Nursing Suctioning Safety

• Suctioning should be limited to 10-15 seconds to prevent alveolar collapse.
• Estimate the suctioning time by holding your breath and counting to 10 or 15.
• Each catheter pass introduces bacteria into the trachea, so infection is a risk.
• Use sterile technique for suctioning and all equipment in the hospital to prevent infection.
• Clean the mouth or nose after suctioning the artificial airway; clean technique is acceptable at home.

Nursing Safety Priority: Suctioning

• Never use oral suction equipment for suctioning an artificial airway to avoid introducing oral bacteria into the lungs, which elevates the risk for infection.
• Vagal stimulation during suctioning can lead to bradycardia, hypotension, heart block, ventricular tachycardia, or other dysrhythmias.
• If vagal stimulation occurs, stop suctioning immediately and manually oxygenate the patient with 100% oxygen.
• The patient may require a bronchodilator to relieve bronchospasm and respiratory distress if bronchospasm occurs when the catheter passes into the airway.
• Monitor cardiac rhythm during suctioning if the patient has cardiac monitoring in place, as hypoxia caused by suctioning can induce dysrhythmias.

Providing Bronchial and Oral Hygiene

• Bronchial hygiene promotes a patent airway and prevents infection.
• Turn and reposition the patient every 1 to 2 hours, support out-of-bed activities, and encourage ambulation to promote lung expansion, gas exchange, and secretion removal.
• Pulmonary hygiene includes coughing, deep breathing, chest percussion, vibration, and postural drainage.
• Good oral hygiene keeps the airway patent, prevents infection from bacterial overgrowth, and promotes comfort.
• Avoid using glycerin swabs or alcohol-containing mouthwash for oral care as they dry the mouth, change its pH, and promote bacterial growth.
• Use a sponge tooth cleaner or soft-bristle toothbrush moistened in water for mouth care.
• Diluted hydrogen peroxide solutions can help remove crusted matter but should be used only if ordered because they can break down healing tissue.
• Chlorhexidine oral rinse can prevent infection in patients requiring mechanical ventilation, helping to decrease the incidence of ventilator-associated pneumonia (VAP).
• Rinse the patient's mouth with normal saline every 4 hours while awake, or as often as desired.
• Assess the mouth for reduced tissue integrity; ulcers and infection are treated medically.
• Apply lip balm or water-soluble jelly to prevent cracked lips and promote comfort.
• Mouth care promotes oral health and comfort, and letting the patient or family perform mouth care increases self-esteem.
• Some artificial airway tubes have an extra lumen to suction secretions above the cuff before deflation, that reduces the risk for aspiration.

Nursing Safety Priority: Oral Care

• Oral care is crucial for all individuals, as poor oral hygiene is associated with systemic inflammation, periodontal disease, tooth loss, pneumonia, bacteremia, pregnancy complications, and even cancer.
• Poor oral hygiene may also be a risk factor for severe COVID-19.
• Patients predisposed to altered biofilms include those with diabetes mellitus, hypertension, or cardiovascular disease.

Systems Thinking/Quality Improvement: Oral Care Protocol

• A nurse-driven oral care protocol can reduce hospital-acquired pneumonia.
• A standardized, evidence-based oral care protocol for hospitalized adults can be implemented.
• The level of oral care needed is determined by whether patients are mechanically ventilated, at-risk, or short-term care.
• Nurses reviewed patient education information handouts, and received training on the new oral protocol.
• A statistically significant decrease in nonventilator hospital-acquired pneumonia (NV-HAP) and mortality from NV-HAP occurred in the intervention group.
• Fewer ventilator-associated events (VAEs) and ventilator-associated pneumonias (VAPs) also occurred in the intervention group.
• Nursing adherence to the new oral care protocol ranged from 36% to 100% monthly but averaged 76%.
• The Ql project reduced overall hospital costs, length of stay, and patient mortality.
• Limitations included difficulty confirming pneumonia and oral care adherence rates and less detailed gap analysis.
• Risks of human error exist in data collection due to reliance on documentation and individual chart review.
• Healthcare organizations should track NV-HAP as a nursing quality indicator and propose automated or regularly managed data tracking methods.
• Further research is needed to standardize effective oral care protocols, that includes oral health assessments.

Coordination and Transition Management

• Before discharge, the patient should be able to provide tracheostomy self-care, nutrition, suctioning, and communication.
• Self-care teaching begins before surgery and taught in the hospital.
• Teach the patient and family member how to care for the tracheostomy tube, review airway cleaning, infection signs, tissue loss, and clean suction technique.
• Instruct the patient to use a shower shield over the tracheostomy tube when bathing.
• Advise the patient to loosely cover the airway with a small cloth during the day to protect it.
• Teach the patient how to increase humidity in the home.
• Patients with a tracheostomy should wear a medical alert bracelet in case they cannot speak.
• The interprofessional health care team assesses specific discharge needs and makes referrals to home care agencies, DME companies, and follow-up care.

Older Adult Health: Tracheostomy and Oxygen Therapy

• Older adults with vision or upper arm movement problems may struggle with tracheostomy care and oxygen management.
• Ensure the patient uses magnifying lenses or glasses to see the oxygen gauge settings.
• Assess the patient's ability to reach and manipulate the tracheostomy, and involve a family member if possible.

Chest Trauma

• Chest trauma accounts for about 25% of traumatic deaths in the United States.
• Many injured die before reaching the hospital.
• Most chest injuries can be treated with basic resuscitation, intubation, or chest tube placement.
• The first emergency approach follows the ABCDE trauma resuscitation approach.

Pulmonary Contusion

• Pulmonary contusion is a common and potentially fatal injury caused by rapid deceleration, often during car crashes.
• Respiratory failure can develop immediately or over time after a contusion.
• Hemorrhage and edema reduce lung movement and the area available for gas exchange, causing hypoxemia and dyspnea.
• Patients may be asymptomatic initially, developing respiratory failure and pneumonia later.
• Symptoms include decreased breath sounds, crackles, wheezes, bruising, dry cough, tachycardia, tachypnea, and dullness to percussion.
• Management includes ventilation, oxygenation, IV fluids, and placing the patient in a moderate-Fowler's position.
• A high-flow nasal cannula (HFNC) may be needed, and side-lying with the "good lung down" can be helpful.
• A vicious cycle can occur where more muscle effort is needed for ventilation, causing hypoxemia and fatigue.
• The patient may need noninvasive or invasive positive-pressure ventilation.

Rib Fracture

• Rib fractures are a common injury from blunt chest trauma.
• The force of the fractures can cause deep chest injury like pulmonary contusion, pneumothorax, and hemothorax.
• The patient experiences pain on movement and splints the chest defensively, reducing breathing depth and secretion clearance.
• Those with preexisting lung disease are more at risk for atelectasis and pneumonia.
• Serious indicators are injuries to the first or second ribs, flail chest, seven or more fractures, or expired volumes of less than 15 mL/kg, indicates a deep chest injury and poor prognosis.
• Management focuses on decreasing pain for adequate ventilation because fractured ribs reunite spontaneously.
• Intercostal nerve blocks for severe pain, opioids for coughing and effective spirometry use NSAIDs, epidural anesthesia, and PCA are other options.

Flail Chest

• Flail chest results from fractures of three or more adjacent ribs in two or more places, causing paradoxical chest wall movement.
• It usually involves one side of the chest, and often results from high-speed car crashes.
• Assess for other possible underlying injuries because the force required is great.
• Gas exchange, coughing, and clearance of secretions are impaired.

Assessment of Flail Chest

• Assess for paradoxical chest movement, dyspnea, cyanosis, tachycardia, and hypotension.
• Patients are often anxious, short of breath, and in pain.
• Work of breathing is increased from the paradoxical movement.

Interventions for Flail Chest

• Interventions include humidified oxygen, pain management, promotion of lung expansion through deep breathing and positioning, and secretion clearance by coughing and tracheal suction.
• Mechanical ventilation is needed if respiratory failure or shock occur.
• Monitor ABG values and vital capacity closely.
• Stabilize flail chest by positive-pressure ventilation, surgical stabilization is used only in extreme cases.
• Monitor vital signs, and fluid/electrolyte balance, provide oxygen and IV fluids as prescribed, relieve pain with analgesics, and provide psychosocial support.

Pneumothorax and Hemothorax

• A pneumothorax is air in the pleural space causing a loss of negative pressure, lung collapse, and a reduction in vital capacity.
• A hemothorax is blood in the chest cavity.
• A simple hemothorax is a blood loss of less than 500 mL; a massive hemothorax is more than 1000 mL.
• A pneumothorax can be open, when cavity is exposed to outside air, or closed:
• A tension pneumothorax is life-threatening where air enters during inspiration and does not exit during expiration, which limits blood return. Therefore decreasing cardiac output.

Assessment of Pneumothorax

• Chest pain.
• Shortness of breath.
• Tachypnea.
• Hypoxia.
• Reduced or absent breath sounds on the affected side.
• Hyperresonance on percussion on the affected side.
• Asymmetric lung expansion with the affected side moving poorly.
• Severely tracheal deviation from midline.

Assessment of Tension Pneumothorax

• Extreme respiratory distress and cyanosis.
• Distended neck veins.
• Tachycardia.
• Hemodynamic instability.
• Respiratory failure.
• Hemothorax percussion produces a dull sound.
• Diagnosis occurs primarily with chest x-rays, CT scans, or ultrasonography.
• Mild symptoms with a stable patient and small pneumothorax may need no treatment.
• Chest tube therapy is essential for more severe pneumothorax or hemothorax.
• Tension pneumothorax is an emergency requiring needle decompression into the second intercostal space in the midclavicular line on the affected side.
• Definitive treatment involves chest tube placement into the fourth intercostal space connected to a water-seal drainage system.
• Interventions include chest tube placement to remove blood, monitoring drainage, serial chest x-rays to determine treatment effectiveness, pain control, pulmonary hygiene, and respiratory failure assessment.
• An open thoracotomy is needed when there is initial blood loss of 1000 ml or persistent bleeding at the rate of 150 to 200 ml/hr over 3 to 4 hours.
• Assess the patient's response to the chest tubes, and infuse IV fluids and blood as ordered.

Nursing interventions

• Teach tracheostomy care and safe oxygen use.
• Identify pulmonary embolism risk factors.
• Identify COVID-19 risks.
• Teach VTE prevention.
• Teach how to prevent injury when taking drugs that reduce clotting.
• Minimize aerosolization in COVID-19.
• Ensure patients and caregivers know who to contact about supplies.
• Good oral hygiene keeps the airway patent, prevents infection, and promotes comfort.
• Use aspiration precautions for any patient with an altered LOC, poor gag reflex, or neurologic impairment.

Chronic conditions

• Ensure long-term mechanically ventilated patients change position every 2 hours to mobilize secretions and prevent skin breakdown.
• Psychological concerns, cuffless tube use, fenestrated tube issues, and swallowing difficulties after tracheostomy all require attention.
• Patient aspiration prevention techniques.
• Interprofessional collaboration is essential, allowing expression of feelings about intubation and mechanical ventilation, and encouraging visual communication.
• Older patients are at higher risk for ventilator dependence and failure to wean.
• Palliative care consults can help families cope and facilitate symptoms.