4335-Tracheostomy & ABGs & pptx-wk 4

which findings are consistent with metabolic acidosis?

-decreased pH & PCO2 **ph is < 7.35

which findings are consistent with respiratory acidosis?

-decreased pH and -elevated PCO2

The nurse is suctioning a client's tracheostomy. What is the correct order of nursing actions when performing this procedure?

1. auscultate the lungs and check HR 2. prepare by turning suction on to between 80-120 mm Hg pressure 3. hyperoxygenation using 100% oxygen 4. don sterile gloves 5. guide the catheter into the tracheostomy tube using a sterile-gloved hand *get pt baseline before starting, turn suctioning on check for adequacy, guide trache tube without using negative pressure.

what are the normal levels for PCO2?

35-45 mm Hg

what are the normal level of pH?

7.35-7.45

What are the normal levels for PO2?

80-100 mm Hg

When the nurse is reviewing a client's arterial blood gas results, which finding is consistent with respiratory alkalosis?

-elevated pH (because of loss of hydrogen ions) -decreased PCO2 (because CO2 lost through hyperventilation) **with resp alkalosis blood pH is >7.45, and PCO2 is decreased.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition?

mental confusion *decreased O2 to the vital centers in the brain results in restlessness and confusion. -cyanosis-late sign of resp failure

A client has a tracheostomy tube with a high-volume, low-pressure cuff. The nurse understands that type of cuff is designed to prevent which occurrence?

mucosal necrosis -this cuff does not compress the capillary beds and does not cause tracheal damage

Which action will the nurse take to support safe oral intake after tracheostomy?

position pt as upright as possible -prevents aspiration -thin liquids more difficult to swallow and increase aspiration -large meals cause overdistention and leads to regurgitation and aspiration **meals should be small and frequent **deflate trache cuff to decrease interference with swallowing

A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care?

the tracheostomy tube interferes with effective coughing *trache tube enters trachea below glottis, client cant close glottis to retain air in the lungs. this prevents an increase in the intrathoracic pressure and the ability to open the glottis to expel an explosive cough.

what is expected to see after a tracheostomy placement?

-small amt of blood at surgical site (monitor for signs of hemorrhage) -tenderness -pt not able to speak with a cuffed tube (because airflow prevents use of the vocal cords)

Assessment findings of a client with smoke inhalation include a negative chest x-ray and arterial blood gases that show a PO 2 of 85 mm Hg, a PCO 2 of 45 mm Hg, and a pH of 7.35. Which interventions would the nurse anticipate will be prescribed? *these measurements are within normal limits

1. coughing (moves secretions out) 2. deep breathing (expands alveoli and increases amt of O2 delivered to the alveolar cap beds) 3. humidified oxygen (increase amt of O2 being delivered to alveolar cap beds)

Which actions will the nurse include when doing tracheostomy care?

1. use of sterile technique when cleaning the inner cannula 2. don sterile gloves before removing the inner cannula *sterile technique used when cleaning the INNER cannula (avoids transmission of microorganisms to lungs) -no need to suction pt before starting trache care, although the pt may be preoxygenated before removing the inner cannula. -use NS to clean skin around trache stoma (don't use hydrogen peroxide=irritate tissue)

The nurse is suctioning a client's airway. Which nursing action will limit hypoxia?

apply suction only after the catheter is inserted -limit suctioning to 10 seconds -lubrication facilitates insertion and minimizes trauma (***will not prevent hypoxia)

when is suctioning done?

as the catheter is withdrawn, NOT during insertion, to prevent hypoxia.

When the nurse is assessing a client after tracheostomy placement, which finding requires immediate action by the nurse?

crackling of the skin on palpation -indicated the presence of subcutaneous emphysema, report to provider asap.

which findings are consistent with metabolic alkalosis?

elevated pH and PCO2

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client?

enourage a fluid intake of 3L/day *helps liquify secretions, enables pt to cleartract by coughing.

The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition?

normal acid base balance **all are within expected limits

A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. Which assessment by the nurse most readily detects this complication?

palpating the neck or face

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning?

preoxygenate the client before suctioning **Admin 100% oxygen for a few minutes before suctioning (reduces risk of hypoxia, the major complication of suctioning)

what is subcutaneous emphysema?

presence of air in the tissue that surrounds an opening in the normally closed respiratory tract -tissue appears puffy and crackling sensation is detected (when trapped air is compressed between the nurse's palpation on pt's tissue. -gas exchange and lungs are not affected

what does negative pressure from suctioning do?

removes O2 and secretions **only suction after the catheter is inserted and is being withdrawn. -during suctioning of pt secretions, negative pressure (suction) should NOT be applied until catheter is ready to be removed, because O2 is also being depleted. -don't remove inner cannula during suctioning (remove during trache care)

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing?

respiratory alkalosis *pH indicates ACIDOSIS, the PCO2 level in the parameter for resp function. The expected PCO2 is 40 mm Hg.

Which finding in a client who has home oxygen therapy with a tracheostomy collar requires immediate action by the home health nurse?

scented candle burning in the room -put out candle and reeducate pt )avoid any flames when O2 present) -O2 itself is not combustible (but is supports it and fire can spread quickly in the presence of O2). -

what is the primary mechanism of positive end-expiratory pressure (PEEP)?

to deliver positive pressure to the lung at the end of expiration. -helps open collapsed alveoli & keeps them open -exchange of CO2 and O2 can take place more efficiently=improves oxygenation -does not force pressure into lung tissue

The nurse is caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. The plan of care for the tube would include which nursing intervention?

verify that a low-pressure cuff is in place -a low pressure cuff permits tidal volume to reach the lungs while preventing tracheal necrosis.

when are tracheostomy cuffs indicated?

when the pt is on mechanical ventilation **Inflating the cuff during mechanical ventilation makes sure that air is entering the lungs and not escaping through the nose and mouth. The cuff also prevents aspiration of saliva in patients who have trouble swallowing.