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TRACHEOSTOMY

TRACHEOSTOMY

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Published by: Jayson RN on Apr 16, 2011
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08/10/2013

FOR CLIENTS WHO NEED LONG TERM AIRWAY SUPPORT

 ACUTE RESPIRATORY DISTRESS due to poor

ventilation
 SEVERE BURNS of head and neck  Laryngectomy (trach-permanent)

Types of Tracheostomy Tubes
DOUBLE LUMEN TUBE  3 major parts:  Outer cannula—fits into the stoma and keeps the airway open .  Inner cannula—fits snugly into the outer cannula; provides universal adaptor for use with ventilator and other respiratory equipment

 Obturator—a stylet with a smooth end used to

facilitate the direction of the tube when inserting or changing a tracheostomy tube; removed immediately after tube placement ; always kept with the client and at the bedside

SINGLE-LUMEN TUBE  (aka “Bull-neck trach”) Long tube used for client with long or extra thick necks  More intensive care required because there is NO INNER CANNULA to ensure patent lumen

 Parts of a Tracheostomy Tube

Single Cannula Silicone Tube

CUFFED TUBE  When inflated seals the airway; used for MECHANICAL VENTILATION, preventing aspiration  Pilot balloon attached to the outside of the tube indicates the presence or absence of air in the cuff

CUFFLESS TUBE  Plastic silicone-like (Silastic) or metal tube , usually with a DOUBLE-LUMEN  Long-term airway of those who can protect themselves from aspiration, and who do not require mechanical ventilation  CAN SPEAK

FENESTRATED TUBE  has pre-cut opening (fenestration) in the upper posterior wall of the outer cannula  Used to WEAN by ensuring client can tolerate breathing through his natural airway before the entire tube is removed  Allows the client to speak

 Fenestrated tubes have an opening in the

tube that permits speech through the upper airway when the external opening is blocked, even if the tube is too big to allow airflow around the outer cannula. Fenestrated tubes are not recommended for small children, because they can obstruct the opening with granulation tissue. The opening of the hole must be at a correct angle to prevent problems.

CUFFED FENESTRATED TUBE  Facilitates mech. vent. and speech and often is used for clients with spinal cord paralysis or neuromuscular disease who DO NOT REQUIRE VENTILATION at all times. When not on the ventilator , the client can have the CUFF DEFLATED and the TUBE capped for speech.

 Never used in weaning from a tracheostomy, because

the cuff, even fully deflated , may partially obstruct the airway

METAL TRACHEOSTOMY TUBE  Used for PERMAMENT tracheostomy  CUFFLESS DOUBLE-LUMEN tube  A special adaptor attaches a manual resuscitation bag.  Popular types are the Jackson and Holinger tubes

TALKING TRACHEOSTOMY  PROVIDES A MEANS OF COMMUNICATION for a client using a ventilator for a LONG-TERM basis  An extra AIR CHANNEL allows air to flow up through the vocal cords so that the client CAN SPEAK with the CUFF INFLATED.

 All tracheostomy tubes should be

fitted with a 15-mm universal adapter to allow for bag ventilation in an emergency. Metal tubes are often made without this adapter.

Use oxygen before and after each suctioning 2. Humidify oxygen 3. STERILE technique in suctioning; CLEAN technique at home
1.

4. Cleanse inner cannula as needed—only leave out 5-10 minutes 5. HEMOSTAT handy if OUTER CANNULA is expelled—have OBTURATOR taped to bed and another TRACH SET handy 6. CUFF must be DEFLATED periodically to prevent necrosis of mucosa, unless low pressure cuff used

7.Maintain Semi-Fowler’s to High Fowler’s 8. Monitor for bleeding, difficulty breathing, absence of breath sounds, and crepitus , which are indications of hemorrhage, pneumothorax, & SQ emhysema 9. If the client is allowed to eat, sit the client up for meals and ensure that the cuff is inflated (if the tube is not capped) for meals and for 1 hour after meals

10. Monitor cuff pressures as prescribed 11. Assess the stoma and secretions for blood or purulent drainage 12. Follow the MD’s order and agency policy for cleaning the tracheostomy site and inner cannula; usually, halfstrength hydrogen peroxide is used

 Surgical stoma in the trachea to

provide open airway  Cuff should be inflated during and after feeding, doing mouth care, when patient is not able to handle oral secretions and during mechanical ventilation  Cuff pressure should not exceed 20cm H20

13. Obtain assistance in changing tracheostomy ties; after placing the new ties; cut and remove the old ties themselves holding the old tracheostomy in place 14. Never insert a decannulation plug into a tracheostomy tube until the cuff is deflated and the inner cannula is removed; prior insertion prevents airflow to the client. 15. Keep a resuscitation (Ambu) bag, obturator, clamps, and a tracheotomy set at the bedside .

 Open the suction catheter – non dominant  Place a sterile water soluble lubricant on the sterile area-


 


 

 

dominant Place a sterile towel on the patient’s chest.- dominant Remove the catheter from its wrapper-dominant Set the suction machine to its suction pressure according to hospital policy between 100- 150 mmHg- non dominant Disconnect the ventilator- non dominant For close tracheal suctioning : insert the suction catheter into the artificial airway –dominant (rotating motion) Apply suction – non dominant, if the client coughs pause briefly and then resume advancement. APPLY SUCTION LESSTHEN 10 seconds and NEVER SUCTION WHEN INSERTING, only when inserted and withdrawal. Withdraw the catheter – dominant Stabilize the ET or tracheostomy tube – non dominant

 Readjust the ventilator oxygen settings and tidal   

volume as orederd. Non dominant Assess the need for upper airway suctioning. If needed suction , make sure that the cuff is inflated. Always change the catheter and gloves every shift or as needed. Discard the gloves and catheter in a waterproof container. Wash hands.

 Removing the catheter from its wrapper

 Insertion, suction and withdrawal

COMPLICATIONS OF A TRACHEOSTOMY
Tube Obstruction: The MD repositions or replaces the tube

 During 72 hrs. following surgical placement of the

tracheostomy:
 Manually ventilates by using a manual resuscitation

(Ambu) bag while another nurse calls up the resuscitation team for help.

 EXTEND the client’s neck and open the tissues of the stoma   

  

to secure the airway GRASP the retention sutures (if they are present) to spread openings USE a tracheal dilator (curved clamp) to hold the stoma open PREPARE to insert tracheostomy tube; place obturator into tracheostomy tube, replace the tube, and remove the obturator MAINTAIN ventilation by resuscitation (Ambu) bag. ASSESS airflow and bilateral breath sounds If unable to secure an airway, CALL the resuscitation team and the anesthesiologist

 Tracheomalacia: Constant pressure exerted by the cuff causes tracheal dilation and erosion of cartilage  Tracheal Stenosis: narrowed tracheal lumen is the result of scar formation from irritation of tracheal mucosa by the cuff

Tracheoesophageal fistula:
 Excessive cuff pressure causes erosion of the posterior

wall of the trachea. A hole is created between the trache and the anterior esophagus. The client at highest risk also has NGT present

Trachea-innominate artery fistula
A malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continual pressure causes necrosis and erosion of the innominate artery. This is a medical emergency.

 Tracheostomy tubes can be

made of metal, plastic or silicone. Plastic and silicone tubes are increasingly popular because they are lightweight and there is less crusting of secretions.

Initially, the tracheostomy must be suctioned and cleaned as often as every 1 -2 hours then once or twice a day
Purposes •To maintain patent airway •Maintain cleanliness and prevent infection of the tracheostomy site •To facilitate healing and prevent skin breakdown around the incision •To promote comfort

Cleaning the stoma and the outer cannula
DOMINANT HAND SHOULD BE USE ALL THE TIME
Put on sterile gloves . Saturate a sterile gauze pad or cotton tipped applicator with the half

strength hydrogen peroxide or cleaning solution. Squeeze excess
fluid to prevent aspiration. Dominant Wipe the patients neck under the tracheostomy tube. Saturate a second pad or applicator and wipe until the skin surrounding the neck is cleaned.

Rinse the debris and peroxide with one or more sterile 4x 4 , and dry
the area with a sterile gauze. Remove the discard the gloves.

Put on sterile gloves Using your non dominant hand, remove and discard the patients dressings. With the same hand disconnect the ventilator or humidification device and unlock the inner cannula in the tracheostomy tube (counter clockwise). With ungloved hand, unlock the inner cannula and place in a hydrogen peroxide solution Remove the soiled tracheostomy dressing and place it in gloved hand Clean the inner cannula Remove the inner cannula from the soaking solution Clean the lumen and entire inner cannula thoroughly using a pipe cleaner moistened with sterile normal saline solution Rinse with sterile NSS and gently tap at the inside edge of sterile saline container  Replace the inner cannula, securing it in place  Clean the incision site and tube flange Using sterile applicators or gauze dressings moistened with NSS, clean the incision site Apply sterile dressing Use commercially prepared trach dressing or open a 4x4 gauze dressing into a V shape  Change the tracheostomy ties

 What is the best position when suctioning the client

with tracheostomy?
 High Fowler’s Position  Flat in Bed  Semi-Fowler’s Position  Trendelenberg Position

 What is the best position when suctioning the client

with tracheostomy?
 High Fowler’s Position  Flat in Bed  Semi-Fowler’s Position  Trendelenberg Position

 Rationale: C – Davis’s NCLEX RN 2007 – Success

Second Edition page 539

What is incorrect when suctioning the patient?
 Apply suction when inserting suction catheter.  Do not apply suction when inserting suction catheter  Use strict aseptic technique  Use clean Gloves

What is incorrect when suctioning the patient?
 Apply suction when inserting suction catheter.  Do not apply suction when inserting suction catheter  Use strict aseptic technique  Use clean Gloves

 Rationale: A – Davis’s NCLEX RN 2007 – Success

Second Edition page 539

 Apply suction intermittently for how long?
 2 – 3 minutes  4 – 8 minutes

 5 – 10 seconds
 1 – 3 seconds

 Apply suction intermittently for how long?
 2 – 3 minutes  4 – 8 minutes

 5 – 10 seconds
 1 – 3 seconds

 Rationale: C – Davis’s NCLEX RN – Success Second

Edition 539

 Before suctioning the client with tracheostomy

administer how many % of oxygen?
 90%  50%  70%  100%

 Before suctioning the client with tracheostomy

administer how many % of oxygen?
 90%  50%  70%  100%

 Rationale: D – Davis’s NCLEX RN – Success Second

Edition page 539

 What is the main goal after the patient has under gone

tracheostomy?
 Health teaching  Maintain patent airway

 Improve nutritional status
 Alleviate apprehension

 What is the main goal after the patient has under gone

tracheostomy?
 Health teaching  Maintain patent airway

 Improve nutritional status
 Alleviate apprehension

 Rationale: B – Davis’s NCLEX RN – Success Second

Edition page 539

 What is the recommended mm Hg of the cuff

pressure?
 18 mm Hg  25 mm Hg  12 mm Hg  30 mm Hg

 What is the recommended mm Hg of the cuff

pressure?
 18 mm Hg  25 mm Hg  12 mm Hg  30 mm Hg

 Rationale: A – Nurse’s Quick Check Skills 2007 page

484

 What is the incorrect use of a Cuffed Tracheostomy

Tube?
 Provide and maintains a patient airway  Prevents aspirating food or secretions

 Removal of tracheobronchial secretions
 Don’t use positive pressure ventilation

 What is the incorrect use of a Cuffed Tracheostomy

Tube?
 Provide and maintains a patient airway  Prevents aspirating food or secretions

 Removal of tracheobronchial secretions
 Don’t use positive pressure ventilation

 Rationale: D – Nurse’s Quick Check Skills 486

 What should you prepare in the clients bed side?
 Suction equipment and a clean obturator  Sterile tracheostomy and sterile tracheal dilator

 Sterile hemostat
 All of the above

 What should you prepare in the clients bed side?
 Suction equipment and a clean obturator  Sterile tracheostomy and sterile tracheal dilator

 Sterile hemostat
 All of the above

 Rationale: D. All – Nurse’s Quick Check Skills 487

 In re-inserting the tracheostomy tube what is to be

avoided?
   

Tracheal trauma Perforation Asphyxiation all

 In re-inserting the tracheostomy tube what is to be

avoided?
   

Tracheal trauma Perforation Asphyxiation all

 Rationale: D – Nurse’s Quick Check Skills 487

The nurse is teaching the client about the proper tracheostomy care at home except:  For tracheostomies older than 2 months, clean technique can be used for tracheostomy care  Tap water can be used for rinsing the inner cannula  Stress the importance of good hand washing technique  Inform the client/relatives of the signs and symptoms that may indicate an infection to the stoma site or lower airway

The nurse is teaching the client about the proper tracheostomy care at home except:  For tracheostomies older than 2 months, clean technique can be used for tracheostomy care  Tap water can be used for rinsing the inner cannula  Stress the importance of good hand washing technique  Inform the client/relatives of the signs and symptoms that may indicate an infection to the stoma site or lower airway

 Answer: A - You can use clean technique as early

as 1 month --- Fundamentals of Nursing 7th Ed. Pg.1318

A client is allowed to eat with a tracheostomy. What should the nurse do first?  Place the client in fowler’s position  Place the client in sitting position  Ensure that the cuff is deflated, if the tube is not capped  Ensure that the cuff is inflated, if the tube is capped

A client is allowed to eat with a tracheostomy. What should the nurse do first?  Place the client in fowler’s position  Place the client in sitting position  Ensure that the cuff is deflated, if the tube is not capped  Ensure that the cuff is inflated, if the tube is capped
 Answer: B - The client is place on a sitting position

and the cuff should be INFLATED if the tube is NOT capped --- Saunders 4th Edition pg.259

In cleaning the tracheostomy site and inner cannula this is used:  Normal Saline Solution  Half-strength hydrogen peroxide  Alcohol  Tap Water

In cleaning the tracheostomy site and inner cannula this is used:  Normal Saline Solution  Half-strength hydrogen peroxide  Alcohol  Tap Water
 Answer: B - Following the physician’s orders and

agency policy for cleaning the tracheostomy site and inner cannula, half-strength hydrogen peroxide is used --- Saunders 4th Edition pg.259

 To provide means of communication for a client with a    

tracheostomy, the nurse should not: Use Magic Slate Give paper and pencil to the client Keep the call light within the client’s reach Talk loud and clear in front of the client

 To provide means of communication for a client with a    

tracheostomy, the nurse should not: Use Magic Slate Give paper and pencil to the client Keep the call light within the client’s reach Talk loud and clear in front of the client alleviate apprehension and to provide means of COMMUNICATION --- Brunner & Suddarth’s Medical Surgical Nursing 10th Ed. Pg.612-613

 Answer: D - Major objectives of nursing care are to

While teaching the family of the client about how to suction his tracheostomy at home, the nurse should not include which of the following procedure?  Encourage the client to clear airway by coughing  Stress importance of adequate hydration  Instruct on how to determine the need for suctioning  Sterile gloves are used when suctioning

While teaching the family of the client about how to suction his tracheostomy at home, the nurse should not include which of the following procedure?  Encourage the client to clear airway by coughing  Stress importance of adequate hydration  Instruct on how to determine the need for suctioning  Sterile gloves are used when suctioning
 Answer: D - Clean gloves should be used when

endotracheal suctioning is performed in the home environment [ARRC, 1999] --Fundamentals of Nursing 7th Ed. Pg.1325

Which of the following action/s is/ are incorrect in tracheal suctioning?  Insert the catheter about 5 inches  Insert the catheter about 12.5cm  Apply intermittent suction for 5-10 seconds while withdrawing the catheter  Allow 5-10 minutes between suctions

Which of the following action/s is/ are incorrect in tracheal suctioning?  Insert the catheter about 5 inches  Insert the catheter about 12.5cm  Apply intermittent suction for 5-10 seconds while withdrawing the catheter  Allow 5-10 minutes between suctions
 Answer: D - Allow 2-3 minutes between suctions

to provide an opportunity for reoxygenation of the lungs---Fundamentals of Nursing 7th Ed. Pg.1324

While changing the tapes on the tracheostomy tube, the client coughs and the tube is dislodged. The initial nursing action is:  Grasp the retention sutures to spread the opening  Call the physician  Cover the tracheostomy site  Apply pressure on the tracheostomy site

While changing the tapes on the tracheostomy tube, the client coughs and the tube is dislodged. The initial nursing action is:  Grasp the retention sutures to spread the opening  Call the physician  Cover the tracheostomy site  Apply pressure on the tracheostomy site
 Answer: A - A dislodged tracheostomy tube is

difficult to reinsert, and respiratory distress may occur --- Brunner & Suddarth’s Medical Surgical Nursing 10th Ed. Pg.614

a) Only as necessary
b) Every 2-4 hours

Once a day d) Never- do not remove the inner cannula for any reasons
c)

a) Only as necessary
b) Every 2-4 hours c) Once a day

d) Never- do not remove the inner cannula for any

reasons

 Rationale
 Once a day cleansing ensures a decrease in growth of

microorganisms and prevents infection  Saunders and Kozier

a) Administering oxygen to the patient before

beginning suctioning b) Applying suction for 20 to 30 seconds; then suction again if no sample is obtained c) Advance the catheter into the trachea, touching the larynx to stimulate cough reflex d) Disconnecting the in-line trap from the suction tubing after suctioning and obtaining the specimen

a) Administering oxygen to the patient before

beginning suctioning b) Applying suction for 20 to 30 seconds; then suction again if no sample is obtained c) Advance the catheter into the trachea, touching the larynx to stimulate cough reflex d) Disconnecting the in-line trap from the suction tubing after suctioning and obtaining the specimen

 Rationale
 Applying suction for 20 to 30 seconds is too long; then

suction again if no sample is obtained may cause vagal stimulation that can lead to cardiac dysrythmia

a) Use of cuffed tracheostomy tube
b) Notify the physician because the child cannot be

inserted with tracheostomy tube c) Use of uncuffed tracheostomy tube d) Keep in mind that tracheostomy will only be use on a shot term basis

a) Change tie tapes every 24 hours

b) Change tracheostomy tie tapes before suctioning

secretions c) Put on face shields and clean gloves when cleaning d) Cleaning of the fresh stoma and suctioning should be performed every 4 hours

a) Change tie tapes every 24 hours

b) Change tracheostomy tie tapes before suctioning

secretions c) Put on face shields and clean gloves when cleaning d) Cleaning of the fresh stoma and suctioning should be performed every 4 hours

 Rationale
 In performing tracheostomy care trachea and pharynx

should be suctioned first before tracheostomy care. Sterile Gloves and cleaning of the fresh stoma should be done every 8 hours , cleaning the inner cannula is 24 hours and suction as needed. Change ties once a day or 24 hours.Lippincott manual of nursing 7th edition page 218-220

a) Respiratory rate and breathe sounds

b) Amount of oxygen ordered to be delivered

How long ago client received any pain medication d) Status of tracheostomy dressing
c)

a) Respiratory rate and breathe sounds

b) Amount of oxygen ordered to be delivered

How long ago client received any pain medication d) Status of tracheostomy dressing
c)

 Rationale  Assessment first the only objective data that peratins

to effectiveness of tracheostomy care the respiratory rate and breathe sounds. Subjective measures are unreliable eventhough the patient is stating it.

a) Call the doctor immediately b) Suction the stoma to remove residual secretions and

prepare new tracheostomy set c) Attempt to reinsert a new tracheostomy tube. d) Grasp and spread the retention sutures to open the stoma

a) Call the doctor immediately b) Suction the stoma to remove residual secretions and

prepare new tracheostomy set c) Attempt to reinsert a new tracheostomy tube. d) Grasp and spread the retention sutures to open the stoma

 Rationale
 Grasp and spread the retention sutures to open the

stoma this technique will ensure that the stoma won’t close. Other measures stated are done by the physician.  Saunders page 241

a) Change the tracheostomy tube b) Suction the tracheostomy tube

Obtain an Arterial Blood Gas(ABG) level d) Increase the oxygen flow rate
c)

a) Change the tracheostomy tube b) Suction the tracheostomy tube

Obtain an Arterial Blood Gas(ABG) level d) Increase the oxygen flow rate
c)

 Rationale
 Suction the tracheostomy tube is the best intervention

because the patient manifests poor oxygenation which might be cause by pool of secretions. Changing the trach set won’t relieve anything. There is already vital information of the O2 sat and pulse. ABG and increase of oxygenation requires physicians order.

a) Suction less than 10 seconds at a time
b) Regulate the suction machine at 300 cm suction

Apply suction to the catheter during insertion only d) Pass the suction catheter into the opening of the tracheostomy tube 2 to 3 cm
c)

a) Suction less than 10 seconds at a time
b) Regulate the suction machine at 300 cm suction

Apply suction to the catheter during insertion only d) Pass the suction catheter into the opening of the tracheostomy tube 2 to 3 cm
c)

• Ideal span of time for suctioning is from 10 to 15 seconds

more than this may interfere with ventilation of the client. Other choices have no basis

a) Change the disposable inner cannula touching the

external portion only b) Use your non-dominant hand when changing the dressing c) Ties should be changed every 24 hours and cleaning the stoma should be every 8 hours d) Tie the tapes at the sides of the neck in a square knot, suction every shift

a) Change the disposable inner cannula touching the

external portion only b) Use your non-dominant hand when changing the dressing c) Ties should be changed every 24 hours and cleaning the stoma should be every 8 hours d) Tie the tapes at the sides of the neck in a square knot, suction every shift

 Rationale
 Tie the tapes at the sides of the neck in a square knot,

suction every shift. Tying the tapes into square ensures smooth fastening and removal of the tie. Suction should be every shift or as the condition necessitates.

Which among the following is a corrrect technique in tracheostomy care? a. Inserting a decannulation plug into a tracheostomy tube until cuff is deflated and the inner cannula is removed. b. Tying two ends using a square knot with two fingers inserted as the knot is tied. c. If client is allowed to eat, ensure the cuff is deflated if the tube is not capped. d. . Cleanse the skin under the neck plate of tube with cotton applicator moistened with saline water.

Which among the following is a corrrect technique in tracheostomy care? a. Inserting a decannulation plug into a tracheostomy tube until cuff is inflated and the inner cannula is removed. b. Tying two ends using a square knot with two fingers inserted as the knot is tied. c. If client is allowed to eat, ensure the cuff is deflated if the tube is not capped. d. . Cleanse the skin under the neck plate of tube with cotton applicator moistened with saline water.

 Rationale: B. Never insert a decannulation plug into a

tracheostomy tube until cuff is deflated and the inner cannula is removed, and cuff should be inflated if the tube is not capped to prevent aspiration..(Saunders, p.221)  Skin under the neck plate should be cleansed with hydrogen peroxide and rinse with sterile or saline water. (Delmar’s Fundamentals of Nursing, p. 1007)

A client with neck cancer has a permanent tracheostomy. The nurse should primarily emphasize to the family the following as part of the long-term intervention A. Supporting psychosocial issues of the patient B. Using humidifiers to prevent thick, tenacious secretions C. Providing tracheostomy site care D. Observing early signs and symptoms of skin breakdown in the tracheostomy site

A client with neck cancer has a permanent tracheostomy. The nurse should primarily emphasize to the family the following as part of the long-term intervention A. Supporting psychosocial issues of the patient B. Using humidifiers to prevent thick, tenacious secretions C. Providing tracheostomy site care D. Observing early signs and symptoms of skin breakdown in the tracheostomy site Rationale: B. Providing adequate humidification to the client with tracheostomy is essential because the client no longer has the function of the nose for warming, moistening, or filtering the air when breathing to the site.

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