Trach Suctioning & Care Flashcards
Assessment
1.
Assessed for risk factors for upper or lower airway obstruction
Assessment
2.
Determined presence of symptoms indicating hypoxia, hypothermia, or hypercapnia
Assessment
3.
Assessed vital signs, oxygen saturation, lung sounds and patient’s ability to clear airway
Assessment
4.
Assessed signs and symptoms of upper and lower airway obstruction requiring airway suctioning and factors that affect volume and consistency of secretions. Assess hydration status
Assessment
5.
Weighed patient’s need for suction, considered contraindications to nasotracheal suctioning. Observe for need for trach care and when trach care was last performed
Assessment
6.
Examined sputum microbiology data
Assessment
7.
Assessed pts understanding of procedure and ability to perform tracheostomy care. Explained procedures and pts participation
Planning
1.
2.
3.
- Identified expected outcomes
- Obtained nurse of NAP to assist if needed
- Had pt assume appropriate position
Planning
4.
PLACED PULSE OX ON PTS FINGER, TOOK READING, LEFT OXIMETER IN PLACE, PLACED TOWEL ACROSS PT’S CHEST IF NEEDED
Implementation
1.
2.
- IDENTIFIED PT USING TWO IDENTIFIERS
2. PERFORMED HAND HYGIENE, APPLIED PPE IF NECESSARY
Implementation
3.
Apply clean gloves and withdrew inner cannula while touching only the outer aspect of the tube and remove soiled dressing. Disposed of contaminated cannula in appropriate receptacle
Implementation
4.
Open sterile kids using aseptic technique. Fill one compartment tray with sterile saline
APPLIED STERILE GLOVES PROPERLY
1) Placed draped across patient’s chest or on over bed table did not allow suction catheter to touch any non-sterile surface.
2) Fill reservoir in trach kit
Implementation
5.
Picked up suction catheter with dominant hand, picked up connecting tubing with non-dominant hand, secured catheter to tubing.
Implementation
6.
Checked that equipment was functioning properly.
Implementation
7.
Suctioned airway. Performed tracheal suctioning.
1) increased oxygen flow rate for face masks as ordered, had patient deep breathe slowly, or hyperoxygenate as needed with Ambu bag or ventilator. (May delegate to NAP)
2) Coated distal end of catheter with saline.
3) removed oxygen delivery device if applicable, inserted catheter into trach without applying section, until resistance was met or patient coughed, pulled back slightly.
4) Applied intermittent suction by placing thumb up and down over vent of catheter and withdrawing catheter while rotating it back and forth between thumb and forefinger, encouraged patient to cough, replaced oxygen device, had patient breathe deeply. Watch for respiratory distress.
5) Rinsed catheter and connecting tubing with normal saline or water until cleared.
