Week 2: Managing Deteriorating Airway and Breathing Flashcards
What are possible causes of airway obstruction?
Foreign body Tongue Vomitus Oedema and inflammation (allergic reaction, infection or burns) Trauma Malignancy
What do you look for when assessing the airway?
Restless Flaring nostrils Choking Rise and fall of the chest -is it symmetrical? Use of accessory muscles Suprasternal retraction Colour Position of the trachea Count respirations
What do you listen for when assessing the airway?
Obvious noises:
stridor
gurgling
no sounds- complete obstruction?
Ausculate:
air entry
lung sounds
What do you palpate for when assessing the airway?
Trachea –is it in the midline
Any subcutaneous emphysema
Feel –percussion:
Dull or tympanic
SpO2
How do you manage an airway obstruction?
Positioning Removing a foreign body Head tilt and chin lift Suctioning Artificial airways: guedelsairway nasopharyngeal airway endotracheal tube
What is a tracheostomy?
Surgical opening into the trachea
What are the indications for a tracheostomy?
Bypass airway obstruction Trauma or surgery to upper airway Facilitate removal of secretions Permit long term mechanical ventilation Reduces risk of long term ETT’s: Increases patient comfort tube is more secure and patient mobility is increased
How are different tracheostomy tubes chosen?
Variety of tubes available on the market though all have similar components
Tube selection will be determined by Medical Officer and depends on the needs of patient
Tubes will either be cuffed or uncuffed
What are cuffed tracheostomy tubes?
Used if patient at risk of aspiration (swallow difficulties or requires mechanical ventilation
Inflated cuff exerts pressure on tracheal mucosa
Cuff pressure should not exceed 20 –25 mmHg
Can cause tracheal necrosis
Cuff can be air or foam
What is the indication for an uncuffed tracheostomy tube?
Uncuffed tubes are only used when patient can protect their own airway and does not require mechanical ventilation
What are possible tracheostomy emergencies?
Haemorrhage Tube dislodgement: decannulation, tube in subcut tissue Tube obstruction Infection Tracheomalacia Skin break down Tracheo-oespohageal fistula
How do you manage tracheostomy tube dislodgement?
Establish an airway:
Tracheal dilators
Insertion suction catheter
Keep a tube the same size and one size smaller at the bedside
How do you manage a tracheostomy tube obstruction?
Humidification
Suctioning
Cleaning inner tubes
How do you manage a tracheostomy infection?
Secretions sit on top of the cuff- need prevention:
Mouth care
Observe for signs of infection
How do you manage tracheomalacia?
Manage cuff pressures <25mmHg (minimal inflations pressures)
Keep tube in a neutral position and ensure there is no traction on the tube.
What is tracheomalacia?
The breakdown of the natural grid structure of the trachea that leads to a flaccid airway
What is an tracheo-oesophageal fistula?
Communication between the trachea and the oesophagus
What are the signs and symptoms of a tracheo-oesophageal fistula?
Copious secretions (often feeds)
Dyspnoea
Cuff leak and
Gastric distention
What are the aspects of care for a patient with a tracheostomy?
Respiratory assessment Suctioning Stoma care Cuff pressure monitoring Observation of secretions Monitoring for infection
What is a pneumothorax?
Air in the apex of the pleural space
What is a pleural effusion?
Fluid in the base of the pleural space
What are the causes of pneumothorax?
Spontaneous
Iatrogenic
Chest trauma
What is a spontaneous pneumothorax?
Rupture of a small bleb
May be associated with COPD, asthma, cystic fibrosis or pneumonia
What is an iatrongenic pneumothorax?
Post operative
Insertion of a central line
What are the types of chest trauma associated with pneumothorax?
Blunt
Penetrating
What are causes of blunt chest trauma?
Seatbelt
Assault
Crush
What are causes of penetrating chest trauma?
Gunshot
Knife
What are the clinical signs of pneumothorax?
Dyspnoea Hypoxia Cyanosis Tachycardia Cough Unequal air entry Decreased breath sounds Tympanic sound on percussion (apex) Subcutaneous emphysema Flail chest Bruising and abrasions Tracheal deviation
What are the clinical signs of a tension pneumothorax emergency?
Use of accessory muscles Hypoxia Cyanosis Unequal air entry Decreased breath sounds Tympanic sound on percussion (apex) Subcutaneous emphysema Tracheal deviation Hypotension Tachycardia Subcutaneous emphysema
What are the types of pleural effusion?
Haemothorax
Chylothorax
What is haemothorax?
Blood in the pleural space
What is chylothorax?
Lymph fluid in the pleural space
What are the clinical signs of pleural effusion?
Dyspnoea Use of accessory muscles Hypoxia Cyanosis Tachycardia Cough Unequal air entry Decreased breath sounds Dull sound on percussion (bases) Flail chest Bruising and abrasions
What is cardiac tamponade?
Blood collection in the pericardial sac that impeded myocardial filling reducing stroke volume:
Hypotension
Tachycardia
Increased JVP
What are chest drains?
Tube placed in the pleural space on underwater seal
What are the indications for chest drains?
Pneumothorax–air in the pleural space
Haemothorax–collection of blood in the pleural space
Pleural effusion –collection of fluid in the pleural space
Haemopneumothorax–air & blood in the pleural space
Chylothorax–chyle-lymphatic fluid in the pleural space
Post operatively following cardio-thoracic surgery
What are the components of a chest drain system?
1) “Catheter”
2) Tubing
3) “Underwater seal” drainage container
How do chest drains work?
Restore negative pressure to the pleural space because the drain is under a water seal and air can come out but not go back in
Allow drainage from the pleural space during expiration when there is positive pressure
The water acts as a one way valve
If there is a leak in the pleural space the application of suction can removes air from the pleural space faster than it can accumulate and helps to keep lung inflated
What is simple underwater seal drainage?
Being under water means there is a one way valve
Prevents the inflow of air because it is below the patient
Permits the outflow of air and fluid
What is the nursing management for a patient with a chest drain?
Monitor vital signs Assess for re-accumulation Analgesia Strict Fluid Balance Encourage deep breathing and coughing to assist with lung expansion Patient comfortable/sitting upright
How often does the patient with a chest drain need to be monitored?
Post insertion every 15 minutes for 1 hour
Half hourly for 2 hours
Hourly until the drain is removed
What drain-specific observations should be done for a patient with a chest drain?
Insertion site dressing/ clean & occlusive
Connections airtight & taped
Drain & tubing not kinked, not under tension
Drainage bottle below level of the patient
Fluid level/bellows in drainage bottle correct
Suction or Free Drainage? –check orders
Correct Suction-check orders
Why do nurses monitor the patient with a chest drain for fluid swing and bubbling?
Swing shows that the tube is patient
Loss of swing may indicate occlusion (kinks and loops) or blockage of the tube
If not resolved may lead to tension pneumothoraxor surgical emphysema
Bubbling:
Signifies that air is being removed from the pleural space
Seen during expiration or coughing
What is fluid swing in a chest drain?
Swing that occurs with changes in pleural pressure during inspiration and expiration
What chest drain issues should be reported immediately?
unexplained change in patients clinical state
respiratory distress/ change in respiratory rate
reduced oxygen saturation
increased air loss
increased drainage, especially if blood
changes in general observations or trends
development of surgical emphysema
What are common mistakes with chest drains?
CLAMPING OF DRAINS -basic rule is never unless specifically ordered or only momentarily to change drainage bottle. Check instrument is a “clamp” and not a pair of scissors!
No “MILKING”
No ELEVATION OF DRAINAGE BOTTLE ABOVE PATIENT –never!
ENSURE NOT A “CLOSED SYSTEM” –equivalent to clamping!
LOW OR HIGH SUCTION? Know the difference!
How is a chest drain removed?
2 person maneuver: patient to take a breath and hold it and/or perform Valsalva maneuver or re-accumulation can occur
One person takes out drain, other pulls on purse string suture, then dressing put over the top
Why is a cuffed tracheostomy tube used?
If patient is at risk of aspiration (swallowing difficulties or mechanical ventilation)
What is maximum cuff pressure for a tracheostomy and why?
20 mmHg
Higher can cause compress capillaries in trachea and cause tracheal necrosis
What can be done to help a patient with a tracheostomy speak?
Cuffless tube or deflated fenestrated cuff: allows air to pass over vocal cords
Enhanced by blocking tracheostomy tube
Must be able to swallow without aspiration in order to speak with a tracheostomy tube
What are the priorities of care for a tracheostomy?
Remove dried secretions and prevent build up
Reduce infection around insertion site and migration to lower airway
Prevent skin break down at stoma site
Manage secretions
What nursing management for a patient with a tracheostomy needs to be performed during a shift?
Check suctioning equipment
Check when inner cannula was last cleaned
Assess sputum
Routine tracheostomy care: assessment, suctioning, exercises, inner cannula cleaning
Check emergency equipment available at bedside
Check oxygen available and functioning
Check cuff pressure
Call bell
What do you do if a tracheostomy becomes dislodged?
Call for assistance or arrest immediately
Attempt to replace tube
Use obturator, smaller tube, dilators or suction catheter (gloved fingers if emergency)
What are the indications for suctioning?
Inability to cough and clear secretions
Inability to maintain patent airway due to vomit, blood or sputum
Sudden respiratory distress
Secretion specimen for diagnosis
What pre-suctioning assessment and management should be performed for a patient with a tracheostomy?
Respiratory assessment: auscultate for lower or upper airway obstruction, audible secretions. Coughing without clearing airway. Assess sputum colour and consistency
Obs before and after
Pre-oxygenation
What emergency tracheostomy equipment should be kept at the bedside?
Tracheal dilators Tracheostomy tube (same size as patient) Tracheostomy tube (one size smaller than patient)
What equipment is required to suction a tracheostomy?
Emergency equipment available at bedside Suctioning apparatus and tubing Suction catheter: half internal diameter of tracheostomy Sterile glove Face shield Non-sterile gloves Bluey Yankauer sucker
What are the complications of tracheostomy suctioning?
Hypoxia/hypoxaemia
Tissue trauma to tracheal/bronchial mucosa
Bronchoconstriction/spasm
Lower airway infection
Atelectasis
Cardiac dysrhythmias (bradycardia from vagus nerve stimulation)
Hyper or hypotension
Change sin cerebral blood flow and increased ICP
What is the post-suctioning care for a person with a tracheostomy?
Return oxygen to prior setting, unless SpO2 below 95%
Respiratory assessment to evaluate intervention
Haemodynamic monitoring
ICP monitoring
Humidification device
Document: time, amount and character of secretions, and response to suctioning
How can you prevent secretions from drying?
Humidification
Adequate fluid intake
Suction
Why are dried secretions an issue?
Can block cannula and cause respiratory distress
How frequently does an inner cannula need to be cleaned?
2-4 hours
