Question

The nurse is preparing to suction a client with a tracheostomy. Before suctioning the tracheostomy, the nurse should give priority to: A. Providing the client with \(100 \%\) oxygen B. Explaining the procedure C. Checking the dressing for soiling D. Changing the neck ties

Short answer

Answer: Providing the client with \(100 \%\) oxygen.

Step-by-step solution

Option A: Providing the client with \(100 \%\) oxygen

Before suctioning a tracheostomy, the client should be given \(100 \%\) oxygen because suctioning can reduce oxygen levels in the patient's body. Hyper-oxygenation is important in order to minimize the risk of hypoxia during suctioning.

Option B: Explaining the procedure

While it is essential to explain the procedure to the client, it is not the highest priority before suctioning a tracheostomy. Safety and client's well-being must be prioritized.

Option C: Checking the dressing for soiling

Checking the dressing for soiling is important to maintain the hygiene, but it is not the highest priority before suctioning a tracheostomy. Maintaining the airway and ensuring proper oxygenation should always be prioritized before focusing on any physical maintenance.

Option D: Changing the neck ties

Changing the neck ties is a part of tracheostomy care, but it is not the highest priority before suctioning a tracheostomy. The main priority before suctioning is ensuring that the patient is receiving enough oxygen to prevent complications.

Conclusion

Based on the analysis of each option, the nurse should give priority to Option A: Providing the client with \(100 \%\) oxygen before suctioning the tracheostomy. This is the most important step because it ensures that the patient's oxygen levels are maintained and reduces the risk of hypoxia during the procedure.

Key concepts

Suctioning Techniques

Suctioning is a critical procedure in tracheostomy care, as it helps remove mucus and other secretions from the airway. This process facilitates easier breathing and prevents infection. Proper suctioning techniques ensure that the patient experiences minimal discomfort and the procedure is done efficiently. The suctioning process typically involves a sterile catheter that is inserted into the tracheostomy tube. Once properly positioned, suction is applied to extract the secretions.

When performing suctioning, it's crucial to maintain sterility to prevent introducing infections. The catheter should not stay in the trachea for more than a few seconds at a time, usually between 10 to 15 seconds, to reduce the risk of harm. During this short period, quick and effective removal of secretions should be prioritized.

• Adequate hand hygiene before and after the procedure.
• Wearing sterile gloves to prevent germ transmission.
• Using the correct size of the suction catheter for the patient's tracheostomy tube.
• Visual observation for any blood or unusual mucous color during suctioning, as these could indicate complications or infection.

By following these techniques, nurses can ensure an effective suctioning procedure while safeguarding the patient's health.

Patient Safety

Patient safety is paramount during tracheostomy care, especially while performing suctioning. Suctioning can lead to oxygen deprivation if not properly managed, which poses a significant risk to the patient. Thus, ensuring patient safety involves a series of preparatory steps to protect the individual from complications.

Before the suctioning begins, it is essential to confirm the tracheostomy tube is securely fastened and clear of obstructions. A loose or clogged tube could be life-threatening. Patients should be pre-oxygenated with 100% oxygen to prevent hypoxia—a condition that arises from inadequate oxygen in the blood.

• Monitor the patient's oxygen saturation levels closely to ensure no drop in oxygen levels occurs during the procedure.
• Keep communication open; inform patients about the steps involved to reduce anxiety and increase cooperation.
• Have suctioning supplies ready and within reach to minimize time delays.
• Observe the patient's reaction continuously and be ready to stop if signs of distress appear.

By maintaining these safety measures, healthcare providers can secure the well-being of their patients during tracheostomy care.

Oxygenation in Nursing

Oxygenation management is a significant component in nursing care, particularly for those with a tracheostomy. Proper oxygenation is vital as it influences the body’s overall functioning and healing process. Hypoxia, or the lack of adequate oxygenation, can lead to severe complications, including organ dysfunction.

Prior to suctioning, ensuring the patient receives adequate oxygen is crucial. This precaution helps minimize the chances of a drop in blood oxygen levels during the procedure. Nurses should provide the patient with 100% oxygen before suctioning to counteract the potential risks associated with the removal of secretions.

• Assess oxygen levels using pulse oximetry to measure the patient’s current oxygen saturation.
• Administer supplemental oxygen as needed, tailoring it to the patient's specific needs and condition.
• Watch for symptoms of hypoxia, like increased heart rate or pallor, to adjust oxygen delivery if necessary.
• Educate patients and families about the importance of regular and proper oxygenation.

Incorporating effective oxygenation practices into nursing care ensures patient safety and promotes better health outcomes.