Help with order of procedures

[shingi]

What is the correct order for the following procedures if a client has a trach, needs a NG tube inserting and is having difficulty breathing? The procedures we needed to perform in the correct order was suctioning the trach, pulmonary assessment, and insertion of the NG tube. We did them in that order but question whether we should have performed the assessment before suctioning. Thanks:)

[CHATSDALE]

with sob in a trach you have an emergency situation..you can suction and make an accessment to determine the quality of the suctioning follow up with ng tube

[S.T.A.C.E.Y, LPN]

I would think you would want to do the assessment first (since thats the first step of the nursing process), then suction the trach as your intervention, then evaluate if that was sucessful by assessing respiratory status again. Then insert the NG tube.

I'd say the assessment should be done before the suctioning, b/c what if the suctioning isn't the cause of the resp distress? By performing an unnecessary procedure, you're prolonging the proper identification of whatever could be causing the respiratory distress, and possibly causing further harm (nothing is without risk).

[canoehead, BSN, RN]

If you've assessed (think 1 second visual assessment) and decided the patient needs to be suctioned then do it immediately. Then do the more in depth assessment, with lung sounds and the whole bit, after the suctioning. NG last because anything airway comes before all else.

[Daytonite, BSN, RN]

If you wait to suction your patient, he/she is going to turn blue and suffocate from the secretions blocking his/her airway. Doing a pulmonary assessment will no longer be necessary because he/she will be dead from respiratory followed by cardiac arrest!!!!!

[augigi, CNS]

Depends what qualifies as a "pulmonary assessment" - if you can eyeball the patient and tell they are compromised, do that then suction. I would not wait to auscultate the lung fields though, although I don't think it's quite as drastic as the poster above me.

[Daytonite, BSN, RN]

ok! maybe i was being a bit dramatic, but i was trying to illustrate an important point by taking the scenario to it's most serious conclusion. students don't have the luxury of having known, or possibly even seeing, a patient that is in distress and need of suctioning. for experienced nurses, this would have been a no-brainer because we've seen these people struggling to hack that sputum out of their trachs. actually, a more realistic response would have been that if you don't suction this patient you're going to get a face full of sputum hacked on you as he uncontrollably struggles to clear his airway and you are trying to assess his lungs. eew!

anyway, the principle that the question is trying to get students to consider is one of priorities in the performance of nursing interventions. it has to do with oxygenation. since the patient's airway is blocked with secretions, his physiological ability to take on oxygen and release carbon dioxide is compromised. the other thing the student is being asked to consider here is if performing a pulmonary assessment is the first step of the nursing process, or is it a nursing intervention? i would take the hint from the way this question is worded: "the correct order for the following procedures". to me, that means that these three things have already been tagged as procedures, or interventions. actually, the question sounds as if the three tasks might have been delegated to the nurse. i would interpret that to mean that the care plan has been decided upon and these are three nursing interventions from the care plan, the insertion of the n/g tube being a collaborative intervention dependent on a doctor's order. a pulmonary assessment that is done as a nursing intervention is part of the monitoring function of the nurse. suctioning and inserting an n/g tube are actual performance of patient care tasks. that is very different on the list of priorities than the data assessment function of the nursing process. attending to physiological needs and clearing the airway will always be #1 when it comes to direct nursing interventions. some will refer to this as addressing the abcs--same thing.

there are four types of nursing interventions (actions) that are written into care plans and that nurses do in providing care for patients:

1. the evaluation of a patient's condition (as in assessing, monitoring, observing and/or evaluating
   
2. actual performance of patient care
   
3. educating the patient or his/her caregivers
   
4. management of the patient's care (as in contacting or notifying appropriate healthcare personnel, referral to appropriate healthcare personnel

[shingi]

Thanks everyone, I will keep you posted as to what our instructers say is correct procedure. I personally thought suctioning first just folliwing the ABC's...but we'll see. Most of the class put pulmonary assessment first, that is why I was questioning myself. Thanks again for advice:)