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Assessing and Managing the Deteriorating Patient > Week 2: Managing Deteriorating Airway and Breathing > Flashcards

Week 2: Managing Deteriorating Airway and Breathing Flashcards

1
Q

What are possible causes of airway obstruction?

A 
Foreign body
Tongue
Vomitus
Oedema and inflammation (allergic reaction, infection or burns)
Trauma
Malignancy
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2
Q

What do you look for when assessing the airway?

A 
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
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3
Q

What do you listen for when assessing the airway?

A

Obvious noises:
stridor
gurgling
no sounds- complete obstruction?

Ausculate:
air entry
lung sounds

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4
Q

What do you palpate for when assessing the airway?

A

Trachea –is it in the midline
Any subcutaneous emphysema

Feel –percussion:
Dull or tympanic

SpO2

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5
Q

How do you manage an airway obstruction?

A 
Positioning
Removing a foreign body
Head tilt and chin lift
Suctioning
Artificial airways:
guedelsairway
nasopharyngeal airway
endotracheal tube
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6
Q

What is a tracheostomy?

A

Surgical opening into the trachea

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7
Q

What are the indications for a tracheostomy?

A 
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
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8
Q

How are different tracheostomy tubes chosen?

A

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

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9
Q

What are cuffed tracheostomy tubes?

A

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

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10
Q

What is the indication for an uncuffed tracheostomy tube?

A

Uncuffed tubes are only used when patient can protect their own airway and does not require mechanical ventilation

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11
Q

What are possible tracheostomy emergencies?

A 
Haemorrhage
Tube dislodgement: decannulation, tube in subcut tissue
Tube obstruction
Infection
Tracheomalacia
Skin break down
Tracheo-oespohageal fistula
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12
Q

How do you manage tracheostomy tube dislodgement?

A

Establish an airway:
Tracheal dilators
Insertion suction catheter
Keep a tube the same size and one size smaller at the bedside

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13
Q

How do you manage a tracheostomy tube obstruction?

A

Humidification
Suctioning
Cleaning inner tubes

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14
Q

How do you manage a tracheostomy infection?

A

Secretions sit on top of the cuff- need prevention:
Mouth care
Observe for signs of infection

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15
Q

How do you manage tracheomalacia?

A

Manage cuff pressures <25mmHg (minimal inflations pressures)

Keep tube in a neutral position and ensure there is no traction on the tube.

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16
Q

What is tracheomalacia?

A

The breakdown of the natural grid structure of the trachea that leads to a flaccid airway

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17
Q

What is an tracheo-oesophageal fistula?

A

Communication between the trachea and the oesophagus

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18
Q

What are the signs and symptoms of a tracheo-oesophageal fistula?

A

Copious secretions (often feeds)
Dyspnoea
Cuff leak and
Gastric distention

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19
Q

What are the aspects of care for a patient with a tracheostomy?

A 
Respiratory assessment
Suctioning
Stoma care
Cuff pressure monitoring
Observation of secretions
Monitoring for infection
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20
Q

What is a pneumothorax?

A

Air in the apex of the pleural space

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21
Q

What is a pleural effusion?

A

Fluid in the base of the pleural space

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22
Q

What are the causes of pneumothorax?

A

Spontaneous
Iatrogenic
Chest trauma

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23
Q

What is a spontaneous pneumothorax?

A

Rupture of a small bleb

May be associated with COPD, asthma, cystic fibrosis or pneumonia

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24
Q

What is an iatrongenic pneumothorax?

A

Post operative

Insertion of a central line

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25
Q

What are the types of chest trauma associated with pneumothorax?

A

Blunt

Penetrating

26
Q

What are causes of blunt chest trauma?

A

Seatbelt
Assault
Crush

27
Q

What are causes of penetrating chest trauma?

A

Gunshot

Knife

28
Q

What are the clinical signs of pneumothorax?

A 
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
29
Q

What are the clinical signs of a tension pneumothorax emergency?

A 
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
30
Q

What are the types of pleural effusion?

A

Haemothorax

Chylothorax

31
Q

What is haemothorax?

A

Blood in the pleural space

32
Q

What is chylothorax?

A

Lymph fluid in the pleural space

33
Q

What are the clinical signs of pleural effusion?

A 
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
34
Q

What is cardiac tamponade?

A

Blood collection in the pericardial sac that impeded myocardial filling reducing stroke volume:
Hypotension
Tachycardia
Increased JVP

35
Q

What are chest drains?

A

Tube placed in the pleural space on underwater seal

36
Q

What are the indications for chest drains?

A

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

37
Q

What are the components of a chest drain system?

A

1) “Catheter”
2) Tubing
3) “Underwater seal” drainage container

38
Q

How do chest drains work?

A

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

39
Q

What is simple underwater seal drainage?

A

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

40
Q

What is the nursing management for a patient with a chest drain?

A 
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
41
Q

How often does the patient with a chest drain need to be monitored?

A

Post insertion every 15 minutes for 1 hour
Half hourly for 2 hours
Hourly until the drain is removed

42
Q

What drain-specific observations should be done for a patient with a chest drain?

A

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

43
Q

Why do nurses monitor the patient with a chest drain for fluid swing and bubbling?

A

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

44
Q

What is fluid swing in a chest drain?

A

Swing that occurs with changes in pleural pressure during inspiration and expiration

45
Q

What chest drain issues should be reported immediately?

A

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

46
Q

What are common mistakes with chest drains?

A

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!

47
Q

How is a chest drain removed?

A

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

48
Q

Why is a cuffed tracheostomy tube used?

A

If patient is at risk of aspiration (swallowing difficulties or mechanical ventilation)

49
Q

What is maximum cuff pressure for a tracheostomy and why?

A

20 mmHg

Higher can cause compress capillaries in trachea and cause tracheal necrosis

50
Q

What can be done to help a patient with a tracheostomy speak?

A

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

51
Q

What are the priorities of care for a tracheostomy?

A

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

52
Q

What nursing management for a patient with a tracheostomy needs to be performed during a shift?

A

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

53
Q

What do you do if a tracheostomy becomes dislodged?

A

Call for assistance or arrest immediately
Attempt to replace tube
Use obturator, smaller tube, dilators or suction catheter (gloved fingers if emergency)

54
Q

What are the indications for suctioning?

A

Inability to cough and clear secretions
Inability to maintain patent airway due to vomit, blood or sputum
Sudden respiratory distress
Secretion specimen for diagnosis

55
Q

What pre-suctioning assessment and management should be performed for a patient with a tracheostomy?

A

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

56
Q

What emergency tracheostomy equipment should be kept at the bedside?

A 
Tracheal dilators
Tracheostomy tube (same size as patient)
Tracheostomy tube (one size smaller than patient)
57
Q

What equipment is required to suction a tracheostomy?

A 
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
58
Q

What are the complications of tracheostomy suctioning?

A

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

59
Q

What is the post-suctioning care for a person with a tracheostomy?

A

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

60
Q

How can you prevent secretions from drying?

A

Humidification
Adequate fluid intake
Suction

61
Q

Why are dried secretions an issue?

A

Can block cannula and cause respiratory distress

62
Q

How frequently does an inner cannula need to be cleaned?

A

2-4 hours

Assessing and Managing the Deteriorating Patient (9 decks)

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