Podcast
Questions and Answers
A client with cystic fibrosis is admitted to the hospital with an exacerbation of respiratory symptoms. Which chest physiotherapy (CPT) technique is MOST beneficial for this client to clear respiratory secretions?
A client with cystic fibrosis is admitted to the hospital with an exacerbation of respiratory symptoms. Which chest physiotherapy (CPT) technique is MOST beneficial for this client to clear respiratory secretions?
- Huff coughing to promote airway clearance.
- Percussion, vibration, and postural drainage to mobilize secretions. (correct)
- Diaphragmatic breathing exercises to improve ventilation.
- Incentive spirometry to prevent atelectasis.
A nurse is preparing to perform endotracheal suctioning on a mechanically ventilated client. What is the MOST critical action to perform to prevent hypoxemia during the procedure?
A nurse is preparing to perform endotracheal suctioning on a mechanically ventilated client. What is the MOST critical action to perform to prevent hypoxemia during the procedure?
- Administering a bronchodilator medication.
- Applying continuous suction during catheter insertion.
- Hyperoxygenating the client before suctioning. (correct)
- Instilling sterile normal saline into the endotracheal tube.
The nurse is caring for a client with an endotracheal tube. Which intervention is MOST important to prevent ventilator-associated pneumonia (VAP)?
The nurse is caring for a client with an endotracheal tube. Which intervention is MOST important to prevent ventilator-associated pneumonia (VAP)?
- Administer prophylactic antibiotics.
- Reposition the endotracheal tube daily.
- Maintain the client in a supine position.
- Provide oral care with chlorhexidine solution. (correct)
The nurse is assessing a client with a nasopharyngeal airway (NPA) in place. Which finding requires IMMEDIATE intervention?
The nurse is assessing a client with a nasopharyngeal airway (NPA) in place. Which finding requires IMMEDIATE intervention?
A client with a tracheostomy tube has thick, tenacious secretions. Which intervention is MOST effective in thinning these secretions?
A client with a tracheostomy tube has thick, tenacious secretions. Which intervention is MOST effective in thinning these secretions?
A nurse is preparing to insert an oropharyngeal airway (OPA) in an unconscious adult client. Which technique is correct for inserting the OPA?
A nurse is preparing to insert an oropharyngeal airway (OPA) in an unconscious adult client. Which technique is correct for inserting the OPA?
A client with a tracheostomy tube is being discharged home. What is the MOST important teaching point for the client and family regarding tracheostomy care?
A client with a tracheostomy tube is being discharged home. What is the MOST important teaching point for the client and family regarding tracheostomy care?
A nurse is performing closed suctioning on a mechanically ventilated client. What is the PRIMARY advantage of using a closed suction system over an open suction system?
A nurse is performing closed suctioning on a mechanically ventilated client. What is the PRIMARY advantage of using a closed suction system over an open suction system?
A nurse is caring for a client receiving chest physiotherapy (CPT). Which condition is a contraindication for percussion?
A nurse is caring for a client receiving chest physiotherapy (CPT). Which condition is a contraindication for percussion?
A nurse is documenting care after performing suctioning on a client with a tracheostomy. Which documentation is MOST important?
A nurse is documenting care after performing suctioning on a client with a tracheostomy. Which documentation is MOST important?
A nurse is caring for a client with an endotracheal tube who requires frequent suctioning. Which nursing intervention is MOST crucial to prevent mucosal damage during suctioning?
A nurse is caring for a client with an endotracheal tube who requires frequent suctioning. Which nursing intervention is MOST crucial to prevent mucosal damage during suctioning?
A client with a tracheostomy tube is being prepared for discharge. Which statement by the client indicates a need for further teaching?
A client with a tracheostomy tube is being prepared for discharge. Which statement by the client indicates a need for further teaching?
A nurse is caring for a client with an oropharyngeal airway (OPA) in place. Which assessment finding indicates that the OPA is the correct size?
A nurse is caring for a client with an oropharyngeal airway (OPA) in place. Which assessment finding indicates that the OPA is the correct size?
A client with a tracheostomy tube develops subcutaneous emphysema around the stoma site. Which intervention is MOST important?
A client with a tracheostomy tube develops subcutaneous emphysema around the stoma site. Which intervention is MOST important?
A nurse is teaching a client how to perform postural drainage at home. Which instruction is MOST important to ensure the client's safety?
A nurse is teaching a client how to perform postural drainage at home. Which instruction is MOST important to ensure the client's safety?
A client with an endotracheal tube is on mechanical ventilation. The high-pressure alarm is sounding. What is the FIRST action the nurse should take?
A client with an endotracheal tube is on mechanical ventilation. The high-pressure alarm is sounding. What is the FIRST action the nurse should take?
A nurse is preparing to suction a client with a new tracheostomy. Which technique is MOST appropriate to prevent tissue damage?
A nurse is preparing to suction a client with a new tracheostomy. Which technique is MOST appropriate to prevent tissue damage?
A nurse is evaluating the effectiveness of chest physiotherapy (CPT) for a client with pneumonia. Which assessment finding indicates that CPT has been effective?
A nurse is evaluating the effectiveness of chest physiotherapy (CPT) for a client with pneumonia. Which assessment finding indicates that CPT has been effective?
A client with a nasopharyngeal airway (NPA) is at risk for aspiration. Which nursing intervention is MOST important to minimize this risk?
A client with a nasopharyngeal airway (NPA) is at risk for aspiration. Which nursing intervention is MOST important to minimize this risk?
A nurse is caring for a client with a tracheostomy tube who is on mechanical ventilation. The client becomes agitated and repeatedly pulls at the tracheostomy tube. Which intervention is MOST appropriate?
A nurse is caring for a client with a tracheostomy tube who is on mechanical ventilation. The client becomes agitated and repeatedly pulls at the tracheostomy tube. Which intervention is MOST appropriate?
A nurse is preparing to perform oropharyngeal suctioning on a client who is unable to cough effectively. Which type of suction catheter is MOST appropriate for this procedure?
A nurse is preparing to perform oropharyngeal suctioning on a client who is unable to cough effectively. Which type of suction catheter is MOST appropriate for this procedure?
A nurse is caring for a client with a tracheostomy who has excessive secretions. Despite frequent suctioning, the secretions continue to obstruct the airway. What additional intervention should the nurse consider?
A nurse is caring for a client with a tracheostomy who has excessive secretions. Despite frequent suctioning, the secretions continue to obstruct the airway. What additional intervention should the nurse consider?
A nurse is teaching a client's family how to perform tracheostomy care at home. Which instruction is MOST important to include regarding infection control?
A nurse is teaching a client's family how to perform tracheostomy care at home. Which instruction is MOST important to include regarding infection control?
A nurse is assessing a client with an endotracheal tube. Which finding is MOST indicative of tracheal stenosis?
A nurse is assessing a client with an endotracheal tube. Which finding is MOST indicative of tracheal stenosis?
A nurse is caring for a client receiving chest physiotherapy (CPT). After performing percussion and vibration, what is the MOST important immediate next step?
A nurse is caring for a client receiving chest physiotherapy (CPT). After performing percussion and vibration, what is the MOST important immediate next step?
A client with a nasopharyngeal airway (NPA) is being transported to another unit. Which action is MOST important to ensure the NPA remains effective during transport?
A client with a nasopharyngeal airway (NPA) is being transported to another unit. Which action is MOST important to ensure the NPA remains effective during transport?
A nurse is caring for a client with a tracheostomy tube who has developed a pressure ulcer at the stoma site. Which intervention is MOST appropriate to promote healing?
A nurse is caring for a client with a tracheostomy tube who has developed a pressure ulcer at the stoma site. Which intervention is MOST appropriate to promote healing?
A nurse is preparing to perform endotracheal suctioning on a mechanically ventilated client. The client's baseline heart rate is 80 bpm. During suctioning, the heart rate drops to 50 bpm. What is the FIRST action the nurse should take?
A nurse is preparing to perform endotracheal suctioning on a mechanically ventilated client. The client's baseline heart rate is 80 bpm. During suctioning, the heart rate drops to 50 bpm. What is the FIRST action the nurse should take?
A client with a tracheostomy tube is being discharged home with a speaking valve. Which instruction is MOST important for the nurse to emphasize to the client and family?
A client with a tracheostomy tube is being discharged home with a speaking valve. Which instruction is MOST important for the nurse to emphasize to the client and family?
A nurse is caring for a client who has undergone a laryngectomy and has a stoma. What is the MOST important measure to prevent aspiration in this client?
A nurse is caring for a client who has undergone a laryngectomy and has a stoma. What is the MOST important measure to prevent aspiration in this client?
A nurse is assessing a client with an endotracheal tube. Which finding indicates that the tube may be displaced?
A nurse is assessing a client with an endotracheal tube. Which finding indicates that the tube may be displaced?
A nurse is caring for a client with a tracheostomy tube. The client develops thick, dried secretions around the stoma site. What is the MOST appropriate intervention to remove these secretions?
A nurse is caring for a client with a tracheostomy tube. The client develops thick, dried secretions around the stoma site. What is the MOST appropriate intervention to remove these secretions?
A nurse is teaching a client and family about the purpose of the cuff on a tracheostomy tube. Which statement BEST explains the function of the cuff?
A nurse is teaching a client and family about the purpose of the cuff on a tracheostomy tube. Which statement BEST explains the function of the cuff?
A nurse is providing care to a client immediately after a tracheostomy procedure. Which intervention has the HIGHEST priority?
A nurse is providing care to a client immediately after a tracheostomy procedure. Which intervention has the HIGHEST priority?
A nurse is caring for a client receiving mechanical ventilation via an endotracheal tube. Despite optimal ventilator settings, the client's oxygen saturation remains low. Which intervention should the nurse consider FIRST?
A nurse is caring for a client receiving mechanical ventilation via an endotracheal tube. Despite optimal ventilator settings, the client's oxygen saturation remains low. Which intervention should the nurse consider FIRST?
Flashcards
Importance of Airway Management
Importance of Airway Management
The airway is the top priority in patient care; a patent airway is crucial for effective patient care, especially in critical situations. It's represented by 'A' in ABCs (Airway, Breathing, Circulation).
Suctioning Techniques
Suctioning Techniques
Suctioning clears secretions from the airway, especially with artificial airways, minimizing infection and discomfort. Knowledge of when and how to suction is critical.
Chest Physiotherapy (CPT)
Chest Physiotherapy (CPT)
A set of techniques to mobilize respiratory secretions; includes percussion, vibration, and postural drainage. Beneficial for conditions like cystic fibrosis.
Postural Drainage
Postural Drainage
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Artificial Airways
Artificial Airways
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Oropharyngeal Airway (OPA)
Oropharyngeal Airway (OPA)
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Nasopharyngeal Airway (NPA)
Nasopharyngeal Airway (NPA)
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Endotracheal Tube (ET)
Endotracheal Tube (ET)
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Tracheostomy Tube
Tracheostomy Tube
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Suctioning Precautions
Suctioning Precautions
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Closed Suctioning Procedure
Closed Suctioning Procedure
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Closed Suction System Advantages
Closed Suction System Advantages
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Study Notes
- Airway management is vital in patient care, the 'A' in ABCs (Airway, Breathing, Circulation) signifies its priority.
- A patent airway is crucial because all other interventions are secondary.
- Airway management techniques are essential for patient care.
Techniques for Airway Clearance
- Suctioning is performed to clear airway secretions, especially with artificial airways.
- Proper suctioning minimizes infection risk and patient discomfort.
- Knowing when and how to suction is important for patient outcomes.
- Chest Physiotherapy (CPT) includes percussion, vibration, and postural drainage to clear secretions.
- CPT benefits patients with conditions like cystic fibrosis.
- CPT reduces the risk of respiratory infections and atelectasis by mobilizing secretions.
Chest Physiotherapy (CPT) - More Details
- CPT includes percussion, vibration, and postural drainage.
- It loosens respiratory secretions and moves them to central airways for coughing or suctioning.
- Removing secretions prevents respiratory infections and atelectasis.
- CPT is performed with bronchodilators, antibiotics, mucolytic agents, and hydration.
Percussion Details
- Percussion is striking the skin over congested lung fields to dislodge secretions.
- Use cupped hands or commercial percussion cups.
- Avoid percussion over the breasts, sternum, spinal column, and kidneys.
Vibration Details
- Vibration follows or alternates with percussion to increase exhaled air turbulence and loosen secretions.
- Place hands on the affected area, either side-by-side or one on top of the other, with fingers extended.
- Vibrate by moving the heel of your hand in a shaking manner on the patient's chest.
Important Notes
- Follow facility policy for airway management and chest physiotherapy.
- Always use PPE and follow infection control guidelines.
Postural Drainage and Suctioning Details
- Postural drainage uses gravity to remove secretions from various lung areas.
- Place the client in various positions for 10-15 minutes, 2-3 times daily.
- Evaluate the client's tolerance for positions and check for airway obstruction.
- Remove secretions by having the client cough or by suctioning the airway.
Artificial Airways
- Artificial airways are used when a client's airway is at risk of obstruction or obstructed.
- Common devices: oropharyngeal, nasopharyngeal airways, endotracheal, and tracheostomy tubes.
Oropharyngeal Airways
- Oropharyngeal airways are made of hard plastic and available in different sizes.
- They prevent the tongue or secretions from obstructing the upper airway.
- Insert with the curved end toward the cheek, then rotate to follow the tongue's curve.
Nasopharyngeal Airways
- The nasopharyngeal is made of soft, flexible rubber.
- Inserted through the nares and into the oropharynx.
- It Can be used for alert clients.
Endotracheal Tubes (ET)
- Endotracheal tubes are for general anesthesia or mechanical ventilation.
- Inserted through the nose or mouth, past the epiglottis and vocal cords into the trachea.
- Not usually left in place for longer than 14 days.
Airway Management Devices
- Endotracheal (ET) tubes are inserted through the nose or mouth into the trachea
- Tracheostomy tubes provide long-term airway support through a neck opening.
- Air inflated cuffs prevent air leaks and aspiration in both tube types.
- Tracheostomy tubes are the only airway management device that requires a surgical procedure for placement
Complications of Tracheostomy Tubes
- Tube obstruction and dislodgement are major complications
- Other complications include pneumothorax, subcutaneous emphysema, hemorrhage, and infection
Suctioning Details
- Suctioning removes secretions from the airway for clients unable to mobilize and expectorate them
- Common types are oropharyngeal, nasopharyngeal, and tracheal suctioning (through artificial airways).
- Suctioning can cause complications like hypoxia, airway injury, nosocomial infections, and cardiac dysrhythmias.
Precautions for Suctioning
- Hyperoxygenate before suctioning.
- Assess the client before, during, and after the procedure.
- Use sterile technique when inserting the catheter.
- Use clean gloves with a Yankauer suction catheter, re-using it on the same client before discarding.
Closed Suctioning Procedure
- Wear clean gloves
- Attach a multi-use catheter (enclosed in plastic sheath) to the client's ventilation port
- Advance the catheter while pulling the plastic sleeve back
- Stop when you meet resistance or the client coughs
- Apply suction for 10-15 seconds
- Withdraw the catheter completely to clear the airway
- Rinse the catheter with 0.9% sodium chloride
Important Notes
- Do not instill 0.9% sodium chloride into the artificial airway before suctioning.
- Wait 1 minute between suction passes for ventilation and oxygenation.
- Rotate the catheter outward when open suctioning.
- Prevent accidental harm by locking the suction-control mechanism before leaving the bedside
Closed Suction System Advantages
- Reduces infection and oxygen desaturation risks
- Does not require disconnecting the ventilator/oxygen source
- Maintains ventilation and oxygenation
Documentation in Healthcare Settings
- It provides information about the care given and the status of the client
- It communicates information to other healthcare workers
- Documentation format varies by agency
- Healthcare providers, including students, must follow HIPAA regulations
- Students should only gather information needed for safe and efficient care
Airway Management Documentation
- Document the client's response and tolerance of the procedure
- Document any client and family teaching done
For Chest Physiotherapy (CPT)
- Date and time CPT was performed
- Breath sounds, heart rate, and oxygen saturation before and after CPT
- Type (postural drainage, percussion, vibration) and duration of CPT performed
- Anatomical area where CPT was performed
- Whether the client was able to cough or required suctioning after CPT
- Amount, color, consistency, and odor of secretions produced
For Endotracheal Tube Care
- Date and time of care
- Depth and position of the tube
- Appearance of the mouth, lips, and any other areas in contact with the tube, securing device, or tape
For Nasopharyngeal and Oropharyngeal Airway
- Date and time the airway was inserted
- Reason the airway was inserted
- Size of the airway
For Suctioning
- Date, time, and frequency of suctioning
- Breath sounds, heart rate, and oxygen saturation before and after suctioning
- Pre- and post-suctioning hyperoxygenation
- Amount, color, consistency, and odor of secretions
For Tracheostomy Care
- Date and time of care
- Respiratory assessment findings before and after care
- Appearance of the tracheostomy site and surrounding skin
- Type and size of the tracheostomy tube
- Amount, color, consistency, and odor of secretions
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