Trach Flashcards
tracheotomy vs tracheostomy
Tracheotomy= A surgical incision into the trachea to create an airway
Tracheostomy = The tracheal opening from the tracheotomy
are all trachs emergent? are all trachs permanent?
• Emergent (trauma) or Scheduled (laryngeal cancer)
• Temporary or permanent
is there less or greater risk of pneumonia with a tracheal intubation when compared to oral intubation?
-less risk for pneumonia with trach vs oral intubation
indications for trach
• Acute Respiratory Failure –> expected needs for prolonged mechanical ventilation
• Copious secretions/ Airway protection
• Laryngeal trauma
• Facial trauma
• Prolonged Unconsciousness
• Acute Airway obstruction
• Head/Neck surgery with airway involvement
• Paralysis
• Inability to be weaned from mechanical ventilator
preoperative care for trachs
• Education
◦ home management- do procedures/care as clean at home (sterile in hospital)
• Self management of airway
◦ Suctioning
• Pain control
◦ require less analgesics than endotracheal tube
◦ suctioning is most painful part !
• Critical care environment
• Nutrition support
• Feeding tubes
• Discharge plans
• Communication/speech- ask yes or no questions, picture board, write
• Include the multi-disciplinary team
top concerns with trachs for nurses
-gas exchange
-communication
-nutrition
-infection
how do we verify a trach placement after surgical placement?
xray
top priority for post op trach?
maintain patent airway
how do we know a trach patient has a patent airway after surgery?
◦ breathing is better (if look worse something is wrong!), looks more comfortable, normal depth
◦ clear breath sounds, some secretions that clear with suctioning
◦ O2 saturation normal
what happens if trach becomes dislodged within first 72 hours post op of placement?
emergency! call a code
complications from trach? top one?
-tube dislodgement
-pneumothorax
-bleeding
-infection
-tube obstruction**
____ _____ is a sign of pneumothorax realted to trach placement
subcutaneous emphysema
signs of tube obstruction
• Difficulty breathing
• Loud breathing
• Difficult to insert a suction catheter
prevention for complications re: tube obstruction?
• Pulmonary Hygiene: mobility! - dangling
• Inner Cannula Care - changed , 1/shift
• Suction as needed- not routinely
• Humidified Oxygen
PISH
how often do we suction trach?
as needed only!
how often should the inner cannula be changed/cleaned?
changed 1/day , 1/shift
what kind of oxygen do trachs need?
humidfied
how do trach patients end up with a pneumothorax?
◦ Occurs as a result of tracheostomy placement if the provider inadvertently enters the chest cavity
‣ need chest tube to regulate pressure to pull the lung back to inflation
◦ Subcutaneous emphysema - sign of pneumothorax
‣ sounds like rice crispies
signs of pneumothorax?
◦ Pain
◦ Unilateral breath sounds- absent breath sounds on side with pneumothorax
◦ Breathing problems
You get report on your patient at the bedside from the day nurse. Your patient
has a #8 XL Shiley tracheostomy tube, which was placed two days ago. The
day nurse tells you she just did tracheostomy care about an hour ago, and other than a scant amount of serosanginous drainage, everything looks great. The CRNA had a difficult time placing the patient’s airway, so the patient has a
“Difficult Airway” sign hanging above his bed. As you scan the patient and the room, what observation would you be most concerned about:
A) The patient’s tracheostomy is only secured with ties, not sutures
B) There is a #9 XL Shiley tracheostomy tube on the bedside table with an obturator nearby.
C) There are no suction catheter kits in the room
D) The patient has audibly rhonchorous breath sounds and is coughing
B) There is a #9 XL Shiley tracheostomy tube on the bedside table with an obturator nearby.
◦ need one size smaller NOT bigger! + need obturator + suction set up + O2 + ambu bag
cuffed vs non cuffed trach- whats the difference?
◦ cuffed = resp failure –> do not want any air escaping up
◦ non-cuffed = permanent trach, weaning
this ind of trach has a little hole so people can talk when it is in
fenestrated
concerns for trach cuff pressure?
can cause pressure ulcer in trach if too much pressure!
trach cuff pressure should be < ____ - ____mmHG
‣ <14-20 mm Hg
• Which patients with a tracheostomy need to be suctioned?
A) Everyone with a tracheostomy should be suctioned routinely
B) The patient with mucus in the artificial airway
C) The patient with noisy secretions
D) The restless patient with tachycardia and tachypnea
B) The patient with mucus in the artificial airway
C) The patient with noisy secretions
D) The restless patient with tachycardia and tachypnea
suctioning complications?
• Hypoxia
• Pain
• Trauma/ Bleeding
• Vagal Stimulation
◦ Bradycardia
◦ Hypotension
◦ Dysrhythmias
• Infection
• Bronchospasm
what do we do before and between suctioning passes?
give 100% o2! hyperoxygenate that fool
max time suctioning down the trach hole
10 seconds
sterile or clean technique for suctioning
sterile
max # times you can go down with catheter?
3
what do we do if vagal stimulation occurs when suctioning? what are the signs of vagal stimulation?
stop suctioning !!
◦ Bradycardia ◦ Hypotension ◦ Dysrhythmias
in addition to pre oxygenating patient what else might we do before sucking snot out of their neck hole?
pre-medicate for pain!
You are observing your preceptor perform tracheostomy suctioning. You become concerned when he…
A) Tells the patient that he is going to perform tracheostomy suctioning, letting the patient know that it may be painful and may cause coughing
B) Uses a sterile kit, remaining sterile through the entire process of suctioning
C) During suctioning, the patient’s heartrate drops from 89 to 53 and the nurse reassures the patient that he is almost done
D) Suctions for about 10-15 seconds, only during withdrawal of the catheter
C) During suctioning, the patient’s heartrate drops from 89 to 53 and the nurse reassures the patient that he is almost done
steps in weaning from a trach?
->Interdisciplinary process that should include the patient and family
• Deflate the cuff –> makes pt lungs have to work harder
• Change to an uncuffed tracheostomy tube
• Reduce size of tube
• Cap the tube (air moves through upper airway) –> never put cap over a cuffed tube!
• Tube can be removed after 24 hours of tolerating capped tube
after tolerating the a capped trach for _____ hours the tube can be removed
24 hours
which specialists/care team people might a someone with a trach need?
• Speech pathology
• Social Work
