Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?
A. Stridor
B. Occasional pink-tinged sputum
C. A few basilar lung crackles on the right
D. Respiratory rate 24 breaths/min
Correct Answer: A. Stridor
The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Post-extubation stridor is uncommon and seen only in less than 10% of unselected critically ill patients and correlates with increased rates of reintubation, prolonged duration of mechanical ventilation, and longer length of ICU stay. Options B, C, and D are not signs that require immediate notification of the physician.
Option B: A pink-tinged sputum is normal after removal of the endotracheal tube. Ensure adequate secretion management, encourage coughing and deep breathing, maintain airway hydration, and patent central airway. The immediate post-extubation phase should be managed as carefully as the ventilated phase because the first 24 hours post-extubation are difficult and tenuous.
Option C: After the removal of the ETT, suction the oral cavity and ask the patient to take a deep breath and cough out all secretions. Frequent airway suction should be considered to prevent re-intubation. There may be a few crackles upon auscultation.
Option D: 24 breaths/min is a normal respiratory rate. The patient should be placed on supplemental oxygen afterward. Ensure adequate oxygenation; consider nasal cannula, oxygen mask, full face mask, venturi mask as appropriate to ensure good O2 supply. In recent times, high flow oxygen systems have gained popularity in selected patients with hypoxemic respiratory failure and studies have shown to reduce the re-intubation rate.
No comments:
Post a Comment