Question Of the Day Tues 4/26

HappyNurse2005, RN · Apr 26, 2005

QOD:
A client's respiratory status necessitates endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for this client would be to:
1. Prepare the client for emergency surgery
2. Facilitate the client's verbal communication
3. Assess the client's response to the mechanical ventilation
4. Maintain sterility of the ventilation system the client is using

It's not number 1-intubation is not surgery

Although #2 is important, it is certainlynot the "most immediate" intervention, like the question states

#3 is good, if it means what i think it does. THe client's response-if this means their o2 sats, resp rate, abg's, then this is a good answer

#4 is also good. I will take this one.

babynursewannab · Apr 26, 2005

3. Assess response ... This is assuming the answers are based on the procedure already having occured.

1. Intubating is not a surgical procedure and is often done at bedside

2. Verbal communication is not a priority at the moment, the person cannot breathe and then when the ETT is placed, they are unable to speak...on top of that, a sedative is usually given (ie. versed) to facilitate placement and help the patient through the procedure...most people get groggy on that, not chatty.

4. is good, and important (we don't want little beasties getting into a wonderful warm, wet environment), but who cares if the patient has an infection if they are not adequately ventilating/perfusing. At the immediate moment, an infection won't have time to develop and compromise.

Resistance to the vent, poor placement (causing unilateral venting), alveolar blowout causing a pneumothorax and extreme anxiety can cause a person to decompensate and poorly exchange gases. These are some of the things that need to be assessed for....#3

Now, in the long run, you don't want your internal workings or your suction sheathing contaminated, but many get prophylactic abx. The outside of the tube is a virtual slip and slide for bacteria from the mouth to the lungs anyway.

Prioritizing... ABC's then infection and/or safety

Now, as is always a possibility, if I have missed something in the translation, please do let me know!

-Alyssa

Mandarella · Apr 26, 2005

Hmmm...I am torn...

#3~ is my DUH response...I want to say it...Stabilize the endotracheal tube for comfort and assess skin integrity around mouth for irritation...

But

#4~Oropharyngeal secretions commonly become colonized with pathogens, especially gram-negative bacteria...ventilator associated pnemo

OK, I'm feeling pressure...I'm not disregarding #1&2 but having to pick... I pick

#3...

Did I just fail??:uhoh21:

Iluvhospice · Apr 26, 2005

I am going to go with my initial thought - which is that the client needs to be able to communicate - and if I were the nurse, I would make sure that the client understood that he/she would be unable to speak, and I would provide an alternate means of communication.

That being said - I would do it BEFORE the procedure...

And... endotracheal intubation is generally done under anesthesia unless it's an emergency procedure - so...

Can I say, all of the above? :chuckle

Ok, I'll be different - #2

Aneroo, LPN · Apr 26, 2005

Ok, I haven't looked at answer yet, although I really want to. I am going with 3. I take response (also) to mean to see how well they are doing- are their sats, color ok? ABG's?

I agree with no for emergency surgery. This is done at the bedside (even if it is an emergency)

Two is a no go. How can you facilite verbal communication if they have a tube in their mouth? I've have pts with ETT's that had a pen and paper in their room so we could communicate, also picture boards.

Four is a maybe. Yes, I want to be remain sterile. However, their response to an ETT is my priority-making sure they have the airway and that it works and they're breathing normally.

I'm going to try and not look at answers til the morning.

Altra, BSN, RN · Apr 26, 2005

I'll go with 3 based on basic Airway, Breathing, Circulation analysis.

Potential infection is a problem, but it won't be if we can't get an airway on the pt.

madwife2002, BSN, RN · Apr 26, 2005

3 is the one as we are looking at priority,

abmsam · Apr 26, 2005

Definitely #3.

Infection is not a priority over perfusion. Of course, sterility must be maintained, but perfusion is most critical.

HyperRNRachel · Apr 26, 2005

I am going with number 3!

If I do not get this one right, then I am not playing anymore :rolleyes:

ckh23, BSN, RN · Apr 26, 2005

I am going with number 3!
If I do not get this one right, then I am not playing anymore

I say #3