Podcast
Questions and Answers
A nurse is caring for a client who has undergone nasal surgery. Which structure of the upper airway is most likely to be directly affected postoperatively?
A nurse is caring for a client who has undergone nasal surgery. Which structure of the upper airway is most likely to be directly affected postoperatively?
- Laryngopharynx
- Nasopharynx (correct)
- Oropharynx
- Trachea
During swallowing, which protective airway structure prevents food and liquid from entering the trachea?
During swallowing, which protective airway structure prevents food and liquid from entering the trachea?
- Epiglottis (correct)
- Mucous membrane
- Tracheal cartilage
- Cilia
A client with a respiratory infection has increased mucus production. Which natural airway defense mechanism is primarily responsible for moving this mucus upward to be expectorated or swallowed?
A client with a respiratory infection has increased mucus production. Which natural airway defense mechanism is primarily responsible for moving this mucus upward to be expectorated or swallowed?
- Ciliary action (correct)
- Epiglottis action
- Mucous membrane trapping
- Tracheal cartilage rigidity
A client is unable to effectively cough due to muscle weakness. This primarily jeopardizes airway patency by interfering with which natural protective mechanism?
A client is unable to effectively cough due to muscle weakness. This primarily jeopardizes airway patency by interfering with which natural protective mechanism?
An elderly client with dysphagia is at increased risk for aspiration. Which assessment finding is most indicative of silent aspiration?
An elderly client with dysphagia is at increased risk for aspiration. Which assessment finding is most indicative of silent aspiration?
A nurse is caring for a client with pneumonia who has thick, tenacious secretions. Which nursing intervention is most appropriate to help liquefy these secretions and promote airway clearance?
A nurse is caring for a client with pneumonia who has thick, tenacious secretions. Which nursing intervention is most appropriate to help liquefy these secretions and promote airway clearance?
A client is ordered chest physiotherapy. Which technique involves rhythmic striking of the chest wall to loosen retained secretions?
A client is ordered chest physiotherapy. Which technique involves rhythmic striking of the chest wall to loosen retained secretions?
The physician orders postural drainage for a client with cystic fibrosis. The primary goal of postural drainage is to:
The physician orders postural drainage for a client with cystic fibrosis. The primary goal of postural drainage is to:
A client with chronic bronchitis is experiencing increased dyspnea and frequent coughing, but is able to expectorate only small amounts of thick mucus. What is an appropriate initial nursing intervention to assist with airway clearance?
A client with chronic bronchitis is experiencing increased dyspnea and frequent coughing, but is able to expectorate only small amounts of thick mucus. What is an appropriate initial nursing intervention to assist with airway clearance?
A client with a decreased level of consciousness requires airway suctioning. What is the primary purpose of pre-oxygenating the client before suctioning?
A client with a decreased level of consciousness requires airway suctioning. What is the primary purpose of pre-oxygenating the client before suctioning?
When performing oropharyngeal suctioning on an adult client, how far should the nurse advance the catheter into the mouth?
When performing oropharyngeal suctioning on an adult client, how far should the nurse advance the catheter into the mouth?
During nasotracheal suctioning, the nurse should apply suction:
During nasotracheal suctioning, the nurse should apply suction:
A nurse notes a client's oxygen saturation drops to 88% during nasotracheal suctioning. What is the immediate priority nursing action?
A nurse notes a client's oxygen saturation drops to 88% during nasotracheal suctioning. What is the immediate priority nursing action?
Which type of artificial airway is contraindicated for use in a conscious client due to the risk of gagging and vomiting?
Which type of artificial airway is contraindicated for use in a conscious client due to the risk of gagging and vomiting?
A client requires frequent nasopharyngeal suctioning. Which artificial airway is most appropriate for maintaining nasal patency and facilitating repeated suctioning?
A client requires frequent nasopharyngeal suctioning. Which artificial airway is most appropriate for maintaining nasal patency and facilitating repeated suctioning?
An endotracheal tube is primarily used for which purpose in airway management?
An endotracheal tube is primarily used for which purpose in airway management?
For a client requiring long-term airway support, a tracheostomy is often preferred over an endotracheal tube. What is the typical timeframe after which a tracheostomy might be considered?
For a client requiring long-term airway support, a tracheostomy is often preferred over an endotracheal tube. What is the typical timeframe after which a tracheostomy might be considered?
A tracheostomy tube has three main parts. Which of the following lists correctly identifies these components?
A tracheostomy tube has three main parts. Which of the following lists correctly identifies these components?
Routine tracheostomy care typically includes cleaning the inner cannula. How frequently should tracheostomy care, including inner cannula cleaning, be performed for a stable client?
Routine tracheostomy care typically includes cleaning the inner cannula. How frequently should tracheostomy care, including inner cannula cleaning, be performed for a stable client?
When cleaning a non-disposable inner cannula of a tracheostomy tube, what is the recommended solution for soaking and cleaning?
When cleaning a non-disposable inner cannula of a tracheostomy tube, what is the recommended solution for soaking and cleaning?
During tracheostomy care, it is essential to secure the tracheostomy tube to prevent accidental decannulation. What safety measure should be implemented when changing tracheostomy ties?
During tracheostomy care, it is essential to secure the tracheostomy tube to prevent accidental decannulation. What safety measure should be implemented when changing tracheostomy ties?
A nurse is preparing to suction a client's tracheostomy. How far should the nurse insert the suction catheter into the tracheostomy tube?
A nurse is preparing to suction a client's tracheostomy. How far should the nurse insert the suction catheter into the tracheostomy tube?
Within the first 72 hours after a tracheostomy placement, accidental decannulation is considered a medical emergency. What is the immediate nursing intervention if this occurs?
Within the first 72 hours after a tracheostomy placement, accidental decannulation is considered a medical emergency. What is the immediate nursing intervention if this occurs?
If accidental tracheostomy decannulation occurs after 72 hours post-procedure and the stoma is well-established, what is the initial step for a nurse to attempt?
If accidental tracheostomy decannulation occurs after 72 hours post-procedure and the stoma is well-established, what is the initial step for a nurse to attempt?
To assess proper placement of a newly reinserted tracheostomy tube after accidental decannulation, the nurse should immediately:
To assess proper placement of a newly reinserted tracheostomy tube after accidental decannulation, the nurse should immediately:
What is the recommended range for tracheostomy cuff pressure to prevent tracheal wall necrosis and tracheal stenosis?
What is the recommended range for tracheostomy cuff pressure to prevent tracheal wall necrosis and tracheal stenosis?
How often should tracheostomy cuff pressure be checked and adjusted to maintain the recommended range?
How often should tracheostomy cuff pressure be checked and adjusted to maintain the recommended range?
A client with a tracheostomy is receiving humidified oxygen via a tracheostomy collar. What is the primary advantage of using a tracheostomy collar for oxygen delivery?
A client with a tracheostomy is receiving humidified oxygen via a tracheostomy collar. What is the primary advantage of using a tracheostomy collar for oxygen delivery?
A water-seal chest tube drainage system is used primarily to remove:
A water-seal chest tube drainage system is used primarily to remove:
A nurse observes continuous bubbling in the water-seal chamber of a chest tube drainage system. This finding most likely indicates:
A nurse observes continuous bubbling in the water-seal chamber of a chest tube drainage system. This finding most likely indicates:
When caring for a client with a chest tube, which of the following nursing actions is contraindicated?
When caring for a client with a chest tube, which of the following nursing actions is contraindicated?
A client with a chest tube is being transported for a diagnostic procedure. What is the most important nursing consideration during transport?
A client with a chest tube is being transported for a diagnostic procedure. What is the most important nursing consideration during transport?
Which nursing diagnosis is most directly related to ineffective airway clearance in a client with excessive mucus production due to pneumonia?
Which nursing diagnosis is most directly related to ineffective airway clearance in a client with excessive mucus production due to pneumonia?
A client is exhibiting signs of hypoxemia. Which of the following is a late sign of hypoxemia that the nurse should assess for?
A client is exhibiting signs of hypoxemia. Which of the following is a late sign of hypoxemia that the nurse should assess for?
A client is diagnosed with aspiration pneumonia. Which adventitious breath sound is most consistent with fluid and secretions in the larger airways?
A client is diagnosed with aspiration pneumonia. Which adventitious breath sound is most consistent with fluid and secretions in the larger airways?
Flashcards
Upper Airway
Upper Airway
Nose and pharynx; includes nasopharynx, oropharynx, laryngopharynx.
Lower Airway
Lower Airway
Trachea, bronchi, bronchioles and alveoli.
Epiglottis
Epiglottis
Closes when swallowing to prevent aspiration.
Tracheal Cartilage
Tracheal Cartilage
Signup and view all the flashcards
Mucous Membrane
Mucous Membrane
Signup and view all the flashcards
Cilia
Cilia
Signup and view all the flashcards
Nose Clearing
Nose Clearing
Signup and view all the flashcards
Airway Clearing Reflexes
Airway Clearing Reflexes
Signup and view all the flashcards
Airway Management
Airway Management
Signup and view all the flashcards
Liquefying Secretions
Liquefying Secretions
Signup and view all the flashcards
Mobilizing Secretions
Mobilizing Secretions
Signup and view all the flashcards
Percussion
Percussion
Signup and view all the flashcards
Vibration
Vibration
Signup and view all the flashcards
Suctioning Types
Suctioning Types
Signup and view all the flashcards
Suctioning Preparation
Suctioning Preparation
Signup and view all the flashcards
Hypoxemia Risks
Hypoxemia Risks
Signup and view all the flashcards
Oral Airway Considerations
Oral Airway Considerations
Signup and view all the flashcards
Endotracheal Tube
Endotracheal Tube
Signup and view all the flashcards
Tracheostomy
Tracheostomy
Signup and view all the flashcards
Tracheostomy Parts
Tracheostomy Parts
Signup and view all the flashcards
Tracheostomy Care
Tracheostomy Care
Signup and view all the flashcards
Tracheostomy Cleaning
Tracheostomy Cleaning
Signup and view all the flashcards
Tracheal Damage
Tracheal Damage
Signup and view all the flashcards
O2 Delivery Methods
O2 Delivery Methods
Signup and view all the flashcards
Study Notes
- Airway management encompasses essential nursing skills for maintaining both natural and artificial airways.
Airway Structures
- The upper airway consists of the nose and pharynx, including the nasopharynx, oropharynx, and laryngopharynx.
- The lower airway includes the trachea, bronchi, bronchioles, and alveoli.
Protective Mechanisms of Natural Airway
- Epiglottis closes during swallowing to prevent food from entering the trachea.
- Tracheal cartilage rings maintain the trachea’s open state.
- Mucous membranes line the respiratory tract, trapping particulate matter.
- Cilia, hair-like projections, push debris upward.
- Sneezing and nose blowing expel irritants and secretions.
- Coughing, expectoration, and swallowing help clear the airway.
Factors Jeopardizing Airway Patency
- Increased volume or thickness of mucus can obstruct the airway.
- Fatigue and weakness can impair the ability to clear secretions.
- Decreased level of consciousness (LOC) reduces protective reflexes.
- Impaired airway, such as obstructions, can compromise breathing.
- Dysphagia (difficulty swallowing) increases aspiration risk.
Airway Compromise Risks
- Risks include those affecting gag reflex, cough effectiveness, and LOC
Signs of Impaired Airway Clearance
- Hypoxemia presents with symptoms that can be reviewed in oxygenation materials.
- Adventitious breath sounds indicate abnormal airway conditions.
- Visible secretions with abnormal consistency or color suggest infection or other issues.
- Absence or ineffectiveness of spontaneous cough impairs secretion removal.
- Silent aspiration may present without obvious signs.
Nursing Interventions for Natural Airway
- Liquefying secretions through hydration and inhalation therapy can aid in expectoration.
- Mobilizing secretions using chest physiotherapy, postural drainage, percussion, and vibration loosens and moves secretions.
- Encouraging coughing and deep breathing facilitates airway clearance.
Chest Physiotherapy Techniques
- Postural drainage involves positioning the patient to use gravity to drain secretions.
- Percussion, or rhythmic striking of the chest wall, helps loosen retained secretions.
- Vibration uses the palms or heel of the hand to shake underlying tissue and loosen secretions.
Suctioning Procedure
- Requires PPE and a kit with a 12-18 French catheter, sterile normal saline, and suction machine.
- Ensure patient privacy and elevate the head of the bed (HOB).
- Wash hands, pre-oxygenate patient. Open kit and apply sterile gloves.
- Pour normal saline into a basin (non-dominant hand, now contaminated).
- Pick up the suction catheter with the dominant (sterile) hand.
- Put the catheter tip in saline and occlude the vent to test suction.
Suctioning Technique
- Insert catheter without suction along the floor of the nose or side of the mouth.
- Advance 5-6 inches in the nose or 3-4 inches in the mouth.
- Occlude the air vent and rotate the catheter as it is withdrawn, and complete the process in 10-15 seconds.
- Rinse secretions in saline and allow the client to rest 2-3 minutes with oxygen.
- Repeat suction if necessary, remove gloves enclosing the suction catheter, and wash hands.
Suctioning Complications and Prevention
- Hypoxemia is indicated by decreased SaO2 or cyanosis; stop the procedure immediately and hyper-oxygenate the client.
- Pre-oxygenate the client, allow enough time between suctioning attempts, limit attempts to 2-3, and suction for no longer than 10-15 seconds per attempt.
- Ease anxiety by explaining the procedure, providing reassurance, and maintaining a calm manner.
Artificial Airways: Oral Airway
- Not used in conscious patients due to gagging or vomiting risk.
- Remove every 4 hours for oral care.
Artificial Airways: Nasopharyngeal
- A nasal trumpet is a pliable rubber tube.
Artificial Airways: Endotracheal Tube
- Inserted via the nose or mouth and used to support ventilation.
- Features an inflatable cuff at the distal end to prevent air leaks.
Artificial Airways: Tracheostomy
- Involves an incision into the trachea, indicated when an endotracheal tube is needed for more than 7-10 days.
- Also used when an airway is obstructed.
- Consists of three parts: outer cannula, obturator, and inner cannula.
Tracheostomy Care
- Clean the skin and inner cannula (if not disposable), and change the dressing and ties every 8 hours or as needed.
- Suction through the trach tube, inserting about 4-5 inches, using sterile or unsterile technique for unsheathed tubes.
Tracheostomy Care Procedure
- Requires PPE, hydrogen peroxide, normal saline, wash hands, position patient supine or in low Fowler’s.
- Remove the stomal dressing with clean gloves and discard both. Wash hands open trach kit and use sterile gloves.
- Mix equal parts of hydrogen peroxide and sterile normal saline in one basin, and use sterile normal saline in another basin.
Inner Cannula Cleaning
- Unlock inner cannula and put in hydrogen peroxide and saline mix.
- Clean inside and outside with pipe cleaners or brush, rinse in normal saline, and tap against the edge of the basin.
- Wipe excess with gauze square or pipe cleaners.
- Replace the inner cannula, turning it clockwise.
Stoma and Trach Tie Care
- Clean around the stoma with a cotton-tipped applicator.
- Place a stomal dressing beneath the flanges and outer cannula.
- Change trach ties, ensuring one or two fingers fit between the tie and neck.
- Secure tie at the side of the neck, and use Velcro making sure it lays flat against neck and keeping old ties in place until the new ties are in place.
Tracheostomy Suctioning
- Suctioning is performed as needed based on assessment findings, such as, audible secretions.
- Similar to other suctioning methods, but the catheter is inserted through the tracheostomy tube.
- Distance of catheter insertion is 4-5 inches; use a sheathed or unsheathed catheter.
Possible Complications: Accidental Decannulation
- Replacement is difficult within the first 72 hours after surgery.
- Ventilate with a manual resuscitation bag and call for help.
- Keep a tracheostomy obturator and two spare trach tubes at the bedside.
- In the event of accidental decannulation after the first 72 hours, hyperextend the neck, insert the obturator into the trach tube, and quickly replace the tube.
Accidental Decannulation Management
- After securing the tube, assess tube placement by auscultating for bilateral breath sounds.
- If unable to replace the tube, administer O2 through the stoma; if still unable, occlude the stoma and administer O2 through the client’s nose and mouth.
Tracheal Damage Prevention
- Maintain cuff pressure between 14-20 mm Hg.
- Check cuff pressure at least once a shift every 8 hours.
- Keep the tube in the midline position and prevent pulling or traction on the trach tube.
Oxygen Delivery Options
- Includes tracheostomy collar, T-piece, and transtracheal oxygen.
Chest Tubes
- They include a water-seal chest tube drainage system, which contains 3 chambers.
- Monitor observations and perform nursing responsibilities accordingly.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
