Exam 2 - Chest Tubes and Tracheostomy's (Ch. 28 &30)

Trachea-Innominate Artery Fistula

-A malpositioned tube causes its distal tip to push against the lateral wall of the trachea. Continued pressure causes necrosis and erosion of the innominate artery. -*this is a medical emergency*

Conditions that require pleural drainage by chest tube:

-A rupture on the surface of the lung (allowing air and/or fluid to escape into the pleural space while the chest remains intact) -A penetration into the chest wall allowing external air/fluid from within the body to enter the pleural space

Tracheoesophageal Fistula (TEF)

-Abnormal passageway pertaining to the trachea and esophagus -The tube has migrated to the esophagus -Excessive cuff pressure causes erosion of the posterior wall of the trachea and loss of tissue integrity. The hole is created between the trachea and the anterior esophagus -*highest risk if they also have an NG tube*

Why would someone need a tracheostomy?

-Acute airway obstruction (most likely trauma, anaphylaxis, smoke inhalation) -Airway protection e.g. Airway reconstruction after laryngeal trauma or cancer surgery -Laryngeal or facial trauma/burns -Airway involvement during head/neck surgery -Prolonged intubation or need for mechanical ventilation -Control of pulmonary secretions -Obstructive sleep apnea

Nursing interventions for someone with a tube obstruction from secretions or cuff displacement

-Assist patient to cough and deep breathe -Provide inner cannula care -Humidify the oxygen source to provide moisture and prevent hardened secretions -Suction as needed, not routinely

The chest tube has become dislodged: Cover the insertion site with a sterile petroleum gauze and call for help. Why?

-By covering the site with petroleum gauze, we are creating a tighter seal and preventing air from entering the pleural space. -The provider will need to be notified to reinsert the chest tube or evaluate if the tube can stay out. -Either way, your job is to keep that seal and chances are you won't have all of the supplies within arms' reach and will need help from your coworkers

Speaking Valve of a tracheostomy tube

-Client must be able to control secretions before deflation of cuff and speaking valve attempted -Placed on the hub or end of a tracheostomy tube to allow air to enter on inspiration -Air is directed around the tube and out the upper airway, through the vocal cords upon expiration, allowing speech -May assist with swallowing *must deflate the cuff before adding the valve*

Increased air and fluid in the pleural space causes:

-Deviation of the heart, trachea and other lung.

What is normal in the chest tube experience?

-Drainage in the collection chamber -Tidaling in the water seal chamber, occasional bubbles -Gentle bubbling in the suction control chamber in wet system or float is in the window in the dry system. -Pain, frustration, anxiety, lack of knowledge for the pt -Asymmetrical chest expansion

How often should a pulmonary assessment be completed for someone with a chest tube?

-Every 2 hours. -RR and effort, breath sounds, palpation, and pulse oximetry

Key nursing assessments of someone with a tracheostomy tube

-Frequent vital signs -Continuous pulse oximetry -Assess bilateral breath sounds -Full respiratory assessmentEnsure patent airway -Assess need for suctioning every 2 hours and prn -Clean/change inner cannula every 8 hours and prn (per facility protocol)

Where is the chest tube inserted?

-If the purpose is to drain air, it is normally inserted near the second intercostal space. -If fluid is to be removed, it is usually placed between the 5th and 6th intercostal space. -Sometimes two tubes are used at each location if air and blood are present.

The inner cannula of a tracheostomy tube:

-Internal portion of tracheostomy tube -Fits snugly within the outer cannula -Promotes cleaning of secretions from inside the tube -Provides universal adapter for use with ventilator and other respiratory equipment -May be disposable or non-disposable

Advantages of using a dry system chest tube:

-It can be knocked over and it is relatively easy to set up.

Disadvantage of using a dry system chest tube:

-It cannot be assessed as precisely as a wet system.

Nursing Assessments of someone with a tracheostomy - Cuff

-Measure and record cuff pressure every 8 hours for cuffed tracheostomy tubes -Cuff pressure must be maintained at 14 to 20 mmHg -Excessive cuff pressure may cause complications: -tracheomalacia -tracheal stenosis -tracheoesophageal fistula

Tracheal Stenosis

-Narrowing of the trachea as a result of scarring from irritation of tracheal mucosa and impaired tissue integrity by the cuff

Speech and Communication teaching for someone with a tracheostomy

-Patient can speak with a cuffless tube, a fenestrated tube, or a speaking valve -Provide writing tablet, communication board -Be sure call light is within reach

Indications that suctioning is needed for someone with a tracheostomy

-Rapid, shallow breathing -Moist, noisy, gurgling sounds -Decreased Sp02 -Visible secretions (on dressing around tube) -Coarse crackles -Vibrations of loose secretions when placing hand over client's chest (tactile fremitus)

Cuff of tracheostomy

-Seals airway and protects client from aspiration of oral or gastric secretions -Used for patients who cannot protect airway (those on ventilator) -Pilot balloon on outside of tube indicates presence or absence of air in balloon

Tracheomalacia

-Softening of the tissues of the trachea from atrophy -Constant pressure exerted by the cuff causes tracheal dilation and erosion of cartilage, leading to loss of tissue integrity.

What is the third chamber in the chest tube system?

-Suction control Chamber. -Controls the amount of negative suction applied in the pleural space. -the gentle bubbling is caused by the air that escaped from the water seal chamber when it goes up and out of the third chamber and the pull from the suction will create a gentle bubbling in this chamber as it pulls on the water filled chamber.

What is abnormal in the chest tube experience?

-Sudden increase or drastic decrease in drainage. -No tidaling in the water seal chamber (the pt's lung has fully expanded or there is a kink) -Constant bubbling in the water seal chamber. -Vigorous bubbling in the suction control chamber.

Nutrition teaching for someone with a tracheostomy

-Swallowing may be more difficult -Encourage smaller, more frequent meals -Thicken liquids -Avoid water and other "thin" liquids -Sit upright while eating

Advantages of using a wet system chest tube:

-The negative pressure needed can be evaluated more closely allowing the clinician to see the changes in the water level as it related to healing.

Disadvantages of using a wet system chest tube:

-The water can evaporate, so it must be monitored frequently to consider refilling. -If the unit is knocked over, it must be replaced.

Fenestrated Tracheostomy Tube

-Tube with opening in the outer cannula -Used to wean client from tracheostomy tube by ensuring client can tolerate breathing through natural airway -Allows pt to speak

Obturator

-Used to facilitate insertion of the outer cannula when inserting or changing a tracheostomy tube or in the event of accidental decannulation -Removed immediately after tube placement and kept at patient's bedside

What is the second chamber in the chest tube system?

-Water Seal -Filled with 2 cm of water -Allows air to escape through the water and up into the tube at the top, but not air to backflow up the tube and into the pt. -Tidaling movement of the water in the chamber to follow the inhalation and exhalation in the lungs. -The water bubbles from the trapped air in the pleural space being sucked into the water seal.

How much O2 should the nurse give the pt before tracheostomy cares? For how long?

100% O2 for a minimum of 2 minutes.

How long is the tube for a chest tube?

6 feet.

Subcutaneous Emphysema

A characteristic crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues. *notify the physician immediately*

Patients with a tracheostomy or endotracheal tube need suctioning. Which nursing interventions apply to proper suctioning technique? SATA a. Preoxygenate the pt for at least 30 seconds before suctioning b. Instruct the pt that he or she is going to be suctioned c. Quickly insert the suction catheter until resistance is met d. Suction the pt for at least 30 seconds to remove secretions e. Repeat suctioning as needed for four to five total suction passes f. Apply suction only when withdrawing the suction catheter

A, B, C, F a. Preoxygenate the pt for at least 30 seconds before suctioning b. Instruct the pt that he or she is going to be suctioned c. Quickly insert the suction catheter until resistance is met f. Apply suction only when withdrawing the suction catheter

A pt with a tracheostomy who receives unnecessary suctioning can experience which complications? SATA a. Brochospasm b. Mucosal damage c. Impaired gag reflex d. Bronchodilation e. Bleeding f. Tracheostomy Obstruction

A, B, E Bronchospasm Mucosal damage Bleeding

The nurse is caring for a patient with a tracheostomy. Which interventions for bronchial and oral hygiene should the nurse delegate to the UAP? SATA a. Turn and repo the pt every 2 hours b. Teach the pt to cough and deep breath c. Elevate the head of the bed for mouth care d. Assist the pt to the bathroom as needed e. Help the pt rise mouth with saline every 4 hours while awake f. Keep glycerin swabs at the bedside for oral care as needed

A, C, D, E a. Turn and repo the pt every 2 hours c. Elevate the head of the bed for mouth care d. Assist the pt to the bathroom as needed e. Help the pt rise mouth with saline every 4 hours while awake

What are possible complications that can occur with suctioning from an artificial airway? SATA a. Infection b. Coughing c. Hypoxia d. Tissue (mucosa) trauma e. Vagal stimulation f. Bronchospasm

A, C, D, E, F a. Infection c. Hypoxia d. Tissue (mucosa) trauma e. Vagal stimulation f. Bronchospasm

An older adult patient is at risk for aspirating food or fluids. Which are the most appropriate nursing actions to prevent this problem? SATA a. Provide close supervision when the pt is self-feeding b. Instruct the pt to tilt the head back when swallowing c. Obtain an order for a clear liquid diet and offer small, frequent amounts d. Instruct the pt to tuck the chin down when swallowing e. Place the pt in an upright position f. Keep emergency suctioning equipment at hand and turned on

A, D, E, F a. Provide close supervision when the pt is self-feeding d. Instruct the pt to tuck the chin down when swallowing e. Place the pt in an upright position f. Keep emergency suctioning equipment at hand and turned on

A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client? a. Air will move from the lung into the pleural space b. The heart and great vessels shift toward the affected side c. There is greater negative pressure within the chest cavity d. Collapse of the other lung will occur if not treated immediately

A. As a person with a tear in the lung inhales, air moves through that opening into the intrapleural space. This creates a positive pressure and causes partial or complete collapse of the lung.

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes? a. Palpate around the tube insertion sites for crepitus b. Auscultate the breath sounds for crackles and rhonchi c. Observe the pt for the presence of a barrel-shaped chest d. Compare the length of inspiration with the length of expiration

A. Subcutaneous emphysema occurs when air leas from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated.

What nursing action will limit hypoxia when suctioning a client's airway? a. Apply suction only after catheter is inserted b. Limit suctioning with catheter to a minute and a half c. Lubricate the catheter with saline before insertion d. Use a sterile suction catheter for each suctioning episode

A. The negative pressure from suctioning removes oxygen as well as secretions; suction should be applied only after the catheter is inserted and is being withdrawn.

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? a. Remove the air that is present in the intrapleural space b. Drain serosanguinous fluid from the intrapleural compartment c. Permit the development of positive pressure between the layers of the pleura d. Provide access for the instillation of medication into the pleural space

A. Air rises and is removed via a tube inserted in the upper intrapleural space

A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client? a. Observe for fluid fluctuations in the water-seal chamber. b. Obtain a prescription for morphine to minimize agitation. c. Apply a thoracic binder to prevent excessive tension on the tube. d. Clamp the tubing securely to prevent a rapid decline in pressure.

A. Fluctuations occur with inspiration and expiration until the lung is fully expanded. If these fluctuations do not occur, the chest tube may be clogged or kinked; coughing should be encouraged.

A pt required emergency intubation and currently has an artificial airway in place. Oxygen is being administered directly from the wall source. Why would warmed and humidified oxygen be a more appropriate choice for this pt? a. Helps prevent drying damage to mucous membranes b. Promotes thick secretions, which are easier to suction c. Is more comfortable for the pt d. Is less likely to cause oxygen toxicity

A. Helps prevent drying damage to mucous membranes

A pt is receiving preoperative teaching for a partial laryngectomy and will have a tracheostomy postoperatively. How does the nurse define a tracheostomy to the pt? a. Opening in the trachea that enables breathing b. Temporary procedure that will be reversed at a later date c. Technique using positive pressure to improve gas exchange d. Procedure that holds open the upper airways

A. Opening in the trachea that enables breathing

A pt has a temporary tracheostomy following surgery to the neck area to remove a benign tumor. Which nursing intervention is performed to prevent obstruction of the tracheostomy tube? a. Provide tracheal suctioning when there are noisy respirations b. Provide oxygenation to maintain pulse oximeter readings c. Inflate the cuff to maximum pressure and check it once per shift d. Suction regularly and prn with an oral suction device

A. Provide tracheal suctioning when there are noisy respirations

The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this pt? a. The pt is encouraged to cough and do deep-breathing exercises frequently b. "Stripping" of the chest tubes is done routinely to prevent obstruction by blood clots c. Water level in the suction chamber need not be monitored, just the collection chamber d. Drainage containers are positioned upright or on the bed next to the pt

A. The pt is encouraged to cough and do deep-breathing exercises frequently

The nurse is caring for a patient with a tracheostomy who has recently been transferred from the ICU, where he has no unusual occurrences related to the tracheostomy or his oxygenation status. What does the routine care for this pt include? a. Thorough respiratory assessment at least every 2 hours b. Maintaining the cuff pressure between 5-100 mm Hg c. Suctioning as needed; maximum suction time of 20 seconds d. Changing the tracheostomy dressing four times a day

A. Thorough respiratory assessment at least every 2 hours

Which complication is the result of constant pressure exerted by a tracheostomy cuff causing tracheal dilation and erosion of cartilage? a. Tracheomalacia b. Tracheal stenosis c. Tracheoesophageal fistula d. Trachea- innominate artery fistula

A. Tracheomalacia

A patient requires long-term airway maintenance following surgery for cancer of the neck. The nurse is using a piece of equipment to explain the procedure and mechanism that are associated with this long-term therapy. Which piece of equipment is the nurse most likely to use for this pt teaching session? a. Tracheostomy tube b. Nasal trumpet c. Endotracheal tube d. Nasal cannula

A. Tracheostomy tube

Chlyothorax

Accumulation of lymphatic fluid in the pleural cavity.

Empysema

Accumulation of pus in the pleural cavity.

Vigorous Bubbles means:

Air leak

Pneumothorax

Air that has entered the pleural space. -Trauma, mechanical ventilation (overexpansion), spontaneous, tension -Can develop during the tracheotomy procedure if the chest cavity is entered

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? SATA a. Hematemesis b. SOB c. Unilateral chest pain d. Increased thoracic motion e. Mediastinal shift toward the involved side

B, C

Which nursing action is important when suctioning the secretions of a client with a tracheostomy? a. Use a new sterile catheter with each insertion b. Initiate suction as the catheter is being withdrawn c. Insert the catheter until the cough reflex is stimulated d. Remove the inner cannula before inserting the suction catheter

B. During suctioning of a client's secretions, negative pressure (suction) should not be applied until the catheter is ready to be drawn out because, in addition to the removal of secretions, oxygen is being depleted.

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? a. Chest tube drainage of 10-15 mL/hr b. Continuous bubbling in the water-seal chamber c. Reports of pain at the chest tube site d. Chest tube dressing dated yesterday

B. Continuous bubbling indicates an air leak that must be identified. With the health care provider's order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require the RN to notify the HCP. If the air bubbling does not stop when the RN applies the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. -Chest tube drainage of 10-15 mL/hr is acceptable. -Chest tube dressings are not changed daily, but are reinforced. -The pt's reports of pain needs to be assessed and treated. This is important but not as urgent as investigating a chest tube leak.

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? a. Clamp the chest tubes when suctioning b. Palpate the surrounding area for crepitus c. Change the dressing daily using aseptic technique d. Empty the drainage chamber at the end of the shift

B. Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is gently palpated. This is referred to as crepitus.

A patient with a tracheostomy is unable to speak. He is not in acute distress but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach in this situation? a. Rely on the family to interpret for the pt b. Ask questions that can be answered with a "yes" or "no" response c. Obtain an immediate consult with the speech therapist d. Encourage the pt to rest rather than struggle with communication

B. Ask questions that can be answered with a "yes" or "no" response

A pt with a tracheostomy tube is currently alert and cooperative but is coughing more frequently and producing more secretions than usual. The nurse determines that there is a need for suctioning. Which nursing intervention does the nurse use to prevent hypoxia for this pt? a. Allow the pt to breath room air prior to suctioning b. Avoid prolonged suctioning time c. Suction frequently when the pt is coughing d. Use the largest available catheter

B. Avoid prolonged suctioning time

A pt has an endotracheal tube and requires frequent suctioning for copious secretions. Which is a major complication of tracheal suctioning? a. Atelectasis b. Hypoxia c. Hypercarbia d. Bronchodilation

B. Hypoxia

A pt sustained a serious crush injury to the neck and had a tracheostomy tube placed 3 days ago. As the nurse is performing tracheostomy care, the pt suddenly sneezes very forcefully and the tracheostomy tube falls out onto the bed linens. What does the nurse do? a. Ventilate the pt with 100% O2 and notify the provider b. Quickly and gently replace the tube with a clean cannula kept at the bedside c. Quickly rinse the tube with sterile solution and gently replace it d. Give the pr oxygen; call for assistance and a new tracheostomy kit

B. Quickly and gently replace the tube with a clean cannula kept at the bedside

To prevent accidental decannulation of a tracheostomy tube, what does the nurse do? a. Obtain an order for continuous upper extremity restraints b. Secure the tube in place using ties or fabric fasteners c. Allow some flexibility in motion of the tube while coughing d. Instruct the patient to hold the tube with a tissue while coughing

B. Secure the tube in place using ties or fabric fasteners

Hemothorax

Blood that has entered the pleural space. -Thoracic surgery, chest trauma, rib fractures.

The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene? a. Suctioning the tracheostomy tube before performing tracheostomy care b. Removing old dressings and cleaning off excess secretions c. Removing the inner cannula and cleaning using standard precautions d. Replacing the inner cannula and cleaning the stoma site

C. When tracheostomy care is performed, a sterile field is set up, and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection.

When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern? a. Rupture of the pericardium b. Infection of the subpleural lining c. Decreased filling of the right heart d. Increased volume of the unaffected lung

C. Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the heart and leads to a decreased cardiac output.

A client with Emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration? a. Pleural friction rub b. Tracheoesophageal fistula c. Rupture of a subpleural bleb d. Puncture would of the chest wall

C. The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters, but are filled with air.

A pt who is breathing on his own has a fenestrated tracheostomy tube with a cuff. Which precaution must the nurse instruct the student about when caring for this pt? a. Always keep the cuff inflated to prevent secretions from entering the lungs b. Suction the pt every 30-60 minutes c. Always deflate the cuff before capping the tube with the decannulation cap d. To reduce the risk of tracheal damage, keep the cuff pressure between 22-30 mm Hg.

C. Always deflate the cuff before capping the tube with the decannulation cap

An older adult pt sustained a stroke several weeks ago and is having difficulty swallowing. To prevent aspiration during mealtimes, what does the nurse do? a. Hyperextend the head to allow food to enter the stomach and not the lungs b. Give thin liquids after each bite of food to help "wash the food down." c. Encourage dry swallowing after each bite to clear residue from the throat d. Maintain a low Fowler's position during eating and for 2 hours afterwards

C. Encourage dry swallowing after each bite to clear residue from the throat

A pt returns from the operating room and the nurse assesses for subcutaneous emphysema, a potential complication associated with tracheostomy. How does the nurse assess for this complication? a. Checking the volume of the pilot balloon b. Listening for airflow through the tube c. Inspecting and palpating for air under the skin d. Assessing the tube for patency

C. Inspecting and palpating for air under the skin

The nurse is suctioning the secretions from a pt's endotracheal tube. The pt demonstrates a vagal response by a drop in heart rate to 54/min and a drop in BP to 90/50 mm Hg. After stopping suctioning, what is the nurses priority action? a. Allow the pt to rest for at least 10 minutes b. Monitor the pt and call rapid response team c. Oxygenate with 100 % oxygen and monitor the pt d. Administer atropine according to standing orders

C. Oxygenate with 100% oxygen and monitor the pt

Which clinical finding in a pt with a recent tracheostomy is the most serious and requires immediate intervention? a. Increased coughing and difficulty expectorating secretions b. Food particles in the tracheal secretions c. Pulsating tracheostomy tube in synchrony with the heartbeat d. Set tidal volume on the ventilator not being received by the pt

C. Pulsating tracheostomy tube synchrony with the heartbeat

A pt returns from the operating room after having a tracheostomy. While assessing the pt, which observation made by the nurse warrants immediate notification of the health care provider? a. Patient is alert but unable to speak and has difficulty communicating his needs b. There is a small amount of bleeding present at the incision c. Skin is puffy at the neck area with a crackling sensation d. Respirations are audible and noisy with an increased RR

C. Skin is puffy at the neck area with a crackling sensation

After the respiratory therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP report to the RN immediately? a. Heart rate of 98 beats/min b. Respiratory rate of 24 breaths/min c. Blood pressure of 168/90 mm Hg d. Tympanic temperature of 101.4° F (38.6° C)

D. Infections are always a threat for a patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system.

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? a. Take the client's vital signs. b. Inform the health care provider. c. Turn the client to the unaffected side. d. Check the tube to ensure that it is not kinked.

D. Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury.

A pt has a cuffed tracheostomy tube without a pressure relief valve. To prevent tissue damage of the tracheal mucosa, what does the nurse do? a. Deflate the cuff every 2-4 hours and maintain as needed b. Change the tracheostomy tube every 3 days or per hospital policy c. Assess and record cuff pressures each shift using the occlusive technique d. Assess and record cuff pressures each shift using minimal leak technique

D. Assess and record cuff pressures each shift using minimal leak technique

While the nursing student changes a pt's tracheostomy dressing, the nurse observes the student using a pair of scissors to cut a 4x4 gauze pad to make a split dressing that will fit around the tracheostomy tube. What is the nurse's best action? a. Give the student positive reinforcement for use of materials and technique b. Report the student to the instructor for remediation of the skill c. Change the dressing immediately after the student has left the room d. Direct the student in the correct use of materials and explain rationale

D. Direct the student in the correct use of material and explain rationale

A patient with a tracheostomy is being discharged home. In pt teaching, what does the nurse instruct the pt to do? a. Use sterile technique when suctioning b. Instill tap water into the artificial airway c. Clean the tracheostomy tube with soap and water d. Increase the humidity in the home

D. Increase the humidity in the home

A pt with a permanent tracheostomy is interested in developing an exercise regimen. Which activity does the nurse advise the pt to avoid? a. Aerobics b. Tennis c. Golf d. Swimming

D. Swimming

Upon observation of a chest tube setup, the nurse reports to the provider that there is a leak in the chest tube and system. How has the nurse identified this problem? a. Drainage in the collection chamber has decreased b. The bubbling in the suction chamber has suddenly increased c. Fluctuation in the water seal chamber has stopped d. There was an onset of continuous vigorous bubbling in the water seal chamber

D. There was an onset of continuous vigorous bubbling in the water seal chamber

A pt with a tracheostomy stoma in place develops increased coughing, inability to expectorate secretions, and difficulty breathing. What are these assessment findings related to? a. Overinflation of the pilot balloon b. Tracheoesophageal fistula c. Cuff leak and rupture d. Tracheal stenosis

D. Tracheal stenosis

A pt with an endotracheal tube in place has dry mucous membranes of the mouth and lips related to the tube and the partial open mouth position. What technique does the nurse use to provide this pt with frequent oral care? a. Cleanses the mouth with glycerin swabs b. Provides alcohol-based mouth rinse and oral suction c. Cleanses with a mixture of hydrogen peroxide and water d. Uses oral swabs or a soft-bristles brush moistened in water

D. Uses oral swabs or a soft-bristles brush moistened in water

Fenestration

Hole in the curvature of the tube to allow speaking

There is a clot in your drainage tubing: Do not clamp, strip, or milk the tubing. Why?

If you notice a clot in the tubing, observe for tidaling in the water seal chamber. If this is still occurring, your system is still patent. Do not clamp, milk, or strip the tube to try to clear a clot. This may result in increased negative pressure in the chest. You may attempt to squeeze the tube gently and release in an effort to break up the clot to ease passage into the CDU. The only time you would clamp the system is if it is ordered by the provider or if you are quickly changing the CDU. Failure to clamp during a CDU swap will introduce air into the chest tube.

Pleural Effusion

Increase in the pleural fluid. -Common with lung and breast cancer

Tension Pneumothorax S/S

Increased RR and effort, dyspnea, chest pain, decreased movement on the effected side of the chest, decreased breath sounds, falling BP, rising pulse, tracheal deviation.

Endotracheal Tube

Inserted through the nose or mouth -Most commonly used in the critical care and OR setting -Used for short-term airway protection and ventilation

Tracheostomy Tube

Inserted through the stoma of the neck -Long-term mechanical ventilation -More comfortable -Increased mobility for the pt

Outer Cannula of a tracheostomy tube

Keeps the airway open -Fits into the stoma

Spontaneous Pneumothorax

More prevalent in young men who are tall, slender build perhaps associated with a growth spurt where the chest wall grows faster than the rest creating a discrepancy in the pleural fluid/space.

Pneumothorax S/S

Shortness of breath, cyanosis, chest pain, absent or diminished breath sounds, increased respiratory effort, increased respiratory rate, asymmetrical chest rise, subcutaneous crepitus, increased pulse, tracheal deviation.

Tracheotomy

Surgical incision into the trachea to create an airway to maintain gas exchange -Emergent or scheduled

What is the first chamber in the chest tube system?

The collection chamber. -Fluid and blood collect and can be measured - typically every hour for the first 24-hours -The air escapes through the tube into the second chamber.

Your patient is suddenly becoming short of breath: check your tubing, stay with the patient, call for help. What happened?

The tubing may have become dislodged, may be inadvertently clamped—investigate those options first. Look at your CDU. Is it functioning properly. Assess your patient. Are there any other indications of a bigger issue? Hemmorrhage? Infection or sepsis? Tracheal deviation?

What is the purpose of a Chest Tube?

There's air, blood, pus, or a combination of those in the pleural space causing problems. By removing those things with a chest tube, we can alleviate the pressure and invite the lung to reinflate. -Allows air and fluid to escape the pleural space but not re-enter.

What is the purpose of petroleum gauze on the insertion site of a chest tube?

To help create an airtight seal.

Tracheostomy

Tracheal stoma (opening) that results from a tracheotomy -Temporary or permanent

Tension Pneumothorax

When air continues to leak into the pleural space with no way of escape. Creates rapid build up of pressure and the pressure becomes positive causing the lung to completely collapse. -The heart can become displaced leading to decreased cardiac output. -Moves to one side of the chest.

The tubing has disconnected: Insert the end into sterile water. Why?

When the tubing becomes disconnected a few things happen. 1) First, your tubing is likely contaminated. The end connected to the CDU probably fell on the floor, and we don't want to just reconnect and open the opportunity for germs to enter the patient through the chest tube. 2) Second, we have now opened the chest to air infiltration. It may be a good idea to call some coworkers for help. You can insert the end of the tube into sterile water to create a new water seal. Keeping this below the level of the chest will ensure that air cannot go back into the pleural space, but it can still escape through the bottle of sterile water. Stay will your patient, assess the patient, and wait for a new CDU to be brought to you by your coworkers.

B: 17-year old male with tall, slender build

Who is at most risk of a spontaneous pneumothorax? A: 32 year old asthmatic female B: 17 year old male with tall, slender build C: 24 year old male motocross racer D: 45 year old female with breast cancer

The drainage was suddenly increased and is bright red: Call your provider. What happened?

You noticed a trend of decreasing amounts of fluid in the collection chamber and suddenly there is a large amount of a different consistency. Bright red. It could be a hemorrhage. Empyema or pleural effusion also can cause an increase in fluid or pus.