Sunday, November 28, 2010

Respiratory Management Excelsior CPNE 17th Edition Study Guide p 244

***wear gloves- be prepared of secretions***

This is assessing the lungs and encouraging/instructing/assisting respiratory hygiene activities and reassessing.
Respiratory Hygiene activities include:
  • incentive spirometry
  • chest percussion
  • deep breathing and coughing
  • suctioning
  1. Position the patient - depending on patient's tolerance - Head of bed high Fowler's or sitting on side of bed, if Chest Percussion have patient lying on side to facilitate drainage
  2. Provide a receptacle for secretions if any are produced (wear gloves)
  3. Assess lungs immediately prior to initiating any respiratory hygiene activities by placing the stethoscope directly on the skin
    1. instruct the patient to breathe in and out slowly and deeply
      1. observe for regularity, use of ancillary muscles, quality and depth
    2. auscultating breath sounds over upper and lover loves by moving the stethoscope from side to side
    3. watch breathing patterns
  4. Directs the patient to perform breathing exercise
    1. Deep Breathing
      1. instructs the patient specifically to breathe in and out as deeply as possible
      2. Repeats deep breathing exercises as ordered or as indicated by the patient's condition
    2. Coughing
      1. instructs the patient specifically to breathe in and out deeply
      2. instructs the patient specifically to cough forcefully on the 3rd or 4th expiration
      3. provides for splinting while the patient is coughing if necessary
    3. Mechanical Devices such as incentive spirometry:
      1. instructs the patient to use the device
        1. video links:
          1. instructions for using Incentive Spirometry
        2. repeats exercise as ordered or as indicated by the patient's condition
    4. Chest Percussion
      1. claps the designated area of the chest wall vigorously with cupped hands unless contraindicate
      2. vibrates the designated area of the chest wall vigorously unless contraindicated
        1. Video link - Nurse's Video of How to Perform Chest Percussion
    5. Suctioning:
      1. when assigned suctioning by catheter (have patient take a few deep breathes if possible)
        1. verifies patency of catheter
        2. set the pressure on the suction machine as designate
        3. insert the catheter before suctioning
        4. suction for no more that 15 seconds at a time
        5. repeat as necessary - allow patient to re-oxygenate prior to re-suctioning
      2. when assigned suctioning by bulb syringe
        1. deflate bulb prior to suctioning
        2. insert bulb into the patient's mouth or nares before suctioning
        3. aspirate secretions
        4. repeat as necessary
    6. Reassesses respiratory status immediately after respiratory hygiene activities
    7. Record
      1. bilateral breath sounds heard after treatment in comparison with those heard initially, related to each of the above assessment findings
      2. abnormal breathing patterns
      3. respiratory hygiene activities implemented
      4. patient response to hygiene activities implemented

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