Care of Patients with Tracheostomy

Question 1

Uses continual positive pressure to keep alveoli open and improve gas exchange; with or without O2 - tubing from wall/machines dial in specific FiO2 - very from tiny machine to free standing that looks like ventilator to achieve this
Uses a tightly fitting mask around nose or nose and mouth - diff masks - nasal pillows (fit under nose), sealed nasal masks, full masks over nose and mouth, full face sealed around head because no intense pressure - fit mask essential in order for this to work
Can be used with or without oxygen
Indications:
Using more and more frequently in acute care settings; not need intubate as often anymore because can bipap until fix underlying prob
CPAP
BiPAP
Nursing considerations:

Answer 1

Noninvasive positive airway pressure/ventilation (NPPV)

Question 2

Sleep apnea - big one; CPAP
Hypercarbia - high CO2 levels; one way help blow off CO2
Acute COPD exacerbation
Manage acute dyspnea - bipap for palliative care
Pulmonary edema – more and more lately; fluid overload, put on bypap to tide over until really dry reefed and then get fluid off of them so can get off machine; pressure helps get fluid out of lungs

Answer 2

Indications: - NIPPV

Question 3

(continuous positive airway pressure)
One set pressure or volume is delivered with each cycle of inhalation/exhalation
One set pressure delivered continually; does not matter if inhaling/exhaling because one set pressure/some machines do based on volume

Answer 3

CPAP

Question 4

(Bi-level positive airway pressure)
Different pressure is set for inhalation and exhalation
Higher pressure for inhalation and lower for exhalation
More support and more hypercarbia and rescue for stop gap before intubate

Answer 4

BiPAP

Question 5

Ensure mask has an adequate seal - work with RT; not sealed not get ventilation adequately; hear leaking/swooshing, machines beep if not good seal
Monitor for skin breakdown - good seal pushing on skin put prophylactic dressing on face so not higher risk for this
Monitor for vomiting/aspiration - mask on and blowing and over mouth more nauseated because blowing into stomach, if vomit with mask on and not take off could aspirate and severe comps; closely monitor them; never restrain pat with BiPAP on because if cannot take mask off and something happened huge safety issue; be aware types pats putting them on and giving appropriate monitoring needed

Answer 5

Nursing considerations:

Question 6

Not used often anymore
Oxygen is delivered through a small flexible catheter that is placed in the trachea through a small incision; small incision in trachea and small catheter O2 given through and catheter attached with chain
Used for patients with long term O2 needs - because bypassing nose - need less liter flow but lot comps because break skin, specific pat that can take care of it because catheters have to be changed out, make sure know about good infection control
Avoids irritation that nasal prongs cause - not like nasal prongs or needing so much O2 through nasal that could not tolerate it anymore so moved up to this; wear high cut shirt and cover it than this
Typically require less O2 when delivered in this method

Answer 6

Transtracheal oxygen

Question 7

Seen more and more
Nursing and RT collab and nurses see how much O2 needs - resting, ambulating and how far walk and monitor that to determine how much needed to go home with
88% or less will quality for home O2; L for walking vs resting if diff
Collab with social services to ensure med equipment set up; equipment need brought to hospital need make sure happens; if already have O2, make sure have O2 when discharged
Verify need for home oxygen
Ensure set up with medical equipment company
Home oxygen supply - 3 diff ways to have O2
Educate
Provide support

Answer 7

Home oxygen

Question 8

Compressed Air/Tank - big tank; get O2 filled into; little ones that walk around with
Liquid oxygen - mobile pat and lot lighter and easier to carry; more expensive
Oxygen concentrator - fill tanks from home; takes air and concentrates it so 90%; not refilled as much

Answer 8

Home oxygen supply - 3 diff ways to have O2

Question 9

use of equipment and safety
Make sure know how use equipment, turn it on, know all safety precautions; get ahold of med equipment company if probs

Answer 9

Educate

Question 10

Tracheotomy—surgical incision into trachea for purpose of establishing an airway
Tracheostomy—stoma (opening) that results from tracheotomy
May be temporary or Permanent; temp = prob getting people off ventilators/have stenosis and need bridge them; trachs much comfier than endotracheal tubes and much better success weaning; permanent - cancers
Indications:
Complications: - imp consider

Answer 10

Tracheostomy

Question 11

Stenosis of airway
Obstruction of airway - occluded airway
Laryngeal or neck trauma
Any type Neck cancer
Extended need for mechanical ventilation

Answer 11

Indications: - trach

Question 12

Dislodgement
Obstruction - lot mucous plugging; can be more drying so need humidify it and can get dry mucous plugs and if obstructed and no other way get air in and out could be detrimental to pat
Subcutaneous emphysema - in airway; if perforate get air in subQ tissue
Skin breakdown - hard plastic that digs into the skin; increased moisture around site; moisture and pressure leads to big issues with breakdown
Infection - no protective airway trapping bacteria so lot higher risk for lung infections
Bleeding – esp if suctioning and lot interventions into airway increased mucosal irritation and bleeding

Answer 12

Complications: - imp consider - trach

Question 13

Bunch of them
Many types and sizes of tubes: - size listed in diameter and length; 4-10 for diameter

Answer 13

Tracheostomy tubes

Question 14

Single lumen and dual lumen - dual seen in hospital where have in inner cannula can take in and out
Cuffed and uncuffed - ventilation through tracheostomy must have cuff because want block off air coming in and out of nose and mouth and just ventilate through trach
Reusable and disposable - reusable - old school; metal trach and reuse them; most often see disposable
Fenestrated and unfenestrated - fenestrated: hole right above cuff; never use on person needs to be ventilated because leaking of air above cuff and some air movement in nose and mouth; used if weaning off ventilator

Answer 14

Many types and sizes of tubes: - size listed in diameter and length; 4-10 for diameter

Question 15

Prevention comps
Stoma care
Humidification of airway
Suctioning
Ensure placement and patency
Monitor cuff pressures
Maintain extra trach and obturator at bedside
Frequent oral care
Aspiration precautions

Answer 15

Nursing care of pat with tracheostomy

Question 16

Essential clean around stoma site at least one time/shift or more frequently; most pats need more often esp if have lots secretions
Prevents infection and skin breakdown

Answer 16

Stoma care

Question 17

Prevents obstruction of airway

Answer 17

Suctioning

Question 18

Obstruction and dislodgment monitoring for

Answer 18

Ensure placement and patency

Question 19

Amount of pressure in the cuff - in airway; not want to high because not want cause irritation and bleeding to mucosa and airway
14-20 mmHg - maintain at; checked periodically; RT may check it
Not too low - ventilating pat will have leaking around cuff

Answer 19

Monitor cuff pressures

Question 20

For if becomes dislodged and need to get it back in
Same size trach
Obturator - white hard plastic and rounded end and lot firmer and smoother; put inside instead inner cannula when need replace trach because goes down easier

Answer 20

Maintain extra trach and obturator at bedside

Question 21

Super imp - lot pats with trachs cannot eat and if can eat increased risk for infection not want bacteria in mouth because can go into airway - good oral care; adequately hydrated

Answer 21

Frequent oral care

Question 22

Always concern for trach pats

Answer 22

Aspiration precautions

Question 23

Cleaning around there at least couple times/day or more
Clean with wound cleanser, saline, sometimes half-strength peroxide - skin around there very sensitive so typ not do that
Gauze - collect secretions so skin stays dry and not increased risk for wounds; cushions plate
Clean around there and change inner cannula one time/day if disposable/clean if dual lumen trach
Assess the patient
Secure tracheostomy tubes in place - ties called commercial ties; hooked on with velcro; if newer trachs will be tied and changed 1-2 weeks after trach in place; commercial ties 1 time/week because get dirty but when do take off only thing holding trach in place high risk for dislodgment
Cleaning and moving trach in airway causes coughing - cough trach out if not secured; make sure holding onto cannula and stays in place - take another person in for tie changes
Prevent accidental decannulation
Teach the patient and family how to perform tracheostomy care
(See Chart 28-3)

Answer 23

Stoma care

Question 24

Tracheostomy tube bypasses nose and mouth, which normally humidify, warm, and filter air
Air must be humidified
Maintain proper temperature
Ensure adequate hydration

Answer 24

Humidification of airway

Question 25

1. Assess the need for suctioning (routine unnecessary suctioning causes mucosal damage, bleeding, and bronchospasm).
2. Wash hands. Don protective eyewear. Maintain Standard Precautions. - hands clean
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. - ensure pat ok
4. Check the suction source.
5. Set up a sterile field. - sterile procedure; sterile gloves; preoxygenate pat and when pass catheter down do not put suction when inserting catheter; no coughing
6. Preoxygenate (hyperventilate) the patient with 100% oxygen for 3 ventilations prior to suction.
7. Quickly insert the suction catheter until resistance is met. Do not apply suction during insertion. - back up at least an in
8. Withdraw the catheter 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. - suction as withdrawing the catheter and twisting it a little bit; lot coughing before hit resistance then suctioning and withdrawing; never suction once hit resistance; draw back then do so so do not cause trauma; not breathing when not doing it; give few breaths in between; time to recover in between suction pass
9. Hyperoxygenate for 1 to 5 minutes or until the patient’s baseline heart rate and oxygen saturation are within normal limits. - extra O2 after

Answer 25

Suctioning

Question 26

Avoid these comps
Hypoxia
Tissue (mucosal) trauma
Infection
Vagal stimulation and bronchospasm
Cardiac dysrhythmias (related to causing hypoxia)
Causes of Complications:

Answer 26

Complications of suctioning

Question 27

Oxygenated before and after suction
Short length time of suctioning
Not suction often because frequently not good
Catheter is right size - smallest necessary to get secretions out because more room outside catheter to breathe

Answer 27

Hypoxia

Question 28

Not put suction once up against resistance because could cause trauma
Not suction frequently because increases trauma
Suction pressure 80-120 mmHg (100); no more than that = irritation to mucosa
Prolonged suction time = irritation to mucosa

Answer 28

Tissue (mucosal) trauma

Question 29

Sterile procedure

Answer 29

Infection

Question 30

Not suctioning long period time

Answer 30

Vagal stimulation and bronchospasm

Question 31

Ineffective oxygenation before, during, after suctioning
Use of catheter that is too large for the artificial airway
Prolonged suctioning time
Excessive suction pressure
Too frequent suctioning

Answer 31

Causes of Complications: - suctioning

Question 32

Higher risk for Aspiration
Having a trach does not mean you cannot eat or drink or that you will aspirate; risk for number of reasons
Is okay to eat (speech involved and what cuff needs to be doing) - are aspirating and cuff is up and collect food and drink on top of cuff; do not want deflate it after eat because put into airway; cogniscant of eating when have trach in; weaker and higher risk for aspiration
Elevate head of bed for at least 30 min after eating to prevent aspiration during swallowing - head of bed should be elevated
May need to be placed on enteral feeding - many on this

Answer 32

Nutritional concerns with tracheostomy

Question 33

Inflated cuff can interfere with passage of food through the esophagus - esophagus right behind there and put pressure on it making more difficult to swallow
Weakened muscles - pats are weak because ill for awhile and weakness is what causes difficulty with swallowing

Answer 33

Causes: - Higher risk for Aspiration

Question 34

Varies on pat and what going on them
Trials of cuff deflation - cuff start putting cuff down if no longer needing ventilation and see how tolerating that; past that slowly decrease size trach
Gradual decrease in size of tracheostomy tube - size: diameter: more room in airway for breathing through nose and mouth and less through trach
May change from cuffed to uncuffed tube - cuff down still plastic in there give more room if moved to uncuffed
May change to fenestrated tube - sometimes move to this (hole in it so more ability to breath in and out of nose and mouth) - doing good with that and handling secretions then cap trach with speaking valve/cap/button
Cap trach with speaking valve or trach button
Capping trach - not breathing through trach and all airway on outside trach tube - working hard because no tube in middle of airway; monitor closely and good eye when weaning on trachs since very diff

Answer 34

Weaning from tracheostomy tube

Question 35

Speaking valve allows for inhalation through trach but not exhalation - one way valve; breath in but not out; if still cuff going in always has to be down
Trach button does not allow for inhalation or exhalation through trach; capped - cannot breath in/out; cap/speaking valve - cuff deflated - huge safety issue

Answer 35

Cap trach with speaking valve or trach button

Question 36

Communication
Going home with trach - tons edu; need lot support for that; nice when can wean down and get speaking valve on there and can call their loved one when been without voice for so long to get it back; be there for them as much as can and patient as much as can
Support for patients and families
Offer opportunities to express concerns
Encourage patients with permanent tracheostomies to become involved in self-care.

Answer 36

Psychosocial support for patient with tracheostomy

Question 37

Huge with these pats - cannot talk
Ensure involvement with speech therapy - give lots ways to communicate; writing if they can; boards can use
Offer communication tools
Patience - lot of this for them, families, yourself because diff take care of pat diff communicate with; need lots of support and encouragement

Answer 37

Communication