Providing tracheostomy care
DELEGATION for providing tracheostomy care
The skill of performing tracheostomy care is not routinely delegated to NAP. In some settings, care may be delegated to NAP for patients who have well-established tracheostomy tubes. In all cases, the nurse is responsible for assessing the patient and for providing proper artificial airway care.
Do not use ____ to cut 4 x 4-inch gauze pads to make a tracheostomy dressing. Cutting causes the pads to shed fibers that the patient could ____. Instead, use a pad specifically designed for use as a _____ dressing.
scissors, inhale, tracheostomy
If accidental extubation occurs, call for assistance. Manually ______ the patient with a resuscitation bag if needed. Keep a tracheostomy obturator at the bedside to facilitate reinsertion of a dislodged outer cannula. For emergency replacement, keep on hand an additional ______ tube of the same size and shape as the one in use
ventilate, tracheostomy
How can the nurse best minimize a patient's risk for infection during tracheostomy care? A. Adhere to sterile technique when appropriate. B. Frequently assess for signs of local or systemic infection. C. Monitor for indications that tracheostomy care is needed. D. Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage.
A is CORRECT. Adherence to sterile technique is the most important factor in minimizing the patient's risk for infection during tracheostomy care
Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? A. Cleaning the stoma with hydrogen peroxide and drying thoroughly B.Cleaning and assessing the skin around the stoma C. Assessing temperature and reporting skin breakdown immediately D. Allowing the patient to re-oxygenate after each tracheal suctioning
B is correct Frequently cleaning and assessing the skin in the tracheostomy area will reduce the patient's risk for skin breakdown.
Which technique would the nurse use to change a patient's tracheostomy ties? A. Use a slipknot. B.Ensure that two fingers fit snugly under the tie. C. Knot the ends of the tie in the eyelets on the faceplate. D.Ask the patient to hold his or her breath while the ties are changed.
B. When the tie is secure, two fingers should fit snugly under it.
Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? A. Having a spare oxygen mask at the patient's bedside B. Keeping an obturator and a tracheostomy tube at the patient's bedside C. Reviewing the agency's policy regarding tracheostomy care D. Instructing the family to call immediately if the patient has difficulty breathing
B. Keeping an obturator and a tracheostomy tube of the correct size at the patient's bedside is the best way to plan for an emergency involving a tracheostomy, such as tube dislodgement.
which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? A. Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago B. Removing the outer cannula and placing the obturator C. Holding the tracheostomy tube while the nurse changes the neck ties D. Monitoring oxygen saturation levels and placing oxygen if needed
C. NAP may hold the tube while the nurse changes the ties during tracheostomy care.
DOCUMENTATION
Record respiratory assessments before and after care. Record the type and size of tracheostomy tube and the frequency and extent of care. Record the type, color, and amount of secretions, the patient's tolerance and understanding of the procedure, and any special care taken for unexpected outcomes. Report accidental decannulation or respiratory distress to the health care provider.
Cleaning a tracheostomy
Use normal saline solution and replace moisture pad with dry pad.
Safety - when replacing the neck tie what should you do.
do not release the tracheostomy until the new tie is in place; do not cut the old tie until the new tie is in place
