Tracheostomy Care Skills • During the skill ○ Promote patient involvement as possible.

○ Assess patient’s tolerance, being alert for signs and symptoms of discomfort and fatigue Completion of procedure ○ Assist the patient to a position of comfort and place needed items within easy reach. Be certain patient has a means to call for assistance ○ Remove gloves and all protective barriers. Store or remove and dispose of soiled supplies and equipment according to agency policy and guidelines form CDC and osha ○ Wash hands after patient contact and after removing gloves. ○ Document patient’s response, expected or unexpected outcomes, ,and patient teaching. ○ Report any unexpected outcomes Oxygen therapy ○ Goal of oxygen therapy is to prevent or relieve hypoxia ○ If combined with other factor, suh as an electrical spark or fire, it will support combustion and ignite. ○ Oxygen therapy is frequently initiated by respiratory therapist, who is a health care professional licensed to deliver Tx that will improve a patient’s ventilation and oxygenation needs. ○ The signs and symptoms manifested by patients who might require oxygen will vary according to the degree of oxygen deficiency. ○ Can not delegate oxygen therapy to assistant personnel Transtracheal oxygen delivery ○ A newer method of oxygen therapy ○ 2nd and 3rd tracheal cartilage ○ Care of the tracheostomy  Artificial opening made by a surgical incision into the trachea  Provide pt. /c a patent airway  The physician insert is a tracheostomy tube and secures it in place with cotton tape  Could be permanent or temporary  It is essential that nursing intervention be consistent  T piece tube • Require constant humidification to the airway • The t-pice is a t shaped deei with a 15mm connection with large-lumen tubing • Tracheostomy  Care of a tracheostomy

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Performed to provide the patient airway patent The primary nursing respon. Tis to maintain patent airway Keep the inner cannula clean Prevent impairment of surrounding tissue Provide a means of communication for the patient to trach suctionging and cleaning Assemble equipment Assess tracheostomy for exudates, edema and respiratory obstruction Position in semi-fowler position ○ This allows for optimum lung expansion ○ Provide paper and pencil for patient (This allows patient to communicate because patient cannot speak) Position self at head of bed ○ Always face the patient while cleaning a tracheostomy  This enables you to access respiratory difficulty and coughing, which expel cannula ○ Auscultate lungs – this provides a baseline assessment ○ Place towel or prepackaged drape under tracheostomy and across the chest this protects gown and bed linens ○ Prepare equipment  This organizes procedure ○ Open suction catheter leaving it in its wrapper and attach it to the suction machine  This maintains sterility ○ Pour cleansing sol’n in one basin and risinsing sol’n in another (w/ ungloved hnd if prepackaged basins) ○ The first basin should hold hydrogen peroxide  This cleanses mucus and secretions from inner cannula ○ Turn on suction machine ○ Apply other sterile glove. Keep dominant hand sterile. ○ Unlock and remove inner cannular place in hydrogen peroxide clensing solution ○ Place fingers on tabs of outer cannula ○ This prevents movement that may irritate surrounding tissue and cause pain and coughing.

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Suction inner portion of outer cannula Prior to suctioning the iner cannula moisten the catheter tip /c sterile saline rinsing solution Preoxygenate the patient Remove thumb from suction control  This prevents suctioning while inserting catheter which could damage the mucosa Insert catheter into trach tube using sterile gloved hand Insert catheter 5 – 6 inches The depth catheter should be the length of outer cannula and extend 1 to 2 inches beyond distal end. Apply intermittent suction by placing thumb on and off suction control and gently rotate catheter as it is withdrawn Suction for a maximum of 10 seconds NO LONGER  Prolonged suctioning depletes oxygen supply  Allow patient to rest between suctioning oxygenate them if previously receiving oxygen  Rinse with sterile saline solution and repeat  Turn off suction and dispose of catheter  Apply second sterile glove if one-glove technique was used or a new pair of sterile gloves • This reduces spread of microorganisms Insert inner cannula and click in place  This secures inner cannula and reestablishes oxygen supply  Clean skin around tracheostomy and tbs of outer cannula with hydrogen peroxide and cotton tipped swabs.  Change cotton tapes • Obtain assistance of another person who will stabilize the tracheostomy tube while one set of ties is removed and replaced. • Do this last Bing clean tape under back of neck

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Hold tracheostomy tube in place to prevent movement of cannula that could stimulate coughing and expelling cannula  Tie ends of two clean cotton tapes together  Auscultate ○ Reassess pat. Tracheostomy for signs and symptoms of bleeding, edema, and respiratory obstruction  Patient’s with tracheostomy frequently have bloody secretion ○ Single cannula tracheostomy is used and called a cuffed tracheostomy tube  It is made of plastic and has an inflatable cuff around the middle of the distal portion of the tube  The type may be ordered initially until the healing process is complete Care of patient with a cuffed tracheostomy ○ IPPB – intermittent positive Endotracheostomy ○ Provide direct route for introduction of pathogens into the lower airway, increasing the risk for infection. ○ Can the patient speak if he has a trach tube?  Endotracheal tubes with uninflated cuffs and syringe for inflation. Patients are unable to speak while tube is in place because air cannot flow through the vocal cords.  Fenestrated – trach tube with inner cannula removed  Trach tube with obturator for insertion and syringe for inflation of cuff is a piece Nursing action Gather equip. Suction pat. Connect This provide inflation/deflation of tube balloon While listening with stethoscope, slowly inflate cuff with 0.5 to 1 mL of air at a time When no air is heard stop withdraw up to 0.5 mL of air until air leak is auscultated with stethoscope If excessive air leak is heard, slowly add 0.5 to 1 mL of air at a time 

Air leak may prevent lung expansion and increase Sign and symptoms  Gurgling respirations  Restlessness  Vomitus in mouth  Drooling ○ Explain tha couging, sneezing,a nd gagging is expected ○ Position patitent – if the patient is conscious  Place in semi-fowler’s (30-45degree) position with head to one side  Placing head to one side promotes drainage of secretions and helps suction ○ If patient is unconscious  Place patient in side-lying position facing  Adults 110-150mm Hg  Common catheter size : Adults 12-16 French ○ Aspirate solution through cathether by placing thumb over open end of connector or over vent ○ Insert catheter ○ Oropharyngeal sunctioning  Gently insert yankauer or tonsillar tip of suction catheter • Gentleness prevents tissue trauma • Glide yankauer toward oropharynx without suction • Apply suction and move yankauer tip around mouth until secretions are cleared • Encourage patient to cough • Rinse yandauer with water in cup or basin until connector tube is clear of secretions Nasopharyngeal suctioning ○ Turn off suction ○ Nasopharyngeal suctioning ○ Sterile gloves should be worn ○ Holding suction cath with thumb and index finger, place nasea catheter near patient’s earlobe tip of nose  This marks the catheter for correct length  Length of insertion for adult = 16 cm  Lubricate with water-soluble jelly ○ ○

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Hold catheter and gently insert c-into one side of nasal catheter  Sterile gloves should be worn  Hold catheter with thumb and index finger, place naasotraheal catheter near earlobe to tip of nose and extend to trachea  Do not touch side of face, nose or earlobe maintain sterility  Length insertion adult =20-44cm Lubricate catheter with a water soluble jelly Ask patient if either side of nose is obstructed use unobstructed side Stimulate cough reflex or have patient to cough Apply intermittent suction by moving thumb over opening rotate catheter gently as it is withdrawn. Observe patient closely suction no loner than 10-15 seconds Allow rest periods of 1-2 minutes in between suctions Place catheter in solution and apply suction Discard catheter Place sterile and unopened catheter at patient’s bedside Provide mouth care Assess breathing pattern Document 

Identify at least four safety precaution for oxygen use in the hospital and home environment (559) The patient is to receive oxygen. What assessments should be made by the nurse (560) When performing tracheostomy care, the nurse is aware of the following: (565-557) Cleansing solution to be used Rinsing solution to be used The part that is removed for cleaning Safety measures What can the nurse do to reduce possible sensory deprivation for the patient with a tracheostomy? 567-568

What criteria are used for the reinflation of a tracheostomy cuff? (570) In prepairing to suction a patient, the nursing implements the following (571-573) Position patient: semi fowler position Appropriate vacuum pressure for adult patient: 110 to 150 mmHg Check the patency of suction catheter tubing by placing thumb over open end of connector or open vent Lubricant use on tubing with water soluble jelly Length of insertion for nasotracheal suctioning for adult patient 20 to 24 cm. Suctioning performed for 10-15 seconds. Identify at least two signs or symptoms of hypoxia (562) 1. Apprehension, anxiety, restlessness 2. Decreased ability to concentrate The patient is to receive oxygen via a nasal cannula. The nurse is aware that the usual flow rate is 2 L/min. Ccomfort measures that should be implemented for this patient include: proper placement of prongs to prevent oxygen from coming in direct contact with nasal Flow rate for the patient who is to receive oxygen via a face mask is 6-10 L/min. The patient requires suctioning pulmonary secretions. Nursing diagnosis = ineffective airway clearance The nursing is working in the special care nursery and will be suctioning the airways of infants. For this age goup, the pressure of the wall suction should be set at: (571) 50 to 95 mm Hg Preparation for tracheostomy care in the acute care environment include: (565567) Preparing cotton swabs with hydrogen peroxide and saline • • • • • • • Salem Sump – a double-lumen tube: one provides an air vent and the other is for removal of gastric contents Dubhoff Cantor Levin – has one lumen and several openings near the tip Foley Lavacuator Sengstaken

Blakemore Know what they are used for.

Of a person has a feeding tube, which for a following type of client? Person needs more teaching if: Which of the following supplies that the nurse gets wrong that get the wrong item. ( straw, tapes)

Gastric content the amount should not exceed 120. Know the names of the tube and what are they used for. Gastric secretion is green.

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