NURS 3725 WEEK 1

Family Care Conferences and Teaching-Learning Process

Family Care Conferences:
 Purpose: Held mainly in hospitals, these conferences offer a platform for
patients, caregivers, and the interdisciplinary healthcare team to:
o Identify care needs.
o Evaluate care goals.
o Assist in planning and coordination of care.
 Functions:
o Teaching: The team educates patients and caregivers about health
strategies and complication prevention.
o Assessment: Identifies additional care needs and shares information on
community supports.
Teaching Plan:
 Assessment: Evaluate the patient’s ability and readiness to learn.
 Identification of Needs: Determine what teaching is required.
 Development of Goals: Set specific learning goals with the patient.
 Implementation: Conduct the teaching sessions.
 Evaluation: Assess the patient’s learning outcomes.
Teaching-Learning Process:
 Teaching: Involves planning and sharing knowledge to achieve specific
learning outcomes in cognitive, affective, and psychomotor domains.
 Learning: The acquisition of knowledge, skills, or attitudes that can result in a
lasting change.
Adult Learning Principles:
 Foundations: Based on Knowles’ principles of andragogy, which are essential
for effective adult teaching. These principles address how adults learn best
and include:
1. Self-Concept: Adults are self-directed learners.
2. Experience: Adults draw on their experiences as a learning resource.
3. Readiness to Learn: Learning is relevant to adults’ current life
situations.
4. Problem-Centered Approach: Adults learn best when the material is
problem-oriented.
5. Motivation: Adults are motivated by internal drives.
6. Relevance: Learning should be directly applicable to their daily lives.
7. Practicality: Adults prefer practical and immediately useful information.

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Determinants of Learning:
 Assessment Needs: Evaluate the patient’s:
o Health Literacy: Understanding of health information and instructions.
o Learning Style: Preference for how they receive and process
information.
o Social Support: Availability of support systems that facilitate learning
and adherence.
Principles of Adult Learning Applied to Patient Teaching
[Link] of Learners:
 Teaching Implications:
o Act as a facilitator rather than the sole provider of information.
o Encourage patients to make their own decisions about learning and
taking responsibility.
2. Readiness to Learn Arising from Life’s Changes:
 Teaching Implications:
o Recognize that patients are more motivated to learn when faced with
new tasks or problems.
o Use health crises or significant life changes as “teachable moments”

3. Past Experiences as Resources for Learning:

 Teaching Implications:
o Build on the patient’s previous experiences and informal learning.
o Use past knowledge to ease the transition to new learning and boost
confidence.
4. Immediate Value of Learning:
 Teaching Implications:
o Focus on teaching content that the patient can apply immediately.
o Emphasize short-term, realistic goals that are directly relevant.
o Avoid overloading with long-term goals

5. Problem-Solving Approach to Learning:

 Teaching Implications:
o Tailor information to address the patient’s specific problems or issues.
o Provide explanations on why certain information is relevant if the
patient does not initially see its importance.
6. Active Learning:
 Teaching Implications:
o Offer hands-on learning opportunities such as demonstrations, practice
sessions, or interactive activities.

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 o Facilitate learning through active engagement rather than passive
reception.
[Link] to Learning:
 Teaching Implications:
1. Avoid treating patients in a paternalistic manner; respect their
autonomy and self-direction.
2. Provide choices and involve patients in their learning process
Nurse as Teacher: Required Competencies and Challenges
[Link] of Subject Matter:
 Competency:
1. Develop a solid understanding of the subject matter to confidently
teach patients.
 Application:
1. Provide comprehensive information about the condition, treatment
options, and resources for further learning.
2. Stay updated with current information and guidelines
3. If uncertain about an answer, inform patient, seek the correct
information, and follow up.
2. Communication Skills:
 Competency:
1. Use effective communication to build a partnership with the patient
and caregiver.
2. Use both verbal and nonverbal communication
 Application:
1. Facilitate empowerment by helping patients identify their strengths
and engage in their own care.
2. Avoid medical jargon
3. Practice active listening, provide feedback, and allow time for
responses without rushing.
3. Empathy:
 Competency:
1. Demonstrate empathy by understanding and validating the patient's
feelings and experiences.
 Application:
1. Assess the patient’s emotional state before starting the teaching
process and address their concerns respectfully.
2. For example, if a patient is distressed, acknowledge their feelings and
offer support, creating a space for more effective teaching.
4. Challenges in Patient and Caregiver Teaching:
 Time Constraints:

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 1. Challenge: Limited time can impact the depth and effectiveness of
teaching.
2. Strategy: Clearly communicate available time at the start of the
interaction and prioritize essential information.
 Expectations and Readiness:
1. Challenge: Mismatched expectations or patient readiness can hinder
learning.
2. Strategy: Discuss and align teaching goals with the patient’s
readiness and willingness to learn.
 Group Teaching:
1. Challenge: Teaching groups can be difficult, especially in acute
situations like a pandemic.
2. Strategy: Adapt teaching methods to the group’s literacy level and
follow public health directives.
 Healthcare System Complexity:
1. Challenge: Shorter hospital stays and complex treatments increase
educational needs.
2. Strategy: Provide clear, concise information and follow-up resources
for patients being discharged with complex care needs. Assist patients
in navigating resources and support systems.

Suggested Approaches to Overcoming Challenges in Patient and Caregiving

Teaching

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ASSESSMENT OF CHARACTERISTICS THAT AFFECT PATIENT TEACHING:

Physical - What is the patient’s age and sex?

- Is the patient acutely ill?
- What is the primary diagnosis?
- Are there other medical problems?
- What is the patient’s hearing ability? Visual ability?
Motor ability?
- What medications does the patient take?
- What is the physical environment where teaching will
occur
Sociocultur Sociocultur
al al
- - Is the patient employed? Current occupation?
- financial status?
- living arrangement?
- family or close friends?
- What are the patient’s beliefs regarding their illness or
treatment?
- What is the patient’s cultural-ethnic identity?

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Education - literacy level? ?- What does the patient already know?
al - What prior learning experiences establish a frame of
reference for current learning needs?
- Is the patient ready to change behavior or learn?
- Can the patient identify behaviors and habits that would
make the problem better or worse?
- How does the patient learn best
- In what kind of environment does the patient learn best:
formal classroom, informal setting, alone, among peers?
Psychologi What is the patient’s current mental status?
cal - Does the patient appear anxious, afraid, depressed, or
defensive?
- Is the patient in a state of denial?
- What is the patient’s level of self-efficacy?
- Is the timing for teaching appropriate?

TECHNIQUES TO ENHANCE PATIENT LEARNING

• Keep the physical environment relaxed and nonthreatening.
• Maintain a respectful, warm, and enthusiastic attitude.
• Let the patient’s expressed needs direct what information is provided.
• Focus on “must-know” information;
• Be aware of and take into consideration the patient’s previous experiences.
• Individualize the teaching plan, even if standardized plans are used.
• Review written materials with the patient.
CHEST TUBES
A pneumothorax is the accumulation of air in the pleural space, causing the lung to
collapse due to the loss of negative pressure. It can occur spontaneously or due to
trauma. Symptoms include sharp, pleuritic pain and worsening dyspnea.
A hemothorax involves blood and fluid accumulation in the pleural cavity, often due
to trauma or ruptured blood vessels from conditions like pneumonia or TB. It hinders
lung expansion and can cause shock if blood loss is significant.
Chest drainage systems, such as Atrium or Pleur-Evac, manage pneumothorax and
hemothorax by removing air and fluid. These systems may have one, two, or three
chambers, with varying capabilities for drainage, water seal, and suction control.
Summary of Chest Tube Removal
 Criteria for Removal: Chest tubes are removed once the lungs have re-
expanded and fluid drainage has stopped, - CONFIRMED VIA CXR . Suction is
usually discontinued, and the patient is placed on gravity drainage before
tube removal.
 Removal Procedure:
o Sutures are cut, and a sterile petroleum jelly gauze dressing is applied.

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 o The patient is instructed to take a deep breath, exhale, and bear down
to prevent air from entering the pleural space during CT removal
o Pain medication is typically administered beforehand to minimize
discomfort.
 Post-Removal Care:
o An airtight dressing is applied to the site, allowing the pleura to seal
and the wound to heal over a few days.
o A follow-up CXR is performed to check for pneumothorax or fluid re-
accumulation.
o The wound should be monitored for drainage, and the dressing should
be reinforced if necessary.
o Continuous observation of the patient for signs of respiratory distress is
essential, as this may indicate a recurrence of pneumothorax.

Potter & Perry (2020) Clinical Skills... Chapter 27 pp. 745-765

Principles for Practice
Pleural Space and Related Conditions:
 The pleural space between the visceral and parietal pleura contains 7-20 mL
of lubricating fluid to facilitate respiration.
 Air, blood, pus, or lymph fluid may enter this space due to trauma, disease, or
surgery, causing lung collapse.
 Pleural effusion involves excess fluid in the pleural space, requiring diagnostic
thoracentesis and fluid analysis.

Chest Tube Management:

 Chest tubes remove air or fluid from the pleural space to improve
oxygenation and ventilation.
 Tube placement varies: high for air (apical) and low for fluid
(posterior/lateral).
 Mediastinal tubes prevent fluid accumulation around the heart, commonly
used post-surgery.
 One-way valves (e.g., Heimlich valves) and pigtail catheters allow for
ambulatory management of pneumothorax.
Chest Drainage Systems:

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  Systems like Atrium and Pleur-Evac manage drainage through single, two, or
three-chamber configurations:
o Single chamber: For pneumothorax but not ideal for fluid.

o Two/Three-chamber: Effective for both pneumothorax and

hemothorax with compartments for fluid, water seals, and suction.
Care and Safety Guidelines:
 Prevent infection and monitor for chest tube blockages or leaks.
 Avoid clamping tubes without a provider’s order, except for specific
situations.
 Maintain drainage systems below chest level and ensure tubing is free from
kinks.
 Monitor drainage output, changes in respiratory status, and potential leaks to
maintain patient safety.

Water-Seal and Waterless Chest Drainage Systems Overview:

Two-Chamber Water-Seal System:
 On expiration, air/fluid exits the pleural space and is pulled through the chest
tube into the collection chamber.
 The water-seal chamber vents air from the system to the atmosphere; it must
remain upright to maintain the seal. Tipping the system disrupts this seal.
Three-Chamber Water-Seal System:

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  Adds a suction-control chamber filled with sterile water, determining the
suction level based on water height (e.g., 20 cm).
 Bubbling in the suction chamber indicates suction is functioning; absence
suggests no suction.
 The middle chamber (water seal) prevents air from re-entering the pleural
cavity during inhalation. Bubbling here signals an air leak.
Two-Chamber Waterless System:
 Functions without fluid; tipping does not affect patient safety.
 A one-way valve replaces the water seal; a diagnostic air-leak indicator
visualizes air leaks.
 Fluid tidalling indicates lung expansion; cessation after 2-3 days suggests
lung re-expansion. Bubbling in the air-leak indicator indicates a leak that
needs correcting.
Three-Chamber Waterless System:
 Includes a suction chamber; the suction level is set by a float ball or bellows.
 The system safeguards against excessive suction to prevent tissue injury.
Dry Suction System:
 Offers advantages like higher pressure levels, quiet operation, and easy setup
without water in the suction-control chamber.
 Uses a self-compensating regulator and a preset dial (typically -20 cm water
pressure, adjustable from -10 to -40 cm).
Delegation and Collaboration:
 Chest tube management is a nursing responsibility and cannot be delegated
to UCPs.
 UCPs should be trained to position patients properly, assist in ambulation,
and monitor for changes in vital signs or chest drainage. Any disconnections,
sudden changes in drainage, or abnormal bubbling should be reported to the
nurse immediately.

Communication and Documentation:

1. Documenting Assessments:
o Record respiratory assessments, type and settings of the drainage
device, amount of suction if used, and amount of drainage in the
chamber.

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 o Note the presence or absence of air leaks and the integrity and
color/type of drainage.
o Document patient comfort levels and baseline vital signs, including
oxygen saturation. For postoperative patients, record these every 15
minutes for the first 2 hours.
2. Patient Education: Document patient teaching and their understanding on
a flow sheet or in the electronic health record (EHR).
3. Reporting: Report any unexpected outcomes immediately to the nurse in
charge or the healthcare provider.
Special Considerations:
Teaching:
 Advise patients to remain in bed if the tube is attached to suction and to
avoid lying on or kinking the tubing.
 Instruct patients to report any changes in chest comfort immediately and to
seek help if the tube becomes dislodged.
Pediatric Care:
 Use pictures and dolls to explain the equipment to children + families before
insertion.
 For pediatric patients, note that drainage greater than 3 mL/kg/hr for more
than 3 consecutive hours is excessive and requires immediate notification of
the healthcare provider.
Gerontological Care: Older patients may have fragile skin; assess and care for the
skin around the chest tube frequently to prevent breakdown.
Care in the Community:
1. Home Management:
o Patients with chronic conditions requiring long-term chest tubes may
use smaller mobile drains at home.
2. Instructions for Caregivers:
o Educate on when to contact HCPs about issues such as chest pain,
breathlessness, changes in drainage color or amount, or leakage
around the chest tube.
o Provide information specific to the type of drain and ensure patients
can demonstrate proper maintenance.
3. Special Cautions: Use small-bore chest tubes and Heimlich valves
cautiously in patients on mechanical ventilators due to the risk of rapid air
accumulation and tension pneumothorax.

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Autotransfusion of Chest Tube Drainage
 Purpose: Autotransfusion involves reinfusing blood lost from trauma, injury,
or surgery back into the patient's circulatory system. It is commonly used
with chest drainage to safely and cost-effectively replace lost blood.
 Benefits:
o Provides an immediate blood supply.

o Eliminates the risk of transfusion reactions.

o Enhances oxygen delivery to vital organs.

Requirements:
 IV Line: A patent intravenous (IV) line must be in place for reinfusion.
 Contraindications: Autotransfusion is not suitable for patients with:
o Coagulation disorders

o Septicemia

o Cancer

o Renal or hepatic insufficiency

Tyerman et al. (2023) pp. 613-617 (4th ed. pp. 626-629)

CHEST TUBES AND PLEURAL DRAINAGE
Purpose and Insertion:
 Chest tubes can be inserted in many settings ie emerge room, op table. Tubes
are placed based on the type of drainage needed: anterior for air and
posterior for fluid.
Pleural Drainage System:
 The drainage system consists of three compartments:
1. Collection Chamber: Receives fluid and air from the chest cavity.
2. Water-Seal Chamber: Prevents backflow of air into the patient;
bubbling indicates air evacuation.
3. Suction Control Chamber: Regulates the amount of suction; typically
set at -20 cm H2O.
Types of Systems:
 Wet Suction: Uses water for suction control; bubbling indicates functioning.

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  Dry Suction: Uses a regulator, with no water involved, making it easier to
manage.
Special Devices:
 Heimlich Valves: One-way valve for evacuating air, used in emergency or
home care settings. This device consists of a rubber flutter one-way valve
within a rigid plastic tube. It is attached to the external end of the chest tube.
The valve opens whenever the pressure is greater than the atmospheric
pressure and closes when the reverse occurs
 Small Chest Tubes ("Pigtail Catheters"): Less traumatic, but prone to kinking
or occlusion. Not suitable for draining blood or trauma patients.
Nursing Management:
 Routine milking or stripping of tubes is not recommended due to the risk of
high intrapleural pressure and can damage pleural tissue. Newer chest tubes
are coated to prevent clotting, making such measures unnecessary. The focus
should be on pain management, securing tubes, and avoiding unnecessary
clamping, which can lead to tension pneumothorax.
Complications:
 Common complications include tube malposition, infection, re-expansion
pulmonary edema, hypotension from rapid fluid removal, and pneumonia.
Proper sterile technique, patient teaching, and monitoring are essential to
prevent these issues.
NURSING MANAGEMENT
Summary of Nursing Care for Chest Drainage Systems
Nursing Guidelines:
 Avoid Routine Milking or Stripping
 Pain and Tube Stability: Chest tube insertion and maintenance can be painful
for patients. Tubes must be stabilized to prevent dislodgement.
 Clamping Practices: Clamping chest tubes during transport or disconnection
is no longer recommended due to the risk of tension pneumothorax from
rapid air accumulation in the pleural space. Clamping is only advised briefly
for changing drainage systems or checking air leaks and during tube removal
simulation.
 Chest Tube Disconnection: If a chest tube becomes disconnected, the primary
intervention is to quickly re-establish the water-seal system and connect a
new drainage setup. In some cases, the disconnected tube is temporarily
placed in sterile water to maintain a seal until proper reconnection.
Keenan et al. (2022) pp. 1109-1110

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Emergency Care: Tube Occlusion and Accidental Dislodgement
NURSING ALERT
Life-threatening occlusion is apparent when the child displays signs of respiratory
distress and a suction catheter cannot be passed to the end of the tube despite
several attempts. This situation requires an immediate tube change,
Accidental decannulation also requires immediate tube replacement. Some children
have a fairly rigid trachea, so the airway remains partially open when the tube is
removed. However, other kids have malformed or flexible tracheal cartilage, which
causes the airway to collapse when the tube is removed or dislodged.
Because many infants and children with upper airway difficulties have little airway
reserve, a smaller-sized tube should be inserted if replacement of the dislodged
tube is impossible.
Summary of Nursing Alert and Chest Tube Procedures
Chest Tube Procedures:
 Nursing Responsibilities:
o Assist with placement, management, monitoring of chest tube
dressings, and removal.
o Check for risks of bleeding before insertion and ensure correct setup of
the drainage system.
o During the procedure, monitor airway, breathing, circulation, and
oxygen levels.
o Secure tubing and adjust suction as prescribed (10-20 cm H2O).

o Monitor the system for clots or obstructions and avoid tube clamping
unless necessary.
Assessment Guidelines:
 Monitor drainage type, amount, and signs of infection or leakage.
Ensure the chest tube and dressing are intact, and the prescribed suction is
applied correctly.

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TRACH CARE
Tyerman et al. (2023) pp. 576-580
(4th ed. pp. 587-593)
A tracheostomy is a surgical
procedure where an incision is
made into the trachea to create an
opening (stoma) for an artificial
airway, typically through a
tracheostomy tube. This procedure
is used to:
1. Bypass upper airway
obstructions.
2. Facilitate the removal of
secretions.
3. Enable long-term mechanical
ventilation.
4. Aid in oral intake and speech
for patients needing
extended ventilation.
Tracheostomies are preferred over
endotracheal tubes (ETTs) for long-
term ventilation due to increased
comfort and reduced risk of vocal
cord damage.
Nursing management of
tracheostomies involves explaining
the procedure to patients and
caregivers, managing various types of tubes, and addressing potential
complications.
Key aspects of care include:
 Keeping spare tracheostomy supplies at the bedside.
 Cleaning the inner cannula if present.
 Suctioning the airway to remove secretions.
 Changing tracheostomy ties.
 Managing cuff inflation pressures to avoid trach damage.
For cuffed tracheostomy tubes, it's crucial to use minimal air to avoid compressing
tracheal capillaries and causing damage. Cuff deflation may be performed to clear
secretions, and careful monitoring is needed to ensure the airway remains
protected.

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Tracheostomy Management Overview:
1. Cuffless Tube Use:
o When: A cuffless tracheostomy tube is used when the patient can
protect the airway from aspiration and does not need mechanical
ventilation.
o Advantages: Avoids complications related to cuff inflation and
supports easier swallowing.
2. Retention Sutures and Tube Dislodgement:
o Retention Sutures: Often placed to secure the trachea and should be
taped for accessibility in case of tube dislodgement.
o Precautions: Keep a replacement tube at the bedside, avoid changing
tracheostomy tapes for 24 hours post-insertion, and ensure the first
tube change is performed by a physician after about 7 days.
3. Handling Accidental Decannulation:
o Replacement Procedure: Use a tracheal dilator or hemostat to open
the stoma and insert a replacement tube with an obturator. Remove
the obturator immediately to allow airflow.
o Alternative Method: Insert a suction catheter to facilitate tube
replacement.
o Emergency Care: If the tube cannot be replaced, manage respiratory
distress by pt positioning and providing bag-mask ventilation.
4. Routine Tube Changes:
o Frequency: Change the tube approximately once a month after the
initial period.
o Patient Training: Patients can learn to change their tube using clean
technique at home once the stoma is well-healed.
5. Swallowing Dysfunction:
o Cuff Impact: An inflated cuff may cause swallowing difficulties; assess
aspiration risk with the cuff deflated.
o Management: If safe, deflate the cuff or use a cuffless tube to
improve swallowing.
6. Vocalization:
o Techniques: Use techniques like cuff deflation or special tubes
(fenestrated, speaking valves) to facilitate speech.

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 o Fenestrated Tube: Allows airflow over vocal cords but requires
careful monitoring for aspiration and respiratory distress.
o Speaking Valve: Requires a cuffless tube or cuff deflation and allows
voice production by directing air over vocal cords.
7. Decannulation:
o Process: Remove the tracheostomy tube when the patient can
breathe and expectorate normally. Close the stoma with tape strips
and cover with an occlusive dressing.
o Post-Removal Care: Instruct the patient to splint the stoma during
activities like coughing or speaking. The stoma will close naturally
within a few days.
Procedure for Suctioning a Tracheostomy Tube
1. Assessment: Evaluate the need for suctioning every 2 hours or as needed
based on coarse crackles, wheezes, moist cough, restlessness, or decreased
oxygen levels. Avoid routine suctioning if the patient can clear secretions by
coughing.
2. Explain the Procedure:
3. Prepare Equipment:
4. Adjust Suction Pressure: Set suction pressure to 100-150 mm Hg for
adults or 50-100 mm Hg for infants and children.
5. Wear Protective Gear:
6. Use Sterile Technique:
7. Baseline Monitoring: Check and document SpO2, heart rate, and rhythm.
8. Preoxygenate: Use a reservoir-equipped mask for 100% oxygen or have the
patient take deep breaths. Choose the method based on patient condition
and acuity.
9. Insert Catheter: Gently insert the catheter without suction to minimize
oxygen loss, then advance it 13-15 cm. Stop if obstruction occurs.
[Link] Technique: Withdraw the catheter slightly (1-2 cm) and apply
suction intermittently while rotating the catheter. For large volumes of
secretion, use continuous suctioning.
[Link] Suction Time: Keep suctioning to 10 seconds. Stop if heart rate
changes significantly, dysrhythmia occurs, or SpO2 drops below 90%.
[Link]: Provide oxygen with three to four breaths or deep breaths
after each suction pass.
[Link]-Use Catheters: Do not reintroduce single-use catheters into the
tracheostomy tube.
[Link] if Needed: Repeat suctioning until the airway is clear,
[Link] Oxygen Levels: Return oxygen concentration to pre-suction settings.
[Link] Suctioning: Suction the oropharynx or use mouth suction if
needed.
[Link] of Equipment:

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 [Link]-Procedure Assessment: Listen to lung sounds, and document the
time, amount, character of secretions, and the patient’s response to
suctioning.

Tracheostomy Care Procedure

1. Explain Procedure:
2. Prepare Equipment:
3. Position the Patient: in a semi-Fowler’s position.
4. Assemble Materials:
5. Wear Protective Gear:
6. Assess and Suction: Auscultate chest sounds. If wheezes or crackles are
present and the patient cannot clear secretions, suction the airway. Remove
soiled dressing and clean gloves afterward.
7. Prepare Sterile Equipment:
8. Inner Cannula Care:
1. If an inner cannula is present, unlock and remove it.
2. For disposable cannulas, replace with a new one.
3. For nondisposable cannulas:
1. Immerse in sterile normal saline and clean with a tube brush or
pipe cleaners.
2. Rinse in normal saline and shake to dry.
3. Insert and lock the inner cannula into the outer cannula, curved
part downward.
9. Clean the Stoma: Remove dried secretions from the stoma, outer cannula,
and neck plate with gauze pad soaked in normal saline. Gently pat the area
around the stoma dry.
[Link] Retention Sutures: If present, tape above and below the stoma
to keep retention sutures in place.
[Link] Tracheostomy Ties:
1. Secure new ties to the flanges before removing old ones.
2. Tie securely with room for one finger between ties and skin.
3. Apply gentle pressure to the tube’s flange to prevent accidental
removal during the tie change.
[Link] Ties: Velcro ties may be used as they are easier to adjust.
[Link] Excessive Drainage: Place dressings around the tube if drainage
is excessive. Use unlined gauze or trache dressing. Avoid cutting gauze to
prevent inhalation of threads.
[Link] Care: Perform tracheostomy care three times a day and as needed.

Keenan et al. (2022) pp. 1107-1109

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Tracheostomy in Pediatric Patients
Pediatric tracheostomy tubes are usually plastic or Silastic and are designed to
soften at body temperature and conform to the trachea and eliminating the need for
an inner cannula.
Common Tube Types:
 Bivona, Tracoe, Arcadia, Hollinger, Shiley
Monitoring and Care: Children with a tracheostomy require vigilant monitoring for
complications Nursing care focuses on maintaining airway patency, managing
secretions, providing humidified air or oxygen, and preventing complications.
Key Considerations:
1. Observation and Monitoring:
1. Direct observation and use of respiratory and cardiac monitors are
crucial.
2. Do a full resp assessment
3. Large amounts of bloody secretions may indicate hemorrhage;
2. Positioning:
1. Keep the child in a semi-Fowler’s position or in the most comfortable
position, with the call light within reach.
3. Equipment at Bedside:
1. Keep suction catheters, suction source, gloves, sterile saline, gauze,
scissors, extra tracheostomy tubes (same size and one size smaller),
and an obturator.
4. Humidification and Hydration:
1. Provide a humidification source because the airway's natural
humidification is bypassed.
Suctioning:
1. Frequency and Technique:
a. Suction frequently in the first hours post-tracheostomy to clear mucous
plugs and secretions.
b. Use proper vacuum pressure: 60-100 mm Hg for infants and children;
40-60 mm Hg for preterm infants.
c. Select a suction catheter with a diameter half that of the tracheostomy
tube.
d. Avoid instilling saline before suctioning as it is no longer
recommended.
2. Procedure:
a. Limit suctioning to 5 seconds to prevent obstruction.
b. Hyperventilate the child with 100% oxygen before and after suctioning.
c. Allow 30-60 seconds of rest between suctioning passes, limiting to
about three passes per period.
d. Monitor oxygen saturation and prevent hypoxia.

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Routine Care:
1. Stoma Care:
a. Perform daily assessments for infection and skin breakdown.
b. Clean with half-strength hydrogen peroxide (avoid with sterling silver
tubes).
c. Prevent skin breakdown from wet dressings.
2. Tracheostomy Ties:
a. Use durable, non-fraying ties. Change daily or when soiled.
b. Use Velcro ties if available, or cotton ties tied snugly with a triple knot.
3. Tube Changes:
a. Change the tube weekly once the tract has formed, ideally with two
caregivers.
b. Perform changes before meals or 2 hours after the last meal.
c. Use sterile technique
4. Humidification:
a. Use humidification systems to prevent drying of mucosa.
5. Inner Cannula:
a. Remove and clean with sterile saline and pipe cleaners with each
suctioning. Reinsert after drying.
Emergency Care:
1. Tube Occlusion: Immediate tube change is required
2. Accidental Decannulation: Replace the tube immediately. If replacement
fails, insert a smaller tube or perform oral intubation if necessary.

Potter & Perry ( 2020) Clinical Skills Chapter 25 Tracheal Care pp. 725-733

Delegation and Collaboration in Tracheostomy Care

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Delegation to Unregulated Care Providers (UCPs):
 Routine Care: However, in some settings where patients have well-
established tracheostomies and the care is stable, it may be delegated to a
UCP as per employer policy.
Nurse's Responsibilities:
1. Assessment and Evaluation:
a. The nurse evaluates the patient’s condition, ensuring that the artificial
airway is managed properly.
b. Collaborate with other healthcare professionals to provide
comprehensive care.
2. Patient and Caregiver Education:
a. Educate the patient and caregiver on how to manage a tracheostomy
at home, including signs to watch for and how to respond to potential
issues.
Delegated Tasks and Reporting: If tracheostomy care tasks are delegated to a
UCP, the following points are crucial:
1. Respiratory Status:
2. Level of Consciousness:
3. Comfort Level:
4. Tube Dislodgement or Movement:
5. Stoma Color and Drainage:
Tracheostomy Care Procedure
ASSESSMENT:
1. Patient Identification:
2. Hand Hygiene and Preliminary Checks: Observe for signs such as
gurgling on expiration, decreased tidal volume, inadequate ventilation,
spasmodic coughing, and changes in the test balloon.
3. Examine Tracheostomy Area: Check for excess secretions, soiled ties or
dressing, and signs of airway obstruction.
4. Inspect Skin: Look for skin breakdown, incl blistering, erythema, or
drainage around stoma.
5. Assess Overall Status: Evaluate hydration, humidity, infection status,
nutrition, and ability to cough.
6. Cardiopulmonary Status: Monitor vital signs, SpO2, end-tidal CO2,
respiratory effort, and lung sounds.
7. Assess Understanding: Ensure the patient or caregiver understands
tracheostomy care.
8. Check Last Care: Verify when the last tracheostomy care performed.
NURSING DIAGNOSES:
 Inadequate airway clearance
 Inadequate breathing pattern

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  Reduced gas exchange
 Insufficient knowledge of tracheostomy care
PLANNING:
1. Expected Outcomes:
a. Cannulas and ties are clean and secure.
b. Stoma is pink, free of infection, and skin is intact.
c. No skin breakdown under ties or holder.
2. Assistive Help: Have another hcp assist to prevent accidental extubation.
3. Preparation: Perform hand hygiene, gather supplies, and ensure privacy.
4. Patient Positioning: Assist the patient into a comfortable position with the
HOB elevated.
5. Procedure Explanation: Explain the procedure to reduce anxiety and
ensure cooperation.
EVALUATION:
1. Effectiveness: Compare pre- and post-care assessments to evaluate
effectiveness.
2. Fit and Comfort: Check the fit of tracheostomy ties and comfort.
3. Cannula Inspection: Inspect cannulas for secretions.
4. Skin Assessment: Check for inflammation, bleeding, or abnormal
discharge.
5. Airway and Fistula Check: Observe for excessive phonation or signs of
a tracheoesophageal fistula.
6. Teach-Back:
Unexpected Outcomes and Interventions:
1. Loose/Tight Ties: Adjust or replace ties or holder.
2. Cuff Leak: Verify tube position, notify respiratory therapy, and follow policy.
3. Stoma Inflammation: Increase care frequency, use topical treatments, and
consult specialists if needed.
4. Accidental Decannulation: Call for help, replace the tube, and ensure
oxygen delivery.
5. Respiratory Distress: Remove and clean cannula or suction as needed.
Special Considerations
Teaching:
 Faceplates: Explain that different TTs have different faceplates—some are
rigid. Caregivers should not lift rigid faceplates as this can dislodge the tube.
 Tie Adjustment: Some commercial TT holders need excess tie material
trimmed to fit properly.
 Long-Term Care: Plan comprehensive teaching for patients and caregivers if
long-term tracheostomy placement is anticipated.

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  Secretions: Inform that new tracheostomies may have bloody secretions for
2-3 days post tubing change.
Pediatric Care:
 Neck Length: Children often have shorter necks, making stoma cleaning
more challenging.
 Tube Size: Pediatric TTs (size 4 or smaller) usually do not have an inner
cannula.
 Routine Changes: Perform TT changes weekly after the tracheostomy tract
has formed, generally after 5 days.

Potter & Perry (2019) Fundamentals Chapter 39 Tracheal Suctioning pp. 980-989,
Tracheal Care pp. 994-997
Types of Suctioning
1. Oropharyngeal and Nasopharyngeal Suctioning
 Purpose: To clear secretions from the oropharynx (behind the mouth) and
nasopharynx (behind the nose) in patients who can cough but cannot clear
secretions effectively.
 Procedure:
o Oropharyngeal Suctioning: Performed through the mouth to reach
the oropharynx. This is typically done after the patient has attempted
to cough up secretions.
o Nasopharyngeal Suctioning: Done through the nose to access the
nasopharynx. This can be necessary when secretions are present but
the patient cannot clear them via coughing or swallowing.
 Technique:
o Use a clean suction catheter with a rounded tip.
o Insert the catheter gently into the oropharynx or nasopharynx,
depending on the target area.
o Apply suction intermittently while withdrawing the catheter.
o Follow up with oral care if needed.
 Indications: Use when:
o The patient cannot clear secretions despite effective coughing.
o Secretions are visible or audible.
o The patient shows signs of distress or difficulty in clearing secretions.

2. Orotracheal and Nasotracheal Suctioning

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  Purpose: To clear secretions from the trachea, often used in patients with
artificial airways or those unable to clear secretions effectively on their own.
 Procedure:
o Orotracheal Suctioning: Performed through the mouth to reach the
trachea.
o Nasotracheal Suctioning: Performed through the nose to reach the
trachea.
 Technique:
o Use a sterile suction catheter.
o Preoxygenate the patient
o Insert the catheter gently through the mouth or nose into the trachea.
o Apply suction intermittently while withdrawing the catheter.

SUCTIONING TRACHEOSTOMY
Delegation Considerations
1. Patient Assessment: Ensure patient stability and readiness for suctioning.
2. Instructions for UCP:
o Unique skill modifications.

o Suction limits and parameters.

o Reporting criteria for changes in respiratory status, secretions, or vital

signs.
Procedure Steps
1. Assessment:
a. Check for signs of airway obstruction, hypoxia, and factors influencing
airway function.
b. Identify contraindications for nasotracheal suctioning.
2. Preparation:
a. Review sputum microbiology data.
b. Obtain prescriber’s order if required.
c. Explain the procedure and its benefits to the patient.
d. Position the patient appropriately.
3. Pre-suctioning Setup:
a. Place pulse oximeter and apply gloves/mask.
b. Set up suction device with appropriate pressure.
4. Suctioning:
a. Oropharyngeal Suctioning:
i. Use Yankauer catheter.

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 ii. Suction mouth, pharynx, and gum line.
b. Nasopharyngeal/Nasotracheal Suctioning:
i. Lubricate catheter, insert gently, and apply intermittent suction.
ii. Rotate catheter while withdrawing to avoid mucosal damage.
c. Artificial Airway (Tracheostomy/ET Tube) Suctioning:
i. Hyperoxygenate patient before suctioning.
ii. Insert catheter without suction, then apply intermittent suction
and rotate.
5. Post-suctioning:
a. Re-assess patient’s vital signs and oxygen saturation.
b. Compare pre- and post-suctioning status.
c. Document findings and response to procedure.
Unexpected Outcomes and Interventions
 Worsening Respiratory Status:
o Limit suction duration.
o Assess frequency and need for supplemental oxygen.
o Notify healthcare provider.
 Bloody Secretions:
o Adjust suction pressure.
o Review suction technique and frequency.
 Difficulty Passing Catheter:
o Try alternate routes or increase lubrication.
o Consult a physician if obstruction persists.
 Paroxysms of Coughing:
o Administer oxygen and allow rest between passes.
o Consider bronchodilators or anesthetics if necessary.
 No Secretions:
o Evaluate hydration, infection signs, and need for chest physiotherapy.

Recording and Reporting

 Document:
o Amount, consistency, color, and odor of secretions.
o Patient’s response and vital signs before and after suctioning.

Home Care Considerations

 Adhere to infection control practices.
 Educate on safe handling and disposal of secretions.
 Use clean suctioning techniques if infection is not present.
Care of Artificial Airways
Endotracheal Tube (ET) Care
1. Assessment: Monitor lung sounds, airway condition, and tube positioning.
2. Preparation: Gather equipment including suction devices, adhesive
remover, and tape or commercial holders.

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 3. Procedure:
a. Tube Assessment: Check for soiled tape, pressure sores, or unstable
tubes.
b. Suctioning: Remove secretions using appropriate suctioning
techniques.
c. Secure Tube: Use tape or commercial holders to ensure ET tube
remains in the correct position.
d. Oral Care: Clean the oral cavity using antiseptic solutions and suction
if needed.
e. Recheck Position: Verify tube depth and secure it appropriately.
Tracheostomy Care
1. Assessment: Check for soiled ties, unstable tubes, and excessive
secretions.
2. Preparation: Open sterile supplies and prepare equipment for cleaning
and securing the tracheostomy.
3. Procedure:
 Suctioning: Remove secretions and clean the stoma area.
 Cleaning: Use sterile saline to clean the outer cannula and stoma.
 Securing: Replace tracheostomy ties or holders and ensure proper
placement.
 Documentation: Record the care provided, any complications, and
patient response.
Promoting Lung Expansion
Noninvasive Techniques
1. Ambulation: Encourages lung expansion and reduces risks of pneumonia.
2. Positioning: Frequent changes in position help prevent stasis of pulmonary
secretions.
Invasive Techniques
1. Chest Tube Management: Used for conditions requiring drainage of pleural
fluid or air, promoting lung expansion.
Unexpected Outcomes and Interventions: decannulation and obstruction,
noted above
Recording and Reporting
 Document respiratory assessments, care procedures, and any complications
for both ET tubes and tracheostomies.
Home Care Considerations (for Tracheostomy)
 Instruct caregivers on care techniques, signs of distress, and infection
symptoms.

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In the Evolve Essentials Collection, watch the following video and read extended
text:
Providing Tracheostomy Care

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