
The advantage of an IS is the device's visual feedback to patients about
the depth of their breaths. There are two types of spirometers: flow-
oriented and volume-oriented. Flow-oriented ISs See Figure 1 have one
or more plastic chambers with freely movable colored balls. As the
patient inhales slowly, the balls are elevated to a premarked area. The
patient's goal is to keep the balls elevated for as long as possible to
ensure maximal sustained inhalation, not to snap the balls to the top of
the chamber with a rapid, very brief, low-volume breath. Even if a very
slow inspiration does not elevate the balls, this pattern may achieve
greater lung expansion. The advantage of a flow-oriented IS is the slow,
steady expansion of the lung.
Volume-oriented ISs See Figure 2 have bellows that the patient must
raise to a predetermined volume by inhaling slowly. An achievement light
or counter is used to provide feedback to the patient. Some devices
have a marker that moves up as the patient inhales. The advantage of
the volume-oriented IS is that a known inspiratory volume can be
achieved and measured with each breath.
The use of an IS encourages patients to breathe deeply and achieve
their normal inspiratory capacity. Before surgery, it is helpful to
determine the patient's baseline inspiratory capacity. An inspiratory
volume one-half to three-quarters of baseline is an acceptable
postoperative volume. Patients benefiting from incentive spirometry
include those using it preoperatively, especially before abdominal,
cardiac, or orthopedic surgery; patients with a history of smoking,
pneumonia, or chronic respiratory disease; and patients with atelectasis.
Expected  Patient demonstrates correct use of the IS.

Outcomes  Patient achieves target volume and number of repetitions per
hour.
 Patient has normal breath sounds.
 Patient is unable to achieve incentive spirometry target volume.

Unexpected  Patient has decreased lung expansion or abnormal breath
Outcomes sounds.
Incentive Spirometry - Assessment and Preparation
 Explain procedure to patient and family.

Preparation  Indicate to patient where on the spirometer is the target volume.
 Flow-oriented IS or volume-oriented IS
Supplies
 Identify patients who would benefit from incentive spirometry,

Assessment especially those who have existing pulmonary disease, are
overweight, or have other debilitating chronic illnesses.
 Assess patient's respiratory status, including symmetry of chest wall
expansion, respiratory rate and depth, sputum production, and lung
sounds.
 Review physician's order for incentive spirometry.
Incentive Spirometry - Procedure
1. Perform hand hygiene.
Rationale: Reduces transmission of microorganisms.
2. Position patient in semi-Fowler or high Fowler position.
Rationale: Promotes optimal lung expansion during respiratory maneuver.
3. Instruct patient to place lips completely over mouthpiece.
Rationale: Showing patient how to correctly place mouthpiece is a reliable

technique for teaching psychomotor skill, and it enables patient to ask questions.
4. Instruct patient to take a slow deep breath and maintain a constant flow, like pulling
through a straw. When maximal inspiration is reached, patient should hold breath for 2
to 5 seconds and then exhale slowly.
Rationale: Maintains maximal inspiration and reduces risk of progressive

collapse of individual alveoli.
Patients with chronic obstructive pulmonary disease may be able to hold
their breath for only 2 to 3 seconds. Encourage patients to do their best
and to try to extend the duration of breath holding. Allow patients to rest
between IS breaths to prevent hyperventilation and fatigue.
5. Have patient repeat maneuver until goals are achieved.

Rationale: Ensures correct use of IS and patient's understanding of use.
Incentive Spirometry - Post Procedure and Variations
1. Observe patient's ability to use incentive spirometry by return

Post demonstration.
Procedure
Rationale: Determines patient's ability to perform breathing
exercise correctly.
2. Assess whether patient is able to achieve target volume or frequency.
Rationale: Measures compliance with therapy and lung

expansion.
3. Auscultate chest during respiratory cycle.
Rationale: Documents lung wall expansion, identifies any

abnormal lung sounds, and determines whether airways are
clear.
 Record the lung sounds before and after incentive spirometry, the
Documentatio frequency of use, the volumes achieved, and any adverse effects.
n  Report any changes in respiratory assessment or patient's inability to
use the IS.
 Teach patient to examine sputum for consistency, amount, and color

Patient changes.
Education  Teach patient the rationale for performing incentive spirometry and the
impact on recovery.
Age-Speficic Pediatrics
Consideration
s  Incentive spirometry is not typically used in pediatrics, except in
school-age children; pediatric patients need the fine motor skills and
ability to follow instructions to use incentive spirometry effectively.
 Allowing the child to play with and try out the IS assists in decreasing
the child's anxiety and encourages participation in care.
 Use games or bubbles and balloons to encourage small children to
take deep breaths. These activities can achieve the same goals as an
IS in some children.
Geriatrics
 Older adults with chronic illnesses or arthritis may have difficulty

coordinating the use of an IS. They may require additional time to
demonstrate the procedure.
 Weakened respiratory muscles and decreased elastic recoil properties
of the lungs affect a patient's ability to cough and breathe deeply.
Therefore, it may take an older adult longer to achieve the target
volume.
Chest Physiotherapy: Postural Drainage - Assessment and Preparation
1. Explain purpose and rationale for procedure. Explain positioning,

Preparation sensations, how long it will take, and any discomforts or side effects.
2. Encourage high fluid intake program unless contraindicated by other
diseases and if physician approves. Maintain record of fluid intake
and output.
Contraindications to high fluid intake are congestive heart

failure and renal failure. When forcing fluids, build up daily
intake gradually, and strive toward 8 to 12 8-oz glasses or
until mucus is thin, white, and watery.
3. Plan treatments so that they do not overlap with meals or tube

feeding. Avoid postural drainage for 1 to 2 hours after meals or bolus
tube feedings. Stop all continuous gastric tube feedings for 30 to 45
minutes before postural drainage. Check for residual feeding in
patient's stomach; if greater than 100 mL, hold treatment.
4. Schedule treatments at appropriate times during day.
5. Have patient remove any tight or restrictive clothing.
 Stethoscope
Supplies  Pulse oximeter
 Trendelenburg hospital bed or tilt table
 Water in pitcher and glass
 Chair (for draining upper lobes)
 One to four pillows
 Tissues and paper bag
 Clear, graduated screw-top container
 Suction equipment (if patient unable to cough and clear own
secretions)
1. Assess patient for contraindications to postural drainage [See Box

Assessment 1] or a history of conditions that pose a risk for impaired airway
clearance, including decreased level of consciousness, muscle
weakness, and disease processes, such as pneumonia and chronic
obstructive pulmonary disease.
2. Assess patient, and review medical record for signs and symptoms
that indicate the need to perform postural drainage: radiographic film
changes consistent with atelectasis, lobar collapse pneumonia, or
bronchiectasis; ineffective coughing; thick, sticky, tenacious, and
discolored secretions that are difficult to cough up; abnormal breath
sounds, such as wheezing and rhonchi; or palpable fremitus
3. Identify which bronchial segments need to be drained by reviewing
chest radiograph reports and performing auscultation over all lung
fields to assess for decreased breath sounds, wheezes, and rhonchi.
Palpate the chest wall over all lung fields to assess for increased or
decreased fremitus and asymmetric chest wall expansion.
4. Assess vital signs and pulse oximetry.
5. Determine patient's understanding of and ability to perform home
postural drainage.
Box 1: Contraindications to Postural Drainage
 Intracranial pressure (ICP) > 20 mm Hg

 Head and neck injury until stabilized (*)
 Active hemorrhage with hemodynamic instability (*)
 Recent spinal surgery (e.g., laminectomy) or acute spinal injury
 Active hemoptysis (*)
 Empyema
 Bronchopleural fistula
 Pulmonary edema associated with congestive heart failure
 Large pleural effusions
 Pulmonary embolism
 Aged, confused, or anxious patients who are unable to tolerate position change
 Rib fracture, with or without flail chest
 Surgical wound or healing tissue
Trendelenburg position is contraindicated for the following:

 Patients in whom increased ICP is to be avoided or ICP greater than 20 mm Hg
 Uncontrolled hypertension
 Distended abdomen
 Esophageal surgery
 Recent gross hemoptysis (*)
 Uncontrolled airway at risk for aspiration
*Indicates absolute contraindication.
1. Perform hand hygiene and apply gloves.
2. Select congested areas to be drained based on assessment of all lung fields, clinical
data, and chest radiograph data.
Rationale: To be effective, treatment must be individualized to treat specific areas involved.
3. Place patient in position to drain congested areas; first area selected may vary from
patient to patient. Use correct position to drain upper, middle, or lower lobe
bronchi. Help patient assume position as needed. Teach patient correct posture and arm
and leg positioning. Place pillows for support and comfort. Drape patient appropriately.
Rationale: Specific positions are selected to drain each area involved. Proper patient
positioning promotes drainage of pulmonary secretions.
4. Have patient maintain posture for 10 to 15 minutes.
Rationale: In adults, draining each area takes time.
5. During 10 to 15 minutes of drainage in each posture, perform chest percussion,

vibration, and shaking over area being drained. Use correct postures and hand
placement for percussion, vibration, and shaking.
Rationale: These maneuvers provide mechanical forces that aid in mobilization of airway
secretions.
6. After 10 to 15 minutes of drainage in first posture, have patient sit up and cough. If
indicated, save expectorated secretions in a clear container. If patient cannot cough,
suctioning may need to be performed.
Rationale: Any secretions mobilized into central airways should be removed by cough or
suctioning before placing patient into next drainage position. Coughing is most effective when
patient is sitting up and leaning forward.
Sometimes patient may experience transient dyspnea and fatigue because of irritation and
bronchospasm from mobilizing secretions. These patients may benefit from an oscillating or
vibrating device, such as an Acapella device. Dyspnea and bronchospasm usually subside after
sputum is coughed up.
7. Have patient rest briefly if necessary.
Rationale: Short rest periods between postures can prevent fatigue and help patient better
tolerate therapy.
8. Have patient take sips of water.
Rationale: Keeping mouth moist aids in expectoration of secretions.
9. Repeat steps 3 through 8 until all congested areas selected have been drained. Each
treatment should not exceed 30 to 60 minutes.
Rationale: Postural drainage is used only to drain areas involved and is based on individual
assessment.

Chest Physiotherapy: Postural Drainage - Post Procedure and Variations
1. Auscultate lung fields.

Post Procedure
Rationale: Clearance of secretions usually relieves
gurgling, early inspiratory crackles, and palpable
crepitus.
2. Inspect character and amount of sputum.
Rationale: Determines if secretions are adequately

thinned.
3. Review diagnostic reports, including sputum

collections/cultures, chest radiograph films, and blood gas
levels.
Rationale: Provides objective data on improvements in

lung function.
4. Obtain vital signs and pulse oximetry.
Rationale: Procedure may result in dysrhythmias and

decreases in oxygen saturation in some patients.
5. Have patient explain purpose and procedure for postural

drainage.
Rationale: Evaluates patient's understanding of

procedure.
 Record in nurses' notes pre-therapy and post-therapy

Documentation assessment of chest and chest radiograph findings;
frequency and duration of treatment; postures used and
bronchial segments drained; cough effectiveness; need for
suctioning; color, amount, and consistency of sputum;
hemoptysis or other unexpected outcomes; and patient's
tolerance and reactions.
 If patient and family receive instruction in home care, chart
instructions given, understanding of therapy, demonstration
of skill, patient acceptance of home care, barriers to learning
and implementation, and referral for follow-up with a home
care, rehabilitation, or pulmonary nurse specialist.
 Inform patient that best times for treatments are (1) in

Patient Education morning before breakfast, when patient can clear secretions
that accumulate overnight and (2) about 1 hour before
bedtime, so that lungs are clear before sleeping and patient
has time after treatment to cough up any mobilized
secretions. Explain that frequency depends on need and
patient's tolerance and may vary from once daily to every 2 to
4 hours in an acute situation.
 Advise patient who receives inhaled bronchodilators or
aerosol treatment to do postural drainage 20 minutes after
such therapy. Encourage patient to plan for rest period after
postural drainage.
 Instruct patient not to schedule major activities (such as
exercise or bath) right after chest therapy treatment,
especially if patient has severe obstructive lung disease.
 Instruct patient's family or primary caregiver to recognize
when patient's respiratory status requires breathing exercises
or postural drainage.
 Encourage primary caregiver or family member to encourage
patient to participate in physical activities that will increase
respiratory efficiency.
 Teach patient and significant others how to assume postures
at home. Some postures may need to be modified to meet
individual needs. For example, side-lying Trendelenburg
position to drain lateral lower lobes may have to be done with
patient lying flat on side or in side-lying semi-Fowler's
position if patient is very short of breath.
Age-Specific Pediatrics
Considerations
 In the child with cystic fibrosis (CF), chest physiotherapy is a
cornerstone therapy and is usually performed at least twice
daily, on rising in the morning and in the evening.Many CF
patients use the chest vest when at home so that they can be
independent.
 Chest physiotherapy is not recommended during acute
exacerbations of asthma.
Geriatrics
 Postural drainage in older adults should be done with extra
care. Change positions more slowly, and closely assess for
any changes in oxygen saturation or vital signs with position
changes.
 Older adults with chronic cardiac and pulmonary conditions
may not tolerate a supine or side-lying position for chest
physiotherapy. In these positions, patients experience
decline in forced vital capacity (FVC) and subsequent decline
in oxygen saturation.
Oxygen Saturation Measurement (Pulse Oximetry) - Overview
Pulse oximetry is the noninvasive measurement of arterial blood

Overview: oxygen saturation-the percent to which hemoglobin is filled with
oxygen. A pulse oximeter is a probe with a light-emitting diode (LED)
connected by cable to an oximeter. Light waves emitted by the LED
are absorbed and then reflected back by oxygenated and
deoxygenated hemoglobin molecules. The reflected light is processed
by the oximeter, which calculates pulse oxygen saturation (SpO2).
SpO2 is a reliable estimate of arterial oxygen saturation (SaO2). For this
reason, the use of oximetry can judiciously reduce the need to collect
arterial blood gas specimens for oxygen saturation analysis. In adults
the oximeter probe can be applied to the earlobe, finger, toe, or bridge
of the nose, because a highly vascular area is needed to detect the
degree of change in the transmitted light.
The measurement of SpO2 is simple, painless, and has few of the risks
associated with more invasive measurements of SaO2 such as arterial
blood gas sampling. However, the measurement of SpO2 is affected by
factors that affect light transmission, such as outside light sources and
patient motion. Avoid direct sunlight or fluorescent lighting when using
an oximeter. Light reflection from hemoglobin molecules can be
influenced by carbon monoxide in the blood, jaundice, and
intravascular dyes. Conditions that decrease arterial blood flow, such
as peripheral vascular disease, hypothermia, pharmacologic
vasoconstrictors, hypotension, or peripheral edema, affect accurate
determination of SpO2.
There are various characteristics of pulse oximeter sensor probes and
sites that can be used to obtain optimal vascular area for accurate
oxygen saturation values.
Reusable Probe
 Digit probe
o Easy to apply, conforms to various sizes.
 Earlobe clip
o Clip-on; smaller and lighter, though more positional, than digit
probe.
o Yields strong correlation with SaO2.
o Research suggests greater accuracy at lower saturations.
o Good when uncontrollable or rhythmic movements (e.g., hand
tremors, exercise) are present.
o Vascular bed least affected by decreased blood.
Disposable Sensor Pad
 Can be applied to a variety of sites: earlobe of adult, nose bridge,

palm or sole of infant.
 Less restrictive for continuous SpO2 monitoring.
 Expensive.
 Contains latex. Skin under adhesive may become moist and harbor
pathogens.
 Available in a variety of sizes; pad can be matched to infant weight.
Because light reflected from hemoglobin molecules is processed to

determine SpO2, any abnormality in the type or amount of hemoglobin
affects oxygen saturation and SpO2 values. The more hemoglobin that
is saturated by oxygen, the higher the oxygen saturation. Normally
SpO2 is greater than 90%. Pulse oximetry is clinically indicated in
patients who have an unstable oxygen status or are at risk for impaired
gas exchange.
Oxygen Saturation Measurement (Pulse Oximetry) - Outcomes
 Patient's SpO2 remains between 90% and 100%.

Expected  Patient's oxygenation therapies are adjusted without requiring
Outcomes invasive assessment measures.
 SaO2 is less than 90%.
Unexpected  Pulse waveform/intensity display is dampened or irregular.
Outcomes  Pulse rate indicated on oximeter is less than radial or apical
pulse rate.
Oxygen Saturation Measurement (Pulse Oximetry) - Assessment and Preparation
1. Obtain appropriate equipment, and place at bedside.

Preparation 2. Explain purpose of procedure to patient and how oxygen saturation
will be measured.
 Oximeter
Supplies  Oximeter probe appropriate for patient and recommended by
oximeter manufacturer
 Acetone or nail polish remover
 Pen, pencil, vital sign flow sheet or record form
1. Determine need to measure patient's oxygen saturation:

Assessment a. Identify risk factors for alteration of oxygen saturation.
b. Assess for signs and symptoms of alterations in oxygen
saturation: altered respiratory rate, depth, or rhythm;
adventitious breath sounds; cyanotic appearance of nail
beds, lips, mucous membranes, and skin; restlessness,
irritability, confusion; reduced level of consciousness; labored
or difficulty breathing.
2. Assess for factors that influence measurement of SpO2: oxygen
therapy; respiratory therapy, such as postural drainage and
percussion hemoglobin level; hypotension; temperature; and
medications such as bronchodilators.
3. Review patient's medical record for physician's order, or consult
institution's procedure manual for standard of care for measurement
of SpO2.
4. Determine previous baseline SpO2 (if available) from patient's record.
5. Determine most appropriate patient-specific site (e.g., finger,
earlobe, bridge of nose) for sensor probe placement by measuring
capillary refill. If capillary refill is less than 3 seconds, select
alternative site.
a. Site must have adequate local circulation and be free of
moisture.
b. Artificial nails and certain nail polish colors will alter readings;
place probe on finger free of polish or artificial nail.
c. If patient has tremors or is likely to move, use earlobe.
d. If patient is obese, clip-on probe may not fit properly; obtain a
single-use (tape-on) probe.
Oxygen Saturation Measurement (Pulse Oximetry) - Procedure
2. Position patient comfortably. If finger is chosen as monitoring site, support lower arm.
Instruct patient to breathe normally.
Rationale: Ensures probe positioning and decreases motion artifact that

interferes with SpO2 determination. Prevents large fluctuations in minute
ventilation and possible changes in SpO2.
3. If finger is to be used, remove fingernail polish with acetone or polish remover from digit
to be assessed.
Rationale: Opaque coatings decrease light transmission; nail polish containing

blue pigment can absorb light emissions an falsely alter saturation.
4. Attach sensor See Figure 1 to monitoring site. Instruct patient that clip-on probe will feel
like a clothespin on the finger but will not hurt.
Rationale: Select sensor site based on peripheral circulation and extremity

temperature. Peripheral vasoconstriction can alter SpO2. Pressure of sensor's
spring tension on a finger or earlobe may be uncomfortable.
Do not attach probe to finger, ear, or bridge of nose if area is edematous or
skin integrity is compromised. Do not attach sensor to fingers that are
hypothermic. Select ear or bridge of nose if adult patient has a history of
peripheral vascular disease. Do not use disposable adhesive sensors if
patient is allergic to latex. Do not place sensor on same extremity as
electronic blood pressure cuff because blood flow to finger will be
temporarily interrupted when cuff inflates and that can cause an inaccurate
reading that can trigger alarms.
5. Once sensor is in place, turn on oximeter by activating power. Observe pulse

waveform/intensity display and audible beep. Correlate oximeter pulse rate with
patient's radial pulse.
Rationale: Pulse waveform/intensity display enables detection of valid pulse or

presence of interfering signal. Pitch of audible beep is proportional to
SpO2 value. Double-checking pulse rate ensures oximeter accuracy.
If oximeter pulse rate, patient's radial pulse, and patient's apical pulse are
different, reevaluate oximeter probe placement and reassess pulse rates.
6. Inform patient that oximeter alarm will sound if sensor falls off or if patient moves
sensor.
7. Leave sensor in place until oximeter readout reaches constant value and pulse display
reaches full strength during each cardiac cycle. Read SpO2 on digital display.
Rationale: Reading may take 10 to 30 seconds, depending on site selected.
8. Discuss findings with patient as needed, and record findings.
Rationale: Promotes participation in care and understanding of health status.
9. If continuous SpO2 monitoring is planned, verify SpO2 alarm limits, which are preset by

the manufacturer at a low of 85% and a high of 100%. Limits for SpO2and pulse rate
should be determined as indicated by patient's condition. Verify that alarms are on.
Assess skin integrity under sensor every 2 hours. Relocate sensor at least every 4
hours and more frequently if skin integrity is altered or tissue perfusion compromised.
Rationale: Alarms must be set at appropriate limits and volumes to avoid

frightening patients and visitors. Spring tension of sensor or sensitivity to
disposable sensor adhesive can cause skin irritation and lead to disruption of
skin integrity.
10. Remove probe, and turn oximeter power off. Store sensor in appropriate location.
Rationale: Batteries can be depleted if oximeter is left on. Sensors are

expensive and vulnerable to damage.
11. Assist patient in returning to comfortable position.

Rationale: Restores comfort and promotes sense of well-being.
Oxygen Saturation Measurement (Pulse Oximetry) - Post Procedure and

Variations
1. If oxygen saturation is assessed for the first time, establish

Post Procedure SpO2 as baseline if it is within acceptable range.
Rationale: Used to compare future assessments of

oxygen saturation.
2. Compare SpO2 with patient's previous baseline and acceptable

SpO2. Note use of oxygen therapy.
Rationale: Allows nurse to assess for change in patient's

condition and presence of respiratory alteration.
3. During continuous monitoring, assess skin integrity underneath

probe at least every 2 hours, based on patient's peripheral
circulation.
Rationale: Prevents tissue ischemia.
 Record SpO2 on vital sign flow sheet, record, or nurses' notes.

Documentation  Record type and amount of oxygen therapy used by patient
during assessment.
 Assessment of O2 saturation after administration of specific
therapies should be documented in narrative form in nurses'
notes.
 Record any signs and symptoms of oxygen desaturation in
nurses' notes.
 Report abnormal findings to nurse in charge or physician.
 Correlate SpO2 with SaO2 obtained from arterial blood gas
measurements, if available, to verify the reliability of
noninvasive assessment.
 Record in nurses' notes patient's use of continuous or
intermittent pulse oximetry to document use of equipment for
third-party payers.
 Teach patient significance of monitoring oxygen saturation.

Patient Education  Teach patient signs and symptoms of hypoxemia: headache,
somnolence, confusion, dusky color, shortness of breath,
dyspnea.
 Teach patient effect of high-risk behaviors, such as cigarette
smoking, on oxygen saturation.
Considerations
 Placement recommendation for an infant is to secure probe to
the great toe, secure wire to foot, and cover foot with a snugly
fitting sock. Placement recommendation for a child is to secure
to the index finger and secure wire to hand.
 Earlobe and bridge-of-nose sensors are not used for infants
and toddlers.
 Sensors can be affected by heat and light sources. Sensors
should be covered when used during phototherapy or with
radiant warmers.
Geriatrics
 Identifying an acceptable pulse oximeter probe site may be

difficult in older adults because of likelihood of peripheral
vascular disease, decreased carbon dioxide level, cold-induced
vasoconstriction, and anemia.
 Older adults require more frequent assessment of skin under
sensor site because of tissue fragility and decreased elasticity
caused by aging.
Administering Intermittent Positive-Pressure Breathing (IPPB) - Overview of the Skill

Overview: Intermittent positive-pressure breathing (IPPB) is a form of intermittent

mechanical ventilation that may be used to provide hyperinflation
therapy and improve the distribution of ventilation, prevent or treat
atelectasis, provide intermittent ventilation for clients with
hypoventilation, and improve airway secretion clearance in clients
who cannot cough or clear secretions effectively. IPPB may be used
to deliver aerosol medication to clients with muscle weakness
affecting the ability to inhale and exhale the medication, for example,
clients with underlying spinal cord injury, trauma, or neuromuscular
disease. IPPB can be used in intubated or nonintubated clients.
Indications for IPPB include the following conditions:

 Atelectasis
 Decreased pulmonary function:
o Vital capacity (VC) of less than 10 to 15 ml/kg
o Forced vital capacity (FVC) of less than 70% of predicted rate
o Forced expiratory volume in 1 second (FEV1) of less than
65% of predicted rate
 Neuromuscular disorders associated with fatigue and decreased

lung volumes
 Bronchospasm that has failed to respond to other medication
delivery systems
IPPB is effective when an increase in alveolar distending pressure is

generated. IPPB creates a positive pressure at the airway (mouth),
causing gas to flow into the lungs, with a resultant increase in tidal
volume, decreased work of breathing, and increased minute
ventilation.

Complications of IPPB therapy include nosocomial infection, gastric
distention, over-distended alveoli, pneumothorax, and other changes
in oxygenation.

Once a popular mode of therapy, IPPB is infrequently used today.
Less expensive and less invasive therapies, such as incentive
spirometry, deep breathing, chest physiotherapy, and early
mobilization are considered to be more effective in managing the
postoperative client. Nebulizers are more effective for delivering
medications.

IPPB is given for short time periods, typically 10 to 20 minutes four
times per day, or every 4 hours with daily assessments.

Assessment: 1. Assess the ability of the client to understand instructions and

cooperate with the procedure to determine how to structure the
procedure and what type of teaching to provide.
2. Assess the orders for IPPB to make sure the orders are clear and
seem appropriate for the client.
3. Assess the equipment being used to review the proper operation
of the equipment.

Diagnosis:  Altered Tissue Perfusion

 Impaired Gas Exchange
 Deficient Knowledge, related to procedure

Planning

Planning Needs: Equipment Needed (see Figures 7-7-1A, 7-7-1B, 7-7-1C and 7-7-
1D):

 IPPB device, available from a variety of manufacturers; the most

common are made by Bird Products Corporation and Nellcor Puritan
Bennett
 Obtain circuit to the IPPB with mouthpiece or appropriately sized
face mask
 Nebulizer (usually included with the circuit)
 Compressed gas source
 Mouthpiece, mouth seal, nose clips, mask, or endotracheal tube
adapter
 Tissues or container for expectorated sputum
 Suction equipment if the client is intubated or trached
 Spirometer
 Gloves, goggles, gown, and mask as indicated
 Saline or appropriate medication in nebulizer

Expected 1. The client will have improved tidal breathing, as measured by a tidal
Outcomes: volume during IPPB of at least 25% greater than taken in during a
regular breath.
2. The client will have a more effective cough.
3. The client will have increased sputum production.
4. The client will have improved breath sounds and an improved chest
X-ray.

Client Education 1. Explain the procedure to the client, why the client is receiving the
Needed: therapy, and the expected outcome.
2. Explain technique, for example, initiate the breath and passively
allow the IPPB to inflate the lungs until the machine terminates
inspiration. Exhalation is through the mouthpiece.
3. Explain the name and purpose of any medication to be nebulized.
4. Remind the client to keep a tight seal with the lips around the
mouthpiece.
Administering Intermittent Positive-Pressure Breathing (IPPB) - Implementation—

Action/Rationale

Implementation
Action/Rationale
ACTION RATIONALE
1. Review and verify health care 1. Ensures application of

provider's order. appropriate therapy.
2. Wash hands. Apply protective 2. Reduces the transmission of

clothing as needed (see Figure 7- microorganisms.
7-2).
3. Explain treatment and technique 3. Encourages client cooperation

to client. and ensures effective treatment.
4. Set up equipment and connect to 4. Prepares mechanics.

gas source.
5. Set parameters on IPPB device: 5. Parameters must be set to meet

flow setting, trigger sensitivity, and orders and meet individual
inspiratory pressure. client's requirements.
6. Fill nebulizer with sterile normal 6. Decreases the drying effect of

saline or medication. the gas during the treatment.
7. Assist the client to an upright 7. Optimizes ventilation

sitting position. distribution.
8. Assess client's breath sounds, 8. Establishes baseline status.

respiratory rate, and pulse and
obtain inspiratory capacity.
9. Initiate therapy and monitor 9. If exhaled volumes are not

effectiveness of treatment, greater or equal to inspiratory
measuring exhaled volumes. Use capacity, incentive spirometry
a nose clip if there is air leakage may be of greater therapeutic
through the nose (see Figure 7-7- value.
3).
10 Discontinue treatment when 10 IPPB is given typically for 10 to

. medication is administered or time . 20 minutes.
limit is reached.
11 Assess breath sounds, respiratory 11 Determines effectiveness.

. rate, pulse, and inspiratory .
capacity.
12 Disconnect IPPB from gas source. 12 Prevents auto-cycling.
. .
13 Rinse nebulizer with sterile water 13 Cleans equipment between

. or sterile saline and air dry. . treatments.
14 Wash hands. 14 Reduces the transmission of

. . microorganisms.
Administering Intermittent Positive-Pressure Breathing (IPPB) - Post-Skill

Evaluation:  The client has improved tidal breathing, as measured by a tidal
volume, during IPPB, of at least 25% greater than taken in
during a regular breath.
 The client has a more effective cough.
 The client has increased sputum production.
 The client has improved breath sounds and an improved chest
X-ray.


 Document IPPB device parameters (flow setting and inspiratory

pressure).
 Record pretest and posttest breath sounds, tidal volumes,
respiratory rate, inspiratory capacity, pulse, and sputum
production.

Medication Administration Record

 Document medication administered.

 Record adverse reactions, if any.

Variations

Geriatric Variations:  A face mask may be appropriate for clients lacking the strength
to effect a tight seal around a mouthpiece.

Pediatric  Lower pressures may be required.
Variations:  Use an appropriately sized face mask.

Home Care
Variations:
 Explain the importance of cleaning the equipment with sterile
saline or sterile water.
 Review the medication dosage with the client.

Long-Term Care  Periodically review techniques for using the equipment.
Variations:  Review with the client the importance of cleaning the equipment
with sterile saline or sterile water.
 Explain the medication dosage to the client.
Administering Intermittent Positive-Pressure Breathing (IPPB) - Common Errors

Possible
The IPPB cycles off before the client is able to obtain adequate breath.
Errors:

Prevention: The pressure limit is set too low. You should consult the physician or qualified
practitioner, or if you are qualified, increase the pressure setting.

Possible The client is stopping flow with the tongue or by exhaling prematurely instead
Errors: of allowing a passive inspiratory phase to occur.

Prevention: Instruct the client to allow a passive inflation and automatic cycling of the
IPPB device after initiating inspiration.

Possible The flow rate is set too high, causing a pressure spike and early termination
Errors: of inspiration.

Prevention: Decrease the flow rate.

Nursing Tips:
 Help the client relax.

 Discuss the treatment before introducing the client to the equipment.
 Adjust flow rate in conjunction with the pressure limit to achieve the
best tidal breath.
 Remember contraindications to IPPB use, including increased
intracranial pressure (greater than 15 mm Hg); facial, skull, or
esophageal surgery; nausea; hiccups; or hemoptysis.


Introduction: Monitor the client on IPPB therapy carefully for problems.

Possible A 57-year-old male client was given IPPB via face mask when he had
Scenario: difficulty using a mouthpiece.

Possible During 10 minutes of IPPB, he suffered gastric distention from air being
Outcome: pushed into his stomach. This caused him to vomit. His panic, confusion, and
the tight face mask caused him to aspirate the vomitus.

Prevention: With careful observation of the client, the nurse would have recognized this
developing problem. IPPB should be discontinued or not initiated with a client
at risk for aspiration.

Assisting with Continuous Positive Airway Pressure (CPAP) - Overview of the
Skill

Overview: Continuous positive airway pressure (CPAP) is the application of
positive pressure to the airways of the spontaneously breathing client
throughout the respiratory cycle. During CPAP therapy, the client
breathes from pressurized tubing that maintains positive, consistent
airway pressures during both inspiration and expiration. CPAP
maintains inspiratory and expiratory pressure above atmospheric
pressure, which should result in an increased functional residual
capacity (FRC), an improvement in static lung compliance, and
decreased airway resistance. Because CPAP increases mean airway
pressure, the associated FRC should improve ventilation- perfusion
relationships and potentially reduce oxygen requirements.

CPAP is used for respiratory distress syndrome, pulmonary edema,
atelectasis, apnea, or recent extubation. There are no absolute
contraindications to the use of CPAP therapy; however, clients with
the following conditions should be carefully evaluated before the
initiation of CPAP therapy: nausea; esophageal surgery; recent facial,
oral, or skull surgery or trauma; intracranial pressure greater than 20
mm Hg; hemodynamic instability; and untreated pneumothorax.

Assessment: 1. Assess for breath sounds. With effective therapy, breath sounds
may clear up or the movement of secretions into larger airways
may cause an increase in adventitious breath sounds. Improved
ease of clearing secretions during and after treatments
supports continuation of the treatments.
2. Assess clients for their response to therapy before, during, and
after. Feelings of pain, discomfort, shortness of breath,
dizziness, and nausea should be considered in modifying and
stopping therapy.
3. Assess changes in vital signs. Moderate changes in respiratory
rate and/or pulse rate are expected. Bradycardia, tachycardia,
increasingly irregular pulse, or a drop or dramatic increase in
blood pressure are indications for stopping therapy.
4. Assess changes in arterial blood gas values or oxygen saturation as
per orders if applicable. Normal oxygenation should return as
atelectasis or other obstruction resolves.
5. Assess changes in chest X-rays as per orders. Improvement or
resolution of atelectasis and localized infiltrates may be slow or
dramatic.

Diagnosis:  Impaired Gas Exchange
 Ineffective Tissue Perfusion

Planning

Needs:

 CPAP machine capable of delivering 5 to 20 cm of pressure during

passive expiration, with one-way valves allowing unobstructed
inspiration
 Continuous noninvasive oxygenation monitoring by pulse oximetry
 Transparent mask or mouthpiece
 Tissues and emesis basin for collecting expectorated sputum
 Gloves, goggles, gown, mask if needed

Expected 1. The client will have a reduction in the work of breathing as indicated
Outcomes: by a decrease in respiratory rate by 30%. The apneic client will have
a decrease in the number and duration of apneic episodes.
2. The client will have a decrease in the severity of retractions, grunting,
and nasal flaring.
3. The client will have improvement in lung volumes and appearance of
lung as indicated by chest x-ray.
4. The client will have increased comfort in breathing as assessed by
the nurse.
5. The client will have an improvement in oxygen saturation.

Client 1. Teach the client the rationale for the use of the CPAP machine.
Education 2. Tell the client what possible side effects there are and what to report
Needed: to the nurse.
3. Have clients try on a CPAP mask before applying the mask for
treatment so they can get used to it and make adjustments.
4. Ask clients to tell you the reason they are having the CPAP
treatment.
5. Teach clients the symptoms they should report such as discomfort,
dyspnea, headache, rapid pulse or palpitations, and dizziness.
Assisting with Continuous Positive Airway Pressure (CPAP) - Implementation—

Action/Rationale

Implementation
Action/Rationale
ACTION RATIONALE

microorganisms.
2. Check orders regarding CPAP 2. Ensures CPAP administration is

administration. appropriate and the correct
settings are used.
3. Assess breath sounds, vital 3. Determine baseline respiratory

sounds, and oxygen saturation. assessment.
4. Assist client into position of 4. Ensures client is more

comfort. comfortable during CPAP
application.
5. Secure mask over the nose 5. An airtight seal is required for

and/or mouth of the client proper functioning of the CPAP
(see Figure 7-8-1). Check machine.
connections.
6. Turn CPAP machine on and 6. Settings should be checked with

check settings. each application.
7. Maintain CPAP for prescribed 7. Prevents hyperventilation and

length of time (see Figure 7-8-2). fatigue.
8. Assess breath sounds, vital signs, 8. Determine changes in

and oxygen saturation. respiratory status.
9. Observe the client for side effects. 9. Assess for potential problems
related to CPAP administration.

. . microorganisms.

Assisting with Continuous Positive Airway Pressure (CPAP) - Post-Skill

Evaluation:  Evaluate the effectiveness of CPAP administration 20 to 30
minutes after the treatment.
 The client had a reduction in the work of breathing as indicated
by a decrease in respiratory rate by 30%. The apneic client had
a decrease in the number and duration of apneic episodes.
 The client had a decrease in the severity of retractions, grunting,
and nasal flaring.
 The client had improvement in lung volumes and appearance of
the lungs as indicated by chest X-ray.
 The client has increased comfort in breathing as assessed by
the nurse.
 The client has an improvement in oxygen saturation.


 Record time CPAP applied.

 Record settings.
 Note breath sounds before and after the procedure.
 Record vital signs, oxygen saturation.
 Note client's response to application of CPAP machine.
 Include signature of nurse applying CPAP machine.

Variations

Geriatric Variations:  Skin in the elderly is thinner and more prone to breakdown.
Care must be taken to assess the skin frequently to prevent
breakdown from occurring.
 Caregivers must be taught the importance of monitoring the
client during CPAP treatment.

Pediatric  Claustrophobia is common with CPAP therapy in young
Variations: children. Education about the mask and what CPAP therapy will
feel like is important.
 Starting therapy for short intervals and slowly increasing the
time can be helpful in overcoming fear and the confinement of
the mask.
 Distraction with TV, books, or games may enhance the
cooperation of the child when using the CPAP mask.

Home Care
Variations:
 Make sure the client demonstrates proper technique for
administration, proper use of equipment, appropriate breathing
patterns and cough techniques, and the ability to modify
technique in response to adverse reactions.
 Teach caregivers in the home to use the CPAP machine and to
care for the equipment.
 Teach caregivers the signs and symptoms of respiratory
infection.
 Medicare may reimburse for the CPAP machine used at home.

Long-Term Care  CPAP equipment needs to be maintained for each client use.
Variations:  Medicare may not reimburse for the CPAP machine in a long-
term care facility.
Assisting with Continuous Positive Airway Pressure (CPAP) - Common Errors

Possible
The oxygen source is disconnected from the CPAP machine.
Errors:

Prevention: Make sure the connections are secure. Be sure the CPAP machine and the
oxygen source are close enough so the connection is not being stressed.

Possible A mucus plug forms in the tubing of the CPAP machine, occluding it.
Errors:

Prevention: Assess tubing before and after application of the CPAP mask. Clean the
tubing or replace it with new tubing prn.

Nursing Tips:
 Familiarize yourself with the CPAP equipment so you will feel

comfortable when using it with a client.
 Determine the policy in your hospital regarding who performs the
initial assessment of the client, who administers CPAP therapy, and
who is responsible for ongoing assessment and care of stable and
unstable clients.
 Claustrophobic or anxious clients will need you to stay at their
bedside during the treatment.
 Demonstrating the mask on yourself may allay the fear and anxiety a
client may have about the treatment.


Introduction: Because of the airtight seal that must be obtained when applying a CPAP
mask, the potential for skin breakdown on the nose, cheeks, and chin is high.
It is important that the nurse be aware of this and observe for early signs of
breakdown so that she or he can intervene before the breakdown is
significant.

Possible Jim is a 44-year-old man who has started on CPAP therapy to aid in
Scenario: mobilization of retained secretions secondary to chronic bronchitis. He
is to wear the CPAP mask 2 hours on, 2 hours off while awake, and
continuously at night. This is his third day of therapy. His nurse applies
the mask and checks for any air leaking around the mask. She then
checks all the connections and settings and turns the CPAP machine
on. She monitors Jim for 15 minutes to make sure he is in no distress,
then leaves the room.

When his nurse returns to remove the mask after Jim has been on
CPAP therapy for 2 hours, she notices areas of redness on his nose
and chin. She leaves the mask off for the prescribed 2 hours, then
returns at 10:00 PM to apply the mask for the night. Jim notices that it
is uncomfortable when the mask is applied; however, he knows he
must have this therapy and does not say anything to the nurse. At 4:00
AM Jim puts his light on and the nurse enters his room to find that he
has removed the mask. He tells her that the discomfort became
unbearable, so he had to remove the mask. The nurse notices that
there are small blisters on his nose and a 1-cm open area on his chin.

Possible CPAP therapy must be discontinued because of the skin breakdown on Jim's
Outcome: nose and chin. Other methods must be used to aid in mobilization of Jim's
secretions, and he recovers from his chronic bronchitis more slowly than
expected.

Prevention: Upon noticing the reddened area on Jim's nose, the nurse could have
adjusted the mask, avoiding this area if possible. She may have needed to
decrease the duration of time that he was to wear the mask that night,
knowing that skin breakdown was likely. The use of an acceptable skin
barrier (no petroleum products or powders, which could be aspirated) when
the redness was noted might have helped to prevent further breakdown.

Preparing the Chest Drainage System - Overview of the Skill

Overview: The chest drainage system is a closed system designed to drain air or
fluid from the pleural cavity while restoring or maintaining the negative
intrapleural pressure needed to keep the lungs properly expanded.
The space between the lungs and chest wall is called the pleural
cavity and it normally contains only a small amount of fluid for
lubrication between the lungs and the chest wall. Negative intrapleural
pressure between the lungs, chest wall, and diaphragm allows the
movement of the chest and diaphragm to expand and contract the
lungs.
Large amounts of fluid or air in the pleural cavity impede the
expansion of the lungs, causing respiratory distress or "collapse" of
the lung. Excess fluid or air can enter the pleural cavity by several
means. Thoracic surgery breaks the vacuum seal in the pleural cavity,
allowing fluid and air to enter. Trauma to the chest wall can lead to
bleeding into the pleural cavity (hemothorax) or air entering the
pleural cavity (pneumothorax). Occasionally, spontaneous
pneumothorax occurs, without apparent cause.

The chest drainage system is designed to help restore the vacuum
seal in the pleural cavity by draining excess fluid or air while keeping
the pleural cavity sealed. Occlusive dressings, water seals, gravity,
and additional suction, if necessary, work together to create a sealed
system with slight negative pressure to draw fluids away from the
chest.

The drainage system uses a water seal to prevent air return into the
pleural cavity. Once pleural air passes through the water seal, it
cannot return to the chest and is vented to the atmosphere. Occlusive
dressings at the puncture site prevent air from entering the pleural
space. All connections between the tubing are airtight.

The chest drainage system can be attached to suction to increase the
negative pressure between the pleural space and the drainage
system, which improves drainage. The amount of suction is controlled
by a dial in some chest drainage setups and by the amount of saline
added to the suction control container in other setups.

When setting up a chest drainage system, it is important to
understand why the system works. Read the manufacturer's
instructions for commercial chest drainage setups.

Assessment: 1. Assess the physician's or qualified practitioner's orders to determine
what kind of chest drainage system is required.
2. Assess the available equipment to determine what kind of
drainage system setups are available.
3. Assess the client's environment to determine what kind of
equipment will be required and what drainage system would be
optimal for the client.

Diagnosis:  Risk for Infection

Planning

Planning Equipment Needed
Needs:

Client 1. Teach the client that some bubbling in the water seal container and
Education the suction container is normal.
Needed: 2. Instruct the client regarding the need to keep the drainage system
below the level of the chest tube insertion site.
Preparing the Chest Drainage System - Implementation—Action/Rationale

Implementation
Action/Rational
e ACTION RATIONALE
Disposable Chest Tube Drainage System
1. Gather equipment in a clean area 1. Helps maintain sterility while

or at the client's bedside. assembling the chest drainage
system.

microorganisms.
3. Open the prepackaged disposable 3. Maintains sterility while

chest tube system using aseptic assembling the chest drainage
technique (see Figure 7-9-2). system. Most prepackaged
disposable chest tube systems
are basically a three-bottle
system packaged in one
disposable container.
4. Set the unit upright (see Figure 7- 4. Allows the unit to be filled.

9-3).
5. If only a water seal has been 5. This provides a water seal to

ordered, pour the measured prevent air from entering the
amount of sterile water or saline pleural cavity.
into the funnel provided
(see Figures 7-9-4 and 7-9-5).
6. If suction has been ordered, fill the 6. This provides extra suction to
suction control chamber to the increase the drainage of fluid or
ordered level of fluid, usually 20 air from the pleural cavity.
cm of water (see Figures 7-9-
6 and 7-9-7).
7. If suction has been ordered, attach 7. Provides suction to the system.

suction tubing to the marked
suction port and to the suction
source.
8. Turn the suction up until there is 8. The level of suction is

gentle bubbling in the suction determined by the air flow
control section of the system. through the water in the suction
chamber. This is indicated by the
bubbling of the suction control
chamber.
9. Set the system up at the client's 9. Prevents backflow of air or fluid

bedside. Keep the drainage into the pleural cavity.
system below the level of the client
(see Figure 7-9-8).

. . microorganisms.
Reusable Bottle Chest Drainage System
11 Repeat Actions 1-3. 11 See Rationales 1-3.

. .
12 Apply sterile gloves. 12 Maintains sterility while

. . assembling the chest drainage
system.
13 One-bottle water seal: 13 This system is generally used

. . only for pneumothorax as one
 Insert a long glass tube bottle is required to act as a
through one hole of a two- water seal and a drainage bottle.
hole rubber stopper. Insert
a short glass tube through  The long tube will provide
the other hole in the a water seal, and the
stopper. shorter tube will work as
 Pour sterile saline or sterile an air vent to prevent the
water into the glass bottle, buildup of pressure in the
filling it to a depth of at bottle as fluid and air
least 4 cm. drain out of the pleural
 Being careful not to cavity and into the bottle.
contaminate the inside of  Provides a sterile water
the rubber stopper or the seal to prevent air return
portion of the glass tubes into the pleural cavity.
that will be inside the bottle,  Maintains sterility while
put the rubber stopper onto assembling the chest
the bottle. drainage system.
 Be sure the end of the long  Provides a water seal that
glass tube is submerged 2 prevents the return of air
cm into the water in the into the pleural cavity.
bottle. If the tube does not The higher water level
extend deeply enough, add creates increased
more water to the bottle. resistance to drainage.
Do not fill the bottle more  The long glass tube is
than one-third full. sealed, providing a
 Attach rubber tubing to the sealed drainage system.
outside end of the long  Documents the amount of
glass tube for drainage drainage from the chest
from the client's chest tube. tube.
 Place a measuring guide
on the side of the bottle,
marking the water level
prior to connection to the
client.
14 Two-bottle drainage and water 14 This system is used when gravity

. seal: . drainage is adequate but a
separate drainage container is
 Insert two short glass tubes desired for accurate assessment
into a two-hole rubber of the drainage and to prevent
stopper. Place this rubber increased resistance as the
stopper onto the drainage drainage bottle fills.
bottle.
 Insert one long glass tube  This allows drainage to
and one short glass tube flow into the bottle without
into a second two-hole creating a water seal in
rubber stopper. this container.
 Pour sterile water or sterile  The long tube will provide
saline into the water seal a water seal, and the
bottle to a depth of about 4 shorter tube will work as
cm. Do not fill the bottle an air vent to prevent the
more than one-third full. buildup of pressure in the
 Place the rubber stopper bottle as fluid and air
with the long glass tube drain out of the pleural
onto the water seal bottle, cavity and into the bottle.
being careful not to  Provides a sterile water
contaminate the inside of seal to prevent air return
the bottle or the glass into the pleural cavity.
tubes.  Maintains sterility while
 Be sure the end of the long assembling the chest
glass tube is submerged 2 drainage system.
cm into the water in the  Provides a water seal that
bottle. If the tube does not prevents the return of air
extend deeply enough, add into the pleural cavity.
more water to the bottle. The higher water level
Do not fill the bottle more creates increased
than one-third full. resistance to drainage.
 Place a length of rubber  The long glass tube is
tubing between the outer sealed by water,
end of one of the short providing a sealed
glass tubes on the drainage drainage system.
bottle and the outer end of  This will provide a
the long glass tube on the continuous sealed system
water seal bottle. for drainage without
 Place a length of rubber allowing air or fluid to
tubing on the outer end of return to the pleural
the second short glass tube cavity.
in the drainage bottle. This  Documents the amount of
tube is for connecting to the drainage from the client's
client for drainage. chest tube.
on the side of the drainage
collection bottle prior to
connection to the client.
15 Two-bottle drainage and suction 15 This system is used when

. control: . additional suction is required to
remove air from the pleural
 Insert a long glass tube cavity. Because the drainage and
through one hole of a two- the water seal occupy the same
hole rubber stopper. Insert bottle, it is not desirable for
a short glass tube through situations in which significant
the other hole in the amounts of drainage are
stopper. expected.
 Insert a long glass tube
through the middle hole of
 The long tube will provide
a three-hole rubber stopper
a water seal, and the
and short glass tubes
shorter tube will connect
through the other two holes
to the suction control
in the three-hole stopper.
bottle.
 Pour sterile saline or sterile
 The long tube will remain
water into the water
open to the air as a vent.
seal/drainage bottle, filling
The two shorter tubes are
it to a depth of at least 4
connectors to the water
cm.
seal/drainage bottle and
 Pour sterile saline or sterile
to the suction source.
water into the suction
 Provides a sterile water
control bottle to the ordered
seal to prevent air return
depth, usually 20 cm of
into the pleural cavity.
water.
 Provides a measured
 Place the two-hole rubber
amount of suction. The
stopper with the long glass
depth of the water
tube onto the water
controls the amount of
seal/drainage bottle, being
suction applied to the
careful not to contaminate
pleural cavity.
the inside of the bottle or
 Maintains sterility while
the glass tubes.
assembling the chest
 Be sure the end of the long
drainage system.
glass tube is submerged 2
 Provides a water seal that
cm into the water in the
prevents the return of air
bottle. If the tube does not
into the pleural cavity.
extend deeply enough, add
The higher water level
more water to the bottle.
creates increased
Do not fill the bottle more
resistance to drainage.
than one-third full.
 Maintains sterility while
 Place the three-hole rubber
assembling the chest
stopper with the long glass
drainage system.
tube and two short glass
 If the long tube touches
tubes onto the suction
the bottom of the suction
control bottle, being careful
control bottle, it will be
not to contaminate the
unable to vent outside air,
inside of the bottle or the
and the suction to the
glass tubes.
 Be sure the long glass tube pleural cavity will be
extends well into the water infinite.
but does not touch the  Connects the water
bottom of the bottle. seal/drainage bottle into
 Attach a length of rubber the suction system.
tubing to the outer end of  Attaches the system to
the short glass tube in the suction.
water seal/drainage bottle  Maintains a vent to the
and connect it to the outer air. This allows control of
end of one of the short the amount of suction
glass tubes in the suction inside the system.
control bottle.  Completes the closed
 Attach the suction tubing to drainage system and
the outer end of the second allows drainage, water
short glass tube in the seal, and suction to work
suction control bottle. to heal the pleural cavity.
 Do not attach any tubing to  The amount of suction is
the outer end of the long controlled by the air being
glass tube in the suction pulled from the outside,
control bottle. through the long glass
 Attach the drainage tubing tube and the water. The
from the client to the outer amount of water the air
end of the long glass tube has to be pulled through
in the water seal/drainage determines the amount of
bottle. suction in the system.
 Turn the suction source up  Accurately documents the
until a gentle bubbling is amount of drainage from
noted in the suction control the pleural cavity.
bottle. To increase the
suction, add more water to
the suction control bottle.
To decrease the suction,
remove water from the
suction control bottle.
on the side of the water
seal/drainage bottle,
marking the water level
prior to connection to the
client.
16 Three-bottle drainage, water seal, 16 This method is used when

. and suction control . significant amounts of drainage
are expected and the client
 Insert short glass tubes requires suction to the chest
through the holes in one of tubes.
the two-hole rubber
stoppers.  Allows drainage to empty
 Insert a long glass tube into the drainage bottle
through one hole of a two-
hole rubber stopper. Insert
a short glass tube through while keeping the bottle
the other hole in the open to the water seal.
stopper.  The long tube will provide
 Insert a long glass tube a water seal, and the
through the middle hole of shorter tube will connect
a three-hole rubber stopper to the suction control
and short glass tubes bottle.
through the other two holes  The long tube will remain
in the three-hole stopper. open to the air as a vent.
 Pour sterile saline or sterile The two shorter tubes are
water into the water seal connectors to the water
bottle, filling it to a depth of seal bottle and to the
at least 4 cm. suction source.
 Pour sterile saline or sterile  Provides a sterile water
water into the suction seal to prevent air return
control bottle to the ordered into the pleural cavity.
depth, usually 20 cm of  Provides a measured
water. amount of suction. The
 Being careful not to depth of the water
contaminate the inside of controls the amount of
the rubber stopper or the suction applied to the
portion of the glass tubes pleural cavity.
that will be inside the bottle,  Maintains sterility while
put the rubber stopper with assembling the chest
the two short glass tubes drainage system.
onto the drainage collection  Maintains sterility while
bottle. assembling the chest
 Place the two-hole rubber drainage system.
stopper with the long glass  Provides a water seal that
tube onto the water seal prevents the return of air
bottle, being careful not to into the pleural cavity.
contaminate the inside of The higher water level
the bottle or the glass creates increased
tubes. resistance to drainage.
 Be sure the end of the long  Maintains sterility while
glass tube is submerged 2 assembling the chest
cm into the water in the drainage system.
bottle. If the tube does not  If the long tube touches
extend deeply enough, add the bottom of the suction
more water to the bottle. control bottle, it will be
Do not fill the bottle more unable to vent outside air,
than one-third full. and the suction to the
 Place the three-hole rubber pleural cavity will be
stopper with the long glass infinite.
tube and two short glass  Entrains the pleural cavity
tubes onto the suction into the closed drainage
control bottle, being careful system.
not to contaminate the  Entrains the drainage
inside of the bottle or the collection bottle to the
glass tubes. water seal.
 Be sure the long glass tube  Entrains the water seal to
extends well into the water the suction control bottle.
but does not touch the  Entrains the system to
bottom of the bottle. suction.
 Attach rubber tubing to the  Maintains a vent to the
outside end of one of the air. This allows control of
short glass tubes extending the amount of suction
from the drainage collection inside the system.
bottle to attach to the  The amount of suction is
client's chest tube. controlled by the air being
 Attach a length of rubber pulled from the outside,
tubing from the second through the long glass
short glass tube in the tube and the water. The
drainage collection bottle to amount of water the air
the long glass tube in the has to be pulled through
water seal bottle. determines the amount of
 Attach a length of rubber suction in the system.
tubing from the short glass  Accurately documents the
tube in the water seal bottle amount of drainage from
to one of the short glass the pleural cavity.
tubes in the suction control
bottle.
 Attach the suction tubing to
the second short glass tube
in the suction control bottle
and to the suction source.
 Do not attach any tubing to
the outer end of the long
glass tube in the suction
control bottle.
 Turn the suction source up
until a gentle bubbling is
noted in the suction control
bottle. To increase the
suction, add more water to
the suction control bottle.
To decrease the suction,
remove water from the
suction control bottle.
on the side of the drainage
bottle prior to connection to
the client.
17 Tape all connections. 17 Prevents accidental breakage of

. . the sealed system.
18 Dispose of gloves in the proper 18 Maintains standard precautions.
. container. .
19 Arrange the drainage system at 19 Prevents backflow of water or

. the client's bedside. Keep the . drainage into the pleural cavity.
drainage system below the level of
the client.

. . microorganisms.
Preparing the Chest Drainage System - Post-Skill

Evaluation:  The chest drainage system is appropriate for the client and
consistent with the system ordered by the health care provider.
 The chest drainage system was set up in accordance with
institutional policy.
 The chest drainage system did not pose a hazard for infection
or loss of air seal to the client.


 Indicate the type of chest drainage system used.

 If suction control was ordered, indicate the centimeter level of
fluid in the suction control bottle.

Variations

Geriatric Variations:  Explain sounds and sensations associated with the chest tube
that the elderly client may not be able to see or hear clearly.

Pediatric  Keep a demonstration (clean and empty) system to teach the
Variations: child how it works. Match your explanations to the age of the
child.
 Explain the sounds that the child will be hearing.
 If the system is attached to suction, reassure the child that the
suction cannot be inadvertently turned up high enough to hurt
him or her.

Home Care  Chest tubes are not used in the home care setting.
Variations:

Long-Term Care  Chest tubes are not used in the long-term care setting.
Variations:

Preparing the Chest Drainage System - Common Errors

Possible The nurse tries to adjust the amount of suction in the system by turning up
Errors: the suction at the source.

Prevention: Know how the system works. The suction is regulated by the depth of fluid in
the suction control chamber, not by the amount of external suction applied.
Increasing the suction source only increases the noise level in the suction
control chamber, not the amount of suction in the system.

Nursing Tips:  Set up the closed drainage system below the level of the chest tube
insertion site.
 Keep the closed drainage system on a flat, sturdy surface so it is not
tipped over. If the system is knocked over, the water seal may be lost,
causing the introduction of air into the client's chest.
 If the water seal container is irretrievably compromised, a stopgap
water seal can be devised by placing the end of the chest tube itself
about 2 cm deep in sterile water or saline.


Introduction: Understand the physics underlying the chest tube setup.

Possible The nurse is assembling the chest tube drainage system using the bottle
Scenario: system. The order is for two bottles, a drainage collection bottle, and a water
seal bottle. As she is setting up the system, she remembers that it is
important that the system be closed to prevent air leakage back into the
pleural cavity. While setting up the water seal bottle, she notices that the
short glass tube is open to the air. She is concerned that this will leave the
system open, so she plugs the short glass tube in the water seal bottle.

Possible The chest tube is placed and hooked up to the drainage system. The
Outcome: physician had expected a large amount of drainage immediately following the
chest tube insertion, but there is no drainage. The client's condition does not
improve. The physician is concerned that she might have misplaced the
chest tube and orders a chest X-ray. The nurse on hand first checks the
chest tube drainage system and notices that the short glass tube is plugged.
She unplugs the vent tube in the water seal bottle to equalize with the
atmospheric pressure. The nurse notifies the physician and the X-ray is
delayed while the client is monitored with the correct setup. There is
substantial drainage through the chest tube and the client's condition
improves. The X-ray is cancelled.

Prevention: Be aware of the physics involved in the closed chest drainage system.
Understand what each chamber of the system is for and how it works.
Despite the name, the system requires one port to be open to the air.
Knowing where in the system the air vent is placed and why it will prevent
serious, if not life-threatening, errors.
Chest Tube Drainage Reinfusion - Overview
Overview:
Reinfusion of chest tube drainage into a patient's circulatory system has become more
common since the public has become aware of the risks associated with blood
transfusions. When reinfusion is linked with chest drainage, it becomes a relatively risk-
free, inexpensive, and easy method of replacing mediastinal blood previously lost during
emergencies and open-heart or thoracic surgery. Patients requiring this procedure must
also have an IV line in place.
Chest Tube Drainage Reinfusion - Outcomes
 Vital signs, hematocrit, and hemoglobin stabilize.

Expected Outcomes  The drainage systel functions correctly, and the lung
reexpands in 48 to 72 hours.
 The IV line remains patent.
 Chest tube is displaced.

Unexpected Outcomes  Patient has dyspnea, chest pain, and labored
respirations.
 Patient has signs of infection, fever, chills.
Manual Reinfusion - Assessment and Preparation
 Explain procedure to patient.

Preparation
 Adult/pediatric single-use chest drainage and

Supplies autotransfusion unit
 Replacement bag
 Gown, gloves, and mask as needed
1. Obtain baseline and serial vital signs, oxygen

Assessment saturation (SpO2), and level of orientation.
2. Assess pulmonary status, including:
a. Respiratory distress and abnormal breath

sounds over affected lung area.
b. Signs and symptoms of increased respiratory
distress: decreased breath sounds over the
affected and nonaffected lungs, marked
cyanosis, and asymmetrical chest
movements.
c. Chest pain on inspiration, hypotension, and
tachycardia.
3. If possible, ask patient to rate level of comfort on a

scale of 0 to 10.
4. Assess patient for known allergies. Ask whether
patient has had a problem with medications, latex, or
anything applied to the skin.
5. Review patient's medication record for anticoagulant
therapy.
6. For patients who have chest tubes, observe:
a. Chest tube dressing and site surrounding tube

insertion.
b. Tubing for kinks, dependent loops, or clots.
c. Chest drainage system, which should be
upright and below level of tube insertion.
2. Assess IV site to determine presence of adequate

and patent IV site for the administration of blood
products (e.g., 18-gauge angiocatheter).
3. Obtain baseline laboratory data (e.g., hemoglobin
and hematocrit).
Chest Tube Drainage
Reinfusion - Procedure
1. System setup
a. Set up the
autotransfusion
system (ATS) See
Figure 1 according
to techniques that
maintain the
sterility of the unit
and following the
three steps printed
on the front of the
unit.
Rationale:
Contamination of
the unit provides
a ready source
of infection to
patient.
b. Make certain that

all connections are
tight and all
clamps are open.
Rationale: Tight
connections
ensure an
airtight system,
and open clamps
allow chest
drainage to enter
the ATS bag.
c. A 200-µm double-
sided mesh filter is
located in the ATS
bag to filter the
drainage.
Rationale:
Filtering the
drainage
removes
extraneous
materials and
microemboli.
d. The ATS
collection bag has
a capacity of 1000
ml and is marked
in increments of
25 ml; it has an
area for marking
times and
amounts.
Rationale:
Expected
drainage in the
adult: Less than
50 to 200 ml/hr
immediately after
surgery in a
mediastinal
chest tube;
approximately
500 ml in the first
24 hours. Dark
red drainage is
expected only
during the
immediate
postoperative
period. The
drainage turns
serous over time.
2. Perform hand hygiene,

and apply gloves.
3. Prepare chest drainage
for reinfusion:
a. Following
manufacturers
directions, open a
replacement bag,
and close the two
white clamps.
Rationale:
Contamination of
the unit provides
a ready source
of contamination
to the patient.
The closed
clamps maintain
a closed system
during
replacement.
b. Use the high-

negativity relief
valve to reduce
excessive
negativity.
Rationale: Eases
the removal of
the initial
collection bag
from the metal
support stand.
c. Bag transfer:
1. Close
clamp on
chest
drainage
tubing.
Rationale:
Prevents
air from
entering
the chest
cavity
through
the tube
and
collapsing
the lung.
2. Close the
two white
clamps on
the top of
the initial
ATS
collection
bag.
Rationale:
Maintains
a closed
system for
the
reinfusion,
preventing
contamina
tion of the
blood.
3. Connect
the chest
drainage
tube to the
new ATS
bag using
the red
connectors
.
Rationale:
Establishe
s a new
ATS.
4. Make
certain that
all
connection
s are tight.
Rationale:
Ensures
an airtight
system.
5. Open all
clamps on
chest
drainage
tube and
replaceme
nt bag.
Rationale:
Reestablis
hes an
autotransf
usion
collection
system.
d. Connect the red

and blue
connectors on top
of the initial
collection bag, and
remove it by lifting
it from the side
hook and then
from the foot hook.
Rationale:
Maintains a
closed system
within the bag
and removes it
for use in
autotransfusion.
e. Secure the
replacement bag
by connecting the
foot hook,
replacing the
metal frame into
the side hook of
the chest drainage
unit and pushing
down to secure
the frame onto the
hook.
Rationale:
Provides safe
attachment of
the replacement
bag to the chest
drainage unit.
f. Remove
replacement bag
by placing the
thumbs on the top
of the metal frame
and pushing up
with the fingers to
slide the bag out.
4. Reinfusion:
f. Use a new
microaggregate
filter to reinfuse
each
autotransfusion
bag.
Rationale:
Prevents the
infusion of
microemboli and
provides
maximal filtration
for each bag.
b. Access the bag by

inverting it and
spiking the bag
through the spike
port with the
microaggregate
filter and twisting.
Rationale:
Connects the
autotransfusion
bag to the
transfusion
tubing.
c. Hang the bag on

an IV pole, and
continue to prime
the tubing until all
air is gone. Clamp
the tubing, attach
it to the patient's
IV access, and
adjust the clamp
to deliver the
reinfusion at the
appropriate rate.
Rationale:
Removes all air
from the
transfusion
tubing.
Reinfusion is
delivered by
means of gravity,
by the
application of a
blood cuff (not to
exceed 150 mm
Hg pressure), or
by using a blood-
compatible IV
pump.
d. If ordered,
anticoagulants
(citrate phosphate
dextrose or
heparin) can be
added to the
reinfusion through
the self-sealing
port in the
autotransfusion
connector.
Rationale:
Prevents clotting
in the
autotransfusion.
5. Discontinuing
autotransfusion:
a. Clamp the chest
drainage tube, and
connect it directly
to the chest
drainage unit
using the red and
blue connectors.
Rationale:
Prevents air from
entering the
chest cavity
through the tube
and collapsing
the lung.
b. Open the chest

drainage tube
clamp.
Rationale: All
drainage will be
collected directly
in the drainage
unit and must be
appropriately
discarded.
6. Discard used supplies,

and perform hand
hygiene.
Chest Tube Drainage Reinfusion - Post Procedure and Variations
1. Monitor vital signs, hematocrit, and hemoglobin.

Post Procedure
Rationale: Helps determine the effects of the treatment.
2. Monitor chest drainage system and patients lung sounds.
Rationale: Helps determine the proper functioning of the

system and its effectiveness.
3. Assess the IV infusion site for infiltration and phlebitis.
Rationale: A patent IV infusion site must be maintained.
 Record drainage and reinfusion, including times and amounts

Documentation of each. Describe condition of IV infusion site.
 Report unusual findings and patient responses to nurse in
charge or physician.
 Prepare patient and family for the procedure so they will

Patient Education understand when the patients blood from the previous
mediastinal drainage is reinfused. Patient and their families
may have had this instruction preoperatively and need
reinforcement. Patients who have had emergent thoracic
surgery will need more in-depth and more frequent information.
Chest s: Assisting - Overview
Chest tubes are placed for the removal or drainage of air, blood, or fluid
Overview: from the intrapleural or mediastinal space. They are also used to
introduce sclerosing agents into the pleural space, thereby preventing a
reaccumulation of fluid.
The thoracic cavity, under normal conditions, is a closed air space. Any
disruption results in the loss of negative pressure within the intrapleural
space; air or fluid entering the space competes with the lung, resulting in
collapse of the lung. Associated conditions are the result of disease,
injury, surgery, or iatrogenic causes.
Chest tubes are sterile, flexible vinyl, silicone nonthrombogenic catheters
approximately 20 inches (51 cm) long, varying in size from 12 to 40
French (Fr). The size of the tube placed is determined by the condition.
Chest tubes inserted for traumatic hemopneumothorax or hemothorax
(blood) should be large (36 to 40 Fr). Medium tubes (26 to 36 Fr) should
be used for fluid accumulation (pleural effusions). Tubes inserted for
pneumothorax (air) should be small (12 to 26 Fr).
Indications for chest tube insertion include the following:
 Pneumothorax (the collection of air in the pleural space)

 Hemothorax (the collection of blood)
 Hemopneumothorax (the accumulation of air and blood in the pleural
space)
 Tension pneumothorax
 Thoracostomy (e.g., open heart surgery, pneumonectomy)
 Pyothorax or empyema (the collection of pus)
 Chylothorax (the collection of chyle from the thoracic duct)
 Cholothorax (the collection of fluid containing bile)
 Hydrothorax (the collection of noninflammatory serous fluid)
 Pleural effusion
A pneumothorax may be classified as open, closed, or a tension

pneumothorax:
 Open pneumothorax: The chest wall and the pleural space are
penetrated, allowing air to enter the pleural space, as in penetrating
injury or trauma; surgical incision in the thoracic cavity (i.e.,
thoracotomy); or iatrogenic: occurs as complication of surgical
treatment (e.g., unintentional puncture during invasive procedures such
as thoracentesis or central venous catheter insertion).
 Closed pneumothorax: The pleural space is penetrated, but the chest
wall is intact, allowing air to enter the pleural space from within the lung,
as in spontaneous pneumothorax. The closed pneumothorax occurs
without apparent injury and is often seen in individuals with chronic lung
disorders (e.g., emphysema, cystic fibrosis, tuberculosis, necrotizing
pneumonia) and in young, tall males who have a greater than normal
height-to-width chest ratio; following blunt traumatic injury; or iatrogenic:
occurs as a complication of medical treatment (e.g., intermittent
positive-pressure breathing [IPPB],


 with positive end-expiratory pressure [PEEP]).
 Tension pneumothorax: Air leaks into the pleural space through a tear
in the lung and has no means to escape from the pleural cavity,
creating a one-way valve effect. With each breath the patient takes, air
accumulates, pressure within the pleural space increases, and then the
lung collapses. This causes the mediastinal structures (i.e., the heart,
the great vessels, and the trachea) to shift to the opposite or unaffected
side of the chest. Venous return and cardiac output are impeded, along
with the possibility of collapse of the unaffected lung. This is a life-
threatening emergency that requires prompt recognition and
intervention.
Special applications: Chest tubes can be used to instill anesthetic

solutions and sclerosing agents.
There are no absolute contraindications to chest tube therapy. Use of
chest tubes in patients with multiple adhesions, giant blebs, or
coagulopathies is carefully considered; however, these relative
contraindications are superseded by the need to re-inflate the lung.
The site selected for chest tube insertion See Figure 1 is determined by
the indication. If draining air, the tube is placed near the apex of the lung
(second intercostal space); if draining fluid, the tube is placed near the
base of the lung (fifth or sixth intercostal space).
Mediastinal tubes are generally placed in the operating room by a surgeon after
cardiac surgery
Chest Tube Placement: Assisting - Outcomes
 Removal of air, fluid, or blood from the pleural space

Expected  Relief of respiratory distress
Outcomes  Reexpansion of the lung (validated by chest radiograph)
 Restoration of negative pressure within the pleural space
 Hemorrhage/shock
Unexpected  Increasing respiratory distress
Outcomes  Infection
 Damage to intracostal nerve resulting in neuropathy, neuritis
 Incorrect tube placement
 Chest tube kinking, clogging, or dislodgment from chest wall
 Subcutaneous emphysema
Chest Tube Placement: Assisting - Assessment and Preparation
 Ensure that patient understands preprocedural teaching. Answer

Preparation questions as they arise and reinforce information as needed.
 Obtain consent if circumstances allow.
 Determine insertion site.
 Assist the patient to the lateral, supine (for pneumothorax), or semi-
Fowler's position (for hemothorax).
 Administer prescribed analgesics or sedatives as needed
 Antiseptic solution
Supplies  Sterile gloves, caps, gowns, masks, drapes
 Protective eyewear (goggles)
 Local anesthetic: 1% lidocaine solution
 Tube thoracotomy tray
o Sterile towels, 4 x 4 sterile gauze
o Scalpel with no. 11 blade
o Two Kelly clamps, curved clamps
o Needle holder
o 2-0, 3-0 silk suture with cutting needle
o Suture scissors
o Two hemostats
o 10-ml syringe with 20-G, 1½ -inch needle
o 5-ml syringe with 25-G, 1-inch needle
o Thoracostomy tube (choose size appropriate to condition)
 Closed chest drainage system

 Suction source
 Suction connector and connecting tubing (usually 6 feet for each
tube)
 Y connector
 1-inch adhesive tape or Parham bands
 Dressing materials (4 x 4 gauze pads, slit drain sponges, petroleum
gauze, tape)
1. Assess significant medical history or injury, including chronic lung

Assessment disease, spontaneous pneumothorax, hemothorax, pulmonary
disease, therapeutic procedures, and mechanism of injury.
2. Assess baseline cardiopulmonary status for signs and symptoms
requiring chest tube insertion.
a. Tachypnea
b. Decreased or absent breath sounds on the affected side
c. Crackles adjacent to the affected area
d. Shortness of breath, dyspnea
e. Asymmetric chest excursion with respirations
f. Cyanosis
g. Decreased oxygen saturation
h. Hyperresonance in the affected side (pneumothorax)
i. Subcutaneous emphysema (pneumothorax)
j. Dullness or flatness in the affected side (hemothorax, pleural
effusion, empyema, chylothorax)
k. Sudden, sharp chest pain
l. Anxiety, restlessness, apprehension
m. Tachycardia
n. Hypotension
o. Dysrhythmias
p. Tracheal deviation to the unaffected side (tension
pneumothorax)
q. Neck vein distention (tension pneumothorax)
r. Muffled heart sounds (tension pneumothorax)
3. Evaluate diagnostic tests (if patient's condition does not necessitate

immediate intervention), including chest radiograph and arterial
blood gases.
Chest Tube Placement: Assisting - Procedure
1. Wash hands, and don sterile personal protective equipment.
Rationale: Reduces the transmission of microorganisms and body secretions;

standard precautions.
Chest tube insertion is a sterile procedure and requires full attire, unless
performed in a life-threatening situation.
2. Open the chest tube insertion tray using sterile technique.
3. Prepare equipment.
Rationale: Facilitates insertion of the tube.
a. Check that all equipment is present.

b. Pour antiseptic solution into basin using aseptic technique.
c. Attach needle holder to suture.
d. Apply a large Kelly clamp to proximal end of tube.
e. Assist with preparing the syringe with lidocaine solution.
5. Assist the patient to the lateral supine (for pneumothorax), or semi-Fowler's position for
hemothorax.
6. Assist the physician or advanced practice nurse with preparation of the insertion site.
Rationale: Assists in preparing area for insertion and proper placement See

Figure 1 of tube.
Air: right or left second intercostal space. Fluid: right or left fifth or sixth
intercostal space, mid-axillary line. Incision site is one rib below insertion
site
6. Connect the chest tube to the closed chest drainage system, and check for respiratory
variation of the H2O column. Apply ordered amount of suction.
Rationale: Ensures the tube is properly positioned.
7. Assist with suturing of the tube to the chest wall.
Rationale: Secures the position of the tube. Secures the tube snugly to prevent
subcutaneous air/emphysema.
Type of stitch used is dependent on the individual. The goal is to prevent
displacement of the chest tube.
8. Apply occlusive dressing See Figure 2 . Secure connection sites See Figure 3 .
Rationale: Provides airtight seal around the chest tube.
a. Petrolatum gauze is used around the chest tube or follow institutional standard.
b. Split drain sponges are placed around the chest tube, one from top, one
underneath.
c. Cover with 4 x 4 gauze.
d. Tape dressing.
10. Tape all connection points to the drainage system.
Rationale: Creates an airtight system. Airtight connections prevent air leaks into
the pleural space.
Check that all holes are in the pleural space.
10. Obtain a chest radiograph.

Rationale: Confirms placement of tube, expansion of lung, and removal of fluid.
Document location, tube size, complications, and result of chest
radiograph in the chart.
11. Dispose of equipment in receptacle.
Rationale: Standard precautions.
12. Document in patient's record.
Chest Tube Placement: Assisting - Post Procedure and Variations
1. Assess cardiopulmonary and vital signs every 2 hours and as

Post Procedure needed.
Rationale: Provides baseline and ongoing assessment of

patient's condition. Abnormalities can indicate
reoccurrence of the condition that required chest tube
insertion.
Tachypnea, decreased or absent breath sounds,
hypoxemia, tracheal deviation, subcutaneous
emphysema, neck vein distention, muffled heart
tones, tachycardia, hypotension, dysrhythmias, or
fever should be reported if they persist despite
nursing interventions.
2. Monitor output every 2 hours and record amount and color.
Rationale: Provides data for diagnosis.

Bloody drainage of 200 ml/hr or greater, sudden
cessation of drainage, or change in character of
drainage should be reported if they persist despite
3. Assess for pain at the insertion site or for chest discomfort.
Rationale: Interferes with adequate deep breathing. Pain

at insertion site, particularly with inspiration, may indicate
improper tube placement.
Pain at insertion site should be reported if it persists
despite nursing interventions.
4. Evaluate the chest drainage system for fluctuation in water-seal

chamber. Check connections.
Rationale: Water level will normally rise and fall with

respiration until lung is expanded. Bubbling immediately
after insertion and with exhalation and coughing is
normal. Persistent bubbling indicates an air leak and
should be corrected.
Absence of fluctuation in water-seal chamber or
persistent bubbling should be reported if it persists
5. Assess insertion site and surrounding skin for presence of

subcutaneous air and signs of infection or inflammation with
each dressing change, or every day.
Rationale: Skin integrity is altered during insertion and

can lead to infection.
Fever, redness around insertion site, purulent
drainage, or subcutaneous emphysema should be
reported if they persist despite nursing interventions.
 Patient and family education

Documentation  Reason for chest tube insertion
 Respiratory and vital sign assessment before and after
insertion
 Description of procedure, including the following: tube size,
date and time of insertion, insertion site, and any complications
associated with the procedure
 Results of procedure, type and amount of drainage
 Presence of fluctuation and bubbling
 Amount of suction
 Patient's tolerance to procedure
 Post insertion chest radiograph results
 Unexpected outcomes
 Nursing interventions
 Explain the procedure (if patient condition and time allows) and
Patient Education the reason for the chest tube insertion
 Explain that the patient's participation during the procedure is
to remain as immobile as possible and do relaxed breathing
 After the procedure, instruct the patient to sit in a semi-Fowler's
position (unless contraindicated)
 Instruct the patient to turn and change position every 2 hours;
the patient may lie on the side with the chest tube but should
keep the tubing free of kinks
 Instruct the patient to cough and deep breathe, splinting the
affected side
 Encourage active or passive range-of-motion exercises of the
arm on the affected side
 Instruct the patient and family about activity as prescribed while
maintaining the drainage system below the level of the chest
 Instruct the patient about the availability of prescribed
analgesic medication and other pain relief strategies
Chest Tube Placement Performing (Advanced Practice) - Overview
Chest tubes are placed for the removal or drainage of air, blood, or fluid
Overview: from the intrapleural or mediastinal space. They are also used to
introduce sclerosing agents into the pleural space, thereby preventing a
reaccumulation of fluid.
The thoracic cavity, under normal conditions, is a closed air space. Any
disruption results in the loss of negative pressure within the intrapleural
space; air or fluid entering the space competes with the lung, resulting in
collapse of the lung. Associated conditions are the result of disease,
injury, surgery, or iatrogenic causes.
Chest tubes are sterile, flexible vinyl, silicone, nonthrombogenic
catheters that are approximately 20 inches (51 cm) long, varying in size
from 12 to 40 French (Fr). The size of the tube placed is determined by
the condition. Chest tubes inserted for traumatic hemopneumothorax or
hemothorax (blood) should be large (36 to 40 Fr). Medium tubes (26 to
36 Fr) should be used for fluid accumulation (pleural effusions). Tubes
inserted for pneumothorax (air) should be small (12 to 26 Fr).
Indications for chest tube insertion include the following:
 Pneumothorax (the collection of air in the pleural space)

 Hemothorax (the collection of blood)
 Hemopneumothorax (the accumulation of air and blood in the pleural
space)
 Tension pneumothorax
 Thoracostomy (e.g., open heart surgery, pneumonectomy)
 Pyothorax or empyema (the collection of pus)
 Chylothorax (the collection of chyle from the thoracic duct)
 Cholothorax (the collection of fluid containing bile)
 Hydrothorax (the collection of noninflammatory serous fluid)
 Pleural effusion
A pneumothorax may be classified as open, closed, or a tension

pneumothorax:
 Open pneumothorax: The chest wall and the pleural space are
penetrated, allowing air to enter the pleural space, as in penetrating
injury or trauma; surgical incision in the thoracic cavity (i.e.,
thoracotomy); or iatrogenic: occurs as complication of surgical
treatment (e.g., unintentional puncture during invasive procedures such
as thoracentesis or central venous catheter insertion).
 Closed pneumothorax: The pleural space is penetrated, but the chest
wall is intact, allowing air to enter the pleural space from within the lung,
as in spontaneous pneumothorax. The closed pneumothorax occurs
without apparent injury and is often seen in individuals with chronic lung
disorders (e.g., emphysema, cystic fibrosis, tuberculosis, necrotizing
pneumonia) and in young, tall males who have a greater than normal
height-to-width chest ratio; following blunt traumatic injury; or iatrogenic:
occurs as a complication of medical treatment (e.g., intermittent
positive-pressure breathing [IPPB] , mechanical ventilation with positive
end-expiratory pressure [PEEP]).
 Tension pneumothorax: Air leaks into the pleural space through a tear
in the lung and has no means to escape from the pleural cavity,
creating a one-way valve effect. With each breath the patient takes, air
accumulates, pressure within the pleural space increases, and then the
lung collapses. This causes the mediastinal structures (i.e., the heart,
great vessels, and the trachea) to shift to the opposite or unaffected
side of the chest. Venous return and cardiac output are impeded, along
with the possibility of collapse of the unaffected lung. This is a life-
threatening emergency that requires prompt recognition and
intervention.
Special applications: Chest tubes can be used to instill anesthetic

solutions and sclerosing agents.
There are no absolute contraindications to chest tube therapy. Use of
chest tubes in patients with multiple adhesions, giant blebs, or
coagulopathies is carefully considered; however, these relative
contraindications are superseded by the need to re-inflate the lung.
The site selected for chest tube insertion See Figure 1 is determined by
the indication. If draining air, the tube is placed near the apex of the lung
(second intercostal space); if draining fluid, the tube is placed near the
base of the lung (fifth or sixth intercostal space).
Mediastinal tubes are generally placed in the operating room by a
surgeon after cardiac surgery.
Chest Tube Placement Performing (Advanced Practice) - Outcomes
 Removal of air, fluid, or blood from the pleural space

Expected  Relief of respiratory distress
Outcomes  Reexpansion of the lung (validated by chest radiograph)
 Restoration of negative pressure within the pleural space
 Hemorrhage/shock
Unexpected  Increasing respiratory distress
Outcomes  Infection
 Damage to intracostal nerve resulting in neuropathy, neuritis
 Incorrect tube placement
 Chest tube kinking, clogging, or dislodgment from chest wall
 Subcutaneous emphysema
Chest Tube Placement Performing (Advanced Practice) - Assessment and

Preparation

Preparation questions as they arise and reinforce information as needed.
 Obtain consent if circumstances allow.
 Determine insertion site.
 Assist the patient to the lateral, supine (for pneumothorax), or semi-
Fowler position (for hemothorax).
 Administer prescribed analgesics or sedatives as needed.
 Antiseptic solution
Supplies  Sterile gloves, caps, gowns, masks, and drapes
 Protective eyewear (goggles)
 Local anesthetic: 1% lidocaine solution
 Tube thoracotomy tray
o Sterile towels, 4 x 4 sterile gauze

o Scalpel with No. 11 blade
o Two Kelly clamps, curved clamps
o Needle holder
o 2-0, 3-0 silk suture with cutting needle
o Suture scissors
o Two hemostats
o 10-ml syringe with 20-G, 1½ -inch needle
o 5-ml syringe with 25-G, 1-inch needle
o Thoracostomy tube (choose size appropriate to condition)
 Closed chest drainage system

 Suction source
 Suction connector and connecting tubing (usually 6 feet for each
tube)
 Y connector
 1-inch adhesive tape or Parham bands
 Dressing materials (4 × 4 gauze pads, slit drain sponges, petroleum
gauze, and tape)
1. Assess significant medical history or injury, including chronic lung

Assessment disease, spontaneous pneumothorax, hemothorax, pulmonary
disease, therapeutic procedures, and mechanism of injury.
2. Assess baseline cardiopulmonary status for signs and symptoms
requiring chest tube insertion.
a. Tachypnea
b. Decreased or absent breath sounds on the affected side
c. Crackles adjacent to the affected area
d. Shortness of breath, dyspnea
e. Asymmetric chest excursion with respirations
f. Cyanosis
g. Decreased oxygen saturation
h. Hyperresonance in the affected side (pneumothorax)
i. Subcutaneous emphysema (pneumothorax)
j. Dullness or flatness in the affected side (hemothorax, pleural
effusion, empyema, chylothorax)
k. Sudden, sharp chest pain
l. Anxiety, restlessness, apprehension
m. Tachycardia
n. Hypotension
o. Dysrhythmias
p. Tracheal deviation to the unaffected side (tension
pneumothorax)
q. Neck vein distention (tension pneumothorax)
r. Muffled heart sounds (tension pneumothorax)
3. Evaluate diagnostic tests (if patient's condition does not necessitate

immediate intervention), including chest radiograph and arterial
blood gases.
Chest Tube Placement Performing (Advanced Practice) - Procedure
1. Wash hands and don sterile personal protective equipment.
Rationale: Reduces the transmission of microorganisms and body secretions;

Chest tube insertion is a sterile procedure and requires full attire, unless
performed in a life-threatening situation.
2. Open the chest tube insertion tray using sterile technique.
3. Prepare equipment.
Rationale: Facilitates insertion of the tube.

a. Check that all equipment is present.
b. Pour antiseptic solution into basin using aseptic technique.
c. Attach needle holder to suture.
d. Apply a large Kelly clamp to proximal end of tube.
e. Prepare syringe with lidocaine solution.
5. Identify insertion site and have assistant position the patient.
Assists in preparing area for insertion and proper placement of tube See Figure
1.
Air: right or left second intercostal space. Fluid: right or left fifth or sixth
intercostal space, mid-axillary line. Incision site is one rib below insertion
site
5. Surgically prepare the skin with antiseptic solution, and drape the area surrounding the
insertion site.
Rationale: Inhibits growth of bacteria at insertion site. Maintains sterility.

Prepare the area from the clavicle to umbilicus; mid-chest to anterior
axillary line.
6. Anesthetize the skin, subcutaneous tissue, muscle, and periosteum with 1% lidocaine
solution.
Rationale: Results in loss of sensation and decreased pain during insertion.

When infiltrating with lidocaine, aspirate as you go to confirm the presence
of air or fluid. As much as 30 to 40 ml of lidocaine may be required for
anesthesia.
a. Using a 5-ml syringe (25-G needle), inject a subcutaneous wheal of lidocaine at

the insertion site.
b. Using a 10-ml syringe (20-G, 1½-inch needle), advance the needle/syringe,
aspirating as you go, until air or pleural fluid confirmed. Inject the lidocaine
deeper, and slowly withdraw the syringe, generously anesthetizing rib
periosteum, subcutaneous tissue, and pleura See Figure 2.
8. Using a No. 11 blade, make a 3-cm transverse skin incision directly over the inferior
aspect of the anesthetized rib below the insertion site See Figure 3.
Rationale: Allows for the diameter of the chest tube.
When making the incision, incise down through the subcutaneous tissue.
The space should be large enough to admit a finger.
8. Introduce the curved clamp through the incision, with the tips down, creating a tunnel
through the subcutaneous tissue and muscle; use an opening and spreading maneuver;
aim toward the superior aspect of the rib until the pleural space is reached See Figure
4.
Rationale: Facilitates insertion of the tube. Blunt dissection minimizes trauma to

the neurovascular bundle.
Additional lidocaine is infiltrated as needed. The direction of the tunnel
created through the subcutaneous tissue and muscle will determine the
direction the chest tube will take after insertion. Make sure the clamp stays
close to the ribs to avoid injury to the neurovascular bundle.
9. When the clamp is just over the superior portion of the rib, close the clamp and push it
with steady pressure through the parietal pleura and into the pleural space. Widen the
hole in the pleural space by spreading the clamp See Figure 5.
Rationale: Ensures opening is large enough for the chest tube. Steady, even,
controlled pressure provides control of the clamp once the pleura is perforated.
This maneuver requires more pressure than might be anticipated. A
lunging motion or use of the trocar may create a hole in lung or injury to
the liver or spleen.
10. Insert the index finger to dilate the tract and hole in the pleura.
Rationale: Releases air or fluid once penetration of the space is made. Ensures
entry into the pleural space and not into a space inadvertently created between
the parietal pleura and chest wall.
Feel for lung tissue (lung should expand and meet finger on inspiration),
diaphragm, or adhesions. Break up clot, if found.
11. Insert the chest tube into the chest cavity using a curved Kelly clamp, holding the
proximal end to guide the tip into the pleural space See Figure 6. Remove the clamp
and guide the tube, in a rotating motion, through the tract and into the space. The tube
is advanced until the last hole is in the pleural space. Condensation of air or fluid in the
tube should be noted.
Rationale: Confirms placement of the tube.

To drain air, aim the tube posteriorly and superiorly toward the apex of the
lung; to drain fluid, aim the tube inferiorly and posteriorly. Do not allow
any side holes of the tube to remain outside the thoracic cavity.
12. Connect the chest tube to the closed chest drainage system and check for respiratory
variation of the H2O column. Have assistant apply ordered amount of suction.
Rationale: Ensures the tube is properly positioned.
13. Suture the tube to the chest wall. Wrap the free ends of the suture around the tube (like
lacing a shoe). Tie the ends of the suture snugly around the top of the tube See Figure
7.
Rationale: Secures the position of the tube. Secures the tube snugly to prevent
subcutaneous air/emphysema.
Type of stitch used is dependent on the individual. The goal is to prevent
displacement of the chest tube.
14. Apply occlusive dressing.
Rationale: Provides airtight seal around the chest tube.
a. Petrolatum gauze is used around the chest tube (or follow institutional standard).
b. Split drain sponges are placed around the chest tube, one from top, one
underneath.
c. Cover with 4 x 4 gauze.
d. Tape dressing.
16. Tape all connection points to the drainage system.
Rationale: Creates an airtight system. Airtight connections prevent air leaks into
the pleural space.
Check that all holes are in the pleural space.
16. Obtain a chest radiograph.
Rationale: Confirms placement of tube, expansion of lung, and removal of fluid.

Document location, tube size, complications, and result of chest
radiograph in the chart.
17. Dispose of equipment in receptacle.

Chest Tube Placement Performing (Advanced Practice) - Post Procedure and
Variations
1. Assess cardiopulmonary and vital signs every 2 hours and as

Post Procedure needed.
Rationale: Provides baseline and ongoing assessment of

patient's condition. Abnormalities can indicate
reoccurrence of the condition that required chest tube
insertion.
Tachypnea, decreased or absent breath sounds,
hypoxemia, tracheal deviation, subcutaneous
emphysema, neck vein distention, muffled heart
tones, tachycardia, hypotension, dysrhythmias, or
fever should be reported if they persist despite
2. Monitor output every 2 hours and record amount and color.
Rationale: Provides data for diagnosis.

Bloody drainage of 200 ml/hr or greater, sudden
cessation of drainage, or change in character of
drainage should be reported if they persist despite
3. Assess for pain at the insertion site or for chest discomfort.
Rationale: Interferes with adequate deep breathing. Pain

at insertion site, particularly with inspiration, may indicate
improper tube placement.
Pain at insertion site should be reported if it persists
4. Evaluate the chest drainage system for fluctuation in water-seal

chamber. Check connections.
Rationale: Water level will normally rise and fall with

respiration until lung is expanded. Bubbling immediately
after insertion and with exhalation and coughing is
normal. Persistent bubbling indicates an air leak and
should be corrected.
Absence of fluctuation in water-seal chamber or
persistent bubbling should be reported if it persists
5. Assess insertion site and surrounding skin for presence of

subcutaneous air and signs of infection or inflammation with
each dressing change or every day.
Rationale: Skin integrity is altered during insertion and

can lead to infection.
Fever, redness around insertion site, purulent
drainage, or subcutaneous emphysema should be

Documentation  Reason for chest tube insertion
 Respiratory and vital sign assessment before and after
insertion
 Description of procedure, including the following: tube size,
date and time of insertion, insertion site, and any complications
associated with the procedure
 Results of procedure; type and amount of drainage
 Presence of fluctuation and bubbling
 Amount of suction
 Patient's tolerance to procedure
 Post insertion chest radiograph results
 Explain the procedure (if patient condition and time allows) and
Patient Education the reason for the chest tube insertion
 Explain that the patient's participation during the procedure is
to remain as immobile as possible and do relaxed breathing
 After the procedure, instruct the patient to sit in a semi-Fowler's
position (unless contraindicated)
 Instruct the patient to turn and change position every 2 hours;
the patient may lie on the side with the chest tube but should
keep the tubing free of kinks
 Instruct the patient to cough and deep breath, splinting the
affected side
 Encourage active or passive range-of-motion exercises of the
arm on the affected side
 Instruct the patient and family about activity as prescribed while
maintaining the drainage system below the level of the chest
 Instruct the patient about the availability of prescribed
analgesic medication and other pain relief strategies
Chest-Drainage Systems: Argyle - Overview

The information in this procedure should be used in conjunction with the
Overview: Chest-Drainage Systems procedure. Chest-drainage devices are used to
evacuate air, fluid, or both from the pleural space and reexpand the lung
by restoring negative intrapleural pressure. Argyle chest-drainage
devices include Aqua-Seal, Thora-Seal III, and Sentinel Seal.
Chest-Drainage Systems: Argyle - Outcomes
 Improved respiratory status

Expected  Reexpansion of lung
Outcomes
 A tension pneumothorax may develop if there are

Unexpected obstructions in the system; kinked or clamped tubing
Outcomes is the most likely source of obstruction
 If the device breaks or the system becomes
disconnected, an open pneumothorax may develop;
if this occurs, place the end of the drainage tubing
(approximately 2.5 cm) in a container of sterile water
until another chest-drainage device can be prepared
 Accidental dislodgment of the chest tube: If this
happens, have the patient cough or exhale forcibly
and apply an occlusive dressing to the area; tape it
on three sides.
Chest-Drainage Systems: Argyle - Assessment and Preparation
Preparation
 The physician or advanced practice nurse inserts a chest tube.

 Assure chest tube is properly secured to the patient's chest and there is an airtight
dressing surrounding the insertion site.
Supplies
 Chest-drainage unit (Aqua-Seal, Thora-Seal III, or Sentinel Seal)
 Sterile water
 1- or 2-inch tape
 Suction setup
Assessment
1. Assess level of dyspnea.

2. Auscultate breath sounds.
Chest-Drainage Systems: Argyle - Procedure
Aqua-Seal
1. Fill the water-seal chamber See Figure 1. Lower the preattached syringe See Figure
2 and fill it to the top with approximately 45 ml of sterile fluid. Raise the syringe and
allow the fluid to flow into the water-seal chamber up to the 2-cm line. The water turns
blue for enhanced visibility. Remove the tubing and the syringe from the water-seal
chamber and discard them. If necessary, the unit can be connected to the patient now.
If the water-seal level needs to be adjusted later, use the needleless access port on the
back of the water-seal chamber.
2. Fill the suction-control chamber. Pour sterile fluid directly into the suction control fill
opening to the prescribed level; -20 cm H2O is the usual setting for patients who are
older than 6 months. Close the suction control chamber with the attached cap; make
sure that the cap snaps into place (suction greater than -25 cm H2O can be achieved
with the suction-control bypass adaptor on the back of the unit; see the package insert
for more information).
3. Attach the chest tube to the thoracic catheter connector (if not done in step 1). Tape the
connection securely.
4. Turn the black suction-control valve See Figure 3 on the suction port clockwise to the
closed position. Connect a regulated suction source to the suction port. Turn the
vacuum on and open the black suction valve a gentle bubbling is achieved in the
suction-control chamber.
5. Excess negative pressure can be relieved with the negative-pressure relief vent on the
top of the unit. Excess positive pressure is automatically relieved by a valve on top of
the unit.
Thora-Seal III
1. Fill the water-seal bottle See Figure 4 . Remove the water-seal cap from the top of the
unit (middle bottle). Pour approximately 120 ml of sterile fluid directly into the opening to
the line indicated on the water-seal bottle. Replace the cap. If necessary, the unit can
be connected to the patient now.
2. Fill the suction-control bottle. Pour sterile fluid into the opening on the top of the suction-
control bottle to the prescribed level; -20 cm H2O is the usual setting for patients who
are older than 6 months.
3. Attach the chest tube to the thoracic catheter connector (if this did not occur in step 1).
Tape the connection securely.
4. Attach the suction tubing to the connection port on top of the suction bottle, turn on the
vacuum, and adjust until a gentle bubbling is achieved in the suction-control bottle.
5. To change the collection bottle, remove the floor stand.
a. With the physicians approval, clamp the patients connecting tubing for a brief
time.
b. Rotate the collection bottle clockwise and pull it down.
c. Insert a new bottle into the manifold and rotate until the bottle neck snaps into a
locked position.
d. Remove the clamp from the patient's connecting tubing.
e. Replace the floor stand.
A tension pneumothorax may develop when a chest tube is

clamped.
Sentinel Seal
1. Fill the underwater-seal chamber. Remove the suction regulator See Figure 5 from the
top of the unit by twisting it at the base. Pour approximately 90 ml of sterile fluid through
the opening and fill to the red -2- line on the suction control chamber. Replace the
suction regulator and twist it into place. Remove the red protector ring from the suction
regulator and discard it.
2. Fill the patient assessment chamber. Remove the instruction tape from the top of the
unit and fill the chamber to the red line with approximately 30 ml of sterile fluid. The fluid
turns blue for enhanced visibility.
3. Attach the chest tube to the thoracic catheter connector. Tape the connection securely.
4. Connect the suction source to the suction regulator. Set the wall suction source to at
least 160 mm Hg (set a portable suction source to at least 50 cm H2O). Watch the
patient assessment chamber while turning the suction regulator until the fluid reaches
the prescribed suction level; -20 cm H2O is the usual setting for patients who are older
than 6 months.
a. Turn the suction regulator clockwise to increase the negative pressure.
b. To release excess negative pressure, remove the red cap and depress the
negative-pressure relief vent.
c. To decrease the vacuum, depress the negative-pressure relief vent while turning
the suction regulator counterclockwise. Do not depress the negative-pressure
relief vent unless the unit is connected to the suction source or the intrapleural
negativity may be lost.
5. For gravity drainage, disconnect the suction tubing from the suction regulator.
Chest-Drainage Systems: Argyle - Post Procedure and Variations
1. Secure the connection sites with adhesive tape.

Post Procedure 2. Keep collection device upright.
Rationale: If the unit tips over, intrapleural negativity may

be lost with air entry into the pleural space. Tipping the
units may result in mixing of fluid from some chambers or
loss of the water seal.
3. Do not clamp the tube unless it is absolutely necessary (to

change the chest-drainage device or to check for air leaks).
Rationale: A tension pneumothorax may develop.
4. Do not raise the device above the patient's chest level.
Rationale: Fluid may reenter the chest and increase the

probability of infection.
5. Do not allow the tubing to coil below the top of the device or lie
on the floor.
Rationale: Dependent fluid-filled loops require increased

intrathoracic pressure to continue the emptying of the
pleural space.
 Time system was put in place
Documentation  Amount of suction in centimeters of water (if applicable)
 Amount of fluid collected (over time)
 Request assistance when moving or turning in bed or when

Patient Education getting out of bed
 Report any shortness of breath, chest pain, or disconnections
in the system immediately
 Do not lie on the tubing or allow it to be kinked
Considerations
 Argyle does not make a pediatric chest-drainage unit, but all
units can be used for pediatric patients.
 -10 to -20 cm H2O is the suction level usually recommended for
pediatric patients.
 Milking or stripping of chest tubes is contraindicated in children.
Chest-Drainage Systems: Atrium - Overview

Overview: general Chest-Drainage Systems procedure. Chest-drainage devices
are used to evacuate air, fluid, or both from the pleural space and re-
expand the lung by restoring negative intrapleural pressure.
Chest-Drainage Systems: Atrium - Outcomes
Expected Outcomes

 Reexpansion of lung
Unexpected Outcomes
 A tension pneumothorax may develop if there are obstructions in the system; kinked or
clamped tubing is the most likely source of obstruction
 If the device breaks or the system becomes disconnected, an open pneumothorax may
develop; if this occurs, place the end of the drainage tubing (approximately 2.5 cm) in a
container of sterile water until another chest-drainage device can be prepared
 Accidental dislodgment of the chest tube: If this happens, have the patient cough or
exhale forcibly and apply an occlusive dressing to the area; tape it on three sides
Chest-Drainage Systems: Atrium - Assessment and Preparation
Preparation

 Assure chest tube is properly secured to the patient's chest and there is an airtight
dressing surrounding the insertion site.
Supplies
 Atrium chest-drainage unit (wet- or dry-suction control)

 Sterile water or saline
 Tape
 Suction setup
Assessment

2. Auscultate breath sounds.
Chest-Drainage Systems: Atrium - Procedure
Wet-Suction Control
1. Turn the suction-control stopcock to the "on" position. Fill the water-seal chamber See
Figure 1 with sterile water by holding the preattached funnel level with the unit. Add
water to the top of the funnel. Raise the funnel and empty the water into the water-seal
chamber up to the 2-cm line. The water turns blue to assist in air-leak detection. If too
much water is added, the excess can be removed by inserting a needle and syringe
through the face grommet. When the water has passed to the chamber, the suction-
control stopcock must be returned to the "off" position before it is connected to the
unregulated suction device. Discard the funnel after use or use it to fill the suction-
control chamber.
2. To fill the suction-control chamber, remove the suction-control vent plug and pour into
the chamber the amount of sterile water or saline needed to achieve the desired suction
pressure [See Table 1]. The water turns blue when the chamber is filled. The usual
pressure setting for adults is -20 cm H2O.
3. Replace the suction-control vent plug.
4. Remove the cap from the patient-tube connector and attach it to the chest tube. Tape
the connection securely.
5. Connect the suction source to the suction-control stopcock.
6. Turn on the suction-control stopcock and increase the suction pressure slowly until
constant gentle bubbling occurs in the suction-control chamber. To increase or
decrease the suction pressure delivered to the patient, adjust the fluid level in the
suction-control chamber by injecting water via the face grommet.
7. Observe the water seal for air leaks and changes in pressure. Absence of bubbling with
minimal float-ball oscillation indicates that there is no air leak. Constant or intermittent
bubbling, with air bubbles going from right to left in the air-leak zone See Figure
2 indicates a leak in either the chest-drainage system or the thoracic cavity.
8. Changes in patient pressure are detected by observing the float ball in the calibrated
water-seal column. When the chest tube is connected to the suction chamber, the
patient's pressure is equal to the suction-control setting plus the float-ball level.
Accumulated positive pressure is automatically released by the in-line positive-pressure
valve.
Dry-Suction Control
1. Turn the suction-control stopcock to the on position. Fill the water-seal chamber with
sterile water by holding the preattached funnel See Figure 3 level with the unit. Add
water to the top of the funnel. Raise the funnel and empty the water into the water-seal
chamber up to the 2-cm line. The water turns blue to assist in air-leak detection. If too
much water is added, the excess can be removed by inserting a needle and syringe
through the face grommet.
2. Remove the cap from the patient-tube connector and attach it to the chest tube. Tape
the connection securely.
3. Connect the chest-drain suction line to the suction source. The suction-control regulator
is preset to -20 cm H2O. Increase the suction source to -80 mm Hg or higher. The
suction-monitor bellows must be expanded to the mark or beyond it for a -20 cm H2O or
higher setting. The monitor bellows does not expand when suction is not operating or is
disconnected. The regulator-control dial See Figure 4 on the side of the drain can be set
between -10 and -40 cm H2O. To change the suction pressure, dial down to lower the
suction pressure and up to increase it.
4. Observe the calibrated water-seal column for changes in patient pressure. When the
suction is operating, the patient pressure equals the suction-control setting plus the
water-seal column level. For gravity drainage, the patient pressure equals the calibrated
water-seal column level only.
5. Observe the water seal See Figure 2 for air leaks. Absence of bubbling with minimal
float ball oscillation indicates that there is no air leak. Constant or intermittent bubbling
indicates a leak in either the chest-drainage system or the thoracic cavity.

Table 1: Water Needed for Various Suction Levels
Suction Water/saline volume

Pressure needed
-20 cm H2O 320 ml
-15 cm H2O 190 ml
-10 cm H2O 80 ml

Chest-Drainage Systems: Atrium - Post Procedure and Variations

Rationale: If the unit tips over, intrapleural negativity may

be lost with air entry into the pleural space. Tipping the
unit may result in mixing of fluid from some chambers or
loss of the water seal.

on the floor.

pleural space.


Considerations
 Infant or pediatric collection units are available in either wet- or
dry-suction control models. The drainage chamber is smaller
than the adult counterpart, and it has large, easy-to-read
drainage gradations.
 -10 to -20 cm H2O is the suction level usually recommended for
pediatric patients.
Chest-Drainage Systems: Pleur-Evac - Overview

Overview: general Chest-Drainage Systems procedure. Chest-drainage devices
are used to evacuate air, fluid, or both from the pleural space and
reexpand the lung by restoring negative intrapleural pressure. Pleur-
Evac and Sahara chest-drainage units are products of the Deknatel
Product Group, Genzyme Surgical Products (Fall River, MA). The
Sahara units are totally dry and are therefore quick and easy to set up.
All Sahara units have 100% latex-free pathway and tubing. The Sahara
and dry suction control units can achieve higher levels of suction (as
much as -40 cm H2O) than the wet suction control units.
Chest-Drainage Systems: Pleur-Evac - Outcomes

Expected  Reexpansion of lung
Outcomes
 A tension pneumothorax may develop if there are

Unexpected obstructions in the system.; kinked or clamped
Outcomes tubing is the most likely source of obstruction
 If the device breaks or the system becomes
disconnected, an open pneumothorax may develop;
if this occurs, place the end of the drainage tubing
(approximately 2.5 cm) in a container of sterile water
until another chest-drainage device can be prepared
 Accidental dislodgment of the chest tube: If this
happens, have the patient cough or exhale forcibly
and apply an occlusive dressing to the area; tape it
on three sides.
Chest-Drainage Systems: Pleur-Evac - Assessment and Preparation

Preparation  Ensure the chest tube is properly secured to the patient's chest and
there is an airtight dressing surrounding the insertion site.
 Pleur-Evac (wet or dry suction control) water-seal unit or Sahara

Supplies (dry) chest-drainage unit
 Sterile water
 Adhesive tape
 Suction setup
 Needle and a 30-ml syringe (to fill the air leak chamber of the Sahara
unit)

Assessment 2. Auscultate breath sounds.
Chest-Drainage Systems: Pleur-Evac - Procedure
Pleur-Evac: Wet Suction Control

1. Attach a funnel to the section tubing connector See Figure 1and fill it to the 2-cm level
with sterile water (approximately 70 ml). Use the Fill to Here mark as a guide. The water
turns blue for enhanced visibility. Disconnect the funnel. If necessary, the unit can now
be attached to the patient.
2. Remove the atmospheric vent cover (muffler) and fill the suction control chamber with
enough sterile water to achieve the desired level of suction; -20 cm H2O is the standard
setting. Replace the muffler, making sure you do not occlude the atmospheric vent.
3. Attach the long tube from the collection chamber to the patient's chest tube and tape all
the connections securely.
4. Attach the tubing from the suction control chamber to a suction source. Adjust the
suction until gentle, continuous bubbling occurs in the suction control chamber. To
increase the suction delivered to the pleural cavity, additional water must be added to
the chamber.
Rationale: Increasing the suction from the source only increases the airflow
through the system without increasing the negativity delivered to the patient.
5. If gravity drainage is desired, omit step 4 and leave the suction tubing open and
unclamped to prevent positive pressure buildup.
Pleur-Evac: Dry Suction Control
1. Attach a funnel to the suction-tube connector See Figure 2 and fill it to the 2-cm level
(Fill to Here mark) with sterile water (approximately 70 ml). The water turns blue for
enhanced visibility. Disconnect the funnel.
2. Attach the long tube from the collection chamber to the patient's chest tube and tape all
connections securely.
3. Attach the tubing from the suction control chamber to a suction source. The suction is
controlled by a dial that is preset at -20 cm H2O. Turn on the suction and increase it until
the orange float is visible in the suction control indicator window. If more negativity is
desired, change the suction control dial.
If the suction level is decreased after the initial setup, the negativity
delivered to the patient may not change unless the excess negativity is
vented with the high-negativity relief valve.
4. If gravity drainage is desired, omit step 3 and leave the suction tubing open and
unclamped to prevent positive-pressure buildup.
Sahara
1. Attach the long tube from the collection chamber See Figure 3 to the patient's chest
tube and tape all connections securely See Figure 4. No fluid needs to be added to the
system before it is connected to the patient because there is a one-way valve, not a
water seal, which prevents air from reentering the thoracic cavity.
2. Use an 18-gauge or smaller needle and a 30-ml syringe to inject 30 ml of sterile water
or saline solution through the injection port of the unit into the patient air leak meter.
3. Connect the suction source to the suction port. The suction control dial is preset at -20
cm H2O; if a different level of suction is prescribed, turn the dial until it clicks into place.
Increase the suction from the suction source until the orange float appears in the
suction control indicator window See Figure 5. If more negativity is desired, change the
suction control dial.
If the suction level is decreased after the initial setup, the negativity
delivered to the patient may not change unless the excess negativity is
relieved by use of the high-negativity relief valve.
4. If gravity drainage is desired, omit step 3 and leave the suction port open to prevent
positive-pressure buildup.
Chest-Drainage Systems: Pleur-Evac - Post Procedure and Variations

Rationale: If a water-seal unit tips over, intrapleural

negativity may be lost with air entry into the pleural space.


on the floor.

pleural space.


Considerations
 All of these devices may be used for children. Infant versions
are available for both the wet and the dry water seal devices;
the most significant differences in the infant versions are that
the drainage chamber is smaller than its adult counterpart and
has finer gradations for accurate measurement of drainage,
and that there is no autotransfusion capability. There is no
infant version of the Sahara drainage device.
 The suction level usually recommended for pediatric patients is
-10 to -20 cm H2O.
Measuring the Output from a Chest Drainage System - Overview of the Skill

fluid from the pleural cavity while restoring or maintaining intrapleural
pressure by creating a vacuum seal. The goal of the chest drainage
system is to allow the lung to re-expand after surgery or trauma.
One or more chest tubes are inserted and covered with airtight
dressings. These tubes are attached to approximately 6 feet of rubber
tubing, which terminates in a water seal drainage collection system
attached to wall suction. The system draws fluid and air away from the
intrapleural space. While the escaping air is not measured, the fluid
drained through the chest tube is considered to be output and must
be measured at regular intervals. The amount is then added to the
intake and output totals.

Because the chest drainage system is a closed system, the drainage
is not emptied from the system when the output measurement is
taken. The drainage level is marked on the outside of the drainage
container at each measurement, and the amount of fluid between the
previous mark and the current mark is calculated for the output
measurement. Disposable plastic chest drainage systems may have
three columns for drainage. If the drainage container has been tipped
or moved, the drainage may have run into the other columns,
requiring marking and calculating the drainage in all the columns.

Assessment: 1. Assess the chest drainage system to determine how the drainage
will be measured.
2. Assess the drainage to determine its color, consistency, and
amount.

Diagnosis:  Risk for Deficient Fluid Volume

Planning

Needs:

 Intake and output record

 Marker or pen

Expected 1. The amount of drainage from the chest drainage system will be
Outcomes: accurately determined and recorded.

Client 1. Explain to the client the need for accurate intake and output
Education measurements.
Needed: 2. Explain the importance of leaving the drainage system below the
level of the chest.
3. Tell the client to be careful not to tip over the drainage system or set
it on the bedside table.
4. Explain that movement of the drainage in the tube is normal.
5. Explain that, unlike urine and other drains, it is normal not to empty
and discard the drainage container regularly.
Measuring the Output from a Chest Drainage System - Implementation—Action/Rationale

Implementation
Action/Rationale
ACTION RATIONALE
1 Wash hands. 1. Reduces the transmission of

. microorganisms.
2 Determine which bottle or 2. Measures the correct fluid level.

. chamber of the chest drainage If the drainage system is a
system contains the drainage plastic, disposable system, there
(see Figure 7-11-1). may be more than one drainage
collection column to measure.
3 With the fluid meniscus as close to 3. For as accurate a reading as

. eye level as possible, note the possible.
level of the drainage.
4 Use the pen or marker to mark the 4. For continuity of care, so the
. current fluid level. Indicate the next nurse will know where and
time and date of the measurement when the last measurement was
and mark it with your initials. taken.
5 Note the level of drainage marked 5. By subtracting the total amount

. just prior to this measurement. of previous drainage from the
Subtract the previous drainage total amount of current drainage,
total from your current drainage the difference will indicate the
total to obtain an accurate amount of drainage since the
determination of the amount of last measurement.
drainage during that time period.
6 Note the amount of drainage since 6. Provides an accurate record of

. the last measurement on the the client's output.
intake and output record
(see Figure 7-11-2). If the
drainage is more than 100 cc per
hour, notify the health care
provider.
7 Wash hands. 7. Reduces the transmission of

. microorganisms.
Measuring the Output from a Chest Drainage System - Post-Skill

Evaluation:  The amount of drainage from the chest drainage system was
accurately determined and recorded.

Documentation: Input and Output Record

 Note the amount of drainage in the intake and output record. If

the amount is significantly different from previous readings,
indicate this.

Variations

Geriatric Variations:  Elderly clients may be at increased risk of dehydration
secondary to large amounts of chest tube drainage. Monitor the
elderly client's intake and output closely.

Pediatric  Children are susceptible to dehydration with much smaller fluid
Variations: losses than adults. Chest tube drainage should be monitored
very closely to be sure the volume of drainage is within
acceptable fluid loss limits.

Home Care  Chest tubes are not generally left in place in the home care
Variations: setting.

Long-Term Care  Chest tubes are not generally left in place for long-term care.
Variations:
Measuring the Output from a Chest Drainage System - Common Errors

Possible If the water seal bottle is also the drainage bottle, the baseline amount is not
Errors: subtracted, and results in an inaccurate reading.

Prevention: If the water seal bottle will also collect drainage, mark the water level when
the chest drainage system is first set up to provide a baseline for drainage
calculations.

Nursing Tips:  Measure the output at the meniscus.
 If the drainage amount seems to be very different from that of the
previous shift, investigate possible reasons.
 While measuring the drainage, check lung sounds and assess the
wound site.
 Document your findings.


Introduction: Subtract the old drainage total from the new drainage total to get the amount
of drainage for the shift.

Possible You are calculating the intake and output totals at the end of the shift for your
Scenario: client, Mr. Miles. As you check his chest tube drainage, you note that there is
no mark from the previous shift's measurement.

Possible Without any notation from the previous shift's output, you note the last mark
Outcome: on the drainage container. It was applied 16 hours earlier. As an estimate of
the shift output, you divide the amount of drainage following the mark 16
hours earlier in half, estimating that the drainage was probably approximately
equal the last two shifts. When you return to duty the next day, you hear in
report that Mr. Miles developed a hemothorax in the night from a clot in his
chest tube. The clot and lack of drainage went unnoticed for a prolonged
period of time because of the incorrect chest tube output you recorded the
day before.

Prevention: You mark the current drainage level and note the last marked measurement.
You then check the chest tube output recorded in the client's chart by the
previous shift. By subtracting the amount of recorded drainage from the
amount of current, unmarked drainage, you can obtain an accurate reading
for the chest tube drainage on your shift. If the previous shift did not record
the amount of drainage in the client's chart, you should record the total
unmarked amount and note that this is a 16-hour total.
Obtaining a Specimen from a Chest Drainage System - Overview of the Skill

fluid from the pleural cavity and help restore its vacuum seal.
Occasionally the drainage will need to be sampled. If the client has
signs of infection or if the drainage is copious or an unusual color, a
specimen may be obtained for analysis. Because the chest drainage
system is closed, the specimen must be obtained using a closed
technique.

Assessment: 1. Assess the physician's or qualified practitioner's orders to determine

what kind of specimen is required.
2. Assess the available equipment to determine what kind of
equipment will be needed for the specimen retrieval.

Diagnosis:  Risk for Infection

Planning

Planning Needs: Equipment Needed (see Figure 7-12-1):
 Povidone-iodine swabs
 Syringe with needle (syringe size determined by the amount of
drainage needed for the specimen)
 Specimen container
 Label for specimen container
 Lab slip

Expected 1. The chest drainage specimen will be obtained without increasing the
Outcomes: client's risk of infection or loss of air seal.

Client Education 1. Explain to the client the reason for collecting the specimen.
Needed:
Obtaining a Specimen from a Chest Drainage System - Implementation—

Action/Rationale

Implementatio
n
Action/Rationa ACTION RATIONALE
le
microorganisms.
2. Determine if there is drainage in the 2. Obtains fresh drainage for a

tubing. If not, curl the tubing on the specimen.
bed.
3. Apply clean gloves. 3. Prevents contact with bodily

fluids.
4. If an access port is present in the 4. Prevents the introduction of

tubing, cleanse it with povidone- microorganisms into the closed
iodine if the client is not allergic or system. Some institutions may
sensitive to iodine products use non-iodine products. Alcohol-
(see Figure 7-12-2). If there is no based products may cause
access port, cleanse the rubber burning.
tubing, near the drainage pool, with
povidone-iodine (see Figure 7-12-
3).
5. Puncture the access port or the 5. Withdraws the drainage specimen

rubber tubing with the syringe and without opening the system. Use
needle. Puncture at a 45° angle a 45° angle to reduce the
(see Figure 7-12-4). possibility of puncturing the
opposite side of the tubing and to
increase the "seal" of the rubber
after the needle has been
removed.
6. Gently withdraw the needed 6. Obtains a sterile specimen.

amount of drainage from the tubing. Gentle suction avoids increasing
the suction in the client's chest to
dangerous levels.
7. Remove the needle from the port or 7. Allows proper testing of the
tubing and place the drainage specimen and prevents possible
specimen into a laboratory contamination in the laboratory.
specimen container, or label the
syringe and send it to the
laboratory, depending on
institutional policy.
8. Dispose of the syringe and needle 8. Observes Standard Precautions.

in the appropriate container.
9. Label the specimen container with 9. Allows proper identification of the

the client's name, room number, the specimen and reduces the
date, and the time the specimen opportunity for laboratory error.
was collected.
10 Remove gloves and dispose of in 10 Observes Standard Precautions.

. the proper container. .

. . microorganisms.
Obtaining a Specimen from a Chest Drainage System - Post-Skill

Evaluation:  The chest drainage specimen was obtained without increasing
the client's risk of infection or loss of air seal.


 Indicate the date and time the specimen was collected. Keep a
copy of the lab slip in the chart if the lab slip has a chart copy.

Input and Output Record

 If the client's chest tube drainage is being monitored closely,

indicate the amount of drainage removed.

Variations

Geriatric Variations:  Elderly clients may be hearing-impaired or confused. Be sure
they can hear and understand your instructions.

Pediatric  Tell the child that obtaining a specimen will not hurt. Remind the
Variations: child that the needle will not be going into him or her. Let the
child watch if possible while you collect the specimen. Answer
questions about the chest drainage system and how it works.

Home Care  Not applicable
Variations:

Long-Term Care  Not applicable
Variations:
Obtaining a Specimen from a Chest Drainage System - Common Errors

Possible
The needle is inserted at a 90° angle into the port or rubber tubing.
Errors:

Prevention: Insert the needle at a 45° angle to help the rubber "heal" itself and to prevent
the needle from piercing the far side of the tubing.

Nursing Tips:  Use gentle suction when withdrawing the specimen to avoid
increasing the suction level in the pleural cavity.
 Insert the needle at a 45° angle to decrease the chance of puncturing
the far side of the tubing as well as to provide a better seal after
withdrawing the needle.
 While obtaining a sample, check for leaks in the system and check
that connections are secure.
 While obtaining a sample, check for other signs of infection.


Introduction: Understand the physics underlying the chest tube setup.

Possible Mr. Rosario's physician ordered a chest tube drainage specimen collected.
Scenario: The nurse assigned to care for Mr. Rosario collected the necessary
equipment and brought it to Mr. Rosario's bedside. There was no drainage in
the tubing when the nurse checked Mr. Rosario's tubing. Thinking she would
use the same technique as collecting a urine specimen from a closed system,
the nurse clamped the chest tube to allow a drainage specimen to collect.

Possible Within 15 minutes Mr. Rosario was in severe respiratory distress. He turned
Outcome: on his call light and started to call for help. His nurse ran to his bedside. As
she assessed his condition, she realized that his distress must somehow be
related to the clamped chest tube and she quickly unclamped the tube.
Within minutes Mr. Rosario's condition stabilized. When the nurse checked
the tubing, she noted that there was still no drainage in the tube.

Prevention: If the nurse had understood the physics underlying the chest tube system,
she would have realized that clamping the chest tube would block drainage
from the chest because the suction was blocked. Also by blocking the suction
she had prevented the chest drainage system from reinflating the client's
lung, potentially causing a tension pneumothorax. If there is no drainage in
the tubing, the nurse should create a dependent loop in the tubing that will
collect future drainage that can be used for a specimen.
Chest Tube Removal Assisting - Overview
Chest tube removal is performed to discontinue a chest tube when it is

Overview: no longer needed for the removal or drainage of air, blood, or fluid from
the intrapleural or mediastinal space. A primary goal of chest tube
removal is to remove tubes without introducing air or contaminants into
the pleural space.
Chest tubes are placed in the pleural or the mediastinal space to
evacuate an abnormal collection of air and/or fluid.
Indications for removal are based on the reason for insertion and include
the following:
 Drainage has decreased to 50 to 100 ml in 24 hours if tube was placed

for hemothorax, empyema, or pleural effusion.
 Drainage has changed from bloody to serosanguineous, no air leak is
present, and amount is less than 100 ml in the past 8 hours (if tube was
placed after cardiac surgery).
 Lungs are reexpanded (as shown on chest x-ray).
 Respiratory status has improved (i.e., nonlabored respirations, equal
bilateral breath sounds, absence of shortness of breath, decreased use
of accessory muscles, symmetrical respiratory excursion, and
respiratory rate less than 24 breaths per minute).
 Fluctuations are absent in the water-seal chamber of the collection
device, and the level of solution rises in the chamber.
 Air leaks have resolved for at least 24 hours (assessed by the air-leak
chamber or the absence of continuous bubbling in the water-seal
chamber) and lung is fully reinflated on x-ray.
The water-seal chamber should bubble gently immediately on insertion

of the chest tube during expiration and with coughing. Continuous
bubbling in this chamber indicates a leak in the system. Fluctuations in
the water level in the water-seal chamber of 5 to 10 cm, rising during
inhalation and falling during expiration, should be observed with
spontaneous respirations. If the patient is on mechanical ventilation, the
pattern of fluctuation will be just the opposite. If suction is being applied,
it must be temporarily disconnected to correctly assess for fluctuations in
the water-seal chamber.
Pleural tubes are placed after cardiac surgery if the pleural cavity has
been entered. They are typically removed singly and within 24 to 48
hours after surgery. Pleural tubes placed for reasons other than post-
cardiac-surgery necessity will remain until the patient no longer needs
them (i.e., no persistent air leak; ongoing fluid leak or bleeding has
stopped; or lung is reexpanded on chest x-ray).
Mediastinal chest tubes are most often removed 24 to 36 hours after
cardiac surgery.
Chest tubes that remain in place for more than 7 days increase the risk
of infection along the chest tube tract.
Chest x-rays are done periodically to determine whether the lung has
reexpanded. Reexpanded lungs, along with respiratory assessments
that demonstrate improvement in the patient's respiratory status, are the
basis for the decision to remove the chest tube.
While the tubes are in place, patients may experience related discomfort.
Therefore prompt removal of chest tubes encourages patients to
increase ambulation and respiratory measures that improve lung
expansion after surgery (e.g., coughing, deep breathing). Additionally,
removal of the chest tube is a painful procedure for the patient.
The types of sutures used to secure chest tubes vary according to the
preference of the physician, the physician assistant, or the advanced practice
nurse. One common type is the horizontal mattress or "purse-string" suture,
which is threaded around and through the wound edges in a U shape, with the
ends left unknotted until the chest tube is removed. Usually there are one or
two anchor stitches accompanying the purse-string suture See Figure 1.
Chest Tube Removal Assisting - Outcomes
Expected Outcomes
 Patient is comfortable and experiences no respiratory distress

 Lung remains expanded following chest tube removal
 Site remains free of infection
Unexpected Outcomes
 Pneumothorax
 Bleeding
 Skin necrosis
 Retained chest tube
 Infected chest tube insertion site
Chest Tube Removal Assisting - Assessment and Preparation

Preparation questions as they arise, and reinforce information as needed.
 Premedicate the patient with adequate analgesics at least 15
minutes before procedure. Intravenous morphine may be used or, in
conjunction with the cardiac surgeon, subfascial lidocaine may be
injected into the chest tube tract.
 Place patient in the semi-Fowler's position or on the unaffected side,
with the bed protector (towel or Chux pad) underneath.
 Suture removal set

Supplies  Povidone-iodine swabs
 Petrolatum gauze
 Kelly clamps (two per chest tube) or disposable umbilical clamps
 Wide, occlusive tape (2-inch)
 Dry 4 x 4 gauze sponges (two to four)
 Towel or Chux pad
 Personal protective equipment (goggles, sterile and nonsterile
gloves, mask, gown)
Additional equipment (to have available depending on patient need)

includes the following:
 Specimen collection cup (if catheter tip is to be sent to the laboratory

for analysis)
1. Assess respiratory status:

Assessment
a. Oxygen saturation within normal limits
b. Nonlabored respirations
c. Absence of shortness of breath
d. Decreased use of accessory muscles
e. Respiratory rate of less than 24 breaths per minute
f. Equal bilateral breath sounds.
2. Assess chest tube drainage (less than 50 to 100 ml in 24 hours or

less than 100 ml in 8 hours after cardiac surgery).
3. Assess for absence of fluctuation in water-seal chamber and air leak
indicator.
4. Evaluate chest x-ray.
5. Assess vital signs and (optional) arterial blood gases.
Chest Tube Removal Assisting - Procedure
1. Wash hands and don personal protective equipment.
Rationale: Reduces transmission of microorganisms and body secretions;

2. Open the sterile suture removal set and prepare petrolatum gauze dressing and two to
four 4 x 4 gauze sponges.
Rationale: Aseptic technique is maintained to prevent contamination of the

wound. Removal of pleural chest tubes must be accomplished rapidly, with the
simultaneous application of an occlusive dressing to prevent air from entering
the pleural space.
3. Discontinue suction from chest-drainage system and check for air leakage in water-seal
chamber. Observe the water-seal chamber while the patient coughs.
a. If tube was placed for a pneumothorax, protocol may require 6 to 24 hours of
water seal and another chest x-ray prior to removal.
Rationale: Bubbling in this chamber is associated with an air leak. When

an air leak is present, removal of the chest tube can cause development
of a pneumothorax. Ensures a recurrent pneumothorax has not occurred.
If an air leak is present, the tube should not be removed. Consult
with the physician or advanced practice nurse to determine
appropriate action.
4. Remove existing tape, clean area around tubes with povidone-iodine and determine
type of suture that secures each chest tube. Clip appropriately. If a purse-string suture
is present, leave the long suture ends intact.
Rationale: Allows access to the chest tube at the skin level and prepares the
sutures for removal.
5. Confirm that the tube is free from the suture and the tape.
6. Clamp each tube to be removed with two Kelly clamps or umbilical clamps.
Rationale: Prevents air from being introduced into the pleural space.
7. According to protocol, tube will be removed while patient is performing Valsalva

maneuver at either end-inspiration or end-expiration.
a. End-inspiration: instruct patient to take a deep breath and hold it while

performing the Valsalva maneuver for each tube removed. If the patient is
receiving ventilator support, pause the ventilator. If the patient is receiving
ventilator support and is unable to follow instructions, remove the tube during
peak inspiration phase.
b. End-expiration: Instruct patient to perform the Valsalva maneuver at end
expiration. According to protocol, the patient may have to hold his or her breath
until sutures are tied.
Rationale: Valsalva maneuver is needed to provide positive pressure in

the pleural cavity and decreases the incidence of an involuntary gasp by
the patient when the tube is removed.
8. Cover pleural insertion sites with petrolatum gauze dressing and mediastinal insertion
site with 4 x 4 gauze pads. Secure with tape.
Rationale: Avoids the influx of air.

Sterile petrolatum gauze should be applied over the skin site immediately
after removal if tube was in pleural space or if no purse-string suture was
present.
9. Obtain a portable chest x-ray per order or protocol (generally 1 to 24 hours after
removal) or as clinically indicated.
Rationale: Assesses that the lung has remained expanded.
10. Dispose of equipment in appropriate receptacle.

11. Wash hands.
Rationale: Decreases transmission of microorganisms.
Chest Tube Removal Assisting - Post Procedure and Variations
1. Ensure adequate respiratory status. Obtain chest x-ray if

Post Procedure difficulties arise.
Rationale: Diminished respiratory status could indicate a

pneumothorax. This could result from removal of the
chest tube before all the air, fluid, or blood in the pleural
space had been drained, or it may recur following removal
of the chest tube if air is accidentally introduced into the
pleural space through the chest tube tract.
Decreased oxygen saturation on pulse oximetry,
increased work of breathing, diminished breath
sounds on affected side, and increased restlessness
and complaints of chest discomfort should be
2. Monitor insertion site for bleeding. Apply pressure at site. Place

a tight occlusive dressing over site.
Rationale: Persistent bleeding from insertion site could

mean chest tube was against a vein or artery of chest wall
before removal.
Persistent bleeding should be reported if it persists
3. Monitor purse-string suture site for signs of skin necrosis. If

seen, remove the suture and cleanse wound.
Rationale: If purse-string suture was pulled too tightly

closed when chest tube was removed, skin necrosis may
be seen.
Dark or inflamed skin with necrotic areas visible
should be reported if they persist despite nursing
interventions.
4. Monitor site for signs of infection. If seen, prepare for wound

cultures.
Rationale: Prolonged insertion of a chest tube increases

the risk that the tract created by the chest tube may
become infected, or infection may occur following removal
of the chest tube if the opening created by the removal
becomes contaminated.
Purulent drainage, increased body temperature,
inflammation, tenderness, or warmth at site should be
5. Monitor insertion area for development of subcutaneous

emphysema.
Rationale: Air may leak into the surrounding tissues,

causing crepitus.
Crepitus should be reported if it persists despite
6. Monitor for signs and symptoms of pericardial effusion or

cardiac tamponade.
Rationale: Removal of chest tubes may cause increased

bleeding into pericardium. Pericardial bleeding may
continue after chest tubes have been removed.
Distant heart tones, decreased blood pressure,
tachycardia, pulsus paradoxus, narrowed pulse
pressure, or equalized pulmonary artery pressures
interventions.

Documentation  Respiratory and vital signs assessments before and after the
procedure
 Date, time, and by whom procedure was performed
 Amount, color, and consistency of any drainage
 Application of a sterile, occlusive dressing
 Type of suture in place and what was done to it (cut or tied)
 Patient's tolerance of the procedure
 Completion and results of chest x-ray
 Specimens sent to lab (if applicable)
 Assess patient and family understanding of the procedure

Patient Education  Explain the procedure, the reason for removal, and the
sensations to be expected
 Explain the patient's role in assisting with removal; explain that
when prompted, she or he should perform the Valsalva
maneuver
 Instruct the patient to turn and reposition every 2 hours after
the chest tube has been removed
 Instruct the patient to cough and deep-breathe after the chest
tube has been removed, splinting the affected side or sternum
(with mediastinal tubes)
 Instruct the patient as to the availability of prescribed analgesic
medication
 Instruct the patient and family to report signs and symptoms of
respiratory distress or infection immediately
Chest Tube Removal Performing (Advanced Practice) - Overview
Chest tube removal is performed to discontinue a chest tube when it is

Overview: no longer needed for the removal or drainage of air, blood, or fluid from
the intrapleural or mediastinal space. A primary goal of chest tube
removal is to remove tubes without introducing air or contaminants into
the pleural space.
Chest tubes are placed in the pleural or the mediastinal space to
evacuate an abnormal collection of air and/or fluid.
Indications for removal are based on the reason for insertion and include
the following:
 Drainage has decreased to 50 to 100 ml in 24 hours if tube was placed

for hemothorax, empyema, or pleural effusion.
 Drainage has changed from bloody to serosanguineous, no air leak is
present, and amount is less than 100 ml in the past 8 hours (if tube was
placed after cardiac surgery).
 Lungs are reexpanded (as shown on chest radiograph).
 Respiratory status has improved (i.e., nonlabored respirations, equal
bilateral breath sounds, absence of shortness of breath, decreased use
of accessory muscles, symmetric respiratory excursion, and respiratory
rate less than 24 breaths per minute).
 Fluctuations are absent in the water-seal chamber of the collection
device, and the level of solution rises in the chamber.
 Air leaks have resolved for at least 24 hours (assessed by the air-leak
chamber or the absence of continuous bubbling in the water-seal
chamber), and lung is fully re-inflated on radiograph.
The water-seal chamber should bubble gently immediately on insertion

of the chest tube during expiration, and with coughing. Continuous
bubbling in this chamber indicates a leak in the system. Fluctuations in
the water level in the water-seal chamber of 5 to 10 cm, rising during
inhalation and falling during expiration, should be observed with
spontaneous respirations. If the patient is on mechanical ventilation, the
pattern of fluctuation will be just the opposite. If suction is being applied,
this must be temporarily disconnected to correctly assess for fluctuations
in the water-seal chamber.
Pleural tubes are placed after cardiac surgery if the pleural cavity has
been entered. They are typically removed singly and within 24 to 48
hours after surgery. Pleural tubes placed for reasons other than post-
cardiac surgery necessity will remain until the patient no longer needs
them (i.e., no persistent air leak, ongoing fluid leak or bleeding has
stopped, or lung is re-expanded on chest radiograph).
Mediastinal chest tubes are most often removed 24 to 36 hours after
cardiac surgery.
Chest tubes that remain in place for more than 7 days increase the risk
for infection along the chest tube tract.
Chest radiographs are done periodically to determine whether the lung
has re-expanded. Re-expanded lungs, along with respiratory
assessments that demonstrate improvement in the patient's respiratory
status, are the basis for the decision to remove the chest tube.
While the tubes are in place, patients may experience related discomfort.
Therefore prompt removal of chest tubes encourages patients to
increase ambulation and respiratory measures to improve lung
expansion after surgery (e.g., coughing, deep breathing). Additionally,
removal of the chest tube is a painful procedure for the patient.
The types of sutures used to secure chest tubes vary according to the
preference of the physician, the physician assistant, or the advanced
practice nurse. One common type is the horizontal mattress or purse-
string suture, which is threaded around and through the wound edges in
a U-shape with the ends left unknotted until the chest tube is removed.
Usually there are one or two anchor stitches accompanying the purse-
string suture See Figure 1.
Chest Tube Removal Performing (Advanced Practice) - Outcomes
 Patient is comfortable and experiences no respiratory distress

Expected  Lung remains expanded following chest tube removal
Outcomes  Site remains free of infection
 Pneumothorax
Unexpected  Bleeding
Outcomes  Skin necrosis
 Retained chest tube
 Infected chest tube insertion site
Chest Tube Removal Performing (Advanced Practice) - Assessment and

Preparation

Preparation questions as they arise, and reinforce information as needed.
 Premedicate the patient with adequate analgesics at least 15
minutes before procedure. Intravenous morphine may be used, or, in
conjunction with the cardiac surgeon, subfascial lidocaine may be
injected into the chest tube track.
 Place patient in the semi-Fowler's position or on the unaffected side
with the bed protector (towel or Chux pad) underneath.
 Suture removal set
Supplies  Povidone iodine swabs
 Petrolatum gauze
 Kelly clamps (two per chest tube) or disposable umbilical clamps
 Wide, occlusive tape (2 inch)
 Dry 4 x 4 gauze sponges (two to four)
 Towel or Chux pad
 Personal protective equipment (goggles, sterile and nonsterile
gloves, mask, gown)
Additional equipment (to have available depending on patient need)

includes the following:
 Specimen collection cup (if catheter tip is to be sent to the laboratory

for analysis)
1. Assess respiratory status.

Assessment
a. Oxygen saturation within normal limits

b. Nonlabored respirations
c. Absence of shortness of breath
d. Decreased use of accessory muscles
e. Respiratory rate of less than 24 breaths per minute
f. Equal bilateral breath sounds
2. Assess chest tube drainage (less than 50 to 100 ml in 24 hours, or

less than 100 ml in 8 hours after cardiac surgery)
3. Assess for absence of fluctuation in water-seal chamber and air leak
indicator.
4. Evaluate chest radiograph.
5. Assess vital signs and (optional) arterial blood gases.
Chest Tube Removal Performing (Advanced Practice) - Procedure

1. Wash hands and don personal protective equipment.

2. Open the sterile suture removal set, and prepare petrolatum gauze dressing and two to
four 4 x 4 gauze sponges.
Rationale: Aseptic technique is maintained to prevent contamination of the

wound.
Removal of pleural chest tubes must be accomplished rapidly with the
simultaneous application of an occlusive dressing to prevent air from
entering the pleural space.
3. Discontinue suction from chest-drainage system, and check for air leakage in water-seal
chamber. Observe the water-seal chamber while the patient coughs.
Rationale: Bubbling in this chamber is associated with an air leak. When an air
leak is present, removal of the chest tube can cause development of a
pneumothorax.
a. If tube was placed for a pneumothorax, protocol may require 6 to 24 hours of

water seal and another x-ray prior to removal.
Rationale: Ensures a recurrent pneumothorax has not occurred.

If an air leak is present, the tube should not be removed. Consult
with the physician or advance practice nurse to determine
appropriate action.
4. Remove existing tape, clean area around tubes with povidone-iodine, and determine
type of suture that secures each chest tube. Clip appropriately. If a purse-string suture
is present, leave the long suture ends intact.
Rationale: Allows access to the chest tube at the skin level, and prepares the
sutures for removal.
5. Confirm that the tube is free from the suture and the tape.
6. Clamp each tube to be removed with two Kelly clamps or umbilical clamps.
Rationale: Prevents air from being introduced into the pleural space.
7. According to protocol, tube will be removed while patient is performing Valsalva

maneuver at either end-inspiration or end-expiration.
Rationale: Valsalva maneuver is needed to provide positive pressure in the

pleural cavity and decrease the incidence of an involuntary gasp by the patient
when the tube is removed.
a. End-inspiration: instruct patient to take a deep breath and hold it while

performing the Valsalva maneuver for each tube removed. If the patient is
receiving ventilator support, pause the ventilator. If the patient is receiving
ventilator support and is unable to follow instructions, remove the tube during
peak inspiration phase.
b. End-expiration: Instruct patient to perform the Valsalva maneuver at end
expiration.
c. According to protocol, patients may need to hold their breath until sutures are
tied.
9. Remove chest tubes rapidly, smoothly, and individually while patient is performing
Valsalva maneuver.
a. Hold sutures in hand closest to head of patient, and apply mild pressure over
exit site with folded 4 x 4 gauze pad.
b. If tube was "Y" connected to another tube, cut the removed tube below the
clamp to allow easier manipulation when removing the remaining chest tubes.
Rationale: Prevents accidental entrance of air into the pleural space.

Some resistance is expected; however, if strong resistance is
encountered and rapid removal of the tube is not possible, stop the
procedure and consult with the physician immediately. This may
indicate that the tube was inadvertently sutured during surgery or
sternal closure.
9. Tie purse-string suture using a square knot, if available See Figure 1.
Rationale: Creates a firm closure of the chest tube site.

Avoid pulling the suture too tight to prevent tissue necrosis at the site and
to facilitate easier removal later.
10. Cover pleural insertion sites with petrolatum gauze dressing and mediastinal insertion
site with 4 x 4 gauze pads. Secure with tape.
Rationale: Avoids the influx of air.

Sterile petrolatum gauze should be applied over the skin site immediately
after removal if tube was in pleural space or if no purse-string suture was
present.
11. Examine each chest tube to verify that all of the tube has been removed.
Rationale: If portion of tube is not removed, resternotomy is necessary to

remove it.
Consult with physician or advance practice nurse immediately.
12. Assess the patient after the procedure, and compare the results with those of previous
assessment.
Rationale: Ensures stable respiratory status after the procedure.

Increased work of breathing, decreased oxygen saturation, increased
restlessness, complaints of chest discomfort, and diminished breath
sounds on the affected side are warning signs to be observed.
13. Obtain a portable chest radiograph per order or protocol (generally 1 to 24 hours after
removal) or as clinically indicated.
Rationale: Assesses that the lung has remained expanded.
14. Dispose of equipment in appropriate receptacle.
15. Wash hands.
Rationale: Decreases transmission of microorganisms.
Chest Tube Removal Performing (Advanced Practice) - Post Procedure and

Variations
1. Ensure adequate respiratory status. Obtain chest radiograph if
Post Procedure difficulties arise.
Rationale: Diminished respiratory status could indicate a

pneumothorax. This could be from removal of the chest
tube before all the air, fluid, or blood in the pleural space
had been drained, or it may recur following removal of the
chest tube if air is accidentally introduced into the pleural
space through the chest tube tract.
Decreased oxygen saturation on pulse oximetry,
increased work of breathing, diminished breath
sounds on affected side, or increased restlessness
and complaints of chest discomfort should be
2. Monitor insertion site for bleeding. Apply pressure at site. Place

a tight occlusive dressing over site.
Rationale: Persistent bleeding from insertion site could

mean chest tube was against a vein or artery of chest wall
before removal.
Persistent bleeding should be reported if it persists
3. Monitor purse-string suture site for signs of skin necrosis. If

seen, remove the suture and cleanse wound.
Rationale: If purse-string suture was pulled too tightly

closed when chest tube was removed, skin necrosis may
be seen.
Dark or inflamed skin with necrotic areas visible
interventions.
4. Monitor site for signs of infection. If seen, prepare for wound

cultures.
Rationale: Prolonged insertion of a chest tube increases

the risk that the tract created by the chest tube may
become infected, or infection may occur following removal
of the chest tube if the opening created by the removal
becomes contaminated.
Purulent drainage, increased body temperature,
inflammation, tenderness, or warmth at site should be
5. Monitor insertion area for development of subcutaneous

emphysema.
Rationale: Air may leak into the surrounding tissues

causing crepitus.
Crepitus should be reported if it persists despite
6. Monitor for signs and symptoms of pericardial effusion or

cardiac tamponade.
Rationale: Removal of chest tubes may cause increased

bleeding into pericardium. Pericardial bleeding may
continue after chest tubes removed.
Distant heart tones, decreased blood pressure,
tachycardia, pulsus paradoxus, narrowed pulse
pressure, or equalized pulmonary artery pressures
interventions.

Documentation  Respiratory and vital signs assessments before and after the
procedure
 Date, time, and by whom procedure was performed
 Amount, color, and consistency of any drainage
 Application of a sterile, occlusive dressing
 Type of suture in place and what was done to it (cut or tied)
 Patient's tolerance of the procedure
 Completion and results of chest radiograph
 Specimens sent to lab (if applicable)
 Assess patient and family understanding of the procedure
Patient Education  Explain the procedure, reason for removal, and sensations to
be expected
 Explain the patient's role in assisting with removal. Explain that
when prompted, she or he should perform the Valsalva
maneuver
 Instruct the patient to turn and reposition every 2 hours after
the chest tube has been removed
 Instruct the patient to cough and deep breath after the chest
tube has been removed, splinting the affected side or sternum
(with mediastinal tubes)
 Instruct the patient as to the availability of prescribed analgesic
medication
 Instruct the patient and family to report signs and symptoms of
respiratory distress or infection immediately
Ventilating the Client with an Ambu(r)-Bag - Overview of the Skill

Overview: An Ambu(r)-bag is an "air mask bag unit" that is used in numerous
situations that require manual ventilation. Common uses of the
Ambu(r)-bag include manual ventilation before and after suctioning an
endotracheal or tracheostomy tube, emergency resuscitation in the
event of respiratory or cardiopulmonary arrest, hyperventilation of the
client with increased intracranial pressure (ICP), and maintenance of
respiratory support during the transfer of ventilator-dependent clients
between care locations.

The Ambu(r)-bag is manufactured in infant, child, and adult models
capable of delivering inspiratory volumes of 240 to 2,000 ml per
breath. It is made up of five basic components: a mask, an adapter for
endotracheal or tracheostomy tubes, the bag (also referred to as a
reservoir), an air control flow system, and an oxygen adapter.
Reservoir tubing may also be used to increase oxygen levels.

Operation of the Ambu(r)-bag is simple; however, incorrect technique
may significantly compromise the client's respiratory status. To use
the Ambu(r)-bag, the mask is either placed over the client's nose and
mouth, making a seal between the mask and the skin, or is connected
to the endotracheal or tracheostomy tube using the adapter.
Additional oxygen may be added to the air in the reservoir. The bag,
or reservoir, is then compressed with one or two hands, forcing the air
into the client's lungs. Once released, the bag automatically reinflates
and additional breaths can be delivered as needed.

Assessment: 1. Determine the need to use manual ventilation. There are many
situations that require the use of manual ventilation. Some
situations are planned, such as client transfer or suctioning,
while others are unexpected emergencies.
2. Identify signs and symptoms that may indicate the need to provide
manual ventilation. It is imperative that a nurse assess the client
for skin color that is dusky or cyanotic in appearance and
decreased or absent (apnea) respirations/pulse, which indicate
cardiopulmonary arrest. Laboratory results such as arterial
blood gas may indicate elevated CO2 and decreased O levels;
client monitoring equipment such as pulse oximetry may set off
an alarm with decreasing O saturation; and intracranial
pressure monitors may become elevated with increasing CO.
3. Review medical history to identify factors that could affect
respiratory status. This includes a history of central nervous
system insult (such as trauma, central nervous system tumor,
seizures), alcohol or drug overdose, altered level of
consciousness, and respiratory alkalosis or acidosis. It also can
occur with pulmonary injury or inability of the thoracic cage to
generate pressure gradients needed for ventilation trauma
(chest trauma, diaphragmatic hernia, motor vehicle accident).
4. In assessment of the alert client (such as a ventilator-dependent
client requiring transfer to another room), assess the client's
knowledge and ability to cooperate with the procedure. Clients may
become anxious when suctioned or moved. It is important to
provide an explanation of the planned procedure, length of time,
and activities the client can do to assist in a smooth process.
Additionally, some alert clients have been ventilator dependent
for a long time and have caregivers that have been trained to
assist in this process.

Diagnosis:  Anxiety, related to the procedure

 Ineffective Airway Clearance
 Impaired Gas Exchange
 Impaired Spontaneous Ventilation

Planning

 Disposable gloves
 Ambu(r)-bag (appropriate reservoir for client size)
 Appropriate-size mask or endotracheal/tracheostomy tube adapter
 Oxygen source (if indicated)
 Oxygen connecting tubing (if indicated)
 Face shield, goggles, or other eye protection
 Suctioning equipment
 Oropharyngeal airway (for unconscious client in cardiopulmonary
arrest)

Expected 1. The client will have spontaneous respirations or will be maintained

Outcomes: on mechanical ventilation with stable vital signs.
2. Laboratory tests and client monitoring equipment will indicate
appropriate CO2 and O2 levels.
3. Intracranial pressure will be within normal limits.
4. The client will be able to maintain effective ventilation during
transportation.
5. The client will have improved airway clearance as evident by removal
of secretions and/or mucus plugs from the
endotracheal/tracheostomy tube.
6. The client/caregiver will report minimal anxiety related to the
procedure.

Client Education 1. Explain the purpose of the procedure.
Needed: 2. Describe the procedure and length of time.
3. Show the client the Ambu(r)-bag and other associated equipment.
4. Explain the sensations the client may feel, for example, during
suctioning.
5. Explain how the client can help with the procedure.
6. Go over basic messages that the client might need to communicate
during the procedure, and assign hand signals.
7. Instruct the alert client to try to breathe with the Ambu(r)-bag.
8. Teaching relaxation techniques can sometimes minimize the anxiety
or restlessness the client may experience during suctioning or
transfer.
9. Provide opportunities for a caregiver to practice with the Ambu(r)-bag
on a dummy prior to initial experience on the client.
Ventilating the Client with an Ambu(r)-Bag - Implementation—Action/Rationale

Implementation
Action/Rational
e ACTION RATIONALE
1. Obtain baseline assessment of 1. Provides a baseline for
client, including vital signs. comparison after procedure to
assess tolerance and
improvement in clinical status.
2. Prepare, connect, and check 2. Provides a safe, organized
functioning of necessary approach to the procedure.
equipment:
 Oxygen supply/tubing
 Suction
equipment/supplies
 Correct-size adapter or
mask
3. Raise or lower bed, table, or 3. Maintains good body mechanics

transport cart to a comfortable for the nurse throughout the
working height. procedure.
4. Wash hands, apply gloves and 4. Practices Standard Precautions
face shield. and reduces the transmission of
microorganisms.
5. For the client with an existing 5.  Opens airway for
endotracheal or tracheostomy Ambu(r)-bag use.
tube requiring suctioning or  Provides hyperinflation
transfer: and increases O2 levels,
which prevents hypoxia,
 Remove the current and decreases CO2
levels prior to suctioning.
mechanical ventilation  Adequate air flow is
system. necessary to fully inflate
 For transfer, attach the lungs.
Ambu(r)-bag to  Maintenance of artificial
endotracheal or airway is of paramount
tracheostomy tube and importance with the use
compress bag to of an Ambu-bag.(r)
administer one breath  Normal saline is used to
every 3 to 5 seconds. loosen secretions and
Compress the reservoir 20 mucus plugs as well as
times per minute to mimic stimulate cough.
a normal breathing  Removes secretions and
pattern. mucus plugs, and
 Adjust the flow meter to maintains patency of
ensure adequate artificial airway.
 Replaces O2 and
oxygenation.
prevents atelectasis.
 The Ambu(r)-bag may be  Verification of adequate
compressed with two inspiratory effort.
hands if the existing
airway tube is stable and
the client is not fighting the
procedure; otherwise, the
nurse may have to use the
dominant hand to
compress the Ambu(r)-bag
while stabilizing the airway
tube during the procedure.
It is preferable to have two
health care providers
perform this skill as Ambu-
bags(r) may be difficult to
compress with one hand.
 For suction, if the client
has thick secretions, some
agencies recommend
instilling normal saline as
per agency protocol
(approximately 5 to 10 ml
depending on the health
care provider's order).
 Suction the client, reattach
the Ambubag, (r) and
repeat the 3 preceding
steps.
 End the procedure with
administration of several
breaths before
reconnecting client to
mechanical ventilatory
support.
 The chest is assessed to
verify air flow.
6. For the client who is unconscious 6.  Some clients presenting

and not intubated: with facial injuries will not
be appropriate for use of
 Assess appropriateness of Ambu(r)- bag with mask,
use of Ambu(r)-bag and and an endotracheal
need for mask or tube must be placed.
immediate intervention  Opens airway; helps
with intubation. prevent aspiration into
 Clear oral cavity of vomit, lungs.
 Assists in maintaining
mucus, or other debris.
airway patency and
 Insert an oropharyngeal preventing the tongue
airway. from falling back into the
 Position client using either oropharynx.
the head-tilt/chin-lift  The modified jaw-thrust
method, or in the case of maneuver maintains the
suspected or potential head in a neutral position
cervical spine injury, use if a cervical spine injury
the modified jaw-thrust is suspected.
maneuver.  A proper seal ensures
 Position Ambu(r)-bag over adequate ventilation.
the client's nose and  Provides adequate
mouth using the oxygenation per
nondominant hand. The cardiopulmonary
thumb and index finger are resuscitation protocol.
used to stabilize the seal  Verifies patent airway
between the mask and the and adequacy of manual
client's face, while the ventilatory support.
remaining fingers maintain  Manual ventilation may
head position. force air into the stomach
 The dominant hand is and the client may vomit
used to deliver breaths to and aspirate secretions.
the client. Breath rate is A nasogastric tube
administered according to decompresses the air in
cardiopulmonary the stomach.
resuscitation protocol.  Suctioning maintains a
 The chest is assessed to patent airway and
verify adequate inspiratory prepares the
flow. oropharyngeal cavity for
 Assess for the need to intubation if necessary.
insert a nasogastric tube.
 Suction as necessary.
7. Ongoing assessment to determine 7. Ongoing assessment is critical

need to discontinue procedure as in determining improvement or
evident by: deterioration in the client's
clinical status.
 Endotracheal or
tracheostomy secretions  Provides information on
minimal and artificial tolerance of the
airway patent procedure.
 Client no longer coughing
or "bucking" ventilation
 Stable vital signs
 Client no longer dusky or
cyanotic
 Return of spontaneous
respirations
 Decreased intracranial
pressure
8. Remove Ambu(r)-bag and 8. Maintains ventilatory and

reattach client to mechanical oxygen support. Additionally, an
ventilation system. unconscious client who required
cardiopulmonary resuscitation
will probably be intubated and
placed on mechanical
ventilatory support.
9. Discontinue oxygen flow to the 9. Promotes client and staff safety
Ambu-bag. by preventing hyperoxygenation
of the room atmosphere.
10 Reposition client and return bed 10 Promotes client comfort and
. and guard rails to original position. . safety.
11 Clean supplies per institution 11 Assists in the prevention of
. protocol (i.e., endotracheal tube . infection transmission.
adapter).
12 Dispose of gloves and face shield 12 Promotes adherence to
. and disposable supplies used . Standard Precautions.
during procedure.
13 Document tolerance of procedure. Provides information on airway
. patency and client knowledge
and comfort with procedure.
Ventilating the Client with an Ambu(r)-Bag - Post-Skill

Evaluation:  The client has spontaneous respirations or is maintained on
mechanical ventilation with stable vital signs.
 Laboratory tests and client monitoring equipment indicate
appropriate CO2 and O2 levels.
 Intracranial pressure is within normal limits.
 The client is able to maintain effective ventilation during
transportation.
 The client has improved airway clearance as evident by removal
of secretions, or mucus plugs, from the
endotracheal/tracheostomy tube.
 The client experiences minimal anxiety related to the procedure.


 Document preassessments and postassessments, including

vital signs and other physiologic parameters such as ICP.
 Note length of and tolerance to procedure.
 Record rate of respirations, volume, and amount of
supplemental O2 utilized.
 Describe secretions, including amount and quality.

Variations

Geriatric Variations:  Older adults must be assessed for dentures, which need to be
removed prior to manual ventilation.
 It may be difficult to obtain an occlusive seal in debilitated
elderly individuals, and assistance may be necessary to
ventilate these clients.

Pediatric  Appropriate-size (infant or child) Ambu-bags(r) are essential to
Variations: provide an occlusive seal and effective air volume. An adult
Ambu(r)-bag mask is never appropriate for use in an infant or
child. Many emergency kits or facilities have a single Ambu(r)-
bag with child and infant face mask adapters. Practice quickly
removing the adult mask and attaching the child mask.
 It is essential to remember that the rate and depth of
respirations in children depend on the child's age and correlated
lung capacity. Compress the bag only partially with each breath,
and deliver breaths more frequently according to the age of the
child.

Home Care  Teach the client (when appropriate) and the caregiver to
Variations: recognize signs and symptoms of ineffective airway clearance,
hypoxia, and abnormal breathing patterns. Because the hand
placement is tricky, the caregiver should be given opportunities
to practice manual ventilation first with a dummy and then
gradually on the client with ample opportunity for return
demonstration. Home ventilator-dependent clients or their
caregivers are often aware of procedures for suction and
care/re-insertion of the tracheostomy tube.

Long-Term Care  Ventilator-dependent clients maintained in long-term care
Variations: facilities usually have a tracheostomy tube in place as their
artificial airway. Care providers need to be aware not only of the
use of an Ambu(r)-bag necessary for suctioning and client
transfer but also of the skills needed to maintain a tracheostomy
tube.
 Additionally, many of the high-tech physiologic assessment
tools such as pulse oximetry and arterial blood gases will not be
routine practice in long-term care facilities. Careful assessment
of airway breathing patterns, lung auscultation, client color, and
vital signs will be of tremendous importance in the care of these
clients using an Ambu(r)-bag.

Ventilating the Client with an Ambu(r)-Bag - Common Errors

Possible The nurse does not use Standard Precautions (gloves and face shield) during
Errors: an emergency situation (cardiopulmonary arrest).

Prevention: Remember that Standard Precautions can help to prevent life-threatening
infections to both the nurse and client, and are just as important in an
emergency as in nonemergency procedures. Practice Standard Precautions
in every aspect of client care. If the error has already been made, stop and
take time to put on gloves and face shield and begin manual ventilation per
protocol.

Possible The correct head position is not used in a client with a potential cervical spine
Errors: injury.

Prevention: Gather a history regarding the events that preceded the onset of respiratory
arrest. Assess the client fully before intervention with manual ventilation and
utilize the appropriate head position in the event of potential cervical spine
injury.

Nursing Tips:  Check all supplies (oxygen, tubing, and so on) to be sure you are
prepared to suction, transfer, or resuscitate a client with functioning
equipment.
 Monitor baseline vital signs and maintain continued client assessment
throughout the procedure.
 The client should be in a comfortable, relaxed position at a level that
is appropriate for the nurse or caregiver to perform manual ventilation.
 The nurse should approach the client with confidence because this
will reduce the client's anxiety level.
 Another nurse should be aware of the procedure in progress, and the
nurse performing the procedure should be able to obtain assistance in
the event of an unexpected outcome.
 Provide comfort measures (e.g., blanket, toy) to the alert child to help
reduce anxiety.


Introduction: The use of an Ambu(r)-bag requires attention to details and continual
assessment of the client. Failure to properly assess the client can result in
significant adverse outcomes such as loss of airway patency,
cardiopulmonary arrest, or paralysis.

Possible A ventilator-dependent client, Mr. Ying, needed to be transferred from the
Scenario: intensive care unit to CT scan. This was a multiple trauma client with
increased intracranial pressure. The intracranial pressure level was stable
and the client was prepared for transfer; however, the endotracheal tube was
not suctioned and portable suction was not taken during the transfer.

Possible Failure to ensure that the endotracheal tube was patent and free of
Outcome: secretions prior to transfer of a critically ill, ventilator-dependent client could
have resulted in hypoxia, hypercapnia, and increased ICP if the tube became
occluded. If portable suction was not available during the transfer, the client
could have experienced a prolonged period of insufficient oxygenation and
ventilation.

Prevention: Clients who are ventilator dependent and require transfer should have the
patency of their artificial airway assessed and be suctioned prior to transfer.
In addition, appropriate support supplies should be taken during transfer to
help maintain the efficiency of manual ventilation with an Ambu(r)-bag.
Potential cervical spine
Nasopharyngeal Airway Insertion - Overview
Overview: Nasopharyngeal airways are used to maintain a patent airway to the

hypopharynx and to facilitate the removal of tracheobronchial secretions
by directing the catheter and by averting tissue trauma that is associated
with repeated suction attempts. The nasopharyngeal airway is most
commonly used in the postanesthesia recovery period to facilitate
pulmonary toilet and in situations in which the patient is semiconscious.
The nasopharyngeal airway is a flexible piece of rubber See Figure 1.It is

passed through the nose and follows the posterior nasal and
oropharyngeal walls to the base of the tongue. The nasopharyngeal airway
has three parts: the flange, cannula, and bevel, or tip. The flange is the
wide, trumpet-like end that prevents further slippage into the airway. The
hollow shaft of the cannula permits airflow into the hypopharynx. The
bevel, or tip, is the opening at the distal end of the tube. When properly
inserted, the tip can be seen resting posterior to the base of the tongue.
The external diameter of the nasopharyngeal airway should be slightly

smaller than the patient's external naris opening. The length of the
nasopharyngeal airway is determined by measuring the distance between
the naris and the tragus of the ear See Figure 2. Improperly sized
nasopharyngeal airways may result in increased airway resistance, limited
airflow (if the airway is too small), kinking and , gagging, vomiting, and
gastric distention (if the airway is too large). Some manufacturers provide
nasopharyngeal airways shaped specifically for the right or left naris.
The advantages of the nasopharyngeal airway include increased comfort

and tolerance in the conscious patient, stable airway positioning for long
periods, decreased incidence of gag reflex stimulation, and minimal
incidence of mucosal trauma during frequent suctioning.
Nasopharyngeal airways are especially useful for relieving airway

obstruction associated with mandibular-type injuries that result in jaw
immobility or soft tissue obstruction. Examples of these injuries include jaw
wiring, trismus, pain, edema, jaw spasms, and mechanical impairment
such as temporomandibular joint fractures and zygomatic fractures. In
selected situations, a nasopharyngeal airway may be used in a patient to
facilitate the passage of a fiberoptic bronchoscope and to tamponade
small bleeding blood vessels in the nasal mucosa.
Insertion of the nasopharyngeal airway in an alert patient may stimulate

the gag reflex, causing retching and vomiting.
Contraindications to use of a nasopharyngeal airway are as follows:
 Patients receiving anticoagulation therapy

 Patients prone to epistaxis
 Patients with obstructed nasal passageways
 Patients with facial or head trauma in whom basilar skull fracture or
cranial vault communication is suspected
 Nasopharyngeal Airway Insertion - Outcomes
 Improvement of respiratory status

Expected Outcomes  Long-term patent airway
 Diminished mucosal edema and
trauma related to frequent suction
passes
 Inability to pass nasopharyngeal airway
Unexpected Outcomes  Airway obstruction
 Head or ear pain
 Epistaxis
 Nares and nasal mucosal ulceration
Nasopharyngeal Airway
Insertion - Assessment and
Preparation
 Ensure
Preparatio patient
n understands
preprocedura
l teaching.
Answer
questions as
they arise
and reinforce
information
as needed.
 Position
patient.
Unless
contraindicat
ed, a supine
or high
Fowler
position is
acceptable.
 Appropriately
Supplies sized nasal
airway
 Nonsterile
gloves
 Water-
soluble
lubricant
 Tape
 Suction
equipment
 Flashlight
 Tongue
depressor
Additional
equipment (to
have available
depending on
patient need)
includes the
following:
 Cotton
swabs
 Topical
anesthetic
 Assess
Assessme cardiopulmo
nt nary status.
 Assess for
patent nasal
passageway.
With finger
pressure,
occlude one
nostril. Feel
for air
movement
under the
open nostril.
Patency also
can be
assessed by
inspection of
each naris
with a
flashlight.
Nasopharyngeal Airway
Insertion - Procedure
1. Wash hands and don
personal protective
equipment.
Rationale: Reduces
transmission of
microorganisms and
body secretions;
For copious
secretions, don
protective eyewear,
face mask, or both.
2. Prepare the
nasopharyngeal airway.
a. Inspect for
smooth edges.
b. Generously
lubricate the tip
and outer cannula
with water-soluble
lubricant.
Rationale:
Decreases
chances of
mucosal trauma
during insertion.
Decreases
incidence of
trauma by
preventing
friction against
dry mucosal
membrane.
3. Remove excess
secretions from naris.
Rationale: Allows for

visual inspection of
naris; removes
possible source of
obstruction; removes
medium for organism
growth.
Nasopharyngeal and
nasotracheal suction
are contraindicated in
patient's with actual
or suspected
maxillofacial and
skull injuries.
4. When difficult insertion is

anticipated (e.g., with
nasal polyps, septal
deviation), apply topical
anesthetic to cotton
swabs, insert as far as
possible, and coat the
nasal passageway.
Rationale: Topical
anesthetics with
vasoconstrictors help
shrink nasal mucosa
and decrease the
incidence of trauma
and bleeding.
Vasoconstrictor
property acts on
capillaries to decrease
bleeding.
Check with physician,
advanced practice
nurse, or institutional
standards for topical
anesthetic usage and
indications.
5. Gently slide airway into

nostril. Guide it medially
and downward along the
nasal passage.
Rationale: Following
the natural contour of
the nasal passage
decreases the
incidence of trauma.
If resistance is
encountered, rotate
the tube and continue
gentle forward
pressure. Do not
force the tube.
Should resistance
continue, withdraw
the tube and try the
other nostril. While
inserting, if the
patient experiences
increasing dyspnea
or respiratory
distress, consider
removing the tube.
6. Ask patient to open his or

her mouth, or hold
patient's mouth open.
Control tongue with a
tongue depressor.
Illuminate oral cavity and
visualize tip of
nasopharyngeal airway
behind uvula See Figure
2.
Rationale: Verifying
location of airway in
pharynx verifies proper
airway positioning.
Allows for inspection of
posterior pharynx for
excessive bleeding or
mucus.
7. Verify patency of airway.

Feel for air movement
over the flange.
Auscultate breath sounds
bilaterally.
Rationale: Optimal
airway positioning
allows for forward gas
flow, removal of
secretions, and
possible prevention of
airway occlusion.
8. Secure airway by taping

it in place.
Rationale: Minimizes
dislodgment, removal,
and deeper penetration
into the nasopharynx.
9. Suction secretions as
necessary.
Rationale: Maintains
patent airway.
Recheck flange for
proper position.
10. Reassess patient's

respiratory status.
Rationale: Indicates
effectiveness of the
nasal airway.
11. Document in patient's

record.
Nasopharyngeal Airway Insertion - Post Procedure and Variations

1. Assess skin in contact with nasal airway.
Post Procedure
Redness, swelling, drainage, bleeding, or skin
breakdown should be reported if they persist
2. Facilitate removal of secretions. Hyperoxygenate and

suction as necessary.
Rationale: Retained secretions increase the potential

for airway obstruction and pulmonary infections.
Aging results in diminishing mucociliary clearance.
Change in character or amount of secretions
interventions.
3. Monitor respiratory status every 2 to 4 hours.
Rationale: Change in respiratory status may indicate

displacement of oral airway or worsening respiratory
condition.
Change in respiratory status not corrected with
repositioning of airway or suctioning should be
reported if they persist despite nursing
interventions.
4. Provide meticulous mouth care every 4 to 8 hours and as

needed.
Rationale: Prevents secretions, encrustations, mouth

infections, and airway port occlusions.
Lacerations, ulcerations, or areas of necrosis
interventions.

Documentation  Insertion of nasopharyngeal airway
 Size of nasopharyngeal airway
 Any difficulties with insertion
 Patient tolerance, including respiratory and vital signs
assessment before and after procedure
 Verification of proper placement
 Appearance and thickness of tracheal secretions, if
present
 Skin integrity around tube
 Explain the purpose of the airway and the necessity of the

Patient procedure if the patient is conscious or to the family of the
Education unconscious patient
 Explain the patient's role in assisting with the insertion of
the airway
 Discuss the sensory experiences associated with nasal
airway insertion, including the presence of a rubber airway
in the nose and possible gagging
Oropharyngeal Airway Insertion - Overview
The oropharyngeal airway is placed to maintain a patent airway for

Overvie patients in the following situations:
w:
 An unconscious, spontaneously breathing patient with an airway
obstruction caused by an impaired gag reflex and a loss of tone to
the submandibular muscles.
 A patient in whom there has been no successful opening of an
airway by other maneuvers, such as the head-tilt, the chin-lift, and
the jaw-thrust.
 A patient ventilated by a bag-valve-mask device. The oral airway
elevates the soft tissues of the posterior pharynx, easing ventilation
and minimizing gastric insufflation.
 An orally intubated patient who bites or clenches the endotracheal
tube; the oral airway is used as a bite-block.
 An unconscious patient during suctioning, to facilitate the removal of
a patient's oral secretions.

Oropharyngeal Airway Insertion - Outcomes
Expected  Patent airway
Outcomes
 Further obstruction of airway due to incorrect

Unexpected placement or size of oropharyngeal airway
Outcomes  Vomiting, aspiration
Oropharyngeal Airway Insertion - Assessment and Preparation
1. Place the patient in the supine position.

Preparation 2. Suction blood, secretions, or other foreign material
from the patient's oropharynx.
Failure to clear the oropharynx of foreign

material before insertion of the airway may
result in aspiration.
3. Select the appropriately sized oropharyngeal

airway [See Table 1]. Align the tube on the side of
the patient's face and choose an airway that extends
from the corner of the mouth to the tragus of the ear
or from the lips to the angle of the jaw.
An airway that is too small may push the

tongue into the oropharynx and cause an
obstruction; an airway that is too large may
obstruct the trachea.
Table 1: Oral Airway Sizing by Age

Age Oropharyngeal Airway Size
Premature neonate 000
Newborn 00
Infant 0
1-3 yrs 1
3-8 yrs 2
9-18 yrs, large child, small 3
adult
Medium-sized adult 4
Large adult 5,6
 Oropharyngeal suction equipment

Supplies  Appropriately sized oropharyngeal airway
 Tongue blade
1. Ensure the patient is unconscious and has no gag

Assessment reflex.
Insertion of an oral airway in a conscious or

semiconscious patient stimulates the gag
reflex and may stimulate airway spasm or
cause the patient to vomit.
2. Maintain a patent airway by use of the jaw-thrust or

the head-tilt/chin-lift maneuver.
Oropharyngeal Airway Insertion - Procedure
1. Use a tongue blade to depress and displace the tongue forward.

Insert the airway with the curve pointing up into the oropharynx.
2. As an alternative procedure, insert the airway upside-down (with the

curve pointing toward the back of the patient's head) into the mouth.
As the tip of the airway reaches the posterior wall of the pharynx,
rotate the airway 180 degrees to the proper position.
Rationale: This alternative may be used in situations where

there is no tongue blade available or the opening to the airway
is limited due to jaw clenching or other mechanical reasons.
3. The distal tip of the airway should lie between the base of the
tongue and the back of the throat. The flange of the tube should sit
comfortably on the lips See Figure 1.
Incorrect placement of an oral airway may compress the

tongue into the posterior pharynx and cause further
obstruction.
4. Reassess airway patency and auscultate the lungs for equal and
clear breath sounds during ventilation.
Oropharyngeal Airway Insertion - Post Procedure and Variations
1. Continually assess airway patency.

Post Procedure 2. Assess respiratory rate and effort.
3. Evaluate for symmetrical rise and fall of the chest.
4. Assess adequacy of oxygenation and ventilation
with SpO2 monitoring and arterial blood gas
evaluation as ordered and as indicated.
5. Monitor for change in level of consciousness and
presence of the gag reflex.
Rationale: The presence of the gag reflex may

result in vomiting and aspiration because
appropriate positioning of the airway may
stimulate a gag response.
6. Ensure the oropharyngeal airway is removed

immediately after the patient regains the gag reflex.
Rationale: To prevent vomiting and aspiration.
 Indication for placement of the oropharyngeal airway

Documentation  Size and procedure used in the placement
o Ongoing assessment data
o Airway patency
o Respiratory rate and effort
o Oxygenation support
o Oxygenation evaluation (e.g., SpO2)
o Ventilation evaluation (e.g., ABG)
 No Patient Education
Patient Education
Considerations
 Depress and displace the tongue forward with a
tongue blade and insert the airway.
 Do not insert an upside-down airway and then rotate
it because this technique may injure the soft tissue
of the soft palate and oropharynx.
Mechanical Ventilation- Weaning Criteria - Overview
Standard weaning criteria are measured to evaluate respiratory muscle

Overview: strength (negative inspiratory pressure [NIP] and positive expiratory
pressure [PEP]) and endurance (spontaneous tidal volume [SVt] and
vital capacity [VC]). The results may help determine the need for
intubation, the ability of the patient to tolerate weaning trials, and the
potential for extubation.
NIP also is called negative inspiratory force or sometimes maximal
inspiratory pressure. The measurement of NIP is effort
independent (meaning that the patient does not have to actively
cooperate), and it is considered the most reliable of the standard
weaning criteria (SWC). NIP is a measure of inspiratory respiratory
muscle strength. It is a strong negative predictor but a poor positive
predictor. The most common threshold cited for NIP is less than or equal
to –20 cm H2O.
PEP, also called positive expiratory force (PEF), is effort
dependent, requiring that the patient cooperate fully to obtain a reliable
value. PEP is a measure of expiratorymuscle strength and ability to
cough. The threshold forPEP is greater than or equal to 30 cm H2O.
SVt is a measure of respiratory muscle endurance. The threshold for SVt
is greater than or equal to 5 ml/kg. When muscles fatigue, the
compensatory breathing pattern is rapid and shallow. As a result,
investigators have combined SVt and spontaneous respiratory rate (fx)
in a ratio called the rapid: shallow breathing index or fx:Vt.
VC is also a measure of respiratory muscle endurance or reserve or
both. A fatigued patient would be unable to triple or even double the size
of a breath. The threshold for VC is greater than or equal to 15 ml/kg (at
least three times SVt).
All SWC are best used in combination with other assessment data to
determine the appropriateness of weaning trials or extubation.
It may be that weaning trials, such as short-duration "sprints" on
continuous positive airway pressure (CPAP) or t-piece, provide enough
information about extubation potential that SWC are not required.
Regardless, the SWC provide information about respiratory muscle
strength and endurance. They may be especially helpful in following
trends in gains in strength and endurance in debilitated, weak patients or
patients with myopathies. They also may help to evaluate respiratory
muscle fatigue.
Mechanical Ventilation- Weaning Criteria - Outcomes
 Valid and reliable measurements

Expected Outcomes
 Invalid and unreliable measurements

Unexpected Outcomes  Untoward physical, emotional, or
hemodynamic changes
Mechanical Ventilation- Weaning

Criteria - Assessment and Preparation
 Ensure the patient

Preparatio understands preprocedural
n teaching. Answer
questions as they arise,
and reinforce information
as needed.
 An aneroid manometer
Supplies (also called a force meter)
 A respirometer (to
measure volumes)
 Appropriate adapters and
one-way valves
*Some ventilators allow

measurement of these parameters
while the patient is on the
ventilator. Refer to specific
ventilator guidelines for
measurement.
1. Assess for the following

Assessme signs and symptoms of
nt inadequate ventilation.
a. Increasing arterial
carbon dioxide
tension.
b. Chest-abdominal
dyssynchrony.
c. Shallow or irregular
respirations.
d. Tachypnea or
bradypnea.
e. Dyspnea.
f. Restlessness,
confusion, lethargy.
g. Increasing or
decreasing arterial
blood pressure.
h. Tachycardia/bradyc
ardia.
i. Atrial or ventricular
dysrhythmias.
2. Assess patients need for a
long-term artificial airway
and mechanical ventilatory
assistance.
3.
Mechanical Ventilation- Weaning Criteria -

Procedure
1. Wash hands.
Rationale: Reduces transmission of

microorganisms.
2. Don examination gloves.
3. Attach portable respirometer to airway

via adapter and series of one-way
valves.
Rationale: Respirometer is used to

measure SVt and VC. Depending on
institutional standard and specific
ventilator, volumes and pressures
may be measured while patient is on
the ventilator.
Generally, a series of one-way
valves are used for attachment of
the respirometer and aneroid
manometer. NOTE: If patient is
on positive pressure ventilation
(PPV), place patient back on
ventilator to rest for a few
minutes between all
measurements.
4. SVt: Instruct the patient to breathe

normally for 1 minute. Count the fx and
record the minute ventilation. Divide
minute ventilation by fx to obtain
average SVt.
Rationale: If patient's saturation

drops or other signs of intolerance of
the procedure emerge, the test is
aborted or may be done for a shorter
interval (i.e., test for 15 seconds,
multiply result by 4 for calculation of
full minute).
5. For VC, instruct patient to inhale as

deeply as possible, zero respirometer,
and instruct patient to exhale as
completely as possible. The VC may be
tested more than once to obtain the
best effort.
Rationale: A good VC effort

mandates a maximum inspiration
followed by a maximum expiration.
6. Measure NIP as follows:

a. The inspiratory one-way valve
should be closed or capped,
thus ensuring a closed system
for measurement of inspiratory
effort. Attach pressure
manometer to airway with
adapter and one-way valves.
Rationale: Ensures best effort

and evaluation reproducibility.
Pressure manometer is used
to measure NIP. Some
ventilators allow the
measurement to be
accomplished with the patient
on the ventilator.
The pressure manometer is
usually attached to the
airway via a series of one-
way valves See Figure
1. The valves (one is for
inspiration and one is for
expiration) are capped as
necessary to ensure a
closed system and a clean
measurement device for
attachment to the patient's
artificial airway.
b. Instruct the patient to inhale as

deeply as possible. Observe the
manometer needle during
inspiration. This test can be
done for 20 seconds with
multiple attempts by patient.
Rationale: The goal is to

obtain the patient's best
effort.
NIP can be frightening for
patients because it is
impossible to get a breath
during the maneuver.
Coaching should include
warning patients that this
test will make them
temporarily unable to take a
breath. Watch the
manometer as the 20
seconds elapse; stop the
procedure if the NIP
measurements begin to get
weaker as time elapses or if
the patient does not
tolerate the procedure (e.g.,
experiences agitation,
bradycardia, desaturation).
7. Measure PEP as follows:

a. The expiratory valve should be
closed or capped. This ensures
that the patient is able to take a
breath in but must exhale
against a closed system. Attach
the pressure manometer to the
airway via adapter and one-way
valves.
b. Instruct the patient to exhale

forcefully after taking a deep
breath. Do this a number of
times (not to exceed 20
seconds). Take the greatest
positive number.
Rationale: Obtains patient's

best effort.
As with NIP, any
deterioration of the patient
indicates that the test
should be aborted.
8. Encourage the patient throughout all

measurements.
Rationale: Provides incentive.
9. Document in patient's record and

discuss with team.
Rationale: Decisions related to

weaning trials, intubation, or
extubation will be made with the
results of these tests in conjunction
with others.

Mechanical Ventilation- Weaning Criteria - Post Procedure and Variations
Post Procedure
 Compare the SWC measurements to the desired patient goals.
Rationale: If the measurements are less than anticipated, the patient may need
either initiation of positive-pressure ventilation or continuance of mechanical
ventilation. If the measurements equal or exceed the goals, initiation of weaning
trials or extubation may be possible.
NIP greater than -20 cm H2O (e.g., -10 cm H2O), PEP less than +30 cm H2O
(e.g., +10 cm H2O), SVt less than 5 ml/kg, VC less than 10 ml/kg, or any
deterioration of patient during measurements that does not immediately
respond by returning to mechanical ventilator or bagging should be
Documentation

 Best values obtained
 How the patient tolerated the tests
Patient Education
 Inform the patient and family about the patient's respiratory status, changes in therapy,
and how to interpret the changes. If the patient or a family member requests specific
information about the measurements, explain the relationship between these
measurements and respiratory muscle strength and endurance.
 Discuss the sensations the patient may experience, such as transient shortness of breath
and fatigue.
 Explain to the patient the importance of cooperation and maximal effort to achieve valid
and reliable measurements.
Mechanical Ventilation- Weaning Process - Overview
The purposes of weaning patients from mechanical ventilation are

Overview: liberation from ventilatory support and removal of artificial airways.
Knowledge and skills related to the care of patients on mechanical
ventilation (e.g., airway management, suctioning, mechanical ventilator
modes, blood gas interpretation) are necessary.
The weaning process is markedly different between short-term
mechanical ventilation (STMV) and long-term mechanical ventilation
(LTMV). In STMV (less than or equal to 3 days), the weaning progress is
linear, whereas in LTMV (greater than 3 days), progress generally is
manifested by peaks and valleys.
Weaning may be viewed as a continuum with distinct stages: prewean,
weaning, and outcome See Figure 1. Some authors also add an acute
stage to describe the time when a patient experiences severe
cardiopulmonary instability. Weaning readiness in STMV is determined
by the patients level of consciousness, hemodynamic stability, adequacy
of gas exchange, and pulmonary mechanics. LTMV weaning readiness
is assessed with a wide variety of factors, including physiologic,
psychological, and pulmonary impediments. To date, no single factor or
impediment has been identified that determines ventilator dependence
or independence. Instead, a combination of factors is responsible.
Weaning indices have proved to be disappointing predictors of a patients
ability to wean. Most predictors focus on pulmonary-specific factors.
Some investigators have combined indices and pulmonary factors,
however, to enhance the comprehensive nature of the indices and their
predictive potential. In general, the indices are poor positive predictors
(they do not tell us the patient will wean), but they are strong negative
predictors (they tell us the patient will not wean). The various weaning
indices are best used to evaluate the components important to the
weaning process and to track progress over time. This type of approach
prevents lapses in care and may result in shorter ventilator durations.
Standard or traditional weaning parameters [See Table 1] have been
defined. There are also several examples of integrated weaning
indices: [See Table 2] rapid shallow breathing (fx/Vt) and compliance,
rate, oxygenation, and pressure (CROP) indices; and burns weaning
assessment program (BWAP) [See Table 3].
Studies about weaning suggest that weaning progress in patients
requiring prolonged ventilation is more likely when rigorous attention is
paid to the correction of impediments and a standardized comprehensive
approach is used. The goal is to decrease system variation in the
provision of care.
No weaning modes or methods of weaning seem to be superior;
however, attention to early testing of ability to wean combined with
distinct trials that balance respiratory muscle work and rest may result in
shorter weaning durations.
The concept of respiratory muscle fatigue must be understood if it is to
be prevented in the ventilated weaning patient. All muscles may fatigue if
work exceeds energy stores. Signs and symptoms of impending fatigue
include dyspnea, tachypnea, chest-abdominal asynchrony, and
increasing arterial partial pressure of carbon dioxide (Paco2) (a late sign).
Generally, fatigue may be prevented by avoiding premature trials or
excessively long or difficult weaning trials.
Protocols for weaning have been noted to improve weaning outcomes in
STMV and LTMV patients. In general, these protocols consist of three
components: entry criteria, definition of weaning trial tolerance (when to
initiate and when to stop trials), and distinct steps for progression of the
specific modes or methods to be used. The concepts of work, rest, and
conditioning are integrated into many protocols. The use of two
classifications–high-pressure, low-volume work and low-pressure, high
volume work–may help with practical applications of specific modes and
methods.
 High-pressure, low-volume work is found with the use of a T-piece,

continuous positive airway pressure (CPAP), and low intermittent
mandatory ventilation (IMV) rates. Generally, any method that requires
that the patient breathe spontaneously (without inspiratory support)
results in high-pressure, low-volume work. This form of muscle
conditioning is thought to build sarcomeres because it employs maximal
muscle loading. Conditioning episodes are generally of short duration
with full muscle rest between episodes. This type of conditioning is
referred to as strengthening training.
 Low-pressure, high-volume work is found with the use of pressure
support ventilation (PSV), in which inspiration is augmented. For any
given pressure level, workload is less than if the patient were breathing
spontaneously. At high levels of PSV, little work occurs, but as the level
is reduced, muscle workload increases. Conditioning with PSV often is
referred to as endurance conditioning; muscles are not worked to
maximal effort. Instead, training focuses on maintaining a specific level
of work for progressively longer intervals trials without inducing fatigue.
Noninvasive criteria that define intolerance as seen in the CPAP
example protocol [See Table 4] as well as the PSV protocol may result
in cessation of the trial and a return to full rest. Rest and fatigue are
described in a separate procedure: "Mechanical Ventilation: Volume
and Pressure Modes;" and in sample CPAP protocol [See Table 4] and
the PSV protocol [See Table 5].
Weaning is the process of gradual reduction of ventilatory support. To

that end, a plan for weaning is essential. The plan, whether it is to
employ a protocol or consists of an individualized written plan, should be
available to all health care workers involved in the weaning process.
Assessment of weaning potential may include checklists of factors
important to weaning, such as the Burns Weaning Assessment Program
(BWAP) [See Table 3], and the measurement and application of various
weaning indices, such as standard weaning criteria [See Table 1],
frequency/tidal volume (Vt) [See Table 2], and BWAP [See Table 3].
Table 1: Standard Weaning Criteria

Negative inspiratory pressure (NIP) less than or equal to 20 cm H2O
Positive expiratory pressure (PEP) greater than or equal to 30 cm H2O
Spontaneous tidal volume (STV) greater than or equal to 5 ml/kg
Vital capacity (VC) greater than or equal to 10–15 ml/kg
Fraction of inspired oxygen (FiO2) less than or equal to 50%
Minute ventilation (MV) less than or equal to 10 L/min
Table 2: Rapid Shallow Breathing (fx/Vt) and Compliance, Rate,

Oxygenation, and Pressure (CROP) Indices
fx/Vt CROP
Spontaneous respiratory frequency in 1 Dynamic characteristic x NIP x
min divided by Vt in liters (PaO2/PaO2) ÷ divided by respiratory rate
fx/Vt less than 105 = weaning success Less than 13 = weaning success
fx/Vt greater than 105 = weaning failure Greater than 13 = weaning failure
Table 3: Burns Weaning Assessment Program (BWAP)

Patient
Patient
history
name
number
NOT
YES NO General Assessment
ASSESSED
1. Hemodynamically stable (pulse rate, cardiac

output)?
2. Free from factors that increase or decrease
metabolic rate (seizures, temperature, sepsis,
bacteremia, hypo/hyperthyroid)?
3. Hematocrit greater than 25% (or baseline)?
4. Systemically hydrated (weight at or near

baseline, balanced intake and output)?
5. Nourished (albumin greater than 2.5,
parenteral/enteral feedings maximized)? (If albumin

is low and anasarca or third spacing is present,
score for hydration should be "No")
6. Electrolytes within normal limits (including Ca

Mg+, PO4)? *Correct Ca2+ for albumin level
7. Pain controlled? (subjective determination)
8. Adequate sleep/rest? (subjective determination)
9. Appropriate level of anxiety and nervousness?

(subjective determination)
10. Absence of bowel problems (diarrhea,

constipation, ileus)?
11. Improved general body strength/endurance
(i.e., out of bed in chair, progressive activity
program)?
12. Chest roentgenogram improving?
Respiratory Assessment

Gas Flow and Work of Breathing
13. Eupneic respiratory rate and pattern
(spontaneous respiratory rate less than 25, without
dyspnea, absence of accessory muscle use). †This
is assessed off the ventilator while measuring #20–
#23.
14. Absence of adventitious breath sounds

(rhonchi, rales, wheezing)?
15. Secretions thin and minimal?
16. Absence of neuromuscular disease/deformity?
17. Absence of abdominal

distention/obesity/ascites?
18. Oral endotracheal tube greater than Fr 7.5 or

trach greater than Fr 6.0
Airway Clearance
19. Cough and swallow reflexes adequate?
Strength
20. Negative inspiratory pressure less than -20?
21. Positive expiratory pressure greater than +30?
Endurance
22. Spontaneous tidal volume greater than 5 ml/kg?
23. Vital capacity greater than 10 to 15 ml/kg?
Arterial Blood Gases
24. pH 7.30 to 7.45?
25. PaCO2 approximately 40 mm Hg (or baseline)
with minute ventilation less than 10 L/min
(evaluated while on ventilator)?
26. PaO2 60 or FiO2 less than 40%?
*To score the BWAP: divide the number of "Yes" responses by 26.
Threshold: Greater than 65% = weaning probable
Less than 65% = weaning improbable.
Table 4: Example CPAP Protocol

A. Mode
CPAP (0, or level of current mechanical ventilator settings)
B. Entry Criteria
BWAP score greater than or equal to 50%
FiO2 less than or equal to 0.5
PEEP less than or equal to 8 cm H2O
C. Protocol Steps
1. Ensure complete rest the previous night and until the trial begins. (Complete
respiratory muscle rest is defined as total cessation of respiratory effort when in
assist-control or IMV modes; respiratory rate less than 20 with inspiratory tidal
volumes of 8 to 12 ml/kg in PSV mode.)
2. Place the patient on a CPAP level of 0 (or level determined by team) at the same
FiO2 as when ventilated.
3. Maintain CPAP at 0 for up to 2 hours unless signs of intolerance develop. Trial is
done once daily.
4. If signs of intolerance develop at any time during the trial, place the patient back
on the previous ventilator settings. Make adjustments as necessary to achieve
complete respiratory muscle rest. Total rest continues until the next day or another
trial is attempted that day (this is only if there is a compelling reason that explains
the patients inability to sustain the earlier trial).
5. If the patient tolerates 2 hours of CPAP trial, consider extubation.
D. Intolerance Criteria
1. Respiratory rate increase to 30 BPM (sustained).
2. Heart rate increase by 20% (sustained).
3. Oxygen saturation falls to less than 91% or 2% below baseline (sustained).
4. Systolic blood pressure greater than180 mm Hg or less than 90 mm Hg.
5. Agitation.
6. Diaphoresis.
7. Anxiety.
8. Tidal volume less than 5 ml/kg (sustained).
9. Excessive dyspnea (new or unrelated to activity).
Table 5: Example PSV Protocol
A. Mode
Pressure support wean/pressure support rest
B. Entry Criteria
BWAP score greater than or equal to 50%
FiO2 less than or equal to 0.5
PEEP less than or equal to 6 cm H2O
C. Protocol Steps
1. The baseline (RESTING) PSV level is set to achieve tidal volume of 8 to 12
ml/kg while ensuring a respiratory rate of less than or equal to 20 breaths per
minute.
2. The PSV level is decreased by 2–5 cm H2O/day. If the patient successfully
maintains the previous day's PSV level for 10 to 14 hours, the PSV level is
decreased by again. This process is continued until the patient reaches a PSV level
of 3 to 5 cm H2O. (If the team wishes to advance weaning based on rapid
improvements in the patient's physical status, the PSV level may be decreased
more rapidly).
3. The patient is rested at night or with any acute events (see "baseline" definition
above).
4. If a patient exhibits signs of fatigue during a PSV trial, the patient is returned to
the previous day's PSV level. After 30 minutes, if the patient continues to be
fatigued, the patient is returned to the resting level of PSV.
5. The patient is progressed to a lower PSV level the following day only if 10 to 14
hours of PSV is achieved on the current setting.
6. When the patient reaches a PSV of 3 to 5 cm H2O and can maintain this level for
the required time, the team is approached for extubation orders. For some patients
(e.g., the obese), the lowest level of PSV may need to be higher.
D. Intolerance Criteria
1. Respiratory rate increases to 30 BPM (sustained).
2. Heart rate increases by 20% (sustained).
3. Oxygen saturation falls to less than 91% or 2% below baseline (sustained).
4. Systolic blood pressure greater than 180 mm Hg or less than 90 mm Hg.
5. Agitation.
6. Diaphoresis.
7. Anxiety.
8. Tidal volume less than 5 ml/kg (sustained).
9. Excessive dyspnea (new or unrelated to activity).
10. Patients are also "rested" and the weaning process held if any of the following
conditions apply:
a. During acute events (hypotension, bronchospasm, etc).
b. Intrahospital transports.
c. Temperature spikes.
d. Decreased weaning indices scores (BWAP less than 50%, WI greater than 4.5).
e. Trendelenburg position required (e.g., for line placement)
Mechanical Ventilation- Weaning Process - Outcomes
 Timely and successful discontinuance of PPV

Expected  Comfortable and adequate breathing pattern during the weaning
Outcomes process
 Tracheal injury
Unexpected  Pulmonary barotrauma
Outcomes  Cardiovascular depression
 Fatigue
 Hypoxemia
 Hypercapnia
 Dyspnea
 Unsuccessful, demoralizing weaning trials
Mechanical Ventilation- Weaning Process - Assessment and Preparation
1. Ensure the patient understands preprocedural teaching.

Preparation Answer questions as they arise, and reinforce information as
needed.
2. Address all factors that are impeding wean potential. In
STMV, this may include factors such as pH level,
hemodynamic stability, electrolytes, strength, and endurance.
In a patient who requires LTMV, other factors, such as
mobility, nutrition, and fluid status, may be more significant.
3. Establish weaning criteria.
 If T-piece or tracheotomy collar setup is required, a flow
Supplies meter with a functional heated aerosol humidifier for the
trials is necessary. The setup should have an in-line
thermometer and a water trap.
 Tracheotomy collar or T-piece adapters
 Pressure manometers
 Weaning protocol or wean plan
 Extubation equipment
1. Regular evaluation of factors that impede weaning in

Assessment conjunction with factors that measure respiratory muscle
strength, endurance, and gas exchange is necessary to
determine when to begin weaning trials. Use of standard
weaning criteria [See Table 1], breathing indices, [See Table
2] and the BWAP [See Table 3] can all be useful.
2. Assess progress toward achievement of individual short-term
goals every 5 to 30 minutes, as appropriate.
3. In patients who are ventilator dependent, assess daily
progress toward achievement of individual long-term goals, in
collaboration with the physician, respiratory therapist, patient,
and family, as appropriate.
4. Observe breathing pattern, and note complaints of dyspnea
in response to decrements in PPV support. Other signs of
fatigue include the following:
a. Accessory muscle use
b. Chest or abdominal asynchrony
c. Retractions
d. Rapid shallow breathing pattern
5. Note if the patient experiences changes in level of
consciousness or nonverbal behavior and complains of
dyspnea or fatigue.
6. Assess arterial blood gases as needed.
7. Assess oxygenation indices–arterial oxygen saturation
(SaO2) or arterial partial pressure of oxygen (PaO2) during
trials.
8. Assess patient anxiety level.

Negative inspiratory pressure (NIP) less than or equal to 20 cm H2O
Positive expiratory pressure (PEP) greater than or equal to 30 cm H
Table 2: Rapid Shallow Breathing (fx/Vt) and Compliance,

Rate, Oxygenation, and Pressure (CROP) Indices
fx/Vt CROP
Spontaneous respiratory Dynamic characteristic x NIP x
frequency in 1 min divided by Vt in (PaO2/PaO2) ÷ divided by respiratory
liters rate
fx/Vt less than 105 = weaning
Less than 13 = weaning success
success
fx/Vt greater than 105 = weaning
Greater than 13 = weaning failure
failure
Table 3: Burns Weaning Assessment Program (BWAP)

Patient
Patient
history
name
number
NOT
ASSESSED
1. Hemodynamically stable (pulse rate,

cardiac output)?
2. Free from factors that increase or
decrease metabolic rate (seizures,

temperature, sepsis, bacteremia,
hypo/hyperthyroid)?
3. Hematocrit greater than 25% (or

baseline)?
4. Systemically hydrated (weight at or
near baseline, balanced intake and
output)?
7.5 or trach greater than Fr 6.0
Airway Clearance
19. Cough and swallow reflexes

adequate?
Strength
20. Negative inspiratory pressure less

than -20?
21. Positive expiratory pressure greater

than +30?
Endurance
22. Spontaneous tidal volume greater

than 5 ml/kg?
23. Vital capacity greater than 10 to 15

ml/kg?
Arterial Blood Gases
24. pH 7.30 to 7.45?
25. PaCO2 approximately 40 mm Hg (or
baseline) with minute ventilation less than
10 L/min (evaluated while on ventilator)?
26. PaO2 60 or FiO2 less than 40%?
*To score the BWAP: divide the number of "Yes" responses by
26.
Mechanical Ventilation- Weaning Process - Procedure
1. Communicate with the patient and family throughout the

weaning process.
Rationale: Attention is given to the patient's subjective

response to weaning. The nurse remains with the
patient (especially at the beginning of the trial);
monitors frequently during trials; coaches the patient;
reinforces the goals and desired outcomes; reminds the
patient that talking, eating, self-care activities, and
mobilization will be facilitated by successful weaning
and extubation; and celebrates weaning progress with
the patient and family.
T-Piece or Tracheotomy Collar Trials
1. Wash hands, and don gloves.
Rationale: Reduces transmission of microorganisms;

2. Connect patient to heated aerosol via T-piece or

tracheotomy collar. Instruct patient to breathe normally, and
monitor frequency, breathing pattern, heart rate, cardiac
rhythm, SaO2, and general appearance of patient.
Rationale: Heated aerosol replaces water that normally

would be added by the upper airway if it were not
bypassed by the endotracheal or tracheostomy tube.
This method of weaning employs high-pressures, low-
volume work. Signs and symptoms of tolerance must
be heeded if respiratory muscle fatigue is to be
prevented.
Abort weaning for any signs of patient intolerance,
and place patient back on PPV support.
3. After a predetermined time, interval or with the emergence of

signs of intolerance, place patient back on resting ventilator
settings.
Rationale: To ensure respiratory muscle conditioning

and forward progress during weaning trials, the work of
breathing must not be excessive; do not exceed
Mechanical Ventilation- Weaning Process - Post Procedure and
Variations
1. Evaluate overall patient stability (i.e., physiologic,

Post Procedure psychologic, and mechanical) in a systematic manner.
Frequency of evaluation may vary depending on
whether the patient requires STMV or LTMV. A
multidisciplinary approach is encouraged.
Rationale: Patient stability and overall condition

must be considered before initiating active weaning
trials. Premature attempts may be harmful and
frustrating for all involved. A multidisciplinary team
approach ensures active attention to the diverse
factors that affect weaning readiness. Use of
standard weaning criteria [See Table 1], breathing
indices, [See Table 2] and the BWAP [See Table
3] can all be useful.
Changes in weaning indices (pulmonary-
specific and integrated) along with general
factors that affect weaning should be reported
if they persist despite nursing interventions.
2. During weaning trials, pay attention to signs and

symptoms of intolerance and respiratory muscle fatigue.
If signs of intolerance occur, prompt return to PPV is
required.
Rationale: Trials that are continued despite

emergence of signs of intolerance lead to fatigue
and failure. Cardiopulmonary failure and collapse
are potential outcomes.
Signs of weaning trial intolerance (tachypnea,
dyspnea, chest and abdominal asynchrony),
agitation, mental status changes, significant
decrease in SaO2 (SaO2 less than 90% or 10%
decrease), changes in pulse rate or rhythm, or
blood pressure increase or decrease should be
reported if they persist despite nursing
interventions.
3. If no signs of intolerance occur during trials, continue

until the patient achieves the trial criteria and report to
team so that additional planning can occur (e.g.,
extubation) or follow protocol steps to extubation.

Negative inspiratory pressure (NIP) less than or equal to 20 cm
O
Positive expiratory pressure (PEP) greater than or equal to 30 cm
O
Table 2: Rapid Shallow Breathing (fx/Vt) and

Compliance, Rate, Oxygenation, and Pressure (CROP)
Indices
fx/Vt CROP
Spontaneous respiratory Dynamic characteristic x NIP x
frequency in 1 min divided by Vt (PaO2/PaO2) ÷ divided by
in liters respiratory rate
fx/Vt less than 105 = weaning
Less than 13 = weaning success
success
fx/Vt greater than 105 =
Greater than 13 = weaning failure
weaning failure
Table 3: Burns Weaning Assessment Program

(BWAP)
Patient
Patient
history
name
number
NOT
ASSESSED
1. Hemodynamically stable (pulse
responses by 26.

Documentation  Individualized goals for weaning
 Procedure used for weaning (e.g., T-piece, decreasing
IMV/SIMV support, pressure support, flow-by positive end-
expiratory pressure, or CPAP)
 Parameters used to assess patient readiness to wean and
weaning trial tolerance such as ABGs, oximetry readings,
BWAP score, negative inspiratory pressure, positive
expiratory pressure, spontaneous Vt, vital capacity, minute
ventilation, dynamic characteristics, static compliance
measurements, airway resistance measurement, breathing
pattern, and accessory muscle use
 Patient response to decrements in MV support
 Mode or method of weaning
 Duration of trial
 Level of support (if appropriate, as in PSV, flow-by, or CPAP)
 Explain the procedures and why weaning is being

Patient Education initiated
 Reassure the patient of the nurses or the
weanintherapist’s presence during initiation of weaning
(especially when tracheostomy collar, T-piece, and
CPAP trials are used)
 Discuss the sensations the patient may experience,
such as smaller lung inflations, dyspnea, and change or
absence of ventilator sounds; describe that weaning
trials are a form of conditioning and do require effort—
some dyspnea is to be expected
 Encourage the patient to relax and breathe comfortably
 Ensure the patient and family that rapid return to
ventilatory support will be accomplished if patient
becomes excessively dyspneic, becomes anxious, or
exhibits untoward physiologic changes (e.g.,
desaturation; blood pressure, heart rate, and rhythm
changes; diaphoresis)

Suctioning: Endotracheal or Tracheostomy Tube - Overview
Endotracheal or tracheostomy tube suctioning is performed to

Overvie maintain the patency of the artificial airway and to improve gas
w: exchange, decrease airway resistance, and reduce infection risk by
removing secretions from the trachea and main stem bronchi.
Suctioning may also be performed to obtain samples of tracheal
secretions for laboratory analysis.
Endotracheal and tracheostomy tubes are used to maintain a patent
airway and to facilitate mechanical ventilation. Presence of these
artificial airways, especially endotracheal tubes, prevents effective
coughing and secretion removal, requiring periodic removal of
pulmonary secretions with suctioning. In acute care situations,
suctioning is always performed as a sterile procedure to prevent
nosocomial pneumonia.
Suctioning is performed by using one of two basic methods. In the
open-suction technique, after disconnection of the endotracheal or
tracheostomy tube from any ventilatory tubing or oxygen sources, a
single-use suction catheter is inserted into the open end of the tube.
In the closed-suction See Figure 1 technique, also referred to as
"in-line suctioning," a multi-use suction catheter inside a sterile
plastic sleeve is inserted through a special diaphragm attached to
the end of the endotracheal or tracheostomy tube. The closed-
suction technique allows for the maintenance of oxygenation and
ventilation support, which may be beneficial when a high level of
inspired oxygen or positive end-expiratory pressure (PEEP) is
required during mechanical ventilation. In addition, the closed-
suction technique decreases the risk for aerosolization of tracheal
secretions during suction-induced coughing. Use of the closed-
suction technique should be considered for patient's who develop
cardiopulmonary instability during suctioning with the open
technique, who have high levels of PEEP (greater than 10 cm H2O)
or inspired oxygen (less than 80%) or both, or who have grossly
bloody pulmonary secretions and for patient's in whom active
tuberculosis is suspected.
Indications for suctioning include the following:
 Secretions in the artificial airway

 Suspected aspiration of gastric or upper airway secretions
 Auscultation of adventitious lung sounds over the trachea or main
stem bronchi or both
 Increase in peak airway pressures when patient is receiving
mechanical ventilation
 Increase in respiratory rate or frequent coughing or both
 Gradual or sudden decrease in arterial blood oxygen (PaO2), arterial
blood oxygen
 saturation (SaO2), or arterial oxygen saturation via pulse oximetry
(SpO2)
 Sudden onset of respiratory distress

 ev when airway patency is questioned
Suctioning of airways should be performed only for a clinical

indication and not as a routine, fixed-schedule treatment.
Hyperoxygenation should always be provided before and after each
pass of the suction catheter into the endotracheal tube, whether
done with the open- or closed- suctioning method.
Suctioning is a necessary procedure for patients with artificial airways.
When clinical indicators of the need for suctioning exist, there is no
absolute contraindication to suctioning. In situations in which the
development of a suctioning complication would be poorly tolerated by the
patient, very strong evidence of a clinical need for suctioning should exist.
Complications associated with suctioning of artificial airways include the

following:
 Respiratory arrest
 Cardiac arrest
 Cardiac dysrhythmias
 Hypertension or hypotension
 Decreases in mixed venous oxygen saturation (SvO2)
 Increased intracranial pressure
 Bronchospasm
 Pulmonary hemorrhage or bleeding
Tracheal mucosal damage (epithelial denudement, hyperemia, loss

of cilia, edema) occurs during suctioning when tissue is pulled into
the catheter tip holes. Areas of tracheal mucosal damage increase
the risk of infection and bleeding. Use of special-tipped catheters,
low levels of suction pressure, or intermittent suction pressure has
not been shown to decrease tracheal mucosal damage with
suctioning.
Postural drainage and percussion may improve secretion
mobilization from small to large airways in diseases in which large
amounts of mucus are produced (e.g., cystic fibrosis, bronchitis).
Adequate systemic hydration and supplemental humidification of
inspired gases assist in thinning secretions for easier aspiration from
airways. Instillation of a bolus of normal saline solution (5 to 10 ml)
does not thin secretions, may cause decreases in arterial and mixed
venous oxygenation, and may contribute to lower airway
contamination caused by mechanical dislodgement of bacteria within
the artificial airway or contamination of saline solution during
instillation.
The suction catheter [See Table 1] should not be any larger than
one half of the internal diameter of the endotracheal or tracheostomy
tube.
Table 1: Guideline for Catheter Size for Endotracheal and

Tracheostomy Tube Suctioning*
Guideline for Catheter Size for Endotracheal and Tracheostomy Tube

Suctioning*
Tracheostomy Tube
Endotracheal Tube Size Suction Catheter
Patient Age
Size (mm) (mm, inner Size (Fr)
diameter)
Small child (2 to 5
4.0 to 5.0 3.5 to 4.5 6 to 8
years)
School-age child (6 to
5.0 to 6.0 4.5 to 5.0 8 to 10
12 years)
Adolescent to adult 7.0 to 9.0 5.0 to 9.0 10 to 16
*This guide should be used as an estimate only. Actual sizes depend on the size and
individual needs of the patient.
Suctioning: Endotracheal or Tracheostomy Tube - Outcomes

 Removal of secretions from the large airways
Expected Outcomes  Improved gas exchange
 Airway patency
 Amelioration of clinical signs or symptoms of need for
suctioning (e.g., adventitious breath sounds, coughing, high
airway pressures)
 Sample obtained for laboratory analysis
 Cardiac dysrhythmias (premature contractions, tachycardias,

Unexpected bradycardias, heart blocks, asystole)
Outcomes  Hypoxemia
 Bronchospasm
 Excessive increases in arterial blood pressure or intracranial
pressure
 Nosocomial infections
 Cardiopulmonary distress
 Decreased level of consciousness
 Airway obstruction
Suctioning: Endotracheal or Tracheostomy Tube - Assessment and

Preparation
 Ensure patient understands preprocedural teaching. Answer

Preparatio questions as they arise, and reinforce information as needed.
n  Assist the patient in achieving a position that is comfortable for the
patient and nurse, generally a semi-Fowler's or Fowler's position.
 Secure additional personnel to assist with hyperoxygenation with
the manual resuscitation bag (MRB) to provide hyperoxygenation
(open-suction technique only).
Open Technique
Supplies
 Suction catheter of appropriate size [See Table 1 in
Extended Text]
 Sterile water-soluble lubricant or sterile saline solution
 Sterile gloves
 Sterile solution container or sterile basin
 Source of suction (wall mounted or portable)
 Connecting tube, 4 to 6 ft
 Self-inflating manual resuscitation bag (MRB) connected to
an oxygen flowmeter, set at 15 L/min (not required if using
the ventilator to deliver hyperoxygenation breaths)
 Goggles or glasses and mask
Additional equipment (to have available depending on patient

need) includes the following:
 Positive end-expiratory pressure (PEEP) valve (for patients

receiving greater than 5 cm H2O PEEP)
Closed Technique
 Closed-suction setup with a catheter of appropriate

size [See Table 1 in Extended Text]
 Sterile saline lavage containers (5 to 10 ml)
 Suction catheter (individually packaged) for oral and nasal
suctioning
 Source of suction (wall mounted or portable)
 Connecting tube, 4 to 6 ft
 Nonsterile gloves
 Goggles or glasses and mask
1. Assess for the following signs and symptoms of airway obstruction:

Assessme a. Secretions in the airway
nt b. Inspiratory wheezes
c. Expiratory crackles
d. Restlessness
e. Ineffective coughing
f. Decreased level of consciousness
g. Decreased breath sounds
h. Tachypnea
i. Tachycardia or bradycardia
j. Cyanosis
k. Hypertension or hypotension
l. Shallow respirations
2. Note peak airway pressures on the ventilator.
3. Evaluate SaO2 by obtaining an arterial blood gas value from the
arterial catheter or arterial puncture and SpO2 levels.
4. Assess for the following signs and symptoms of inadequate
breathing patterns:
a. Dyspnea
b. Shallow respirations
c. Intercostal and suprasternal retractions
d. Frequent triggering of ventilator alarms
e. Increased respiratory rate
Table 1: Guideline for Catheter Size for Endotracheal and

Tracheostomy Tube Suctioning*
Guideline for Catheter Size for Endotracheal and Tracheostomy Tube

Suctioning*
Tracheostomy Tube
Endotracheal Tube Size Suction Catheter
Patient Age
Size (mm) (mm, inner Size (Fr)
diameter)
Small child (2 to 5
4.0 to 5.0 3.5 to 4.5 6 to 8
years)
School-age child (6 to
5.0 to 6.0 4.5 to 5.0 8 to 10
12 years)
Adolescent to adult 7.0 to 9.0 5.0 to 9.0 10 to 16
*This guide should be used as an estimate only. Actual sizes depend on the size and
individual needs of the patient.
Suctioning: Endotracheal or Tracheostomy Tube - Procedure
1. Perform hand hygiene and don personal protective equipment.

2. Turn on suction apparatus and set vacuum regulator to 100 to 120 mm Hg.
Follow manufacturer's directions for suction pressure levels when using
closed-suction catheter systems.
Rationale: The amount of suction applied should be only enough to effectively
remove secretions. High negative-pressure settings may increase tracheal
mucosal damage.
3. Secure one end of the connecting tube to the suction machine, and place the
other end in a convenient location within reach.
Rationale: Prepares suction apparatus.
4. Monitor patient's cardiopulmonary status before, during, and after the

suctioning period.
Rationale: To observe for signs and symptoms of complications: decreased

arterial and mixed venous oxygen saturation, cardiac dysrhythmias,
bronchospasm, respiratory distress, cyanosis, increased blood pressure or
intracranial pressure, anxiety, agitation, or changes in mental status.
Development of cardiopulmonary instability, particularly cardiac dysrhythmias

or arterial desaturation, requires immediate termination of the suctioning
procedure.
5. Prepare to suction.
Closed-Suction Technique Only

Connect the suction tubing to the closed system suction port, according
to manufacturer's guidelines. Proceed to step 6.
Open-Suction Technique Only
Open sterile catheter package on a clean surface, using the inside of
the wrapping as a sterile field.
Rationale: Prepares catheter and prevents transmission of
microorganisms.
Set up the sterile solution container or sterile field. Be careful not to
touch the inside of the container. Fill with approximately 100 ml of sterile
normal saline solution or water.
Rationale: Prepares catheter flush solution.
Don sterile gloves.
Rationale: Maintains sterility and standard precautions.In the event that
one sterile glove and one nonsterile glove are used, apply the
nonsterile glove to the nondominant hand and the sterile glove to the
dominant hand. Handle all nonsterile items with the nondominant hand.
Pick up suction catheter, being careful to avoid touching nonsterile
surfaces. With the nondominant hand, pick up the connecting tubing.
Secure the suction catheter to the connecting tubing.
Rationale: Maintains catheter sterility. Connects the suction catheter
and the connecting tubing.The dominant hand should not come in
contact with the connecting tubing. Wrapping the suction catheter
around the sterile dominant hand will help prevent inadvertent
contamination of the catheter.
Check equipment for proper functioning by suctioning a small amount of
sterile saline solution from the container.
Rationale: Ensures equipment function.
2. Hyperoxygenate the patient for at least 30 seconds by one of the following

three methods.
Rationale: Hyperoxygenation with 100% oxygen is used to prevent a

decrease in arterial oxygen levels during the suctioning procedure.
Limited data indicate that use of a ventilator to deliver the
hyperoxygenation may be more effective in increasing arterial
oxygen levels.
b. Press the suction hyperoxygenation button on the ventilator with the

nondominant hand.
or
c. Increase the baseline fraction of inspired oxygen (FiO2) level on the

mechanical ventilator.
Rationale: When using this method, caution must be used to return the
FiO2 to baseline levels after completion of suctioning.
or
d. Disconnect the ventilator or gas delivery tubing from the end of the
endotracheal or tracheostomy tube, attach the MRB to the tube with the
nondominant hand, and administer 5 to 6 breaths over 30 seconds.
Attach a PEEP valve to the MRB for patients receiving greater than 5
cm H2O PEEP. Verify 100% oxygen delivery capabilities of MRB by
checking manufacturer's guidelines or by direct measurement with an
in-line oxygen analyzer when baseline ventilator oxygen delivery to the
patient is greater than 60%.
Rationale: Some models of MRB entrain room air and deliver less than
100% oxygen.
Use of a second person to deliver hyperoxygenation breaths

with the MRB will significantly increase tidal volume
delivery. One-handed bagging rarely achieves adult tidal
volume breaths (greater than 500 ml).
b. With the suction off, gently but quickly insert the catheter with the dominant
hand into the artificial airway until resistance is met; then pull back 1 cm.
Rationale: Suction should be applied only as needed to remove secretions and

for as short a time as possible to minimize decreases in arterial oxygen levels.
Directional or coudé catheters are available for selective right or left main stem
bronchus placement. Straight catheters usually enter the right main stem
bronchus.
Saline solution should not be routinely instilled into the artificial airway
before suctioning.
c. Place the nondominant thumb over the control vent of the suction catheter and
apply continuous or intermittent suction. Rotate the catheter between the
dominant thumb and forefinger as you withdraw the catheter over 10 seconds
or less into the sterile catheter sleeve (closed-suction technique) or out of the
open airway (open-suction technique).
Rationale: Tracheal damage from suctioning is similar with intermittent or

continuous suction.
Decreases in arterial oxygen levels during suctioning can be kept to a

minimum with brief suction periods.
d. Hyperoxygenate for 30 seconds as described in step 6.
e. One or two more passes of the suction catheter, as delineated in steps 7 and
8, may be performed if secretions remain in the airway and the patient is
tolerating the procedure. Hyperoxygenate for 30 seconds as described in step
6.
Rationale: Arterial oxygen desaturation and cardiopulmonary complications

increase with each successive pass of the suction catheter.
If secretions remain in the airways after two to three suction catheter

passes, allow the patient to rest before additional suctioning passes.
f. If the patient does not tolerate suctioning despite hyperoxygenation, try the
following steps.
Rationale: Use of a different suctioning technique may be physiologically less
demanding.
Ensure that 100% oxygen is being delivered.
Maintain PEEP during suctioning. Check that the PEEP valve is

attached properly to the MRB if using that method for hyperoxygenation.
b. Switch to another method of suctioning (e.g., closed-suctioning

technique).
c. Allow longer recovery intervals between suction passes.
d. Hyperventilation may be used in situations in which the patient does

not tolerate suctioning with hyperoxygenation alone, using either the
MRB or the ventilator.
b. Rinse the catheter and connecting tubing with sterile saline solution until clear.
Rationale: Removes buildup of secretions in the connecting tubing and, when

the closed-suction catheter system is used, in the in-line suction catheter.
c. Once the lower airway has been adequately cleared of secretions, perform
nasal or oral pharyngeal suctioning.
Rationale: A separate suction catheter must be opened for this step when the
closed-suction technique is used.
Prevents contamination of the lower airways with upper airway

organisms, particularly gram-negative bacilli. Care should be taken to
avoid nasal or oropharyngeal tissue trauma and induction of gagging
during suctioning.
d. Open-suction technique only: On completion of upper airway suctioning, wrap

the catheter around the dominant hand. Pull glove off inside out. Catheter will
remain in glove. Pull off other glove in same fashion, and discard. Turn off
suction device.
e. Reposition patient.
f. Perform hand hygiene.
g. Discard remaining normal saline solution and solution container. If basin is

nondisposable, place in soiled utility room. Suction collection tubing and
canisters may remain in use for multiple suctioning episodes.
Rationale: Solutions and catheters, which come in direct contact with the lower
airways during suctioning, must be sterile to decrease the risk for nosocomial
pneumonia. Devices that are not in direct contact have not been shown to
increase infection risk.
Check institutional standards for equipment removal.
h. Document in patient's record.
Suctioning: Endotracheal or Tracheostomy Tube - Post Procedure and

Variations
 Monitor patient's cardiopulmonary status before,

Post Procedure during, and after the suctioning period.
Rationale: To observe for signs and symptoms of

complications.
Decreased arterial or mixed venous oxygen

saturation, cardiac dysrhythmias,
bronchospasm, respiratory distress, cyanosis,
increased blood pressure or intracranial
pressure, anxiety, agitation, or changes in
mental status should be reported if they
persist despite nursing interventions.
 Reassess patient for signs of suctioning

effectiveness.
Diminished breath sounds, decreased

oxygenation, increased peak airway
pressures, coughing, and increased work of
breathing should be reported if they persist

Documentation  Presuctioning assessment, including clinical
indication for suctioning
 Suctioning of endotracheal or tracheostomy tube
 Size of suction catheter
 Type of hyperoxygenation method used
 Number of passes of the suction catheter
 Volume, color, consistency, and odor of secretions
obtained
 Any difficulties during catheter insertion or
hyperoxygenation
 Tolerance of suctioning procedure, including
development of any unexpected outcomes during
or after the procedure
 Postsuctioning assessment
 Explain the procedure for endotracheal or

Patient Education tracheostomy tube suctioning
 Explain that suctioning may be uncomfortable,
causing the patient to experience shortness of
breath
 Explain the patient's role in assisting with
secretion removal by coughing during the
procedure
Endotracheal Intubation: Assisting - Overview

Endotracheal intubation can be done via a nasal or an oral
Overview: route. The skill of the practitioner performing the intubation
and the patient's clinical condition determine the route used.
Nasal intubation is relatively contraindicated in trauma
patients with facial fractures or suspected fractures at the
base of the skull and postoperatively after cranial surgeries
such as transnasal hypophysectomy.
Indications for endotracheal intubation include the following:
 Upper airway obstruction (e.g., secondary to swelling,

trauma, tumor, bleeding)
 Apnea
 Ineffective clearance of secretions (i.e., inability to maintain
airway adequately)
 High risk for aspiration
 Respiratory distress
Applying cricoid pressure (Sellick maneuver) may decrease

the incidence of pulmonary aspiration and gastric distention.
This procedure is accomplished by applying firm, downward
pressure on the cricoid ring, pushing the vocal cords
downward so that they can be visualized more easily. Once
begun, cricoid pressure must be maintained until intubation is
complete See Figure 1.
Two types of laryngoscope blades exist: straight and curved.
The straight (Miller) blade is designed so that the tip extends
below the epiglottis, lifting and exposing the glottic opening. It
is recommended for use in obese patients, pediatric patients,
and patient's with short necks because their tracheas may be
located more anteriorly. When a curved (MacIntosh) blade is
used, the tip is advanced into the vallecula (the space
between the epiglottis and the base of the tongue), exposing
the glottic opening.
Endotracheal tube size reflects the size of the internal
diameter of the tube. Tubes range in size from 2.5 mm for
neonates to 9 mm for large adults. Endotracheal tubes
ranging in size from 7 to 8 mm are used for average-sized
women, whereas endotracheal tubes ranging in size from 8 to
9 mm are used for average-sized men See Figure 2. The tube
with the largest clinically acceptable internal diameter should
be used so as to minimize airway resistance and assist in
suctioning.
Primary and secondary confirmation of endotracheal
intubation should be performed. Primary confirmation of
proper endotracheal tube placement includes visualization of
the tube passing through the vocal cords, the absence of
gurgling over the epigastric area, auscultation of bilateral
breath sounds, bilateral chest rise and fall during ventilation,
and mist in the tube. Secondary confirmation of proper
endotracheal tube placement is necessary to protect against
unrecognized esophageal intubation. Methods include use of
disposable end-tidal carbon dioxide (CO2) detectors,
continuous end-tidal CO2 monitors, and esophageal detection
devices. End-tidal CO2 monitoring devices have been shown
to be reliable indicators of expired CO2 in patient's with
perfusing rhythms. During cardiac arrest (nonperfusing
rhythms), there may not be sufficient expired CO2 due to low
pulmonary blood flow. If CO2 is detected using an end-tidal
CO2 detector, it is a reliable indicator of proper tube
placement. If CO2 is not detected, the use of an esophageal
detector device is recommended.
Disposable end-tidal CO2 detectors are chemically treated
with a nontoxic indicator that changes color in the presence of
CO2, indicating that the endotracheal tube has been placed
successfully into the trachea. Continuous end-tidal
CO2 monitors may be used to confirm proper endotracheal
tube placement after intubation attempts; they allow for the
detection of possible future dislodgment of the tube.
Esophageal detector devices work by creating suction at the
end of the endotracheal tube when a flexible bulb is
compressed or a syringe plunger is pulled back. When the
tube is placed correctly in the trachea, air allows for
reexpansion of the bulb or movement of the syringe plunger.
If the tube is located in the esophagus, no movement of the
syringe plunger or reexpansion of the bulb is seen. These
devices may be misleading in patient's who are morbidly
obese, in patient's in status asthmaticus, in patient's in late
pregnancy, and in patient's with large amounts of tracheal
secretions.
The endotracheal tube also provides a route for the
administration of emergency medication (e.g., lidocaine,
epinephrine, atropine, and naloxone).
Endotracheal Intubation: Assisting - Outcomes

 Placement of patent artificial airway
Expected Outcomes  Properly positioned and secured airway
 Improved oxygenation and ventilation
 Facilitation of secretion clearance
 Intubation of esophagus or right main stem bronchus

Unexpected (improper tube placement)
Outcomes  Accidental extubation
 Cardiac dysrhythmias because of hypoxemia and
vagal stimulation
 Broken or dislodged teeth
 Leaking of air from endotracheal tube cuff
 Tracheal injury at tip of tube or at cuff site
 Laryngeal edema
 Vocal cord trauma
 Suctioning of gastric contents or food from
endotracheal tube (aspiration)
 Obstruction of endotracheal tube
Endotracheal Intubation: Assisting - Assessment and Preparation
 Ensure that the patient understands preprocedural

Preparation teaching. Answer questions as they arise, and reinforce
information as needed.
 Before intubation, initiate intravenous access.
 Position the patient appropriately.
a. Positioning of the nontrauma patient is as follows:

Place patient supine with head in sniffing
position, in which the head is extended and the
neck is flexed. Placement of a small towel under
the occiput elevates it several inches, allowing for
proper flexion of the neck See Figure 3.
b. Positioning of the trauma patient is as follows: In-
line cervical spinal immobilization must be
maintained during the entire process of
intubation.
 Premedicate as indicated.
 As appropriate, notify the respiratory therapy department
of impending intubation.
 Personal protective equipment, including eye protection

Supplies  Endotracheal tube with intact cuff and 15-mm connector
(women, 7- to 8-mm tube; men, 8- to 9-mm tube)
 Laryngoscope handle with fresh batteries
 Laryngoscope blades (straight and curved)
 Spare bulb for laryngoscope blades
 Flexible stylet
 Self-inflating resuscitation bag with mask connected to
supplemental oxygen (greater than or equal to15 L/min)
 Oxygen source and connecting tubes
 Swivel adapter (for attachment to resuscitation bag or
ventilator)
 Luer-tip 10-ml syringe for cuff inflation
 Water-soluble lubricant
 Rigid pharyngeal suction-tip (Yankauer) catheter
 Suction apparatus (portable or wall)
 Suction catheters
 Bite-block or oropharyngeal airway
 Endotracheal tube-securing apparatus or appropriate
tape
o Commercially available endotracheal tube holder

o Adhesive tape (6 to 8 inches long)
o Twill tape (cut into 30-inch lengths)
 Stethoscope
 Monitoring equipment: continuous oxygen saturation and
cardiac rhythm
 Secondary confirmation device: disposable end-tidal
CO2 detector, continuous end-tidal CO2 monitoring
device, or esophageal detection device
 Drugs for intubation as indicated (sedation, paralyzing
agents, lidocaine, atropine)
Additional equipment (to have available depending on

patient need or practitioner preference) includes the
following:
 Anesthetic spray (nasal approach)

 Local anesthetic jelly (nasal approach)
 Magill forceps (to remove foreign bodies obstructing the
airway)
 Ventilator
 Assess immediate history of trauma when spinal cord

Assessment injury is suspected and after cranial surgery.
 Assess nothing-by-mouth (NPO) status and signs of
gastric distention.
 Assess level of consciousness, level of anxiety, and
respiratory difficulty.
 Assess vital signs and for the following:
a. Tachypnea
b. Dyspnea
c. Shallow respirations
d. Cyanosis
e. Apnea
f. Altered level of consciousness
g. Tachycardia
h. Cardiac dysrhythmias.
 Assess patency of nares (for nasal intubation).

 Assess need for premedication for sedation or paralysis
of the patient.
Endotracheal Intubation:
Assisting - Procedure
1. Wash hands, and
don personal
protective
equipment.
Rationale:
Reduces
transmission of
microorganisms
and body
secretions;
standard
precautions.
Protective
eyewear should be
worn to avoid
exposure to
secretions.
2. Insert
oropharyngeal
airway. Connect
patient to pulse
oximeter and
cardiac monitor.
Rationale: Assists
in maintaining
upper airway
patency.
Used only in
unconscious
patients.
3. Set up suction
apparatus and
connect rigid
suction-tip catheter
to tubing.
Rationale:
Prepares for
oropharyngeal
suctioning as
needed.
4. Assist in positioning
the patient's head
by flexing the neck
forward and
extending the head
(sniffing
position) See Figure
3 .
Rationale: Allows
for visualization of
the vocal cords by
aligning the axes
of the mouth,
pharynx, and
trachea.
Placement of a
small towel
under the occiput
elevates it,
allowing for
proper neck
flexion. Do not
flex or extend the
neck of a patient
with suspected
spinal cord
injury; the head
must be
maintained in a
neutral position
with in-line
cervical spine
immobilization.
5. Check the mouth for

dentures, and
remove if present.
Suction the
mouth as needed.
Rationale:
Dentures should
be removed before
oral intubation is
attempted but may
remain in place for
nasal intubation.
6. Preoxygenate using
a self-inflating bag-
valve-mask
device attached to
100% oxygen for 3
to 5 minutes.
Provide frequent
and gentle breaths.
Rationale: Helps
prevent
hypoxemia. Gentle
breaths reduce the
incidence of air
entering stomach
(leading to gastric
distention),
decrease airway
turbulence, and
more evenly
distribute
ventilation within
the lungs.
7. Premedicate patient
as indicated.
8. Apply cricoid
pressure as
requested.
Rationale: Gentle
cricoid
pressure See
Figure 1 may
assist in
visualization of
vocal cords and
decrease the risk
of gastric
distention and
subsequent
pulmonary
aspiration. Once
cricoid pressure is
begun, it must be
continued until the
tube is correctly
placed.
9. Have manual
resuscitation bag
connected to 100%
oxygen source and
face mask ready for
hyperoxygenation
and manual
ventilation.
Rationale:
Intubation
attempts should
not take longer
than 30 seconds.
Patients will have
to be
hyperoxygenated
and ventilated
between intubation
attempts.
10. Once the

endotracheal tube
has been placed,
confirm tube
placement while
bagging with 100%
oxygen.
Rationale:
Confirms
placement of the
endotracheal tube.
a. Attach
disposable
CO2 detector
(if available).
Watch for
color change
indicating
the presence
of CO2.
Rationale:
Disposable
CO2 detecto
rs may be
used to
assist in the
identificatio
n of proper
tube
placement.2
CO2 detect
ors are
usually
placed
between
the self-
inflating
bag and
the
endotrache
al tube.
CO2 detect
ors should
be used in
conjunctio
n with
physical
assessmen
t findings.
b. Auscultate
over
epigastrium.
Rationale:
Allows for
identificatio
n of
esophageal
intubation.
If air
movement
or gurgling
is heard,
esophagea
l intubation
has
occurred;
the tube
must be
pulled and
intubation
reattempte
d.
Improper
insertion
may result
in
hypoxemia
, gastric
distention,
vomiting,
and
aspiration.
c. Auscultate
lung bases
and apices
for bilateral
breath
sounds.
Rationale:
Assists in
verification
of correct
tube
placement
into the
trachea. A
right main-
stem
bronchus
intubation
results in
diminished
left-sided
breath
sounds.
Equal
breath
sounds
indicate
proper
placement
of the
endotrache
al tube.
d. Observe for
symmetrical
chest wall
movement.
Rationale:
Assists in
verification
of correct
tube
placement.
Absence
may
indicate
right main-
stem or
esophagea
l
intubation.
e. Evaluate
oxygen
saturation
(SpO2) by
noninvasive
pulse
oximetry.
Rationale:
SpO2 decre
ases if the
esophagus
has been
inadvertentl
y intubated.
It may or
may not
change in a
right main-
stem
bronchus
intubation.
SpO2 findin
gs should
be used in
conjunctio
n with
physical
assessmen
t findings.
11. If CO2 detection,
assessment
findings, or
SpO2 level reveals
that the tube has not
been correctly
positioned, deflate
cuff and remove
tube immediately.
Hyperoxygenate
with 100% oxygen
for 3 to 5 minutes
and reattempt
intubation,
beginning with step
1.
Rationale:
Esophageal
intubation results
in gas flow
diversion and
hypoxemia.
12. If breath sounds are

absent on the left,
the cuff should be
deflated and the
tube pulled 1 to 2
cm. Reevaluate for
correct tube
placement, as
shown in step 10.
Rationale:
Absence of breath
sounds on the left
may indicate right
main-stem
intubation, which
is common as a
result of the
anatomic position
of the right main
stem bronchi.
When correctly
positioned, the
tube tip should be
halfway between
the vocal cords
and the carina.
13. Connect
endotracheal tube to
oxygen source or
mechanical
ventilator, using
swivel adapter.
Rationale:
Reduces motion
on tube and mouth
or nares.
14. Insert a bite-block or

oropharyngeal
airway (to act as a
bite block) along the
endotracheal tube.
Rationale:
Prevents the
patient from biting
down on the
endotracheal tube.
The bite-block
should be
secured
separately from
the tube to
prevent
dislodgment of
the tube.
15. Secure the

endotracheal tube in
place (according to
institutional
standard).
Rationale: To
prevent
inadvertent
dislodgment of
tube.
Various methods
are used for
securing
endotracheal
tubes, including
the use of
specially
manufactured
tube holders,
twill tape, or
adhesive tape.
Use of Adhesive Tape
a. Prepare
tape See
Figure 4.
Rationale:
Use of a
hydrocolloid
membrane
(e.g.,
DuoDerm)
on the
patients
cheeks will
help protect
the skin.
b. Secure tube
by wrapping
double-sided
tape around
patients
head and
torn tape
edges
around
endotracheal
tube.
17. Reconfirm tube
placement, as
shown in step 10.
Rationale: Verifies
that the tube was
not inadvertently
repositioned
during the
securing of the
tube.
17. Note position of

tube at teeth (use
centimeter markings
on tube).
Rationale:
Common tube
placement at the
teeth is 21 cm for
women and 23 cm
for men.
18. Hyperoxygenate
and suction
endotracheal tube
and pharynx as
needed.
Rationale:
Remove
secretions that
may obstruct tube
or accumulate on
top of cuff.
19. Confirmation of
correct tube position
should be verified
by a chest x-ray.
Rationale: Chest
x-ray documents
actual tube
location (distance
from the carina).
Because chest x-
ray is not
immediately
available, it should
not be used as the
primary method of
tube assessment.
Endotracheal
tubes placed
bronchoscopicall
y may not require
chest x-ray
verification
(check
institutional
standard).
20. Document in
patient's record.
Post Procedure 1. Auscultate breath sounds on insertion and every 2 to 4 hours.
Rationale: Allows for detection of tube movement or

dislodgment.
Absent, decreased, or unequal breath sounds should
be reported if they persist despite nursing
interventions.
2. Maintain tube stability using specially manufactured holder, twill

tape, or adhesive tape.
Rationale: Prevents movement and dislodgment of tube.

Unplanned extubation or tube movement from
original position should be reported if it persists
3. Monitor and record position of tube at teeth or nose (in

reference to centimeter markings on tube).
Rationale: Provides for identification of tube migration.

Tube movement from original position should be
reported if it persists despite nursing interventions.
4. Maintain tube cuff pressure at 20 to 25 mm Hg.
Rationale: Provides adequate inflation to decrease

aspiration risk and prevents overinflation of cuff to avoid
tracheal damage.
A cuff pressure of 20 mm Hg or less and a cuff
pressure of 25 mm Hg or more should be reported if
they persist despite nursing interventions.
5. Hyperoxygenate and suction endotracheal tube, as needed.
Rationale: Prevents obstruction of tube and resulting

hypoxemia.
Inability to pass a suction catheter; copious, frothy,
or bloody secretions; and significant change in
amount or character of secretions should be reported
if they persist despite nursing interventions.
6. Inspect nares or oral cavity once per shift while patient is

intubated.
Rationale: Will allow for the detection of skin breakdown

and necrosis.
Redness, necrosis, and skin breakdown should be

Documentation  Vital signs before, during, and after intubation, including
oxygen saturation
 Confirmation of tube placement including chest radiograph
(how placement was confirmed)
 Type of intubationoral– oral or nasal
 Number of intubation attempts
 Use of any medications
 Size of endotracheal tube
 Depth of endotracheal tube insertion– centimeters at teeth or
nose
 Measurement of cuff pressure
 Assessment of breath sounds
 Confirmation of tube placement, including chest radiograph
(how placement was confirmed)
 Occurrence of unexpected outcomes
 Secretions
 Patient response to procedure
 Assess level of understanding about condition and rationale for

Patient Education endotracheal intubation.
 Explain the procedure and the reason for intubation.
 If indicated, explain the patient's role in assisting with insertion
of endotracheal tube.
 Explain that patient will be unable to speak while the
endotracheal tube is in place, but that other means of
communication will be provided.
 Explain that the patient's hands often are immobilized to
prevent accidental dislodgment of the tube.
Endotracheal Tube Care - Overview
Endotracheal tubes (ETs) are used as short-term artificial

Overview: airways to administer mechanical ventilation, relieve upper
airway obstruction, protect against aspiration, and clear
secretions. Routine care is needed to maintain correct position
of the tube and to maintain good hygiene.
After insertion of an ET tube, the cuff is inflated. Preventing
cuff-related problems is a critical component of nursing care
and depends on securing the tube and inflating the cuff
properly. In many institutions, these functions are shared by
nursing and respiratory therapy staff. An inadequately secured
ET tube moves up and down the tracheobronchial tree.
Allowing an ET tube to slip too far down into the lungs can
prevent ventilation of a lung, usually the left lung (and
sometimes the right upper lobe also) because of anatomic
differences. Allowing an ET tube to slide too far up the
tracheobronchial tree can allow air to escape through or
damage the vocal cords and epiglottis or permit aspiration of
upper airway secretions. Properly securing the ET tube
prevents incidental extubation due to coughing or pulling on
the tube. In addition, movement of an ET tube can cause
development of granulation tissue on the vocal cords,
epiglottis, or trachea. Additional risks of movement of an
artificial airway are tracheal stenosis, tracheomalacia, erosion
of the innominate artery, and tracheoesophageal fistula,
particularly when the cuff is overinflated. Risks for each of
these complications can be reduced with proper nursing care.
After the tube is inserted and secured and the cuff is inflated,
the chief concern of the nurse is to maintain the patency of the
ET tube. In patients who cannot clear the airway of secretions,
patency is achieved primarily through periodic suctioning of the
artificial airway.
Endotracheal Tube Care - Outcomes
Expected Outcomes
 ET tube is maintained in correct position in patient's trachea.

 Patient's skin around mouth and oral mucous membranes does not have pressure areas or
other injury from biting: tube is repositioned on opposite side of mouth or center of
mouth at least every 24 to 48 hours, according to institution protocol (oral ET tube only).
Oral airway, if used, is cleaned and reinserted to prevent biting of tongue or inner cheeks.
 ET tube is resecured at proper depth as evidenced by the following: clean tape is firmly
secured to cheeks, upper lip, or top of nose and tube only; depth of tube is same as when
started or as ordered (same centimeter marking at gums or lips); bilateral breath sounds
are equal.
Unexpected Outcomes
 Unexpected extubation
 Movement of ET tube
 Unequal breath sounds
 Pressure areas from tube
 Air escaping around tube
Endotracheal Tube Care - Assessment and Preparation
 Obtain assistance in this procedure.

Preparation  Explain procedure and patient's participation, including importance of the
following: not biting or moving ET tube with tongue; trying not to cough
when tape is off ET tube; keeping hands down and not pulling on tubing;
and noting that removal of tape from face can be uncomfortable.
 Assist patient in assuming position comfortable for both nurse and patient
(usually supine or semi-Fowler).
 Place towel across chest.
 Towel
Supplies  Endotracheal (ET) and oropharyngeal suction equipment
 1- or 1½ -inch wide adhesive or waterproof tape (do not use paper or silk
tape) or commercial ET tube holder and mouthguard (follow
manufacturer's instructions for securing)
 Nonsterile gloves (two pairs)
 Adhesive remover swab or acetone on cotton ball
 Mouthwash-soaked, clean 4 x 4 inch gauze secured on tongue blade or
sponge-tipped applicators
 Toothbrush, toothpaste (optional), and shaving supplies
 One wet and one soapy washcloth or paper towels
 Clean 2- x 2-inch gauze
 Tincture of benzoin, liquid adhesive, or skin prep pads
 Tongue blade (optional)
 Face shield, if indicated
 Observe for signs and symptoms of need to perform ET tube care: soiled
Assessment or loose tape; pressure sore on naris, lips, or corner of mouth; excess
nasal or oral secretions; patient moving tube with tongue, biting tube or
tongue; tube repositioned by physician or other specially trained
personnel; and foul-smelling mouth.
 Observe for factors that increase risk of complications resulting from ET
tube: type and size of tube, movement of tube up and down trachea (in
and out), duration of tube placement, cuff overinflation or underinflation,
presence of facial trauma, malnutrition, and neck or thoracic radiation.
 Determine proper ET tube depth as noted as centimeters to lip or gum
line. This line is marked on the tube and recorded in the patient's record
at time of intubation.
 Assess patient's knowledge of procedure.
Endotracheal Tube Care - Procedure
1. Perform hand hygiene. Apply face shield if indicated.
2. Administer endotracheal, nasopharyngeal, and oropharyngeal suction.
Rationale: Removes secretions. Diminishes patient's need to

cough during procedure.
3. Connect oral suction catheter to suction source.
Rationale: Prepares patient for oropharyngeal suctioning.
4. Prepare method of securing ET tube.
a. Tape method. Cut a piece of tape long enough to go completely

around patient's head from naris to naris plus 6 inches: adult, 30
to 60 cm (1 to 2 feet). Lay tape adhesive side up on bedside
table. Cut and lay 8 to 15 cm (3 to 6 inches) of tape, adhesive
sides together, in center of long strip to prevent tape from
sticking to hair. The smaller strip of tape should cover the area
between ears around back of head.
Rationale: Preparing tape ahead of time allows nurse to

have one hand positioned on ET tube throughout
procedure. Adhesive tape must encircle head below the
ears with sufficient tape left to wrap around tube.
b. Commercially available ET tube holder. Open package per

manufacturer's instructions. Set device aside with head guard in
place and Velcro strips open.
position.
2. On one side of face, secure tape from ear to naris (nasal

ET tube) or over lip to ET tube (oral ET tube). Tear
remaining tape in half lengthwise, forming two pieces that
are ½- to ¾-inch wide. Secure bottom half of tape across
upper lip See Figure 1 (oral ET tube) or across top of
nose (nasal ET tube) to opposite ear. Wrap top half of
tape around tube and up from bottom. See Figure 2. Tape
should encircle tube at least two times for security.
Rationale: Secures tape to face. Using top tape to

wrap prevents downward drag on ET tube.
3. Gently pull other side of tape firmly to pick up slack;

secure it to opposite side of face and ET tube See Figure
3 in the same way as the first piece. Note: ET tube is
secured. Assistant can release hold. (Nurse may want
assistant to help reinsert oral airway.)
Rationale: Secures tape to face and tube. ET tube

should be at same depth at lips or gum line. Check
earlier assessment for verification of tube depth in
centimeters.
b. Commercially available device
1. Thread ET tube through opening designed to secure ET

tube. Be sure that pilot balloon is accessible See Figure
4.
Rationale: Commercially available holders have a slit

in front of holder designed to secure ET tube.
2. Place strips of ET holder under patient at occipital region

of head.
3. Verify that ET tube is at established depth using lip or
gum line marker as a guide.
Rationale: Ensures ET tube remains at correct

depth, as determined during assessment.
4. Attach Velcro strips at base of patient's head. Leave 1 cm

(½ inch) slack in strips.
5. Verify that tube is secure, that it does not move forward
from patient's mouth or backward down into patient's
throat, and that there are no pressure areas on the oral
mucosa or occipital region of head.
Rationale: Tube must be secure so that position of

tube remains at correct depth. Tube can be secured
without being tight and causing pressure.
15. If not already done, remove and clean oral airway in warm soapy water
and rinse well. Hydrogen peroxide can aid in removal of crusted
secretions. A mouthwash rinse will freshen patient's mouth. Shake
excess water from oral airway.
Rationale: Promotes hygiene. Reduces transmission of

microorganisms.
16. Reinsert oral airway without pushing tongue into oropharynx. Secure
with tape.
Rationale: Prevents patient from biting ET tube and allows access

for oropharyngeal suctioning.
17. Discard soiled items in appropriate receptacle. Remove towel and place
in laundry.
18. Reposition patient.
Rationale: Promotes comfort.
19. Remove gloves and face shield, discard in receptacle, and perform hand
hygiene. Assistant is also to remove gloves and perform hand hygiene
before leaving patient's room. Place clean items (e.g., tincture of
benzoin, mouthwash, excess swabs) in storage.

Contaminated gloves and hands should not touch clean items.
Endotracheal Tube Care - Post Procedure and
Variations
1. Compare
Post Procedure respiratory
assessments
before and
after ET tube
care.
Rationale:
Identifies
any changes
in presence
and quality
of breath
sounds after
procedure.
2. Observe
depth and
position of ET
tube
according to
physician's
recommendat
ion.
Rationale:
Position of
ET tube
should not
be altered.
3. Assess
security of
tape by gently
tugging at
tube.
Rationale:
Tape should
remain
attached to
face. Patient
may cough.
4. Assess skin
around mouth
and oral
mucous
membranes
for intactness
and pressure
areas.
Rationale:
Tape should
not tear skin.
Pressure
areas should
be absent.
 Record
Documentation assessments
before and
after care,
supplies
used,
patient's
tolerance of
procedure,
appropriate
depth of ET
tube,
frequency of
ET tube care,
integrity of
oral mucosa,
pressure sore
care as
needed, and
designated
intervals.
 Instruct the
Patient Education patient and
family not to
manipulate
the ET tube,
tape, or ET
tube holder. If
the patient is
complaining
or appears
uncomfortabl
e, instruct
family to ask
for the nurse.
 Instruct the
patient and
family to tell
the nurse if
the tube
causes
gagging so
that
interventions
will be taken
to reduce
gagging. This
may include
repositioning
of the tube
and/or
sedation.
Age-Specific Considerations Pediatrics
 Neonatal and
pediatric
procedures
for securing
ET tubes and
suctioning
airways may
vary.
 Infant skin
may be more
prone to
tearing when
tape is
removed.
 Because of
infants'
delicate skin,
skin prep may
not be used
before
securing ET
tube. ET tube
holders are
best used in
this
population.
Geriatrics
 Older adult
skin may be
more prone to
tearing when
tape is
removed.
 Older adults
with tendency
toward
inadequate
nutrition may
be more
prone to
complications
(e.g.,
infection,
breakdown of
oral mucosa).
Endotracheal or Tracheostomy Tube Cuff Inflation

- Overview
The goals of correctly inflating the cuff of an

Overvie artificial airway are to promote lung inflation
w: for mechanical ventilation, to prevent
aspiration of gastric contents [See Box 1],
and at the same time to allow drainage of
secretions that accumulate between the
epiglottis and the cuff. The amount of air
inserted in the cuff is based on several
factors; the two most important factors are
the size of the patient's trachea and the
external diameter of the artificial airway. If
two patients of approximately the same size
are intubated—one with a size 6 and one
with a size 8—the patient with the larger
tube (size 8) requires less air in the cuff.
This is because the larger tube occludes
more of the airway than the smaller tube
does.
There is no recommendation for a preferred
method of cuff inflation. The minimal leak
technique and the minimal occlusive
technique are both acceptable methods of
cuff inflation [See Table 1].
Box 1: Indications for Cuff Inflation
Mechanical Ventilation
 Continuous airway pressure

 Positive end-expiratory pressure (PEEP)
 Inability to meet ventilatory requirements with cuff down
 Inability to meet oxygen requirements with cuff down
Risk for Aspirating Gastric Contents
 Feeding tube, especially large bore, in stomach

 Gastroesophageal reflux disease
 Hiatal hernia
 During and after meals
 Impaired gastric emptying
 Decreased gag reflex
 Impaired swallowing
Table 1: Endotracheal and Tracheostomy Cuff

Inflation Methods
Inflation Method Procedure

Minimal occlusive technique 1. Inject air into the cuff
until no airflow is
auscultated over the
trachea during the peak
inflation pressure of a
positive pressure breath.
2. Record the cuff volume.
Minimal leak technique 1. Inject air into the cuff

until the air leak around
the cuff is eliminated.
2. Remove a small amount
of air from the cuff until a
slight leak occurs (50 to
100 ml tidal volume
decrease) at peak
inflation pressure during
a positive pressure
breath.

- Outcomes
 Mechanically ventilated patient

Expected receives prescribed tidal volume.
Outcomes  Minimal leak is auscultated at end
inspiration.
 No evidence of excessive
phonation, aspiration of gastric or
mouth contents, tracheoesophageal
fistula, or tracheomalacia is found.
 Cuff pressure is excessive.

Unexpected  Excessive volume is required to
Outcomes inflate cuff.
 Excessive air leak is heard.
 Cuff requires increased amounts of
air to maintain minimal leak.


- Assessment and Preparation
 Explain procedure and how patient can

Preparatio participate. Explain that some
n coughing during procedure is normal.
 Assist patient into position comfortable
for nurse and patient (usually semi-
Fowler).
 Endotracheal/tracheostomy suction
Supplies apparatus
 Stethoscope
 5- or 10-ml syringe
 Alcohol wipe
 Face shield, if indicated
 Gloves, if indicated
 Observe for signs and symptoms of

Assessme need to perform care, including
nt gurgling on expiration, decreased
exhaled tidal volume (mechanically
ventilated patient), spasmodic
coughing, tense test balloon on tube,
flaccid test balloon on tube, and
unexpected phonation.
 If patient is discharged with a cuffed
tracheostomy tube, determine
caregiver's understanding of
procedure.
Endotracheal or Tracheostomy Tube Cuff

Inflation - Procedure
1. Perform hand hygiene and apply
gloves and face shield, if indicated.
Rationale: Reduces transmission

of microorganisms.
2. Suction secretions through

endotracheal (ET) or tracheostomy
tube and also mouth.
Rationale: Ensures patent airway

and facilitates hearing airflow with
stethoscope. Prevents aspiration
of oral secretions when cuff is
deflated.
3. Connect syringe to pilot balloon.
Rationale: Allows immediate

access to equipment for adjusting
cuff pressure.
4. Place stethoscope in sternal notch or

above tracheostomy tube. Listen for
minimal amount of air leak at end of
inspiration See Figure 1.
Rationale: Assesses proper cuff

inflation.
5. If no air leak is heard, remove all air

from cuff.
Rationale: Releases excessive

cuff pressure, which reduces
capillary blood flow and increases
risk for tissue necrosis.
6. Inflate cuff according to institutional

policy [See Table 1].
Rationale: Inflates cuff to minimal

leak. If air leak is audible by ear,
air leak is too large. If no air leak
is heard, cuff is overinflated.
7. If excessive air leak is heard, slowly

add air as in step 6.
Rationale: Air leak may prevent

adequate lung expansion and
increase risk for aspiration.
8. Remove stethoscope and wipe

diaphragm with alcohol wipe.

of microorganisms.
9. Remove syringe and discard into

appropriate receptacle or store per
policy. Do not leave attached to pilot
balloon valve.

of microorganisms.
Leaving syringe in pilot balloon
can cause valve to break or
"stick open." When syringe is
removed, air is lost from cuff.
10. Reposition patient.
Rationale: Promotes comfort.
11. Remove gloves and face shield.

Discard into appropriate receptacle.
Perform hand hygiene.

of microorganisms.
Table 1: Endotracheal and Tracheostomy Cuff Inflation

Methods
Inflation Method Procedure

Minimal occlusive 1. Inject air into the cuff until no airflow is
technique auscultated over the trachea during the
peak inflation pressure of a positive
pressure breath.
Minimal leak 1. Inject air into the cuff until the air leak
technique around the cuff is eliminated.
2. Remove a small amount of air from the
cuff until a slight leak occurs (50 to 100
ml tidal volume decrease) at peak
inflation pressure during a positive
pressure breath.

- Post Procedure and Variations
1. Compare respiratory assessments

Post before and after cuff care.
Procedure
Rationale: Determines
effectiveness of cuff care
procedure.
2. Observe exhaled tidal volume from

mechanical ventilator.
Rationale: Exhaled tidal volume

should be no less than 50 ml of
delivered tidal volume.
3. Auscultate for audible air leak.
Rationale: Air leak should be

heard only with stethoscope.
4. Observe for excessive phonation,

presence of gastric secretions in
airway secretions, or
tracheoesophageal fistula.
Rationale: Occurs with

inadequate or excessive cuff
inflation.
 Record presence of minimal leak at

Documentati end inspiration, volume of air
on injected into cuff, secretions
obtained when suctioning, and
frequency of cuff care. Documents
safe cuff pressure levels.
Consideratio
ns  Pediatric tracheostomy tubes do
not have cuffs.
 Neonatal and many pediatric ET
tubes do not contain cuffs.
Maintaining a Double Cannula Tracheostomy

Tube - Overview of the Skill

Overview: A tracheotomy is an incision made

into the trachea with insertion of a
cannula for airway management.
Tracheostomy is the creation of an
opening into the trachea through
the neck. The two terms can be
used interchangeably. The term
tracheostomy will be used in this
skill. A tracheostomy is performed
for the client with potential or
present airway obstruction, for
ventilatory assistance, to provide
pulmonary hygiene, to decrease the
anatomic dead space in the client
with chronic obstructive pulmonary
disease, to avoid prolonged
endotracheal intubation, and to
provide an airway for clients with
severe obstructive sleep apnea
syndrome. A tracheostomy is
usually performed between the
second, third, and fourth tracheal
rings. The tracheostomy tube can
have a single or double cannula.
The determination of the tube
design used is based on the needs
of the client. Many of the longer
tracheostomy tubes are single
cannula because of the curvature of
the tube. The double cannula tube
allows for the tube to be cleaned to
prevent obstruction caused by dried
secretions.

Assessme 1. Assess respirations for rate,

nt: rhythm, and depth to evaluate
the airway.
2. Assess the client's lung
sounds to determine the need
for suctioning.
3. Assess the client's arterial
blood gases and/or pulse
oximetry values to evaluate air
exchange and blood oxygen
levels.
4. Assess the movement of air
through the tracheostomy
tube to evaluate the air
exchange through the tube
and determine whether there
is any obstruction.
5. Assess the amount and color of
tracheal secretions to evaluate
for bleeding, infection, and
the need for suctioning.
6. Assess the client's level of
consciousness. Anxiety and
restlessness could be
symptoms of hypoxia.
7. Assess the client's
understanding of the
procedure to determine client
education and support
needed.

Diagnosis:  Ineffective Airway Clearance

 Risk for Infection
 Risk for Suffocation
 Impaired Skin Integrity
 Impaired Verbal
Communication
 Deficient Knowledge, related to
maintaining the double cannula
tracheostomy
 Anxiety

Planning


Needs:

Cleaning the Inner Cannula
(see Figure 7-20-1)

 Sterile gloves
 Disposable inner cannula (if
available)
 Tracheostomy care kit: 2
basins, tracheostomy brush,
tracheostomy ties
 Hydrogen peroxide
 Sterile water or sterile saline

Expected 1. The client's airway will be free

Outcomes: of obstruction.
2. The procedure will be
performed with a minimum of
client anxiety.
3. The client's skin will remain
intact and free of redness and
excoriation.
4. The client will remain free of
signs and symptoms of
infection.

Client 1. Explain to the client that

Education cleaning the inner cannula will
Needed: promote breathing.
2. Inform the client that the
procedure may cause
coughing.
3. After performing the procedure
and explaining each step to the
client, the nurse should
supervise the client in self-care.
Make a list of the steps the
client should follow when
performing the procedure.
4. Allow the client to observe the
procedure in a mirror. The
mirror should be placed at a
comfortable level and in a
setting similar to that used by
the client once discharged from
the hospital.
5. Suggest alternative types of
equipment. For example, if
tracheostomy brushes cannot
be purchased once the client is
discharged from the hospital, a
small percolator brush, gauze,
or pipe cleaners can be used to
remove crusted secretions.

Maintaining a Double Cannula Tracheostomy Tube -

Implementation—Action/Rationale

Implementation
Action/Rational
e ACTION RATIONALE
1. Wash hands. 1. Reduces the

transmission of
microorganisms
.
Conventional/Reusable Inner Cannula
2. Open 2. Provides sterile

tracheostomy equipment for
care set. use in the
procedure.
3. Place hydrogen 3. Prepare

peroxide solution solutions prior
in one basin and to applying
sterile water or gloves.
saline in a
second basin.
4. Apply sterile 4. Uses aseptic

gloves. technique.
5. Remove inner 5. To clean

cannula. tracheostomy
double cannula
tube.
6. Place inner 6. Loosens

cannula in basin secretions.
of hydrogen
peroxide.
7. Clean the area 7. Decreases

under the neck microorganisms
plate of the and removes
tracheostomy crusting.
tube using a
cotton applicator
moistened with
hydrogen
peroxide
(see Figure 7-
20-2). Dip the
applicator in the
basin of
hydrogen
peroxide before
the cannula is
added to the
basin to prevent
contamination of
the applicator.
8. Rinse area 8. Removes

under neck plate hydrogen
with cotton peroxide from
applicator the skin.
moistened with
sterile water or
saline.
9. Dry skin under 9. Prevents skin

neck plate with excoriation from
cotton-tip moisture.
applicator.
10 Apply 10 Prevents
. tracheostomy irritation of skin
24 Record the 24 Provides
. procedure and . documentation
client's tolerance of the
of the procedure, procedure.
including amount
and consistency
of secretions.

Maintaining a Double Cannula Tracheostomy Tube
- Post-Skill

Evaluation:  The client's airway is free of
obstruction.
 The procedure was performed
with a minimum of client
anxiety.
 The client's skin remains intact
and free of redness and
excoriation.
 The client remains free of signs
and symptoms of infection.


 Document what procedure was

done and the client's tolerance
of the procedure.
 Indicate the amount and
consistency of any secretions
that were noted in the inner
cannula.
 Document client teaching and
participation.

Variations

Geriatric  Elderly clients often have thin,
Variations: fragile skin that is at increased
risk of irritation and excoriation.
Keep the area around the
tracheostomy clean and dry.

Pediatric  Pediatric tracheostomy tubes
Variations: are generally single cannula
tubes.
 Because of the small internal
diameter of the lumen of a
pediatric tracheostomy tube,
double cannula tubes are
usually not available in
pediatric sizes.

Home Care  It is essential that the
Variations: procedure be taught to the
client.
 Routine cleaning of the inner
cannula of a double cannula
tracheostomy tube will prevent
obstruction and airway distress.

Long-Term Care  Once a client is discharged
Variations: from the hospital, the
procedure is converted from a
sterile technique to a clean
technique.
 When the client is doing self-
care, good handwashing
technique and clean
procedures should be stressed.
Instead of using sterile water or
sterile saline, tap water can be
used for rinsing the inner
cannula.
 In a home care or long-term
care setting, inner cannula care
should be performed on a
routine basis. It must be
remembered that the
tracheostomy is the client's
only airway. Once obstruction
occurs, hypoxia and respiratory
arrest can occur quickly.
Maintaining a Double Cannula Tracheostomy Tube -

Common Errors

Possible
There is alteration in aseptic technique.
Errors:

Prevention: Think about what steps you must follow to
prevent contaminating the inner cannula
during this procedure. Review the
procedure. Arrange your equipment and
open the tracheostomy care kit before
applying sterile gloves.

Possible The equipment is inadvertently
Errors: contaminated.

Prevention: Think about why this procedure is performed
sterilely and what will happen to the client if
it is not done that way. The procedure is
performed sterilely in the hospital setting for
several reasons. The client is generally ill
and, therefore, the client's immune system is
compromised. The tracheostomy is a direct
route to the lungs with no intervening nose
and sinuses to filter out bacteria. Hospitals
are a breeding ground for germs and
disease. Compromising sterile technique
endangers your client's health and possibly
his life.

Nursing  Assemble equipment prior to
Tips: beginning the procedure. If all the
equipment is within reach once
sterile gloves are applied, the
procedure can proceed with little
difficulty.
 While assembling the equipment and
performing the procedure, the nurse
should use this time to instruct the
client. The need to clean the inner
cannula will continue as long as the
tracheostomy tube is in use. Inner
cannula care is one of the first
procedures that can be taught to the
client in preparation for hospital
discharge.


Introduction: When cleaning the inner cannula of a double
cannula tracheostomy tube, it is important to
clean and reinsert the tube in a timely
manner before secretions are allowed to dry
on the outer cannula.

Possible Mr. Jinwon had a tracheostomy
Scenario: performed following surgery in the oral
cavity. During routine cleaning of the
inner cannula, the nurse removed the
inner cannula and placed it in hydrogen
peroxide to loosen secretions. During
this time, she was called away from the
client's bedside.

Possible Becoming involved in another procedure, the
Outcome: nurse did not return to Mr. Jinwon's bedside
to complete the procedure until several
hours later. After cleaning the inner cannula,
the nurse found she could not reinsert it. The
outer cannula of the tracheostomy was
encrusted with dried secretions and the inner
cannula could not be reinserted. The entire
tracheostomy tube had to be changed to
restore the client's airway.

Prevention: Double cannula tracheostomy tubes are
used to provide a removable cannula for
cleaning. In a double cannula tracheostomy
tube, an inner cannula can be removed,
cleaned, and replaced. In the anecdote, the
double cannula tube became a single
cannula tube. Secretions that can normally
be removed by removing the inner cannula
accumulated in the lumen of the outer
cannula and obstructed the airway. In a
situation where a single cannula tube is used
or in the case study just discussed,
supplemental humidification should be
applied to the tracheostomy site to moisten
secretions and prevent drying, which would
result in obstruction.

Plugging the Tracheostomy Tube - Overview of the Skill

Overview: A tracheostomy is an incision made into the trachea

with insertion of a cannula for airway management. A
tracheostomy is performed for the client with potential
or present airway obstruction, for ventilatory
assistance, to provide pulmonary hygiene, to
decrease the anatomic dead space in the client with
chronic obstructive pulmonary disease, to avoid
prolonged endotracheal intubation, and to provide an
airway for the client with severe obstructive sleep
apnea syndrome. The tracheostomy is performed
below the level of the vocal cords, and allows air to
enter and exit the tracheostomy rather than through
the upper airway. The tracheostomy tube can be
plugged to evaluate the client's ability to tolerate
removal of the tracheostomy tube (decannulation) and
to provide verbal speech to the client with a
tracheostomy.

Assessment: 1. Assess respirations for rate, rhythm, and depth, to

evaluate airway.
2. Assess the client's ability to speak, to determine if
air is passing around the tracheostomy tube,
vibrating the vocal cords.

Diagnosis:  Impaired Verbal Communication

 Disturbed Body Image
 Powerlessness

Planning


 Syringe to deflate cuff of tracheostomy tube

 Smaller uncuffed tracheostomy tube
 Capped inner cannula of tracheostomy tube
currently in use

Expected Outcomes: 1. The client will tolerate plugging of the tracheostomy

tube while maintaining an adequate airway.

Client Education Needed: 1. Explain the procedure to the client.

2. Reinforce descriptions of airway anatomy using
illustrations.
3. Inform the client that capped inner cannula can be
removed within seconds if the client exhibits
difficulty breathing.

Plugging the Tracheostomy Tube - Implementation—Action/Rationale

Implementation
Action/Rational
ACTION RATIONALE
Plugging the Tracheostomy
Tube - Post-Skill 1 Deflate the cuff on a 1 Determines the client's
. cuffed tracheostomy . ability to handle
tube. secretions without

aspiration.
Evaluation:  The client
tolerated 2 Change the 2 Determines the client's
plugging of . tracheostomy tube to a . ability to breathe
the smaller uncuffed tube. around the tube and
tracheosto through the nose and
my tube mouth.
while 3 Replace the inner 3 Occludes the opening
maintainin . cannula with a capped . of the tracheostomy
g an inner cannula. tube and evaluates
adequate the client's ability to
airway. breathe.

Documentati Nurses’ Notes
on:

Document the
client's tolerance
of:

 Cuff
deflation
 Ability to
breathe
through a
smaller
tube
 Ability to
breathe
with a
plugged
tracheosto
my tube

Variations

Geriatric  Elderly
Variations: clients
may lack
the manual
dexterity to
place and
remove
the
tracheosto
my plug.

Pediatric  Pediatric
Variations: tracheosto
my tubes
are
generally
single
cannula
tubes.
Because
of the
small
internal
diameter
of the
lumen of
the
pediatric
tracheosto
my tube,
an inner
cannula is
usually not
available.
For short
periods of
time, a
finger can
be placed
over the
opening of
the
tracheosto
my tube,
allowing
the client
to speak.
However,
pediatric
tubes are
usually not
plugged.

Home Care  Teach the
Variations: client or
caregiver
the signs
and
symptoms
of
respiratory
distress
caused by
the
plugged
tracheosto
my tube,
and how to
respond to
these
signs and
symptoms.

Long-Term  Teach the
Care client or
Variations: caregiver
the proper
care and
handling of
the
tracheosto
my plug.
Because it
is inserted
into the
tracheosto
my, it must
be handled
cleanly.

e
Plugging the Tracheostomy Tube - Common Errors

Possible A plugged tracheostomy tube is inserted in a client with an inflated

Errors: cuff.

Prevention: Think about why you can never use a capped tracheostomy inner
cannula in a client with an inflated cuff. Once the plugged inner
cannula is used, the client will breathe around the tracheostomy
through the upper airway. If the cuff is inflated, the client will be
unable to pass air around the tube, resulting in an inability to
breathe.

Nursing  Assemble all equipment prior to beginning procedure.

Tips:  Explain the procedure to the client to avoid anxiety.


Introduction: Careful assessment is crucial to good care.

Possible Mr. Sinclair had a tracheostomy performed at the time of head and
Scenario: neck surgery. Healing has progressed and an order is written to
begin decannulation. The first step in the decannulation procedure
is to determine the client's ability to handle secretions without
aspiration. This is performed by deflating the tracheostomy cuff.

Possible During the next 5 to 10 minutes, the client continuously coughs,

Outcome: expectorating large amounts of mucus through the tracheostomy
tube. The nurse determines that the client is probably aspirating
secretions and is unable to tolerate the deflation of the cuff.
Because the cuff cannot be deflated, the tracheostomy tube cannot
be plugged.

Prevention: Better assessment of the client's airway, presence of secretions,

and frequency of coughing and suctioning may have indicated the
client is not ready for decannulation (see Figure 7-21-2).

E Learning Notes: Administering Oxygen Therapy - Overview of The Skill

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E Learning Notes: Administering Oxygen Therapy - Overview of The Skill

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E LEARNING NOTES

Administering Oxygen Therapy - Overview of the Skill

Administering Oxygen Therapy - Implementation—Action/Rationale

Oxygen via an Artificial Airway (tracheostomy or endotracheal tube)

 Record O2 saturation and respiratory status.

Administering Oxygen Therapy - Common Errors

Assisting a Client with Controlled Coughing and Deep Breathing - Overview of

Assisting a Client with Controlled Coughing and Deep Breathing -

9. Reassess lung fields after 9. Evaluation of procedure is

11 Repeat as necessary to clear 11 It is essential to clear airways to

 Record date and time of procedure.

Assisting a Client with Controlled Coughing and Deep Breathing - Common

Measuring Peak Expiratory Flow Rates - Overview of the Skill

 Peak flow meter with mouthpiece (see Figures 7-6-1A and 7-6-1B)

Implementation ACTION RATIONALE

2. Identify the client and confirm 2. Promotes accuracy in teaching

3. Explain and demonstrate the 3. Promotes client's compliance.

4. Have the client stand up or sit in 4. Expands the lungs to their

6. Have the client take a deep 6. Maximizes expansion of the

10 Teach the client how to read the 10 Ensures accurate documentation

13 Write down the highest of the 13 The highest number is used to

14 Use the zone determination to 14 Zone determination provides an

Measuring Peak Expiratory Flow Rates - Post-Skill Evaluation:

 Record the best reading.

Variations Geriatric Variations:

Home Care Variations:

Long-Term Care Variations:

Incentive Spirometry - Overview

Incentive spirometry assists the patient in deep breathing. An incentive

Expected  Patient demonstrates correct use of the IS.

 Patient is unable to achieve incentive spirometry target volume.

Incentive Spirometry - Assessment and Preparation

 Explain procedure to patient and family.

 Identify patients who would benefit from incentive spirometry,

Incentive Spirometry - Procedure

1. Perform hand hygiene.

Rationale: Reduces transmission of microorganisms.

2. Position patient in semi-Fowler or high Fowler position.

Rationale: Promotes optimal lung expansion during respiratory maneuver.

3. Instruct patient to place lips completely over mouthpiece.

Rationale: Showing patient how to correctly place mouthpiece is a reliable

Rationale: Maintains maximal inspiration and reduces risk of progressive

5. Have patient repeat maneuver until goals are achieved.

6. Perform hand hygiene.

Rationale: Reduces transmission of microorganisms.

Incentive Spirometry - Post Procedure and Variations

1. Observe patient's ability to use incentive spirometry by return

2. Assess whether patient is able to achieve target volume or frequency.

Rationale: Measures compliance with therapy and lung

3. Auscultate chest during respiratory cycle.

Rationale: Documents lung wall expansion, identifies any

 Teach patient to examine sputum for consistency, amount, and color

 Older adults with chronic illnesses or arthritis may have difficulty

Chest Physiotherapy: Postural Drainage - Assessment and Preparation

1. Explain purpose and rationale for procedure. Explain positioning,

Contraindications to high fluid intake are congestive heart

3. Plan treatments so that they do not overlap with meals or tube

1. Assess patient for contraindications to postural drainage [See Box

 Intracranial pressure (ICP) > 20 mm Hg

Trendelenburg position is contraindicated for the following:

*Indicates absolute contraindication.

1. Perform hand hygiene and apply gloves.

Rationale: Reduces transmission of microorganisms.