# Situation: A 64-year-old man on a medical ward is eating lunch in bed when he suddenly grasps his throat. He has no pacemaker and no do-not-resuscitate order. The unit's adult choking protocol calls for cycles of 5 back blows and 5 abdominal thrusts for severe airway obstruction in a responsive adult. When asked, 'Are you choking?' he nods. His coughs are weak and growing quieter, he makes a high-pitched sound on inhaling, and his lips are turning dusky. He is still standing and responsive. What should the nurse do?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630236  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 64-year-old man on a medical ward is eating lunch in bed when he suddenly grasps his throat. He has no pacemaker and no do-not-resuscitate order. The unit's adult choking protocol calls for cycles of 5 back blows and 5 abdominal thrusts for severe airway obstruction in a responsive adult.

When asked, 'Are you choking?' he nods. His coughs are weak and growing quieter, he makes a high-pitched sound on inhaling, and his lips are turning dusky. He is still standing and responsive. What should the nurse do?

## 보기

1. Stay with him and encourage him to keep coughing
2. Give him sips of water to wash the food down
3. Alternate 5 back blows with 5 abdominal thrusts **✔ 정답**
4. Lay him flat and start chest compressions at once

**정답: 3**

## 해설

A weak, ineffective cough, a high-pitched inspiratory noise, and cyanosis mean severe airway obstruction even though he is still coughing. A responsive adult with severe obstruction receives back blows and abdominal thrusts per protocol until the object is expelled or he becomes unresponsive.

## 심화 해설

Severe vs. mild airway obstruction

The first clinical decision is to classify the obstruction. A responsive adult who can speak, cough forcefully, and maintain good air exchange has a mild obstruction. This patient cannot do that. His cough is weak and fading, he makes a high-pitched inspiratory stridor, and his lips are becoming dusky. Those findings indicate severe airway obstruction with poor air movement, even though he is still conscious and nodding “yes.”

A weak, ineffective cough, inspiratory stridor, and cyanosis mean the airway is critically narrowed, not simply irritated. Encouraging continued coughing is appropriate only when the cough is strong and air exchange is adequate. Giving water is dangerous because liquid can pool above the obstruction and worsen aspiration. Laying the patient flat and starting chest compressions is reserved for an unresponsive victim, not a responsive one.

Why back blows and abdominal thrusts are paired

In a responsive adult with severe foreign body airway obstruction, the recommended sequence is alternating 5 back blows with 5 abdominal thrusts. The two maneuvers work through different mechanisms. Back blows create a sudden increase in intrathoracic pressure and vibration that can dislodge a foreign body from the upper airway. Abdominal thrusts force the diaphragm upward, rapidly compressing the lungs and generating an artificial cough to expel the object.

Alternating the two techniques increases the chance of dislodging the object because each maneuver produces a different pressure pattern in the airway. The cycle is repeated until the obstruction is relieved or the victim becomes unresponsive. If unresponsiveness develops, the responder lowers the victim to the ground and begins CPR with chest compressions, checking the mouth for a visible object before each set of ventilations.

Watch out! A patient who is still coughing does not automatically have a mild obstruction. The quality of the cough matters more than its presence. A weak, silent cough with stridor and cyanosis is a severe obstruction and requires immediate active intervention, not observation.

Clinical recognition in adults

Foreign body airway obstruction in adults is most often caused by food, especially meat, and frequently occurs during meals. The presentation can be subtle in older adults because the cough reflex may be diminished and the initial choking episode may not be witnessed. A high index of suspicion is needed when an adult suddenly stops speaking, grasps the throat, or develops respiratory distress while eating.

| Feature | Mild obstruction | Severe obstruction |
| --- | --- | --- |
| Cough | Strong, effective | Weak, ineffective, or absent |
| Speech | Able to speak | Unable to speak, may only nod |
| Breath sounds | Wheezing possible, good air movement | High-pitched stridor, poor air movement |
| Color | Pink | Dusky or cyanotic |
| Nursing action | Encourage coughing, observe closely | Back blows and abdominal thrusts immediately |

Key point! The universal choking sign—clutching the throat—plus a weak cough, stridor, and cyanosis is a severe airway emergency. Do not delay intervention to obtain equipment or wait for the patient to improve on his own.

Immediate nursing actions

The nurse should stand behind the patient, support the chest with one hand, and deliver five sharp back blows between the shoulder blades with the heel of the other hand. If the obstruction persists, the nurse performs five abdominal thrusts by placing a fist just above the umbilicus, grasping it with the other hand, and pressing inward and upward with quick thrusts. The sequence continues until the object is expelled or the patient loses consciousness.

Once the patient becomes unresponsive, the protocol changes: lower him to the floor, activate the emergency response system, and begin CPR starting with chest compressions. Before each ventilation attempt, the rescuer opens the mouth and looks for a visible foreign body, removing it only if it is clearly seen. Blind finger sweeps are avoided because they can push the object deeper.

In a hospital setting, the nurse should also call for help early so that advanced airway equipment and a crash cart are available. However, calling for help does not replace immediate manual maneuvers. The back blow–abdominal thrust cycle is the first-line intervention for a responsive adult with severe obstruction, and it should begin without delay.

## 임상 시나리오

Responsive Adult Choking ProtocolSevere obstruction requires alternating back blows and abdominal thrusts
Classify obstruction first. Mild obstruction allows a strong cough and good air exchange. Severe obstruction presents with weak cough, inspiratory stridor, and cyanosis even if the patient is responsive.

For a responsive adult with severe obstruction, perform cycles of 5 back blows alternating with 5 abdominal thrusts until the object is expelled or the patient becomes unresponsive.

CautionDo not give water or encourage coughing in severe obstruction. If the patient becomes unresponsive, lower them to the floor and begin CPR with chest compressions.

## 핵심 개념

- **Severe airway obstruction** — Airway blockage with poor air movement, indicated by weak cough, inspiratory stridor, and cyanosis.
- **Back blows** — Sharp blows between the shoulder blades that increase intrathoracic pressure to dislodge a foreign body.
- **Abdominal thrusts** — Inward-upward thrusts above the navel that force the diaphragm upward to create an artificial cough.
- **Inspiratory stridor** — A high-pitched sound during inhalation indicating critical narrowing of the upper airway.
- **Mild airway obstruction** — Airway blockage with adequate air exchange, allowing the person to speak and cough forcefully.

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