5 ways to give better care to your respiratory patients
I love and hate nursing respiratory patients in equal measure.
I love them because they can be really fun to nurse, and there are a lot of skills we can use to really help make a difference to them - including some fun advanced skills!
But I also really hate that they are on a knife edge, and the most minor thing can result in them decompensating.
This is something that we need to have in the back of our minds all the time when we’re nursing respiratory patients - because it means things like sedation, a hands-off approach, gentle handling and avoiding excessive interaction are really important considerations.
In the second post in our ‘Up Your Medical Nursing Skills’ challenge, I’m going to share 5 top tips, skills and hacks to make nursing your respiratory patients easier. We’ll look at examining respiratory patients, collecting arterial blood samples, performing point-of-care ultrasounds, placing nasal cannulas and caring for ventilator patients - to really help you use more skills when performing respiratory nursing!
Don’t forget…
If you want to access the additional mini trainings and case studies that accompany this challenge, you’ll need to be on the VIP email list - you can get on it here. Plus, if you complete all the case studies you’ll be in with a chance of winning one of 4 different prizes!
With all of that said, let’s look at our first respiratory nursing skill…
#1: How to examine the respiratory patient
Examining respiratory patients is a key nursing skill. It’s often us performing these daily assessments, monitoring these patients, and spotting subtle changes in their condition.
And to do that, we need to know how to thoroughly assess these patients.
The distant assessment
Our respiratory exam should begin with a distant assessment, to avoid disturbing our patient and causing changes to their respiration that could make our examination less representative of the patient’s condition.
Things to look at from a distance include:
Respiratory rate - how quickly is the patient breathing?
Respiratory pattern - is the patient taking deep or shallow breaths, for example?
Respiratory effort - is it increased? If so, where? Thoracic or abdominal? Inspiratory or expiratory?
Body position - is the patient adapting their body position to make breathing easier? We often see our dyspnoeic patients remain standing or in sternal recumbency, with their neck extended and their elbows abducted, to aid airflow and chest wall expansion.
Demeanour - how stressed is your patient? The more stressed they are, the higher their oxygen demand will be - so we may need to intervene with some anxiolytics or sedatives if this is the case.
The hands-on assessment
Once you’ve examined your patient from a distance, it’s then a case of auscultating them and checking their SpO2 (+/- any further “non-respiratory” assessments as needed).
When you’re auscultating your patient, imagine drawing a 3x3 grid on either side of the chest. You’ve now got 9 spots over each lung to pop your stethoscope in - this ensures you’ve listened to all lung fields bilaterally.
Listen for any abnormal lung sounds, such as crackles or wheezes. Also note if the patient’s normal lung sounds are muffled or harder to hear - if that’s the case, it could indicate they have pleural space disease.
You also want to auscultate over the upper respiratory tract if possible, noting any abnormal upper respiratory tract noise.
#2: How to collect an arterial blood sample
Arterial blood gas analysis is an important diagnostic tool in our hypoxaemic patients.
It allows us to thoroughly assess oxygenation (the delivery of oxygen from the lungs to the bloodstream) and ventilation (the delivery of air to the lungs, and elimination of carbon dioxide from the lungs) and helps us make decisions on how we’ll administer oxygen to our patients.
Collecting blood from an artery for analysis is something we can (and should!) be doing as veterinary nurses. There are some significant differences between arterial and venous sampling, so let’s look at how to collect an arterial sample for analysis:
Clip and aseptically prepare over the target artery (either the dorsal pedal or coccygeal artery).
Avoid vigorous scrubbing back-and-forth which could cause arterial spasm, making it harder to hit.
Assemble your needle and syringe and pre-draw the syringe to the required volume.
With your non-dominant hand, palpate the pulse just above where you're going to insert your needle.
With your needle at a steeper angle than a usual blood sample (approx 45 degrees), insert the needle and direct it towards where you can feel the pulse.
When you're in the artery a flashback of blood will automatically appear. Hold your needle and syringe still. The blood will flow into the syringe by pulsatile flow.
Remove the needle/syringe and apply pressure. Remove any air bubbles from the syringe, as these can change O2 and CO2 levels in the sample. Run the sample ASAP, as gas levels inside it can change quickly!
#3: How to care for a ventilated patient
Ventilator patients are really intensive and challenging, but also SUPER rewarding to nurse.
Mechanical ventilation is reserved for either our most hypoxaemic patients, or patients at risk of respiratory failure (for example, patients with diseases that affect respiratory muscle function, or patients with severe hypoxaemia where the respiratory muscles become fatigued from overworking).
Patients on mechanical ventilation are anaesthetised, intubated, and connected to a long-term ventilator. This differs from the ventilators we use for general anaesthesia, as they deliver warmed, humidified inspired air/oxygen, and have multiple settings allowing us to tailor the respiratory support we provide.
So how do we nurse a ventilator patient?
Nursing ventilator patients is like a combination of anaesthetic nursing and recumbent nursing, with a few extra things thrown into the mix.
There is a lot to think about when caring for these patients, including:
Recumbency care - turning, bladder and bowel management (these patients require urinary catheterisation, since they are anaesthetised and cannot eliminate normally)
Special sense care - ocular lubrication every 4 hours and daily fluorescein staining to check for corneal ulceration
Minimising stimulation - we generally use the lowest doses of sedatives that we can get away with, balancing their cardiorespiratory depressant effects with keeping the patient intubated. Medications commonly used include midazolam, fentanyl, propofol and ketamine CRIs in varying combinations. Because we keep our patients on the lighter side, noise and light can still stimulate them - so the ward needs to be kept quiet. We also pop cotton wool in their ears to dull noise, and cover their eyes to minimise visual stimulation.
Ventilator management - the ventilator settings need to be checked regularly to ensure they are still meeting the patient’s needs, alongside ensuring that the levels of oxygen, medical air and sterile water (in the humidification chamber) are sufficient.
Airway management - the patient is intubated with a sterile ET tube, which is carefully inflated using a pressure manometer, to avoid excessive pressure on the trachea. The cuff should be deflated, the tube repositioned, and the cuff carefully reinflated regularly. The breathing system should be changed every 48 hours.
Aseptic technique - hospital-acquired pneumonia is an important consideration with ventilator patients, and careful aseptic technique is required to minimise the risk of this.
#4: How to perform a thoracic point-of-care ultrasound
Point-of-care ultrasound is a fantastic diagnostic tool for respiratory cases. It’s minimally invasive, the patient does not need restraint, and they can be receiving oxygen at the same time.
It’s also something we can - and should! - be doing as nurses alongside our respiratory examinations.
A thoracic POCUS is a really easy skill to perform, with practice. So let’s look at how we do it:
Place the patient in sternal recumbency, or have them standing
Wet the fur down over the 3 probe sites (see below)
Evaluate the following 3 sites on both sides of the chest, fanning the probe up, down, left, and right at each site
Site 1: The chest tube site
The chest tube site allows us to examine the lung tissue and spot pneumothorax. You can find it by placing the probe on the dorsolateral aspect of the thoracic wall, between the 7-9th intercostal spaces with the transducer pointing cranially.
Site 2: The pericardial site
The pericardial site allows us to spot pleural or pericardial effusion, and examine the heart. You can find it by placing the probe at the 5th - 6th intercostal space.
Site 3: The diaphragmatic-hepatic site
The DH site allows us to assess pleural and pericardial effusion. To find it, place the probe just caudal to the sternum.
Note the presence of fluid at any site or the absence of a glide sign at the chest tube site. No glide sign means pneumothorax is likely!
Once you've ruled in or out pleural fluid or pneumothorax, it's time to look at the lung tissue in more detail. This is ideal in patients who are not stable enough for radiographs.
To do this, place your probe over the caudal (1), perihilar (2), middle (3) and cranial (4) lung lobes on each side with the transducer pointing cranially.
But what are we looking for?
We can see many different normal and abnormal findings on a thoracic POCUS. Here are some of the most common ones we see:
A-Lines: Horizontal hyperechoic equal lines caused by reverberation from lung movement. A normal finding.
B-Lines: Vertical hyperechoic lines running perpendicular to A-lines. Also called 'rockets'. Wide or large lots of B-lines are abnormal, indicating pulmonary oedema, pneumonia, or contusions.
Shred Sign: An abnormal, irregular torn-paper-like margin separating areas of consolidated and aerated lung.
Tissue Sign: Abnormal, consolidated lung tissue.
Glide Sign: The normal, rhythmic back-and-forth movement of the lung against the chest wall.
#5: How to place nasal oxygen cannulas
Nasal oxygen cannulas are a great option for administering high inspired oxygen concentrations - if placed bilaterally, they can reach inspired oxygen levels of up to 60%. They are quick and easy to place, and another skill we can use as nurses to support our respiratory patients.
Here’s what you’ll need:
Nasal oxygen cannulas of appropriate size (nasal feeding tubes can be used)
3-way-tap (if bilateral cannulas are placed)
Male-to-male connector (if a unilateral cannula is placed)
Oxygen bubble tubing OR syringe, ETT end and circuit.
3-0 nylon suture material
23 g x 5/8" needle
Sterile lubricant
Ophthalmic local anaesthetic pipette (e.g. proxymetacaine)
And here’s how to do it:
Place a drop of local anaesthetic in the nostril.
Measure the cannula from the nostril to the medial canthus of the opposite eye. Mark the tube here
Lubricate the end of the cannula.
Insert the cannula into the nostril and advance ventromedially to the marked point.
Place the needle through the skin just behind the nostril and thread the suture material through it. Remove the needle and tie a finger-trap suture around the cannula.
Repeat for the other nostril if bilateral cannulas are needed.
Connect the cannula ends to the 3-way tap, ensuring it is open, and attach this to the oxygen bubble tubing.
So there you have it - 5 skills for you to use when nursing patients with respiratory disease! From performing thorough respiratory examinations to performing point-of-care ultrasounds, there are so many things we can do to support our respiratory patients!
Don’t forget - if you want to learn even more about respiratory nursing, you can sign up for the challenge emails for additional mini trainings, and a case study to put your skills into practice! To be a part of it, make sure you’re on the VIP list by signing up here.
