Skills lab- trach, blood admin Flashcards
What is a tracheostomy and purpose?
Surgical opening in anterior wall of trachea that provides alternate airway, bypasses upper obstructions, facilitates removal of secretions, and permits long term mechanical ventilation
Fresh trach stoma, non established stoma, and established stoma definitions?
FTS- not yet had intial trach tube change
NES- tube change done 7-10 days post op
ES- more than 14 days post op and had 2 uncomplicated trach tube changes
How to change the inner cannula?
Stabilize neck plate of trach tube with one hand and squeeze inner cannula to prep for removal. Inspect cannula for integrity/cleanliness and insert a new/cleaned inner cannula and lock it into place
What does the inner and outer cannula and obturator do?
IC- fits inside outer cannula and helps facilitate cleaning/mucous buildup (can be removed)
OC- can’t be removed, keep stoma open
O- helps in the insertion process, removed after inserting
What is accenidetnal decannulation?
Trach tube comes out. Make sure you have bag mouth nearby and call for help. If not completely dislodged then you can reinsert with the obturator (don’t force it)
Complications of trach tubes?
Pneumothorax, hemorrhage, subcutaneous emphysema around site, infections, tube displacement
How to clean the stoma?
Sterile gloves + Cleanse with NS around site (5-10cm outwards). Discard in between cleansing certain areas/pat dry. Use a 4x4 sponge between pt skin and their ties to prevent further breakdown
Trach care?
Have smaller size trach at bedside, use sterile technique, assess patency q4-6 hrs/PRN (secretions). Change inner cannula q24h. Change trach ties with 2 people once a week/PRN (need a doctors order)
Suctioning trach tube process?
Assess pt by coughing/RR/crackles to see if they need a suction. Put them in semi fowlers and use sterile gloves. Have one person hold down plate while other person suctions. During inhalation insert catheter until resistance is met or what the orders say. Withdraw 1 cm and begin to suction as you withdraw. Max suction time is 15 sec for 3 passes (1 minutes in between)
How to change trach ties?
Have another HCP with you as you remove one tie and slip the new tie in. Other HCP removes opposite tie and puts the new one in on the other side. Secure into place and should be able to slip 1 finger in between the neck and ties
What is blood administration used for and what do they receive?
Management of AAA, trauma, post op, cancer, septic shock, fluid overload. Can either get whole blood (everything) or a certain part (like hemoglobin or albumin)
Blood type and Rh factors?
Need to know blood type/Rh for transfusion and compatibility purposes. Can be either + or -, or A,B,AB,O determined by RBC antigens (O has no antigen).
Complications of blood administration?
Circulatory overload (edema, increased RR, change in O2 stats), berle reaction (fever, mismatch of blood type), allergy (itchy, rash), electrolyte imbalance, transition related acute lung injury (sick really fast, drown in fluid, dyspnea, fluid overload), sepsis, and acute hemolytic reaction
What is acute hemolytic reaction and S+S and interventions?
Incompatibility between donor/recipients blood and person antibodies will destroy the new cells. Causes hypotension, tachycardia, chills, hematuria, renal failure, shock, fever, rash. If this happens then stop transfusion, start IV with new fresh tubing and NS, complete VS, call physician, recheck blood and pt information
Nursing responsibilities for blood admin?
Baseline VS, begin transfusion slowly to assess for reactions, follow policies for admin, ensure large bore IV access (18g), piggyback with NS in case of transfusion reaction, never run meds with blood/other solutions
Process of blood administrations
- Check chart, order, infusion rate, consent form, screen results, and pt informations
- Visually inspect blood for clots/clumps/foreign objects
- Verify pt with ID band, ask for name/DOB and confirm with chart
- Check blood product against group/screen results
- HH, gloves
- Check unit number on blood component matches unit number on slip/tag, ask well as expiry date
- Montior pt VS pre transfusion 30 min, q15 min after starting, q1hr once stable, and at completion
- Prime line with NS, spike blood bag and unclamp tubing for blood/clamp tubing for NS
- Prime filter by squeeze drip chamber to allow blood to come down, prime tubing set with blood
- Run IV NS at 999 mL/hr and VTBI at 15-20 mL
- Transfuse slowly for 1st 15 min (50mL/hr) then as ordered if no adverse reaction
- Max infusion time is 4 hrs
T or F: 2 nurse must check and sign transfusion record and blood bag
True
Objectives for blood admin?
Increase circulating blood volume after surgery/trauma, increase number of RBCs, provide selected cellular components as replacement therapy
