The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse’s best action?
A. Raise the head of the bed.
B. Notify the emergency team.
C. Loosen the dressings on the chest.
D. Document the findings as the only action.
Correct Answer: B. Notify the emergency team.
Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose the effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway and the swelling usually precludes intubation.
Option A: Raising the head of the bed would be not much help because of the obstructed airway. Airway protection should include considering early and preemptive intubation for patients with inhalation injury.
Option C: Dressings may be loosened, but emergency intubation would still be needed. Airway edema may occur suddenly as edema worsens, and often, the upper airways develop injury and obstruction earliest, prior to the parenchymal injury.
Option D: This is not a normal finding. There may be accessory muscle usage, tachypnea, cyanosis, stridor, and rhonchi/rales/wheezing. Findings of stridor or upper airway turbulence/noise are often a sign of impending airway compromise, and prompt intubation should be strongly considered.
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