NMNC 4335 - Tracheostomy Care

tracheostomy button

- Fits in the stoma and does not require ties - If patient needs positive pressure ventilation and/or suctioning, button should be replaced with a standard tracheostomy tube - Not used in inpatient settings but may be an option for patients after discharge

cuff less fenestrated tracheostomy tube

- The fenestrations allow air to travel through the tube of the tracheostomy, passing through the vocal chords, allowing for speech - If tube is not the proper fit, granulation tissues may grow within the fenestration, making removal a surgical problem - Requires a specialist to ensure the proper fit - Secretions can collect in the fenestrations, so humidification is necessary to ensure secretions mobilize

how do you perform oropharyngeal suctioning?

(1) Apply clean gloves. (Reduces transmission of microorganisms.) (2) Connect the Yankauer suction catheter to the connecting tubing. (Prepares the suction apparatus.) (3) Remove patient's oxygen mask, if present, but keep it close. Nasal cannula may remain in place. (Allows access to mouth. Reduces chance of hypoxia.) CLINICAL DECISION: If patient has been suctioned prior to oropharyngeal suctioning, they may require some recovery from the suctioning procedure before oropharyngeal suctioning is performed. Allow for that recovery to happen by reapplying the oxygen mask until just before oropharyngeal suctioning. (4) Insert catheter into mouth along gum line to pharynx. Move catheter around mouth until secretions have cleared. Encourage patient to cough. Replace oxygen mask. (Movement of catheter prevents suction tip from invaginating oral mucosal surfaces and causing trauma. Coughing moves secretions from lower airway into mouth and upper airway.) CLINICAL DECISION: If ETT is present, be careful when moving the catheter so as not to dislodge the ETT. Be careful when suctioning a patient who had recent oral or head/neck surgery. Aggressive suctioning and excessive coughing should not be used or encouraged in patients who have undergone throat surgery, such as a tonsillectomy. Aggressive suctioning in these patient populations can aggravate the operative site, increasing the risk of bleeding or infection (5) Rinse catheter with water or normal saline in cup or basin until connecting tubing is cleared of secretions. Turn off suction. Place catheter in clean, dry area. (Rinses catheter and reduces probability of transmission of microorganisms. Clean suction tubing enhances delivery of set suction pressure. Catheter may be reused.)

how do you perform nasotracheal suctioning?

(1) Have patient take deep breaths, if able, or increase oxygen flow rate with delivery device through cannula or mask (if ordered). (May help to decrease risks of hypoxemia.) (2) Lightly coat distal 6 to 8 cm (2-3 inches) of catheter with water-soluble lubricant. (Lubricates catheter for easier insertion.) (3) Remove oxygen-delivery device, if applicable, with nondominant hand. (Allows access to nares and catheter.) As patient takes deep breath, advance catheter following natural course of naris. Advance catheter slightly slanted and downward to just above entrance into larynx and then trachea. While patient takes deep breath, quickly insert catheter: for adults insert approximately 16-20 cm (6-8 inches) into trachea. Patient will begin to cough; then pull back catheter 1-2 cm (½ inch) before applying suction. Note : In older children, 16-20 cm (6-8 inches); in infants and young children, 8-14 cm (3-5½ inches)

how do you perform nasopharyngeal suctioning?

(1) Have patient take deep breaths, if able, or increase oxygen flow rate with delivery device through cannula or mask (if ordered). (decrease risks of hypoxemia) (2) Lightly coat distal 6-8cm (2-3 inches) of catheter with water-soluble lubricant. (Lubricates catheter for easier insertion.) (3) Remove oxygen-delivery device, if applicable, with nondominant hand. (Allows access to nares and catheter.) As patient takes deep breath, insert catheter following natural course of naris; slightly slant catheter downward and advance to back of pharynx. Do not force through nares. In adults insert catheter 16cm, older children - 8-12cm, infants and young children - 4-7.5cm. Rule of thumb - insert cath from tip of nose to angle of mandible.

how do you perform tracheostomy suctioning?

(1) Perform hand hygiene and apply appropriate personal protective equipment (mask with face shield or goggles; gown if necessary). (Reduces transmission of microorganisms.) (2)Adjust bed to appropriate height (if not already done) and lower side rail on side nearest you. Check locks on bed wheel. (Minimizes caregiver's muscle strain and prevents injury. Prevents bed from moving.) (3) Connect one end of connecting tubing to wall suction device and place other end in convenient location near patient. Turn suction device on and set suction pressure to as low a level as possible and yet able to effectively clear secretions. This value is typically 80-120mmHg adults & 60-100mmHg neonates. Suction pressure should not exceed 180mmHg Occlude end of suction tubing to check pressure. (Ensures equipment function. Excessive negative pressure damages tracheal mucosa and induces greater hypoxia) (4) Prepare suction catheter for all types of open suctioning. (5) Using aseptic technique, open suction kit or catheter package. If sterile drape is available, place it across patient's chest or on bedside table. Do not allow suction catheter to touch any nonsterile surfaces. N ote : When performing oropharyngeal suction only, there is no need to place a sterile drape; it is a clean procedure, not sterile. (Prepares catheter, maintains asepsis, and reduces transmission of microorganisms. Provides sterile surface on which to lay catheter between passes.) (6) Unwrap or open sterile basin and place on bedside table. Be careful not to touch inside of basin. Fill with about 100mL sterile NS solution/H2O. (used to clean tubing after each suction pass) (7) Apply sterile gloves (8) Pick up suction catheter with dominant hand without touching nonsterile surfaces. Pick up connecting tubing with nondominant hand. Secure catheter to tubing (see illustration). (9) Place tip of catheter into sterile basin and suction small amount of normal saline solution from basin by occluding suction vent. (Ensures equipment function. Lubricates internal catheter and tubing.) (10) Suction airway.

What are the benefits to the patient to having a tracheostomy?

(1) establish a patent airway (2) bypass an upper airway obstruction (3) facilitate removal of secretions (4) permit long-term mechanical ventilation (5) assist with weaning from mechanical ventilation

speech valve

- Can be used with fully deflated cuff or the cuffless tube - CONTRAINDICATIONS - required ventilator support, unstable, unconscious, unmanageable secretions, inflated cuff, laryngectomy, upper airway stenosis, no swallow reflex, paralysis of muscles involved in speech - Heated, humidified air needed for supplemental oxygen - If using on a cuffed tracheostomy, cuff must be completely deflated

capping trials

- Capping the tracheostomy tube allows air to be inhaled and exhaled through the natural airway - Possible airway obstruction with mucus buildup around or within the tube - Capping should be attempted only with cuffless tracheostomy tubes - Nasal canula or face mask now used is capped - Anxiety may be a factor in a failed capping trial, educate patient and guide/support them

what are some nursing interventions used to prevent/treat tracheostomy's complications?

- Confirm tube placement · Auscultate pt chest for air entry · End-tidal capnography · Passage of suction cath thru trach tube - Monitor HR, RR, BP, SPO2 - Observe for blood @ trach tube insertion site - Assess trach site Q shift - Confirm patency of trach tube - Observe site for redness, inflammation, edema, ulceration, infection - Perform sterile dressing changes Q12H - Inflate cuff w least volume of air needed to obtain airway seal - prevent unnecessary pressure on tracheal mucosa, compressing tracheal capillaries, limit blood flow, tracheal necrosis - Suction airway via trach tube prn - avoid suctioning newly created trach in the first few hours after the procedure - Humidification - keep secretions thin & decrease formation of mucus plugs - Clean nondisposable inner cannula at least Qshift - 2 fingers should fit under trach tapes to ensure they aren't too tight around neck - Keep replacement tube of equal/smaller size at bedside available for emergency insertion, do not change trach tubes for 24h after surgery, HCP perform first tube change no sooner than 7 days after tracheostomy

digital occlusion

- Used for assessment of the patient's ability to tolerate capping or use of a speaking valve - Bulkiness of the deflated cuff may cause marked airway obstruction and resistance - Cuff must be completely deflated before digital occlusion - Suctioning before and after can help prevent aspiration, coughing or respiratory distress

What is the purpose of a tracheostomy tube cuff?

- Used when pt needs mechanical ventilation - Inflated via balloon inflation port on tracheostomy tube - Ensures pt receives volume of air delivered by ventilator - Helps decrease risk for aspiration

flail chest

- fracture of 3 or more consecutive ribs, in 2 or more separate places, causing an unstable segment - can be caused by fracture of the sternum & several consecutive ribs - resulting instability of chest wall causes paradoxical movement during breathing - affected (flail) area moves in opposite direction with respect to intact part of chest - during inspiration, affected part is sucked in, & during expiration, it bulges out - paradoxical chest movement prevents adequate ventilation & increases WOB - underlying injured lung may be contused, aggravating hypoxemia

airway obstruction

- medical emergency - causes - aspiration of food/foreign body, allergies, edema & inflammation, peritonsillar/retropharangeal abscesses, cancer, laryngeal/tracheal stenosis, trauma - may be partial/complete - S/S - choking, stridor, accessory muscle use, suprasternal & intercostal retractions, flaring nostrils, wheezing, restlessness, tachycardia, cyanosis, change in LOC

tracheostomy

- surgically created stoma in the anterior part of the trachea

acute laryngitis

- swelling + inflammation of voice box - virus - most common cause - other causes - inflammatory/ infectious conditions (tonsillitis, bronchitis), voice overuse, smokey environments, chemical inhalation - S/S tingling & burning at the back of the throat, persistent need to clear throat, hoarseness, loss of voice

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.

To prevent potential aspiration, which technique would the nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula? 1. Apply precut dressing around the insertion site with the flaps pointing upward. 2. Replace the tube with a sterile obturator. 3. Use sterile cotton balls to cleanse the outer cannula. 4. Remove the cannula after the high-volume, low-pressure cuff has been deflated.

1. Apply precut dressing around the insertion site with the flaps pointing upward.

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 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

how do you perform tracheostomy care?

1. Explain procedure to patient. 2. Use trach care kit or collect necessary sterile equipment (EX) suction catheter, 1 pair sterile gloves, 1 pair nonsterile gloves, water basin, trach ties, tube brush/pipe cleaners, 4X4 gauze, sterile water/NS, trach dressing 3. Place pt in semi-Fowler's 4. Assemble needed materials on bedside table 5. Wash hands. Put on PPE. 6. Auscultate chest sounds. If wheezes or coarse crackles are present, suction patient if unable to cough up secretions. Remove soiled dressing & clean gloves. 7. Open sterile equipment, pour sterile H2O/NS into 2 compartments of sterile container or 2 basins, & put on sterile gloves. Hydrogen peroxide (3%) is only used if infxn present. If it is used, rinse inner cannula & skin w sterile H2O/NS after to prevent tissue trauma. 8. If present, unlock & remove inner cannula. Many tracheostomy tubes do not have inner cannulas. Care for these tubes includes all steps except for inner cannula care. 9. Replace a disposable inner cannula w new cannula. For nondisposable cannula: - Immerse inner cannula in sterile solution & clean inside + outside using tube brush/pipe cleaners - Rinse cannula in sterile solution. Remove from solution & shake to dry - Insert inner cannula into outer cannula w curved part downward, and lock in place 10. Remove dried secretions from stoma using 4X4 gauze soaked in sterile H2O/saline. Gently pat area around stoma dry. Clean under trach flange (faceplate), using cotton swabs. 11. Place dressing around tube. Use a pre-cut trach dressing/unlined gauze. Do not cut gauze because threads may be inhaled or wrap around trach tube. Change dressing prn. Wet dressings promote infxn & stoma irritation. 12. Change tracheostomy tapes, using 2-person change technique. Tie tracheostomy tapes securely w room for 2 fingers between tapes & skin. To prevent accidental tube removal, secure trach tube by gently applying pressure to flange of tube during tape changes. Do not change tracheostomy tapes for 24h after tracheostomy procedure. 13. Some patients prefer tracheostomy tapes made of Velcro, which are easier to adjust. 14. Repeat care 3Xday & PRN.

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 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

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.

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

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 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.

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

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

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? SATA 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. Use sterile technique when cleaning the inner cannula. 4. Don sterile gloves before removing the inner cannula.

Which action would the nurse include when performing tracheostomy care on a client receiving mechanical ventilation? SATA 1) Using hydrogen peroxide 2) Inserting a catheter without suction 3) Placing the client in the recumbent position 4) Rinsing the inner cannula with normal saline 5) Changing both tracheostomy ties at same time

4) Rinsing the inner cannula with normal saline

Which clinical manifestation would the nurse expect when assessing a client with atelectasis? 1. Hyperresonance to percussion 2. Rhonchi and wheezes 3. Sudden onset shortness of breath 4. Crackles at the bases

4. Crackles at the bases

Which nursing assessment supports a diagnosis of atelectasis in a postoperative client? 1. Productive cough 2. Clubbing of the fingertips 3. Low-pitched expiratory rhonchi 4. Diminished breath sounds on auscultation

4. Diminished breath sounds on auscultation

Which action will the nurse take when a client's chest x-ray shows atelectasis? 1. Administer oxygen. 2. Suction the upper airway. 3. Position for postural drainage. 4. Encourage incentive spirometer use.

4. Encourage incentive spirometer use.

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.

what are potential complications of a tracheostomy?

air leak airway obstruction altered body image aspiration bleeding fistula formation impaired cough infection: wound or respiratory tract subcutaneous emphysema tracheal necrosis tracheal stenosis tube displacement

laryngeal polyps

Develop on vocal cords from vocal abuse (EX excessive talking, singing) or irritation (EX intubation, smoking) - hoarseness - tx w voice rest + hydration - large polyps can cause dysphagia, dyspnea, stridor - may need to be surgically removed - usually benign but can become cancerous

how often should you assess the tracheostomy site at minimum?

Q shift

how often should you clean a nondisposable inner cannula? what is the purpose?

Q shift cleaning removes mucus from inside the tube to prevent airway obstrxn

Decannulation

removal of tracheostomy tube from the trachea pt must - be hemodynamically stable - have stable, intact respiratory drive - be able to adequately exchange air - independently expectorate secretions

what is chest physiotherapy? what are the benefits?

× External chest wall manipulation using postural drainage, percussion, vibration, or high-frequency chest wall compression × Benefit - can help mobilize pulmonary secretions × Pts with retained secretions who cannot expectorate them (EX) CF, bronchiectasis × Need to be properly trained otherwise you can cause complications - fractured ribs, bruising, hypoxemia, bronchospsm and discomfort

What do you do if a trach tube comes out of a pt's stoma?

× Immediately call for help × Quickly assess pt LOC, ability to breathe, & presence/absence of resp distress × In case of resp distress is present, use hemostat to spread opening where tube was displaced. Either: - Insert obturator in replacement (spare) tracheostomy tube, lubricate w saline, & insert tube into stoma, Once tube is inserted, remove obturator at once so air can flow through tube. - Insert a suction catheter to allow passage of air & serve as a guide for insertion. Thread trach tube over catheter & remove suction cath. Trying to reinsert will be easier if the stoma tract is mature/older than 1 week.

List various airway adjuncts and describe their correct placement

× Oropharyngeal airways - Inserted into mouth - Used only on unconscious, unresponsive victims w/o gag reflex - If placed improperly, can depress tongue into back of throat, further blocking the airway - Once you have positioned device, use resuscitation mask/bag-valve-mask resuscitator (BVM) to ventilate a nonbreathing victim. - Should not be used if victim has suffered oral trauma, such as broken teeth, or has recently undergone oral surgery × Nasopharyngeal airways - Inserted into nose - Used on conscious, responsive victim or an unconscious victim - Unlike oral airway, the nasal airway does not cause the victim to gag. - Should not be used on victims w suspected head trauma or skull fracture

Describe indications for a tracheostomy. How does it differ from intubation with an endotracheal tube?

× Tracheostomy IND - occlusions of airway above trachea (EX) foreign objects or acute inflammation of the airway, bypasses oral cavity, epiglottis, & vocal chords, still invasive but can be done w/o premedication & only local anesthetic - Trach is shorter in length & slightly wider in diameter than ET tube - easier to keep the tube clean and facilitates better oral & bronchial hygiene - Trach may increase patient comfort because no tube is present in the mouth - less risk for long-term damage to vocal cords - Pt can still move lips, swallow, eat & sometimes speak, more active & less restricted - Bypasses risk of damage to vocal chords & creates access port for inhalant med admin × ET tube - Often causes substantial trauma to airway - Requires many meds to insert & maintain - Very uncomfortable and pt often try to rip them out upon waking - Pts need to be sedated & unconscious due to invasive nature of ET tube & pt situation indicating placement of an ET tube - Short-term artificial airway used to administer invasive mechanical ventilation, relieve upper airway obstruction, protect against aspiration, or clear secretions - A physician or specially trained clinician inserts the ET tube - Tube is passed through mouth, past the pharynx, and into trachea - Generally removed within 14d - Sometimes used for longer if pt is still showing progress toward weaning from invasive mechanical ventilation & extubation (removal of the endotracheal tube) × Both procedures usually done by physician, APRN, PA, specially licensed paramedic in transport, transport/flight RN