N4581 Nursing of Adults with Complex Needs

1. What do the ABGs indicate? 2. What treatment would you anticipate? Arterial Blood Gases pH 7.25 PaCO2 64 mm Hg HCO3 20 mm Hg Arterial Oxygen Saturation (SaO2) 88% Airway and Chest Tube Management 1. What do the ABGs indicate? 2. What treatment would you anticipate? Arterial Blood Gases pH 7.25 PaCO2 64 mm Hg HCO3 20 mm Hg Arterial Oxygen Saturation (SaO2) 88% Resp failure is present. Resp failure occurs when retained CO2 causes resp acidosis (↓ pH) and/or there is hypoxemia. Airway and Chest Tube Management 1. What do the ABGs indicate? 2. What treatment would you anticipate? Arterial Blood Gases pH 7.25 PaCO2 64 mm Hg HCO3 20 mm Hg Arterial Oxygen Saturation (SaO2) 88% Resp failure is present. Resp failure occurs when retained CO2 causes resp acidosis (↓ pH) and/or there is hypoxemia. Respiratory support with CPAP or intubation and mechanical ventilation. Airway and Chest Tube Management CPAP Purpose: the machine exerts positive pressure throughout respiratory cycle to help keep alveoli open (doesn’t allow airway/alveoli to collapse). Advantages: delivered noninvasively - may prevent intubation. Keeping the alveoli open allows for a longer time for gas exchange. Disadvantages: Increases WOB  patient must exhale forcibly against CPAP  use cautiously with patients with myocardial conditions! Airway and Chest Tube Management Airway and Chest Tube Management Airway and Chest Tube Management A patient is being emergently intubated by the critical care physician. Which action would best assure the nurse of proper positioning of an endotracheal tube? A. Listen for bilateral breath sounds. B. Check for bilateral chest expansion. C. Listen for air over the stomach. D. Check to see whether mucus can be aspirated during suctioning of the tube. Airway and Chest Tube Management A patient is being emergently intubated by the critical care physician. Which action would best assure the nurse of proper positioning of an endotracheal tube? A. Listen for bilateral breath sounds. B. Check for bilateral chest expansion. C. Listen for air over the stomach. D. Check to see whether mucus can be aspirated during suctioning of the tube. • Answer = A • The best bedside indication of proper position of an endotracheal tube is bilateral breath sounds. Bilateral breath sounds should be heard prior to inflation of the endotracheal balloon. Chest x-ray film will also be used to ensure that the tip of the tube is 3 to 5 cm above the carina; it may take some time for bedside x-ray to be performed. As breath sounds are auscultated, assess for bilateral chest expansion ensuring that the tube has not gone down the right mainstem bronchus (B). If the tube is in the right mainstem bronchus (where it preferentially goes when positioned down too far), breath sounds will not be heard on the left side. If unable to auscultate breath sounds, the physician should immediately remove the tube; listening for air over the stomach delays ventilation of the patient (C). The patient should be ventilated with an ambu bag prior to reintubation attempt. Look for the answer that ensures that air is getting into the lungs. Airway and Chest Tube Management Which of the following would not be an indication that the intubated and mechanically ventilated patient should be suctioned? A. Rhonchi audible throughout lung fields B. Coughing during the inspiratory cycle of the ventilator C. Visible secretions in the tracheostomy or endotracheal tube D. Fine crackles audible in the lung bases Airway and Chest Tube Management Which of the following would not be an indication that the intubated and mechanically ventilated patient should be suctioned? A. Rhonchi audible throughout lung fields B. Coughing during the inspiratory cycle of the ventilator C. Visible secretions in the tracheostomy or endotracheal tube D. Fine crackles audible in the lung bases • Answer = D • Crackles indicate an intra-alveolar process (D). The alveoli cannot be suctioned. Rhonchi indicate fluid or mucus in the airway and indicate that a patient should be helped to cough or that secretions should be suctioned (A). Coughing during the inspiratory cycle of the ventilator or the high-pressure alarm of the ventilator sounding indicates that the patient requires suctioning of secretions (B). Visible secretions in the tracheostomy or endotracheal tube indicate that the patient requires suctioning of secretions. Patients should not receive suctioning routinely. • Options a, b, and c indicate that there is mucus. Crackles indicate intra-alveolar fluid, atelectasis, or pulmonary fibrosis, which are not amenable to suctioning. Remember that this is a negatively stated question, so read slowly and carefully and consider highlighting not as a reminder of what the question is asking. Airway and Chest Tube Management Which of the following is recommended in relation to suctioning of an endotracheal tube? Select all that apply. A. Preoxygenating with 100% oxygen before suctioning B. Suctioning when indicated C. Saline lavage D. Humidification E. Preoxygenating with 60% oxygen for those patients with COPD. Airway and Chest Tube Managements Which of the following is recommended in relation to suctioning of an endotracheal tube? Select all that apply. A. Preoxygenating with 100% oxygen before suctioning B. Suctioning when indicated C. Saline lavage D. Humidification E. Preoxygenating with 60% oxygen for those patients with COPD. • Answer = A, B, D • Patient hydration and humidification are essential to liquefy secretions. Suctioning should never be performed routinely but only as indicated. Indications include hypoxemia evidenced by a decrease in functional oxygen saturation; clinical indications of hypoxia such as restlessness, tachycardia, and mild hypertension; patient coughing during the inspiratory cycle of the ventilator; high-pressure alarm during the inspiratory cycle of the ventilator; or secretions bubbling from the endotracheal tube. Preoxygenation with 100% oxygen before suctioning provides a safety cushion to prevent hypoxemia during suctioning. Preoxygenate with 100% O2 for EVERY patient. • Instillation of saline (saline lavage) is ineffective in liquefaction of secretions and contributes to hypoxemia and nosocomial pneumonia. Airway and Chest Tube Management When suctioning secretions from a patient through an endotracheal tube, the patient's heart rate drops dramatically. What action is indicated? A. Stop suctioning and administer 100% oxygen. B. Continue suctioning and then administer 100% oxygen. C. Turn the head to the left side. D. Instill saline down the endotracheal tube.