Med-Surge (Upper Respiratory EAQ)

A client's respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. What is the nurse's most immediate intervention at this time?

Assess the client's response to the interventions.

The nurse reviews teaching with a client with cancer of the larynx who is scheduled for a total laryngectomy and radical neck dissection. The nurse concludes that the teaching is effective when the client states, "After surgery, I will still be able to:

Chew and swallow food There is still a pathway from the mouth to the stomach; eating patterns are not lost when a laryngectomy is performed

Several days after a client had a total laryngectomy, the health care provider prescribes a progressive diet as tolerated. What should the nurse do?

Keep suction apparatus readily available in case excessive respiratory secretions occur. Initial attempts at oral feeding may cause a choking feeling that may produce severe coughing that raises secretions. Effective coughing is difficult because with a laryngectomy there is no glottis to close to assist with an expulsive cough. Excessive secretions may block the airway and must be removed by suctioning. Swallowing does not have an adverse effect on the suture line; a nasogastric tube is not used because it can traumatize the suture line. A progressive diet is started with liquids, not pureed foods. Airway patency is the priority, not administering medication for pain.

Following a laryngectomy a client experiences frequent coughing episodes and copious production of secretions. The nurse explains that the client's responses are related to:

The reaction of the mucous membranes to air that is dry and cool Air is moisturized and warmed as it passes through the nasopharynx. With a laryngectomy this area is bypassed and the tracheobronchial tree compensates by producing copious amounts of secretions. Irritation of the stoma by the tracheostomy tube will produce local irritation and a local response. Upper respiratory inflammation because of allergies is not a response to allergies but to the stress of the air that is entering the tracheobronchial tract. The air is no longer warmed or humidified by passing through the nose. Insufficient coughing and deep breathing do not create a response of coughing.

A client returns from surgery after a total laryngectomy with a laryngectomy tube in the permanent stoma. In which position should the nurse place this client to facilitate respirations and promote comfort?

The semi-Fowler position helps maintain the head in functional body alignment and facilitates respiration; gravity moves the abdominal organs down and away from the diaphragm, facilitating respiratory excursion. The side-lying position, unless the head is elevated, inhibits respiratory excursion. The orthopneic position may cause flexion of the neck, which will inhibit respirations and place pressure on the suture line; also, rest is difficult to maintain in this position. The high-Fowler position may cause flexion of the neck, which will inhibit respirations and place pressure on the suture line; also rest is difficult to maintain in this position.

During a follow-up visit three weeks after a laryngectomy, a client exhibits concern that the laryngectomy tube may become dislodged. What should the nurse teach the client to do if the tube becomes dislodged?

The client's concerns will be reduced if it is known that the stoma will stay open long enough so that another tube can be inserted easily. A permanent opening into the trachea is formed after two or three weeks, and a tube need not be reinsertedpromptly. The client is in no immediate danger, and it is not imperative to notify the health care provider at once. A permanent opening into the trachea is formed after two to three weeks and will not close quickly.

A nurse is suctioning a client's tracheostomy. Place the nursing actions in order of priority when performing this procedure.

The status of the client should be ascertained as a baseline before starting the procedure (Auscultate Lungs and check heart rate). The suction should be turned on between 80 and 120 mm Hg pressure to check its adequacy before beginning. Because oxygen will be lost during suctioning, the client should be oxygenated using 100% oxygen before initiating the procedure. Then the nurse should don sterile gloves to protect the client from infection and guide the catheter into the tracheostomy tube without using negative pressure.

What should the nurse include in the plan of care for a client who just had a total laryngectomy?

Suctioning the tracheostomy tube whenever necessary Secretions are increased because of alterations in structure and function. A patent airway must be maintained. Whispering can put tension on the suture line; initially nonverbal and written forms of communication should be encouraged. The outer tube is not removed because the stoma may close. The orthopneic position may cause neck flexion and block the airway.

Which action should the nurse implement when performing tracheal suctioning for a client with a tracheostomy?

Administration of 100% oxygen for a few minutes before suctioning reduces the risk of hypoxia, the major complication of suctioning. Suction is applied as the catheter is withdrawn, not during insertion, to prevent hypoxia. Tracheostomy cuffs are indicated when the client is on mechanical ventilation. Although a dilute solution may be instilled into a tracheostomy, this requires a health care provider's prescription.

A client is admitted to the hospital for cancer of the larynx, and a laryngectomy is scheduled. What should the nurse include in the postoperative teaching plan?

Importance of cleanliness around the site of the stoma The procedure should be explained so the client understands that the tracheostomy can serve as an entrance for bacteria and that cleanliness is imperative. Clients with a laryngectomy may no longer swim because water will flood the lungs. Suctioning must be performed only as needed; a pattern is not necessary. Sterile technique is not required; medical aseptic technique is adequate and realistic.

A client has a laryngectomy and radical neck dissection for cancer of the larynx. Two tubes from the area of the incision are connected to portable wound drainage systems. Inspection of the neck reveals moderate edema even though the drainage systems are functioning. For which clinical indicator should the nurse assess the client?

Restlessness The client has a high risk for airway obstruction from the edema; restlessness and dyspnea indicate cerebral hypoxia.

A client who had a laryngectomy for cancer of the larynx is being transferred from the postanesthesia care unit to a surgical unit. Which is the most important equipment that the nurse should place in the client's room?

Suction Equipment Respiratory complications can occur after a laryngectomy is performed because of the production of excessive secretions, edema of the glottis, or injury to the recurrent laryngeal nerve. Also, after a laryngectomy the client will be unable to cough effectively to raise secretions. Although writing supplies along with a picture board are helpful for promoting communication, they are not the priority. A tracheostomy set is unnecessary. When a laryngectomy is performed a permanent stoma in the trachea is surgically created and a laryngectomy tube is in place. An additional sterile laryngectomy tube should be kept at the bedside. A client with a tracheal stoma cannot use an incentive spirometer.

A client has a laryngectomy. The avoidance of which activity identified by the client indicates that the nurse's teaching about activities and the stoma is understood?

Water sports pose a severe threat; should water enter the stoma, the client will drown. Strenuous exercises are not harmful; as long as there is no obstruction, adequate oxygen will be available because the respiratory rate will increase. Pillows are not contraindicated, although care should be taken not to occlude the airway by any bedding while asleep. Humidity is desirable and helpful in keeping secretions liquefied.