Skills 118

Tuesday, 20 August 2024

2:14 pm

Manual Ventilation (ambu bag)

 It is a basic skill that involves airway assessment and maneuvers to open the
airway, and application of simple and complex airway device and effective
pressure ventilation using ambu-bag or bag valve mask.

Mechanical Ventilation
 Use of machine (respirator) move air in and out of the lungs

Continuous Positive Airway Pressure (CPAP)

 Use for pedia and a common treatment with sleep apnea or apnea.

o Pedia vital signs-

 Weight, basis of computation of doses in pedia's medications
 Age, if weight is not viable age can be the secondary vital signs but not
reliable.
 Input and output, viable assessment in pedia using scaling the diaper.

Bag-Valve Mask Ventilation (Ambu-bag)

 Standard method or rapid rescue ventilation to patient with apnea or respiratory
failure
 Successful BVM requires technical competence and depends on 4 things:
a. Patent airway
b. Adequate mask seal
c. Proper ventilation technique
d. Keep bag as needed to improve oxygenation (KBIO)
  Equipment: gloves, mask, gown, ambu-bag, eye protection, oropharyngeal
airway, KY jelly (lube)/sterile water, Positive End-Expiratory Pressure valve
(PEEP), face mask, O2 (100% 15L/min), suctioning apparatus, catheter, pulse
oximeter, capnography
 Indicated: OR apnea, respiratory failure/arrest, pre-ventilation, oxygenation for
artificial airway (ET airway)
 Contraindicated: DNR patient
 Complications: prolonged/improper way cause gastric distension (remove the
tube ASAP)

When is BVM Needed?

 Apneic
 Bradypnea
 Tachypnea
 Shallow pulse
 Decrease LOC without the decrease of O2 sat
 Respiratory distress- cardinal sign: rising and falling of shoulder

Additional considerations for BVM ventilation

 Two- person bag-valve mask (BVM) ventilation is used whenever possible. Bag-
valve mask ventilation can be done with one person or two, but two-person BVM
ventilation is easier and more effective because a tight seal must be achieved
and this usually requires 2 hands on the mask.
 Characteristics that predict difficult bag ventilation (and can thus help
troubleshoot if ventilation is difficult) are described by the mnemonic MOANS:
o M – Mask Seal: Facial hair or facial trauma can interfere with creating an
adequate seal
o O – Obesity/Obstruction: Obesity can be a sign of increased soft tissue
in the airway and thus may cause further occlusion when the patient is
obtunded. Obstruction by other soft tissues or a foreign body can also
prevent adequate ventilation.
o A – Age: Extremes of age can predict who may be difficult to ventilate
using a BVM due to anatomical changes.
o N – No teeth: Performing BVM on a patient without teeth is usually
ineffective, a supraglottic airway may be indicated.
 o S – Snoring: Snoring respirations can indicate that soft tissue, usually the
tongue, is occluding the airway and that repositioning (e.g., head-tilt, chin-
lift, jaw thrust) is required.

Performing BVM
1. Use BVM ventilation to provide assistive breaths.
2. Attach the BVM to an oxygen flow meter at greater than 10 L/min.
3. Place the mask over the patient’s mouth and nose with one hand and using your
other hand, follow the patient’s breathing by gently and slowly squeezing the
BVM to provide assistive ventilation.
4. Be aware that hyperventilation and overinflation force air into the stomach, which
can lead to gastric distention and place the patient at risk for aspiration. Also, the
patient won’t be adequately ventilated.
5. You’re providing ventilation, watch for the rise and fall of your patient’s chest,
listen for clear breath sounds on auscultation, and check for improved oxygen
saturation and skin color.
6. Applying techniques you learned in basic life support helps you manage the
patient’s airway and ensure effective BVM ventilation.

Inserting an Oral or Nasal Airway

 If you can’t provide adequate ventilation, the patient’s tongue may be obstructing
the upper airway. Use an oral or nasal airway to displace the tongue forward.

Using the Head-tilt/Chin-lift Maneuver

 Use the head-tilt/ chin-lift maneuver to open a patient’s airway, unless you
suspect cervical spine injury, in which case, you should use a modified jaw
thrust.
 Position the mask so it covers the patient’s nose and mouth. If the mask sits over
the patient’s chin, you may have to read – just it so it sits near the edge of the
chin, or get a smaller mask.

Tongue Trouble
 The illustration on the left shows the patient’s tongue obstructing the upper
airway. In the illustration on the right, the patient’s head has been properly
positioned to move the tongue forward, so air can flow into the lungs.
Using a Bag-Valve Mask (BVM) Resuscitator for Ventilations
1. Select and insert the correct size of OPA, if applicable:

2. Responder 1: Assemble right size of BVM.

3. Responder 2: Attach BVM (adult, child, or baby) to supplemental oxygen.

4. Responder 1: Position mask, then open airway and seal mask:

a. Place thumbs on each side of the mask.
b. Place fingers on both hands along jawbone.
c. Open airway using head-tilt/ chin-lift (or jaw thrust if head and/or spine
injury is suspected); for a baby, place padding under shoulders prior to
opening airway.
d. Apply downward pressure with thumbs while lifting jaw upward with
fingers.
 5. Responder 2: Begin ventilations:
a. Squeeze bag smoothly just wait until chest starts to rise.
b. Give 1 ventilation every 5-6 seconds (1 every 3-5 seconds for a child or a
baby).
c. Watch chest to see if air is going in.
d. Recheck pulse and breathing after minutes and every few minutes
thereafter.

Endotracheal and Tracheostomy Care and Suctioning

Endotracheal Suctioning
 Endotracheal tube (ETT) suction is essential to clear secretions so that airway
patency can be maintained. A stuck suction catheter is ETT is an uncommon
event, and it can be dangerous in patients with difficult airway cases.

What is Endotracheal Suctioning?

 The suction of the endotracheal tube (ETT) is a routine and common procedure
in the intensive care unit to clear secretions and to keep the airway patent so that
oxygenation and ventilation in an intubated patient can be optimized.
 ETT suction can cause hypoxia due to oxygen suction from the lung and alveoli
collapse. However, it can be managed with ventilation with 100 oxygen with
positive and expiratory pressure for some time. However, impaction of the
suction catheter in ETT can be a hazardous event as the patient cannot be
ventilated unless ETT is changed.
Purpose
1. To maintain a patent airway by removing accumulated tracheobronchial
secretions using sterile technique.
2. To improve oxygenation and reduce the work of breathing.
3. Prevent infection and atelectasis from the retained secretion.

Indications
 The need to remove accumulated pulmonary secretions as evidenced by one of
the following:
a. Coarse breath sounds by auscultation of lungs or ‘noisy’ breathing
(rhonchi sound)
b. Increased peak inspiratory pressures during volume-controlled mechanical
ventilation or decreased tidal volume during pressure-controlled
ventilation.
c. Patient’s inability to generate an effective spontaneous cough.
d. Visible secretions in the airway.
e. Changes in monitored flow and pressure graphics.
f. Deterioration of arterial blood gas values.
g. Suspected aspiration of gastric or upper airway secretions.
h. Clinically apparent increased work of breathing.

Parts of Endotracheal Tube

Potential Complications
1. Hypoxemia (Decreased oxygen in the blood)
2. Dysrhythmias
3. Nosocomial pulmonary tract infection (most common complication of ETT tube
suctioning)

Nursing Management
 1. Observe for the sign and symptoms of need to perform ET tube care: soiled or
loose tape, pressure sore or nares, lips or corner of mouth, and excess nasal or
oral secretions.
2. Observe for factors that increase risk of complications from ET tube: type and
size of trachea (in and out), duration of tube placement, cuff over inflation or
under inflation, presence of fascial trauma, malnutrition and neck or thoracic
radiation.
3. Assess client’s knowledge of procedure.
4. Obtain another nurse’s assistance in the procedure.
5. Explain procedure and client’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, removal of tape from face
can be uncomfortable.
6. Assess client to assume position comfortable for both nurse and client (usually
supine or semi-fowlers)
7. Wash hands and administer endotracheal, nasopharyngeal and oropharyngeal
suction.

Tracheostomy
 It is a surgical incision into the trachea via the throat with a tube inserted.

Indication
1. For exploration.
2. For removal of foreign body.
3. For obtaining specimen.
4. For gaining access to the airway for assisting in inspiration.

Types of Tracheostomy
 Permanent
 Temporary

Purposes
1. To facilitate prolonged artificial ventilation.
2. To by-pass serious upper respiratory obstruction.

Objectives of Tracheostomy Care

1. To keep tracheostomy tubes patent and free from mucus.
2. To prevent infection to the area and respiratory complications.
3. To prevent trauma to the ostomy-bronchial areas.
4. To develop skills in tracheostomy care and suctioning effectively with little
discomfort for the patient.
Tracheostomy Care
Purpose
 Maintain airway patency by removing mucus and encrusted secretions.
 Promote cleanliness and prevent infection and skin breakdown at the stoma site.

Assessment of Tracheostomy
 Identify factors that influence tracheostomy care:
o Inadequate nutritional status predisposes the client to infection, poor
healing and weak cough reflex.
o Respiratory infection: pulmonary secretions increase in amount. Note
color, amount, and odor.
o Fluid status: inadequate hydration increases the tenaciousness of
secretions. A client may have difficulty coughing up thick secretions.
o Humidity: tracheostomy collars deliver humidified air to prevent dry,
cracked membranes and thickened secretions.

Equipment
 Sterile tracheostomy care kit containing:
o Two basins
o Small brush or pipe cleaners
o 4” x 4” gauze
o Commercially available tracheostomy dressing
o Twill tape or tracheostomy ties
 Hydrogen peroxide
 Normal saline
 Sterile gloves
 Scissors
Procedure
Procedure Rationale
1. Verify the physician order and identify Prevents potential errors.
the client.
2. Wash your hands and don gloves. Handwashing and gloves
reduce the transmission of
microorganisms.
3. Explain the procedure to the client. Teaching decreases client
Place the client in semi – to high anxiety and increases
Fowler’s position. compliance.

Fig 1: Greet client and explain procedure.

4. Suction tracheostomy tube. Before Removing secretions maintains
discarding gloves, remove soiled a patent airway while doing
tracheostomy dressing and discard tracheostomy cleaning.
with catheter inside glove. When
suctioning through a tracheostomy
tube, insert catheter about 10 to 12 cm
(in an adult).
5. Replace oxygen or humidification Maintain good oxygenation
source and encourage client to deep- status. Promotes easy removal
breathe as you prepare sterile prior to sterile procedure.
 supplies. Do not snap in place.
6. Open sterile tracheostomy kit (Fig. 2). Preparing equipment allows for
Pour normal saline into one basin, smooth, organized performance
hydrogen peroxide into the second of tracheostomy care.
(Fig. 3). Don Sterile gloves (Fig. 4).
Open several sterile cotton-tipped
applicators and one sterile precut
tracheostomy dressing and place on
sterile field (Fig. 5). If kit does not
contain tracheostomy ties, cut two 15-
inch pieces of twill tape and set aside.

Figure 2. Open sterile tracheostomy kit.

Fig 3: Pour sterile hydrogen peroxide into

basin.

Fig 4: Don sterile gloves.

Fig 5: Place items on sterile field.

7. Remove oxygen source (Fig. 6). The Prevents contamination of

hand that touches the oxygen source is sterile gloves.
no longer sterile. Note: For trache ostomy
tube with inner cannula, complete Steps
7 to 25. For tracheostomy tube without
inner cannula or plugged with a button,
complete Steps 14 to 25.

Fig 6. Remove oxygen source.

8. Unlock inner cannula by turning
counterclockwise. Remove inner cannula
(Fig. 7)

Fig 7: Unlock inner cannula by turning counter-

clockwise.
9. Place inner cannula in basin with Hydrogen peroxide loosens
hydrogen peroxide (Fig. 8). and removes secretions from
inner cannula.
Fig 8: Place inner cannula into basin with
hydrogen peroxide.
10. Replace oxygen source over or near Maintain a constant supply of
outer cannula. oxygen to prevent respiratory
or cardiac distress. Note: Not
all clients require a constant
oxygen supply during
tracheostomy care.
11. Clean lumen and sides of inner cannula Mechanical force and friction
using pipe cleaners or sterile brush (Fig. are needed to remove thick
9). or dried secretions
12. Rinse inner cannula thoroughly by Rinsing and agitation remove
agitating in normal saline for several secretions and water from
seconds (Fig. 10). cannula and provide
lubrication for easy
reinsertion.

Fig 10: Rinse inner cannula in normal saline.

13. Remove oxygen source and replace Oxygen is reestablished to a
inner cannula into outer cannula. "Lock" secured inner cannula.
by turning clockwise until the two blue
dots align (Fig. 11). Replace oxygen or
humidity source.

Fig 11: Replace inner cannula, then lock into

place.
 14. Remove tracheostomy dressing from
under faceplate (Fig. 12).

Fig 12: Remove soiled tracheostomy dressing.

15. Clean stoma under faceplate with circular Dried secretions are a good
motion using hydrogen peroxide-soaked medium for bacterial growth.
cotton applicators. Clean dried secretions
from all exposed outer cannula surfaces
(Fig. 13).

Fig 13: Clean secretions from tracheostomy site

with cotton applicator.
16. Remove foaming secretions using normal Hydrogen peroxide can be
saline-soaked, cotton-tipped applicators. irritating to the skin.
17. Pat moist surfaces dry with 4" × 4" Moist surfaces support
gauze. growth of microorganisms
and skin excoriation.
18. Place dry, sterile, precut tracheostomy Frayed cotton fibers from cut
dressing around tracheostomy stoma and gauze could be aspirated into
under faceplate (Fig. 14). Do not use cut the trachea.
4" × 4" gauze.

Fig 14: Replace new precut tracheostomy

dressing.
 19. If tracheostomy ties are to be changed, This action prevents
have an assistant don a sterile glove and accidental displacement of
hold the tracheostomy tube in place. the tracheostomy tube if
the client moves or coughs
when the ties are not
secure.

For Tracheostomy Ties, follow steps 20-24

20. Cut a 12-inch slit approximately 1 inch
from one end of both clean
tracheostomy ties. This is easily done
by folding back on itself 1 inch of the
tie and cutting a small slit in the
middle.
21. Remove and discard soiled
tracheostomy ties.
22. Thread end of tie through cut slit in tie. The tie is secured to the
Pull tight. faceplate without using knots.
Knots are difficult to undo when
ties become crusted with
secretions.
23. Repeat Step 21 with the second tie.
24. Bring both ties together at one side of Ties must be taut enough to
the client's neck. Assess that ties are prevent accidental dislodging of
only tight enough to allow one finger tracheostomy tube but loose
between tie and neck. Use two square enough not to cause choking or
knots to secure the ties. Trim excess pressure on the jugular veins.
tie length. Note: Assess tautness of Ties at side of neck are more
tracheostomy ties frequently in clients comfortable for the client.
whose neck may swell from trauma or
surgery.

For Tracheostomy Collar, follow steps 25-27

25. While an assisting nurse holds the faceplate,
gently pull the Velcro tab and remove the collar
on one side. Insert the new collar into the
opening on the faceplate and secure the
Velcro tab.
26. Hold faceplate in place as the assisting nurse
repeats step on the second side (Fig. 17).
 Fig 17: Insert new collar on second side and secure
Velcro tab.
27. Remove the old collar and ensure that the new
collar is securely in place (Fig. 18).

Fig 18: Discard soiled collar, ensure new collar is

securely in place.
28. Remove gloves and discard disposable Opened normal saline
equipment. Label with date and time, and store is considered sterile for
reusable supplies. 24 hours.
29. Assist client to comfortable position and offer Promotes client
oral hygiene. comfort.
30. Wash your hands. Maintains infection
control and
communicates with
other healthcare team
members.

Tracheostomy Tube Anatomy

Foreign Object Removal/ Heimlich Maneuver
 Each year, many people die from choking on objects that obstruct their airways
and cause suffocation.
 Choking is in fact the fourth leading cause of unintentional death. However, there
is a simple technique you can use to help expel a trapped object from another
person’s airway. You can even use a version of this technique on yourself. The
technique is called the Heimlich maneuver or abdominal thrusts.
 Abdominal thrusts lift your diaphragm and expel air from your lungs. This causes
the foreign object to be expelled from your airway. The Red Cross also
recommends including five back blows, although some institutes, such as the
American Heart Association, don’t teach this technique.

How to Perform Heimlich Maneuver

This steps you need to perform a Heimlich maneuver depend on who you’re aiding:
 Another person who isn’t pregnant or an infant (under a year old)
 A pregnant woman or an infant
 Yourself
 Regardless of whom you perform the maneuver on, that person should still get
medical help afterward. This is to ensure no physical damage has occurred to
their throat and airways.

On Someone (other than a Pregnant or an Infant)

 Determine whether you need to perform abdominal thrusts. If a person who
appears to be choking is conscious and coughing, they may be able to dislodge
the object on their own. Administer first aid if the person is:
o Not coughing
o Unable to speak or breathe
 o Signaling for help, typically by holding their hands around their throat
 First, if there’s a bystander, have them call 911 (or your local emergency phone
number) for emergency help. If you’re the only person present, begin first aid
treatment:
o Get the person to stand up.
o Position yourself behind the person.
o Lean the person forward and give five blows to their back with the heel of
your hand.
o Place your arms around their waist.
o Make a fist and place it just above the navel, thumb side in.
o Grab the fist with your other hand and push it inward and upward at the
same time. Perform five of these abdominal thrusts.
o Repeat until the object is expelled and the person can breathe or cough
on their own.
 Alternatively, if the person can’t stand up, straddle their waist, facing their head.
Push your fist inward and upward in the same manner as you would if they were
standing.

On a Pregnant Woman
 On pregnant women, you need to place your hand a little higher on their torso,
around the base of their breastbone. If that person is unconscious, place them on
their back and try to clear the airway with your finger in a sweeping motion. If you
can’t remove the lodged object, begin performing.

On An Infant
1. If the person who is choking is younger than 1 year, you need to follow other
steps
2. Sit down and hold the infant face down on your forearm, which should be resting
on your thigh.
3. Give five back blows gently with the heel of your hand.
4. If that doesn’t work, position the infant face up and resting on your forearm and
thigh so their head is lower than their trunk.
5. Place two fingers at the center of their breastbone and perform five quick chest
compressions.
6. Repeat the back blows and chest thrusts until the object is expelled and the
infant can breathe or cough on their own.
On Yourself
1. If you’re alone and choking, follow these steps
2. Make a fist and place it just above your navel, thumb side in.
3. Grab the fist with your other hand and push it inward and upward at the same
time. Perform five of these abdominal thrusts.
4. Repeat until the object is expelled and you can breathe or cough on your own.
5. You can also thrust your upper abdomen against a hard edge like the corner of a
table or counter, or back of a chair.

Glasgow Coma Scale

 Was developed to assess the level of neurologic injury, Including movements,
speech, and eye-opening assessments. Is a neurological scale that aims to give
a reliable and objective way of recording the conscious sate of a person for initial
as well as subsequent assessment.
 The scale was published in 1974 by Graham Teasdale and Bryan Jennett,
professors of neurosurgery at the University of Glasgow's Institute of
neurological sciences at the city southern general hospital.
  Is a neurological scale that aims to give reliable way of recording the conscious
state of a person

GCS has 3 components:

 Eye response (1-4)
 Verbal response (1-5)
 Motor response (1-6)

Glasgow Coma Scale

Behavior Response Score
Eye Response Spontaneously 4
To speech 3
To pain 2
No response 1
Verbal Response Oriented to time, place, etc. 5
Confused 4
Inappropriate sound 3
Incomprehensible sound 2
No response 1
Motor Response Obeys command 5
Flexion withdrawal from pain 4
Abdominal flexion (decorticate) 3
Abnormal extension (decerebrate) 2
No response 1

Total Score: Best Response 15

Comatose Client <8
Totally Unresponsiveness 3

Eye Response (E)

 There are four grades starting with the most severe:
a. No eye opening.
b. Eye opening in response to pain stimulus (a peripheral pain stimulus, such
as squeezing the lunula area of the patient's fingernails more effective
 than a central stimulus such as trapezius squeeze due to grimacing
effect).
c. Eye opening to speech. (Not to be confused with the awakening of a
sleeping person; such patients receive a score of 4, not 3.
d. Eye opening spontaneously

Verbal Response (V)

 There are five grades starting with the most severe.
a. No verbal response
b. Incomprehensible sounds. (Moaning but no wards)
c. Inappropriate words. (Random or exclamatory articulated speech, but no
conversation exchange, Speaks words but no sentences)
d. Confused. (The patient responds to questions coherently but there is
some disorientation and confusion)
e. Oriented. (Patient responds coherently and appropriately to questions
such as the patient's name and age, where they are and why, the year,
month, etc.)

Motor Response (M)

 There are six grades starting with the most severe:
a. No motor response
b. Decerebrate posturing accentuated by pain (extensor response adduction
of arm, internal rotation of shoulder, pronation of forearm and extension at
elbow, flexion of wrist and fingers, leg extension, plantar flexion of foot)
c. Decorticate posturing accentuated by pain (flexor response: internal
rotation of shoulder, flexion of forearm and wrist with clenched fist, leg
extension, plantar flexion
of foot) 4. Withdrawal from pain (absence of abnormal posturing: unable to lift
hand past chin with supra orbital pain but does pull away when nail bed is
pinched).
d. Localizes to pain (purposeful movements towards pain stimuli; e.g., brings hand
up beyond chin when supra orbital pressure is applied)
e. Obeys commands (the patient does simple things as asked)

Motor Response:
Localizes=5 points
 Patient will respond by raising arm, flexing elbow, raising hand above collar bone
Withdraws/Normal Flexion = 4 points
 Patient will flex the elbow joint but quickly withdraw from it.
 No rotating of the wrist; hand does not reach pressure stimulus

Abnormal Flexion Decorticate = 3 points

 Patient will flex elbow as arm moves to center "cor" of the body

Extension/Decerebrate = 2 points
 Pronation of the forearm; wrist flexion;
 Patient will extend elbow, rotate arm internally
 Worst posturing type

Stimulus
 Stimuli used during the assessment can range from verbal or audible stimuli to
painful/pressure stimuli
 There are two types of painful/ pressure stimuli that can be used to achieve a
response in a patient. These types include: central and peripheral stimuli.

Central Stimuli:
 Pressure or pain is applied to the center of the body (hence its core) to create
pain. This tests the brain's response to it.

Trapezius Squeeze:
o Use the index finger and thumb to squeeze about 1.5 to 2 inches of the trapezius
muscle.
o Increase pressure gradually for up to 10 seconds
o Note the patient's response
 Used first is the trapezius squeeze
 To do this: use the index finger and thumb and squeeze 1% inches of this
trapezius muscle. Start with slight pressure and then increase the pressure for up
to 10 seconds. Note patient's motor movement
 No response, move to the supraorbital pressure

Supraorbital Pressure:
o Use if no response indicated during trapezius squeeze
o Find the notch of the eye bone under the inner part of the eyebrow and apply
pressure with the thumb for up to 10 seconds Note the patient's response
 Find the notch under the inner part of the eyebrow. Apply pressure to this notch
with the thumb and gradually increase pressure for up to 10 seconds. Note the
patient's motor movement.
 Sternal rub is no longer recommended because it can cause bruising (BMJ case
reports, 2014).
Peripheral Stimuli:
 Pressure or pain is applied to a peripheral extremity like the fingernail bed to
create pain. This tests the spinal cords response to pain.

Interpretation
 Generally, brain injury is classifies as:
o Severe, GCS <8-9
o Moderate, GCS 8 or 9-12
o Minor, GCS ≥ 13

Limitation
 Tracheal intubation and severe facial/eye swelling or damage make it impossible
to test the verbal and eye response.
 In these circumstances the score is given as 1 with a modifier attached (e.g.
"E1c", where "c" closed, or "V1t") where t-tube). Often the 1 is left out, so the
scale reads E1 or Vt.
 The GCS has limited applicability to children, especially below the age of 36
months (where the verbal performance of even a healthy child would be
expected to be poor).