BOX 50–1 The Cough Reflex

■ Nerve impulses are sent through the vagus nerve to the medulla.
■ A large inspiration of approximately 2.5 L occurs.
■ The epiglottis and glottis (vocal cords) close.
■ A strong contraction of abdominal and internal intercostal muscles
dramatically raises the pressure in the lungs.
■ The epiglottis and glottis open suddenly.
■ Air rushes outward with great velocity.
■ Mucus and any foreign particles are dislodged from the lower respiratory
tract and are propelled up and out.
LIFESPAN CONSIDERATIONS Respiratory Development
INFANTS
■ Respiratory rates are highest and most variable in newborns. The
respiratory rate of a neonate is 40 to 80 breaths per minute.
■ Infant respiratory rates average about 30 per minute.
■ Because of rib cage structure, infants rely almost exclusively on diaphragmatic
movement for breathing. This is seen as abdominal
breathing, as the abdomen rises and falls with each breath.
CHILDREN
■ The respiratory rate gradually decreases, averaging around 25 per
minute in the preschooler and reaching the adult rate of 12 to 18
per minute by late adolescence.
■ During infancy and childhood, upper respiratory infections are common
and, fortunately, usually not serious. Infants and preschoolers
also are at risk for airway obstruction by foreign objects such as coins
and small toys. Cystic fibrosis is a congenital disorder that affects the
lungs, causing them to become congested with thick, tenacious
(sticky) mucus. Asthma is another chronic disease often identified in
childhood. The airways of the asthmatic child react to stimuli such as
allergens, exercise, or cold air by constricting, becoming edematous,
and producing excessive mucus. Airflow is impaired, and the child
may wheeze as air moves through narrowed air passages.
ELDERS
■ Elders are at increased risk for acute respiratory diseases such as
pneumonia and chronic diseases such as emphysema and chronic
bronchitis. Chronic obstructive pulmonary disease (COPD) may affect
elders, particularly after years of exposure to cigarette smoke
or industrial pollutants.
■ Pneumonia may not present with the usual symptoms of a
fever, but will present with atypical symptoms, such as confusion,
weakness, loss of appetite, and increase in heart rate and
respirations.
Nursing interventions should be directed toward achieving optimal
respiratory effort and gas exchange:
■ Always encourage wellness and prevention of disease by reinforcing
the need for good nutrition, exercise, and immunizations, such
as for influenza and pneumonia.
■ Increase fluid intake, if not contraindicated by other problems, such
as cardiac or renal impairment.
■ Proper positioning and frequent changing of positions allow for
better lung expansion and air and fluid movement.
■ Teach the client to use breathing techniques for better air exchange
(see Client Teaching boxes throughout this chapter).
■ Pace activities to conserve energy.
■ Encourage the client to eat more frequent, smaller meals to
decrease gastric distention, which can cause pressure on the
diaphragm.
■ Teach the client to avoid extreme hot or cold temperatures that will
further tax the respiratory system.
■ Teach actions and side effects of drugs, inhalers, and treatments.
CLINICAL MANIFESTATIONS HYPOXIALINICAL MANIFESTATIONS HYPOXIA
■ Rapid pulse
■ Rapid, shallow respirations and dyspnea
■ Increased restlessness or light-headedness
■ Flaring of the nares
■ Substernal or intercostal retractions
■ Cyanosis
CLIENT TEACHING Home Care Oxygenation
MAINTAINING AIRWAY CLEARANCE AND EFFECTIVE
GAS EXCHANGE
■ Emphasize to the client and family the importance of not smoking
or lighting any flammable materials (e.g., candles) in the same
room. Refer them to smoking cessation programs as needed. For
family members resistant to not smoking, emphasize the need to
avoid smoking inside the home.
■ Instruct the client in effective coughing techniques such as controlled
coughing or “huff” coughing (see “Deep Breathing and
Coughing” in the “Implementing” section).
■ Discuss the significance of changes in sputum, including the
amount and characteristics such as color, viscosity, and odor. Instruct
the client when to contact a health care provider.
■ Teach the client to maintain a fluid intake of 2,500 mL (2.5 qt) to
3,000 mL (3 qt) per day.
■ Instruct the client of the rationale for using and how to use nebulizers
or inhalers if prescribed; see Chapter 35 , pages 895–898.
■ Teach the client and family how to use home oxygen delivery
systems.
PROMOTING EFFECTIVE BREATHING
■ Teach relaxation techniques such as progressive muscle relaxation,
meditation, and visualization. Use prerecorded tapes as needed.
■ Help the client identify specific factors that affect breathing such as
stress, and exposure to allergens or air pollution, and exposure to
cold. Assist with identifying possible interventions and measures to
avoid these factors.
MEDICATIONS
■ Teach the client about prescribed medications, including the rationale
for the medications, the dose, the desired and possible adverse
effects, and any precautions about using a medication with
food, beverages, or other medications.
SPECIFIC MEASURES FOR OXYGENATION PROBLEMS
■ Provide instructions and rationale for specific procedures and problems
such as
a. Suctioning oropharyngeal and nasopharyngeal cavities.
b. Caring for a temporary or permanent tracheostomy.
c. Preventing the spread of tuberculosis and other respiratory infections
to family members and others.
REFERRALS
■ Make appropriate referrals to home health agencies or community
social services for assistance in obtaining medical and assistive equipment
such as grab bars, respiratory and physical therapy services, and
home health or housekeeping services to assist with ADLs.
COMMUNITY AGENCIES AND OTHER SOURCES OF HELP
■ Provide information about where durable medical equipment can
be purchased, rented, or obtained free of charge; how to access
home oxygen equipment and support services; physical and occupational
therapy services and where to obtain supplies such as tracheostomy
supplies or nutritional supplements.
■ Suggest additional sources of information such as the American Lung
Association and the Asthma and Allergy Foundation of America.
CLIENT TEACHING Promoting
Healthy Breathing
■ Sit straight and stand erect to permit full lung expansion.
■ Exercise regularly.
■ Breathe through the nose.
■ Breathe in to expand the chest fully.
■ Do not smoke cigarettes, cigars, or pipes.
■ Eliminate or reduce the use of household pesticides and irritating
chemical substances.
■ Do not incinerate garbage in the house.
■ Avoid exposure to secondhand smoke.
■ Use building materials that do not emit vapors.
■ Make sure furnaces, ovens, and wood stoves are correctly
ventilated.
■ Support a pollution-free environment.
CLIENT TEACHING Abdominal
(Diaphragmatic) and Pursed-Lip
Breathing
■ Assume a comfortable semi-sitting position in bed or a chair or
a lying position in bed with one pillow.
■ Flex your knees to relax the muscles of the abdomen.
■ Place one or both hands on your abdomen, just below the ribs.
■ Breathe in deeply through the nose, keeping the mouth closed.
■ Concentrate on feeling your abdomen rise (expand) as far as
possible; stay relaxed, and avoid arching your back. If you have
difficulty raising your abdomen, take a quick, forceful breath
through the nose.
■ Then purse your lips as if about to whistle, and breathe out
slowly and gently, making a slow “whooshing” sound without
puffing out the cheeks. This pursed-lip breathing creates a resistance
to air flowing out of the lungs, increases pressure within
the bronchi (main air passages), and minimizes collapse of
smaller airways, a common problem for people with COPD.
■ Concentrate on feeling the abdomen fall or sink, and tighten
(contract) the abdominal muscles while breathing out to enhance
effective exhalation. Count to seven during exhalation.
■ Use this exercise whenever feeling short of breath, and increase
gradually to 5 to 10 minutes four times a day. Regular practice
will help you do this type of breathing without conscious effort.
The exercise, once learned, can be performed when sitting upright,
standing, and walking.
MediaLink Deep
CLIENT TEACHING Controlled
and Huff Coughing
■ After using a bronchodilator treatment (if prescribed), inhale
deeply and hold your breath for a few seconds.
■ Cough twice. The first cough loosens the mucus; the second expels
secretions.
■ For huff coughing, lean forward and exhale sharply with a “huff”
sound. This technique helps keep your airways open while moving
secretions up and out of the lungs.
■ Inhale by taking rapid short breaths in succession (“sniffing”) to
prevent mucus from moving back into smaller airways.
■ Rest.
■ Try to avoid prolonged episodes of coughing because these may
cause fatigue and hypoxia.
CLIENT TEACHING Using Cough
Medications
■ Do not take cough medications in excessive amounts because
of adverse side effects.
■ If you have diabetes mellitus, avoid cough syrups that contain
sugar or alcohol; these can disturb metabolism.
■ When a cough medicine does not act as expected, consult a
health care professional.
■ Be aware of side effects (e.g., drowsiness) that can make the
operation of machinery dangerous.
CLIENT TEACHING
Using an Incentive Spirometer
■ Hold or place the spirometer in an upright position. A tilted floworiented
device requires less effort to raise the balls or discs; a
volume-oriented device will not function correctly unless upright.
■ Exhale normally.
■ Seal the lips tightly around the mouthpiece.
■ Take in a slow, deep breath to elevate the balls or cylinder, and
then hold the breath for 2 seconds initially, increasing to 6 seconds
(optimum), to keep the balls or cylinder elevated if possible.
■ For a flow-oriented device, avoid brisk, low-volume breaths that
snap the balls to the top of the chamber. Greater lung expansion
is achieved with a very slow inspiration than with a brisk,
shallow breath, even though it may not elevate the balls or keep
them elevated while you hold your breath. Sustained elevation
of the balls or cylinder ensures adequate ventilation of the alveoli
(lung air sacs).
■ If you have difficulty breathing only through the mouth, a nose
clip can be used.
■ Remove the mouthpiece and exhale normally.
■ Cough after the incentive effort. Deep ventilation may loosen
secretions, and coughing can facilitate their removal.
■ Relax and take several normal breaths before using the spirometer
again.
■ Repeat the procedure several times and then four or five times
hourly. Practice increases inspiratory volume, maintains alveolar
ventilation, and prevents atelectasis (collapse of the air sacs).
■ Clean the mouthpiece with water and shake it dry.
BOX 50–2 Oxygen Therapy
Safety Precautions
■ For home oxygen use or when the facility permits smoking, teach
family members and roommates to smoke only outside or in provided
smoking rooms away from the client and oxygen equipment.
■ Place cautionary signs reading “No Smoking: Oxygen in Use” on
the client’s door, at the foot or head of the bed, and on the oxygen
equipment.
■ Instruct the client and visitors about the hazard of smoking with
oxygen in use.
■ Make sure that electric devices (such as razors, hearing aids, radios,
televisions, and heating pads) are in good working order to
prevent the occurrence of short-circuit sparks.
■ Avoid materials that generate static electricity, such as woolen blankets
and synthetic fabrics. Cotton blankets should be used, and
clients and caregivers should be advised to wear cotton fabrics.
■ Avoid the use of volatile, flammable materials, such as oils,
greases, alcohol, ether, and acetone (e.g., nail polish remover),
near clients receiving oxygen.
■ Be sure that electric monitoring equipment, suction machines,
and portable diagnostic machines are all electrically grounded.
■ Make known the location of fire extinguishers, and make sure personnel
are trained in their use.
BOX 50—3 Nursing Interventions for Clients
with Endotracheal Tubes
■ Assess the client’s respiratory status at least every 2 hours, or
more frequently if indicated. Include respiratory rate, rhythm,
depth, equality of chest excursion, and lung sounds; level of consciousness;
and skin color in your assessment.
■ Frequently assess nasal and oral mucosa for redness and irritation.
Report any abnormal findings to the primary care provider.
■ Secure the endotracheal tube with tape or a commercially prepared
tracheostomy holder to prevent movement of the tube farther into
or out of the trachea. Assess the position of the tube frequently.
Notify the primary care provider immediately if the tube is dislodged
out of the airway. If the tube advances into a main bronchus,
it will need to be repositioned to ensure ventilation of both lungs.
■ Unless contraindicated, place the client in a side-lying or semiprone
position as tolerated to prevent aspiration of oral secretions.
■ Using sterile technique, suction the endotracheal tube as needed
to remove excessive secretions.
■ Closely monitor cuff pressure, maintaining a pressure of 20 to
25 mm Hg (or as recommended by the tube manufacturer) to
minimize the risk of tracheal tissue necrosis. If recommended, deflate
the cuff periodically.
■ Provide oral and nasal care every 2 to 4 hours. Use an oropharyngeal
airway to prevent the client from biting down on an oral endotracheal
tube. Move oral endotracheal tubes to the opposite
side of the mouth every 8 hours or per agency protocol, taking
care to maintain the position of the tube in the trachea. This prevents
irritation to the oral mucosa.
■ Provide humidified air or oxygen because the endotracheal tube
bypasses the upper airways, which normally moisten the air.
■ If the client is on mechanical ventilation, ensure that all alarms are
enabled at all times because the client cannot call for help should
an emergency occur.
■ Communicate frequently with the client, providing a note pad or
picture board for the client to use in communicating.
OROPHARYNGEAL, NASOPHARYNGEAL, AND NASOTRACHEAL SUCTIONING
Purposes
■ To remove secretions that obstruct the airway
■ To facilitate ventilation
ASSESSMENT
Assess for clinical signs indicating the need for suctioning:
■ Restlessness
■ Gurgling sounds during respiration
■ Adventitious breath sounds when the chest is auscultated
■ Change in mental status
■ Skin color
■ Rate and pattern of respirations
■ Pulse rate and rhythm
■ Decreased oxygen saturation
LIFESPAN CONSIDERATIONS Suctioning
INFANTS
■ A bulb syringe is used to remove secretions from an infant’s nose or
mouth. Care needs to be taken to avoid stimulating the gag reflex.
CHILDREN
■ A catheter is used to remove secretions from an older child’s
mouth or nose.
ELDERS
■ Elders often have cardiac and/or pulmonary disease, thus increasing
their susceptibility to hypoxemia related to suctioning. Watch
closely for signs of hypoxemia. If noted, stop suctioning and hyperoxygenate.
OROPHARYNGEAL, NASOPHARYNGEAL, AND NASOTRACHEAL SUCTIONING
continued
SAMPLE DOCUMENTATION
12/12/2007 0830 Producing large amounts of thick,
tenacious white mucus to back of oral pharynx but unable to
expectorate into tissue. Uses Yankauer suction tube as needed.
O2 sat increased from 89% before suctioning to 93% after suctioning.
RR also decreased from 26 to 18–20 after suctioning.
Continuous O2 at 2 L/min via n/c. Will continue to reassess q
hour. _____________________________L. Webb, RN
EVALUATION
■ Conduct appropriate follow-up, such as appearance of secretions
suctioned; breath sounds; respiratory rate, rhythm, and
depth; pulse rate and rhythm; and skin color.
■ Compare findings to previous assessment data if available.
■ Report significant deviations from normal to the primary care
provider.
HOME CARE CONSIDERATIONS Suctioning
■ Teach clients and families that the most important aspect of infection
control is frequent hand washing.
■ Airway suctioning in the home is considered a clean procedure.
■ The catheter or Yankauer should be flushed by suctioning recently
boiled or distilled water to rinse away mucus, followed by the suctioning
of air through the device to dry the internal surface and,
thus, discourage bacterial growth. The outer surface of the device
may be wiped with alcohol or hydrogen peroxide. The suction
catheter or Yankauer should be allowed to dry and then be stored
in a clean, dry area.
■ Suction catheters treated in the manner described above may
be reused. It is recommended that catheters be discarded after
24 hours. Yankauer suction tubes may be cleaned, boiled, and
reused.
LIFESPAN CONSIDERATIONS Suctioning a Tracheostomy or Endotracheal Tube
INFANTS AND CHILDREN
■ Have an assistant gently restrain the child to keep the child’s hands
out of the way. The assistant should maintain the child’s head in
the midline position.
ELDERS
■ Do a thorough lung assessment before and after suctioning to determine
effectiveness of suctioning and to be aware of any special
problems.
HOME CARE CONSIDERATIONS Suctioning a Tracheostomy or Endotracheal Tube
■ Whenever possible, the client should be encouraged to clear the
airway by coughing.
■ Clients may need to learn to suction their secretions if they cannot
cough effectively.
■ Clean gloves should be used when endotracheal suctioning is performed
in the home environment.
■ The nurse needs to instruct the caregiver on how to determine the
need for suctioning and the correct process and rationale underlying
the practice of suctioning to avoid potential complications of
suctioning.
■ Stress the importance of adequate hydration as it thins secretions,
which can aid in the removal of secretions by coughing or suctioning
LIFESPAN CONSIDERATIONS Tracheostomy Care
INFANTS AND CHILDREN
■ An assistant should always be present while tracheostomy care is
performed.
■ Always keep a sterile, packaged tracheostomy tube taped to the
child’s bed so that if the tube dislodges, a new one is available for
immediate reintubation (Bindler & Ball, 2003, p. 95).
ELDERS
■ Older adult skin is more fragile and prone to breakdown. Care of
the skin at the tracheostomy stoma is very important.
HOME CARE CONSIDERATIONS Tracheostomy Care
■ For tracheostomies older than 1 month, clean technique (rather
than sterile technique) is used for tracheostomy care.
■ Stress the importance of good hand hygiene to the caregiver.
■ Tap water may be used for rinsing the inner cannula.
■ Teach the caregiver the tracheostomy care procedure and observe
a return demonstration. Periodically reassess caregiver knowledge
and/or tracheostomy care technique.
■ Inform the caregiver of the signs and symptoms that may indicate
an infection of the stoma site or lower airway.
■ Names and telephone numbers of health care personnel who can
be reached for emergencies or advice must be available to the
client and/or caregiver.
■ If the tracheostomy is permanent, provide contact information for
available support groups.