MedSurg Unit 1 Skills: Providing Care of a Tracheostomy Tube

Delegation Consideration Providing Care of a Tracheostomy Tube

- Do not delegate to NAP or UAP. - Depending on the state and/or state of patients needs/circumstances you can delegate to LPN/LVN

Nursing Diagnosis Examples Providing Care of a Tracheostomy Tube

- Impaired Skin Integrity - Risk for Infection - Ineffective airway clearance

Assesment Providing Care of a Tracheostomy Tube

- Need for tracheostomy care: soiled dressings, holders, or ties; secretions in the tube; diminished airflow; or in accordance with facility policy. - asses insertion site for redness or purulent drainage (potential infection) - asses patients pain (if new, the patient may need pain meds for trach care) - Assess lung sounds (should be equal in all lobes) and O2 saturation levels (if trach is dislodged lung sounds and O2 will diminish) - Inspect the area on the posterior portion of the neck for any skin breakdown from irritation or pressure from trach holder or ties

Evaluation Providing Care of a Tracheostomy Tube

- Patient exhibits a trach tube and site free from drainage, secretions, skin irritation/breakdown, appropriate O2 saturation level, patent airway, and no evidence of respiratory distress. - Patient verbalizes that the site is free of pain.

Outcome Identification and Planning Providing Care of a Tracheostomy Tube

- The patient will exhibit a trach tube and site free from drainage, secretions, skin irritation/breakdown and a patent airway. Other: - oxygen saturation levels will be within acceptable parameters - the patient will have no signs of respiratory distress

Documentation Providing Care of a Tracheostomy Tube

- assessment prior to and after interventions. (site, presence of pain, lung sounds, and O2 saturation levels. - Any skin breakdown that may be resulted from trach collar. - Document care given.

Equipment Providing Care of a Tracheostomy Tube

-Disposable gloves -Sterile gloves -Goggles and mask or face shield -Additional PPE, as indicated -Sterile normal saline -Sterile cup or basin -Sterile cotton-tipped applicators -Sterile gauze sponges -Disposable inner tracheostomy cannula, appropriate size for the patient -Sterile suction catheter and glove set -Commercially prepared tracheostomy or drain dressing -Commercially prepared tracheostomy holder -Plastic disposal bag Additional nurse

The nurse is changing a disposable inner cannula on a tracheostomy client, Place in order, from first to last, the actions the nurse will perform. Use all options.

1)Open supplies using aseptic technique. 2)Remove oxygen source to tracheostomy if present. 3)Use nondominant hand to stabilize the outer cannula and faceplate. 4)Remove inner cannula and site dressing and place them in disposable bag. 5)Remove and discard clean gloves, and put on sterile gloves. 6)Use dominant hand to pick up the new inner cannula, and insert it into the outer cannula. Rationale:First, the nurse should open all supplies using aseptic technique and prepare the sterile field. Next, the nurse should remove the oxygen source, if one is present; this action would not be performed first, because the client should continue to receive the oxygen during the preparations. After removing the oxygen source, the nurse should stabilize the outer cannula and faceplate of the tracheostomy with the nondominant hand. Then, using the dominant hand, the nurse should grasp the locking mechanism of the inner cannula and gently remove the inner cannula and site dressing, placing them in the previously prepared disposable bag. Working quickly, the nurse should then discard the current clean gloves and put on sterile gloves. Once sterile gloves are donned, the nurse should pick up the new inner cannula with the dominant hand; stabilize the faceplate with the nondominant hand, and gently insert the new inner cannula into the outer cannula. Finally, the nurse should press the tabs to allow the lock to grab the outer cannula and reapply the oxygen source, if needed.

Implementation Providing Care of a Tracheostomy Tube

1. Gather equipment 2. Perform hand hygiene 3. Identify the patient 4. Assemble equipment on the overbed table or other surface within reach. 5. Provide Privacy 6. Determine the need for trach care - assess patients pain level and administer medication if indicated 7. Explain to the patient regardless of alertness the procedure that you will perform and reassure patient that you will interrupt the procedure if he/she has respiratory difficulty 8. Adjust the bed to comfortable working position. Lower side rail closest to you. IF CONSCIOUS: place patient in a semi-fowler's position. IF UNCONSCIOUS: place patient in lateral position facing you. position overbed table close to you at comfortable position and trash receptacle within easy reach of the work area. 9. Put on face shield/goggles and mask. Suction trach if necessary. Remove soiled site dressing and discard. As well as gloves used while suctioning was performed. CLEANING THE TRACH: DISPOSABLE INNER CANNULA (steps 10-13) 10. Carefully open package with the new disposable inner cannula, careful not to contaminate the inner cannula or inside of package. carefully open the package with sterile cotton-tipped applicators, taking care not to contaminate them. Open the sterile cup or basin and fill 0.5 in deep with saline. Open the plastic disposable bag and place within reach on work surface. 11. Put on disposable gloves. 12. Remove the oxygen source (if present), stabilize outer cannula and faceplate with your non-dominate hand and gently insert new inner cannula into the outer cannula. Press the tabs to allow the lock to grab the outer cannula. Reapply oxygen source (if needed). APPLYING CLEAN DRESSING AND HOLDER: steps 14-20 14. Remove oxygen source (if necessary). Dip cotton-tipped applicator or gauze sponge in cup basin with sterile saline and clean stoma under faceplate. Use each applicator/sponge only once, moving from stoma site outward. 15. Pat skin gently with dry 4X4in. dressing under faceplate. 16. Slide commercially prepared trach dressing or pre-folded non-cotton-filled 4x4in. dressing under the faceplate. 17. Change the trach holder. 18. Remove gloves, facesheild/goggles, and mask. assist patient to comfortable postition. 19. Reassess patients respiratory status (rate, effort, O2 saturation, and lung sounds) 20. remove additional PPE (if used) perform hand hygiene.

Changing the tracheostomy Holder

1. OBTAIN ASSISTANCE TO HOLD TRACH TUBE IN PLACE. 2. Open the package for new trach collar 3. Both nurses put on clean gloves. 4. One nurse hold faceplate, other pulls the velcro tabs. gently remove collar 5. The first nurse continues to hold the trach faceplate. 6. The other nurse places the collar around the patients neck and inserts the first tab, then the other into openings of the faceplate and secures velcro. 7. Check the fit of the trach collar - one finger should fit between neck and the collar. Check that as patient moves his neck around that the collar fits comfortably. reapply oxygen if necessary.

The nurse is preparing to provide tracheostomy care to a client with a new tracheostomy. Which action should the nurse take before beginning the procedure?

Assess the client for pain and administer analgesic as needed. Rationale:Before beginning the procedure, the nurse should assess the client for pain or discomfort and administer the prescribed analgesic if indicated. Hyperventilating the client is done with suctioning, not with tracheostomy care. Analgesics are not applied to the stoma site. Any oxygen source would need to be removed to perform tracheostomy care.

After changing the disposable inner cannula and changing the dressing of a client who has a tracheostomy, a nurse prepares to change the client's tracheostomy collar. Which action would the nurse take first?

Enlist the assistance of a second nurse. Rationale:The nurse changing a tracheostomy collar would first enlist the assistance of a second nurse to hold the tracheostomy in place during the procedure. The primary nurse would then unfasten one hook-and-loop fastener strip from the faceplate and remove it from behind the client's neck. The nurse would then remove the second hook-and-loop fastener strip and the soiled collar, and then replace it with a new one.

The nurse is providing tracheostomy care to a client and is preparing to change the client's tracheostomy collar. Which action would be most appropriate?

Enlist the help of a second nurse to hold the tracheostomy tube in place while the old collar is removed and the new collar is placed. Rationale:The nurse changing the tracheostomy collar should enlist the help of a second nurse to hold the tracheostomy tube in place while the old collar is removed and the new collar is applied. Holding the tracheostomy tube in place ensures that the tracheostomy will not inadvertently be expelled if the client coughs or moves. The nurse would check the fit of the collar after applying it, confirming that one finger can be inserted between the neck and the collar. This permits neck flexion that is comfortable and ensures that the collar will not compromise circulation to the area.

The nurse has just finished replacing a disposable inner cannula of a client's tracheostomy. The client begins coughing and dislodges the tracheostomy. Which action should the nurse take first?

Insert the obturator into a new tracheostomy and insert the tracheostomy into the stoma. Rationale:To maintain aseptic technique, the nurse should insert the obturator into a new, sterile tracheostomy and insert the tracheostomy into the stoma. The nurse need not notify the health care provider, unless the tracheostomy is not easily reinserted. Neither simply rinsing off the expelled tracheostomy nor replacing its collar and then reinserting it would maintain aseptic technique, as the tracheostomy became unsterile upon being expelled.

On assessment, the nurse notes significant secretions on the client's tracheostomy dressing. The health care provider's prescription states that tracheostomy site care is to be done once per shift. The nurse has already performed site care once during the current shift. What is the best action by the nurse?

Perform site care again and document the procedure. Rationale:The best action by the nurse is to perform the needed site care again and document the procedure. The prescription for site care once per shift indicates the minimum frequency for the procedure. The nurse uses his or her judgement to determine if and when it needs to be done more than once a shift. Failure to change the dressing puts the client at risk of infection and skin breakdown. There is no need to notify the health care provider, because it is within the nurse's scope of practice to make the judgement that the dressing needs to be changed and site care performed in order to prevent harm to the client. Postponing the site care by requesting that it be performed by the nurse on the next shift places the client at risk of infection and skin breakdown. Simply wiping the secretions off the dressing will not remove all the potential pathogens.

The nurse is providing tracheostomy care for a client and cleans the nondisposable inner cannula with the brush. What should the nurse do next?

Place the inner cannula in a basin of sterile saline. Rationale:After cleaning the inner cannula with the brush, the nurse should place the cannula in a basin of sterile saline and agitate it to rinse the cannula thoroughly. The nurse should then remove the cannula from the saline, tap it against the inner edge of the basin to remove excess fluid, and place it on a sterile gauze to dry. The nurse should not use a sterile precut gauze to dry the cannula after cleaning it with the brush, because, at this point, the cannula has not yet been rinsed. The nurse should use sterile saline, not hydrogen peroxide, at this point of the procedure. The peroxide is to be used before cleaning the inner cannula with the brush. Lubricants are not used on the inner cannula.

The nurse if providing tracheostomy care to a client with a nondisposable inner cannula. Which action should the nurse take next after removing the inner cannula?

Replace the client's oxygen source over the outer cannula. Rationale:After removing the inner cannula the nurse should next replace the client's oxygen source over the outer cannula to provide the needed oxygen supplementation and to help prevent a decline in oxygen saturation. The nurse should soak nondisposable inner cannula in a basin of hydrogen peroxide or half hydrogen peroxide and half sterile saline, based on the facility's policy but it should never be placed in alcohol for cleaning. After replacing the oxygen source, the nurse can proceed with the procedure and clean the cannula with the pipe cleaner and saline. The nurse should have performed any needed suctioning before beginning the tracheostomy care.

On assessment, the nurse notes that the tracheostomy ties are grossly soiled and require changing. No one is available to assist at this time. What is the best action by the nurse?

Secure the new tracheostomy ties before removing the old ties. Rationale:The best action by the nurse at this time is to change the ties by first securing the new ties and then removing the old ties. Delaying care until someone is available places the client at risk of infection from the grossly soiled ties. Taping the collar is not an appropriate action, because secretions will cause the tape to loosen. Tracheostomy care can cause the client to need to cough, so this would not be a proper instruction. The client may not be able to help but cough, and this may dislodge the cannula if the trach is not secured with ties or being held in place by a second person.

The nurse is providing site care for a client with a tracheostomy using a nondisposable inner cannula. Which step is recommended to release the lock on the device?

Stabilize the outer cannula and faceplate with the nondominant hand. Rationale:The nurse opening the lock on a tracheostomy would stabilize the outer cannula and faceplate using the nondominant hand and rotate the inner cannula counter-clockwise with the dominant hand. This action unlocks the outer cannula and releases the nondisposable inner cannula so that it can be cleaned.

While providing care to a client who has a tracheostomy with a nondisposable inner cannula, the nurse observes secretions that have accumulated in the outer cannula. Which action would the nurse take?

Suction the outer cannula using strict aseptic technique. Rationale:If secretions have accumulated in the outer cannula during cleaning of the inner cannula, the nurse should suction the outer cannula using aseptic technique. The brush used to clean the inner cannula is now contaminated and should not be inserted into the outer cannula. Encouraging the client to cough may dislodge the outer cannula. Wiping away the secretions with a tissue could introduce fibers and, possibly, organisms into the client's respiratory tract.

The nurse is observing a family caregiver doing a return demonstration of tracheostomy care for a client with a nondisposable inner cannula. Which action by the family caregiver indicates that additional teaching is required?

The family caregiver rotates the inner cannula clockwise with the nondominant hand to release the lock. Rationale:Further teaching is indicated when the caregiver rotates the inner cannula clockwise with the nondominant hand to release the lock. The caregiver should be taught to use the dominant hand to turn the inner cannula counter clockwise to release the lock. The following actions by the caregiver are all correct and appropriate: raising the bed to the caregiver's elbow level and the head of the bed to semi-Fowler's; performing hand hygiene, donning clean gloves and a face shield to begin the procedure; and agitating the inner cannula in a basin of sterile saline after cleaning it with the brush.

The nurse is providing tracheostomy care for a client. When changing the dressing, which action would be most appropriate for cleaning the stoma?

Use each applicator only once, moving from the stoma site outward. Rationale:When cleaning the stoma while changing the dressing of a tracheostomy, the nurse would clean the stoma using each applicator only once, moving from the stoma site outward. The nurse would dip the cotton-tipped applicator in a cup of sterile saline, not water. The nurse would pat the skin gently using a 4 × 4 gauze sponge prior to applying the new dressing. Saline is nonirritating to tissue and the gauze removes excess moisture. Cleansing outward and using each applicator only once adheres to aseptic technique.

The nurse is preparing to provide tracheostomy care to a client. The client's tracheostomy dressing is soiled, but a commercially prepared tracheostomy dressing is not available. Which action should the nurse perform?

Use two folded gauze sponges on each side of the stoma. Rationale:If a commercially prepared tracheostomy dressing is not available, the nurse should fold two gauze sponges on the diagonal to form triangles; the nurse should then slide one triangle under the faceplate on each side of the stoma, with the longest side of the triangle against the tracheostomy. Waiting for a commercially prepared dressing would be inappropriate, because the client's dressing is soiled and needs to be changed to reduce the risk of infection. Cutting a gauze pad can create loose fibers, which can become lodged in the stoma and cause irritation or infection. Loose fibers could also be inhaled into the trachea and cause respiratory distress. Water-soluble lubricant is not used around the stoma.

When providing tracheostomy care to a client with a disposable inner cannula, at which point would the nurse put on sterile gloves?

after removing the old inner cannula Rationale:Sterile gloves are put on after the inner cannula is removed and discarded, just before the nurse picks up the new inner cannula whose package was opened previously. Gloves do not need to be worn when opening the package for the new cannula, opening the cotton-tipped applicators, or filling the sterile cup with saline.

After changing a client's tracheostomy holder, the nurse determines that the collar fits properly when:

the client can flex the neck comfortably. Rationale:A tracheostomy holder fits properly when the nurse can insert one finger between the neck and the holder to allow the client to flex the neck comfortably. Neither adherence of the tabs nor a centered faceplate ensures that the holder is properly fitted.