On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse’s next action?
A. Documenting the findings
B. Loosening any dressings on the chest
C. Raising the head of the bed
D. Preparing for intubation
Correct Answer: D. Preparing for intubation
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. The swelling usually precludes intubation.
Option A: Documentation of findings should be done after the interventions. There may be only a small window of opportunity to easily place an ET tube because edema from burn shock may obstruct the airway.
Option B: Loosening any dressings on the chest should be done right after the assessment of wheezes. If there is edema or evidence of burn in the upper airways, assessment for whether an endotracheal (ET) tube is needed to maintain the airway should be done immediately.
Option C: The head of the bed should be flat to prepare for intubation. Emergency airway intubation should be done immediately after assessment to avoid complete obstruction of the airway due to edema.
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