Basic and advanced oxygenation is very essential practical information is need of the hour

1. Oxygenation Needs
Mr. Ramprasad S M.Sc (N), SCEM
Associate Professor
Medical Surgical Nursing, Neurosciences Nursing
Trainer In Skills Lab, FRT, ENLS, BLS, TCLS, GFATM, Research Guide,
Reviewer (IJMR/IJNR/IJOGN), (Member TNAI/NTAI/IPA/NSS/IRS)
14-03-2024 1

2. Factors affecting Respiration
• The following factors affects the normal respiration of
the individual. They are,
a. Internal factors
b. External factors
14-03-2024 2

3. Conditions that affecting the
AIRWAY
14-03-2024 3

4. 1. Allergies
A condition that occur when immune system
respond to foreign particles, such as pollens, dust,
certain food, chemicals, etc.
Allergies are characterized by rashes, cough, sneeze,
running nose, chest congestion, wheezing etc.
14-03-2024 4

5. 2. Bronchial Asthma
A condition characterized by inflammation,
bronchospasm, and edema airway.
Characterized by, cyanosis, rapid pulse, cough,
shortness of breath.
14-03-2024 5

6. 3. Common Cold
Infection of the upper respiratory tract results in
narrowing of the airway.
Common characteristics are,
Cough, running nose, fever, congestion, nose block
14-03-2024 6

7. 4. Bronchitis
It is an inflammatory condition of the bronchial tube.
Common signs are
Production of the mucus, chest tightness, low grade
fever,
14-03-2024 7

8. Conditions that affecting the
Movement of the Airway
14-03-2024 8

9. 1. Dyspnea/Shortness of breath
It is defined as the sensation of breathlessness or
decrease breathing.
Tight feeling in chest, caused by asthma, heart failure,
and lung disease.
14-03-2024 9

10. Grading
Grade 1 :occurs when strenuous activity
Grade 2 : person cant climb the stairs
Grade 3 : occurs in usual activities
Grade 4 : requires assistance during ADL
Grade 5 : occurs at rest
14-03-2024 10

11. Causes
Anemia/
Asthma
Heart and lung disease
Obesity/rib injury/ poisoning
14-03-2024 11

12. 2. Tachypnea
Condition that occurs when respiratory rate more than
20 per minute
14-03-2024 12

13. Causes
Exercise
Increased physical activity
Allergy
Pneumonia / TB
14-03-2024 13

14. Symptoms
Shortness of breath
LOC
Confusion
Sweating
14-03-2024 14

15. 3. Bradypnea
A condition where heart rate less than 16 per minute
Caused by,
Opiods , smoking, alcoholism, sleep apnea, neuro
muscular disorder
14-03-2024 15

16. Symptoms,
Itching , dry skin, hair loss, dizziness, cyanosis, coma
14-03-2024 16

17. Conditions Affecting Diffusion
14-03-2024 17

18. 1. Pulmonary Edema
Abnormal accumulation and collection of fluid in the
lung tissue or in the alveolar space.
14-03-2024 18

19. Causes are,
Severe HTN, MI, cardiomyopathy, kidney failure
14-03-2024 19

20. Clinical Features are
Central cyanosis (lips /nails)
Blood mixed secretions
Dyspnea
Respiratory distress
14-03-2024 20

21. Grunting and wheezing sound
Pale skin
Rapid heart rate
14-03-2024 21

22. Causes
Cardiogenic causes
artherosclerosis, HTN, MI, cardiomyopathy
Non cardiogenic causes
pneumonectomy , renal failure, toxic inhalation
14-03-2024 22

23. 2. COPD
Condition where airflow is obstructed due to
emphysema chronic bronchitis, or both
14-03-2024 23

24. Causes are,
Chronic smoking, infections , obesity , asthma, air
pollution , occupation exposure
14-03-2024 24

25. Features are,
Chronic cough, sputum, chest pain, dyspnea,
hemoptysis, weakness,fatigue
14-03-2024 25

26. A condition characterized by collapse of the lungs, may be acute or
chronic.
Atelectasis
14-03-2024 26

27. Caused due to blockage in the air passages or pressure on the lungs by
outside. The other risk factors are,
Anesthesia, foreign object in the airway, lung disease, tumor
14-03-2024 27

28. Factors affecting Oxygen Transport
14-03-2024 28

29. It is an inability of the heart to pump adequate blood to the parts of the
body.
The primary causes are CHD, HTN, VHD,Cardiomyopathies,
Arrythmias
1. Heart Failure
14-03-2024 29

30. Other causes,
Pulmonary embolism, anemia, anesthesia, increase sodium intake.
14-03-2024 30

31. Nursing Interventions To Promote
Oxygenation
14-03-2024 31

32. Oxygen Administration
14-03-2024 32

33. it is to treat the deficiency in oxygen among the individual but not to
treat the underlying causes. This is important to keep the healthy level
of tissue oxygen.
Introduction
14-03-2024 33

34. To reduce the effect of anoxemia
To maintain healthy tissue level oxygen
Purposes
14-03-2024 34

35. Basics of Anantomy
14-03-2024 35

36. Low Flow System High Flow System
Nasal cannula Venturi mask
Simple mask T-Piece
NRVM/NRBM
Partial Rebreather mask
Methods of oxygen administration
14-03-2024 36

37. Basic Oxygen Delivery Methods
Nasal cannula and face mask are noninvasive interventions.
Useful to deliver O2 if the patient is breathing on their own
Nasal Cannula
(nasal prongs)
Simple face mask Face Mask with
Reservoir bag
Bag-Valve-Mask
(BVM / AMBU bag)
Page 7
14-03-2024 37

38. 1. Nasal cannula
2. Nasal prongs
3. Oxygen mask
4. Oxygen tent
5. Venturi mask
6. Oxygen hood
Methods of oxygen administration
14-03-2024 38

39. A plastic tube that used to administer oxygen which connected to the
oxygen cylinder. The maximum flow of the oxygen will be upto 4L/Min
Nasal cannula
14-03-2024 39

40. 14-03-2024 40

41. It is a disposable.
plastic devise with two protruding prongs for
insertion into the nostrils, connected to an
oxygen source.
Used for low-medium concentrations of
Oxygen (24-44%).
14-03-2024 41

42. Disadvantages
Advantages
Priority Nursing
Interventions
Amount Delivered
F1o2 (Fraction
Inspired Oxygen)
Method
may cause
irritation to the
nasal and
pharyngeal mucosa
if oxygen flow
rates are above 6
liters/minute
Variable FIO2
 Client able to
talk and eat
with oxygen in
place
Easily used in
home setting
Check
frequently that
both prongs are
in clients nares
Never deliver
more than 2-3
Lmin to client
with chronic lung
disease
Low flow
24-44 %
1 Lmin=24%
2 Lmin=28%
3 Lmin=32%
4 Lmin=36%
5 Lmin=40%
6 Lmin=44%
Nasal
Cannula
14-03-2024 42

43. The types of face mask are
The Simple Oxygen Mask
The Partial Rebreather Mask:
The Non Rebreather Mask:
The Venturi Mask:
Face mask
14-03-2024 43

44. 14-03-2024 44

45. The simple Oxygen mask
Simple mask is made of clear,
flexible , plastic or rubber that
can be molded to fit the face.
14-03-2024 45

46. The simple Oxygen mask
It delivers 35% to 60% oxygen .
A flow rate of 6 to 10 liters per minute.
Often it is used when an increased delivery of oxygen is
needed for short periods
(i.e., less than 12 hours).
14-03-2024 46

47. Disadvantages
Advantages
Priority Nursing
Interventions
Amount
Delivered
F1o2 (Fraction
Inspired Oxygen)
Method
Tight seal required to
deliver higher concentration
Difficult to keep mask in
position over nose and
mouth
Potential for skin
breakdown (pressure,
moisture)
Wasting
Uncomfortable for pt while
eating or talking
Expensive with nasal tube
Can provide
increased
delivery of
oxygen for
short period of
time
Monitor client
frequently to check
placement of the
mask.
Support client if
claustrophobia is
concern
Secure physician's
order to replace
mask with nasal
cannula during meal
time
Low Flow
6-10 Lmin
35%-60%
Simple
mask
14-03-2024 47

48. The partial rebreather mask
The mask is have with a reservoir bag must
inflated during both inspiration & expiration
 It collection of the first parts of the patients'
exhaled air.
It is used to deliver oxygen concentrations up
to 80%.
14-03-2024 48

49. The partial rebreather mask
The oxygen flow rate must be
maintained at a minimum of 6
L/min to ensure that the patient
does not rebreathe large amounts
of exhaled air.
The remaining exhaled air exits
through vents.
14-03-2024 49

50. The non rebreather mask
 This mask provides the highest
concentration of
oxygen (95-100%) at a flow rate6-15
L/min.
It is similar to the partial rebreather
mask
except two one-way valves prevent
conservation of exhaled air.
The bag is an oxygen reservoir
14-03-2024 50

51. Disadvantages
Advantages
Priority Nursing
Interventions
Amount Delivered
F1o2 (Fraction
Inspired Oxygen)
Method
Requires
tight seal
(eating and
talking difficult,
uncomfortable
Not as drying
to mucous
membranes
PT can inhale
room air
through
openings in
mask if
oxygens
supply is
briefly
interrupted
Set flow rate
so mask
remains tow-
thirds full
during
inspiration
Keep
reservoir bag
free of twists
or kinks
Low Flow
6 Lmin
75%-80%
oxygen
Partial
Rebreather
Mask
14-03-2024 51

52. Disadvantages
Advantages
Priority Nursing
Interventions
Amount
Delivered
F1o2
Method
Impractical for long
term Therapy
Malfunction can cause
CO2 buildup
suffocation
Expensive
Feeling of suffocation
Uncomfortable
Costly
Delivers the
highest possible
oxygen
concentration
Suitable for pt
breathing
spontaneous with
sever hypoxemia
Maintain flow rate so
reservoir bag collapses
only slightly during
inspiration
Check that valves and
rubber flaps are
function properly (open
during expiration )
Monitor SaO2 with
pulse oximeter
Low
Flow
6-15 L
min
80%-
100%
Non
rebreather
MASK
14-03-2024 52

53. Venturi mask
 It is high flow concentration of
oxygen.
Oxygen from 40 - 50%
At liters flow of 4 to 15 L/min.
14-03-2024 53

54. Disadvantages
Advantages
Priority
Nursing
Interventions
Amount
Delivered
F1o2
Method
uncomfortable
Risk for skin
irritation
produce respiratory
depression in COPD
patient with high oxygen
concentration 50%
Delivers most
precise oxygen
concentration
Doesn’t dry
mucous
membranes
(humidity
Requires
careful
monitoring to
verify F1O2 at
flow rate
ordered
Check that
air intake
valves are not
blocked
Oxygen from
40-- 50%
of 4 to 15
L/min.
Venturi
Mask
14-03-2024 54

55. T-piece
Used on end of ET
tube when weaning
from ventilator
Provides accurate
FIO2
Provides good
humidity
14-03-2024 55

56. Side effect & complication of oxygen therapy
Oxygen toxicity
Retrolental fibroplasia
Absorption atelectasis
14-03-2024 56

57. oxygen toxicity
It is a condition in which ventilator failure
occurs due to inspiration of a high
concentration of oxygen for aprolonged
period of time.
Oxygen concentration greater than 50% over 24 to 48 hours can
cause pathological changes in the lungs.
14-03-2024 57

58. Signs and symptoms of oxygen toxicity
Non-productive cough.
• Nausea and vomiting.
• Sub sternal chest pain.
• Fatigue.
• Nasal stuffiness.
14-03-2024 58

59. Sore throat.
• Hypoventilation.
. Nasal congestion.
. Dyspnea.
. Inspiration pain
14-03-2024 59

60. Evaluation
Breathing pattern regular and at normal rate.
 pink color in nail beds, lips, conjunctiva of eyes.
 No confusion, disorientation, difficulty with cognition.
Arterial oxygen concentration or hemoglobin
 Oxygen saturation within normal limits.
14-03-2024 60

61. Documentation
Date and time oxygen started.
Method of delivery.
Oxygen concentration and flow rate.
Patient observation.
Add oro nasal care to the nursing care plan
14-03-2024 61

62. Oxygen Delivery and Maintaining the Airway
Page 9
Delivery Method O2 lpm O2 % Skill level Airway Patency
BASIC
Nasal Cannula 1-4 24 - 36 Minimal
Conscious patient with patent airway,
If the patient is breathing spontaneously
Simple Mask 5-10 40 - 60 Minimal
Non-Rebreather Mask 10-15 60 - 90 Minimal
Bag Valve Mask (BVM) /
AMBU bag
>15 20 - 95 Basic
Reduced consciousness (or unconscious)
Consider insertion of nasal or oral airway
Manual positive pressure ventilation (PPV)
ADVANCED
LMA, ETT and Crico-
thyroidotomy >15 21 - 100 Advanced
Unconscious (if not, needs sedation) and
airway not protected
Start with manual PPV with bag valve.
Connect to ventilator when available
14-03-2024 62

63. Summary
Oxygen Administration can be done under the following ways.
Invasive and Non Invasive
Supraglotic and Infra Glottis
Slow flow rate and High flow rate
14-03-2024 63

64. Maintaining The Airway
Methods of Maintaining Airway Patency
14-03-2024 64

65. The following methods are used to maintain the airway,
1. Positioning
2. Manoeuvres
a. Head Tilt and Chin lift
b. Jaw Thrust
3. Suction
4. Use of airway adjuncts
a. Nasopharyngeal Airway
b. Oropharyngeal Airway
14-03-2024 65

66. 5. Advanced Airway Methods
a. Laryngeal Mask Airway (LMA)
b. Endotracheal Intubation (ETT)
c. Cricothyroidotomy
14-03-2024 66

67. • Patient positioning:
• Manual airway maneuvers
• Towel support under shoulders
• Suctioning
• Supplemental oxygen
• Airway adjuncts
• Advanced airway placement
67
14-03-2024 67

68. Airway Management Techniques
• Airway Maneuvers: Chin lift / jaw thrust (most basic)
• Airway adjuncts: Oral, nasal
• Bag-Valve-Mask (BVM)
• Supraglottic Airways
• Endotracheal intubation
• Cricothyrotomy (most advanced)
68
14-03-2024 68

69. Airway Management – The Basics
The tongue is the commonest cause of airway obstruction.
69
14-03-2024 69

70. Jaw thrust
head tilt
chin lift
Head Tilt
+
Chin Lift
Or
Jaw Thrust
Head tilt and chin lift contraindicated in:
- Trauma
- History of neck surgery or cervical spine pathology
Only jaw thrust
Airway Management – Open the Airway!
14-03-2024 70

71. Airway Adjuncts
Airway adjuncts should be used as early as possible when needed
Nasopharyngeal Airway (NPA) Oropharyngeal Airway (OPA)
• In conscious and
unconscious patients
• Only in unconscious
patients
• DON’T use if gag reflex is
intact
14-03-2024 71

72. Nasopharyngeal Airway
1. Can be used both conscious and unconscious patients
2. Used easily and effectively
3. Check the appropriate size of the NPA
4. Position the airway accurately
5. Contraindicated in nasal fractures
14-03-2024 72

73. 14-03-2024 73

74. Adult 6 to 9 cm.
small adult 6 to 7
medium size adult 7 to 8 cm
large adult 8 to 9 cm
NPA airway sizes
14-03-2024 74

75. Oropharyngeal Airway
1. Can be used only in unconscious patients
2. Avoid using when the Gag reflex in intact
3. Avoid in oral trauma/spasm of mouth muscles
4. Check the appropriate size of the OPA
5. Position the airway accurately
6. Contraindicated in conscious patient
14-03-2024 75

76. OPA airway sizes
14-03-2024 76

77. Neonatal 00
Infant 0
Child 1
Small adult 2
Adult 3
Large adult
4
5
6
14-03-2024 77

78. Endotracheal Intubation
https://www.youtube.com/watch?v=70fhNvE6aGQ
14-03-2024 78

79. ENDOTRACHEAL INTUBATION
Endotracheal Intubation is placement of special
tube in trachea. Endotracheal intubation is employed to
relieve upper airway obstruction, maintain a patent
airway or treat impending or actual respiratory failure
from any cause.
14-03-2024 79

80. Indications/Purposes
To secure airway
To supply oxygen
For general anesthesia
For cardiopulmonary resuscitation
For ventilator therapy in ICU
14-03-2024 80

81. Articles
Endotracheal tubes
Laryngoscope blades
Oral airway
Suction devices: catheters and tonsil tip
Intravascular catheters, spinal needle, or bone marrow
needle.
Oro gastric tube
14-03-2024 81

82. Laryngoscope handles and blades
Scissors ,Gloves, Syringes, Needles,
14-03-2024 82

83. Pre-Procedure
I. Assess current respiratory status and history including
Reason for intubation.
Response to intubation.
II. Auscultate breath sound bilaterally
III. Evaluate respiratory effort
Respiratory rate
Respiratory pattern
14-03-2024 83

84. V. Auscultate breath sound bilaterally.
VI. Evaluate respiratory effort.
Respiratory rate, Respiratory pattern,
Chest expansion: equal and bilateral
14-03-2024 84

85. VIII. Observe colour and tissue perfusion.
IX. Assess heart rate.
Assess activity and alertness, irritability, confusion, fatigue,
lethargy, inappropriate behavior and coma.
Assess child and family's understanding of need, purpose and
functioning of intubation.
14-03-2024 85

86. Procedure
1. Confirm availability of all equipment
2. Wear PPE
3. Perform hand washing
4. Don gloves
5. Take laryngoscope and place inside the throat to visualize the glottis
6. Take appropriate sized ET tube and put bougie into it
7. Inflate the ET tube and check its efficacy
8. Bend the ET tube and insert into the mouth upto trachea
14-03-2024 86

87. Procedure (Contd…)
9. Once the ET tube is placed remove the styllet or bougie and inflate the tube
with 5-7 ml of air.
10. Secure the ET Tube with the adhesive plaster and confirm its placemat by
auscultation.
11. Check the inflation by using AMBU (chest should expand)
12. Do 5 point auscultation including epigastrium (sound will be absent at
epigastrium)
14-03-2024 87

88. CHEST PHYSIOTHERAPY
14-03-2024 88

89. Definition
Chest physiotherapy (CPT) is a therapeutic
intervention applied to help natural airway clearance
mechanisms (cough and ciliary cleansing mechanisms)
reduce or prevent blockage of airways by thick,
tenacious mucus
14-03-2024 89

90. Purposes/Indication
• Assist in coughing
• Reeducate breathing muscles
• Improve ventilation of the lungs
14-03-2024 90

91. Contraindications
• Increased ICP
• Unstable head or neck injury
• Active haemorrhage or heamoptysis
• Recent spinal injury
• Rib fracture
• Uncontrolled hypertension
• Thoracic surgeries
14-03-2024 91

92. Articles Needed
Tilt bed and/or pillows
Towels or thick pad
Sputum cup/tissue
Stethoscope
14-03-2024 92

93. Types of CPT
The procedure of chest physiotherapy includes the
following types,
1. Percussion
2. Chest Vibration
3. Deep breathing Exercises
4. Postural drainage
5. Coughing
14-03-2024 93

94. Preprocedure care
• Identify physical indications for CPT.
• Identify possible contraindications for CPT.
• Determine child's age, developmental level, ability to
understand procedure, and ability to cooperate.
• Assess diversional activities child might enjoy during CPT.
• Determine parent's under-standing of and ability to perform
CPT at home.
• Assess ability of older child to do self-physiotherapy
14-03-2024 94

95. Percussion/tapotment/clapping/cupping
• Therapist and parents should wash hands before
treatment.
• Administer bronchodilators as ordered before CPT.
• Select areas of lungs to be percussed.
• Treatments may be split up into sections and
performed at various times throughout the day
14-03-2024 95

96. • Assist person in assuming proper positioning, placing
pillows for comfort, support and to maintain position.
• Perform percussion using cupped hands. Clap
rhythmically over specific area to be drained. Mold hands
side by side.
14-03-2024 96

97. Alternate hands while clapping. Clapping should be
vigorous, not painful. Percuss 1 minute over lung segment to
be drained.
14-03-2024 97

98. Procedure
1. Check the right patient
2. Explain the procedure to the patient
3. Check the last meal that he has consume
4. Wash hands and dry
5. Inform the patient to perform diaphragmatic
breathing
6. Position the patient
14-03-2024 98

99. Percussion
1. clap with cupped hands over the chest wall for over 1-2
min in each lung area
2. the percussion should be from lower ribs to shoulder on
the back and from lower ribs to top of the chest in the front
3. Avoid percussion on spine, liver , kidney, spleen, breast
and clavicle.
14-03-2024 99

100. 14-03-2024 100

101. 14-03-2024 101

102. Vibration
1. place hand /palm down on chest area to be drained with one
hand over the other or fingers together.
2. Patient should inhale and exhale slowly through pursed lips
3. Vibrate for 5 exhalations in each lungs after 3-4 vibrations
encourage patient to cough and clear the secretion
14-03-2024 102

103. Post Procedure
1. Allow patient to rest
2. Auscultate and check the breath sound
3. Repeat cycle for 10-15 minutes based on patient condition
4. Wash hands
5. Comfort the patient
14-03-2024 103

104. Special Considerations
1. CPT should be perform 1 hour before meals and 1-3 hours after meal
2. Administer bronchodilator and MDI 15 minutes earlier
3. Check breathing pattern and cyanosis in him
4. Administer pain killers 15-20 minutes before
5. Stop procedure if there is tachycardia/fall in BP/chest pain
14-03-2024 104

105. Postural Drainage
Also called as bronchial drainage, an intervention
for airway clearance by mobilizing secretions in
one or more lung segments to the central airway
by placing the patient in various positions.
14-03-2024 105

106. Indications
1. Cystic fibrosis
2. Bronchiectasis
3. Pulmonary diseases
4. Patient with artificial airway
14-03-2024 106

107. Contraindications
1. Severe hemoptysis
2. Cardiac arrhythmias
3. Neurosurgery patients
4. Unstable angina
14-03-2024 107

108. 5. Plural effusion
6. Pneumothorax
7. Pulmonary embolism
14-03-2024 108

109. Preparations
1. Check the clinical findings and indications for
PD
2. Tilt the patient to drain the secretions
3. Lower lobes requires the PD than upper lobe
14-03-2024 109

110. 4. Provide bronchodilators or Nebulizer
5. The PD can be scheduled 3-4 times a day based
on degree of lung congesion
6. Time is before breakfast/lunch and bed time
14-03-2024 110

111. Care of Chest Drainage
14-03-2024 111

112. 14-03-2024 112

113. 14-03-2024 113
• Parietal pleura: Inside membrane of the rib cage
• Pulmonary or visceral pleura: Outside membrane of the lungs
• The two membranes are separated by a lubricating fluid (pleural
fluid) which enables them to slide against each other. Lung can
expand and contract
• Vacuum or “negative pressure” in the pleural space keeps the two
pleurae together. If fluid or air enters the pleural space, lungs cannot
fully expand during each respiratory cycle

114. Chest TUBE Placement

115. Normal Breathing Mechanics
Diaphragm
contracts down &
draws air into the
trachea, bronchi,
bronchioles, and
alveoli. Negative
pressure between
the pleurae is
approximately
-8cmH2O
Diaphragm relaxes,
rises, and pushes air
& CO2 back out the
same route. Negative
pressure between
the pleurae is
approximately -
4cmH2O
INHALATION EXHALATION

116. 14-03-2024 116
• Pneumothorax: Air in the pleural space (trauma, lung
disease, procedure complications)
• Hemothorax: blood in the pleural space (blunt or penetrating
trauma)
• Hemopneumothorax: air & Blood in the pleural space
• Tension pneumothorax: occurs when injured tissue forms a
one way valve or flap allowing air to enter but preventing it
from escaping naturally, (emergent situation)

117. Indications For Chest Tube Insertion
•Pleural effusion: excessive fluid in pleural space
•Empyema: collection of pus d/t infection
•Chylothorax: lymphatic fluid accumulation in the
pleural space (trauma, expanding tumor, surg in the
mediastinum) – milky white pleural fluid
14-03-2024 117

118. Insertion Site
Superior Tube Placement:
Removal of Air (ie.
Pneumothorax)
Inferior Tube Placement:
Removal of Fluids (ie.
Hemothorax, Empyema)
Posterior Tube Placement:
Loculated (confined pocket)
fluid or air

119. Insertion Site
“Safe Triangle”
Tube placed in the midaxillary line
btw 4th and 5th Ribs should
successfully drain fluid or vent air

120. CHEST TUBE SYSTEM

121. 3 Bottle System
Patient
Suction
Collection
Bottle
Water
Seal
Suction
Control

122. Collection Bottle and Water Seal
Collection Chamber: Collects drainage
Water Seal: Maintained at 2cm, One way valve; Prevents air or
fluid from returning to the chest
Patient
SUCTION

123. Nursing Assessments
and Interventions

124. Assessment
USE THE ACRONYM
S = Site
T = Tubing
O = Output
P = Patency

125. STOP
S = Site
Check Site:
• Ensure tube is in place,
• No S&S of infection
• Dressing CDI, change q48h & PRN wet
or soiled. Sterile technique, occlusive
dressing
 Subcutaneous emphysema

126. Subcutaneous Emphysema (Air
Underneath the Skin)
Subcutaneous emphysema
(air trapped under skin)
a. Palpate – Crepitis (Rice Krispies)
b. Notify MD
c. Continuous Monitoring

127. Check the Dressing & Site

128. sTOP
T = Tubing
 Connections are secured
 No dependent loops, kinks
 Straighten periodically
 Keep the drainage system
below patient’s level

129. STOP
O = Output
 Document amount, type and color
 Check the level regularly
 Document in Epic – LDA
 Use the white write-on column on
the drainage chamber to mark
drainage include date & time
(Check with your unit to see how
often)

130. STOP
P = Patency (A: water seal)
 Assess the water seal with the suction off
 If water seal level is too high, it will be more difficult
for air to leave the chest (aspirate water via grommet)
 If the water seal level is too low, it leaves the water
seal chamber at risk for exposure to air and can cause
a pneumothorax (add sterile water via grommet)

131. STOP
P = Patency (B: Bubbling)
Bubbling means there is a leak in the system unless the
patient has a pneumothorax.
• Intermittent bubbling may indicate air leak from
pleural space, will resolve when lung re-expands
• Continuous bubbling suspect a leak in the system

132. STOP
P = Patency (C: fluctuations)
 Normal:
 Inspiration the water seal level will reach -10cm
 Expiration the water seal level will reach -4cm of
negative pressure normally
 If fluctuations stop, the tubing may be obstructed (kinks,
pt lying on tubing, stuck in railing, etc.)
 If more than 2cm of water the drainage will decrease
 If less than 2cm of water there is risk of pneumothorax

133. Assess pulmonary status
• Respiration Rate
• Work of Breathing
• Breath Sounds
• Continuous SpO2
Monitoring

134. At the bedside
• Always keep drain BELOW the
chest for gravity drainage
• Creates a pressure gradient with
relatively higher pressure in the
chest
• Fluid moves from an area of
higher pressure to an area of
lower pressure

135. At the bedside –
Emergency actions
Dislodged tube from pt.
• Cover open insertion site with
Vaseline gauze at peak
inspiration
• Cover with 4x4’s gauze & tape
three sides only
• Notify M.D. STAT
• chart event
Dislodged from collection
device
• place the end of the tube into
bottle of sterile water to create a
one way valve.
• Prepare new drainage device
and connect to pt tubing

136. Items to be kept at bedside
• 2 clamps
• Vaseline gauze
• 4x4 gauze dressing
• Non-porous tape
• Sterile water bottle or NS

137. Clamping
Clamp Only When
 Changing the device (the drainage system)
 Checking for an air leak
 Tubing is disconnected and sterile water is out of reach
 Checking lung re-expansion prior to chest tube removal
DO NOT Clamp
 Ambulating Patient (will increase risk of tension
pneumothorax)
 Transport – Disconnect suction tubing at Suction Control Stop
cock, leave open

138. Chest Tube removal
INDICATIONS:
• Improved respiratory status
• Symmetrical rise and fall of chest
• Bilateral Breath Sounds
• Decreased chest tube drainage
• Absence of bubbling in the water seal chamber during
inspiration
• Improved CXR findings

139. Chest Tube removal
Process:
• Premedicate to relieve pain
• Teach valsalva maneuver (preformed before tube removal
to prevent air from reentering pleural space)
• Supplies: sterile gloves, goggles, gown, mask, dressing
supplies, sterile suture removal kit, wide occlusive tape.

140. • Semi-Fowlers position
• Practitioner clamps chest tube, pt peforms
Valsalva maneuver, chest tube removed
• Occlusive dressing applied
• Post CT removal CXR – ensure lung
remains fully inflated
14-03-2024 140

141. Pulse Oximetry
Pulse Oximeter is used to measure the level of
oxygen saturation in the body that shows the
amount of oxygen that hemoglobin is carrying in
the blood
14-03-2024 141

142. Normal oxygen saturation in adult is 95%-100%
14-03-2024 142

143. 14-03-2024 143

144. Working Principles
14-03-2024 144