Chapter 25: Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy Flashcards
Exam 2 (Dr. Lyons)
places in the airway where air flows but the structures are too thick for gas exchange
anatomic dead space
increased partial pressure of arterial carbon dioxide (PaCO2) levels
hypercarbia
low levels of oxygen in the blood
hypoxemia
decreased tissue oxygenation
hypoxia
a machine that removes nitrogen from rooom air, increasing oxygen levels to more than 90%
oxygen concentrator (oxygen extractor)
the trachial stoma (opening) in the neck that results from the tracheotomy
tracheostomy
the surgical incision into the trachea to create an airway to help maintain gas exchange
tracheotomy
the 2 main respiratory problems
airway issue and gas exchange issues
provides instant information about how effectively CO2 is eliminated by the pulmonary system, how effectively it is transported through the vascular system, and how effectively CO2 is produced by cellular metabolism. ;is measured near the end of exhalation
;Also known as end-tidal CO2 monitoring.
capnography
How are oxygen delivery systems classified?
- low-flow
- high-flow
The choice of delivery system depends on several factors, what are they?
- the required oxygen concentration
- the achievable oxygen concentration with a specific delivery system
- the need to maintain and control the oxygen concentration
- patient comfort
- the use of humidity
- patient mobility.
Oxygen delivery systems are categorized based on what?
the rate of oxygen delivery
simple facemasks deliver what percentage of oxygen concentration
40- 60%
partial rebreather masks offer what concentration of oxygen?
60- 75%
nonrebreather masks provide what percentage of oxygen concentration?
> 90%
Numerous respiratory and cardiac issues, whether acute or chronic, have the potential to do what to gas exchange?
impair gas exchange
The use of what can enhance proper gas exchange and tissue perfusion?
oxygen therapy (with or without tracheostomy)
What conditions are often associated with respiratory and cardiac issues?
hypoxemia and hypoxia
What are some factors that may necessitate oxygen therapy?
fever, sepsis, anemia
How does anemia, sepsis and fever affect oxygenation?
either increase the demand for oxygen or decrease the blood’s capacity to carry oxygen
How should oxygen therapy be administered?
at the lowest possible fraction of inspired oxygen (FiO2) that maintains an acceptable blood oxygen level
While oxygen therapy can improve the partial pressure of arterial oxygen (PaO2), it does not do what?
address the underlying cause of the issue
What is the gold standard for assessing the need for and evaluatng the effectiveness of oxygen therapy?
arterial blood gas analysis
What noninvasive monitoring methods are used to detemine oxygen requirements?
pulse oximetry and capnography
Why do low-flow systems deliver a lower FiO2?
because the oxygen is diluted with room air during paitent breathing.
How are high-flow systems designed to supply the total oxygen volume?
by adjusting the amount of room air within the delivery system
Who are the high-flow systems particularly designed for?
critically ill patients and situations where precise oxygen levels are crucial
If a patient requires a facial mask for oxygen therapy but is capable of eating/ or able to feed themselves what should be ordered for them?
a nasal cannula to be used during mealtimes (the mask must be reapplied after the meal)
Attaching a 50 feet of connecting tubing can increase what?
the patient’s mobility, but also their fall hazard
Examples of low-flow oxygen delivery systems
- nasal cannula
- simple facemask
- partial rebreather
- nonrebreather masks
What percentage range of oxygen concentration does the nasal cannula produce?
24- 44%
is used at flow rates ranging from 1 to 6 L/min
nasal cannula
Which form of oxygen therapy is often utilized for chronic lung disease and long-term oxygen therapy?
the nasel cannula
How do you position a nasal cannula?
position in the patient’s nostrils with the openings facing the patient, following the natural curve of the nares
For what purpose are simple facemasks used to deliver oxygen concentrations of 40% to 60%?
for short-term or emergency oxygen therapy
What is the minimum flow rate necessary to prevent the rebreathing of carbon dioxide from exhaled air when using a simple facemask?
5L/ min
What is crucial for maintaining inspired oxygen levels when a patient is where a simple face mask?
prope fit of the mask
Attention should be given to skin care under the mask and strap to prevent what?
skin breakdown
Which oxygen therapy offers flow rates ranging from 6 to 11 L/min?
partial rebreather masks
These masks feature a reservoir bag without flaps?
partial rebreather mask
To ensure optimal oxygen delivery, when a patient is using a partial rebreather mask, it is important to maintain?
maintain slight inflation of the bag at the end of inspiration
Among the low-flow systems, this provides the highest oxygen levels, delivering a FiO2 greater than 90%.
nonrebreather masks
Typically used for patients with unstable respiratory status who may require intubation.
nonrebreather masks
This mask includes a one-way valve between the mask and the reservoir, along with two flaps over the exhalation ports.
nonrebreather mask
What is the one-way valve on the on the nonrebreather mask for?
The valve enables the patient to draw required oxygen from the reservoir bag, while the flaps prevent room air from entering through the exhalation ports. During exhalation, air exits through these ports, and the one-way valve prevents exhaled air from re-entering the reservoir bag.
What flow rate is maintained to keep the bag of the nonrebreather mask inflated during inhalation?
a high flow rate of 10 to15 L/ min
How often should the bag of a nonrebreather mask be assessed for proper inflation?
regular assessment, at least hourly
Type of high-flow oxygen delivery systems
- Venturi mask
- aerosol mask
- face tent
- high-flow nasal cannual
- tracheostomy collar
- t-piece
When properly fitted, high-flow devices deliver precise oxygen levels at what percentages, and what flow rates??
24- 100%; 8 to 15L/ min
High-flow nasal cannulas provide better temperature and oxygen regulation and humidification. It allows for precise what? at what flow rates?
FiO2 maintenance at flows of 30 to 60 L/min.
High-flow nasal cannulas control heat and humidity which reduces what?
damage to mucous membranes
Which high-flow system is often better tolerated?
high-flow nasal cannula
Why is the risk of skin breakdown reduced with high-flow nasal cannulas compared to other high-flow systems?
due to the lack of tight-fitting mask
What device to monitor patient’s response is necessary to monitor while wearing high-flow nasal cannulas?
pulse oximetry
Venturi masks provide what without the need for intubation?
the most accurate oxygen concentration
What allows specific amounts of air to mix with the oxygen ensuring precise delivery on Venturi masks?
adaptors with different-sized holes, positioned between the mask and the oxygen source
What does each adaptor on a Venturi mask require?
a specific flow rate (according to manufactors guidelines)
ex: to deliver 24% oxygen, a flow rate of 4L/ min is necessary
Other high-flow systems are used to deliver what?
high humidity along with oxygen
What type of patient is a face tent suitable for?
patients with facial trauma or burns
How is a face tent positioned on a patient?
extends halfway across the face and fitted under the chin
Which high-flow oxygen delivery devices is utilized when high humidity is essential?
aerosol mask
Which high-flow delivery device special adaptor would a patient with a tracheostomy, laryngectomy or endotracheal tube?
t-piece
Which high-flow delivery device that delivers high humidity and the required oxygen would a tracheostomy patient need?
tracheostomy collar
NPPV
Noninvasive Position- Pressure Ventilation
A noninvasive ventilation that uses positive pressure to maintain alveolar patency and enhances gas exchange with the risks associated with intubation.
noninvasive positive- pressure ventilation
Used to treat dyspnea, hypercarbia, and acute exacerbations of conditions such as COPD, pulmonary edema, sleep apnea, and acute asthma attacks
noninvasive position- pressure ventilation
What needs to happen for a NPPV to be effective?
a seal needs to be made with the mask
The seal that is needed to make the NPPV effective can result in what?
skin breakdown
What are some potential complications from NPPV usage?
- uncomfortable pressure around the eyes due to leaks
- gastric insuffiation leading to vomiting and the risk of aspiration
Due to the potential risks from NPPV usage it is recommended that who not use it?
those who are not alert and cannot protect their airway
NPPV can administer oxygen or utilize room air with what accessories?
nasal masks, nasal pillows, or full-face masks
What are the 3 primary modes of NPPV delivery?
- continuous positive airway pressure
- volume- limited or flow-limited
- pressure-limited
provides a constant positive airway pressure throughout each inhalation and exhalation cycle to open collapsed alveoli
CPAP (continuous positive airway pressure)
delivers a preset tidal volume based on the patient’s inspiratory effort
volume-limited or flow-limited
What does pressure-limited include?
pressure support, pressure control, and bi-level positive airway pressure
Has different pressure cycles during inspiration and expiration
BiPAP
delievers a set inspiratory positive airway pressure during inhalation and lower set pressureduring exhalation
BiPAP (Bi-level positive airway pressure
What do patient often bring with them from home to the hospital for their stay?
CPAP or BiPAP
Oxygen Therapy Safety Practices
- verify prescription
- humidification
- assess equipment
- assess skin
- prevent skin breakdown
- assess mucous membrane
- prevent drying
- clean equipment
- avoid pressure
- prohibit smoking
- avoid sparks or flames
- assess response
- transportation
- respiratory therapy
Verfiying the prescription entails what details?
delivery system, liter flow, and percentage of oxygen to be administered; for flows of 4L/ min or highter- humidification is necessary
why regularly assess equipment
ensure proper functioning
assess the patient’s skin
around the ears, back of the neck and the face every 4-8 hrs for signs of irritation and impaired skin integrity
How often should you assess the patient’s skin who is undergoing oxygen therapy?
4-8 hrs
What do you do to prevent skin breakdown for patient’s going through oxygen therapy?
pad the elastic band and reposition frequently
What should oral and nasal mucous membrane be assessed for?
dryness and cracking
Assess oral & nasal membrane and do mouth care how often?
every 8 hrs
To prevent drying of the nares, face and lips
apply nonpetroleum cream, as needed
To clean oxygen therapy equipment
rinse cannulas or masks with clear, warm water every 4 to 8 hrs and clean the skin under the tubing, straps, and masks as needed
Why should you position the tubing?
to avoid pulling on the patient’s face, nose, or artificial airway
Regularly assess and document the patient’s what?
response to oxygen therapy
During any transport, you should guarantee the patient has what?
an adequate oxygen source
Who is it essential to collaborate with to ensure oxygen managment?
the respiratory therapists
Oxygen therapy complications
- combustion
- toxicity
- absorptive atelectasis
- drying of the mucous membranes
- infection
Oxygen does not itself….
ignite or explode but can feed a fire or spark
Why is it imparative to avoid an open flame where oxygen therapy is being administered?
oxygen is an accelerant
What should be displayed outside a patient’s room who is using oxygen therapy?
“oxygen in use” sign
What is strictly prohibited in the patient’s room during oxygen therapy?
smoking
What is important in regards to electrical equipment being used in a room where oxygen is being used?
a it should be grounded with a three-pronged plug and frayed cords should be discarded
What should not be stored in rooms where oxygen is being used
flammable solutions with high concentrations of alcohol or oil
is associated with the concentration of delivered oxygen, the duration of therapy, and the extent of lung disease
oxygen toxicity
Prolonged exposure to oxygen levels exceeding 50% for more than 24 to 48 hrs may result in what?
lung injury and reduced tissue integrity
Symptoms of oxygen toxicity
- dyspnea
- nonproductive cough
- chest pain
- gastrointestinal upset
- crackles on auscultation
What are some severe issues due to oxygen toxicity?
decreased lung capacity, reduced lung compliance, and hypoxemia
conditions that happen with continued exposure to oxygen
atelectasis, pulmonary edema, and hemorrhage
Surviving oxygen toxicity relies on what?
correcting the underlying disease process and reducing the delivered oxygen
Since oxygen toxicity treatment is challenging, what is key?
prevention (by prescribing the lowest necessary oxygen levels for maintaining gas exchange)
humidification of the delivery system is recommended to prevent tissue injury when the oxygen flow rate exceeds what?
4L/ min
What can further raise humidity and is suitable for oxygen delivery through artificial airways?
a heated nebulizier
What can accumulate in the tubing?
condensation
What can condensation accumulating in the tubing potentially present?
a souce of infection
What is advised for tubing for prevention of creating a source for infection?
routine removal of condensation by disconnecting the tubing and emptying the water
The humidifer and/ or nebulizer may pose infection risks, how can this be prevented?
following equipment changes based on agency policy
What is essential before considering home oxygen?
the patient should be stable
Teaching the patient and their family about what is crucial?
about the necessary equipment for home oxygen therapy and the safety protocols for its use and maintenance
What does the education encompass for the patient and their family regarding home oxygen therapy?
oxygen sources, delivery devices, humidity sources
Sensitivity to the patient’s emotional adjustment during when is important?
discharge planning and teaching
Wha
What should be encouraged during patient discharge planning and teaching?
open communication about feelings and concerns, including potential worries about social acceptance
What should be emphasized for participating in daily activities when educating patient’s upon discharge with oxygen therapy?
adherence to oxygen therapy
the 3 methods of home oxygen therapy
- compressed gas in a tank or cylinder
- liquid oxygen in a reservoir
- an oxygen concentrator
commonly used and patients should be taught to check the gauge daily for oxygen levels and ensure the tanks are securely placed in a stand or rack for safety
compressed gas in an oxygen tank
stored in a lightweight, portable container similar to a Thermos, offers longer-lasting oxygen but comes at a higher cost
liquid oxygen
remove nitrogen from room air to increase oxygen levels beyond 90% and are cost-effective; they do not require refilling and are portable units provide convenience
oxygen concentrators
involves surgically cutting into the trachea to establish an airway creating a tracheal stoma called a tracheostomy
tracheotomy
Why is a tracheotomy done?
as an emergency intervention or a planned surgical operation and may be either temporary or permanent
What are the indications for a tracheotomy?
- acute airway obstruction
- protection of the airway
- laryngeal or facial trauma or burns
- prolonged unconsciosness
- paralysis
- ventilator dependency
What is emphasized in tracheotomy care?
educational interventions focusing on tracheotomy care, communication strategies, and speech considerations
What does immediate postoperative care focus on?
airway maintenance, assessing bilateral breath sounds, and conducting respiratory assessments at least hourly
What is essential in identifying and addressing any complications arising from the tracheotomy procedure?
ongoing monitoring
There is a variety of tracheotomy tubes available, selection is based on what?
on individual requirements
Tracheotomy tube variations
- various sizes
- plastic or metal
- usually disposable
- cuff or uncuffed
- inner cannula
When are cuffed tracheostomy tubes used?
in patients undergoin mechanical ventilation
What is a cuffed tube?
a small balloon around the outside of the tube
How do you inflate the cuff?
- it is inflated through a pilot balloon accessible on the outside of the body connected to the cuff
- to inflate the cuff an air-filled syringe is attached to the pilot balloon valve
- remain inflated when the cuff is filled
What does the pilot balloon serve to indicate?
the cuff’s air content
What is essential for tubes with reusable inner cannulas?
regular inspection, suctioning, and cleaning of the inner cannula
In the initial 24hrs post-surgery, cannula care should be performed how often?
frequently as needed, possibly hourly, and subsequent care is tailored to the patient’s needs and institutional policies
When preparing for self-care, patients should be educated on what?
removing the inner cannula, ensuring cleanliness, and instructed on suctioning and trach cleaning to prevent infections
Why does cuff inflation not completely prevent aspiration?
due to the movement caused by breathing and swallowing
How does fenestrated tubes offer versatility?
- when the inner cannula is in place, the fenestration are closed, thus it behaves like a double-lumen tube
- by removing the inner cannula and securing the plug or stopper, air can enter the fenestration, circulate around the tube. and travel through the natural airway allowing the patient to cough and speak
A fenestrated tube may or may not include a what?
a cuff
When a cuff is in place with a fenestrated tube what can still happen?
some air can flow through the natural airway
Befoe capping the trach tube, what is imperative?
to deflate the cuff, otherwise, the patient lacks an airway (suffocation results)
If a patient with a metal tracheotomy is scheduled for an MRI, what needs to happen first?
switch to a plastic tube
When assessing a patient with a tracheotomy, what should you observe and compare?
- observe: the quality, pattern, and rate of breathing
- compare: to the patient’s baseline
What may tachypnea indicate?
hypoxia and dyspnea could indicate airway secretions
What should you examine for in a trach patient?
cyanosis, particularly around the lips, as it may signify hypoxia
Auscultate the lungs for what in a trach patient?
abnormal breath sounds
Assess oxygen saturation and ensure the the what is administered in trach patients?
the prescribed amount of oxygen is administered with the appropriate equipment and humidification if nec.
What should you evaluate the tracheostomy site for?
color, consistency, and the quantity of secretions inside and outside of the tube
If the tracheostomy site is sutured, what should you inspect?
for redness, swelling, or drainage from suture sites
For tracheostomies that are secured with ties, assess what?
the condition and security of the ties, replacing them if soiled
What should you examine when looking at a tracheostomy?
the skin around the tracheostomy, and neck for any signs of impaired tissue integrity including areas behind the neck affected by the ties or excess secretions
Check behind the faceplate for what?
the space between the outer cannula and the patient’s tissue, noting any accumulation of secretions in this area
If the trach tube is cuffed what should you verify?
verify cuff pressure or collaberate with the respiratory therapist to ensure proper cuff pressure
What should be confirmed is at the bedside?
an emergency tracheostomy tube and an oburator of the correct size
Tracheostomy Complications
- tube obstruction
- tube dislodgment and accidental decannulation
- pneumothorax
- subcutaneous emphysema
- bleeding
- infection
How can tube obstruction happen?
secretions or cuff displacement
What are signs of a tube obstruction?
difficulty breathing, noisy respirations, challenges in inserting a suction catheter, thick dry secretions, and elevated peak pressures on a mechanical ventilator
What should regularly be assessed the patient for to medigate complications?
tube patency at least hourly
How can the risk for obstruction be reduced?
by assisting the patient in coughing and deep breathing, providing inner cannula care, humidifiying oxygen, and suctioning
If tube prolapse causes tube obstruction what should happen?
the respiratory healthcare provider will reposition of replace the tube
To prevent tube dislodgment and accidental decannulation what should be secured?
secure the tube firmly to minimize movement or inadvertent pulling by the patient
What is dislodgment happening within the first 72hrs postop considered?
an emergency due to the immature tracheostomy tract, making replacement challenging
What should be at the beside for a postop trach patient?
tracheostomy tube of the same size or smaller, along with a tracheostomy insertion tray
If dislodgment occurs in an immature tracheostomy what should you do?
manually ventilate the patient and have someone call for the rapid response team and the surgeon
What should be done for decannulation after 72 hrs?
extend the patient’s neck, open the stoma tissyes with a curved Kelly clamp, replace the tube using an obturator, and check for airflow and bilateral sounds. Seek assistance if the airway is unable to be secured.
Why is a chest x-ray after placement of a trach necessary?
to identify a potential pneumothorax
How is subcutaneous emphysema observed?
by inspecting and palpating for air around the tracheostomy site
What is expected initially for a tracheotomy?
minor bleeding
Continuous bleeding oozing from a tracheostomy or tracheotomy is….
abnormal
What should be done if there is bleeding coming from the tracheostomy site?
wrap gauze around the tube, pack guaze into the wound, and ensure proper cuff inflation to manage bleeding
What can occur any time with a tracheostomy site?
infection
In the hospital, what should be adhered to when suctioning or caring for the tracheostomy site?
sterile technique
Assess the stoma site at least every _ hrs for signs of _ and use tracheostomy __ to keep the site clean and dry.
8; infection: dressings
If trach dressings are unavailable what should you use in it’s place?
fold standard sterile 4x4s to fit around the tube
Why should you not cut the 4x4s to fit around the trach site?
this can lead to aspiration of gauze bits into the stoma site
What may occur at the site where the inflated cuff exerts pressure on the tracheal mucosa?
a tissue injury, which is considered a “never event”
How do you minimize tracheal damage with a cuffed tube?
inflate the cuff to establish a seal between the trachea and the cuff using the least amount of pressure nec
If achieving an effective seal requires excessive pressure, what may be necessary?
a larger-diameter tube
How should a cuffed trach be monitored at least once a shift?
by using either a pressure cuff inflator or the minimal leak technique
When utilizing an inflator to monitor the pressure of a cuff trach, what should be ensured?
pressure remains within the specified manufacture’s gudielines
Most cuffs are adequately inflated with how many mLs of air?
10
Wen using the minimal leak technique, attach a what to the pilot balloon valve?
a 10-mL Luer-Lok syringe
the minimal leak technique
- place a stethoscope on the side of the patent’s neck near the tracheostomy tube
- slowly deflate the cuff and listen for distinctive air rush as the seal breaks during inhalation
- reinject air while listeing for any air passing the cuff
*once no sound is detected remove 1 mL of the air from the cuff this ensures sufficient airway sealing for adequate ventilation maintaining a slightly loose tube fit to prevent tracheal injury
*in addition to cuff pressure additional factors contribute to the potentional for damage.
What patients are at an increased risk for tissue damage?
malnourished, dehydrated, hypoxic, elderly, or those receiving corticosteroids
Tube friction and movement contribute to what?
to mucosal damage, leading to tracheal stenosis
To prevent tissue damage in trach patients, what is essential to do?
secure the tube, suction only when necessary, and prevent malnutrition, dehydration, and hypoxia
The tracheostomy tube bypasses what where usual processes of humidifying and warming air occur?
the nose and mouth
There is a risk of tracheal damage if what is not adequate?
humidification and warming
Inadequate humidity can lead to a formation of what?
thick, dried secretions that may obstruct airways and increase the likelihood of infection
What should be regularly checked for with tracheostomy collars or t-pieces during ventiliation?
a fine mist coming from the track collar or t-piece
How do you enhance humidity delivery?
-connect a warming device to the water source with a temperature monitor (monitor the circuit temp by assessing the tubing by checking the probe reading hourly)
-maintain the air entering the tracheostomy within the range of 98.6ºF to 100.4ºF, and never exceed 104ºF
What is essential for maintaining a clear airway and facilitating gas exchange concerning trach patients?
by removing secretions when the patient cannot cough effectively
What are the indications for suctioning (a trach tube)?
audible or noisey secretions, the presence of crackles or wheezes, restlessness, increased pulse or respiratory rates, the presence of mucus in the artificial airway, or by patient requesting or an increase in peak airway pressure on the ventilator
Suctioning without clear indications is avoided why?
to prevent damage, bleeding, or bronchospasms
Deep endotracheal suctioning can be what, even for unconscious patients, who may still perceive pain?
uncomfortable
What is crucial to acknowledge and address during deep endotracheal suctioning?
reassurance about the duration
While suctioning is typically done through an artificial airway, it can done how?
through the nose or mouth
Nasal suctioning has the potential for complications and discomfort, so what can be used to help eliminate those complications?
using a small suction catheter coated with a water-soluable sterile lubricant minimizes trauma and enhances comfort.
What can be used to further prevent trauma to the nasal mucosa?
the nasopharyngeal airway
Suctioning carries what risks?
hypoxia, mucosal tissue injury, trauma, infection, vagal stimulation, bronchospasm, and cardiac dysrhythmias
To minimize risks from suctioning
hyperoxygenate the patient with 100% oxygen before suctioning and instruct them to take deep breaths.
What is vital to monitor during suctioning?
continuous monitoring of heart rate, blood pressure, and oxygen saturation
When should you stop suctioning?
if hypoxia occurs
What may help reduce the risk of complications when suctioning?
using the correct size catheter, limiting suction duration to 10-15 sec, and using a twirling motion during withdrawal of the suction catheter
Infection risk is minimized by?
adhering to sterile technique in the hospital setting, but clean techniquw is acceptable at home
Why should oral suction equipment never be used for artificial airway suctioning?
to prevent introduction of oral bacteria into the lungs
What is important to regularly monitor to identify cardiac dysrhythmias during suctioning?
cardiac rhythm
Best practice for suctioning the Artificial Airway
- assess for need
- standard precautions
- communicate
- suction source
- sterile procedure
- preoxygenate
- avoid suctioning during insertion
- no routine instillation of NS
- continuous suctioning
- twirling motion
- hyperoxygenate
- repeat up to 3 times
- document
What expected sensations should the patient be informed of that could happen during suctioning?
shortness of breath, coughing, brief discomfort
What should you do to check the suction source prior to suctioning?
occlude it and adjust the pressure dial
What should the pressure dial be adjusted to for suctioning? what is this to prevent?
a range of 80 to 120; hypoxemia and mucosal trauma
How long should you preoxygenate the patient with 100% oxygen prior to suctioning?
30 seconds to 3 minutes prevent hypoxemia
Why is routine instillation of NS not encouraged?
due to impaired gas exchange, increased infection risk and hypoxia
Quickly insert the suction catheter until what is felt?
resistance
Avoid suction during what stage of suctioning?
insertion
You should withdraw the catheter how far after meeting resistance and then apply continuous suction, employing what kind of motion during withdrawal?
1 to 2cm (0.5 in); twirling motion
Why is a twirling motion used on withdrawal of the suctioning catheter?
to safeguard tissue integrity
Suctioning duration should not exceed how long?
a total of 10 to 15 seconds
How long should hyperoxygenate the patient after withdrawaling the suction catheter?
for 1 to 5 minutes or until the patient’s baseline heart rate and oxygen saturation returns to normal
Can you repeat the suctioning procedure?
Yes, up to 3 times
What should you document after suctioning a patient?
secretion characteristics and patient response to complete the suctioning process in accordance with established best practices
Care for the tracheostomy includes what?
cleaning the tube, cleaning the stoma
What does tracheostomy care prevent?
an obstructed airway
How should you start tracheostomy care?
using a penlight to assess the inner lumen of the tube for secretions
How should the tracheostomy be secured during cleaning?
either by using ties or commercial tube holders
*remember to change them either when soiled or at least daily
When changing ties or tube holders what is beneficial to have?
another nurse stablizing the tube to prevent decannulation
A well-secured tie or holder should allow for what
only enough space for one finger between it and the patient’s neck
Why is tube placement important?
tube movement can cause irritation, coughing, potential decannulation, and impaired gas exchange
How do you prevent tube decannulation during care procedures?
maintain the existing ties or holder on the tube while applying new ones until the tube is secured
What should be encouraged in trach care?
patient involvement, as it is a step toward fostering self-care
Best Practices for Tracheostomy Care
- equipment
- standard precautions
- suction if needed
- remove soiled dressing
- set up sterile field
- remove and clean inner cannula
- clean stoma and plate
- change ties
- document
What should be used for cleaning the inner cannula?
half-strength hydrogen peroxide for cleaning and sterile saline for rinsing
If the inner cannula is disposable what should you do instead of cleaning it?
replace it with a new one
What should you use to clean the trach plate?
half-strength hydrogen peroxide for cleaning and sterile saline to rinse it (make sure none of the solution enters the tracheostomy)
What should be documented when cleaning the tracheostomy site?
type and amount of secretions, the overall condition of the stoma, and the integrity of surrounding skin tissue; patient’s response to the procedure
Maintaining bronchial and oral hygiene does what for the patient?
helps to keep the airway open, prevents infections, and promotes patient comfort
How often should you turn and reposition the trach patient?
every 1 to 2 hrs
What should you encourage and promote for a trach patient that is alert?
to get out of bed as much as possible and ambulate to enhance lung expansion which faciliates gas exchange and aids in the removal of secretions
What does ambulation enhance in a post-surgical patient?
lung expansion facilitating gas exchange and aiding in the removal of secretions
What techniques contribute to pulmonary hygiene in post-surgical patients?
coughing, deep breathing, chest percussion, vibrations, and postural drainage
What should be regularly assessed on a trach patient for signs of impaired tissue integrity such as ulcers and infections?
the mouth
What products should be avoided as they promote drying of the mouth and the fostering of bacterial growth?
glycerin swabs or alcohol- containing mouthwashes
What should be used instead of glycerin swabs/ alcohol-containing mouthwashes for oral hygiene?
a sponge tooth cleaner or a soft-bristled toothbrush dampened with water for oral care
What oral care helps prevent infections in mechanically ventilated patients and reduces the incidence of ventilator-associated pneumonia?
chlorhexidine oral rinse
If the patient is alert and oriented, assist them in doing what oral hygiene care techniques?
rinsing the mouth with normal saline every 4 hrs while awake or as frequently as desired
What should be done for the trach patient to prevent cracked lips and enhance comfort?
apply lip balm or water-soluable jelly
What should the family members or patient be encouraged to do to boost self-esteem in the patient?
perform mouth care
Ways of preventing aspiration (trach patient)
- deflate the cuff if possible
- position upright during meals
- elevate the HOB
- avoid eating when fatigued
- smaller, more frequent meals
- suction equipment available
- avoid thin liquids and straws
- eat slowly
- tuck chin when swallowing
- assess respiratory status
What can pose challenging with trach tubes in place?
swallowing
What hinders the normal upward and forward movement of the larynx during swallowing, making it difficult for food and saliva to be properly prevented from entering the airway?
trach tubes
An inflated cuffed- trach tube can interfere with what??
food passage in the esophagus due to its proximity to the trachea
The HOB should be kept upright for how long after a trach patient finishes eating?
at least 30 minutes
Unless approved by a speech-language pathologist, avod the use of what?
“thin” liquids, the use of a straw and foods that create thin liquids during chewing (such as some fruits)
Encourage the trach patient to do what when they eat?
- take each bite slowly
- swallow twice after each bite
- discourage consecutive swallows of liquids
- instruct to tuck chin down while swallowing
- if coughing occurs- stop the feeding until the patient indicates the airway is clear
What is important to assess for a trach patient throughout the feeding/ mealtimes?
respiratory rate, ease of swallowing, pulse ox, and heart rate (to monitor the patient’s condition and ensure a safe swallowing process)
If speech is not possible, for trach patient, what is essential to educate both the patient and their family about?
alternative communication methods: writing tablets, boards with pictures and letters, communication flashcards, hand signals, computer tablets, and smartphones
Using alternative communication methods reduces what for the patient and their family?
frustration associated with a lack of communication
Asking trach patients questions that prompt a “yes” or “no” response makes what easier?
communication
What should be clearly marked at the nurse’s desk when a trach patient who cannot speak is a patient on that floor?
their call light to indicate the patient’s inability to speak
Who should be collaberated with to ensure the patient gets help with communication challenges?
speech-language pathologist
Verbal communication for a trach patient is possible how?
by using a cuffless trach tube, fenestrated trach tube or when a fenestrated tube is capped
Attending to the psychosocial needs of patients with a tracheostomy is a crucial aspect of what?
nursing care
Nurses should recognize and address what psychosocial need while caring for a trach patient?
patient’s frustrations with communication and allow ample time for communication
When engaging in conversations with trach patients, what is important that a nurse not do?
increase the volume of their voice as the tube does not affect their hearing or understanding
What kind of shifts may the trach patient experience due to the presence of a stoma or artificial airway, alterations in speech, changes in eating methods, or difficulties with communications?
shifts in self-image
A trach patient should be assisted with establishing what kind of goals for their psychosocial health?
realistic
Who should a nurse collaberate with to facilitate the patient’s social interactions?
their family
What should the nurse provide while exhibiting acceptance and supportive behaviors?
continuous encouragement and positive reinforcement
The need for counseling should be assessed for whom?
the trach patient and their family/ caregiver
A trach patient may feel what psychosocial feelings after surgery?
shyness and social isolation
What kind of clothes should be encouraged to promote a sense of normalcy and aiding in their comfort and confidence?
the use of loose-fitting shirts, decorative collars, or scarves to discreetly cover the tracheostomy tube
the gradual transition of the patient from a tracheostomy tube
weaning
What does the process of weaning involve?
reducing the tube size until eventually removing the tube
How does the process of wearning begin?
deflating the cuff once the patient can effectively manage secretions and no longer requires mechanical ventilation
What does the adjust of weaning allow the patient to do?
breathe both through the tube and the upper airway
If the patient is tolerateing the deflated cuff, what should happen next?
the tube is exchanged for an uncuffed tube
If the patient tolerates the uncuffed tube and the changes that comes with the different airway, what happens next?
the tube size is progressively reduced
After the patient tolerates the smaller tube what kind of tube comes next in the weaning process?
a small fenestrated tube
When the patient is introduced to a smaller fenestrated tube during the weaning process, what do patients have to get used to with this particular tube?
when the tube is capped, it allows all air to pass through the upper airway and fenestrations with none passing through the tube
What should be assessed when patients are introduced to the fenestrated tube during the weaning process?
assess the patient to ensure adequate airflow around the capped tube
When does tube removal become feasible in the weaning process?
once the patient successfully tolerates more than 24 hrs of capping
After the removal of the tubing, what should happen with the stoma site?
a dry dressing is applied over the stoma, which gradually heals naturally
What is an alternative device for facilitating the transition from tracheostomy to natural breathing?
the tracheostomy button
What does the tracheostomy button maintain?
the stoma’s patency while supporting spontaneous breathing
Upon discharge, what should the patient be able to perform?
self-care taskts, such as tracheostomy care, nutritional care, suctioning, and communication
While some education is provided before the tracheostomy surgury, when does the majority of the self-care instructions take place?
during hospitalization
Who needs to be instructed on trach tube care, clean suctioning technique, airway maintenance, cleaning techniques, abd signs of infection or impaired tissue integrity?
the patient and caregiver
What should you teach the patient regarding showering?
use a shower shield over the tracheostomy tube to prevent water from entering the airway
What should be used during the day to filter the air entering the stoma, maintain humidity in the airway, and enhance overall appearance?
a small cotton cloth should be used to loosely cover the tube
What should be taught to be increased in the home when the patient is discharged home?
the humidity within the home environment
What should be worn by the patient that communicates their inability to speak and ensures appropriate awareness in emergency situations?
a medical alert bracelet
KEY POINTS for quick studying: chapter 25
- Never allow water condensation in an oxygen delivery system to drain back into the system
- Use sterile technique when performing endotracheal or tracheal suctioning
- Assess tissue integrity of the oral mucous membranes for injury or infection each shift for anyone who has an endotracheal tube
- Keep a tracheostomy tube (and obturator) and tracheostomy insertion tray at the bedside, and ensure that tracheostomy care is performed with two licensed personnel for the first 72 hours after a tracheostomy has been created
- Verify safe use of oxygen delivery systems and tracheostomy equipment
- Keep the tracheal cuff pressure between 14 and 20 to prevent loss of tissue integrity
- Teach the patient and caregivers about home management of oxygen therapy, including the avoidance of smoking or open flames in rooms in which oxygen is being used
- Teach the patient and caregivers how to perform tracheostomy care
- Ensure that the patient and caregiver(s) know whom to contact about needed supplies and durable medical equipment
- Allow the patient and family to express concerns about a change in breathing status or the possibility of intubation and mechanical ventilation
- Teach caregivers and family members ways to communicate with a patient who is intubated or being mechanically ventilated
- Reassure patients who are intubated that the loss of speech is temporary
- Apply oxygen to anyone who is hypoxemic
- Monitor arterial blood gases (ABGs) and oxygen saturation of all patients receiving oxygen therapy
- Assess the skin under the mask and under the plastic tubing every shift for patients receiving oxygen by mask
- Assess the tissue integrity of the nares and under the elastic band every shift for patients receiving oxygen by nasal cannula
- Assess patients receiving oxygen at a 50% concentration or higher for early indications of oxygen toxicity (i.e., dyspnea, nonproductive cough, chest pain, GI upset)
- Use a manual resuscitation bag to ventilate the patient if the tracheostomy tube has dislodged or become decannulated
- Assess the new tracheostomy stoma site at least once per shift for purulent drainage, redness, pain, and swelling as indicators of infection or loss of tissue integrity
