O2 Therapy & Tracheostomy

Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hours would alert the nurse to the possibility of oxygen toxicity? a. Increased dyspnea b. Decreased rate and depth of respiration c. Wheezing on inhalation and exhalation d. Increased excretion of thick, white, frothy sputum

ANS: A An oxygen level higher than 50% when given continuously for more than 24 to 48 hours may damage the lungs. Initial symptoms include nonproductive cough, substernal chest pain, gastrointestinal upset, and dyspnea. Decreased rate and depth of respiration, wheezing on inhalation and exhalation, and increased excretion of thick, white, frothy sputum are not considered to be initial symptoms of oxygen toxicity.

A client has a newly diagnosed lung disease and has been placed on 2 L of nasal oxygen while hospitalized. The client has only been on the oxygen for approximately 30 minutes when he suddenly seems even more short of breath than previously, although he is neither gray nor ashy in color. The nurse recognizes that the client is experiencing which of the following? a. Oxygen-induced hypoventilation b. Oxygen toxicity c. Absorption atelectasis d. Hypocarbia

ANS: A Assess for oxygen-induced hypoventilation in the client whose main respiratory drive is hypoxia (hypoxic drive), such as in the client with chronic lung disease who also has carbon dioxide retention (hypercarbia). The symptoms listed are not characteristic of oxygen toxicity, absorption atelectasis, or hypocarbia.

The nurse assesses the client with a new tracheotomy, and the tracheostomy tube is pulsating in synchrony with the client's heartbeat. Which is the nurse's priority action? a. Notify the physician immediately. b. Stabilize the tube by reapplying the ties. c. Change the inner cannula of the tube. d. Increase the inflation pressure of the tracheostomy cuff.

ANS: A If a tracheostomy tube is pulsating with the client's heart rate, this could indicate proximity to the innominate artery and may cause erosion of the artery if left in this position. The physician should be notified immediately. Reapplying the ties, changing the inner cannula, or increasing the inflation pressure of the cuff are all interventions that will not solve the immediate problem of proximity of the tube to the innominate artery.

The nurse assesses a client receiving 60% oxygen via a tracheostomy collar. Which assessment finding requires immediate action by the nurse? a. Constant, nonproductive coughing b. Blood-tinged sputum c. Rhonchi in upper lobes d. Dry mucous membranes

ANS: A The causes and manifestations of lung injury from oxygen toxicity are the same as those for acute respiratory distress syndrome (ARDS). Initial symptoms include nonproductive cough, substernal chest pain, gastrointestinal (GI) upset, and dyspnea. Blood-tinged sputum is expected in clients with new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and is not an emergent problem. Dry mucous membranes should be lubricated and the client's hydration status can be checked.

The nurse is teaching the client about his fenestrated tracheostomy tube. Which statement by the client indicates an accurate understanding of the tube? a. "I'm glad I will still be able to talk with this tube in place." b. "It is great that this tube does not have to be cleaned or suctioned." c. "This tube will not become dislodged." d. "Because I won't be able to swallow, will another tube be needed for eating?"

ANS: A The client can speak with a fenestrated tube, which has a hole in it and allows air to flow over the vocal chords. The tube still needs to be cleaned and suctioned. The tube may still become dislodged, and the client is able to swallow.

The client tells the nurse that she feels shy going out in public with her tracheostomy. Which of the following should be the highest priority action on the part of the nurse? a. Helping the client drape attractive scarves so that the tracheostomy is hidden b. Recommending that the client begin counseling sessions to cope more effectively c. Avoidance of going out in public for a few more weeks until she is comfortable d. Talking with the client's family members to involve them in encouraging her efforts

ANS: A The most effective intervention on the part of the nurse will be to help her learn to wear scarves attractively so that she can confidently go out in public. The client does not necessarily need counseling and does not need to avoid going out in public. The nurse's efforts should primarily involve the client.

Which interventions would help prevent aspiration during eating for a client with a temporary tracheostomy? (Select all that apply.) a. Avoid having the client eat a meal when he or she is fatigued. b. Add water or broth to foods to make them thinner and easier to swallow rapidly. c. Inflate the cuff of the tracheostomy tube to maximum pressure before initiating a feeding to mechanically block aspirated food from moving further down the airway. d. When feeding the client, allow the client to indicate when he or she is ready for the next bite. e. Encourage the client to tuck his or her chin down and forward while swallowing. f. Urge the client to swallow three or four bites or mouthfuls in a row to reduce the time when he or she is at risk for aspiration. g. Place the client in a lithotomy position for 30 minutes immediately following a meal.

ANS: A, D, E Aspiration is less likely to occur if the client is well rested. Do not rush the client. Allow him or her to indicate when ready for another bite. Teaching interventions should include instructing the client to tuck the chin down and forward while swallowing to encourage food to move down smoothly. Food may actually become easier to aspirate if it is thinner in texture. The nurse should not initiate adding air to inflate the cuff of a tracheostomy tube further without a physician's order. Aspiration may become more likely if the client is urged to swallow faster. Placing the client in a lithotomy position after the meal will not prevent aspiration.

The nurse enters the room of a client who has a tracheostomy and finds a visitor in the room speaking loudly to the client. The client appears to be angry and frustrated. Which intervention should the nurse implement to address this problem? a. The nurse should excuse himself from the room quietly, allowing the client and visitor to resolve their issue in private. b. The nurse should tactfully remind the visitor that the client's comprehension has not been affected, only his ability to speak. c. The nurse should intervene and ask the visitor to leave because the conversation is obviously upsetting the client. d. The nurse should obtain an order for a PRN antianxiety medication from the physician and administer it to the client.

ANS: B Addressing psychological concerns is an important aspect of nursing care for clients recovering from a tracheostomy. While providing physical care, keep in mind the emotional impact of an artificial airway. Acknowledge the client's frustration with communication and allow time for communication. When speaking to the client, use a normal tone of voice. The tracheostomy tube does not alter hearing or comprehension.

A client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What will the nurse do first? a. Notify the physician. b. Assess the client's pulse oximetry. c. Document the observation. d. Lower the head of the bed.

ANS: B Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen. Although you would want to notify the physician of the change in the client's condition, the best action is first to assess pulse oximetry and then increase the oxygen. You would not just document the assessment finding without intervening. Lowering the head of the bed would not help the client oxygenate better.

Which statement by the client's family member indicates an accurate understanding of the correct way to provide the client with mouth care while he has a tracheostomy? a. "I can clean his mouth with glycerin swabs." b. "I can clean his mouth with water and a toothette." c. "I can clean his mouth with hydrogen peroxide." d. "I can clean his mouth with mouthwash."

ANS: B The best choice for mouth care is water and a toothette because these are the least irritating. Glycerin swabs, hydrogen peroxide, and mouthwash are all too irritating to the mucous membranes of the mouth.

A client is being discharged with a tracheostomy and voices concern about appearance. What discharge teaching will assist the client with maintaining a positive body image? a. "Tell people how sick you were when they ask about the tracheostomy." b. "Your clothing can help hide the tracheostomy so it is not as noticeable." c. "You can put a bandage around your tracheostomy." d. "You have to ignore comments that people make about your appearance."

ANS: B The client may have an alteration in body image because of the tracheostomy stoma. Encourage the client to wear loose-fitting shirts and collars to help hide the appearance of the stoma. Clients should not be encouraged to tell people about the illness, because they should not be made to "justify" their appearance. You should not bandage the tracheostomy because airflow would be impaired. Ignoring comments will not help the client's self-image.

The client is being weaned from his tracheostomy tube and has tolerated the tube being capped for 24 hours. Which of the following should be the highest priority action on the part of the nurse? a. Collecting all materials that will be needed for suturing of the stoma b. Placing a dry dressing over the stoma and secure it in place c. Assessing the client to determine that no air is leaking around the tube d. Selecting the next smallest size tracheostomy tube for the physician to insert

ANS: B The tube will be able to be removed after the client has tolerated it being capped for 24 hours. Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be sutured. It will heal on its own with a small scar. There should be adequate airflow around the capped tube. The physician will not likely insert the next smallest size tube but will instead remove the existing tube.

Which action is highest priority for the nurse to teach the client with a tracheostomy to decrease the risk for aspiration? a. Swallow quickly. b. Thicken all liquids. c. Rinse all food with water. d. Chew food completely.

ANS: B Thickening liquids may assist the client in swallowing and help prevent aspiration. Swallowing quickly will not decrease the risk of aspiration, and may actually put the client at a greater risk. It is not recommended that the client drink water to wash down food. Chewing food completely will help prevent choking but will not decrease aspiration risk.

The client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. What is the nurse's first action? a. Auscultates breath sounds bilaterally b. Ventilates with resuscitation bag with mask c. Calls a code d. Inserts obturator into neck

ANS: B Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. First, ventilate the client using a manual resuscitation bag and face mask while another nurse calls for help. Although auscultation of breath sounds is important, the client's airway must be opened and ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion of a fresh tracheostomy tube will require the physician's intervention.

Which signs and symptoms are most indicative of hypercarbia? a. pH = 7.33 while experiencing mechanical ventilation b. Bicarbonate = 20 mEq/L, unable to tolerate low levels of oxygen c. PaCO2 = 60 mm Hg, unable to tolerate more than 2 L of oxygen d. PaO2 = 80 mm Hg while receiving 40% oxygen via Venturi mask

ANS: C Assess for oxygen-induced hypoventilation in the client whose main respiratory drive is hypoxia (hypoxic drive), such as in the client with chronic lung disease who also has carbon dioxide retention (hypercarbia). The arterial carbon dioxide (PaCO2) level for these clients gradually rises over time. The central chemoreceptors in the brain (medulla) are normally sensitive to increased PaCO2 levels. When these receptors are active, they stimulate breathing and cause an increased respiratory rate. When the PaCO2 increases gradually to above 60 to 65 mm Hg, this normal mechanism no longer functions. The central chemoreceptors lose sensitivity to increased levels of PaCO2 and do not respond by increasing the rate and depth of respiration.

The nurse assesses the client receiving oxygen via a partial rebreather mask. The nurse will intervene for which assessment finding? a. The bag is two thirds inflated during inhalation. b. The client's pulse oximetry reading is 93%. c. The oxygen flow rate is 2 L/min. d. The arterial oxygen is 90%.

ANS: C Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not adequately inflate the bag. A bag that is two thirds inflated is desired. A pulse oximetry reading of 93% and higher is adequate, as is an arterial oxygenation of 90%.

The nurse is caring for a client with a new tracheostomy. Which assessment finding requires the nurse's immediate action? a. Need for inner cannula care every 2 hours and PRN b. Recannulation of the airway after the client accidentally coughs out the tube c. Crackling sensation around the neck when skin is palpated d. Small amount of bleeding around the incision for the first few days

ANS: C Subcutaneous emphysema occurs when there is an opening or tear in the trachea and air escapes into fresh tissue planes of the neck. Air can also progress through the chest and other tissues into the face. Inspect and palpate for air under the skin around the new tracheostomy. If the skin is puffy and you can feel a crackling sensation, notify the physician immediately. Although it is important to provide inner cannula care, it usually is performed every shift and PRN, not every 2 hours. Although the nurse may attempt recannulation of the airway, it will be difficult during the first 72 hours after surgery and will require the physician's intervention. It is not unusual to have a small amount of bleeding around the incision for the first few days after surgical placement.

A client is to be discharged to home on oxygen therapy. What information will the nurse teach the client? a. "Carry the H cylinder tank with you wherever you go." b. "Only use the E tank when stationary." c. "The D or C cylinder can be carried." d. "Roll the tank gently when transporting."

ANS: C The D and C cylinders are small enough to be carried. The H cylinder cannot be carried. The E tank can be transported. The tanks should not be rolled and should only be in a stand or rack.

Which statement by the client indicates that he has an accurate understanding of home self-care of his tracheostomy? a. "I need to keep the airway open so that it will stay dry during the day." b. "I need to put normal saline in my airway twice daily." c. "I need to keep water from entering the airway." d. "I don't need to use tracheostomy ties on a daily basis."

ANS: C The client should put a shield over the tracheostomy to keep water from entering the airway. The airway should remain covered during the day with cotton or foam. Saline should be put in the airway 10 to 15 times daily. Tracheostomy ties should be used daily.

The client requires oxygen using a face mask but wants to remain as mobile as possible once he is discharged home. Which intervention by the home health nurse will best provide the client with maximal mobility? a. Arrange for a consultation with a physical therapist for strength training. b. Encourage the client to remove the mask occasionally to begin the weaning process. c. Add extra connecting pieces of tubing to the client's existing oxygen setup. d. Change the face mask to a nasal cannula occasionally, such as at mealtimes.

ANS: C To increase mobility, up to 50 feet of connecting tubing can be used with connecting pieces. Strength training will not be effective when the main problem keeping the client from being mobile is the oxygen face mask. The nurse cannot decide to begin weaning the client from the mask nor change the face mask to a nasal cannula without a physician's order.

The client is becoming frustrated because of his inability to communicate while he has a tracheostomy. Which intervention by the nurse will most effectively enhance his ability to communicate? a. Explaining to the client that he will speak clearly and distinctly with a fenestrated tube b. Reassuring the client and asking the physician to provide him with a sedative c. Placing a sign above the client's bed indicating that he cannot speak d. Providing the client with a communication board and keeping the call bell within reach

ANS: D A communication board and the call light will reassure the client that his needs will be communicated and met. It is doubtful that the client with a tracheostomy will ever speak clearly and distinctly, no matter what type of tube he uses. Ordering a sedative for the client is merely an evasive response on the nurse's part. Placing a sign above the client's bed indicating that he cannot speak will not enhance his ability to communicate.

The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped? a. Heart rate increases 10 beats/min b. Respiratory rate increases from 16 to 20 breaths/min c. Blood pressure increases from 110/70 to 120/80 mm Hg d. Heart rate decreases from 78 to 40 beats/min

ANS: D A decrease in the heart rate indicates that the client is not tolerating the procedure and the vasovagal reflex may be stimulated. An increase in the heart rate may be stimulated by the suctioning and is expected, as is a slight increase in blood pressure. The client will not be breathing during the procedure.

While suctioning the client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. What is the nurse's priority action? a. Increases the inflation pressure in the tracheostomy cuff b. Documents the finding as the only action c. Makes the client NPO d. Performs a more thorough assessment

ANS: D A more thorough assessment must be performed so that additional data can be gathered before the nurse contacts the physician for orders. The nurse should not decide to increase the inflation pressure in the tracheostomy cuff on his or her own, nor should the nurse decide to make the client NPO without a physician's order. Additional nursing interventions are required other than documentation alone.

The nurse observes the nursing student suctioning the client. Which intervention on the student nurse's part has the greatest potential to cause tissue damage? a. Oxygen saturation postsuctioning of 93% b. Hyperoxygenating the client after removing the suction catheter c. Applying intermittent suction d. Applying suction when the catheter is inserted

ANS: D Applying suction as the catheter is introduced allows the tubing to adhere to the airway and destroy cells. Oxygen saturation of 93% is acceptable postsuctioning. The client should be hyperoxygenated before and after suctioning. Intermittent suctioning as the catheter is withdrawn is standard procedure to prevent tissue damage.

The client has been placed on 6 L of humidified oxygen via nasal cannula. What will be the highest priority action of the nurse? a. Ensuring that condensation is drained back into the humidifier to maintain a closed system b. Replacing sterile water by draining the water collected in the water trap back into the humidifier c. Emptying condensation in tubing into a sterile container for bacterial analysis d. Removing condensation in tubing by disconnecting and emptying into trash can.

ANS: D Condensation often forms in the tubing when a client receives humidified high-flow oxygen. Remove this condensation as it collects by disconnecting the tubing and emptying the water. Some humidifiers and nebulizers have a water trap that hangs from the tubing so that the condensation can be drained without disconnecting. To prevent bacterial contamination, never drain the fluid back into the humidifier or nebulizer. If a closed system is maintained, there should be no reason for bacterial analysis of the condensation. Minimize how long the tubing is disconnected because the client does not receive oxygen during this period.

The nurse is assessing a client with chronic lung disease on 6 L/min oxygen via nasal cannula. Which finding indicates a potentially acute problem? a. Wheezes on auscultation b. Pulse oximetry of 93% c. pH of 7.35 d. Respiratory rate of 6/min

ANS: D The client with chronic lung disease is driven by the hypoxic drive to breathe. If the client receives too much oxygen, the respiratory rate will slow. The nurse should decrease the oxygen flow. Respiratory failure could result. Wheezes are not an acute problem. A pulse oximetry of 93% is acceptable, as is a pH of 7.35.

The nurse is teaching a family member how to suction the client's tracheostomy at home. Which of the following should be the highest priority action on the part of the nurse to teach the family member? a. Always suction using sterile technique. b. Suction the mouth first and then the airway. c. Be prepared to recannulate the tube frequently. d. Suction using clean technique.

ANS: D The family member can suction using clean technique because there are fewer organisms in the home in comparison to the hospital. Never suction the mouth first because the airway pathogenic organisms could be introduced into the airway. The family member should not be required to recannulate tube except in an emergency.

Loss of sensitivity to high levels of PaCO2. For these patients, the stimulus to breathe is a decreased arterial oxygen level.

CO2 narcosis

Uses positive pressure to keep alveoli open, improve gas exchange without airway intubation,Noninvasive Positive-Pressure Ventilation (NPPV) ______: the effect is to open collapsed alveoli. Patients who may benefit from this form of oxygen or air delivery include those with atelectasis after surgery or cardiac-induced pulmonary edema or those with COPD. Used for atelectasis after surgery, sleep apnea _______:Together, these two pressures improve tidal volume, can reduce respiratory rate, and may relieve dyspnea

CPAP BiPAP

• Ineffective oxygenation before, during, and after suctioning• Use of a catheter that is too large for the artificial airway• Prolonged suctioning time• Excessive suction pressure• Too frequent suctioning

Hypoxia can be caused by these factors in the patient with a tracheostomy

new-onset crackles and decreased breath sounds

Lung sounds may indicate absorption atelectasis.

c/o dyspnea, cough, chest pain under sternum, crackles *Prevention is a priority symptoms of..

Oxygen toxicity

60%-75% at 6-11 L/min, a liter flow rate high enough to maintain reservoir bag two-thirds full during inspiration and expiration

Partial Rebreather Mask low flow oxygen system

Delivers desired FIO2 for tracheostomy, laryngectomy, ET tubes, Ensures humidifier creates enough mist, Mist should be seen during inspiration and expiration

T piece

excessive cuff pressure causes erosion of the posterior wall of the trachea. A hole is created between the trachea and the anterior esophagus. The patient at highest risk also has a nasogastric tube present.

Tracheoesophageal fistula (TEF)

constant pressure exerted by the cuff causes tracheal dilation and erosion of cartilage, food particles are seen in secretions

Tracheomalacia

Oxygen can also be humidified via a large-volume jet nebulizer in mist form also called

aerosol

Always _____ ____ ______ before capping the tube with the decannulation cap; otherwise, the patient has no airway.

deflate the cuff

can deliver 24%-100% at 8-15 L/min Venturi mask ('Venti masks'), Face tent, Aerosol mask, Tracheostomy collar, T-piece

high flow oxygen systems

low levels of oxygen in the blood

hypoxemia

decreased tissue oxygenation

hypoxia

is used at flow rates of 1 to 6 L/min. Oxygen concentrations of 24% (at 1 L/min) to 44% (at 6 L/min) can be achieved. Flow rate >6 L/min does not increase O2 because anatomical dead space is full

nasal cannula low flow oxygen system

24%-40% FiO2 at 1-6 L/min ≈24% at 1 L/min ≈28% at 2 L/min ≈32% at 3 L/min ≈36% at 4 L/min ≈40% at 5 L/min ≈44% at 6 L/min

nasal cannula low flow oxygen system

To prevent bacterial contamination of the oxygen delivery system, _____ drain the fluid from the water trap back into the humidifier or nebulizer. The humidifier or nebulizer may be a source of bacteria, especially if it is heated. Pseudomonas aeruginosa is often the organism involved.

never

80%-95% FiO2 at a liter flow high enough to maintain reservoir bag two-thirds full , Highest O2 level Can deliver FIO2 greater than 90%, Used for unstable patients requiring intubation, Ensure valves are patent and functional

non-rebreather low flow oxygen system

provide oxygen concentrations of 60% to 75% with flow rates of 6 to 11 L/min. It is a mask with a reservoir bag but no flaps One-third exhaled tidal volume with each breath Adjust flow rate to keep reservoir bag inflated

partial rebreather mask low flow oxygen system

Air in the pleural (chest) cavity.

pneumothorax

40%-60% FiO2 at 5-8 L/min; flow rate must be set at least at 5 L/min to flush mask of carbon dioxide ≈40% at 5 L/min ≈45%-50% at 6 L/min ≈55%-60% at 8 L/min

simple facemask low flow oxygen system

used to deliver oxygen concentrations of 40% to 60% for short-term oxygen therapy or in an emergency (Fig. 30-4). A minimum flow rate of 5 L/min is needed to prevent the rebreathing of exhaled air. monitor close for aspiration

simple facemask low flow oxygen system

The presence of bubbles under the skin because of air trapping; an uncommon late complication of fracture notify hcp immediately

subq emphysema

If the tube is dislodged on an immature tracheostomy do what?

ventilate the patient using a manual resuscitation bag and facemask while another nurse calls the Rapid Response Team

Adaptor located between bottom of mask and O2 sources Delivers precise O2 concentration—best source for chronic lung disease Switch to nasal cannula during mealtimes, deliver the most accurate oxygen concentration without intubation.

venturi mask