Possibly evidenced by
Changes in rate or depth of respiration
Abnormal breath sounds
Anxiety and restlessness
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Airway Patency
Maintain patent airway with breath sounds clear.
Be free of aspiration.
Identify potential complications and initiate appropriate actions.
Nursing intervention with rationale:
1. Assess airway patency.
Rationale: Obstruction may be caused by accumulation of secretions, mucous plugs, hemorrhage, bronchospasm, and problems with the position of tracheostomy or ET tube.
2. Evaluate chest movement and auscultate for bilateral breath sounds.
Rationale: Symmetrical chest movement with breath sounds throughout lung fields indicates proper tube placement and unobstructed airflow. Lower airway obstruction, such as pneumonia
or atelectasis, produces changes in breath sounds, such as rhonchi and wheezing.
3. Monitor ET tube placement. Note lip line marking and compare with desired placement. Secure tube carefully with tape or tube holder. Obtain assistance when retaping or
Rationale: The ET tube may slip into the right main-stem bronchus, thereby obstructing airflow to the left lung and putting client at risk for a tension pneumothorax.
4. Note excessive coughing, increased dyspnea (using a 0 to 10 scale), high-pressure alarm sounding on ventilator, visible secretions in endotracheal or tracheostomy tube,
and increased rhonchi.
Rationale: The intubated client often has an ineffective cough reflex, or client may have neuromuscular or neurosensory impairment, altering ability to cough. Client is usually dependent on suctioning to remove secretions. Note: Research supports use of a dyspnea rating scale (like those used to measure pain) to more accurately quantify and measure
changes in dyspnea as experienced by client.
5. Suction as needed when client is coughing or experiencing respiratory distress, limiting duration of suction to 15 seconds or less. Choose appropriate suction catheter. Hyperventilate before and after each catheter pass, using 100% oxygen if appropriate, using vent rather than Ambu bag, which has an increased risk of barotrauma. Suction continuously or intermittently during withdrawal.
Rationale: Suctioning should not be routine, and duration should be limited to reduce hazard of hypoxia. Suction catheter diameter should be less than 50% of the internal diameter of the ET or tracheostomy tube for prevention of hypoxia. Hyperoxygenation with ventilator sigh on 100% oxygen may be desired to reduce atelectasis and to reduce accidental hypoxia. Note: Instilling normal saline (NS) is no longer recommended (although it persists in practice) because research reveals that the fluid pools at the distal end of the ET or tracheal tube, impairing oxygenation and increasing bronchospasm and the risk of infection.
6. Use inline catheter suction when available.
Rationale: Reduces risk of infection for healthcare workers and helps maintain oxygen saturation and PEEP when used.
7. Instruct client in coughing techniques during suctioning, such as splinting, timing of breathing, and “quad cough,” as indicated.
Rationale: Enhances effectiveness of cough effort and secretion clearing.
8. Reposition or turn periodically.
Rationale: Promotes drainage of secretions and ventilation to all lung segments, reducing risk of atelectasis.
9. Encourage the client to drink fluids and provide fluids within individual capability.
Rationale: Helps liquefy secretions, enhancing expectoration.
10. Provide chest physiotherapy as indicated, such as postural drainage and percussion.
Rationale: Promotes ventilation of all lung segments and aids drainage of secretions.