NUR 460: Trachesotomy Care
NUR 460: Trachesotomy Care 460
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This 6 page Class Notes was uploaded by ndp33 on Wednesday July 13, 2016. The Class Notes belongs to 460 at Niagara University taught by in Summer 2016. Since its upload, it has received 5 views. For similar materials see Nursing Concepts IV: Health of Maturing Adults / Chronic Disease in Nursing and Health Sciences at Niagara University.
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Date Created: 07/13/16
TRACHEOSTOMY QUIZ What are the categories that would indicate the need to place a tracheostomy tube? 1) Ventilation, 2) Airway obstruction, 3) Airway protection, 4)Secretions. Category 1 is of patients who require longterm mechanical ventilation b/c of chronic respiratory failure, who cannot maintain respiratory function unassisted, or who cannot be weaned from ventilator support. Category 2 is of patients who have tumors in their airway, paralyzed vocal cords, swelling, stricture, or unusual airway anatomy. Category 3 is of patients who cannot protect their airway, and patients with an inefficient cough and/or swallow mechanism, common in patients with high SCI, CVA, or TBI. Category 4 is of patients who cannot mobilize or manage their secretions. What are the recommendations from the American College of chest surgeosn? The American College of Chest Surgeons recommends consideration of a tracheostomy for patients who require an endotracheal tube for over 21 days. what are the benefits of this recommendation? The benefits (over a direct endotracheal tube) are decreasing direct laryngeal injury, improving comfort, and increasing ADLs (including mobility, speech, and eating). Name the two ways that a tracheostomy tube may be placed: Surgically or percutaneously. Percutaneously is performed on intubated patients and does not require direct visualization of the trachea; bronchoscopy is used as a guide and to confirm placement What are the contraindications to a percutaneous tracheostomy? Uncorrected coagulopathy, infection at the incision site, high ratio of PEEP to fraction of inspired oxygen, elevated ICP, tracheal obstruction, unusual neck anatomy, and the need for emergency airway management. What are the immediate postoperative priorities of care? Ensure that the tracheostomy tube is securely in place and patent. Also, perform routine care, as well as prompt care of postop complications. Have the supplies and equipment at the bedside. Name 5 consensus statements for tracheostomy care 1.) All supplies to replace a tracheostomy tube should be at the bedside or within reach. 2.) If no aspiration, tracheostomy tube cuffs should be deflated when a patient no longer requires mechanical ventilation. 3.) In an emergency, a dislodged tube from a mature tracheostomy should be replaced with the same size tube or a tube 1 size smaller or an endotracheal tube through the tracheostomy wound. 4.) In an emergency, patients with a dislodged tracheotomy tube that cannot be reinserted should be intubated. 5.) A patient can be turned in the bed once the security of the tube has been assessed to avoid accidental decannulation. They address:1.) the initial change of the tracheostomy tube, 2)management of emergencies and complications, 3)prerequisites for decannulation, 4)management for tube cuffs and communication devices, 5) specific needs of patients and their caregivers. Name 5 products that should be included in the bedside tracheostomy kit: 1.) Tracheostomy tube of the same size and type currently in place; Tracheostomy tube 1 size smaller than the one currently in place; 3)Suction catheters (usu 12F or 14F); 4) oxygen source 5) intubation equipment Also: H2O2; drain sponges; tracheostomy cleaning kit; intubation equipment; obturator; ties If a tracheostomy were changed prematurely, what would happen? The tissue of the dilated stoma tract would recoil than if the tracheostomy were changed later. Most manufacturers recommend changing the tube every: 12 months.Yet, routine changes q2weeks may decrease the formation of granulation tissue. What kind of problems would be corrected by changing tracheostomy tubes? They can correct problems that cause asynchrony; changing the tubes can also improve comfort by reducing the tube size; changing the tubes can correct a cuff leak d/t tracheomalacia or malposition or fracture of the tracheostomy tube or flange. How often should the stoma be cleaned? Every 4 to 8 hours.Use H2O2 to rid of dry secretions, and rinse with NS. How many fingers should fit between the tie and the neck? 1 finger should fit between the tie and the neck once the new ties are secure. what factors comprise mobilization of secretions? Adequate hydration, physical mobility, and removal of secretions. *Adequate hydration keeps secretions thin and mobile. (Humidity may need to be provided as well from tracheostomy, such as from heat and moisture exchanger, a T tube, a tracheostomy mask, or by capping the tube). Physical mobility can prevent deconditioning. Even having the patient sit in a chair helps the patient use the diaphragm and have a more productive cough. Removal of secretions can be accomplished with suctioning and by allowing the patient to cough. What should the Vital Capacity be to clear secretions? Vital capacity should be at least 15 mL/kg to clear secretions. (When cough strength is less, or when the cough reflex is diminished, more frequent suctioning may be required.) What is the purpose of the cuff? The purpose of the cuff is to provide a closed system to allow effective ventilation and/or airway protection. Normal cuff pressure is 2025 cm H2O with most tracheostomy tubes. W hat problems occur with overinflation of the cuff? Longterm complications such as tracheomalacia, tracheoinnominate artery fistula, tracheal ulcerations, fibrosis, tracheal stenosis, and tracheoesophageal fistula. How will a persistent leak be manifested? Audible noises around the tracheostomy tube and loss of returned volumes within ventilation. (That is, the patient will not get the entire benefit tidal volume he needs if, say, the tidal volume rises and there is a lower return tidal volume.) This may be because the pilot balloon is ineffective at sealing the airway, or the trachea may have lost its rigid composition. What are the three most common tracheostomy emergencies? 1.)Hemorrhage, 2)tube dislodgement, and 3) tube obstruction What is one of the most deadly complications? Tracheoinnominate fistula (although rare), in which the innominate artery is eroded through the trachea, causing exsanguination within minutes. It has a mortality rate of almost 100%. What would cause it and when is it most likely to occur? Pressure necrosis from cuffs with high pressures, improper placement of the cannula tip (from direct weight or torque on the tracheostomy tube from the ventilator circuit), low placement of the tube, hyperextension of the head, radiotherapy, and steroid use. It is most likely to occur 34 weeks after surgery. What are the predisposing factors to tube dislodgement? Loose ties, edema of the neck, excessive coughing, agitation, undersedation, morbid obesity, a tracheostomy tube that is too short for the tract, the technique used to place the tracheostomy tube, and downward traction caused by the weight of the ventilator circuit. Complete healing of the tracheosotmy tube occurs when… Complete healing of the stoma occurs 1 week after tracheostomy placement. If a tube is dislodged before this time, what will occur? The stoma can quickly collapse; this tube dislodgement is a medical emergency. The tube needs to be secured. What is subcutaneous emphysema? It can occur d/t a tube dislodgement within the initial incision and move through the stoma into the trachea, allowing air to escape in between the two openings. Subcutaneous emphysema feels like bubblewrap when it is palpated, and it can be palpated on an inadvertent dislodgement when positive pressure is applied to the tube within a false passage. Name the preventive methods to prevent tube dislodgement: Keep tracheostomy ties secure and snug (one finger should fit underneath); removing added weight and traction from ventilator circuit; keep the tracheostomy tube in a midline and neutral position; minimize transport of the patient as much as possible. what is the treatment for decannulation of an immature stoma? It depends on the maturity of the stoma, in which the rates at which they close depend on how old they are… immediate treatment in complete decannulation includes mask ventilation and then orotracheal intubation. Why is it important to keep a tube of the same size or smaller at the bedside? A mature stoma can close to 50% within 12 hours and up to 90% within 24 hours; complete closure may take 2 weeks. What is the first step in caring for a tracheostomy patient in respiratory distress? Remove and inspect inner cannula. If there are secretions, quickly clean and replace the cannula. If the patient is still in distress, call for help, and attempt to insert a suction catheter. What is tracheomalacia and how is it manifested? Breakdown of the natural rigid structure of the trachea that leads to a flaccid airway in the affected area. It is manifested by the presence of a cuff leak (air escaping around the cuff) combined with overinflation of the cuff and high pressures. Name several things you can do to prevent skin complications: Regular skin inspection; prevent traction(keep too much weight from being pulled down on the tracheostomy tube), have the patient keep the tube in a neutral position and attached to an oxygen device; apply protective skin dressings; How would you know your patient had a tracheoesophogeal fistula? You would know from the presence of tube feedings in the tube. You can also tell by copious secretions, dyspnea, s/sx of aspiration, cuff leak, and gastric distention. (The presence of feedings in the tube can be d/t to an overinflation of the cuff in patients who have a feeding tube or d/t direct trauma in the tracheostomy procedure.) Note: a tracheoesophageal fistula is when the trachea and esophagus communicate through an opening in each. When reporting off to the next nurse, what information whould be included? Information such as the date it was put in the patient; the tracheostomy tube type; the tube size; cuff or cuffless, and if a cuff is present, what the type of cuff it is, along with the cuff status (inflated or deflate) and cuff pressure; any secretions and their characteristics; frequency of suctioning; last time the inner cannula was cleaned or changed; last time the entire tube was changed; last time the tube was suctioned. How do you care for the skin around the trach? Regularly assess the area around the trach. Clean the stoma with a gauze soaked with NS, start at the 12 oclock position, and work your way towards the 3o’clock. Using a new gauze soaked in NS, and starting at the 12 position, clean your way towards 9. When cleaning the lower half, clean your way from 3 to 6 o’clock. Use a new gauze to clean from 9 to 6 o’clock. Avoid the use of hydrogen peroxide. Be sure to keep the area around the stoma dry, and apply a new dressing (foam dressing or splitdrain) to it at least once a shift. What concerns do you have about hydrogen peroxide? Hydrogen peroxide may impair healing. It should be avoided unless the stoma is already infected. Rinse it with N.S. if using hydrogen peroxide. How do you change trach ties and how often would you do it? One person should hold the tube while a second person removes and replaces the ties. Upon removal of the old ties, the skin underneath should be assessed. One finger should be able to fit b/t the ties and neck. You would change the trach ties daily or as soon as they get soiled. Can you change them after a patient has eaten? No Since the upper airway humdification is being bypassed, how does the body compensate The body makes more mucous secretions (to act as a protective barrier for the respiratory tract and to also limit air entry into the lungs.) *This is why suctioning is very important. What is a fenestrated trach tube? A fenestrated trach tube allows speech and assists with breathing (from the opening in the neck leading directly into the trachea).
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