308 Management of the Patient with Respiratory Problems: Airway management week 7 (7/01/19)

Pneumothorax complication from tracheotomy

(air in the chest cavity) can develop during the tracheotomy procedure if the chest cavity is entered. Chest x-rays after placement are used to assess for pneumothorax.

Classification of Pulmonary Disorders Vascular

* PERFUSION --> * increased dead space: I. Narrowing II. occlusion of *pulmonary blood vessels* (PE) - *o2 WON'T help*

Tracheal stenosis Intervention

pertaining to narrowing of the trachea - can be caused by Tube friction and movement damage the mucosa and lead to tracheal stenosis. Reduce local airway damage by maintaining proper cuff pressures, stabilizing the tube, suctioning only when needed, and preventing malnutrition, dehydration, and hypoxia. Intervention: 1) Surgery 2) tracheal Dilation

Types of Intubation Oral endotracheal tube

preferred route size 6.5 - 8.5 average

Tracheostomy placement

typically between 2nd and 3rd tracheal rings bedside or operating room

Fenestrated tracheostomy tube❇

used for stable pt. breathing on own (but can't manage secretions). Holes allow air to go over vocal chords --> speech. ❇ allows the patient to speak, breathe, or clear secretions from the upper airway. Can come w/ or w/o cuff ❇ commonly used when pt is not on mechanical

Subcutaneous emphysema Nursing assessment/ intervention

air present in the subcutaneous tissue sometimes af 1) Assess - Palpate area for puffiness or crackling that may indicate 2) Intervention: Notify HCP because will compromise airway

Possible Complications of Suctioning

*1) Tissue trauma* results from frequent suctioning, prolonged suctioning, excessive suction pressure, and non-rotation of the catheter. Prevent trauma to the mucosa by suctioning only when needed and lubricating the catheter with sterile water or saline before insertion. *2) Infection of lungs by bacteria from the mouth* because each catheter pass introduces bacteria into the trachea. - In the hospital, use sterile technique for suctioning and for all suctioning equipment (e.g., suction catheters, gloves, saline or water). - *Suction the mouth or nose after* suctioning the artificial airway . - Clean technique is used at home because the number of virulent organisms in the home environment is lower than in the hospital. 3) Vagal stimulation—stop suctioning immediately and oxygenate patient manually with 100% oxygen 4) Bronchospasm—may require a bronchodilator 5) Cardiac dysrhythmias from hypoxia caused by suctioning

Trachesotomy Tubes Advantages & Disadvantages

*Advantages* 1) Does not impair oral hygiene or sinus drainage 2) Speech is possible 3) Decreased work of breathing 4) Suctioning is easier 5) Easily stabilized 6) Reinsertion easier 7) Ventilator easily attached *Disadvantages* 1) Requires surgical procedure 2) May be difficult to reinsert 3) Higher rate of complications

Nasal Endotracheal Tube

*Advantages* Easy to stabilize Well tolerated by patient Enables patient to swallow *Disadvantages* Must use a smaller tube Sinusitis Consider CSF leaks Necrosis of nasal passages

What should you INTERPRET and how should you RESPOND to a patient experiencing inadequate gas exchange with oxygenation and tissue perfusion as a result of a respiratory problem? Perform and interpret physical assessment, including: 8

*Perform and interpret physical assessment, including:* 1) Taking vital signs 2) Auscultating all lung fields 3) Monitoring oxygen saturation by pulse oximetry 4) Checking most recent laboratory values for hematocrit, hemoglobin, and ABG levels 5) Assessing cognition (Mini-Mental State Examination [MMSE]) 6) Assessing for the use of accessory muscles 7) Assessing for the presence of thick or excessive secretions 8) Assessing the patient's ability to cough and clear the airway *Respond by:* 1) Applying oxygen and assessing the patient's responses to this intervention *2) Keeping the patient's head elevated to about 30 degrees* 3) Suctioning (oral, pharyngeal, endotracheal, tracheostomy), if needed 4) Notifying the physician or Rapid Response Team 5) Prioritizing and pacing activities to prevent fatigue On what should you *REFLECT* 1) Observe the patient for evidence of restored gas exchange 2) Think about what may have made the impaired gas exchange worse and what steps could be taken to either prevent a similar episode or identify it earlier. • 3) Think about what additional resources could improve the nursing response to this situation.

A patient requiring prolonged mechanical ventilation after laryngeal trauma is scheduled for tracheostomy surgery. What does the nurse include when teaching this patient about the reason for this surgery? 1 "This may make it possible to stop using the ventilator." 2 "The tracheostomy will help the trauma site to heal faster." 3 "The tracheostomy will help prevent respiratory infection." 4 "You will be able to talk and eat once you have a tracheostomy."

1) A tracheostomy placed for patients with laryngeal trauma will essentially bypass the damaged airway and improve the patient's ability to breathe without mechanical ventilation. ----------- It does not help the trauma site to heal faster or prevent respiratory infection. Patients with a tracheostomy will eventually be able to eat and speak, but not immediately.

Tracheostomy Priority NI

1) Airway 2) Stable vital signs

Bronchial and Oral Hygiene

-Bronchial hygiene promotes a patent airway & prevents infection. -Oral hygiene is important to keep the airway patent, to prevent bacterial overgrowth, & dental caries & to promote comfort. -Oral secretions can move down the trachea & collect about the inflated cuff of the endotracheal tube. When the cuff is deflated the secretions can move into the lungs. -Turn/reposition every 1 to 2 hours, support out of bed activities, encourage early ambulation. -Coughing & deep breathing, chest percussion, vibration, & postural drainage promote pulmonary care. -Avoid glycerin swabs or mouthwash containing alcohol for oral care; assess for ulcers, bacterial/fungal growth, infection.

A patient with a tracheostomy is receiving feedings via a nasogastric tube, during which the patient experiences increased coughing and choking. The nurse notes that the tracheostomy cuff requires increasing amounts of air to maintain the seal, and when suctioning the tracheostomy, food particles are present in the tracheal secretions. After notifying the provider of these observations, which procedure does the nurse expect to be performed? 1 Placement of a jejunostomy tube 2 Tracheal dilatation in the operating room 3 Insertion of a fenestrated tracheostomy tube 4 Reintubation with a larger tracheostomy tube

1 This patient has *signs of a tracheoesophageal fistula* - patient experiences increased coughing and choking. - the tracheostomy cuff requires increasing amounts of air to maintain the seal - when suctioning the tracheostomy, food particles are present in the tracheal secretions *a tracheoesophageal fistula* is where *excessive cuff pressure causes an erosion of the posterior wall of the trachea and into the anterior esophagus. * TX: Patients who develop this should either 1) be fed with a very small bore feeding tube; or 2) should have surgical placement of a gastrostomy or jejunostomy tube A fenestrated tracheostomy tube is used to facilitate coughing or speaking. Placing a larger tracheostomy tube will increase pressure on the tracheal wall. The trachea does not need to be dilated.

A patient is being discharged home with a tracheostomy. Which statement by the patient indicates the need for further teaching about correct tracheostomy care? 1 "I can only take baths, but no showers." 2 "I will have to learn to suction myself." 3 "I should put cotton or foam over the tracheostomy hole." 4 "I can put normal saline in my tracheostomy to keep the secretions from getting thick."

1 "I can only take baths, but no showers." the patient does not understand that he or she *can shower with the use of a shower shield over the tracheostomy tube to prevent water from entering the airway*. Additional teaching is necessary. 4) Normal saline should be instilled into the artificial airway 10 to 15 times a day, as prescribed. 3) The stoma should be covered with cotton or foam to protect it during the day; this filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. 2) Patients with tracheostomies should be taught clean suction technique.

Which technique or action does the nurse use to prevent a tracheoesophageal fistula (TEF) in a patient after a tracheotomy has been performed? 1 Maintain proper cuff pressure. 2 Manually administer oxygen by mask. 3 Prevent pulling or tugging on the tube. 4 Apply direct pressure to the stoma site

1 A TEF is a hole created between the trachea and the anterior esophagus due to excessive cuff pressure. *Three methods of preventing this complication are* 1) to progress to a deflated cuff or cuffless tube as soon as possible 2) maintain proper cuff pressure 3) and monitor the amount of air needed for inflation for any change. -------- Manually administering oxygen by mask is an appropriate intervention once the fistula has formed, but it does not prevent the formation. Applying direct pressure is an intervention for a trachea-innominate artery fistula. *Preventing pulling of and traction on the tracheostomy tube is a prevention measure for tracheal stenosis. *

Which factor is a manifestation of tracheoesophageal fistula (TEF)? 1 Increased cough and choking while eating 2 Lacking food particles in tracheal secretions 3 Receiving the set tidal volume on the ventilator 4 Decreasing air in the cuff needed to achieve a seal

1 TEF causes excessive pressure on the cuff that leads to erosion of the posterior wall of the trachea which, in turn, *leads to increased coughing and choking while eating.* A manifestation of TEF is the presence of food particles in tracheal secretions. With TEF, the patient does not receive the set tidal volume on the ventilator, and* increasing air in the cuff is needed* in order to achieve a seal.

When planning the care of a patient with a tracheostomy, which interventions does the nurse include? Select all that apply. 1 Encourage ambulation and out-of-bed activities. 2 Use lemon glycerin swabs to provide oral hygiene. 3 If the patient is bedbound, turn and reposition every 4-6 hours. 4 Mix equal parts of hydrogen peroxide and water to use as a mouthwash. 5 Use a sponge tooth cleaner or soft toothbrush moistened in water for oral hygiene

1 Encourage ambulation and out-of-bed activities. 5 Use a sponge tooth cleaner or soft toothbrush moistened in water for oral hygiene Ambulation and increased activity promote lung expansion, gas exchange, and removal of secretions. These are desirable outcomes for the patient with an artificial airway. The recommended best practice to clean and protect oral mucosa is to use water and a soft toothbrush or sponge tooth cleaner. ------------ Lemon glycerin swabs have a drying effect on oral mucosa and change the normal pH, contributing to bacterial overgrowth. Hydrogen peroxide may damage healthy tissue and is not routinely recommended. It requires a prescription by the health care provider. The patient should be turned and repositioned every 1 to 2 hours.

Which nursing interventions are appropriate to prevent hypoxia in the patient with tracheostomy? Select all that apply. 1 Monitoring the heart rate 2 Monitoring the temperature 3 Monitoring the respiratory rate 4 Hyperoxygenating the patient with 100% oxygen 5 Having the patient take deep breaths before suctioning

1 Monitoring the heart rate 4 Hyperoxygenating the patient with 100% oxygen 5 Having the patient take deep breaths before suctioning The nurse monitors the heart rate of the patient to assess the patient's tolerance to tracheostomy. One of the preventive interventions for hypoxia is hyperoxygenating the patient with 100% oxygen using a manual resuscitation bag attached to an oxygen source. Instructing the patient to take deep breaths three or four times before suctioning with the existing oxygen delivery system may also prove to be helpful. -------------- Monitoring the temperature and respiratory rate are not relevant to preventing hypoxia.

Oral hygiene for traces ❇

1 - avoid glycerin swabs or alcohol mouthwash. ❇ 2) Preform every 2-4 hours when on ventilator --> avoid VAP

Which assessment findings may indicate a tracheostomy tube is obstructed? Select all that apply. 1 Dyspnea 2 Bradypnea 3 Noisy respirations 4 Edema around the stoma 5 Asymmetrical chest movement 6 Difficulty inserting a suction cathete

1 3 6 1) Noisy respirations are heard when secretions accumulate and obstruct air flow in the tube. 2) Dyspnea will occur if the airway is obstructed. 3) Dried secretions may make it difficult to pass a suction catheter through the tube. 4) if the tracheostomy is obstructed, *tachypnea would result* --------- Asymmetry of chest movement does not indicate an obstructed airway. If the tracheostomy is obstructed, tachypnea would result, not bradypnea. E edema around the stoma is external to the tracheostomy tube and would not obstruct the tube.

Prevention of Aspiration During Swallowing

1) Avoid serving meals when the patient is fatigued. 2) Provide smaller and more frequent meals 3) Provide adequate time; do not "hurry" the patient. 4) Provide close supervision if the patient is self-feeding. 5) Keep emergency suctioning equipment close at hand. 6) Avoid water and other "thin" liquids. / Thicken liquids. 7) Avoid foods that generate thin liquids during the chewing process, such as fruit. 8) Position the patient in the most upright position possible. 9) When possible, completely (or at least partially) deflate the tube cuff during meals. 10) Suction after initial cuff deflation to clear the airway and allow maximum comfort during the meal. 11) Feed each bite or encourage the patient to take each bite slowly 12) Encourage the patient to "dry swallow" after each bite to clear residue from the throat. 13) Avoid consecutive swallows by cup or straw 14) Provide controlled small volumes of liquids, using a spoon. 15) Encourage the patient to "tuck" his or her chin down and move the forehead forward while swallowing. 16) Allow the patient to indicate when he or she is ready for the next bite. 17)If the patient coughs, stop the feeding until the patient indicates the airway has been cleared. 18) Continuously monitor tolerance to oral food intake by assessing *respiratory rate, ease, pulse oximetry*

Oropharyngeal Airways Disadvantages

1) Can stimulate gag reflex 2) can actually obstruct the airway 3) can cause tissue necrosis

Tracheostomy Complications

1) Hemorrhage - (brachiocephalic trunk or innominate artery) 2) Wound infections: - secretions - immunocompromised pt - ventilator associated *3) Subcutaneous emphysema* - tear or opening 4) Tube obstruction 5) Displacement of tube 6) Tracheal stenosis Tube friction (pulling) and movement damage the mucosa and lead to tracheal stenosis. Reduce local airway damage by maintaining proper cuff pressures, stabilizing the tube, suctioning only when needed, and preventing malnutrition, dehydration, and hypoxia.

Causes of Hypoxia in the Tracheostomy

1) Ineffective oxygenation before, during, after suctioning 2) Use of catheter that is* too large *for the artificial airway 3) Prolonged suctioning time (no longer than 10-15 x 3 times) 4) Excessive suction pressure 5) Too frequent suctioning

Speech and Communication

1) Patient can speak with a cuffless tube, fenestrated tube, or cuffed fenestrated tube that is capped or covered. 2) Patient can write. 3) Phrase questions to patient for "yes" or "no" answers. 4) A one-way valve that fits over the tube and replaces the need for finger occlusion can be used to assist with speech.

What might you NOTICE if the patient is experiencing inadequate gas exchange with oxygenation and tissue perfusion as a result of respiratory problems? (9)

1) Respirations *rapid* and *shallow* 2) Respirations noisy 3) Cannot speak more than 4 or 5 words without pausing for breath 4) Change in cognition, acute confusion 5) Decreased oxygen saturation by pulse oximetry 6) Skin cyanosis or pallor (lighter-skinned patients) 6) Cyanosis or pallor of the lips and oral mucous membranes (in patients of any skin color) 7) Tachycardia 8) Patient appears to strain to catch breath 9) Fatigue

Cardiac dysrhythmias from hypoxia caused by suctioning

1) bradycardia 2) hypotension 3) heart block 4) ventricular tachycardia 5) any other dysrhythmia Interventions:

If decannulation occurs after 72 hours,

1) extend the patient's neck back to open the tissues of the stoma with a curved Kelly clamp to secure the airway 2) With the obturator inserted into the tracheostomy tube, quickly and gently replace the tube and remove the obturator. 3) Check for airflow through the tube and for bilateral breath sounds. *If you cannot secure the airway, notify a more experienced nurse, respiratory therapist, or physician for assistance. 4) Ventilate with a bag-valve mask. If the patient is in distress, call the *Rapid Response Team for help. because airway was is compromised* **Not calling code b/c pt is breathing 5) Notify HCP *If the tube is dislodged on an immature tracheostomy , ventilate the patient using a manual resuscitation bag and facemask while another nurse calls the Rapid Response Team.*

minimal leak technique

1) take syringe with *10 mls of air* 2) auscultate throat and push air in until no more breath sounds are heard. 3) Now remove 0.5mls of air to rehear breath sounds. 4) Over inflation could lead to damage. Use drain sponge around trach. 5) RT can use manometer to check cuff pressure (should be 14-22 mmhg)

Supraglottic Method of Swallowing

1. Place yourself in an upright, preferably out-of-bed, position. 2. Clear your throat. 3. Take a deep breath. 4. Place to 1 teaspoon of food into your mouth. 5. Hold your breath, or "bear down" (Valsalva maneuver). 6. Swallow twice. 7. Release your breath, and clear your throat. 8. Swallow twice again. 9. Breathe normally . This method exaggerates the normal protective mechanisms of cessation of respiration during the swallow . *The double swallow attempts to clear food that may be pooling in the pharynx, vallecula, and piriform sinuses. * *This method is used only after a dynamic radiographic swallow study has demonstrated that it is appropriate and safe for the patient.*

NURSING CONSIDERATIONS TRACH CARE

1. Assemble the necessary equipment. 2. Wash hands. Maintain Standard Precautions. 3. Suction the tracheostomy tube if necessary . 4. Remove old dressings and excess secretions. 5. Set up a sterile field. 6. Remove and clean the inner cannula. *Use half-strength hydrogen peroxide to clean the cannula and sterile saline to rinse it. * If the inner cannula is disposable, remove the cannula and replace it with a new one. 7. Clean the stoma site and then the tracheostomy plate with half strength hydrogen peroxide followed by sterile saline. Ensure that none of the solutions enters the tracheostomy . 8. Change tracheostomy ties if they are soiled. Secure new ties in place before removing soiled ones to prevent accidental decannulation. If a knot is needed, tie a square knot that is visible on the side of the neck. Only one finger should be able to be placed between the tie tape and the neck. 9. Wash hands. 10. Document the type and amount of secretions and the general condition of the stoma and surrounding skin. Document the patient's response to the procedure and any teaching or learning that occurred.

NURSING CONSIDERATIONS TRACH SUCTIONING

1. Assess the need for suctioning (routine unnecessary suctioning causes mucosal damage, bleeding, and bronchospasm). 2. Wash hands. Don protective eyewear. Maintain Standard Precautions. 3. Explain to the patient that sensations such as shortness of breath and coughing are to be expected but that any discomfort will be very brief. 4. Check the suction source. Occlude the suction source, and adjust the pressure *dial to between 80 and 120 mm Hg to prevent hypoxemia and trauma to the mucosa.* 5. Set up a sterile field. 6.* Preoxygenate the patient with 100% oxygen for 30 seconds to 3 minutes (at least three hyperinflations)* to prevent hypoxemia. Keep hyperinflations synchronized with inhalation. *7. Quickly insert the suction catheter until resistance is met. Do not apply suction during insertion. * 8. Withdraw the catheter 0.4 to 0.8 inch (1 to 2 cm), and begin to apply suction. Apply suction and use a twirling motion of the catheter during withdrawal. *Never suction longer than 10 to 15 seconds. * 9.* Hyperoxygenate for 1 to 5 minutes or until the patient's baseline heart rate and oxygen saturation are within normal limits. * 10. Repeat as needed for up to three total suction passes. 11. Suction mouth as needed, and provide mouth care. 12. Remove gloves, and wash hands. 13. Describe secretions, and document patient's responses

MANUAL RESUSCITATION BAG (AMBU) When used with a mask, can provide

100% oxygen to the patient

Which principle should guide the nurse's decision regarding oral care for a patient with a tracheostomy during the first 24 hours postoperative? 1 High protein intake is indicated to promote optimal healing. 2 Oral care is indicated to decrease the accumulation of organisms. 3 If the patient is not taking oral nutrition, it is not a concern at this time. 4 Oral care is not indicated if the patient is being suctioned on a regular basis.

2 Oral care helps decrease the accumulation of organisms present in the mouth that can contribute to pneumonia and should be a regular part of postoperative care. Good oral care is important even if the patient is not eating, which actually serves to facilitate cleansing of the oral cavity. Protein will aid healing but does not negate the need for oral care.

The primary health care provider has written an order to resume the diet for a patient with a tracheostomy following a laryngectomy. What does the nurse include when teaching the patient about prevention of aspiration? 1 Raise the head of the bed 30 degrees when eating. 2 All liquids will need to be thickened, including water. 3 When swallowing, raise the chin as though looking at the ceiling. 4 If not already inflated, inflate the tube cuff when eating or drinking.

2 Thickening all liquids gives the patient more control over aspiration when swallowing. The patient should be *sitting upright when eating* and should *tuck the chin down and lower the forehead while swallowing *to prevent aspiration. Due to the close proximity of the cuffed tube to the esophagus, it may interfere with the passage of food; the cuff should therefore be *deflated to facilitate swallowing and prevent aspiration. *

A patient has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? 1 Suction as needed. 2 Listen to lung sounds. 3 Change the tracheostomy dressing as needed. 4 Clean the tracheostomy inner cannula and stoma.

2 the first nursing action for a patient following an airway procedure is to* assess* the patient's respiratory status; this requires auscultation of the lungs. ---------- Suction is not needed if the lungs are clear to auscultation. Although cleanliness is a priority, the nurse must assess the patient's respiratory status before cleaning or performing a dressing change.

When suctioning a tracheostomy or endotracheal tube, what nursing actions ensure safe and effective practice? Select all that apply. 1 Not suctioning longer than 20 seconds 2 If needed, repeating suctioning up to three passes 3 When suctioning, using a gentle twirling motion of the catheter 4 Adjusting the pressure dial on the suction source to 120-160 mm Hg 5 Applying suction while quickly inserting the catheter and slowly removing it 6 Preoxygenating the patient with 100% oxygen for 30 seconds to 3 minutes before suctioning

2 3 6 Preoxygenation is a proactive strategy to diminish suction-related hypoxemia. The technique of suctioning using a gentle twirling motion diminishes the risk of mucosal injury. No more than three suctioning passes are recommended to minimize hypoxemia, tissue hypoxia, and related complications. The recommended negative pressure for suction is 80-120 mm Hg. ------ Suction should not be applied during catheter insertion, but rather only during removal. The rule is not to suction more than 10 to 15 seconds to prevent hypoxia and complications.

The nurse is suctioning a patient's tracheostomy and notes a heart rate of 98 and an oxygen saturation of 89% during the procedure. Which action by the nurse is correct? 1 Continue suctioning to fully clear the airway of secretions. 2 Reoxygenate the patient with a 100% oxygen delivery system. 3 Stop suctioning until the heart rate and oxygen saturation return to normal. 4 Ask the patient to take three or four deep breaths before resuming suctioning.

2 Reoxygenate the patient with a 100% oxygen delivery system. If a patient becomes hypoxic during suctioning, the nurse should reoxygenate the patient with 100% oxygen. ---------------------- Patients are asked to take three to four deep breaths, if possible, prior to beginning suctioning. Continuing suctioning will increase the hypoxia.

What actions prevent tracheostomy decannulation during tie replacement? *Select all that apply.* 1 Always have a coworker assist with the procedure. 2 Do not remove the old ties until the new ones are in place. 3 Give the patient a cough suppressant to prevent coughing. 4 Hold the tracheostomy tube in place with one hand during the process. 5 Know the tracheostomy tube size and type if replacement is necessary

2 Do not remove the old ties until the new ones are in place. 4 Hold the tracheostomy tube in place with one hand during the process. Holding the tracheostomy tube in place with one hand during the process and not removing the old ties until the new ones are in place are two approaches to ensure that the tracheostomy tube does not become dislodged. ------------ Although it is important to know the tracheostomy tube size and type in case of dislodgement, it doesn't prevent decannulation during tie replacement. Having a coworker assist with the tie change is helpful, but it does not directly prevent dislodgement like the other actions do. Manipulating the tracheostomy may trigger coughing; a cough suppressant is not likely to prevent this problem.

A registered nurse is educating nursing students about precautions to prevent aspiration during swallowing in patients with tracheostomy tubes in place. Which nursing student statements require further teaching? Select all that apply. 1 "I'll avoid giving fruit to the patient." 2 "I'll give water and other 'thin' liquids to the patient." 3 "I'll provide smaller and more frequent meals for the patient." 4 "I'll position the patient in the most relaxed position possible." 5 "I'll avoid serving meals to the patient when the patient is fatigued." 6 "I'll assist the patient in turning in bed at regular intervals."

2 4 6 While caring for patients with tracheostomy tubes in place, the nurse should take precautions to prevent aspiration during swallowing. 1) The nurse should avoid giving fruit to the patient, *because fruits generate thin liquids during the chewing process*. 2) Water and other "thin" liquids should not be given to the patient. 3) The patient should be *positioned in the most upright position possible.* 4) The nurse should provide smaller and more frequent meals for the patient 5) avoid serving meals when the patient is fatigued. ------------ * The patient should be turned at regular intervals to reduce the risk for pressure ulcers, not to reduce the risk for aspiration.*

In caring for a patient during the first few days after tracheostomy placement, what nursing action is included in wound care? 1 Applying Steri-Strips to secure the tube 2 Folding standard gauze 4 × 4s to fit around the tube 3 Cutting a slit in standard gauze 4 × 4s for ease of placement around tube 4 Assessing the stoma site every 24 hours for purulent drainage, redness, and swelling

2) It is recommended that intact 4 × 4s be folded and placed around the tube. ------------------ Cutting the 4 × 4 gauze might release small pieces of gauze that may be aspirated. *The stoma site should be assessed every shift. * Steri-Strips are not used to stabilize the tube.

An older patient receiving mechanical ventilation with a tracheostomy has poor nutritional status and is dehydrated. Which nursing action is most important to prevent complications in this patient? 1 Provide warm, humidified air and suction the tube frequently. 2 Encourage the patient to cough frequently to clear secretions. 3 Keep the pressure on the tracheal tube cuff between 14 and 20 mm Hg. 4 Change the tracheostomy tube dressing and reposition the tube every 4 hours

3 Older patients and those who are malnourished and dehydrated *are at increased risk for tissue breakdown caused by tracheostomy tube pressure.* Anything that causes movement of the tube causes friction and can contribute to tissue breakdown. Maintenance of cuff pressure between 14 mm Hg and 20 mm Hg will allow adequate circulation to the tracheal mucosa. -------- The nurse should change dressings and suction the tube only as needed, taking care not to move the tube. Coughing will increase tube friction.

patient with a new tracheostomy has a soiled dressing. What is the best nursing intervention? 1 Reinforce the dressing with sterile 4 × 4 gauze. 2 Replace the dressing with clean, folded 4 × 4 gauze. 3 Replace the dressing with sterile, folded 4 × 4 gauze. 4 Cut sterile 4 × 4 gauze to fit around the tracheostomy tube

3 Tracheostomy dressings may be used to keep the tracheostomy clean and dry. These dressings resemble a 4 × 4 gauze pad with an area removed to fit around the tube. If tracheostomy dressings are not available, *fold* standard *sterile* 4 × 4s to fit around the tube. The dressing should never be cut because small bits of gauze could then be aspirated through the tube. Dressings should be changed often because moist dressings provide a medium for bacterial growth, leading to infection

the nurse discovers that a patient's tracheostomy tube has an air leak and notes a cuff pressure of 20 mm Hg. Which action by the nurse is correct? 1 Inflate the cuff to a pressure of 20-30 mm Hg. 2 Secure the outer cannula of the tracheostomy with tape. 3 Suction the patient more often to prevent frequent coughing. 4 Contact the provider to request a larger-diameter tracheostomy tube

4 The tracheostomy cuff should be inflated to a pressure of 14-20 mm Hg, or 20-30 cm H 2O. If the patient continues to show signs of an air leak after properly inflating the cuff, a larger-diameter tube should be used. ---------- A range of 20-30 is the range of cm H 2O, not mm Hg. Securing the cannula with tape or suctioning the patient frequently does not prevent an air leak.

A new graduate RN discovers that her patient, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first? 1 Replace the obturator while reinserting the tracheostomy tube. 2 Auscultate the patient's breath sounds while applying a nasal cannula. 3 Apply a 100% non-rebreather mask while administering high-flow oxygen. 4 Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask.

4 Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. Because a fresh tracheostomy stoma will collapse, the patient will lose airway patency, which will require the nurse to ventilate the patient through the mouth and nose while waiting for assistance to recannulate the patient. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the patient. \ ---------------- Auscultation of the patient's breath sounds at this time will not improve the patient's respiratory status and will be ineffective until airway patency is restored. Further, auscultation should not be done while a nasal cannula is simultaneously applied. *Effective use of a 100% non-rebreather mask requires a patent airway. * During the first 72 hours following a tracheostomy, reinsertion of the tube is difficult and should not be attempted by the nurse. Reinsertion of the tracheostomy tube should be done once a Rapid Response Team is available to accomplish this.

The nurse is preparing to change a cuffed tube tracheostomy to a fenestrated tracheostomy tube. Which action is most important prior to cuff deflation? 1 Ask the patient to perform the Valsalva maneuver. 2 Insert an oral airway to prevent airway obstruction. 3 Teach the patient how to use an incentive spirometer. 4 Suction the patient's oropharynx before deflating the cuff

4. Before deflating a cuff, the nurse should suction the airway above the cuff to remove any secretions that might be aspirated into the lungs. It is not necessary for the patient to perform the Valsalva maneuver or for the nurse to insert an oral airway. An incentive spirometer is not indicated.

NURSING CONSIDERATIONS ASSESSMENT

ASSESSMENT 1) Note the quality , pattern, and rate of breathing: Within patient's baseline? *Tachypnea can indicate hypoxia. Dyspnea can indicate secretions in the airway * 2) Assess for any cyanosis, especially around the lips, which could indicate hypoxia. 3) Check the patient's pulse oximetry reading. 4) If oxygen is prescribed, is the patient receiving the correct amount, with the correct equipment and humidification? 5) Assess the tracheostomy site: Note the color, consistency , and amount of secretions in the tube or externally . 6) If the tracheostomy is sutured in place, is there any redness, swelling, or drainage from suture sites? If the tracheostomy is secured with ties, what is the condition of the ties? Are they moist with secretions or perspiration? Are the secretions dried on the ties? Is the tie secure? Assess the condition of the skin around the tracheostomy and neck. Be sure to check underneath the neck for secretions that may have drained to the back. Check for any skin breakdown related to pressure from the ties or related to excess secretions. Assess behind the faceplate for the size of the space between the outer cannula and the patient's tissue. Are any secretions collected in this area? • If the tube is cuffed, check cuff pressure. • Auscultate the lungs Are a second (emergency) tracheostomy tube and obturator available?

Endotracheal Tubes Indications

Airway Obstruction 1) Secretion Management 2) Airway Protection 3) Delivery of high concentration of O2 4) Impaired gas exchange 5) Impaired neuro status

What does the nurse include in the discharge teaching of a patient with a laryngectomy and tracheostomy? 1 Cover the airway loosely with plastic wrap when showering. 2 Use a dehumidifier in the home if secretions become excessive. 3 Use colored seam binding as tracheostomy ties after the stoma has matured. 4 When coughing, place a finger over the tracheostomy to expectorate secretions through the mouth

Choosing colored seam binding that blends with the patient's clothing may enhance body image. Secretions are expectorated through the tracheostomy. Plastic wrap would create a risk for suffocation and is contraindicated. A shower shield is recommended during bathing or showering. A humidifier is recommended to liquefy tracheal secretions and facilitate airway clearance.

suction pressure for tracheostomy

between 80 and 120 mm Hg to prevent hypoxemia and trauma to the mucosa.

Care Issues for the Tracheostomy Patient Prevention of tissue damage:

Cuff pressure can cause mucosal ischemia. Use minimal leak technique and occlusive technique. Check cuff pressure often. Prevent tube friction and movement. Prevent and treat malnutrition, hemodynamic instability, or hypoxia.

Tracheostomy cuff

For *patients receiving mechanical ventilation, a cuffed tube is used.* *An uncuffed tube is used when mechanical ventilation is not required.* ❇ Increased risk of aspiration Cuff: seals trachea, helps to prevent aspiration *ensures air only flows THROUGH trach, not around* Because breathing and swallowing move the tube, a cuffed tube does not protect against aspiration. Having a cuffed tube inflated may give a false sense of security that aspiration cannot occur during feeding or mouth care. In addition, the pilot balloon does not reflect whether the correct amount of air is present in the cuff.

obturator❇

Initial placement: obturator used due to blunt tip, replaced with inner cannula. *KEEP OBTURATOR AT BEDSIDE in case of emergency decannulation* Safety equipment = just as important as the ambu bag *KEEP AT BEDSIDE*❇

stopped here - test review

Neuro 41 - mylens sheath ganglion, neuro assessment, Cranial nerves *ASSESSMENT* 42 - S&S, causes, NI Diagnosis MANAGEMENT Myasthenia gravis pk AD ALS GB MS *INFECTIONS that contributed to diseases* Migraine - assessment, types of seizures time & indications interventions, medications eye anatomy near or far sighted post opt preop Ear - otis - what will the implants do? Respiratory - TB - Xdr vs MDR Medications *Nursing management = * what s&S see, what am I going to do about it *INTERVENTIONS*? Medications?

Sleep Apnea Three types-

Obstructive, central & mixed *Risk factors: - males - overweight >40y/o* - short neck ( tongue can obstruct) *Types: 1) Obstructive type-blockage of airway* *2) Central type*- brain involvement *3) mixed*

Tracheostomy Tubes Used with

Preferred method of long term ventilation (>21 days) Used for: 1) upper airway obstruction 2) Failed intubation 3) Repeated intubation 4) Chronic inability to clear secretions

By the time of discharge, the patient should be able to provide self-care, which may include tracheostomy care, nutrition care, suctioning, and communication. Although education begins before surgery , most selfcare is taught in the hospital. Teach the patient and family how to care for the tracheostomy tube.

Review airway care: 1) including cleaning and signs of infection. 2) Teach clean suction technique, and review the plan of care. 3) Instruct the patient to use a *shower shield over the tracheostomy tube when bathing to prevent water from entering the airway* 4) * Teach him or her to cover the airway loosely with a small cotton cloth* to protect it during the day . *Covering the opening: - filters the air entering the stoma - keeps humidity in the airway - enhances appearance. Attractive coverings are available as cotton scarves, decorative collars, and jewelry* 5) Teach the patient to increase humidity in the home. 6) Tell the patient to continue using the method of communication that began in the hospital and to wear a medical alert bracelet that identifies the inability to speak. The health care team assesses specific discharge needs and makes referrals to home care agencies and durable medical equipment companies (for suction equipment and tracheostomy supplies). Followup visits occur early after discharge, and the home care nurse also is an important resource for the patient and family . This nurse initiates and coordinates the services of dietitians, nurses, speech and language pathologists, and social workers. He or she informs the patient and family of community resources that can offer support and friendship. Considerations for Older Adults Patient-Centered Care* Self-managing tracheostomy care and oxygen therapy can be difficult for the older patient who has vision problems or difficulty with upper arm movement. 1) Teach him or her to use magnifying lenses or glasses to ensure the proper setting on the oxygen gauge. 2) Assess his or her ability to reach and manipulate the tracheostomy 3) If possible, work with a family member who can provide assistance during tracheostomy car

A patient has developed subcutaneous emphysema after surgery for a tracheostomy. Why must the nurse notify the health care provider immediately? 1 Bleeding has occurred related to the surgical incision; hemoglobin is low. 2 Ventilator pressures are too high, forcing air into tissue, and must be lowered. 3 There is an opening or tear in the trachea, allowing air leakage into the tissues. 4 The patient has a pneumothorax and will require a chest tube for decompression.

Subcutaneous emphysema occurs when there is an opening or tear in the trachea adjacent to the tracheostomy, allowing air to leak into the surrounding tissues. *Air can also progress throughout the chest and other tissues into the face. This requires immediate action to maintain adequate oxygenation.* A pneumothorax may occur in the apex of the lung; however, this is not likely to cause subcutaneous emphysema. When ventilator pressures are too high, lung damage may occur from this, rather than from subcutaneous emphysema. Some bleeding after surgery is not abnormal, and the incision area should be monitored for hematoma, leakage, or evidence of bruising; this is not related to the subcutaneous emphysema.

brachiocephalic artery (or brachiocephalic trunk or innominate artery)

The first major branch off of the aorta and the major artery to the forelimbs and head. is an artery of the mediastinum that supplies blood to the right arm and the head and neck. It is the first branch of the aortic arch, and soon after it emerges, the brachiocephalic artery divides into the right common carotid artery and the right subclavian artery. There is no brachiocephalic artery for the left side of the body. The left common carotid, and the left subclavian artery, come directly off the aortic arch. However, there are two brachiocephalic veins.

Vagal stimulation to the heart causes

Tracheal suctioning can cause a vagal response. This stimulus influences the electrical system of the heart, potentially leading to 1) decreased heart rate (bradycardia) 2) , heart block 3) asystole 4) hypotension 5) other dysrhythmias. if a patient develops bradycardia during nasopharyngeal suctioning Administer 100% oxygen by bag-valve-mask. Hyperoxygenation the patient can reverse bradycardia caused by vagal stimulation during suctioning. Bronchodilators are used if it becomes difficult to pass a suction tube to open the airways.

In a patient with a tracheostomy, the nurse notes that the cuff requires increasing amounts of air in order to maintain the seal and observes food particles in the tracheal secretions. Which tracheal complication does the nurse suspect occurred in this patient? 1 Dilation 2 Infection 3 Stenosis 4 Obstruction

Tracheomalacia occurs when the constant pressure from the cuff causes tracheal dilation and erosion of the cartilage. Manifestations of this condition are a need for increasing amounts of air in the tracheal tube cuff, food in tracheal secretions, and failure to receive the full tidal volume delivered by the ventilator. ------------ Tracheal infection is characterized by purulent drainage at the stoma site, along with redness, pain, and swelling. Tracheal stenosis involves scar formation caused by tracheal tube pressure and is usually observed after the tracheostomy tube is removed when stridor, difficulty breathing and swallowing, and coughing occur. Tracheal obstruction is characterized by an inability to move air in and out of the lungs.

Preferred method of long term ventilation❇

Tracheostomy Tubes (>21 days)

Trach Care Cleaning solution

Use half-strength hydrogen peroxide to clean the cannula and sterile saline to rinse it

Nasopharyngeal Airway

Use when Oral Airway cannot be used Nosebleeds Suctioning

Classification of Pulmonary Disorders Restrictive three types:

VENTILATION: *I shunting:* decreased blood return to L atria *Limited expansion of the lungs; * *II. intrinsic * 1) pneumonia 2) acute bronchitis 3) atelectasis *III.extrinsic * 1) chest trauma 2) obesity 3) kyphoscoliosis

Weaning from a Tracheostomy Tube❇

Weaning is a gradual decrease in the tube size and ultimate removal of the tube. *Cuff can be deflated as soon as the patient can manage secretions and does not need assisted ventilation.* Size of tube is decreased by capping; use a smaller fenestrated tube. 1) begin by decreasing trach size then plug trach for 30 mins and monitor *❇(Always suction mouth/lungs BEFORE touching cuff)❇* 2) Remove all air in cuff 3) take out inner cannula 4) take red cap and occlude stoma --> oral airway patent (check O2, RR, asc muscle use, breath sounds). Hear gurgling? 5) Remove red caps, insert new inner cannula, inflate cuff using minimal leak technique, suction patient.

The nurse is performing wound care on a tracheostomy placed 48 hours ago. While replacing the ties, the patient becomes agitated and moves unexpectedly, causing the tube to come out. Which actions does the nurse immediately take? Select all that apply. 1 Insert a nasal airway. 2 Call the Rapid Response Team. 3 Provide 100% oxygen via a nonrebreather mask. 4 Attempt to place the tracheostomy tube back into the surgical stoma. 5 Ventilate the patient using a manual resuscitation bag with facemask.

When a newly placed tracheostomy tube comes out, the priority is to reestablish the airway. The nurse should manually ventilate the patient while another nurse calls the Rapid Response Team. The nurse should not attempt to manually replace the tube. A nasal airway is not indicated in this situation. A nonrebreather mask does not provide ventilation, which is vital.

The Compromised Airway Partial or complete obstruction Clinical Manifestations:

_respiratory distress, gurgling, sonorous or stridor Complete_ Absent breath sounds, severe respiratory distress arrest Conscious versus unconscious

STOP-BANG questionnaire

eight parameters: *S* Snoring *T* Tired *O* Observed stopping breathing during sleep high blood *P* pressure *B* BMI (>35), *A* Age (>50 years) *N* Neck circumference (>40 cm), *G* Gender (male) -- 3 or more = high risk of OSA

Tracheostomy Ties

keeps Tracheostomy in place Immediately after Tracheostomy: the pt will have ties after a few Postop days = changed into velcro SAFETY: 1) Change one at a time 2) Change tracheostomy ties if they are soiled. Secure new ties in place before removing soiled ones to prevent accidental decannulation. If a knot is needed, tie a square knot that is visible on the side of the neck. Only one finger should be able to be placed between the tie tape and the neck.