Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? quizlet

C. Bronchospasm

Rationale:
If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

Test-Taking Strategy:
Note the strategic word, immediately. Eliminate option B first because it is unrelated to the procedure. Next, eliminate option A because a dry cough may be expected. Noting that a biopsy has been performed will assist in elimination option D, because blood-streaked sputum would be expected. Note that the correct option relates to the airway.

C. Stop the procedure and reoxygenate the client

Rationale:
During suctioning, the nurse should monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

Test-Taking Strategy:
Focus on the subject, a decreased heart rate, and recall that suctioning can cause cardiac irregularities. Also, use of the ABCs-airway-breathing-circulation-should direct you to the correct option.

B. Report yellow eyes or skin immediately.

Rationale:
Isoniazid is hepatotoxic, and therefore the client is taught to report signs and symptoms of hepatitis immediately, which include yellow skin and sclera. For the same reason, alcohol should be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or lightheadedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine (vitamin B6) during the course of isoniazid therapy.

B. Place a patient with altered consciousness in a side-lying position.

Rationale:
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with decreased level of consciousness are placed in side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.

-Tracheostomy tubes are used for long-term airway support.
-They are inserted through a small opening in the neck into the trachea.
-This type of airway may be permanent or temporary depending on the patient's condition and reason for the tracheostomy.
-Tracheostomy tubes are made of either plastic or metal and are available in a variety of sizes.
-Because metal tracheostomy tubes are temperature-sensitive, they must be protected from heat and cold to prevent tissue injury. Like ET tubes, tracheostomy tubes may have a cuff that is inflated with air after insertion.
- Most tracheostomy tubes have an inner cannula that is temporarily removed during tracheostomy care.
-a tracheostomy tube is the ONLY one whose placement requires a surgical procedure.
-Postoperatively, the nursing priority is maintaining a patent airway. Tube obstruction is a major complication, as is tube dislodgement during the first 72 hours postoperatively.
-It is essential to keep a manual resuscitation bag, a tracheostomy tube of the same size and type, a tracheostomy insertion tray, and an obturator at the patient's bedside. If the tracheostomy tube becomes dislodged, exert minimal pressure onto the tube to ease the tube back into place and then re-secure the tube by adjusting the ties to reduce movement of the tube.
-Some other possible complications are pneumothorax, subcutaneous emphysema, hemorrhage (although small amounts of blood are to be expected), and infection, manifested by purulent drainage, erythema, pain, and edema.

Sets with similar terms

"Lubrication of the patient's nostrils, face, and lips is essential to prevent drying."

"Ensure that the oxygen and humidification equipment are functioning properly."

"Position the tubing so it does not pull on the patient's face or the artificial airway."

During oxygen therapy, lubrication of the patient's nostrils, face, and lips with nonpetroleum cream is essential to relieve the drying effects of oxygen. For effective oxygen therapy, the oxygen and humidification equipment should be functioning properly. The tubing should be positioned in such a way that it does not pull on the patient's face or artificial airway. Mouth care is an integral part of caring for a patient who is undergoing oxygen therapy, and should be provided every 8 hours or as needed. Care should be taken that smoking, lit matches, and candles are not present in the immediate vicinity of the oxygen therapy room or area because oxygen is combustible.

Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy?

How can the nurse best minimize a patient's risk of infection during tracheostomy care *?

How can you best minimize a patient's risk for infection during tracheostomy care?

What are the nursing interventions to prevent complications with tracheostomy tubes?