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NURS 2863 Med Surg Final
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NURS 2863Med Surg Final 1Med Surg Final
Chapters 30, 31, 32, 33, 38, 40, 42, 44, 45, 46, 47, 49, 51
Chapter 30
Care of patients requiring oxygen therapy
1) Conditions such as heart failure, sepsis, fever, some poisons and decreased hemoglobin
levels can affect oxygen levels.
2) Apply oxygen to anyone who is hypoxic
3) Monitor arterial blood gas and oxygen saturation in all patients receiving oxygen therapy
4) Arterial blood gas analysis is the best measure for determining the need for oxygen therapy
and evaluating its effect
5) Monitor the rate and depth of respiration at least every hour on a patient with hypercarbia and
Co2 narcosis who is receiving oxygen by mask or nasal cannula
6) Aspiration precautions for ANY patient with an altered level of consciousness or who has
an endotracheal tube
7) Assess the skin under the mask and under the plastic tubing every shift for patient’s receiving
oxygen by mask
8) Assess the skin in the nares and under the elastic band every shift for patient’s receiving
oxygen by mask
9) Inspect oral mucous membranes each shift for anyone that has an endotracheal tube
10) Use STERILE techniques when preforming endotracheal or tracheal suctioning
11) Observe patients receiving oxygen at greater than a 50% concentration for early signs of
oxygen toxicity
12) Signs of oxygen toxicity: dyspnea, nonproductive cough, chest pain, and GI upset
13) Hypoxemia: low blood oxygen
14) Hypoxia: low tissue oxygen
15) PAO2: Partial Pressure of Oxygen in Arterial Blood
16) PAO2 may improve the problem but it will not cure the problem or stop the disease process.
17) Most patients with some degree of hypoxia require O2 flow of 2-4 liters via nasal cannula or
up to 40% via Venturi mask
18) Patients that have hypoxemic and chronic hypercarbia may need lower levels of oxygen delivery.
Usually only 1-2 liters/min per nasal cannula to decrease respiratory effort
19) Clean the cannula or mask by rinsing with clear, warm water every 4-8 hours as needed
20) Lubricate the patients nostrils, face and lips with nonpetroleum cream to relieve drying effects
of oxygen
21) Provide mouth care every 8 hours as need
22) All electrical equipment around oxygen needs to be grounded.
23) The hypoxic drive is a result of chronic CO2 retention not the other way around. The body has
a high CO2, low oxygen, and low pH( whether it's due to respiratory or metabolic).
24) Do not give COPD patients high flow oxygen
25) Monitor patients receiving high levels of oxygen closely for indications of absorption
atelectasis (new onset of crackles and decreased breaths sounds)
26) When oxygen flow rate is higher than 4 liters/min make sure it bubbles through a humidifier
, NURS 2863Med Surg Final 2
27) Notify physician if Paco2 is greater than 90 (too much oxygen in the arteries!)
28) Heated nebulizer raises humidity even more and is used for oxygen delivery through
artificial airways
29) Pseudomonas is the bacteria that can grow in oxygen tubing
30) Change equipment as per policy or protocol which is about every 24 hours for humidification
to every 7 days, and whenever necessary for cannulas and masks
31) For safety of a patient with a tracheostomy, make sure there is a tube of the same type ,
including obturator, and size (or smaller) at the bedside at all times along with a tracheostomy
insertion tray
32) If the tube is dislodged ventilate the patient using manual resuscitation bag and facemask while
another nurse calls the rapid response team
33) If decannulation occurs within the first 72 hours, extend the patients neck and open the tissues
of the stoma with a curved Kelly clamp to secure the airway. Replace the tube, check for
airflow through the tube and check for bilateral breath sounds.
34) Pneumothorax: air in the chest cavity. Can happen during the tracheostomy procedure if air
enters the chest cavity
35) CHEST XRAY AFTER the tracheostomy to check for placement and to assess for pneumothorax
36) Subcutaneous emphysema: occurs when there is an opening or a tear in the trachea and air
escapes into fresh tissue planes of the neck. Air can also progress throughout the chest and
other tissues into the face. Inspect and palpate for air under the skin around the new
tracheostomy
37) If the skin around the new tracheostomy is puffy and you can feel a crackling sensation when
pressing on the skin, notify the physician IMMEDIATLEY!
38) Bleeding in small amounts from the tracheotomy incision can be expected for the first few
days, BUT CONSTANT OOZING IS ABNORMAL! Wrap gauze around the tube and pack gauze
gently into the wound to apply pressure to the bleeding sites.
39) Infection can occur at any time. In the hospital use sterile technique during suctioning and trach
care.
40) Assess the trach site once a shift for purulent drainage, redness, pain or swelling.
41) DO NOT CUT trach dressing because small bits of gauze could aspirated through the tube
42) ALWAYS deflate the cuff before capping the tube with cap, otherwise the patient has NO airway!
43) Ensure adequate hydration which will help liquefy secretions
44) Keep temperature of air entering a tracheostomy between 98.6 and 100.4 degrees (37 -
38 degrees C) and NEVER exceed 104 F
45) Suctioning artificial airway: wash hands, wear protective goggles, maintain standard precautions,
occlude suction source and adjust pressure dial to between 80 and 120 mm Hg to prevent
hypoxemia and trauma to the mucosa. Set up a sterile field, preoxygenate patient for 30
seconds to 3 minutes with 100% oxygen (at least 3 hyperinflations) to prevent hypoxemia.
Keep hyper inflations synchronized with inhalation. DO NOT APPLY SUCTION DURING
INSERTION
46) NEVER SUCTION FOR LONGER THAN 10 to 15 seconds
47) Hyperoxygenate for 1 to 5 minutes or until patient’s baseline heart rate or O2 sats are
within normal limits.
48) Describe secretions, and document patient’s response
49) Suctioning can cause: hypoxia, tissue/mucosal damage, infection, vagal
stimulation, bronchospasm and cardiac dysrhythmias
50) Clean suctioning technique at home!
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