Chapter 18 Care of Client with a Tube

Meds Administration & NG or Gastrostomy Tube

* Check for placement; if the tube is incorrectly placed, the client is at risk for aspiration. * Flush with saline before & after med administration to facilitate delivery & absorption. 1. Use elixir (liquid) forms of medication if available; if not, ensure that all meds can be crushed or opened (capsule). 2. Dissolve crushed meds in 15 to 30 mLs of water. 3. Check tube placement & residual contents before instilling the meds; check for bowel sounds. 4. Draw up the meds into a catheter tip syringe, clear excess air from syringe, and insert the meds into the tube. 5. Flush with 30 to 50 mL of water or NS (agency policy). 6. Clamp the tube for 30 to 60 minutes (med & agency policy) for absorption. * If the tube is not clamped and is reattached to suction, then the meds will be aspirated out with the suction. 7. The client should be in an upright position (30 degrees) to avoid aspiration. 8. Document the administration of meds.

Vomiting & NG Tube

* If the client vomits, stop the tube feeding and place the client in a side-lying position; suction the client as needed. - Measure abdominal girth. - Do not allow the feeding bag to empty. - Do not allow air to enter the tubing. - Elevate the head of bed. - Administer anti-emetics as prescribed.

Interventions & Tracheostomy, Part II

* SS of hemorrhage or pneumothorax: bleeding, difficulty breathing, and crepitus (subcutaneous emphysema) * Check for stoma and secretions of blood or purulent drainage. 7- Follow PHCP's prescriptions & agency policy for cleaning the tracheostomy site and inner cannula: Many inner cannulas are disposable. If cleaning, use a half-strength hydrogen peroxide. *The normal humidification process is bypassed in a client with a tracheostomy. 8. Obtain assistance when changing the tracheostomy ties. 9. Keep a resuscitation (Ambu) bag, an obturator, clamps, and a spare tracheotomy set (same type & size) at the bedside. 10. Provide frequent mouth care to reduce the risk of pneumonia. *Never insert a decannulation plug into a tracheostomy tube until the cuff is deflated and the inner cannula is removed. Prior insertion prevents airflow to the client.

Precautions for Esophageal & Gastric Tubes

* Sengstaken-Blakemore & Minnesota tubes are uncomfortable for the client and can cause complications, but their use may be necessary when other interventions are not feasible. * Not used if the client has ulceration or necrosis of the esophagus or has had previous esophageal surgery because of the risk of rupture a. Hence, sclerosing therapy is the treatment of esophageal varices. b. Sclerosing therapy is a chemical injected into the vein to obliterate it.

Types of Urinary Catheters

* Strict aseptic technique is necessary for insertion and care of the catheter. 1. A single lumen is used to empty the client's bladder (straight catheterization), obtain sterile urine specimens or check the residual amount of urine after the client voids. 2. A double lumen is used for continuous bladder drainage, one lumen is for drainage, and the other is for balloon inflation. 3. A triple lumen is used when bladder irrigation and drainage is necessary: one lumen for continuous bladder drainage, the other lumen for balloon inflation, and the last lumen is for instilling the bladder irrigant solution.

Tube Feedings, Part I

* Warm the feeding to room temperature to prevent diarrhea and cramps and administer the feeding slowly (prevent vomiting). * Monitor for lactose intolerance. Interventions: - Check for placement to prevent aspiration of the formula. - Explain procedure to client. - Irrigate the tube with saline to ensure the formula flows well through the tube.

Chest Tube Drainage System Interventions

*If the chest tube is pulled out, pinch the skin opening together, apply an occlusive sterile dressing, cover the dressing with overlapping pieces of 2-inch tape, and call the RN & PHCP immediately. - Coughing and deep breathing exercises - Change positions frequently to promote drainage and ventilation. - Stable clients may ambulate by disconnecting the suction from the chest drainage apparatus and allowing the tube to be opened to the atmosphere. - Stripping, milking or clamping a chest tube is never done without a written prescription from the PHCP (agency policy). - Keep a clamp & a sterile occlusive dressing at the bedside at all times. *If the drainage system cracks or breaks, notify the RN, and the chest tube is inserted into a bottle of sterile water in order to maintain the water seal.

Gastrointestinal Tubes

*Refer to page 209. 1- A levin tube is used to drain fluid & gas from the stomach. 2- Weighted flexible feeding tube with stylet Access port with irrigation adapter allows maintenance of the tube without disconnecting the feeding set. 3- A salem sump tube has a double-lumen: The small vent tube within the large suction tube prevents mucosal suction damage by maintaining the pressure in open eyes, at the distal end, less than 25 mm Hg. - These tubes are available with an anti-reflux valve that is placed in the air vent, which allows air in one way -- preventing any leakage. *The air vent cannot be clamped and is kept above the level of the stomach. If leakage occurs through the air vent, instill 30 mLs of air into the the air vent and irrigate the main lumen with NS.

Removal of a Chest Tube

- A chest tube is removed when the lung has fully re-expanded or there is limited drainage. - Take a deep breath and hold it: Proceed to remove the chest tube. - A dry sterile dressing, petroleum gauze dressing or Telfa dressing is taped in place. - When the chest tube is removed, the client may be asked to take a deep breath, exhale, and bear down (Valsalva's maneuver). * Bear down or the Valsalva's maneuver is similar to having a BM.

Urinary Catheter & the Male Client, Part II

- Advance catheter to the bifurcation of the catheter 17 cm to 22.5 cm (7 to 9 inches) in adult or until urine flows out of catheter end. - Lower penis and hold catheter securely in non-dominant hand. - Inflate balloon (must be in the bladder) fully per manufacturer's directions; be reminded that a male urethra is about 20 cm or 8 inches long. * The balloon should not be inflated when urine is first observed, after advancing several more centimeters or when resistance is felt. - Secure catheter tubing to inner thigh with strip of nonallergic tape. * Use paper tape if allergic to silk tape or a multipurpose tube holder with a Velcro strap.

Crepitus & Chest Tube

- Aka subcutaneous emphysema - Air caught under the skin or a leakage of air into the subcutaneous tissues - A puffed up appearance - It is monitored by palpating around the chest & neck for a crackling sensation (feels like a bubble wrap).

Fistula

- An abnormal connection between two hollow spaces, i.e., blood vessels, intestines, and hollow organs

Tube Feedings & Residual

- Check agency procedure concerning residual amounts. - Feeding is administered with a residual of 100 mLs or less. * Large volume aspirates indicate delayed gastric emptying and place the client at risk for aspiration. - Check for bowel sounds; hold the feeding and notify the RN if bowel sounds are absent. *Data about bowel obstruction: nausea, bowel sounds, and abdominal distention * If feeding is withheld, flush with 30 mL saline to decrease the risk of clogging from residual formula. - Check tube placement by aspirating gastric contents and measuring the pH (should be 3.5 or lower). *The pH is affected by formulas & prescribed proton-pump inhibitors. - Aspirate all stomach contents (residual), measure the amount, and return the contents to the stomach to prevent electrolyte imbalance, unless the color or characteristics of the residual is abnormal or the amount is greater than 250 mLs.

Feeding Container & NG Tube

- Check for bowel sounds; feedings cannot be administered if bowel sounds are absent. - Shake the formula well before pouring it into the container or feeding bag. a. Some feedings require the use of a bag in which formula is added. b. Use bottles where feeding tubing can be attached. c. The tubing sometimes have a Y-site connection, so a regular flow can be programed using the pump rather than using a piston syringe. - Change the feeding container and tubing every 24 hours & check expiration date on the formula before administering it. - Do not hang more solution than required for a 4-hour period; this prevents bacterial growth unless it is a closed system. - Flush with 30 to 50 mLs of water or NS with the irrigation syringe after the feeding.

Irrigation & NG Tube

- Check for placement before irrigating, instilling feeding solutions or administering medications. - Perform irrigation every 4 hours to monitor and maintain the patency of the tube. - Gently instill 30 - 50 mLs of water or NS with an irrigation syringe. * Irrigation must be specifically prescribed if the client underwent gastric surgery. - Pull back on the syringe plunger to withdraw the fluid to check patency; repeat if the tube flow is sluggish.

Interventions & Intestinal Tubes

- Check prescription for advancement or removal of the tube and tungsten. - Right side facilitates passage of the weighted bag in the tube through the pylorus of the stomach and into the small intestine. - Do not secure the tube to the face with tape until it has reached final placement in the intestine. - Check abdomen during the procedure: Monitor drainage from the tube and abdominal girth. - Notify the RN & PHCP if the tube becomes blocked. *When the tube is removed, the tungsten is removed from the balloon portion of the tube with a syringe; the tube is removed gradually (6 inches every hour) as prescribed by the PHCP.

Purpose of NG Tube

- Decompress the stomach by removing fluids or gas in order to promote abdominal comfort. - Allow surgical anastomoses (a connection of two things that are normally diverging, i.e., bowel or blood vessels) to heal without distention. - Decrease the risk of aspiration. - Administer meds to clients that are unable to swallow. - Provide nutrition as a temporary feeding tube. - Irrigate the stomach and remove toxic substances, e.g., poison.

Prevention of Catheter-Associated UTI

- Discontinue catheter when no longer indicated. - Avoid dependent loops in tubing and utilize commercial catheter holder.

Clogged NG Tube

- Flush tube with 30 to 50 mL of water or NS before and after medication administration and before and after bolus feeding. - Flush with water every 4 hours for continuous feeding. * If the tube becomes clogged, attempt to irrigate to remove the obstruction. Notify the PHCP (primary health care provider) if unable to declog the tube.

Aspiration & the NG Tube

- If aspiration occurs, suction as needed, monitor respiratory rate, auscultate lung sounds, monitor temperature for aspiration pneumonia, and prepare to obtain chest radiograph. - Keep the head of bed elevated.

Orotracheal Tube

- Inserted through the mouth - Allows for the use of a larger-diameter tube and reduces the work of breathing - The client may have a nasal obstruction or a predisposition to epistaxis (nose bleeds) - Can be manipulated by the tongue, causing obstruction & uncomfortable for the client - An oral airway may be needed to prevent the client from biting on the tube

Nasotracheal Tube

- Inserted through the nose - This smaller tube increases both resistance and the client's work of breathing. - More comfortable - The client is unable to manipulate it with his or her tongue. * Avoid in clients with bleeding disorders

Removal of a NG Tube

- Irrigate the tube with NS before removal to prevent aspiration. - Ask the client to take a deep breath and hold, closing the epiglottis and obstructing the airway temporarily. - Remove the tube slowly and evenly over the course to 3 to 6 seconds (coil the tube around hand while removing).

Endotracheal Suction

- It removes the secretions and clears the airway. - If a client becomes cyanotic, restless, develops tachycardia, bradycardia or another abnormal heart rhythm, discontinue suctioning until the client is stabilized. * Monitor the VS and pulse oximetry. - If the condition continues to deteriorate, then the respiratory department & PHCP may need to be notified.

Esophageal Gastric Tubes

- May apply pressure against bleeding esophageal veins to control the bleeding when other interventions are ineffective or contraindicated a. Sengstaken-Blakemore tube (3 lumens) - Two ports inflate an esophageal and a gastric balloon for tamponade - The third lumen is used for nasogastric suction, reducing the risk of aspiration. * This tube does not provide esophagel suction, but a nasogastric tube may be inserted in the opposite narish of the mouth and allow to rest on top of the esophageal balloon. b. Minnesota tube - A modified Sengstaken-Blakemore tube with an additonal lumen for aspirating esophagopharyngeal secretions

Tracheostomy

- May be temporary or permanent - An opening made surgically, directly into the trachea to establish an airway - A tracheostomy tube is inserted into the opening, and the tube attaches to the mechanical ventilator or another type of oxygen delivery device. * A fenestrated tracheostomy tube is used when a client is being weaned from breathing through the tracheostomy: a. It has small openings in the outer cannula that enables the client to speak. b. The cuff must be deflated before the fenestrated tube is capped.

Chest Tube System

- Must be maintained as a closed system in order for the air to be removed by suction and for the lungs to re-expand to a normal state - Tubes to the suction and chest tube remain patent (no kinks or obstructions)

Ureteral & Nephrostomy Tubes

- Never clamp the tubes - Maintain patency. * Monitor output closely: Urine output of less than 30 mLs per hour or lack of output for more than 15 minutes should be reported to the PHCP. - Tube irrigation may be prescribed by the PHCP and will be done by the RN.

Intestinal Tubes

- Pass nasally into the small intestine. - Decompress the bowel or remove intestinal secretions when other interventions to decompress are ineffective. - Design to enter the small intestine through the pyloric sphincter with the use of the weight of a small bag containing tungsten at its end - Types: a. Cantor tube (single lumen) - A gauge of 21 or smaller or balloon may leak b. Miller-Abbott (double lumen) - One lumen leads to a balloon that is filled with tungsten once it is in the stomach. - The second lumen is for irrigation and drainage.

Removal of Urinary Catheter

- Position the client in the same position as during catheterization. - Remove tape and place the towel between the client's thighs (male or female). - Insert a 10 mL syringe into the balloon injection port. Slowly withdraw all of the solution to deflate the balloon totally. - After deflation, explain to the client that they may feel a burning sensation as the catheter is withdrawn. Pull the catheter out smoothly and slowly. - Monitor the client's urinary function by noting the first voiding after catheter removal and documenting the time and amount of voiding for the next 24 hours.

Pleur-Evac & Suction-control Chamber

- Provides suction, which can be controlled to provide negative pressure to the chest. - Filled with various levels of water to achieve the desired level of suction. *Without this control, the lung tissue could be sucked into the chest tube. * Gentle bubbling indicates that there is suction. It does not indicate that air is escaping from the pleural space. * Vigorous bubbling indicates that an air leak; notify the RN & PHCP.

Lavage Tubes

- Remove toxic substances from the stomach. a. Ewald tube is similar to a lavacuator tube: A single-lumen large tube used for rapid one-time irrigation and evacuation. b. A lavacuator tube has a large suction lumen and a smaller lavage / vent lumen that provides continuous suction because irrigating solution enters the lavage lumen while stomach contents are removed through the suction lumen.

Chest Tube Drainage System

- Returns negative pressure to the intra-pleural space - Removes abnormal accumulations of air (top) & fluid from the pleural (bottom) space INTERVENTIONS: - An occlusive sterile dressing is maintained at the insertion site; ensure that all connections are secure. - Chest radiograph assesses the position of the tube and determines whether the lung has re-expanded. - SS of pneumothorax or hemothorax (blood accumulates in the pleural cavity): respiratory distress, crepitus (subcutaneous emphysema), increase in bloody discharge - Keep the drainage system below the level of the chest (gravity to drain the pleural space), and tubes free of kinds, no dependent loops or other obstructions.

Interventions & Esophageal and Gastric Tubes

- Sengstaken-Blakemore & Minnesota tubes - The patency and integrity of all balloons are checked before insertion and each lumen is labeled. - Fowler's position, x-ray study immediately after insertion to verify placement, monitor for respiratory distress as well as bloody drainage that indicates bleeding * AN ESOPHAGEAL RUPTURE IS AN EMERGENCY: drop in BP, increase HR, back and abdominal pain. - Maintain head elevation after the tube is in place. - The balloons ports are double-clamped to prevent air leaks. * Scissors are kept at the bedside at all times: The tube may move upward, occluding the airway or the gastric balloon of the tube ruptures. * Cutting the tube below the bifurcation (Y) will deflate all balloons and allow the tube to be removed manually.

Pleur-Evac & Dry-suction System

- The absence of bubbling is noted in the suction control chamber. - A knob is used to set the prescribed amount of suction: The wall suction source dial is turned until a small orange floater valve appears in the window on the device. When the orange floater valve is in the window, the correct amount of suction is applied. *The control flutter valve prevents the back-flow of air into the client's lung.

Pleur-Evac & Water-seal Chamber

- The tip of the tube is underwater, allowing fluid and air to drain from the pleural space and preventing air from re-entering the pleural space. - Water oscillates (up) as the client inhales & moves down during exhalation = a patent drainage system. * Excessive, continuous bubbling indicates an air leak in the chest-tube system. INTERVENTIONS: - Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly or the lung has re-expanded. - With a pneumothorax (collapsed lung), intermittent bubbling is expected as air is drained from the chest. * The apparatus and all connections must remain airtight at all times, and the drainage is never emptied: a risk of disruption in the closed system, which can result in lung collapse.

Urinary Catheter & the Male Client, Part I

- Use square, sterile or fenestrated (with openings or windows) drape. - Pour solution over sterile cotton balls. - Grasp penis at shaft, just below gland. - Retract skin with the non-dominant hand. - With dominant hand, pick up antiseptic-soaked cotton ball with forceps or swab stick and clean penis. - Move cotton ball or swab in circular motion from urethral meatus down to base of glans. - Repeat cleaning 3 more times, using clean cotton ball / stick each time. - Pick up catheter with gloved dominant hand and insert catheter by lifting penis to position perpendicular to the client's body and apply light traction.

Endotracheal Tube

- Used to maintain a patent airway (mechanical ventilation) * If the client requires an artificial airway for longer than 10 to 14 days, a tracheostomy may be created to avoid the mucosal & vocal cord damage.

Routine Urinary Catheter Care

- Wash perineal area with warm, soapy water. - Clean along the catheter with soap and water. - Anchor the catheter to the thigh. - Maintain the catheter bag below the level of the bladder.

Ventilator-associated Pneumonia

- With respiratory airway tubes - Position head of bed higher than 30 degrees. - Suction the oropharynx and use endotracheal tubes that have continuous subglottic suction ports. * A resuscitation (Ambu) bag needs to be kept at the bedside of a client with an endotracheal or tracheostomy tube at all times.

Urinary Catheter & the Female Client

- With the non-dominant hand, fully expose urethral meatus by spreading labia. - Using forceps in sterile dominant hand, pick up cotton ball or swab sticks saturated with antiseptic solution, wiping from front to back (from clitoris toward anus). - Using a new cotton ball or swab for each area you clean, wipe far labial fold, near labia fold, and directly over center of urethral meatus. - Open packet containing lubricant and lubricate catheter tip. - Advance catheter a total of 7.5 cm (3 inches) in adult or until urine flows out of catheter end. - When urine appears, advance catheter another 2 to 5 cm (1 or 2 inches). Do not use force to insert catheter.

Interventions & Tracheostomy, Part I

1- Monitor respiration and look for bilateral breath sounds. 2- Monitor pulse oximetry & ABGs. 3- Encourage coughing & deep breathing. 4- Semi-Fowler's & high Fowler positions 5- Provide respiratory treatments as prescribed. 6- Hyper-oxygenate the client before suction. * If the client is allowed to eat, sit him or her up for meals and ensure that the cuff is inflated (if the tube is not capped) for meals and for 1 hour after meals; the inflated cuff will prevent aspirations.

Interventions & Respiratory Airway Tubes, Part I

1- Placement is confirmed by chest x-ray study: a. 1 to 2 cm above the carina, a ridge of cartilage in the trachea that occurs between the division of the two main bronchi. b. By auscultating both sides of the chest while manually ventilating with a resuscitation (Ambu) bag c. If breath sounds and chest wall movements are absent on the left side, the tube may be in the right main stem bronchi. d. Auscultation over the stomach to rule out esophageal intubation e. If the tube is in the stomach, louder breath sounds will be heard over the stomach than over the chest and abdominal distention will be present. 2- The tube is secured immediately after intubation with adhesive tape or commercial device to hold endotracheal tube in place.

Tube Feedings, Part II

1. Bolus: - Resembles normal meal feeding patterns - Formula is administered over a 30 to 60 minute period, every 3 to 6 hours. - High Fowler's position for 30 minutes after the feeding - 50 to 60 mL syringe with the plunger removed 2. Cyclical: - Feeding is administered either during the day or night time for approximately 8 to 16 hours. * Feeding at night allow for more freedom during the day.

Pleur-Evac & Drainage Chamber

1. Drainage collection chamber: - Chest tube from the client connects to the system - Drainage from the tube drains into & collects in a serious of calibrated columns in this chamber 2. Interventions: - A client, with a lung resection, may have increased amounts of drainage initially. * Notify PHCP if the drainage is more than 70 to 100 mLs per hour or if the drainage becomes bright red or increases suddenly.

Extubation

1. Hyper-oxygenate the client and suction the endotracheal tube and oral cavity. 2. Semi-Fowler's position 3. The cuff is deflated; the client is asked to inhale; at peak inspiration, the tube is removed, and the airway is suctioned through the tube as it is pulled out. 4. Cough and deep breathe to assist with the removal of accumulated secretions from the throat. 5. Apply oxygen therapy as prescribed. 6. Contact RN & PHCP if respiratory difficulty occurs. 7. Hoarseness or a sore throat is normal and limit talking if it occurs.

Types of Tubes & Anatomical Placement

1. Nasogastric (aka NG): nose to stomach 2a. Nasoduodenal: nose to duodenum (first section of the small intestine) 2b. Nasojejunal: jejunum (second section of the small intestine) 3. Gastrostomy: stomach 4. Jejunostomy: jejunum (second section of the small intestine) *Refer to picture.

Insertion Procedures for a NG Tube, Part I

1. Position the client with pillows behind shoulders. 2. Determine which nostril is more patent. 3. Measure the length of the tube from the bridge of the nose to the earlobe; from there, measure to the xiphoid process and indicate this length with a piece of tape on the tube. 4. Lubricate the tip of the tube with water-soluble lubricant. 5. Gently insert the tube into the nasopharynx and advance the tube. 6. When the tube nears the back of the throat (1st. measurement on the tube), instruct the client to swallow or drink water if he or she is conscious and alert (follow agency procedure). 7. If resistance is met, then slowly rotate and aim the tube downward and toward the closer ear; in the intubated or semiconscious client, flex the head toward the chest while passing the tube. 8. Immediately withdraw the tube if any change is noted in the respiratory status.

Insertion Procedures for a NG Tube, Part III

15. Before adding an irrigation solution (NS), feeding or administering meds, aspirate stomach contents and test the pH. * A pH of 3.5 or lower indicates that the tip of the tube is in a gastric location. 16. Observe for fluid & electrolyte balance. 17. Remove daily the adhesive tape that is securing the tube to the nose and clean and dry the skin, assessing for excoriation or pressure areas that can cause pressure ulcers; then, reapply the tape.

Insertion of Urinary Catheter

1a. Female Supine with knees flexed, support legs with pillows to reduce muscle tension and promote comfort. 1b. Male Supine position with thighs slightly abducted. 2. Wearing clean gloves, wash perineal area with soap and water and dry thoroughly. 3. Remember that all components of the catheterization tray are sterile; all supplies are arranged in the box in order of sequence of use. 4. Apply waterproof sterile drape. 5. Inflate balloon fully per manufacturer's directions. 6. Record type and size of catheter inserted, amount of fluid used to inflate the balloon, characteristics & amount of urine, specimen collection if appropriate, client's response to procedure, and that teaching is completed.

Complications of a Tracheostomy, Part I

1a. Tracheo-malacia: Constant pressure (cuff) causes tracheal dilation & erosion of cartilage. 1b. Manifestation: - A larger tracheostomy tube is required to prevent an air leak at the stoma. - The client does not receive the set tidal volume on the ventilator. - Food particles are seen in tracheal secretions. 1c. Prevention: - Use an un-cuffed tube ASAP. 2a. Tracheal stenosis (narrow lumen): - Scar formation from irritation of tracheal mucosa (cuff) 2b. Manifestation: - Increased coughing, inability to expectorate secretions, difficulty breathing or talking * Stenosis is usually seen after the cuff is deflated or the tracheostomy tube is removed. 2c. Prevention: - No pulling or traction on the tube - Properly secure the tube in the mid-line position. - Minimize oro-nasal intubation time. 2d. Management: - Surgical intervention may be used for tracheal dilation.

Interventions & Respiratory Airway Tubes, Part II

3- Monitor the skin and mucous membranes. 4- Suction the tube only when needed. * Moving the tube to the opposite side of the mouth should be done by two PHCPs daily: a. Prevents pressure and necrosis of the lip & mouth area; nerve damage; and facilitate the inspection and cleaning of the mouth. 5- To prevent dislodgment and pulling or tugging on the tube: a. Suction, coughing, and speaking attempts by the client place extra stress on the tube and can cause dislodgment. * Maintain cuff inflation, which creates a seal and allows complete mechanical control of respiration.

Tube Feedings, Part III

3. Continuous: - Administer continuously for 24 hours. - A feeding pump regulates the flow and allows the feeding to infuse via gravity; do not plunge the feeding into the stomach. - Administer a set amount of sterile water every 4 hours to prevent clogging the tube. - Semi-Fowler's position at all times, allowing gravity to help the flow of formula and prevent reflux and aspiration

Complications of a Tracheostomy, Part II

3a. Tracheo-esophageal fistula (TEF): A hole is created between the trachea and the anterior esophagus (cuff pressure causes erosion). 3b. Manifestation: - The client does not receive the set tidal volume on the ventilator. - Food particles are seen in tracheal secretions. - The client has increased coughing and choking while eating. 3c. Management: - Manually administer oxygen by mask to prevent hypoxemia. - Use a small, soft feeding tube (no NG tube). - A gastrostomy or jejunostomy may be performed. 3d. Prevention: - Deflate or use a cuffless tube ASAP.

Complications of a Tracheostomy, Part IV

5. Tube Obstruction Manifestation: - Difficulty breathing and inserting the suction catheter - Noisy respirations and thick, dry secretions - Unexplained peak pressures if client is on mechanical ventilator Management: - The PHCP repositions or replaces the tube if obstruction occurs as a result of a cuff prolapse over the end of the tube. Prevention: - Cough and deep breathe. - Provide humidification and suctioning. - Clean the inner cannula regularly.

Complications of a Tracheostomy, Part V

6. Tube Dislodgment Manifestation: - Difficulty in breathing; noisy respirations; restlessness; excessive coughing; audible wheeze or stridor Management: - For the first 72 hours (3 days) following the surgical placement of the tracheostomy, manually ventilate the client with an Ambu bag while another nurse calls for the Rapid Response team: a. Extend the client's neck and open the tissues of the stoma to secure the airway or use retention sutures to spread its opening. b. Use a tracheal dilator (curved clamp) to hold the stoma open. c. Prepare to insert a tracheostomy tube: Place the obturator into the tracheostomy tube, replace the tube and remove the obturator. d. Maintain ventilation with an Ambu bag. e. Assess airflow and bilateral breath sounds. f. If unable to secure an airway, call the Rapid response team and the anesthesiologist. Prevention: - Secure the tube in place & minimize manipulation and traction.

Insertion Procedures for a NG Tube, Part II

9. Secure the tube to the client's nose with adhesive tape and to the client's gown (agency procedure and check for allergies to the tape). 10. Abdominal x-ray to confirm placement of the tube (most reliable) 11. Connect the tube to suction, intermittent or continuous setting, as prescribed (no balloon). 12. Observe the client for N/ V, abdominal fullness or distention and monitor output. 13. Check residual volumes every 4 hours, before each feeding, and before giving medications. 14. Aspirate all stomach contents and measure the amount. Re-instill residual to prevent excessive fluid and electrolyte losses, unless the residual contents appear abnormal and the volume is large, greater than 250 mLs. *Withhold feeding if the amount is more than 100 mLs.

Complications of a Tracheostomy, Part III

A MEDICAL EMERGENCY 4a. Trachea-innominate artery fistula: - A mal-positioned tube causes its distal tip to push against the lateral wall of the trachea, causing necrosis and erosion of the innominate artery. 4b. Manifestation: - Heavy bleeding from the stoma - The tracheostomy pulsates in synchrony with the heartbeat. 4c. Management: - Remove the tracheostomy tube immediately. - Apply pressure to the innominate artery at the stoma site. - Prepare the client for immediate repair surgery. 4d. Prevention: - Notify PHCP of a pulsating tube. - Use the correct tube size & length and maintain the tube in mid-line position. - No pulling or tugging of the tube