Trach Care - Care of Patients with Chronic Conditions (NMNC 4335)

An ETT is connected to a _____ after inserted

ventilator

How often should trach care occur?

At least once a shift

Is the OPA used on conscious people?

No

Which two artificial airways are used for temporary airways for manual OR mechanical ventilation?

Supraglottic airway (i-Gel) and Laryngeal Mask Airway (LMA)

Things that may potentially obstruct airways?

Tumor, swelling, stenosis, ENT surgery, trauma, facial/airway burns

Can you speak with a cuffed or uncuffed trach tube, or both/neither?

Uncuffed

ETT size is based on

based on age, body weight

Bag Valve Mask

(BVM) Manual ventilation

Oral pharyngeal airway

(OPA) Helps when ventilating using BVM

What are indications to place a tracheostomy?

- Bypass an obstructed upper airway - Remove secretions from airway - Long term mechanical ventilation - Airway protection

CPT is used for which patients:

- cystic fibrosis - bronchiectasis - COPD - lung abscesses - pneumonia

CPT is contraindicated for patients with:

-increased intracranial pressure - spinal cord injuries - abdominal aneurysm resection -thoracic trauma/surgery - cognitive impairments

What types of conditions can impair airway or breathing?

vocal cord paralysis, diaphragm injury, neurological or neuromuscular disorders

When the nurse is assessing a client after tracheostomy placement, which finding requires immediate action by the nurse? 1 Crackling of the skin on palpation 2 Small amount of blood at the surgical site 3 Client reports the area around incision is tender 4 The client is unable to speak with a cuffed tube

1 Crackling of the skin on palpation

A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. Which assessment by the nurse most readily detects this complication? 1 Palpating the neck or face 2 Evaluating the blood gases 3 Auscultating the lung fields 4 Reviewing the chest x-ray film

1 Palpating the neck or face Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy, and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue. Gas exchange and thus blood gases are not affected. The lungs are not affected.

Which nursing action is appropriate when suctioning the secretions of a client with a tracheostomy? 1 Use a new sterile catheter with each insertion. 2 Initiate suction as the catheter is being withdrawn. 3 Insert the catheter until the cough reflex is stimulated. 4 Remove the inner cannula before inserting the suction catheter.

2 Initiate suction as the catheter is being withdrawn.

Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct. 1 Suction the client before starting tracheostomy care. 2 Use sterile technique when cleaning the inner cannula. 3 Use sterile cotton-tipped swabs to clean the inner cannula. 4 Don sterile gloves before removing the inner cannula. 5 Use hydrogen peroxide to clean the skin around the stoma.

2 & 4 2 Use sterile technique when cleaning the inner cannula. 4 Don sterile gloves before removing the inner cannula.

When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention? 1 Maintains a sterile field 2 Applies suction during insertion of the catheter 3 Preoxygenates with 100% oxygen for 1 minute 4 Tests suction pressure at 100 mm Hg before inserting catheter

2 Applies suction during insertion of the catheter

How would the nurse position a client to practice supraglottic swallowing after tracheostomy? 1 In bed 2 Upright 3 Lying down 4 Position of comfort

2 Upright

What should be documented for trachs?

•Type and size of tracheostomy •Intervention on the trach (suctioning, cleaning/replacing cannula, tie changes) •Color and consistency of secretions, is there an odor? •Oxygen saturation, FiO2 •How the patient tolerated procedure •Any adverse events •Patient education, how patient participated

5 potential complications for trachs:

1. mucus plug 2. decannulation/tube dislodgement 3. hemorrhage 4. Skin breakdown/device related pressure injury 5. infection

The nurse is suctioning a client's airway. Which nursing action will limit hypoxia? 1 Limit suctioning with catheter to 30 seconds. 2 Apply suction only after the catheter is inserted. 3 Lubricate the catheter with saline before insertion. 4 Use a sterile suction catheter for each suctioning episode.

2 Apply suction only after the catheter is inserted.

A client has a tracheostomy tube with a high-volume, low-pressure cuff. The nurse understands that type of cuff is designed to prevent which occurrence? 1 Any leakage of air 2 Lung infection 3 Mucosal necrosis 4 Tracheal secretions

3 Mucosal necrosis

The nurse is caring for a client whose mechanical ventilator settings include the use of positive end-expiratory pressure (PEEP). This treatment improves oxygenation primarily through which mechanism of action? 1 Providing more oxygen to lung tissue 2 Forcing pressure into lung tissue, which improves gas exchange 3 Opening collapsed alveoli and keeping them open 4 Opening collapsed bronchioles, which allows more oxygen to reach lung tissue

3 Opening collapsed alveoli and keeping them open

The nurse instructs a client to breathe deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation? 1 The alveoli need oxygen to live. 2 The alveoli have no direct effect on oxygenation. 3 Collapsed alveoli increase oxygen demand. 4 Oxygen is exchanged for carbon dioxide in the alveolar membrane.

4 Oxygen is exchanged for carbon dioxide in the alveolar membrane.

Which action will the nurse take to support safe oral intake after tracheostomy? 1 Include thin liquids. 2 Provide large meals. 3 Inflate the tracheostomy cuff fully. 4 Position client as upright as possible

4 Position client as upright as possible

What does XLT mean for trachs?

Extended lengths, to accommodate body types

Use caution inserting NPA when the patient has:

Facial fractures

Supraglottic airway (i-Gel) and Laryngeal Mask Airway (LMA) are inserted in what type of emergencies

Field emergencies, so they are inserted blindly

What artificial airway prevents tongue from obstructing the pharynx

OPA

What valve should be used when the patient is awake with a trach

Passy Muir valve, or move up to a trach cap if the patient tolerates the passy muir valve well

Who is involved in trachs?

Various: Patient, Nurse, provider, speech therapist, OT/PT, RT, dietician, social worker, case manager, Pharmacist, wound care nurse

Do trach tubes need oxygen with or without humidity?

With humidity

Is the NPA used on conscious people?

Yes

When inserting a NPA, should you use lubricant?

Yes

Patient education for trachs

•Communication strategies •Clinical progression •Permanent trach? Start teaching ASAP •Teach cleaning, complications, emergency management

Do tracheostomies need suctioning to maintain patency?

Yes, when they are immature.

Before inserting a NPA, measure

from nose to tragus of ear

Is a Trach or ETT safer?

trach

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning? 1 Preoxygenate the client before suctioning. 2 Employ gentle suctioning as the catheter is being inserted. 3 Loosen the client's secretions before suctioning by instilling saline. 4 Ensure that the cuff of the tracheostomy is inflated during suctioning.

1 Preoxygenate the client before suctioning.

Which action by the nurse would best facilitate communication for a client with a partial laryngectomy and tracheostomy in the immediate postoperative period? 1 Provide a means for the client to write. 2 Allow time to lip read what the client says. 3 Deflate the cuff on the tracheostomy tube to allow verbalization. 4 Remind the client that speech is possible after partial laryngectomy.

1 Provide a means for the client to write.

A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. Which action would the nurse take? 1 Hold the tracheostomy open with a tracheal dilator and call for assistance. 2 Insert an obturator into the tracheostomy and gently reinsert the tracheostomy tube. 3 Pick up the tracheostomy tube from the bed and replace it until a new tube is available. 4 Obtain a new tracheostomy tube, prepare the new holder, and insert the tube using the obturator.

1 Hold the tracheostomy open with a tracheal dilator and call for assistance.

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? 1 Encouraging a fluid intake of 3 L daily 2 Suctioning via the tracheostomy every hour 3 Applying an occlusive dressing over the surgical site 4 Using cotton balls to cleanse the stoma with peroxide

1 Encouraging a fluid intake of 3 L daily Increased fluids help liquefy secretions, enabling the client to clear the respiratory tract by coughing. Suctioning frequently will irritate the mucosal lining of the respiratory tract, which can result in more secretions. An occlusive dressing will block air exchange; the tracheostomy is now the client's airway. The use of cotton balls around a tracheostomy introduces the risk of aspiration of one of the cotton fibers; gauze should be used.

After a laryngectomy is scheduled, which is the most important factor for the nurse to include in the preoperative teaching plan? 1 Establishing a means for communicating postoperatively 2 Demonstrating how to care for a permanent laryngeal stoma 3 Teaching how to cough to expectorate bronchial secretions effectively 4 Explaining differences between esophageal speech and transesophageal puncture

1 Establishing a means for communicating postoperatively

Types of artifical airways

1. Bag Valve Mask 2. Oral pharyngeal airway 3. Nasal pharyngeal airway 4. Supraglottic airway 5. Laryngeal Mask airway 6. Endotracheal tube 7. Tracheostomy tube

A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care? 1 Humidified oxygen is saturated with fluid. 2 The tracheostomy tube interferes with effective coughing. 3 The inner cannula of the tracheostomy tube irritates the mucosa. 4 The weaning process increases the amount of respiratory secretions.

2 The tracheostomy tube interferes with effective coughing.

The nurse is caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. The plan of care for the tube would include which nursing intervention? 1 Verify that an inner cannula is in place. 2 Change the tracheostomy tube every week. 3 Clean the tracheostomy once a day. 4 Verify that a low-pressure cuff is in place.

4 Verify that a low-pressure cuff is in place.

Which finding in a client who has home oxygen therapy with a tracheostomy collar requires immediate action by the home health nurse? 1 Condensation in the tubing 2 Oxygen flow rate 9 L/min 3 Low fluid level in the humidifier 4 Scented candle burning in the room

4 Scented candle burning in the room

The nurse is suctioning a client's tracheostomy. What is the correct order of nursing actions when performing this procedure? (select all that apply) 1.Auscultate the lungs and check the heart rate. 2.Prepare by turning suction on to between 80 and 120 mm Hg pressure. 3.Hyperoxygenate using 100% oxygen. 4.Don sterile gloves. 5.Guide the catheter into the tracheostomy tube using a sterile-gloved hand.

All correct 1.Auscultate the lungs and check the heart rate. 2.Prepare by turning suction on to between 80 and 120 mm Hg pressure. 3.Hyperoxygenate using 100% oxygen. 4.Don sterile gloves. 5.Guide the catheter into the tracheostomy tube using a sterile-gloved hand.

Is a cuffed or uncuffed trach tube used for mechanical ventilation?

Cuffed

Assessments for tracheostomies

Respiratory: work of breathing, chest rise/symmetry, O2 sat, Lung sounds, secretions, cough, type/size of trach Skin: Skin around stoma, trach ties/sutures

What is chest physiotherapy (CPT) used for:

Therapies for mobilizing pulmonary secretions - postural drainage, chest & back percussion, and vibration

Are tracheostomies permanent?

They can be permanent

Do uncuffed or cuffed trach tubes decrease the risk of aspirtation?

Uncuffed (b/c larynx and esophagus aren't under pressure by cuff)

Can air move through the upper airway in a cuffed or uncuffed trach tube, or both/neither?

Uncuffed - air can flow through tube and upper airway (Cuffed tubes seal off the upper airway)

Before inserting OPA, you should measure:

from corner of mouth to earlobe

What is a HME?

heat moisture exchange valve - used if continued humidification needed

When inserting an ETT, a ____ is used for visual guidance

laryngoscope

A tracheostomy tube is inserted through

neck into trachea

The NPA is useful for

oral suctioning

Nasal pharyngeal airway (NPA)

provides airway between nares and pharynx

An ETT needs ___ to maintain patency

suction

Endotracheal Tube (ETT) are inserted:

through mouth into trachea

Potential RN diagnoses for Tracheostomies

•Acute pain •Anxiety •Disturbed body image •Impaired verbal communication •Ineffective airway clearance •Risk for aspiration •Risk for bleeding •Risk for infection •Enhanced readiness for learning

During trach care, the RN should:

•Assess and clean/change out inner cannula •Scrub flange, remove dried secretions •Keep skin as dry as possible •Clean skin under flange •Assess ties, change PRN •Suction PRN •Ensure appropriate oxygen delivery •Clean/change out trach shield/tubing •Humidification REQUIRED

4 different types of trach tubes?

•Cuffed/cuffless tube with reusable/disposable inner cannula •Single cannula tracheostomy •Fenestrated cuffed/cuffless tube •Metal tube with reusable inner cannula

Info to include in handoff report for patient's with trachs:

•Date tracheostomy tube was placed •Tracheostomy tube type •Tracheostomy tube size •Cuffed or cuffless •Cuff status (inflated or deflated) •FiO2 •Secretions: type, amount, color, odor •Frequency of suctioning •Last time inner cannula was changed or cleaned •Last time entire tracheostomy tube was changed •Last time the tube was suctioned

What are required equipment in a room for a patient with a trach?

•Functioning suction canister •Suction catheters (10, 12, or 14Fr) •Yankuer •Oxygen set-up WITH HUMIDITY! •BVM •Correctly sized obturator taped above the head of the bed •Trach cleaning kit •Saline •1 or 2 extra correctly sized inner cannulas (if it's the disposable type) •Call light next to patient always

Quality trach care is so important because:

•Prevents airway complications •Decreases the risk of infection •Prevents skin breakdown •Promotes healing and clinical progression