Tracheostomy / Oxygen

My patient requires both pharyngeal and tracheal suctioning. Does it matter which area I suction first?

The mouth and the pharynx house more bacteria than the trachea does. So, suction the trachea before you suction the pharyngeal area.

suctioning a patient with a tracheostomy

The nurse is responsible for evaluating the patient's airway patency and response to airway suction

What is a tracheostomy?

The stoma (opening) that results from the tracheotomy.

ABGs

Arterial Blood Gases pH 7.35- 7.45 HCO3 (Bicarbonate) normal values 22-26 mEq/L PaCO2 ( CO2 or carbon dioxide content) 35-45 mm Hg PaO2 (oxygen saturation in arteria blood)- 80-100 mm Hg takes time to get test results back but once you do you oxygen saturation can be altered by MD order

oropharyngeal airway

a tube inserted through the mouth and the pharynx to establish and maintain airway patency

nasal trumpet

a tube inserted through the nose and the pharynx to establish and maintain airway patency; also called a nasopharyngeal airway

Which of the following is an appropriate nursing response?

"Right now we're going to get you to surgery so that your doctor can stop this bleeding. Then we'll get you comfortable again and see what your options are." This is the correct choice. This represents the therapeutic communication technique of formulating an action plan. This approach can help keep the patient's anxiety about this setback from escalating to an uncontrollable level.

ATP

(adenosine triphosphate) main energy source that cells use for most of their work

How many fingers space do you have for a trach secure tie device?

- 2 fingers

How can you tell if your trach is cuffed or not?

- Balloon attached around the outside of the tube.

Why is it important with a Shiley cannula; to have an extra one at the ready?

- In case you break sterility or to re insert an improperly inserted cannula

Would a nurse clean a cannula that is labeled DCT?

- No because the cannula is disposable.

complications of tracheostomy

- hypoxia - infection - tracheal tissue damage - atelectasis - accidental removal - constipation - dysphagia inability to clear airway inability to maintain adequate breathing pattern inability to tolerate activity ineffective airway clearance anxiousness, fearfulness, or despair compromised verbal communication deficient knowledge

During the procedure

1-. Promote patient involvement as much as possible. (Participation encourages the patient's cooperation and increases patient's knowledge of condition and care. It also may increase the patient's sense of independent and importance and increase the patient's compliance with treatment. 11. Determine the patient's tolerance of the procedure, being alert for signs and symptoms of discomfort and fatigue. If the patient cannot tolerate a procedure being alert for signs and symptoms of discomfort and fatigue. If the patient cannot tolerate a porcedure describe this inability in the nursing notes (patient's ability to tolerate interventions varies, depending on severity of illness and disability. It is necessary to determine when to provide the patient with an opportunity to rest and when to provide comfort measures).

nasal cannula

1-6 LPM = 24% - 44%

4. If a patient's condition requires a very precise delivery of oxygen concentration, the nurse anticipates that the health care provider will order oxygen to be delivered via which device?1. Venturi mask2. Simple face mask3. Nasal cannula4. Transtracheal cannula

1. "You will have oxygen on 24 hours a day at home by use of a nasal cannula, with the flow meter set at 2 liters."

3. What is the maximum time suction should be applied during nasotracheal suctioning?1. 15 seconds2. 20 seconds3. 30 seconds4. 45 seconds

1. 15 seconds (think it is 10 seconds - what did Ms. Baysal say?)

8. Which PT is most likely a candidate for endotracheal tube?1. PT is discovered in the bathroom, unresponsive and pulseless2. PT is choking on a foreign body that cannot be dislodged3. PT needs long-term mechanical vent for oxygenation4. PT needs precise, controlled concentration of O2

1. PT is discovered in the bathroom, unresponsive and pulseless--ETs are used in emergency situations to establish an airway for patients who are not breathing

8. The nurse is reviewing the arterial partial pressure of oxygen (PaO2) level on the patient's arterial blood gas report. Which level is most concerning to the nurse?1. PaO2 75 mm Hg2. PaO2 80 mm Hg3. PaO2 85 mm Hg4. PaO2 90 mm Hg

1. PaO2 75 mm Hg

1. The LPN/LVN is suctioning a patient through an endotracheal tube. What indicates proper technique? (Select all that apply.) 1. Preoxygenating the patient before suctioning 2. Dipping the suction catheter into sterile saline before suctioning 3. Using a clean catheter with each suctioning attempt 4. Withdrawing the catheter with the thumb continually covering the suction control vent 5. Suctioning the tube for at least 30 seconds with each suctioning attempt

1. Preoxygenating the patient before suctioning 2. Dipping the suction catheter into sterile saline before suctioning

Tracheostomy Suctioning and Care

1. Refer to standard steps 1 to 9 2. Assemble equipment: Sterile suction catheter kit sterile water or normal saline if not contained in kit sterile gloves clean gloves clean, water-repellent gown, and mask with face shield (if indicated) stethoscope 3. Check patient's tracheostomy for exudate, edema, and respiratory obstruction; check that tracheostomy phalange is secure with ties/strap (allows the nurse to identify potential need for further nursing inteventions) 4. Position patient in semi fowler's position. (Allows for optimal lung expansion; during suctioning the patient may cough forcefully and dislodge the tracheostomy if it not secure). 5. Provide paper and pencil or a communication board for patient (because patient cannot speak this offers a means of communication) 6. Position self at head of bead facing patient. Always face patient while cleaning or suctioning a tracheostomy (Enables close observaton for respiratory difficulty and coughing, which could expel the tracheostomy cannula) 7. Auscultate lung sounds (Provides Baseline information regarding airway for comparison after suctioning) 8. Place towel or prepackaged drape under tracheostomy and across chest (Protects patient's gown and the bed linens and provides a sterile field on the chest) 9. Perform hand hygiene. Prepare equipment and supplies on overhead table (organizes procedure) a. Open suction catheter kit but maintain sterility of contents, leaving the catheter in its wrapper (maintains sterility). The order of steps depends on how the equipment is placed in the kit and if there is a pre-filled container of sterile saline or water. Don sterile gloves if there is a pre-filled container of saline or water. Open the container. If there is only an empty basin for saline to be added, open the basin and remove the lid from the bottle of sterile saline or water outside of the kit, then done sterile gloves. Fanfold or wrap suction catheter around dominant hand (helps protect the sterility of the catheter tip) Pick up tubing from the machine with the non dominant hand and attach the end of the suction catheter to the suction machine tubing (This hand will no longer be sterile for the remainder of the procedure) b. If sterile saline or water is to be added to an empty basin inside the suction kit, use the nondominant hand to pour the sterile saline or water into the basin (sterile saline or water is used to rinse suction catheter. The nondominant hand is no longer sterile and can be used to pour solution). c. Turn on suction machine with nondominant hand and check that suction is working by suctioning a small amount of the sterile saline or water. This ia accomplished by covering the port on the suction tubing with the thumb of the nondominant hand 10. Preoxygenate patient by having patient take several deep breaths by setting ventilator to deliver 100% oxygen with sigh breaths, or by having an assistant use a resusitator bag. If patient is receiving oxygen, wait to remove oxygen delivery system until just before suctioning (Prevents oxygen depletion during procedure) 11. Suction tracheal cannula (Aids in maintaining patent airway) a. Suction tracheal cannula (aids in maintaining patent airway). a. Place thumb over suction control vent; place tip of suction catheter in container of sterile rinse solution. Withdraw sterile rinsing solution through catheter by placing thumb over suction control (moistens catheter and clears any mucus from the catheter tip) b. Remove thumb from suction control; advance catheter gently through the tracheostomy while maintaining sterility until resistance is met, and then withdraw catheter approximately 1 cm (depth of catheter approximately equals the length of outer cannula, the distal end of which protrudes from the opening approximately equals the length of outer cannula, the distal end of which protrudes from the opening approximately 1 to 2 inches). (Keeping thumb off of suction vent prevents suctioning while inserting catheter, which has the potential to damage the mucosa. Resistance is met when the catheter reaches the junction of the main bronchi) c. Apply intermittent suction by placing thumb on and off suction control and gently rotate catheter as it is withdrawn (sections are suctioned around the circumference of the trachea) d. Suction for a maximum of 10 seconds at a time, never long (prolonged suctioning depletes oxygen supply) e. Rinse catheter with sterile solution by suctioning sterile solution through it. Repeat steps 11b through 11e if needed. Most facilities policies indicate no more than three attempts during the suctioning procedure. f. Follow patient to rest between each suctioning effort. If patient was receiving oxygen previously reapply it at the prescribed rate between each suctioning episode (Suctioning is often exhausting and frightening for patients. Resting helps patient regain depleted oxygen and decreases fears). g. Turn off suction, and dispose of catheter appropriately by rolling catheter up into one gloved hand and pulling glove offer over catheter; then placing glove with catheter into other hand and pulling glove off over the glove with the catheter. h. perform hand hygiene i. Auscultate lung sound (Evaluate effectiveness of suctioning) 12. Refer to standard steps 10 to 17 13. Document the following (Verifies performance of procedure and ensures continuity of care) date time respiratory evaluation before suctioning tracheostomy suctioned characteristics of material that was suctioned amount (it will not be possible to determine the exact amount suctioned because the sterile saline for rinsing the catheter is in the suction canister along with the respiratory secretions. This is a subjective measure noting the amount is small/moderate/large or copious color consistency respiratory evaluation after suctioning adverse reactions patient's response if oxygen is administered, note flow rate and method use patient teaching

15. The nurse is assessing a patient who is displaying early signs of hypoxia. What signs and symptoms will the nurse observe? (Select all that apply.) 1. Restlessness 2. Increased pulse rate 3. Decreased blood pressure 4. Irregular apical pulse 5. Dyspnea

1. Restlessness2. Increased pulse rate4. Irregular apical pulse5. Dyspnea

12. The nurse is preparing to perform tracheostomy care and suctioning. What is the best order of actions when performing these two procedures? Place the steps in the correct order.1. The nurse performs tracheostomy suctioning.2. The nurse changes the tracheostomy ties/strap.3. The nurse changes the dressing around the tracheostomy.4. The nurse cleans around the tracheostomy with prescribed solution.

1. The nurse performs tracheostomy suctioning.4. The nurse cleans around the tracheostomy with prescribed solution.3. The nurse changes the dressing around the tracheostomy.2. The nurse changes the tracheostomy ties/strap.

9. The home health care nurse is observing the patient while he is filling the humidifier bottle attached to the oxygen tank. Which action by the patient demonstrates knowledge of this procedure?1. The patient fills the bottle with distilled water.2. The patient fills the bottle with tap water.3. The patient fills the bottle sterile normal saline.4. The patient fills the bottle with spring water.

1. The patient fills the bottle with distilled water.

13. In caring for a PT with a trach, what interventions will the nurse use to reduce the risk of infection? Select all that apply.1. evaluate PT for excess secretions and suction as often as necessary2. provide constant airway humidification3. provide frequent mouth care4. wear a mask when performing routine trach care5. remove water that condenses in equipment tubing6. change or clean all respiratory therapy equipment Q8 hrs

1. evaluate PT for excess secretions and suction as often as necessary2. provide constant airway humidification3. provide frequent mouth care5. remove water that condenses in equipment tubing6. change or clean all respiratory therapy equipment Q8 hrs

Tracheostomy Care

1. refer to standard steps 1 to 9 2.Check patient's tracheostomy for exudate, edema, and respiratory obstruction (Allows the nurse to identify potential need for further nursing interventions) 3. Perform suctioning if it is needed before performing tracheostomy care (Removes excess secretions and prevents soiling new dressing) 4. Position patient in semi fowler's position (Provides for optimal lung expansion) 5. Perform hand hygiene; then position self at head of bed, facing patient. Always face patient while cleaning or suctioning a tracheostomy (hand hygiene prevents spread of miscroorganisms. Facing patient enables close observation for respiratory difficulty and coughing) 6. Don clean gloves. Remove old dressing from around tracheostomy stoma, and discard it in appropriate receptacle (Removes any exudate or drainage from stoma site) 7. Prepare equipment and supplies on overbed table organizes procedure a. open tracheostomy cleaning kit with aseptic technique prevents contamination of supplies b. if basins are packed with sterile gloves, apply one sterile glove to dominant hand. Separate basins with dominant hand. Use nondominant hand to pour cleansing solution (hydrogen peroxide) in one basin and rinsing solution (sterile solution) in another basin (cleanses mucus and secretions from inner cannula and to rinse cannula) In some facilities, a third solution of half hydrogen peroxide and half normal saline is used to clean around the tracheostomy stoma. Check facility procedure. 8.. With nondominant hand, unlock and remove inner cannula; place in hydrogen peroxide cleaning solution The nondominant hand has a clean glove on it and can remove contaminated inner cannula without breaking sterile technique Never remove outer cannula. If it is expelled by patient, use hemostat to hold tracheostomy open, and cal for assistance. Always have a sterile package hemostat, as well as an extra sterile tracheostomy set available at bedside (Prevents closure of stoma until new outer cannula can be inserted) 9. Apply second sterile glove or apply new pair of sterile gloves if contamination has occurred (reduces spread of microorganisms) 10. Clean inner cannula (Removes secretions and hydrogen peroxide from inner cannula) a. Use brush to clean inside and outside of inner cannula b. Place inner cannula in sterile normal saline solution (Rinses away the hydrogen peroxide) c. At some facilities, pipe cleaners are used to dry inside of inner cannula. Check facility policy. d. Inspect inner and outer areas of inner cannula. Remove excess liquid e. Insert inner cannula in the direction of the tracheostomy and lock in place (Secures inner cannula and reestablishes oxygen supply) 11. Clean skin around tracheostomy and tabs of outer cannula with hydrogen peroxide (or half and half mixture) and cotton tipped swabs clean away from the opening. Use wipes that are free of lint around the tracheostomy opening (Removes any remaining exudates or drainage. Inhaled lint (e.g. from cotton balls] irritates the respiratory passages and tends to cause undue coughing. Special tracheostomy dressings are available. 12. It may be necessary to rinse cleansing solution skin. If so, use sterile 4 x 4 gauze. Aseptically removes secretions from stoma site) Place dry, sterile 4 x 4 drainage sponge around the tracheostomy opening Prevents skin impairment caused by rubbing of flange of tracheostomy tube against the skin. 13. Changes ties/straps holding tracheostomy in place if necessary (Always do this after cleaning inner and outer cannula to prevent cannula from being expelled) a. If assistance is not available, thread clean tie through opening in flange of outer cannula along old tie. If assistance is available untie one side of cotton tape from outer cannula and replace with clean one while the assistant stablizes the tracheostomy tube (Prevents accidental expulsion of outer cannula) b. Bring clean tape under back of neck (securely holds tracheostomy tube in place to prevent movement of cannula) c. If assistance is not available, thread tie through opening in opposite flange of outer cannula along old tie. If assistance is available, remove other side from outer cannula and replace with clean tape. d. Tie ends of clean cotton tapes together in a knot at side of neck (Secures ties and cannula in place. Putting knot at side of neck avoids pressure and skin irritation at back of neck) 14. Auscultate lung sounds (Enables the nurse to determine any changes from baseline) 15. Provide mouth care. Promotes good oral hygiene. Patients with tracheostomies often have halitosis 16. Refer to standard steps 10 - 17 17. Place call light, paper and pencil within easy reach of the patient Enables patient to communicate needs 18. Reassess patient's tracheostomy for signs of bleeding, edema and respiratory obstruction (patients with tracheostomy frequently have bloody secretions for 2 to 3 days after procedure or for 24 hours after each tracheostomy tube change) 19. Document the following (Verifies performance of procedure and ensures continuity of care Date/time of tracheostomy care performed and solution used to clean around the stoma patient's response evaluation of respiratory status adverse reactions evaluation of respiratory status adverse reactions condition of tracheal stoma and peristomal skin if oxygen is administered, note flow rate and method used patient teaching

steps for oxygen administration

1. standard steps 1-9 2. assemble equipment specific oxygen delivery system (e.g. mask, cannula, or tent, the last of which is used primarily for pediatric patients) oxygen tubing (consider extension tubing) source of oxygen flowmeter humidifer bottle and distilled water "oxygen in use" sign clean gloves stethoscope 3. Explain necessary precautions during oxygen therapy (increases patient knowledge and compliance and promotes safety) 4. Position patient in fowler's or semi fowler's position (allows for maximum lung expansion) 5. Auscultate lung sounds and observe for signs and symptoms of hypoxia or respiratory distress. Review arterial blood gas results ABG's (Enables the nurse to confirm patency of airway and to determine need for oxygen) suction any secretions obstructing the airway, and listen to lung sounds after suctioning (Assists in clearing airway and increasing oxygenation) 6. Use a prefilled humidification container or fill the humidifier container with distilled water designated level, if necessary. Humidify oxygen if flow rate is greater than 4 L/min. Use only distilled water in humidifier (Provides moisture to prevent drying of the nasal and oropharyngeal mucosa. Distilled water provides bacteria and mineral free water 7. Attach flowmeter to humidifier and insert in proper oxygen cylinder, or oxygen concentrator. The oxygen then is turned on to the prescribed liter flow. If the flowmeter has a metal ball, the oxygen is turned on until the middle of the metal ball is positioned on the line on the flowmeter for the prescribed oxygen flow (it is necessary to secure flowmeter properly to oxygen source for adequate deliver of oxygen) Verify that water is bubbling (presence of bubbling indicates that oxygen is humidified before delivery to patient) 8. Administer oxygen therapy: a. A nasal cannula allows patient to eat and talk normally, and its use is appropriate for all age groups (1) Attach nasal cannula tubing to flowmeter (Oxygen delivery system must be continuous to ensure adequate supply of oxygen) (2) Adjust flowmeter to 6 to 10 L/min to flush tubing and prongs with oxygen. Feel the oxygen on your skin to ensure flow (enables the nurse to determine patency and removes any microscopic particles possibly in tubing). (3) Adjust flow rate to prescribed amount; 1 to 6 L/min may be ordered (Ensures delivery of oxygen flow rate as directed by the health care provider) (4) Place a nasal prong into each nostril of the patient in the direction that the prongs are curbed (see illustration) (Directs flow of oxygen into patient's upper respiratory tract). (5) Place cannula tubing over the patient's ears, and tighten under the chin (see illustration). (Proper fit is snug and comfortable to prevent displacement of prongs). (6) Place padding between strap and ears if needed. Use lamb's wool, gauze, or cotton balls. Some nasal cannula tubing already has protective devices in place (Prevents skin irritation and breakdown) (7) Ensure that the cannula tubing is long enough to allow for patient movement (Reduces risk that one or both prongs will cause pressure on the nares, as well as risk of displacement, as patient moves or is repositioned). (8) Regularly evaluate equipment and patient's respiratory status (Ensures delivery of prescribed oxygen flow rate. Determines whether patient needs further respiratory interventions) a. Evaluate cannula frequently for possible obstruction. b. Observe external nasal area, nares, and superior surface of both ears for skin impairment every 6 to 8 hours. c. Observe nares and cannula prongs at least once a shift for irritation or breakage. Cleanse skin with cotton tipped applicator as needed (prevents skin irritation or trauma to the nares from damaged cannula prongs.) d. Apply water-soluable lubricant to nares if needed (Prevents drying and irritation of nares. Water-soluable lubricant will not occlude the nasal cannula.) e. Refer to health care provider's orders for any prescribed changes in flow rate. f. Maintain solution in humidifier container, if used, at appropriate level at all times (prevents inhalation of dehumidified oxygen). g. Auscultate lung sounds (Verifies adequate oxygenation and patency of airway.) h. Consult with health care provider regarding need for pulse oximetry if patient's oxygen level is unstable. (Assists in determining oxygenation needs and helps prevent oxygen toxicity) FACE MASK b. Depending on patient's respiratory condition, the health care provider may prescribe delivery of oxygen by a mask. the mask is designed to fit snugly over the patient's nose and mouth. Different types of masks are used according to patient's needed such as the VENTURI MASK, the partial rebreather mask, the non-rebreathing mask and the simple face mask. (1) Explain to the patient the need for oxygen mask (Decreases patient's fear and increases compliance) (2) Adjust flow rate of oxygen per health care provider's order. Usually 6 to 10 L/min which is measured in percentages (35% to 95%) is prescribed. In some facilities, the respiratory therapist assumes responsibility for maintaining proper flow. Observe for maintaining proper flow. Observe for fine mist or bubbling in humidifer. (3) Allow patient to hold the oxygen mask over the bridge of the nose and mouth, if he or she is able. Assist as necessary. (Placing mask over patient's face sometimes causes feeling of suffocation and apprehension. Allowing patient to place the mask helps patient become accustomed to mask and to have some control over place it on face.) (4) Adjust straps around patient's head and over ears. Place cotton ball or gauze over ears under elastic straps (Provides comfort and prevents skin impairment.) (5) Cover the reservoir hold in the mask and allow the reservoir bag to completely fill BEFORE placing on the patient. Observe reservoir bag for appropriate movement if one is attached to mask. (Mask's expanding and collapsing with patient's breathing confirm appropriate fit and that oxygen delivery is maintained.) (a) partial-rebreathing mask: When functioning properly, the reservoir fills on exhalation and almost collapses on inhalation. (b) Nonrebreathing mask: when functioning properly, the reservoir fills on exhalation but never totally collapses on inhalation. (6) Evaluate equipment function regularly. (Ensures that mask is working properly that the patient is receiving appropriate amount of oxygen). (a) Remove mask and evaluate skin every 2 to 4 hours. Clean and dry skin as needed (Removes condensation and other debris that may form and prevents skin breakdown.) (b) Refer to health care provider's orders for prescribed flow rate and any changes. (c) Maintain solution in humidifier container, if used, at appropriate level at all times. Always use distilled, never tap water (Prevents inhalation of dehumidified oxygen. Distilled water decreases the growth of microorganisms. 9. Refer to standard steps 10 to 17 10. Document the following (verifies performance of procedure and ensures continuity of care) Date Time Flow rate Method of oxygen delivery Evaluation of respiratory status Patient's response to oxygen therapy Changes in health care provider's orders Adverse reactions or side effects of oxygen therapy Assess condition of skin around oxygen device Patient teaching

How long should you apply suction during this suction pass?

10 seconds This is the correct choice. Generally, suction time should to limited to no more than 10 to 15 seconds on a single pass. For patients who have a tracheostomy, limiting suction to less than 10 seconds is often recommended to minimize oxygen loss and prevent hypoxia and dysrhythmias.

how long can tracheostomy suction be applied at a time

10 seconds (no longer)

After the procedure

12. Assist the patient to a position of comfort, and place needed items within easy reach. Ensure that the patient has a means to call for help and knows how to use it (promotes comfort and safety. patient often try to reach items and risk falling or injury) 13. Raise the side rails and lower the bed to the lowest position (this minimises the patient's risk in getting out of bed unattended. Use nursing judgment and facility policy to safely allow alert, cooperative patients to have their side rails down) 14. Remove gloves and all protective barriers such as gown, face shield, and masks. Store appropriately or discard. Remove and dispose of soiled supplies or discard. Remove and dispose of soiled supplies and equipment according to agency policy and guidelines from CDC and OSHA (reduces spread of microrganisms maintains cleanliness of environment and enhances patient comfort and safety. 15. Performs hand hygiene after removing gloves (wearing gloves does not eliminate the need for HH. HH is the most important technique for preventing and controlling the spread of microorganisms). 16. Document the patient's response to the procedure, expected or unexpected outcomes and all patient teaching. Specific ares of documentation are indicated in each skill box (timely and accurate documentation is legally requirement, records patient's progress and promotes continuity of care). 17. Report any unexpected outcomes. Specific notes for reporting unexpected outcomes are included in each skills (additional procedures or treatments may be necessary).

Exhalation

16% oxygen

13. The nurse has just performed oropharyngeal suctioning. Which documentation is the most complete after this procedure?1. "Suctioned patient using a Yankaur suction catheter. Large amount of mucus suctioned. Patient tolerated procedure well and is breathing better."2. "Performed oropharyngeal suctioning using Yankaur suction catheter. Moderate amount of thick green, odorless, mucus suctioned. Tolerated procedure well and respirations are nonlabored."3. "Oropharyngeal suctioning performed due to patient being unable to expectorate secretions. Used Yankaur suction catheter to perform procedure. Patient breathing better following suctioning."4. "Patient requiring suctioning. Oropharyngeal suctioning performed. Patient unable to cough up thick mucus. Breathing improved after suctioning. Used a Yankaur suction catheter for procedure."

2. "Performed oropharyngeal suctioning using Yankaur suction catheter. Moderate amount of thick green, odorless, mucus suctioned. Tolerated procedure well and respirations are nonlabored."

14. The health care provider has ordered a patient diagnosed with pneumonia to have oxygen via a simple face mask. The nurse is aware that the patient will be receiving a FiO2 of what percentage depending on the flowmeter setting?1. 24%-44%2. 35%-55%3. 24%-55%4. 60%-90%

2. 35%-55%

6. The home health nurse is visiting a patient who is on home oxygen therapy. What action by the patient and family members alerts the nurse that further teaching about home oxygen therapy is necessary? (Select all that apply.) 1. The nurse notes a fire extinguisher in the kitchen. 2. The patient's brother-in-law is in a separate room smoking a cigarette. 3. The patient states that when shaving an electrical razor is used. 4. The patient is using a water-soluble gel to help with lubricating dry mucous membranes. 5. The oxygen tubing is coiled and secured with a rubber band to prevent the patient from tripping over the tubing.

2. The patient's brother-in-law is in a separate room smoking a cigarette.3. The patient states that when shaving an electrical razor is used.5. The oxygen tubing is coiled and secured with a rubber band to prevent the patient from tripping over the tubing.

10. The nurse observes the student nurse suction the patient with a tracheostomy. Which action by the student nurse requires the nurse to intervene? (Select all that apply.) 1. The student preoxygenates the patient before beginning suctioning. 2. The student suctions the patient for 30 seconds during each suctioning attempt. 3. The student uses tap water to clear the catheter tubing between suction attempts. 4. The student applies intermittent suction when withdrawing the suction catheter from the airway. 5. The student places the thumb over the suction control vent when advancing the catheter into the patient's airway.

2. The student suctions the patient for 30 seconds during each suctioning attempt.3. The student uses tap water to clear the catheter tubing between suction attempts.5. The student places the thumb over the suction control vent when advancing the catheter into the patient's airway.

11. Nurse is caring for a PT with a tracheostomy. What S/S indicate the need for suctioning? Select all that apply1. fine crackles in posterior lobes2. gurgling sounds heard during respiration3. restlessness or anxiety4. emesis in the oral cavity5. drooling excessive secretions6. PT indicates need for suctioning

2. gurgling sounds heard during respiration3. restlessness or anxiety4. emesis in the oral cavity5. drooling excessive secretions6. PT indicates need for suctioning

6. The nurse is caring for a PT who is on 3L O2 per nasal cannula. What tasks can be delegated to the UAP? Select all that apply.1. ensuring O2 flow is set at 3L/min throughout shift2. helping PT clean area around nares and ers3. counting respirator rate and taking pulse ox reading4. listening to breath sounds before and after PT coughs5. assisting PT to semi-fowler's position6. observe nares, external nasal area, ears for breaks in skin integrity

2. helping PT clean area around nares and ers3. counting respirator rate and taking pulse ox reading5. assisting PT to semi-fowler's position

12. PT had an uneventful hip surgery several days ago and will soon be transferred to a rehab unit. PT says to the nurse, "I feel silly complaining about this, but I feel short of breath and a little anxious and fuzzy-headed." PT has no known history of respiratory or cardiac issues. What should the nurse do first?1. reassure PT she is not being silly, and anxiety is normal2. take VS, apply a pulse ox, listen to breath sounds3. ask PT to describe what she is feeling and what she thinks is going on4. apply O2 per nasal cannula, notify charge nurse, call provider

2. take VS, apply a pulse ox, listen to breath sounds--symptoms are vague and the patient is not in acute distress

oxygen delivery devices - mother earth

21% oxygen

10. Nurse must be vigilant for signs of hypoxia in an older PT who has dementia and also risk for decreased oxygenation because of chronic respiratory disease and immobility. What is an early sign that warrants additional assessment of respiratory status?1. lips are cyanotic, fingers are cool, capillary refill is sluggish2. respirations are slow and shallow3. PT seems restless and anxiously picks at linens4. pulse is slower than normal and thready + weak

3. PT seems restless and anxiously picks at linens--PTs who are unable to verbalize complaints or symptoms, nurse must be vigilant and investigate subtle changes in behavior, IE anxiety or a change in mental status. Cyanosis and slowing of pulse and respiratory rate are late signs.

11. The health care provider has ordered oxygen at 100% via a nonrebreathing mask. The nurse evaluates that the mask is working properly when making which observation?1. The reservoir bag collapses 50% when the patient inhales.2. The reservoir bag collapses completely when the patient inhales.3. The reservoir bag remains nearly full when the patient inhales.4. The reservoir bag inflates when the patient inhales.

3. The reservoir bag remains nearly full when the patient inhales.

7. The nurse encourages the patient to drink an adequate amount of fluids to help with dry mucous membranes and to liquefy secretions. What fluids should the nurse include in this teaching? (Select all that apply.) 1. Coffee 2. Milk 3. Water 4. Juice 5. Tea

3. Water4. Juice

9. Nurse walks into the room and notices PT is anxious, demonstrates labored breathing, and seems to be struggling to get out of bed. What should the nurse do first?1. gently advise PT to calm down, then ask what is wrong2. count respiratory rate, note rhythm, auscultate breath sounds3. assist him to sit upright and calmly instruct to take slow, deep breaths4. stay with PT, apply O2, have another nurse call the provider

3. assist him to sit upright and calmly instruct to take slow, deep breaths--PT is in obvious distress and there are many things that could be causing his behavior, but oxygenation is the priority; Quickest action is to help the patient sit upright; this allows for maximum chest expansion and is the most comfortable position for PTs with respiratory distress. Helping him to take slow deep breaths, maximizes use of room air oxygen

3. In performing nursing skills & procedures for PTs, which nursing action demonstrates the nurse's understanding and use of Standard Precautions?1. always check PT's armband and ask PT to state his or her name2. assess PT's understanding and teaches accordingly3. performs hand hygiene before and after every PT4. evaluate PT's response to and tolerance of procedure

3. performs hand hygiene before and after every PT--encourages infection control, other options are part of standard procedures

What is the appropriate value for the venturi mask? Oxygen delivery devices with percent of oxygen delivered Delivery device Amount of delivered FiO2 Nasal cannula 1-6 L/min = 24%-44% O2 (goes up by 4) Simple face mask 5-8 L/min = 35%-55% O2 Venturi mask: 4-10 liters per minute = 24% - 55% Partial rebreather mask 6-12 L/min = 60%-90% O2 Nonrebreather mask 6-15 L/min = 70%-100% O2

4-10 L/min = 24%-55% O2

Venturi mask

4-10 LPM = 24% - 55%

2. A patient's physician told the patient that she was suffering from hypoxia. The patient asks the nurse what that means. Which statement by the nurse is most accurate?1. "Hypoxia means that there is a deficient amount of oxygen in your blood."2. "It would be best if you asked your physician to explain hypoxia."3. "There is too much carbon dioxide in your blood."4. "Hypoxia means that the cells in your body's tissues are not receiving enough oxygen."

4. "Hypoxia means that the cells in your body's tissues are not receiving enough oxygen."

7. Nurse is reviewing lab results and sees PaO2 level for a 75 y/o PT is 80mmHg. What should the nurse do first?1. notify provider about unusually low level2. contact clinical lab to verify low result3. check previous lab values for comparison4. assess PT for S/S of respiratory distress

4. assess PT for S/S of respiratory distress--immediately assess PT for respiratory distress and intervene as necessary. If the patient is not in immediate distress, the nurse would consider factors that could affect PaO2: such as age or chronic health conditions

5. What is included in the preparation for trach-care in the acute care environment?1. using clean technique and supplies for cleaning2. preparing cotton balls to clean inside ostomy3. removing and cleaning the outer cannula4. placing PT in semi-Fowler's position

4. placing PT in semi-Fowler's position--position allows PT to breathe easier and allows easy access for nurse. Sterile technique is required. The outer cannula is not removed. Cotton balls should not be inserted into the tracheostomy.

Simple face mask

5-8 LPM = 35% - 55%

partial rebreather mask

6-12 LPM = 60% - 90%

nonrebreather mask

6-15 LPM = 60 - 90%

6. The nurse is caring for a patient with an endotracheal tube. What interventions will the nurse implement? (Select all that apply.)

A Turn and reposition the patient every 2 hours. B Change or clean all respiratory therapy equipment every 24 hours. C Provide constant airway humidification. D Elevate the head of the bed.

oxygen toxicity

A condition of excessive oxygen consumption resulting in cellular and tissue damage - scarring of respiratory tract tissues

suction catheter

A hollow, cylindrical device used to remove fluid from the patient's airway.

oxygen toxicity

A serious, even life-threatening condition that occurs if too much oxygen is delivered for too long a period of time. Can cause scarring of respiratory tract tissues

Which of the following actions should you implement?

Attempt to reposition the tracheostomy tube. This is the correct choice. If the tube is not completely dislodged and most of it is still in place, it might be possible to exert minimal pressure to ease it back in place and re-secure it by adjusting the ties.

Should I use normal saline solution to loosen secretions when I suction a patient's airway?

Although instilling normal saline solution to loosen secretions used to be a common practice, recent research has indicated that this practice may no longer be acceptable. Instilling normal saline while suctioning could disperse micro-organisms in the lower respiratory tract, thus increasing the patient's risk of infection.

What methods of oral care have been shown to reduce infection in patients who require endotracheal intubation?

An evidence-based oral care protocol to decrease ventilator-associated pneumonia

3 Which of the following is the appropriate nursing action to maintain airway patency prior to arranging transportation to the surgical suite?

Apply sterile gauze around the tracheostomy site. This is the correct choice. Wrapping sterile gauze around the tube and packing it lightly into the wound might help slow the bleeding and prevent seepage of blood into the tube.

Tachycardia

Abnormally rapid heartbeat

Described what a cuff trach is, and what is it used for? Can you use an ambu bag on a non-cuffed trach?

Balloon attached around the outside of the tube; provides a seal so that air doesn't leak through the mouth or nose to use an ambubag. No.

Just before you suction the patient's airway, which of the following actions should you perform?

Hyperoxygenate the patient. This is the correct choice. To help prevent a decline in oxygen saturation during suctioning, ask the patient to take several deep breaths, or, if the patient is receiving supplemental oxygen, increase the oxygen to 100% or as prescribed by the provider.

Yankauer suction tip

Category: suctioning and aspirating Other Names: tonsil suction tip, oral Use(s): is used for suctioning in all types of wounds. Allows effective suction w/out aspiration damage to the surrounding tissue. Description: a hollow plastic tube w/a grip handle and a slightly bent shaft that terminates w/a bulbous tip and large opening. Instrument Insight: the disposable Yankauer is the most widely used suction tip. requires sterile technique (Mr. Hahn said clean technique)

What methods of oral care have been shown to reduce infection in patients who require endotracheal intubation?

Chlorhexidine decreases the risk of ventilator-associated pneumonia in intensive care unit patients: A randomized clinical trial

After I use a closed-suction system to suction a patient's airway, is it necessary for me to close or lock the suction-control mechanism?

If the system you use has a suction-control mechanism, close it after you are finished suctioning. Otherwise, the suction catheter could migrate into the patient's airway and partially obstruct it.

A nurse is suctioning a patient's airway using in-line suctioning. When using this method, it is appropriate for the nurse to

reuse the catheter repeatedly. With in-line suctioning, the catheter attaches to the ventilator tubing and does not have to be replaced until the system is replaced. It can be used repeatedly.

My patient tends to develop respiratory distress during suctioning. What should I do when this happens?

Immediately withdraw the suction catheter and administer oxygen and breaths from a manual resuscitation bag as needed. In an emergency, you can deliver oxygen directly through the catheter by disconnecting the suction and attaching oxygen at the prescribed flow rate.

My patient has a prescription for chest physiotherapy. Can I delegate this to unlicensed assistive personnel (AP)?

In certain situations, chest physiotherapy can be delegated to appropriately trained AP. However, it is still your responsibility to assess the patient, review laboratory and x-ray results, and determine whether or not the patient is stable and can tolerate the procedure.

Which of the following is the priority action for this patient?

Elevate the head of the bed to 90 degrees. This is the correct choice. Keeping the patient upright prevents aspiration of blood through the tracheostomy tube.

Which of the following should you do next?

Extend the patient's neck. This is the correct choice. Your highest priority is to open the tissues of the stoma to establish and secure the airway and allow ventilation. Extending the patient's neck allows this to happen.

A nurse is preparing to perform endotracheal (ET) tube care and plans to use tape to secure the tube. Which of the following is an appropriate preparatory action for this procedure?

Have tincture of benzoin ready to apply to the patient's face

Which of the following interventions should you decide to add to the patient's nursing care plan to help thin his secretions?

Increase fluid intake. This is the correct choice. Increasing oral hydration is an appropriate intervention for patients who retain thick pulmonary secretions. The additional fluids help liquefy mucus and make it easier to remove during suctioning.

How far should I insert the catheter when I suction a patient's airway?

Insert the suction catheter until you meet resistance at the carina or until the patient coughs. Then pull it back 1 cm (1/2 inch) and slowly withdraw it while applying intermittent suction and using a rotating motion.

If sterile tracheostomy dressing is not available, should I cut a sterile 4 x 4 gauze pad and use it as a sterile dressing under a tracheostomy tube's flanges?

It is not safe to cut a gauze pad and use it with a tracheostomy tube. The patient could aspirate fibers from the gauze, resulting in an infection or an abscess in the trachea. Use commercially prepared tracheostomy dressings or a folded 4 x 4 gauze pad instead.

Oxygen delivery devices

Nasal cannula (1-6 L) 24-44% (goes up in 4s) Simple face mask (5-8 L) 35% - 55% Venturi mask (4-10 LPM) = 24% - 55% Partial rebreather mask (6-12 LPM = 60% - 90% Non-rebreather mask (6-15 LPM = 70% - 100% oxygen hood, halo or tent

Described what a cuff trach is, and what is it used for? Can you use an ambu bag on a non-cuffed trach?

No

What methods of oral care have been shown to reduce infection in patients who require endotracheal intubation?

Oral care with 0.12% chlorhexidine for the prevention of ventilator-associated pneumonia in critically ill children: Randomized, controlled and double blind trial

As you advance the catheter, you meet resistance and the patient begins to cough. Which of the following is the appropriate nursing action?

Pull the catheter back about a half inch to an inch. This is the correct choice. Resistance and coughing generally indicate that the suction catheter has reaching the carina, the anatomical point where the trachea divides into the right and left bronchi. Pulling back 1 to 2 cm (1/2 to 1 inch) prevents damage to the mucous membranes at this bifurcation.

six rights of drug administration

Right drug Right dose Right time Right route Right patient Right documentation

An 80 year old patient was admitted to the emergency department with an asthmatic/COPD episode. Oxygen therapy was ordered. What precautions should the nurse take in administering oxygen to a patient in acute respiratory distress? Upon arrival the patient is supine. What is the very first thing you are going to do?

Sit Fowler's

Which of the following is your priority intervention for this patient at this time?

Suction the patient's airway This is the correct choice. The patient is conscious and able to communicate, and his respiratory rate, although high, is not high enough to warrant mechanical ventilation. As is common with a new tracheostomy, secretions have probably accumulated in the patient's airway. Removing them is likely to raise his oxygen saturation and help stabilize his other vital signs.

oxygen therapy - patient teaching

Teach patient how to apply the oxygen equipment such as the nasal cannula or oxygen mask appropriately discus safety precautions for oxygen use Stress the dangers of adjusting the oxygen flow rate without notifying the health care provider. Emphasize that it is possible for the patient to be short of breath because of reasons other than hypoxia and to contact the health care provider if shortness of breath increases. Instruct patient to ambulate or change positions frequently to mobilize secretions. Teach the patient to cough and practice deep breathing and encourage practising these techniques frequently, as directed by the patient condition or provider's orders, to facilitate air exchange. Teach the patient to maintain adequate fluid intake to help liquefy secretions. Recommend fluids that are free of caffeine and sugar because drinks high in caffeine and sugar sometimes cause dehydration. Teach the patient to avoid dairy products, which tend to thicken secretions. Teach the rationale for prescribed medications, as well as side effects. This helps increase compliance. Teach that performing oral hygiene at regular intervals helps rid the mouth of any bad taste from secretions coughed up or expectorated.

What is oxygen therapy?

The administration of oxygen at greater than 21% (the concentration of oxygen in room air). must be ordered by a health care provider and closely monitored by the nurse

When I use twill tape to secure a tracheostomy tube, does it matter how I tie it?

Tie the ends of the twill tape in a double square knot near the flange of the tracheostomy tube. Cut off any long ends, leaving approximately 1 to 2 cm (0.5 inch). Tying the ends this way helps prevent slippage and loosening; leaving a short amount on the ends keeps the knots from becoming untied.

My patient needs to have an oral airway inserted. How do I know what size to use?

To be precise in choosing the correct size, you'd have to measure from the corner of the patient's mouth to the angle of the jaw just below the ear. The distance should equal the distance from the flange of the airway to the tip. If you use an airway that is too small, the patient's tongue will not stay positioned in the anterior part of the mouth. If you use an airway that is too large, you'll push the patient's tongue toward the epiglottis and obstruct the airway. With practice and experience, you should be able to select from the sizes available which would be best for your patient.

When should I use an oral airway? A nasal airway?

Use an oral airway only for patients who have an altered level of consciousness because it tends to stimulate the gag reflex. A nasal airway, on the other hand, does not stimulate the gag reflex; you can use it for patients who are more alert but still need their airway protected. Do not use a nasal airway for any patient who has any sort of facial or head injuries.

Suctioning

Use of a vacuum device to remove blood, vomitus, and other secretions or foreign materials from the airway. HIGH IMPORTANCE - you are stealing breath so you must monitor with pulse oximeter at all times when suctioning

Which of the following is the appropriate nursing action at this time?

Use the obturator at the bedside to insert a new tube. This is the correct choice. It is essential to keep a manual resuscitation bag, a tracheostomy tube of the same size and type, and a tracheostomy insertion tray with an obturator at the patient's bedside. Because of the emergent nature of this complication, nurses must be able insert the obturator and replace the tube with a fresh tube.

Transtracheal Oxygen Delivery

Used for long-term delivery of oxygen directly into the lungs Avoids the irritation that nasal prongs cause and is more comfortable Flow rate prescribed for rest and for activity Patient with tracheostomy oxygen is delivered throughout the entire respiratory cycle especially suited for home use

What should you do next?

While an assistant holds the tube in place, secure the tracheostomy ties. Yes. This is the correct choice. Now that you have re-established the airway, the priority is to secure it to keep the tube from dislodging.

A nurse is preparing to suction secretions from the mouth of a patient who has dysphagia. Which of the following is the appropriate suction device or method for the nurse to use?

Yankauer catheter

What is cyanosis?

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood (you will see in lips and eyes - tongue can have greyish hue)

vibration

a chest physiotherapy technique that involves applying pressure and a shaking movement of the hand to various areas over the lungs to mobilize pulmonary secretions

percussion

a chest physiotherapy technique that involves rhythmic clapping of cupped hands over various segments of the lungs to mobilize secretions

obturator

a device used to guide the outer portion of a tracheostomy tube during insertion and removed immediately after the outer tube is in place

hypoemia

a diminished amount (reduced saturation) oyxgen in arterial blood

endotracheal (ET) tube

a hollow tube inserted in the trachea to establish and maintain a patent airway

nasotracheal tube

a hollow tube inserted through the nose into the trachea to establish and maintain a patent airway

chest physiotherapy

a method of mobilizing pulmonary secretions by positioning the patient's head downward to incline the trachea below the affected area and then applying percussion and vibration techniques; often used synonymously with postural drainage, although that term technically refers to drainage by gravity without percussion and vibration

Respiratory Therapist

a specially trained technician who administers, among other treatments, inhalation therapy to patients with lung disease. also can be initiated by a nurse, an emergency medical technician (EMT) or any other licensed health care provider with an appropriate order for the oxygen.

A nurse is preparing to suction secretions from the mouth of a patient who has dysphagia. Which of the following is the appropriate suction device or method fo the nurse to use?

a yankauer catheter (tonsil tip) suction catheter helps clear secretions from the mouth. This is the appropriate device to use for patients who can cough effectivelybut cannot swallow or expectorate secretions.

apnea

absence of breathing

to prevent depression of the respiratory center

advisable to give analgesics and sedatives with caution

What do you need to stay alive?

air and sugar

atelectasis

airlessness or collapse of a lung, usually as a result of hypoventilation or obstruction

Nurse must provide

alternative means of communication to pt - pad and pen agree signals for pt pain/discomfort before tubing inserted e.g. raising hand

You conclude the blood in the secretions to be

an expected finding for this patient at this time. This is the correct choice. Minor bleeding is expected 24 to 48 hours after tracheostomy tube placement. The patient's vital signs do not indicate any distress.

tracheostomy

an opening created by a surgical incision into the trachea for the purpose of establishing and maintaining an airway

Artificial Airway

any device inserted into the respiratory tract to facilitate breathing or secretion removal

signs and symptoms of hypoxia

apprehension, anxiety, restlessness behavioral changes cardiac dysrhythmias cyanosis decreased ability to concentrate decreased level of consciousness digital clubbing (with chronic hypoxia) dyspnea elevated blood pressure increased fatigue increased pulse rate: as hypoxia advances, bradycardia results, which in turn results in decreased oxygen saturation increased rate and depth of respiration: as hypoxia progresses, respirations become shallow and slower, and apnea develops pallor vertigo

signs and symptoms of hypoxia

apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes, tachycardia, dynea

care of tracheostomy

artificial opening made by a surgical incision into the trachea. A tracheostomy may be created for patients who are experiencing apnea or some form of respiratory obstruction of breathing or some form of respiratory obstruction. It also may be used to prevent aspiration of secretions and blood or to provide easier access to the lower airways. Many types of tracheostomy tubes are available.

how often is suction performed with a tracheostomy

as often as necessary

the nurse walks into the room and notices that the patient is anxious, demonstrates labored breathing, and seems to be struggling to get out of bed. what should the nurse do

assist him to sit upright and calmly instruct him to take slow, deep breaths.

As a general rule of thumb under normal conditions effective Fi02 can be gauged by

at 1 liter per minute the estimated Fi02 is 24% at 2 liters per minute the estimated Fi02 is 28% at 3 liters per minute the estimated Fi02 is 32% at 4 liters per minute the estimated Fi02 is 36% at 5 liters per minute the estimated Fi02 is 40% at 6 liters per minute the estimated Fi02 is 44% at 7 liters per minute the estimated Fi02 is 48% at 8 liters per minute the estimated Fi02 is 52%

the older adult

at greater risk for skin impairment. Therefore, frequent monitoring for erythema and skin breakdown over the ears i necessary when a nasal cannula is being use for oxygen delivery. Early interventions such as loosening the straps, repositioning the the tubing, or adding padding over the ears often prevent impairment.

where is tracheostomy inserted?

between 2nd and 3rd tracheal cartilage

how is respiratory drive normally initiated?

by arterial carbon dioxide (PaCO2) levels rising, but in patients with chronic obstructive pulmonary disease (COPD), hypoxia tends to be the driving force behind respiratory effort (Hypoxic drive). If the hypoxia is corrected in a patient with COPD, then the respiratory drive is reduced, and respiratory difficulty will occur. For this reason, oxygen flow rates greater than 2 L/min are to be given with great caution in these individuals. Flow rates higher than 2 L/min could eliminate the respiratory drive, and breathing may stop.

suctioning tracheostomy

see skill 14.2 require sterile technique in certain situations unlicensed assistive personnel, patients or caregivers may perform tracheostomy suctioning

pasymuir valve

cap that you can speak with

how would you identify the patient

check the name band and ask patient for his or her name

provide privacy

close to the door of the room and pull the curtain around the bed or table

Describe oxygen

colorless, odorless, tasteless it does not burn or explode but supports combustion (avoid smoking and use of electrical appliances)

A nurse is caring for a patient who has a tracheostomy tube in place. During the tracheostomy care, which of the following should the nurse place underneath the flanges of the outer cannula?

commercially prepared fenestrated dressing. A commercially prepared tracheostomy dressing is made of material that does not unravel and has a fenestration (slit) designed to fit around the tracheostomy tube under the flanges.

What is hypoxia?

deficiency in the amount of oxygen reaching the tissues and cells (cell metabolism slows down and cells begin to die)

Dysnea

difficult or labored breathing

why type of water in humidifier set up?

distilled water

Oxygen

dries mucous membranes

in caring for a patient with tracheostomy what interventions will the nurse use to reduce the risk of infection

evaluate the patient for excess secretions and suction as often as necessary.provide constant airway humidificationprovide frequent mouth careremove water condenses om equipment tubingchanging or clean all respiratory therapy requirements every 8 hrs

hypercapnia

excessive carbon dioxide in the blood

Hyperventilation

excessively rapid and deep breathing

suction is performed as often as necessary

first postoperative hours whenever respirations are noisy and the pulse and respiratory rates are increased, the patient needs suctioning patients who are conscious are usually able to indicate when they need suctioning a patient who is able to expectorate secretions requires less suctioning the amount of mucus decreases gradually and the nurse performs suctioning less frequently. A pt who remains apprehensive may require constant attendance and reassurance

A nurse is caring for a patient who has a tracheostomy tube with an inner cannula in place. Which of the following supplies should the nurse use to dry the inner cannula of the patient's tracheostomy tube after cleaning it?

folded pipe cleaner

A nurse is caring for a patient who has a tracheostomy tube with an inner cannula in place. which of the following supplies should the nurse use to dry the inner cannula of the patient's tracheostomy tube after cleaning it?

folded pipe cleaners they remain intact without leaving any particulate matter the patient could aspirate.

autonomy

full control / independence

the nurse is caring for a patient with a tracheostomy what signs and symptoms indicated the need for suctioning

gurgling sounds heard during respirations, restlessness or anxiety, EMEsis in the oral cavitydrooling excessive secretionspatients indicates need for suctioning

A nurse is preparing to perform endotracheal (ET) tube care and plans to use tape to secure the tube. Which of the following is an appropriate preparatory action for this procedure?

have a tincture of benzoin ready to apply to the patient's face. Tincture of benzoin or a liquid adhesive not only protects the patient's skin, but it also prepares the skin around the nose or mouth and on the face for better adherence of the tape

the nurse is caring for a patient who is on 3 L oxygen per nasal cannula. what tasks can be delegated to the unlicensed assistive personnel

helping the patient to clean area around nares and ears counting respiratory rate and oximeter assisting pt to semi fowler

Vital before procedure

high fowlers pulse ox ausculate lung sounds hyper oxginate before and after procedure

what do you clean inner cannula with?

hydrogen peroxide then wash in sterile water before drying and re-inserting

CNA/UAP

not allowed to administer oxygen because it is considered a drug - NURSE'S RESPONSIBILITY as is adjusting oxygen flow rate and evaluating the patient's response to oxygen therapy only help with correct placement and adjustment of oxygen devices after the care provider is instructed about the possible complications and outcomes associated with oxygen delivery and the need to report these to the nurse immediately if they occur. Adjustment of the oxygen flow rate is not delegated to UPA

when balloon inserted

nurse must regularly monitor to prevent absences forming in trachea

monitor for

skin breakdown over ears when using cannula

oxygen therapy home care considerations

if oxygen is used at home, instruct the patient's family to post a "no smoking" sign on all entry doors of the house. When oxygen cylinders are used, it is necessary to secure them so that they will not fall over. Oxygen cylinders are stored upright, chained on appropriate holders. In home settings, oxygen tubing is sometimes as long as 50 feet (15.2 m), which presents a tripping hazard. Instruct patient on risks for falling that are associated wi this length of tubing. Instruct patient's family on safety measures of oxygen therapy Teach patient and family members how to use home equipment Instruct patient and family members to observe level of oxygen in canister tanks and to use portable tanks when patient is not at home Instruct patient and family members to fill plastic humidifier bottle with distilled water every 24 hours. Instruct patient and family members to use only distilled water, not tap water. Provide two complete sets of tubing so that one set of equipment is available for use while the other is being cleaned or repaired. Evaluate home for availability of a three pronged outlet for the compressor, to prevent electric shock. Teach patient to maintain constant flow rate and to change flow rate only with the health care provider's knowledge and advice. Evaluate home for appropriate storage of equipment. Evaluate family's willingness to assist patient with home delivery system. Teach patient and family deep breathing and coughing exercises. Teach patient and family adequate nutritional and hydration needs based on the patient's diagnosis and current condition.

before suctioning

important to have spare trachea tube

respiratory distress

in general, difficulty breathing, which can include any aspect of respiration: ventilation, perfusion, or gas exchange, for example

the patient requires suctioning of pulmonary secretions. what is the most accurate problem statement for this patients condition

inability to clear airway

patient problem statements

inability to clear airway inability to maintain adequate breathing pattern inability to tolerate activity anxiousness, fearfulness or despair compromised verbal communication

identifying patient problem statements to promote oxygenation

inability to clear airway relating to ineffective cough related to excessive secretions inability to maintain adequate breathing pattern related to respirator muscle weakness related to fatigue related to abnormal breathing patterns inability to tolerate activity related to imbalance between oxygen supply and demand anxiousness, fearfulness or despair related to dyspnea and feelings of suffocation related to fear of dying compromised verbal communication related to presence of tracheostomy related to intubation

Oxygen (Flowmeter)

is device used to set the prescribed rate of oxygen

why can't a person speak with a endotracheal tube with inflated cuff?

its inserted between the vocal chords so stops vibrations and therefore sound also prevents emesis from going into lungs

nursing responsibilities for maintaining a tracheostomy tube

keep airway clear, keep the inner cannula clean, prevent impairment of the surrounding tissue and provide the patient with a means of communication minimise infection risks evaluate the patient for excess secretions and suction as often as necessary provide constant airway jumidificaton change or clean all respiratory therapy equipment every 8 hours remove water that condenses in equipment tubing provide frequent mouth care (apply moisuturizing agents to dry, cracked lips) maintain nutritional levels pts with ET tubes are allowed nothing by mouth (NPO) it is necessary to provide parenteral or enteral nourishment patients with a tracheostomy may not be limited in regard to drinking fluids and eating once initial healing phase of the new tracheostomy ahs passed. If pt is able to eat, a cuffless tracheostomy tube is best. Not all patients have cuffless tracheostomy tubes. The may have a tracheostomy tube with a cuff to provide maximum sealing of the airway. Cuffed tracheostomy tubes generally are used for patients whoh are at rsk for aspiration becaue of swallowing difficulties or who hare receiving mechanical ventilation. The cuff must be deflated at prescribed intervals to prevent tissue necrosis of the trachea. Noncuffed tracheostomy tubes often are used to maintain the patient's airway when a ventilator is not needed or when the patient is being prepared to have the tracheostomy discontinued. The physician often with consultation with the respiratory therapist choose the tube based on the patient's condition neck shape and size and purpose of the tracheostomy. ensure adequate ventilation and oxygenation listen to lung sounds regularly elevate the head of bed to assist with ventilation turn and reposition the patient every 2 hrs for maximal ventilation and lung expansion evaluation the effects of respiratory therapy regularly provide safety and comfort check tube placement at regularly inernvals change the tapes or ties whenever they are soiled enhance communication

what is by product of lack of oxygen?

lactic acid

If patient unconscious

left side preferred because gastric contents more likely to stay in right side second preference

The flow rate of oxygen therapy is given in:

liters per minute

why do put pt in sitting position?

maximum lung expansion

Humidification of air

may be necessary when administering oxygen toxicity can cause scarring of the respiratory tract tissue and blindness

postural drainage

method of positioning a patient so that gravity aids in the drainage of secretions from the bronchi and lobes of the lungs

ensure patients safety

monitor the patient carefully, put bed in lowest position and put the side rails up if needed

A nurse is caring for a patient who has a cuffed endotracheal (ET) tube in place. Which of the following is an appropriate component of ET tube care for this patient?

moving the ET tube to the other side of the patient's mouth every 12 hr (or according to facility policy) helps prevent irritation to the oral mucous membranes.

device consisting of small tubes inserted into the nares and is the most common way to administer oxygen

nasal canula

aging

normal arterial oxygen levels sometimes decreases with age but not usually low enough to fall outside the normal range. It may be possible for a 70 year old person to have an arterial partial pressure oxygen level (the amount of oxygen found in the arterial circulation) between 80 and 85 mm Hg (normal range is 80 to 100 mm Hg) without experiencing significant alterations in health.

Arterial partial pressure oxygen (Pa02) level

normal range 80 - 100 mm Hg

what symptoms does a patient needing oxygen exhibit?

nurse needs to identify quickly so she can administer oxygen apprehension, anxiety, restlessness behavior changes cardiac dyshythmias cyanosis decreased ability to concentrate decreased level of consciousness digital clubbing (with chronic hypoxia) dyspnea elevated blood pressure increased fatigue increased pulse rate: as hypoxia advances, bradycardia results, which in turn results in decreased oxygen saturation increased rate and depth of respiration: AAs hypoxia progress, respirations becomes shallow and slower, and apnea develops pallor vertigo

The older adult

often at increased risk of skin impairment. Therefore frequent monitoring for erythema and skin breakdown over the ears is necessary when a nasal cannula is being used for oxygen delivery. Early interventions such as loosening the straps, repositioning the tubing, or adding padding over the ears often prevent impairment.

bronchus

one of the largest passageways conveying air to and within the pulmonary system

Bronchiole

one of the subdivisions of the branched bronchial tree of the pulmonary system

When suctioning airway

one pass into suction and then throw out if another suction necessary, new catheter/sterile gloves etc needed

what relieves hypoxia

oxygen therapy

Endotracheal tube with inflated cuff and endotracheal tubes with uninflated cuffs and syringe for inflation

patient is unable to speak while tube is in place because air cannot flow through the vocal cords

Transtracheal Oxygen Delivery

patient with a tracheostomy oxygen is delivered throughout the entire respiratory cycle especially suited for home use A newer method of oxygen delivery is the transtracheal catheter, which is inserted directly into the trachea between the second and third tracheal cartilages. Delivery does not interfere with drinking, eating, or talking Needs to be cleaned often

A nurse is performing chest physiotherapy for a patient who needs helps mobilizing and expectorating thick pulmonary secretions. To increase the turbulance of the air the patient exhales, the nurse should use which of the following techniques?

percussion

in performing nursing skills and procedures for patients, which nursing action demonstrates the nurse's understanding and use of standard precautions

perform hand hygiene before and and after every patient encounter

What is included in the preparation for tracheostomy care in the acute care environment

placing the patient in a semi fowler position

The wife of a patient with a cuffed tracheostomy ask why the cuff is inflated intermittently. What is the purpose of the inflated cuff?

prevent aspiration when eating

7. For patients who are intubated, why is it important to provide good oral care? How would a nurse provide adequate oral care for an intubated patient?

prevent infection

Oxygen is a drug

procedures must be followed to provide patient with safe, effective nursing care (six rights of drug administration)

An 80-year-old male patient has been admitted to the acute care facility with the diagnosis of pneumonia. He is receiving oxygen via nasal cannula at 2 L/min. The nurse assesses respirations at 24/min, PaO2 level 88 mm Hg, and pink skin tone. What action should the nurse implement?

record O2 level notify the health care provider

cuff

referring to a tracheostomy, a cuff is a soft, inflatable balloon encircling the distal end of a tracheostomy tube

anxiousness, fearfulness or despair

related to dyspnea and feelings of suffocation related to fear of dying

inability to tolerate activity

related to imbalance between oxygen supply and demand

inability to clear airway

related to ineffective cough related to excessive secretions

compromised verbal communication

related to presence of tracheostomy related to intubation

inability to maintain adequate breathing pattern

related to respiratory muscle weakness related to fatigue related to abnormal breathing patterns

A nurse is caring for a patient who has a cuffed endotracheal (ET) tube in place. Which of the following is an appropriate component of ET tube care for this patient?

repositioning the ET tube in the patient's mouth every 12 hr (or according to the facility policy) helps prevent irritation to the oral mucous membranes

Oxygen Administration

requires the critical thinking skills of a nurse. Nurse is responsible for ensuring that the oxygen is administered in the correct manner, adjusting oxygen flow rate and evaluating the patient's response to oxygen therapy. Correct placement and adjustment of oxygen devices may be delegated to unlicensed assistive personnel (UAP) after the care provider is instructed about the possible complications and outcomes associated with oxygen delivery and the need to report these to the nurse immediately if they occur. Adjustment of the oxygen flow rate is not deleted to UAP.

COPD

respiratory drive normally is initated by arterial carbon dioxide (paCO) levels rising, but in patients with chronic obstructive pulmonary disease (COPD) hypoxia tends to be the driving force behind respiratory effort (hypoxic drive). If the hypoxia is corrected in a patient with COPD, then the respiratory drive is reduced and respiratory difficulty will occur. For this reason, oxygen flow rates greater than 2 L/min are to be given with great caution in these individuals. Flow rates higher than 2 L/min could elminate the respiratory drive, and breathing may stop

A nurse is suctioning a patient's airway using in-line suctioning. When using this method, it is appropriate for the nurse tp

reuse the catheter repeatedly

yankauer or tonsillar tip suction catheter

used to perform oropharyngeal suctioning requires sterile technique See skill 14.5

transtracheal oxygen delivery

small oxygen tube (8-French or 9-Fr) is inserted through the transtracheal tract opening through which oxygen is administered. After the insertion tract has matured (healed) it is possible for the pt or a family member to remove the tube for cleaning. A single transtracheal catheter may last up to 3 months. After that perod, the catheter is likely to become brittle and must be replaced. this method of oxygen delivery is suited especially for home use. It allows the individual to be more active and can be concealed under a shirt. Some transtracheal oxygen deliver systems even have a beaded chain necklace attached to help disguise the catheter. The patient should be instructed to inspect the transtracheal tract opening regularly for erythema, edema, or excessive exudate. Area cleaned twice daily with hydrogen

fire risk of oxygen

supports combustion - so combines with other factorrs such as an electrical spark or fire, oyxgen enables combustion and nearby objects ignite. therefore smoking, wool blankets and friction toys should be avoided when oxygen administered. dries mucous membraneswhich increases risk of tissue cracking and opening leaving the patient at risk for infection

T-piece or t-ube

t-shaped device that is connected to large-bone tubing and then can deliver humidification, oxygen, or both.

Patient teaching

teach patient to apply the oxygen equipment, such as the nasal cannula or oxygen mask discuss safety precautions for oxygen use stress the dangers of adjusting the oxygen flow rate without notifying the health care provider. Emphasize that it is possible for the patient to be short of breath because of reasons other than hypoxia and to contact the health care provider if shortness of breath increases instruct patient to ambulate or change positions frequently to mobilize secretions. teach the patient to cough and practice deep breathing and encourage practising these techniques frequently, as directed by the patient condition or providers orders to facilitate air exchange. Teach the patient to maintain adequate fluid intake to help liquefy secretions. Recommend fluids that are free of caffeine and sugar because drinks high in caffeine and sugar sometimes cause dehydration. Teach the patient to avoid dairy products, which tend to thicken secretions. Teach the rationale for prescribed medications as well as side effects, this helps increase compliance teach that performing oral hygiene at regular intervals helps rid the mouth of any bad taste from secretions coughed up or expectorated.

Trachea

the cartilaginous and membranous tube that descends from the larynx and branches into the right and left main bronchi

a patient is receiving an iv infusion of blood, once the infusion has begun, what is the length of time. the nurse should stay with patient to monitor vital signs and watch for an allergic reaction

the first 15 to 20 mins

intubation

the insertion of a tube into a body canal or cavity, as in endotracheal intubation

suctioning patient with tracheostomy

the nurse is responsible for evaluating the patient's airway patency and response to airway suctioning suction is performed as often as necessary

fraction of inspired oxygen (FiO2)

the oxygen level inhaled by or delivered to the patient, expressed in a percentage of atmospheric air

oropharynx

the part of the pharynx between the soft ppalate and the upper edge of the epiglottis

which patient is the most likely candidate for an endotracheal tube

the patient is discovered in the bathroom, unresponsive, and pulseless

nasopharynx

the portion of the pharynx (the passage between the mouth and posterior nares and the larynx and esophagus) that lies above the level of the soft palate

patency

the state of being open

Pharynx

the throat, the cavity between the nasal passages and the mouth

giving pt water

thins secretions

endotracheal tube

this tube ensures an open airway to the level of the lungs but is is an advanced life support technique not done by EMTs

alveolus

tiny air sac at the end of a bronchiole in the lungs that provides surface area for gas exchange to occur

Nurse's Role

to monitor patency/opening of airway

trach collar

tracheostomy collar is also designed to supply humidification and humidified oxygen to the lower respiratory tract. the collar covers the open end of the tracheostomy tube and has an adjustable strap that extends around the patient's neck.

A nurse is caring for a patient who sustained trauma to his head and neck and will require long-term airway support. Which of the following devices will be required for home health care for this patient?

tracheostomy tube used for long term airway support. they are sustainable devices for long term management of airway obstruction

A nurse is caring for a patient who sustained trauma to his head and neck and will require long-term airway support. Which of the following devices will be required for home health care for this patient?

tracheostomy tube (used for long-term airway support. They are suitable devices for long term management of airway obstruction.

difference between tracheostomy tube and transtracheal catheter

transtracheal catheter does not interfere with drinking, eating or talking. With a nasal cannula, oxygen is delivered only during inhalation. With transtracheal oxygen deliver system, oxygen is delivered throughout the entire respiratory cycle. Oxygen deliver is less expensive because non lost in atmosphere. Additionally no humidification is not necessary because the nasopharynx is bypassed.

oxygen hood, halo or tent

types of devices for oxygenation

reduce the spread of microorganism

use standard precautions, especially hand hygiene, and surgical asepsis indicated

A nurse is performing chest physiotherapy for a patient who needs helps mobilizing and expectorating thick pulmonary secretions. To increase the turbulence of the air the patients exhales, the nurse should use which of the following techniques?

vibration Vibration is used during or after percussion to increase the turbulence of exhaled air and loose secretions

can unlicensed assistive personnel, patients or caregivers perform tracheostomy suctioning?

yes but sterile technique required