Module 13
The nurse is orienting a new graduate nurse to common procedures performed on the unit. Which statement, if made by the graduate nurse, indicates understanding of nasotracheal suctioning?
"A 1- to 2- minute interval should be allowed between suctioning passes." Intermittent suction up to 15 seconds safely removes pharyngeal secretions. The maximum time to suction the trachea is 10 seconds, with a 1- to 2-minute interval in between suctioning passes for reoxygenation. The mouth carries the highest bacterial count. Whenever possible, suction via the nasotracheal route. To avoid tissue damage, intermittent suction is applied as the catheter is being withdrawn.
The nurse is teaching the spouse of a patient how to perform oral suctioning for when they return home. Which of the following statements, if made by the spouse, indicates further instruction is needed?
"Because oral secretions are thick, suction settings should always be set on high." Suction settings should be low to ensure that the oral tissue is uninjured during suctioning. Bloody secretions may be an indication of mucosal damage. The oropharynx should be assessed for any tissue injury, and the frequency of suctioning should be evaluated. Touching the back of the throat can stimulate the gag reflex. Unless contraindicated, fluids should be encouraged to reduce the viscosity of secretions.
The nurse is preparing to perform routine tracheostomy care. Which statements, if made by the nurse, indicate that further instruction is needed? (Select all that apply.)
"I will double knot the ties behind the patient's neck." The inner cannula should be dropped into the sterile basin of normal saline for cleaning, or if disposable, the inner cannula would be discarded. The ties should be secured in a double square knot on the side of the neck. One finger of slack prevents the ties from being too tight and also prevents movement of the tracheostomy tube. The stoma site should be cleaned to remove secretions. Moving in an outward circle pulls mucus and other contaminants away from the stoma to the periphery. The tracheostomy brush is used to remove thick or dried secretions from the cannula. It would be too harsh and contaminated to use on the peristomal skin. Sterile 4-by-4 gauze is used to clean around the stoma.
A discussion is taking place on the unit regarding the application of lubricant to the suction catheter before passing it through the nasal passage. Which statement is accurate?
"Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia." Oil-based lubricants increase the risk for aspiration and pneumonia. Water-soluble lubricant is applied to the catheter to ease insertion and prevent tissue trauma. It is unrelated to the patient's fluid status. Suctioning a small amount of sterile normal saline from the basin ensures that the suction system is working correctly. It is unnecessary to lubricate the end of the suction catheter when performing oropharyngeal suctioning.
Which of the following patients would have the greatest potential for an alteration in respiration?
A 44-year-old female with anemia. Hemoglobin carries about 97% of oxygen to the tissues. Anemia lowers the oxygen-carrying capacity of the blood and potentially leads to hypoxia.
Which of the following would lead to an increase in oxygen demand?
A fever. Increased metabolic activity associated with a fever increases tissue oxygen demand. Postural drainage is an intervention used to mobilize secretions and maintain an open airway.
Which of the following is a potential complication for a patient who is having nasotracheal suctioning? (Select all that apply.)
A significant drop in oxygen concentration. The patient is at risk for developing hypoxemia at any point from assessment of airway secretions to a short time after the suctioning procedure. The suctioning procedure itself removes oxygen from the airways. A patient may experience bradycardia as a result of vagal stimulation. Dysrhythmias are a potential complication of nasotracheal suctioning. Coughing is an expected outcome of nasotracheal suctioning and will aid in clearing the airways.
Which of the following is an unexpected outcome during or after endotracheal suctioning and endotracheal tube care?
A sudden drop in oxygen saturation. The nurse should stop suctioning and administer oxygen. The other items are expected outcomes of performing endotracheal tube care.
The nurse performs nasotracheal suctioning. Which of the following is an incorrect sequence for this procedure?
Apply sterile gloves, pick up the suction catheter with dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on. The connecting tubing should be attached to the suction machine and turned on before applying sterile gloves.
The nurse is preparing to perform oropharyngeal suctioning. Which of the following steps in the sequence is incorrect?
Assist the patient into a supine position. Prepare supplies. Turn the suction unit on and set the suction control gauge to high. Connect the suction tubing to the suction machine and to the Yankauer suction catheter. The nurse should place the patient in a Fowler's position, then perform hand hygiene, and finally set the suction control gauge according to manufacturer's directions. A high setting on the suction control gauge could cause damage to the oral mucosa. The other options are correct steps in the sequence for performing oropharyngeal suctioning.
Which situation can be delegated to NAP in regard to endotracheal tube care?
Assisting the nurse during a tape change by holding the endotracheal tube. NAP can help with reporting signs that the tube is loose, the tapes are soiled, or that the patient is uncomfortable and assisting in holding the tube during a tape change. Assessment requires the skill and knowledge of the nurse and should not be delegated to NAP.
Chronic emphysema with long-term smoking
Chronic sonorous wheeze
The nurse was changing the patient's tube holder on his endotracheal tube when he reached up and extubated himself. What actions should the nurse take? (Select all that apply.)
Correct nursing actions for unexpected extubation include: remain with the patient; call for assistance; assess the patient for airway patency, spontaneous breathing, and vital signs (including oxygen saturation); and prepare for reintubation by the health care provider, administering breaths with an Ambu-bag in the meantime.
Which of the following, if exhibited by the patient, is a late sign of hypoxia?
Cyanosis Restlessness and anxiety are early indicators of hypoxia. Cyanosis is a late indicator of hypoxia. Eupnea is normal respiration.
Heavy sedation
Decreased oxygen saturation after surgery
What nursing intervention is appropriate for the patient with a large amount of sputum?
Encourage the patient to cough every hour while awake. A patient with a large amount of sputum should be encouraged to cough every hour while awake. Adequate fluids should be maintained to help keep secretions thin and easier to expectorate. Although milk has a protein structure similar to sputum, it does not increase sputum production and plays an important role in nutrition. Suctioning should be performed on an as-needed basis.
A patient may go home with a tracheostomy tube. Prior to discharge, the patient and the patient's family should be taught all of the following routine tracheostomy tube care measures except:
How to remove the tracheostomy tube. The patient and/or the patient's family should not remove the tracheostomy tube as this may result in closure of the patient's airway. Only the inner cannula should be removed for cleaning. The patient and the patient's family should be taught tracheostomy care, including suctioning, cleaning, replacing the ties, and recognizing the signs and symptoms of hypoxia and infection so they may take corrective action or seek additional medical care.
An elderly woman is hospitalized with pneumonia and anemia, and has a history of heart failure. She is weak and has a poor cough effort. Her current vital signs are temperature 100.2 ˚F (37.9 ˚C), pulse 114, respiration 26, blood pressure 106/58. She has oxygen ordered at 2 liters by nasal cannula. Her oxygen saturation measures 88% when on room air, 93% with supplemental oxygen. She develops shortness of breath on any activity and eats little because it is difficult for her to eat and breathe at the same time. Which of the following are risk factors for this patient developing hypoxia? (Select all that apply.)
Hypoxia results when there is inadequate tissue oxygenation at the cellular level. Lowered oxygen-carrying capacity from anemia can lead to hypoxia. A diminished concentration of inspired oxygen, such as with an obstructed airway from secretions, results in lowered oxygen saturation. Impaired cardiac function results in poor tissue perfusion with oxygenated blood. With pneumonia there is decreased diffusion of oxygen from the alveoli to the blood, leading to inadequate tissue oxygenation. An increase in pulse rate is an adaptive response to meet the body's oxygen demand. Shortness of breath (dyspnea) is a symptom of decreased oxygenation.
The nurse is caring for a patient who has an endotracheal tube inserted orally. The nurse instructs the NAP to report if the patient indicates signs of pain. Because the patient cannot communicate verbally, what signs of pain should the NAP report?
Increased restlessness or a sudden change in vital signs. Increased restlessness, inability to sleep, crying, and a sudden change in vital signs are all indicators of pain in the nonverbal patient. Coughing or audible gurgling, foul-smelling breath, or remaining secretions in the mouth indicate the patient may require suctioning but are not a sign of pain. If the patient is able to move the tub with his tongue or bite down on it, the tube may need to be resecured
Pneumonia
Increased restlessness, increases in secretions, and frequent coughing
You are reviewing the signs, symptoms, and prevention of hypoxia with the family of a patient who requires frequent suctioning at home. Choose the information that you should cover. (Select all that apply.)
Indications of hypoxia include restlessness, anxiety, confusion, disorientation, altered consciousness as well as increases in pulse rate, respiration rate, and blood pressure. Feeling out of breathe and looking blue also indicate hypoxia.
While cleaning the inner cannula, place the oxygen source over the outer cannula.
Maintains supply of oxygen to patient
Which of the following should NOT be delegated to NAP?
Nasotracheal suctioning. Because sterile technique and critical thinking skills are required, it is inappropriate to delegate nasotracheal suctioning to NAP. The other tasks can be performed by NAP on stable patients.
A patient has an endotracheal tube inserted orally. When should the nurse expect to perform endotracheal tube care?
On a routine schedule every 24 to 48 hours to reposition the tube. If endotracheal tube is inserted orally, the tube is often repositioned on the opposite side of the mouth or center of mouth at least every 24 to 48 hours according to facility protocol to prevent prolonged pressure and ulceration. Endotracheal tube care is usually performed on a routine schedule. Coughing, especially continued coughing, usually indicates a need for more frequent suctioning. Endotracheal tube care is indicated if the depth of the tube has changed.
The nurse is performing routine assessments of the patients on the unit. The nurse notes audible gurgling on inspiration and expiration of the stable postoperative patient. Which of the following tasks can be delegated to competent NAP?
Performing oral suctioning. Since the patient is stable, the task of performing oral suctioning may be delegated to NAP. However, the responsibility for assessing the adequacy of respiratory functioning and evaluating the patient outcome of oral suctioning remains with you. Nasotracheal suctioning requires sterile technique and cannot be delegated to NAP.
Have another nurse or family member assist in the procedure.
Prevents accidental extubation
Which of the following patients is most likely to experience some difficulty with effective coughing?
The patient who is postoperative for abdominal surgery. Abdominal surgery causes pain and weakness of the abdominal muscles, both of which can result in ineffective airway clearance. Learning coughing techniques preoperatively will aid in postoperative performance of these skills.
Keep the dominant hand sterile throughout the procedure.
Reduces the transmission of microorganisms
Suction the tracheostomy before cleaning the cannula and changing the dressing.
Removes secretions to avoid occluding the outer cannula while inner cannula is removed; reduces the need for the patient to cough
Which of the following would be an appropriate nursing diagnosis for the patient who has a tracheostomy tube?
Risk of altered skin integrity. The nurse must be alert to the development of skin irritation below the tracheostomy flange and around the site of insertion. Neither impaired mobility, fluid volume deficit, nor risk of fluid volume excess are related to the presence of a tracheostomy tube. The nurse must be alert for defining characteristics of other nursing diagnoses, including impaired airway clearance, infection, pain, or altered skin integrity.
Identify the situations that require endotracheal tube care. (Select all that apply.)
Signs and symptoms of the need to perform endotracheal tube care include: soiled or loose tape; a pressure sore on the naris, lips, or corner of the mouth; excess nasal or oral secretions; patient moving the tube with the tongue or biting the tube or tongue; tube repositioned by the physician or other specially trained personnel; foul-smelling mouth. The endotracheal tube should remain at the same depth when breath sounds are equal. Shaving a male patient may be performed during endotracheal tube care.
Which of the following patients may likely require oropharyngeal suctioning? (Select all that apply.)
The Yankauer suction device is useful in the removal of secretions from the mouth in patients after oral and maxillofacial surgery, trauma to the mouth, neurovascular injury and/or cerebrovascular accident causing hemiparesis and drooling, or impaired swallowing. Patients with artificial airways and impaired swallowing ability may require use of the Yankauer suction device to promote oral hygiene. Patients with lung cancer or pneumonia may be able to cough up or swallow secretions on their own.
The nurse is caring for a patient who underwent major abdominal surgery 24 hours ago. The 72-year-old male patient is weak and lethargic because of large doses of medication for pain control. After noting audible gurgling on inspiration and expiration, the nurse completes a respiratory assessment. Which assessment parameters indicate the need for oral suction? (Select all that apply.)
The following signs indicate the need for oropharyngeal suctioning: (1) restlessness, especially if it is new or unusual for the patient; (2) obvious, excessive oral secretions as evidenced by drooling and/or gagging; (3) gurgling and/or audible crackles and wheezes that occur on inspiration and/or expiration; (4) evidence of gastric contents and/or emesis in the mouth; (5) persistent coughing that fails to clear the upper airway; and (6) weakness and lethargy accompanied by drooling and gagging. Persistent complaints of pain are more likely related to the surgery
Which of the following can be removed for cleaning, especially if the patient has copious or tenacious secretions?
The inner cannula of the tracheostomy tube. The inner cannula may be removed and cleaned, or if disposable, discarded and replaced. The outer cannula should never be removed. Removal of the outer cannula would cause the tracheostomy tract to close, and in turn this would close the patient's airway. The obturator is a stylet used for initial insertion of the tracheostomy tube and is then removed to allow for airflow. The area under the flange, as well as the flange itself, is cleaned but not removed as it aids in securing the entire system to the patient's neck.
Which of the following patients should be assessed for a worsening clinical situation?
The patient with presence of blood in the secretions. Bloody secretions are an unexpected outcome. The cause should be investigated. The removal of secretions helps to improve the oxygen saturation level. In patients with chronic pulmonary diseases such as COPD, the pulse oximetry value may remain the same. The absence of adventitious sounds is an expected finding. An expected outcome of oropharyngeal suctioning is lessened or absence of drooling.
A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. Upon arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. This patient is at risk for airway occlusion.
True She must constantly be monitored for airway occlusion.
A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. Upon arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. This patient's risk factors for respiratory problems include history of smoking, her illness, and her age.
True She was a smoker for many years, and her age and illness place her at greater risk for respiratory distress
The nurse desires to suction the patient's left main stem bronchus. In what position should the patient be placed?
Turn the patient's head to the right. To effectively suction the left main stem bronchus, turn the patient's head to the right.
Which of the following is an inaccurate statement in regard to performing endotracheal tube care?
When rotating the endotracheal tube from one side of the mouth to the other, deflate the cuff. Never deflate the cuff during tube rotation. This could potentially dislodge the tube
objectives
· Discuss the effect of a patient's level of health, age, lifestyle, and environment on oxygenation. · Assess for the risk factors affecting a patient's oxygenation. · Assess for the physical manifestations that occur with alterations in oxygenation. · Develop a plan of care for a patient with altered need for oxygenation. · Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. · Identify guidelines for managing a patient's airway. · Describe the nursing interventions for airway management. · Discuss the indications for airway suctioning. · Determine when oropharyngeal suctioning is appropriate for your patient. · Correctly perform oropharyngeal suctioning · Identify clinical signs and symptoms that indicate the need for tracheal suctioning. · Describe factors that create risks during tracheal suctioning. · Identify complications of tracheal suctioning. · Properly perform tracheal suctioning. Discuss the indications for endotracheal tube care. · List expected and unexpected outcomes of endotracheal tube care. · List the appropriate supplies for endotracheal tube care. · Describe emergency interventions if the patient is accidentally extubated. · Correctly perform endotracheal tube care. Identify situations requiring tracheostomy tube care. · List expected and unexpected outcomes of tracheostomy tube care. · List the appropriate supplies for tracheostomy tube care. · Describe emergency interventions if the patient is accidentally extubated. · Correctly perform tracheostomy tube care.
