Lab 5 Flashcards
(108 cards)
1
Q
when is suctioning necessary
A
- when a pt in unable to clear respiratory tract secretions w coughing
2
Q
suctioning techniques include.. (5)
A
- oropharyngeal suctioning
- nasopharyngeal suctioning
- orotracheal suctioning
- nasotracheal suctioning
- suctioning of an artifical airway
3
Q
what common principle is used with suctioning
A
- sterile technique (bc the trachea is considered sterile)
4
Q
describe the order of suctioning
A
- suctioning of oral secretions should be performed after suctioning of the oropharynx and trachea
(trachea = sterile, mouth = clean)
5
Q
what is the frequency of suctioning determined by? why?
A
- pt assessment and need
ex. if secretions are identified by inspection or auscultation, then suctioning is required - sputum is not continuously or every 1-2 hrs, there is no rationale for routine suctioning of all pts every 1-2 hrs
6
Q
what negative outcome might suctioning cause? what clinical indication does this have?
A
- suctioning reduces the amt of available dead space in the oropharynx and trachea, often resulting in signif desaturation
= monitor the pt to ensure adequate oxugenation
7
Q
what are other negative effects of suctioning (4)
A
- hypoxemia
- hypotension
- arrhythmias
- possible trauma to the mucosa of the lungs
8
Q
what is the oropharynx
A
- extends behind the mouth from the soft palate above the level of the hyoid bone and contains the tonsils
9
Q
where is the nasopharynx located
A
- located behind the nose and extends to the lvl of the soft palate
10
Q
when is oropharyngeal or nasopharyngeal suctioning used
A
- when the pt is able to cough effectively but is unable to clear secretions by expectorating or swallowing
- used after the pt has coughed
11
Q
when is orotracheal and nasotracheal suctioning necessary
A
- when the pt w pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway
12
Q
describe how orotracheal and nasotracheal suctioning is done; which is the preferred route and why?
A
- a catheter is passed thru the mouth or nose into the trachea
- procedure is similar to nasopharyngeal suctioning but the catheter tip is moved farther into the pt’s trachea
- preferred route = nose, bc stimulation of the gag reflex is minimal
13
Q
describe the length of duration of orotracheal and nasotracheal suctioning; unless in resp distress the pt should be allowed to ….
A
- the entire procedure from catheter passage to its removal should be done quickly –> no more than 10 sec
- pt should be allowed to rest between passes of the catheter , with replacement of the oxygen cannula or mask (if the pt is using supplemental o2) during rest preiods
14
Q
how is tracheal suctioning accomplished
A
- thru an artifical airway, such as endotracheal or tracheostomy tube
15
Q
describe the size of the suction catheter for tracheal suctioning
A
- should be no greater than one-half the size of the internal diameter of the artifical airway
16
Q
how can we avoid trauma w tracheal suctioning (3)
A
- never apply suction pressure while inserting the catheter
- maintain suction less than 150 mmHg in adults
- apply suction intermittently only as the catheter is withdrawn
17
Q
rotating the catheter w tracheal suctioning will…
A
- enhance removal of secretions that have adhered to the sides of the endotracheal tube
18
Q
what should you wear w tracheal suctioning? why>
A
- mask
- goggles
- barrier gown
–> to prevent splashes w body fluids
19
Q
describe the practice of normal saline instillation..
A
- the practice of NSI into artifical airways to improve secretion may be harmful and is not recommended
- clinical studies comparing suctioning after NSI w standard suctioning have not demonstrated any clinical or signif results
20
Q
what are the 2 current methods of tracheal suctioning
A
- open
- closed
21
Q
describe open tracheal suctioning (2)
A
- involves a sterile catheter that is opened at the time of suctioning
- sterile gloves are worn to perform the suction procedure
22
Q
who is closed suctioning used for? why?
A
- often used on pts who require mechanical ventilation to support their respiratory efforts, bc it permits continuous delivery of oxygen while suction is performed = reduced risk of oxygen desaturation
23
Q
are sterile gloves required for tracheal suctioning
A
- no, but at least nonsterile (disposable) gloves are recommended to prevent contact w splashes of body fluids
24
Q
when is an artifical airway indicated
A
- for pts w a decreased lvl of consciousness or an airway obstruction
- to aid in the removal of tracheobronchial secretions
25
what is the oral airway
- the simplest and least invasive type of artifical airway
- prevents obstruction of the trachea by displacement of the tongue into the oropharynx
- extends from the teeth to the oropharynx, maintaining the tongue in the normal position
26
when is an oral pharyngeal airway used
- for emergency situations
27
how is proper oral airway size determined
- by measuring the distance from the corner of the mouth, to the angle of the jaw just below the ear
- the length is equal to the distance from the flange of the airway to the tip
28
why is proper airway size important w an oral airway (2)
- if the airway is too small = tongue is not held in the anterior portion of the mouth
- if the airway is too large = it may force the tongue toward the epiglottis and obstruct the airway
29
how is an oral airway inserted
- by turning the curve of the airway toward the cheek and placing it over the tongue
- when the airway is in the oropharynx, turn is so the opening points downwards
- when correctly placed, the airway moves the tongue forward away from the oropharynx & the flange (the flat portion of the airway) rests against the pts teeth
30
what does incorrect insertion of the oral airway cause?
- forces the tongue back into the oropharynx
31
what risk is associated w the insertion of an artifical airway (1)? how can this be prevented (2)
- places the pt at high risk for infection and airway injury
- prevented by using sterile technique in caring for and maintaining an artifical airway to help prevent health care-associated infection
- artifical airways need to be cared for and maintained in the correct position to prevent airway damage
32
what are endotracheal tubes used for ? (5)
- short-term artificial airways
- administer mechanical ventilation
- relieve upper airway obstruction
- protect against aspiration
- clear secretions
33
who can insert ET tubes
- only HCP with special training
34
how long are ET tubes generally in place for (3)
- short-term
- generally removed within 14 days
- may be used for a longer period of time if the pt is showing progress toward weaning from mechanical ventilation and extubation
35
if the pt requires long-term assistance from an artifical airway, what is considered?
- a tracheostomy
36
what is a tracheostomy used for (3)
- to by-pass upper airway obstruction
- used for removal of secretions
- allow for long term mechanical ventilation
37
describe how a tracheostomy is inserted
- a surgical incision is made into the trachea and a short artificial airway is inserted
38
what is sleep apnea
- a disorder in which people stop breathing for a period of at least 10 seconds while asleep
39
what are 2 types of sleep apnea
- obstructive sleep apnea (OSA)
| - central sleep apnea
40
what is OSA
- most common form of sleep apnea
| - results from an obstruction of the upper airway
41
what is central sleep apnea
- represents a loss of inspiratory effort due to an underlying pathological condition
42
what are risk factors for developing OSA (9)
- age
- obesity
- gender
- ethnicity
- smoking
- alcohol
- positive family history
- more common in asians than caucasians
- may affect middle-aged men more frequently
- most commonly in postmenopausal women , younger women, children
43
what are the most common complaints of individuals w OSA
- excessive daytime sleepiness and fatigue --> daytime naps, disruption in their daily activities bc of sleepiness
44
when are feelings of sleepiness usually most intense for an individual w OSA
- most intense when waking up just after falling alseep
| - 12 hours after the mid-sleep period
45
what are other symptoms of OSA, in addition to excessive daytime sleepiness (8)
- fatigue
- morning headaches
- choking or gasping upon awakening
- irritability
- depression
- difficulty concentrating
- decreased sex drive
- snoring
46
OSA occurs when..
- the muscles or structures of the oral cavity or throat relax during sleep
- the upper airway becomes partially or completely blocked = diminishing the nasal airflow (hypopnea) or stopping it (apnea) for as long as 10-30 seconds
47
apneic episodes are normally terminated by....
- gasps
- snoring
- or brief periods of awakening
48
which structural abnormalities predispose an individual to OSA (4)
- deviated septum
- nasal polyps
- certain jaw configuration
- enlarged tonsils
49
OSA causes...
- a serious decline in the saturation lvl of arterial oxygen
50
individuals w OSA are at risk for... (7)
- cardiac dysrhytmias
- heart failure
- pulmonary HTN
- angina
- stroke
- HTN
- metabolic syndrome
51
what is included in treatment for OSA
- continuous positive airway pressure (CPAP)
52
describe CPAP
- consists of a mask that fits over the nose and mouth thru which air is continuously delivered into the airway to assist in keeping it open during sleep
53
airway obstruction may be..
- complete --> medical emergency
| - partial
54
what may cause partial airway obstruction (6)
- result of aspiration of food
- foreign body
- laryngeal edema following extubation
- laryngeal or tracheal stenosis
- CNS depression
- allergic reactions
55
what are symptoms of airway obstruction
- stridor
- use of accessory muscles
- suprasternal and intercostal retractions
- wheezing
- restlessness
- tachycardia
- cyanosis
56
what is important w partial airway obstruction? why?
- prompt assessment and treatment --> may quickly progress to complete obstruction
57
what are some interventions to re-establish a patent airway (4)
- obstructed airway (Heimlich) manoeuvre
- cricothyroidotomy
- endotracheal intubation
- tracheostomy
58
what is a tracheostomy (2)
- a surgical incision into the trachea for th epurpose of establishing an airway
- an artifical airway that is inserted into the trachea during a tracheostomy
59
what are indications for a tracheostomy
- to bypass an upper airway obstruction
- facilitate removal of secretions
- permit long-term mechanical ventilation
- permit oral intake and speech in the pt who require mechanical ventilation
60
most pts who require mechanical ventilation are initially managed w...
- an endotracheal tube, which can be quickly inserted in an emergency
61
a tracheostomy may be performed for pts requiring intubation longer than..
- 7 to 10 days when an airway is obstructed due to trauma, tumours, or swelling
62
how is a tracheostomy tube usually inserted?
- by an open procedure in the operating room
| - can also be inserted emergently in a percutaneous procedure at the bedside
63
what advantages make a tracheostomy a better option than an ETT for long-term nursing management and weaning from the ventilator (3)
- increased pt comfort and mobility (without a tube in the mouth)
- risk for long-term damage to the vocal cords is decreased
- pt is able to eat and talk w a tracheostomy bc it enters lower in the airway
64
what should be kept at the bedside for pts w a tracheostomy and why
- a spare tracheotomy set & a obturator and tracheal dilator in the event of accidental decannulation
- ideally taped at the head of the bed
65
what should be taught to the pt prior to tracheotomy procedure (3)
- nurse should explain to the pt and caregivers the purpose of the procedure
- inform the pt that they will not be able to speak while an inflated cuff is used
- a number of complications can occur w tracheostomies
66
care of the pt w tracheostomy involves.. (4)
- suctioning the airway to remove secretions
- cleaning around the stoma
- changing tracheostomy ties
- if an inner canula is used, inner cannula care
67
what are 2 types of tracheostomy tubes
- cuffed
| - uncuffed
68
when is a cuffed tracheostomy used
- if the pt is at risk for aspiration or needs mechanical ventilation
69
what is an important consideration w a cuffed tracheostomy (2)
- no air above the cuff can get through, only thru the air opening = tube cannot be blocked, otherwise the pt has no other way to get air
- pt cannot talk, bc air doesnt pass thru the vocal chords
70
describe cuff inflation w a cuffed tracheostomy (3)
- bc an inflated cuff exerts pressure on tracheal mucosa, is it important to inflate the cuff w the minimum volume of air required to obtain an airway seal
- should not exceed 20 mmHg or 25 cm H2O bc higher pressure may compress tracheal capillaries, limit blood flow, and predispose to tracheal necrosis
- minimal leak technique
71
what happens if the cuff is overinflated? under?
- over = irritate and erosion of tissue
| - under = allows secretion from stomach regurgitation into lungs, risk of aspiration
72
describe the minimal leak technique
- involves inflating the cuff within the minimum amount of air to obtain a seal and then withdrawing 0.1 mL of air
73
what does cuff up mean? cuff down?
- cuff up = cuff inflated, only flow of air thru opening , used when pt is more sick and in early stages of recovery
- cuff down = still have cuffed trach, but is deflated for few hours to trial
74
what is an endotracheal naometer
- shows cuff pressure
| - want to be in green/20-25 mmHg
75
what are disadvantages of MLT (2)
- risk of aspiration from secretions leaking around the cuff
- difficulty maintaining positive end-expiratory pressure
76
with some patients, why might cuff deflation be performed
- to remove secretions that accumulate above the cuffq
77
describe the process of cuff deflation (4)
- before deflation, the pt should cough up secretions and the tracheostomy tube & mouth should be suctioned (to prevent secretions from being aspirated during deflation)
- the cuff is deflated during exhalation (bc exhaled gas helps propel secretions into the mouth)
- pt should cough or be suctioned after cuff deflation
- cuff reinflated during inspiration
78
when should a cuffless tracheostomy tube be used
- when the pt can protect the airway from aspiration and does not require mechnical ventilation
79
what are often placed when a tracheotomy is performed
- retention sutures in the tracheal cartilage with the free ends taped to the skin in a place and manner that leaves them accessible if the tube becomes dislodged
80
care should be taken not to dislodge the tracheostomy tube during the first few days when the stoma is not mature (healed). because tube replacement can be difficult, what precautions are required? (3)
- a replacement tube of equal or smaller size is kept at the bedside
- tracheotsomy tapes are not changed for at least 24 hrs after the insertion procedure
- the first tube change is performed by a physician, usually no sooner than 7 days after the tracheotomy
81
what is done if accidental decannulation occurs?
- if present, the retention sutures are grasped and the opening is spread w a tracheal dilator or hemostat
- the replacement tube is guided in, using the obturator
- to permit airflow, the obturator is immediately removed once the tube is inserted
OR
- insert a suction catheter to allow passage of air
- a new tube is threaded over the catheter, followed by removal of the suction catheter
- if the tube cannot be replaced, the lvl of resp distress is assessed
82
after the first tracheostomy tube is changed, how often should it be changed?
- once a month
83
what are 6 potential tracheostomy complications
- abnormal bleeding
- tube dislodgement
- obstructed tube
- subcutaneous emphysema
- tracheo-esophageal fistula
- tracheal stenosis
84
what can cause abnormal bleeding w a tracheostomy (2)
- surgical intervention
| - erosion or rupture of blood vessel, or both
85
describe nursing management for abnormal bleeding w a tracheostomy (2)
- monitor bleeding
| - notify physician if it continues or is excessive
86
what can cause tube dislodgement w a tracheostomy (2)
- excessive manipulation
| - excesive suctioning
87
describe nursing management for tube dislodgment (2)
- ensure ties are secure
| - keep obturator, hemostate, and new tracheostomy tube at bedside
88
what can cause an obstructed tracheostomy tube
- dried or excessive secretions
89
describe nursing management for an obstructed tube (5)
- assess pt's resp status
- suction as necessary
- maintain humidification
- perform tracheostomy care
- ensure adequate hydration
90
what can cause subcutaneous emphysema
- air escapes from the incision to the subcut tissue
91
describe nursing management for subcut emphysema (2)
- monitor for
| - reassure pt and family
92
what can cause a tracheo-esophageal fistual
- tracheal wall necrosis
93
describe nursing management for tracheo-esophageal fistula (2)
- monitor cuff pressure
| - monitor pt for coughing & choking while eating or drinking
94
what can cause tracheal stenosis
- narrowing of tracheal lumen owing to scarring caused by tracheal irritation
95
describe nursing management for tracheal stenosis (3)
- monitor cuff pressure
- ensure prompt treatment of infections
- ensure ties are secure
96
what may compromise a pt's airway? (10)
- obstruction
- epiglottitis
- croup
- foreign object
- excessive blood or sputum
- decreased LOC
- head injury
- neuro issues
- weak cough & gag reflex
- CNS depression
97
what is the difference between airway protection and patency
- patency = airway open, no obstruction
| - protection = intact cough, gag, swallowing fnxn, can the pt prevent aspiration
98
how long is an endotracheal tube left in place
- no more than 2 weeks
99
what are some bedside equipment for pts w a trach for safety (11)
- suction
- humidifer (air thru the opening is not humidified by the nose)
- extra trach tube (in case needs to be replaced)
- inner cannula
- trach ties
- suction catheter
- trach dilator
- yonker suction
- NS and sterile water
- cotton tipped applicators
- dressings
100
what can no humidifying of the air cause
- mucus plug = can plug tubing, hypoxia, etc,
101
describe the purpose of an inner cannula
- safety feature that sits inside the trach tube and collects secretions
- replaced easily compared to trach tube so if any signs of obstruction, change/check inner cannula
102
what is the purpose of trach ties? what is an important consideration w them?
- holds the trach in place
| - change PRN to avoid pressure sores
103
how is the suction catheter size determined
(trach tube size - 2) x 2
104
what should the suction pressure be at
80-100 mmHg
105
what is the purpose of a trach dilator
- holds skin open if case of accidental decannulation
106
when should we suction our patients? (8)
- increased resp rate
- adventitious sounds
- nasal secretions
- drooling
- gurgling
- gastric secretions or vomitus in the mouth
- loose, nonproductive cough
- tactile fremitus
107
what is the importance of a trach mask
- sits over trach and is connected to the o2 and humidifier
| = if it is not on, there will be no humidificaction or oxygenation = risk of mucus plug & deoxygenation
108
what should always be hooked on during trach care
- O2 sat
