Dona Remedios Trinidad Romualdez Medical Foundation

College of Nursing

Worksheet on NCM 109 – RLE

Concept: Nursing Procedures related to Oxygenation (Respiratory System)

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11. Procedure: TRACHEOSTOMY TUBE INSERTION

Purpose
 Tracheostomy is usually planned, either as an adjunct to therapy for respiratory dysfunction
or for longer-term airway management when ET intubation has been used for more than 14
days.
 May be done at the bedside in an emergency when other means of creating an airway have
failed
Indication
 Acute respiratory failure, central nervous system (CNS) depression, neuromuscular disease,
pulmonary disease, chest wall injury
 Upper airway obstruction (tumor, inflammation, foreign body, laryngeal spasm)
 Anticipated upper airway obstruction from edema or soft tissue swelling due to head and
neck trauma, some postoperative head and neck procedures involving the airway, facial or
airway burns, decreased LOC
Contraindication/Precautions and Interfering Factors
1. Laryngeal or tracheal injury
a. Sore throat, hoarse voice
b. Glottic edema
c. Trauma (damage to teeth or mucous membranes, perforation or laceration of pharynx, larynx,
or trachea)
d. Aspiration
e. Laryngospasm, bronchospasm
2. Pulmonary infection and sepsis
3. Dependence on artificial airway
Equipment
 Tracheostomy tube (sizes 6 to 9 mm for most adults)
 Sterile instruments: hemostat, scalpel and blade, forceps, suture material, scissors
 Sterile gown and drapes, gloves
 Cap and face shield
 Antiseptic prep solution
 Gauze pads
 Shave prep kit
 Sedation
 Local anesthetic and syringe
 Resuscitation bag and mask with oxygen source
 Suction source and catheters
 Syringe for cuff inflation
 Respiratory support available for post tracheostomy (mechanical ventilation, tracheal oxygen
mask, CPAP, T-piece)
Nursing Actions & Responsibilities: Rationale:
Preparatory phase 1. Provides a baseline to estimate the
1. Assess the patient’s heart rate, level of consciousness, and patient’s tolerance of the procedure.
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respiratory status.
Nursing Actions & Responsibilities: Rationale:
Performance phase 1. Apprehension about inability to
1. Explain the procedure to the patient. Discuss a talk is usually a major concern of the
communication system with the patient. tracheostomized patient.
2. Obtain consent for operative procedure. 3. Hair and beard may harbour
3. Shave neck region. microorganisms. If the beard is to be
4. Assemble equipment. Using aseptic technique, inflate removed, inform the patient or
tracheostomy cuff and evaluate for symmetry and volume family.
leakage. Deflate maximally. 4. Ensures that the cuff is functional
5. Position the patient (in a supine position with head before tube insertion.
extended and a support under the shoulders). 5. This position brings the trachea
6. Obtain an order for and apply soft wrist restraints if the forward.
patient is confused. 6. Restraint of the confused patient
7. Give medication if ordered. may be necessary to ensure patient
8. Position the light source. safety and preservation of aseptic
9. Assist with antiseptic prep. technique.
10. Assist with gowning and gloving. 7. Sedation may be needed.
11. Assist with sterile draping. 12. Spraying of blood or airway
12. Put on face shield. secretions may occur during this
13. During procedure, monitor the patient’s vital signs, procedure.
suction as necessary, give medication as prescribed, and be 13. Bradycardia may result from
prepared to administer emergency care. vagal stimulation due to tracheal
14. Immediately after the tube is inserted, inflate the cuff. manipulation, or hypoxemia.
The chest should be auscultated for the presence of bilateral Hypoxemia may also cause cardiac
breath sounds. irritability.
15. Secure the tracheostomy tube with twill tapes or other 14. Ensures ventilation of both lungs.
securing device and apply dressing. 17. Excessive cuff pressure may cause
16.Apply appropriate respiratory assistive device tracheal damage.
(mechanical ventilation, tracheostomy, oxygen mask, CPAP, 18. Should the tracheostomy tube
T-piece adapter). become dislodged, the stay sutures
17. Check the tracheostomy tube cuff pressure. may be grasped and used to spread
18. “Tie sutures” or “stay sutures” of silk may have been the tracheal cartilage apart,
placed through either side of the tracheal cartilage at the facilitating placement of the new
incision and brought out through the wound. Each is to be tube.
taped to the skin at a 45-degree angle laterally to the
sternum.
Nursing Actions & Responsibilities: Rationale:
Follow-up phase: 1. Provides baseline.
1. Assess vital signs and breath sounds; note tube size used, 2. Documents proper tube
physician performing procedure, type, dose, and route of placement.
medications given. 3.
2. Obtain chest X-ray. a. Some bleeding around the stoma
3. Assess and chart condition of stoma: site is not unusual for the first few
a. Bleeding hours. Monitor and inform the
b. Swelling physician of any increase in bleeding.
c. Subcutaneous air Clean the site aseptically when
4. An extra tube, obturator, and hemostat should be kept at necessary. Do not change
the bedside. In the event of tube dislodgement, reinsertion tracheostomy ties for first 24 hours,
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of a new tube may be necessary. For because accidental dislodgement of
emergency tube insertion: the tube could result when the ties
a. Spread the wound with a hemostat or stay sutures. are loose, and tube reinsertion
b. Insert replacement tube (containing the obturator) at an through the as-yet-unformed stoma
angle. may be difficult or impossible to
c. Point cannula downward and insert the tube maximally. accomplish.
d. Remove the obturator c. When positive pressure respiratory
assistive devices are used
(mechanical ventilation, CPAP) before
the wound is healed, air may be
forced into the subcutaneous fat
layer. This can be seen as
enlargement of the neck and facial
tissues and felt as crepitus or
“cracking” when the skin is
depressed. Report immediately.
4. The hemostat will open the airway
and allow ventilation in the
spontaneously breathing patient.
Avoid inserting the tube horizontally,
because the tube may be forced
against the back wall of the trachea.
Special considerations
 Patients need to lie at a 30-degree, or greater, angle to facilitate breathing and lung
expansion.
 All tracheostomy patients must have suction equipment and emergency supplies at the
bedside. Emergency equipment is usually in a clear bag on an IV pole attached to the
patient’s bed. A tracheostomy patient must be assessed every two hours to determine if
suctioning is required.
 Tracheostomy patients are often not permitted anything to drink or eat. Consult with the RN
in charge.
 A patient with a tracheostomy tube cannot speak; because the vocal cords are above the
level of the tracheostomy tube, air cannot pass over the vocal cords. Speech is not possible
without a speaking device.
 Tracheostomy patients always have the tracheostomy tied securely around the neck using
ties, according to agency policy.
Complications
 Early potential complications:
 Hemorrhage
 Pneumothorax
 subcutaneous emphysema
 cuff leak
 tube dislodgement
 respiratory/cardiovascular arrest
Late potential complications:
 airway obstruction
 fistulae
 infection

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  aspiration
 Tracheal damage/erosion.
Patient & SO teaching
 Instruct the patient the following in case of troubled breathing:
 Take deep breaths and cough.
 Suction your trach tube as directed.
 Gently move the trach tube. Your tube opening may be against your airway. Gently
reposition the tube to make sure it sits in the center of your airway.
 Replace your trach tube. Insert a new trach tube. Try a smaller size if a regular sized tube will
not go in properly.
 Call for emergency if still have trouble breathing
Illustrate the 3 different types of tracheostomy tubes and state advantages and disadvantages of
each.
Uncuffed tube:

Advantages:
 Lower resistance to air flow
 Allows easy suctioning
 Avoids trauma to sub-glottic region
 Prevents increase in work of breathing
Disadvantages:
 May impair swallowing
 Increased risk of infection
 Impairs speech
 Invasive surgical procedure

Cuffed tube:

Advantages:
 Allows use of lower fresh gas flow
 Reduced air pollution

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  Reduced risk of aspiration
 Avoids multiple laryngoscopies and intubations
 Improved ventilation
Disadvantages:
 Requires extra care for correct placement
 Potential tracheal injury
 Higher costs
 Smaller tubes increase the risk of occlusion due to secretions

Speaking valve:

Advantages
 improvement of olfaction and taste
 use of the upper airway, which improves the ability to cough and manage secretions
 facilitation of voicing, even in ventilator-dependent patients
Disadvantages:
 High cost
 Diversion of airflow away from larynx
 Inadequate Inadequate subglottic subglottic pressure to cause vocal pressure to cause vocal
 fold vibration fold vibration

12. Procedure: TRACHEOSTOMY CARE

Purposes
 To maintain airway patency
 To maintain cleanliness and prevent infection at the tracheostomy site
 To facilitate healing and prevent skin excoriation around the tracheostomy incision
 To promote comfort
Indication
 to keep your trach tube clean
 helps prevent a clogged tube and decreases your risk for infection
Contraindication/Precautions and Interfering Factors
No absolute contraindications exist to tracheostomy
Equipment
 Sterile disposable tracheostomy cleaning kit or supplies including sterile containers, sterile
nylon brush and/or pipe cleaners, sterile applicators, gauze squares
 Disposable inner cannula if applicable
 Towel or drape to protect bed linens
 Sterile suction catheter kit (suction catheter and sterile container for solution)
 Sterile normal saline (Some agencies may use a mixture of hydrogen peroxide and sterile
normal saline. Check agency protocol for soaking solution.)
 Sterile gloves (2 pairs—one pair is for suctioning if needed.)
 Clean gloves
 Moisture-proof bag

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  Commercially prepared sterile tracheostomy dressing or
 sterile 4 x 4 gauze dressing
 Cotton twill ties or Velcro collar
 Clean scissors
Nursing Actions & Responsibilities: Rationale:
Preparatory phase 1. The presence of skin breakdown or
1. Assess the condition of the stoma before tracheostomy infection must be monitored. Culture
of the site may be warranted by
care (redness, swelling, character of secretions, and
appearance of these signs.
presence of purulence or bleeding). 2. Indicates air leak into
2. Examine the neck for subcutaneous emphysema. subcutaneous tissue.
Nursing Actions & Responsibilities: Rationale:
Performance phase 1. Hydrogen peroxide may help
1. Cleaning a stoma and outer cannula loosen dry crusted secretions.
Clean the stoma area with 2 peroxide-soaked gauze pads. 2. Because cannula is dirty when you
Make only a single sweep with each gauze pad before remove it, use your contaminated
discarding. hand. It is considered sterile once
2. Cleaning a non-disposable inner cannula you clean it, so handle it with your
If inner cannula is reusable, remove it with your sterile hand.
contaminated hand and clean it in hydrogen peroxide
solution, using brush or pipe cleaners with your sterile hand. 4.
When clean, drop it into sterile saline solution and agitate it a. Stabilization of the tube helps prevent
to rinse thoroughly with your sterile hand. Tap it gently to accidental dislodgement and keeps
dry it and replace it with your sterile hand. irritation and coughing due to tube
manipulation at a minimum.
3. Caring for a disposable inner cannula
f. To prevent irritation and rotate
 Check policy for frequency of changing inner cannula
pressure site.
because standards vary among institutions.
g. Excessive tightness of tapes will
 Open a new cannula package.
compress jugular veins, decrease
 Using a gloved hand, unlock the current inner
blood circulation to the skin under
cannula (if present) and remove it by gently pulling it
the tape, and result in discomfort for
out toward you in line with its curvature.
the patient.
 Check the cannula for amount and type of secretions
and discard properly.
5. Provides a baseline.
 Pick up the new inner cannula touching only the
outer locking portion.
 Insert the new inner cannula into the tracheostomy.
 Lock the cannula in place by turning the lock (if
present) or clipping in place.
4. Changing tracheostomy ties
a. Cut soiled tape while holding tube securely with other
hand. Use care not to cut the pilot balloon tubing.
b. Remove old tapes carefully.
c. Grasp slit end of clean tape and pull it through opening on
side of the tracheostomy tube.
d. Pull other end of tape securely through the slit end of the
tape.
e. Repeat on the other side.
f. Tie the tapes at the side of the neck in a square knot.
Alternate knot from side to side each time tapes are

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changed.
g. Ties should be tight enough to keep tube securely in the
stoma, but loose enough to permit two fingers to fit
between the tapes and the neck
5. Concluding tracheostomy care
Document procedure performance, observations of stoma
(irritation, redness, edema, subcutaneous air), and character
of secretions (color, purulence). Report changes in stoma
appearance or secretions.
6. Deflating and inflating a tracheostomy cuff
a. To inflate the cuff, inject air into adaptor at the end
of the pilot balloon. Inject the least amount of air
needed to adequately create a seal around the tube.
The amount of air necessary will vary depending on
the diameter of the tracheostomy tube and the
patient's trachea. Inject 0.5 cc of air at a time until air
cannot be felt or heard escaping from the nose or
mouth (usually 5 to 8 cc).
b. To deflate, place syringe into adaptor at end of pilot
balloon and pull back on plunger until pilot balloon is
completely deflated and resistance is met.
Nursing Actions & Responsibilities: Rationale:
Follow-up phase: 1. Provides a baseline.
1. Document procedure performance, observations of stoma 2. The area must be kept clean and
(irritation, redness, edema, subcutaneous air), and character dry to prevent infection or irritation
of secretions (color, purulence). Report changes in stoma of tissues.
appearance or secretions.
2. Clean the fresh stoma every 8 hours or more frequently if
indicated by accumulation of secretions. Ties should be
changed every 24 hours, or more frequently if soiled or wet.

13. Procedure: TRACHEAL SUCTIONING

Purpose
 To maintain a patent airway and prevent airway obstructions
 To promote respiratory function (optimal exchange of oxygen and carbon dioxide into and
out of the lungs)
 To prevent pneumonia that may result from accumulated secretions
Indication
 Ineffective coughing may cause secretion collection in the artificial airway or
tracheobronchial tree, resulting in narrowing of the airway, respiratory insufficiency, and
stasis of secretions
Contraindication/Precautions and Interfering Factors
 Severe bleeding disorder, unexplained hemoptysis
 Severe bronchospasm or laryngeal spasm, irritable airway
 Epiglottitis or croup
 Basal skull fractures / facial injury
 5. Cerebral spinal fluid leak

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Equipment
 Resuscitation bag (Ambu bag) connected to 100% oxygen
 Sterile towel (optional)
 Equipment for suctioning (see Skill 50–2)
 Goggles and mask if necessary
 Gown (if necessary)
 Sterile gloves
 Moisture-resistant bag
Nursing Actions & Responsibilities: Rationale:
Preparatory phase 1. Handwashing minimizes the risk
1. Wash hands; identify child; explain procedure to child. for spread of microorganisms;
identifying the child ensures that you
2. Assess child, especially breath sounds; analyse
are performing the procedure on the
appropriateness of procedure. Plan ways to modify care
right child; explaining the procedure
based on individual circumstances. helps to encourage cooperation and
3. Assemble supplies: suction source and tubing, sterile minimize anxiety.
suction catheter (#12 or 14F) or sterile suction kit, sterile 2. Assessment prior to procedure
gloves, bottle of sterile normal saline, sterile medicine provides a baseline for future
dropper or syringe, manual resuscitator. Plan method to evaluation. Modifications enhance
individualization of nursing care
keep child from touching sterile catheter (placing a restraint,
based on client need.
distraction, or asking assistance from another nurse). 3. Organizing supplies will increase
efficiency of procedure.
Nursing Actions & Responsibilities: Rationale:
Performance phase 1. Sterile technique is important to
1. Open the bottle of sterile normal saline and suction prevent introducing microorganisms.
catheter or kit. Pour a small amount of saline solution into 2. Proper handling of equipment
using sterile technique reduces the
disposable container included in kit. Prepare syringe or
risk of contamination because once a
dropper with small amount of sterile normal saline; put on sterile glove touches suction tubing,
sterile gloves. it is no longer sterile. Using sterile
2. Hold suction catheter with one gloved hand, suction normal saline to suction through the
tubing with other gloved hand, and attach tubing to sterile catheter and tubing ensures patency.
catheter; dip tip of catheter into normal saline and suction a 3. Hyper oxygenation prevents child
small amount through catheter. from developing hypoxia during
suctioning.
3. If necessary, instruct assistant to hyper oxygenate child
4. Holding your breath helps you not
with manual resuscitator. to suction longer than is
4. Hold your breath; introduce sterile catheter into comfortable. Applying suction only
tracheostomy tube to desired length. Apply suction for 5 to on withdrawal allows the catheter to
10 sec and gently withdraw, rotating gently pass freely without irritating the
5. Rinse catheter by dipping tip in normal saline and applying trachea and prevents over
suction. suctioning. Prolonged suctioning
longer than 10 sec can cause
6. Repeat procedure until airway sounds clear. Be careful not
hypoxia.
to suction longer than necessary. 5. Rinsing catheter ensures that it
remains patent.
6. Suctioning is fatiguing to children.
Extended suctioning can lead to
airway irritation and further mucus
production.

Nursing Actions & Responsibilities: Rationale:

Follow-up phase: 1. Comparing initial baseline
1. Assess effectiveness and efficiency of procedure; plan assessments with post procedure
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teaching such as importance of procedure to parents; status provides information about
document procedure. effectiveness of the procedure.
2. Comfort child; remain with child for support. Provide Teaching is an important
opportunities for therapeutic play independent nursing care activity for
the child and parents.
2. Suctioning is frightening; offering
support and comfort after all such
procedures helps to decrease fears
and anxieties.

Special Considerations:
 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.
Complications:
 Hypoxia
 Airway Trauma
 Psychological Trauma
 Pain
 Bradycardia
 Infection
 Ineffective Suctioning

14. Procedure: ADMINISTERING OXYGEN BY NASAL CANNULA

Purpose
 To deliver a relatively low concentration of oxygen when only minimal O2 support is required
 To allow uninterrupted delivery of oxygen while the client ingests food or fluids
Indication
 Indicated to deliver oxygen when a low flow, low or medium concentration is required, and
the patient is in a stable state.
Contraindication/Precautions and Interfering Factors
 Blocked nasal passages/choanal atresia
 Trauma/surgery to nasopharynx
 Fire hazard is increased in presence of higher than normal oxygen concentrations.
Equipment
 Oxygen source
 Plastic nasal cannula with connecting tubing (disposable)
 Humidifier filled with sterile water
 Flow meter
Advantages: Disadvantages:
Can provide 24% to 40% O2 (oxygen) Easily dislodged, not as effective is a patient is a
concentration. Most common type of mouth breather or has blocked nostrils or a deviated
septum or polyps.
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oxygen equipment. Can deliver O2 at 1 to 6
litres per minute (L/min). It is convenient as
patient can talk and eat while receiving
oxygen. May be drying to nares if level is
above 4 L/min. Easy to use, low cost, and
disposable.
Preparation:
1. Determine the need for oxygen therapy, and verify the order for the therapy.
• Perform a respiratory assessment to develop baseline data if not already available.
2. Prepare the client and support people.
• Assist the client to a semi-Fowler’s position if possible. Rationale: This position permits easier chest
expansion and hence easier breathing.
• Explain that oxygen is not dangerous when safety precautions are observed. Inform the client and
support people about the safety precautions connected with oxygen use.
Key steps: Performance phase Nursing Responsibility Rationale:
1. Show the nasal cannula to the patient and a) Ensure that a) A poorly fitting
explain the procedure. prongs are in the nasal cannula
2. Make sure the humidifier is filled to the nares properly. leads to
appropriate mark. b) Apply water- hypoxemia and
3. Attach the connecting tube from the nasal soluble jelly to skin breakdown.
cannula to the humidifier outlet. nares PRN. b) This substance
4. Set the flow rate at the prescribed liters c) Assess the prevents mucosal
per minute. Feel to determine if oxygen is patency of the irritation related
flowing through the tips of the cannula. nostrils to the drying
5. Place the tips of the cannula in the d) Assess the patient effect of oxygen;
patient’s nose and adjust straps around ears for changes in promotes comfort
for snug, comfortable fit. respiratory rate c) Congestion or a
and depth. deviated septum
prevents effective
delivery of oxygen
through the
nares.
d) The respiratory
pattern affects the
amount of oxygen
delivered. A
different delivery
system may be
needed.
Illustrate the different parts of the nasal cannula and the correct placement on patient:

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15. Procedure: ADMINISTERING OXYGEN BY SIMPLE FACE MASK

Purpose
 To provide moderate O2 support and a higher concentration of oxygen and/or humidity than
is provided by cannula
Indication
 Indicated to eliminate the danger of suffocation present if a mask with one-way valves
becomes disconnected from oxygen.
Contraindication/Precautions and Interfering Factors
 Poor respiratory efforts
 Apnea
 Severe hypoxia
Equipment
 Oxygen supply with a flow meter and adapter
 Humidifier with distilled water or tap water according to agency protocol
 Prescribed face mask of the appropriate size
 Padding for the elastic band
Advantages: Disadvantages:
 Can provide 40% to 60%  Hot and confining
O2 concentration. Flow  May irritate the patient's skin
meter should be set to  Intereferes with eating and talikng
 Impractical for long-term theraphy because of
deliver O2 at 6 to 10
imprecision
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 L/min.  Tight seal required for higher oxygen concentration may
 Used to provide moderate cause discomfort.
oxygen concentrations.
 Efficiency depends on how
well mask fits and the
patient’s respiratory
demands.
 Readily available on most
hospital units.
 Provides higher oxygen for
patients.
Preparation:
1. Verify correct patient. Determine current vital signs, LOC, and SaO2 or ABG, if patient is at risk for
CO2 retention.
Key steps: Performance phase Nursing Responsibility Rationale:
1. Guide the mask toward the a) Be sure mask fits a) A poorly fitting mask
client’s face, and apply it from the securely over nose and reduces the FiO2
nose downward. mouth delivered.
2. Fit the mask to the contours of b) Assess skin and provide b) Pressure and moisture
the client’s face skin care to the area under the mask may
3. Secure the elastic band around covered by the mask. cause skin breakdown.
the client’s head so that the mask c) Monitor the patient c) The mask limits the
is comfortable but snug. closely for risk for patient’s ability to clear
4. Pad the band behind the ears aspiration. the mouth, especially if
and over bony prominences. d) Provide emotional vomiting occurs.
support to the patient d) Emotional support
who feels decreases anxiety,
claustrophobic. which contributes to a
claustrophobic feeling.
Illustrate the different parts of the simple face mask and the correct placement on patient:

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16. Procedure: ADMINISTERING OXYGEN BY VENTURI MASK

Purpose
 A Venturi mask mixes oxygen with room air, creating high-flow enriched oxygen of a settable
concentration
 It provides an accurate and constant FiO2 in range of 24-50%
 Venturi mask is often employed when the clinician has a concern about CO2 retention
Indication
 Desire to deliver exact amount of FiO2
Contraindication/Precautions and Interfering Factors
 Poor respiratory efforts
 Apnea
 severe hypoxia
Equipment
Oxygen source
Flowmeter
Venturi mask for correct concentration (24%, 28%, 31%, 35%, 40%, 50%) or correct concentration
adapter if interchangeable color-coded adapters are used
If high humidity desired
Compressed air source and flowmeter
Humidifier with distilled water
Large-bore tubing
Advantages: Disadvantages:

Preparation:
1. Verify correct patient. Determine current vital signs, LOC, and most recent ABG.
2. Assess risk of CO2 retention with oxygen administration.
Key steps: Performance phase Nursing Responsibility Rationale:
1. Show the Venturi mask to the a) Keep the orifice for the a) If the Venturi orifice is
patient and explain the venturi adaptor open covered, the adaptor
procedure. and uncovered does not function and
2. Connect the mask by b) Provide a mask that fits oxygen delivery varies
lightweight tubing to the oxygen snugly and tubing that b) FiO2 is altered if
source. is free of kinks. kinking occurs or if the
3. Turn on the oxygen flowmeter c) Assess the patient for mask fits poorly
and adjust to the prescribed rate dry mucosal c) Comfort measures may

13
(usually indicated on the mask). membranes. be indicated
Check to see that oxygen is d) Assess the patient for d) The respiratory pattern
flowing out the vent holes in the changes in respiratory affects the amount of
mask. rate and depth. oxygen delivered. A
4. Place Venturi mask over the e) Assess skin and provide different delivery
patient’s nose and mouth and skin care to the area system may be
under the chin. Adjust elastic covered by the mask. needed.
strap. e) Pressure and moisture
5. Check to make sure holes for air under the mask may
entry are not obstructed by the cause skin breakdown.
patient’s bedding.
6. If aerosol nebulizer used:
a. Connect the humidifier to a
compressed air source.
b. Attach large-bore tubing to the
humidifier and connect the tubing
to the fitting for high humidity at
the base of the Venturi mask.
7. Record flow rate used and
immediate patient response. Note
the patient’s tolerance of
treatment. Report if intolerance
occurs.
8. If CO2 retention is present,
assess ABG every 30 minutes for 1
to 2 hours or until the PaO2 is
greater than 50 mm Hg and the
PaCO2 is no longer increasing.
Monitor pH. Report if the pH
decreases below the initial
assessment value.
9. Determine patient comfort with
oxygen use.
Illustrate the different parts of the Venturi mask and the correct placement on patient:

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17. Procedure: ADMINISTERING OXYGEN BY PARTIAL REBREATHING OR NONREBREATHING MASK

Purpose
 Simple masks with additional reservoir that allows the accumulation of the oxygen enriched
gas for rebreathing
 Allows for the initial portion of the expired gases containing little or no CO2 (rich in oxygen)
to be collected in a reservoir while the remaining expiratory gases are vented to the
atmosphere
Indication
 Relatively high FiO2 requirement
Contraindication/Precautions and Interfering Factors
 Poor respiratory efforts
 Apnea
 severe hypoxia
Equipment
Oxygen source
Plastic face mask with reservoir bag and tubing
Humidifier with distilled water
Flowmeter
Advantages: Disadvantages:
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PARTIAL REBREATHER MASK PARTIAL REBREATHER MASK
ADVANTAGES ADVANTAGES
 Effectively delivers concentrations  Hot and confining
 Tight seal required for accurate oxygen
of 40% to 70%
concentration may cause discomfort.
 Openings in the mask allow the
 Interferes with eating and talking
patient to inhale room air of  May irritate skin
oxygen source fails  Bag may twist
NONREBREATHER MASK ADVANTAGES  Impractical for long-term therapy
 Delivers the highest possible NONREBREATHER MASK ADVANTAGES
oxygen concentration (60 -80%)  Requires a tight sela that may cause discomfort
short of intubation and mechanical and difficult to maintain
ventilation  May irritate the skin
 Interferes with talikng and eating
 Effective for shot-term therapy
 Impractical for long-term therapy
 Doesn’t dry mucous membranes
 Can be converted to a partial
rebreather mask, if necessary, by
removing the one-way valve
Preparation:
1. Verify correct patient. Determine current vital signs and LOC.
2. Determine most recent SaO2 or ABG.
Key steps: Performance phase Nursing Rationale:
2. Attach tubing to flowmeter. Responsibility a) The patient may
3. Show the mask to the patient and a) Closely assess require intubation
explain the procedure. the patient on b) Comfort measures may
4. Flush the reservoir bag with oxygen to increased FiO2 be indicated
inflate the bag and adjust flowmeter to 6 via non- c) This substance
to 10 L/minute. rebreather prevents mucosal
5. Place the mask on the patient’s face. mask. irritation related to the
6. Adjust liter flow so the rebreathing bag Intubation is drying effect of oxygen;
will not collapse during the inspiratory the only way promotes comfort
cycle, even during deep inspiration. to provide d) The mask limits the
7. Stay with the patient for a time to make more precise patient’s ability to clear
the patient comfortable and observe FiO2. the mouth, especially if
vomiting occurs.
reactions. b) Assess the
e) Rationales as for partial
8. Remove mask periodically (if the patient for dry rebreather mask.
patient’s condition permits) to dry the face mucosal Monitoring ensures
around the mask. Apply waterbased lotion membranes. proper functioning and
to skin and massage face around the c) Apply water- prevents harm.
mask. soluble jelly to
9. Record flow rate and immediate patient nares PRN.
response. Note the patient’s tolerance of d) Monitor the
treatment. Report if intolerance occurs. patient closely
10. Observe the patient for change of for risk for
condition. Assess equipment for aspiration.
malfunctioning and low water level in e) Interventions
humidifier. as for partial
rebreather
mask; this pt
requires close
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Illustrate the different parts of the Non-rebreather mask and the correct placement on patient:
Non-rebreather mask

Partial re-breather mask

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