Which action would the nurse include when performing tracheostomy care on a client receiving mechanical ventilation? Select all that apply. One, some, or all responses may be correct.
Using hydrogen peroxide
Inserting a catheter without suction
Placing the client in the recumbent position
Rinsing the inner cannula with normal saline
Changing both tracheostomy ties at same time
Rinsing the inner cannula with normal saline
RATIONALE:
When removing the inner cannula, it must be rinsed with normal saline; hydrogen peroxide is only used if an infection is present. A catheter is inserted into the cannula when suctioning. The client would be placed in the semi-Fowler position. The nurse would change one tracheostomy tie at a time to ensure that the cannula stays in place.
Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct.
Suction the client before starting tracheostomy care.
Use sterile technique when cleaning the inner cannula.
Use sterile cotton-tipped swabs to clean the inner cannula.
Don sterile gloves before removing the inner cannula.
Use hydrogen peroxide to clean the skin around the stoma
Use sterile technique when cleaning the inner cannula.
Don sterile gloves before removing the inner cannula.
RATIONALE:
Sterile technique is used when cleaning the inner cannula to avoid transmitting microorganisms to the lungs. Sterile gloves are worn when removing the inner cannula. There is no need to suction the client before starting tracheostomy care, although the client may be preoxygenated before removing the inner cannula. A brush is used to clean the inner cannula. Hydrogen peroxide is used to clean secretions from the inner cannula, the cannula is rinsed
with normal saline. Because hydrogen peroxide can be irritating to tissue, normal saline is used to clean the skin around the tracheostomy stoma.
Which action by the nurse would best facilitate communication for a client with a partial laryngectomy and tracheostomy in the immediate postoperative period?
Provide a means for the client to write.
Allow time to lip read what the client says.
Deflate the cuff on the tracheostomy tube to allow verbalization.
Remind the client that speech is possible after partial laryngectomy.
Provide a means for the client to write.
RATIONALE:
After laryngeal surgery, the initial communication is through writing, use of picture boards, and computer applications. Lip reading is an option, but takes more time for the client and nurse and is likely to be frustrating to use. Deflation of the cuff in the immediate postoperative time would be
avoided because of the high risk for aspiration. Although ability to speak will be available with partial laryngectomy, the client currently is breathing through a tracheostomy and will not be able to speak.
The nurse is suctioning a client's tracheostomy. What is the correct order of nursing actions when performing this procedure?
1. Auscultate the lungs and check the heart rate.
2. Hyperoxygenate using 100% oxygen.
3. Prepare by turning suction on to between 80 and 120 mm Hg pressure.
4. Guide the catheter into the tracheostomy tube using a sterile-gloved hand.
5. Don sterile gloves
1, 3, 2, 5, 4
Auscultate the lungs and check the heart rate.
Prepare by turning suction on to between 80 and 120 mm Hg pressure.
Hyperoxygenate using 100% oxygen.
Don sterile gloves.
Guide the catheter into the tracheostomy tube using a sterile-gloved hand.
RATIONALE:
The
status of the client should be ascertained as a baseline before starting the procedure. The suction should be turned on to check its adequacy before beginning. Because oxygen will be lost during suctioning, the client should be oxygenated using 100% oxygen before initiating the procedure. Then the nurse should don sterile gloves to protect the client from infection and guide the catheter into the tracheostomy tube without using negative pressure.
To prevent potential aspiration, which technique would the nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula?
Apply precut dressing around the insertion site with the flaps pointing upward.
Replace the tube with a sterile obturator.
Use sterile cotton balls to cleanse the outer cannula.
Remove the cannula after the high-volume, low-pressure cuff has been deflated.
Apply precut dressing around the insertion site with the flaps pointing upward.
RATIONALE:
A precut dressing is used to prevent raveling and potential aspiration of small particles of the gauze into the airway. Only a precut dressing should be used around the site and should be positioned to collect expectorations. An obturator is used only for inserting the outer cannula. The use of sterile cotton balls to cleanse the outer cannula is contraindicated; cotton balls have small threads that may be inhaled. The status of the cuff has
no effect on tracheostomy care.
The nurse is caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. The plan of care for the tube would include which nursing intervention?
Verify that an inner cannula is in place.
Change the tracheostomy tube every week.
Clean the tracheostomy once a day.
Verify that a low-pressure cuff is in place.
Verify that a low-pressure cuff is in place.
RATIONALE:
A low-pressure cuff permits tidal volume to reach the lungs while preventing tracheal necrosis. The tracheostomy tube can be a single-lumen tube or can have inner and outer cannulas. A tracheostomy tube does not have to be changed weekly. The tracheostomy should be cleaned every 8 hours and whenever necessary.
A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. Which action would the nurse take?
Hold the tracheostomy open with a tracheal dilator and call for assistance.
Insert an obturator into the tracheostomy and gently reinsert the tracheostomy tube.
Pick up the tracheostomy tube from the bed and replace it until a new tube is available.
Obtain a new tracheostomy tube, prepare the new holder, and insert the tube using the obturator.
Hold the tracheostomy open with a tracheal dilator and call for assistance.
RATIONALE:
By holding the tracheostomy open with a tracheal dilator and calling for assistance, an immediate airway is provided without causing trauma; with assistance, a new tracheostomy tube can be inserted. The obturator will obstruct the airway. Replacing the tube that fell on the bed linen is contraindicated because it is contaminated; a sterile
tube should be inserted. If the airway is not held open, the client will experience hypoxia.
Which action will the nurse take to support safe oral intake after tracheostomy?
Include thin liquids.
Provide large meals.
Inflate the tracheostomy cuff fully.
Position client as upright as possible.
Position client as upright as possible.
RATIONALE:
After tracheostomy, positioning the
client as upright as possible supports safe eating by preventing aspiration. Thin liquids are more difficult to swallow and increase the risk for aspiration. Large meals may cause overdistention of the stomach and lead to regurgitation and aspiration; meals should be small and frequent. The tracheostomy cuff should be deflated to decrease interference with swallowing.
When the nurse is assessing a client after tracheostomy placement, which finding requires immediate action by the nurse?
Crackling of the skin on palpation
Small amount of blood at the surgical site
Client reports the area around incision is tender
The client is unable to speak with a cuffed tube
Crackling of the skin on palpation
RATIONALE:
Crackling of the skin on palpation indicates the presence of subcutaneous emphysema, which the nurse will immediately report to the health care provider. A small
amount of blood at the surgical site is expected and will be monitored for signs of hemorrhage. Tenderness after the surgical procedure would be expected. Inability of the client to speak with a cuffed tube is expected because airflow prevents use of the vocal cords.
Which finding in a client who has home oxygen therapy with a tracheostomy collar requires immediate action by the home health nurse?
Condensation in the tubing
Oxygen flow rate 9 L/min
Low fluid level in the humidifier
Scented candle burning in the room
Scented candle burning in the room
RATIONALE:
Oxygen itself is not combustible, but it supports combustion and fire can spread quickly in the presence of oxygen. The nurse will immediately put out the candle and reeducate the client and caregivers about the need to avoid any flame when oxygen is being used. Condensation in the tubing should be emptied but
does not present an immediate danger to the client. Oxygen flow rate for tracheostomy collars should be at least 10 L/min and the oxygen flow may need to be increased, but the higher priority would be to decrease fire risk. Water should be added to the humidifier, but this can be done after putting out the candle to decrease risk for fire.
Which nursing action is appropriate when suctioning the secretions of a client with a tracheostomy?
Use a new sterile catheter with each insertion.
Initiate suction as the catheter is being withdrawn.
Insert the catheter until the cough reflex is stimulated.
Remove the inner cannula before inserting the suction catheter.
Initiate suction as the catheter is being withdrawn.
RATIONALE:
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 sterility of the catheter can be maintained during one suctioning session; a new sterile catheter should be used for each new session of suctioning. A cough reflex may be absent or diminished in some clients; the catheter should be inserted approximately 12 cm (4-5 inches) or just past the end of the tracheostomy tube. The inner cannula is not removed during suctioning; it may be removed during tracheostomy care.
A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care?
Humidified oxygen is saturated with fluid.
The tracheostomy tube interferes with effective coughing.
The inner cannula of the tracheostomy tube irritates the mucosa.
The weaning process increases the amount of respiratory secretions.
The tracheostomy tube interferes with effective coughing.
RATIONALE:
Because the tracheostomy tube enters the trachea below the glottis, the client is unable to close the glottis to retain air in the lungs; this prevents an increase in the intrathoracic pressure and the ability to open the glottis to expel an explosive cough. Humidified oxygen decreases the need for suctioning because it liquefies secretions, which then are easier to expel. The outer, not inner,
cannula of a tracheostomy tube irritates the mucosa. Weaning begins when the respiratory status improves and the amount of respiratory secretions subsides.
A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. Which assessment by the nurse most readily detects this complication?
Palpating the neck or face
Evaluating the blood gases
Auscultating the lung fields
Reviewing the chest x-ray film
Palpating the neck or face
RATIONALE:
Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy, and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue. Gas exchange and thus blood gases are not affected. The lungs are not affected.
The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning?
Preoxygenate the client before suctioning.
Employ gentle suctioning as the catheter is being inserted.
Loosen the client's secretions before suctioning by instilling saline.
Ensure that the cuff of the tracheostomy is inflated during suctioning.
Preoxygenate the client before suctioning.
RATIONALE:
Administration
of 100% oxygen for a few minutes before suctioning reduces the risk of hypoxia, the major complication of suctioning. Suction is applied as the catheter is withdrawn, not during insertion, to prevent hypoxia. Tracheostomy cuffs are indicated when the client is on mechanical ventilation. Although a saline solution may be instilled into a tracheostomy, this practice is not recommended.
A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client?
Encouraging a fluid intake of 3 L daily
Suctioning via the tracheostomy every hour
Applying an occlusive dressing over the surgical site
Using cotton balls to cleanse the stoma with peroxide
Encouraging a fluid intake of 3 L daily
RATIONALE:
Increased fluids help liquefy secretions, enabling the client to clear
the respiratory tract by coughing. Suctioning frequently will irritate the mucosal lining of the respiratory tract, which can result in more secretions. An occlusive dressing will block air exchange; the tracheostomy is now the client's airway. The use of cotton balls around a tracheostomy introduces the risk of aspiration of one of the cotton fibers; gauze should be used.
The nurse is suctioning a client's airway. Which nursing action will limit hypoxia?
Limit suctioning with catheter to 30 seconds.
Apply suction only after the catheter is inserted.
Lubricate the catheter with saline before insertion.
Use a sterile suction catheter for each suctioning episode
Apply suction only after the catheter is inserted.
RATIONALE:
The negative pressure from suctioning removes oxygen and secretions; suction should be applied only after the catheter is inserted and is being
withdrawn. Limiting suctioning with the catheter to half a minute is too long; suctioning should be limited to 10 seconds. Lubrication will facilitate insertion and minimize trauma; it will not prevent hypoxia. The use of a sterile catheter helps prevent infection, not hypoxia.
Which nursing assessment supports a diagnosis of atelectasis in a postoperative client?
Productive cough
Clubbing of the fingertips
Low-pitched expiratory rhonchi
Diminished breath sounds on auscultation
Diminished breath sounds on auscultation
RATIONALE:
Atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Rhonchi are most commonly heard in clients with
infectious or inflammatory diagnoses such as pneumonia or chronic bronchitis.
Which action will the nurse take when a client's chest x-ray shows atelectasis?
Administer oxygen.
Suction the upper airway.
Position for postural drainage.
Encourage incentive spirometer use.
Encourage incentive spirometer use.
RATIONALE:
Atelectasis signifies alveolar collapse and indicates a need for
the client to take deep breaths that will expand the alveoli. Oxygen administration does not improve atelectasis. Suctioning is not indicated for atelectasis and is unnecessarily invasive and uncomfortable. Postural drainage is used to help clients clear airways of secretions, but would not help decrease atelectasis.
Which of the nurse's assigned clients may have atelectasis?
Client A:
Palpation - Decreased chest wall
movement
Percussion - Hyper-resonance
Auscultation - Wheezes
Client B:
Palpation - Increased vibrations over chest wall above effusion
Percussion - dull
Auscultation - Diminished or absent over effusion
Client C:
Palpation - Decreased fremitus
Percussion - Dull over affected area
Auscultation - Crackles
Client D:
Palpation - Increased fremitus over affected area
Percussion - Dull over affected area
Auscultation - Bronchial sounds
Client C
RATIONALE:
A client suffering from atelectasis may have decreased fremitus, dull percussion over the affected area, and crackling sounds upon auscultation like client C. Decreased chest wall movements, hyperresonance, and wheezing indicate asthma in client A. Client B with increased vibrations over the chest wall above effusion, dull percussion, and diminished or absent breath sounds over the affected area may have a pleural effusion. Client D with
increased fremitus over the affected area, dull percussion over the affected area, and bronchial sounds upon auscultation may have pneumonia.
Which clinical manifestation would the nurse expect when assessing a client with atelectasis?
Hyperresonance to percussion
Rhonchi and wheezes
Sudden onset shortness of breath
Crackles at the bases
Crackles at the bases
RATIONALE:
Atelectasis
involves collapsing of alveoli distal to the bronchioles, and fine crackles at the lung bases are typically heard as the alveoli expand with deep breathing. Dullness to percussion may occur with atelectasis because the alveoli are collapsed. Rhonchi and wheezes are associated with narrowing or obstruction of the larger airways, not with collapse of the alveoli. Atelectasis occurs more gradually when clients do not take deep breaths, and it is not sudden in onset.