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N342 > Tracheostomy > Flashcards

Tracheostomy Flashcards

1
Q

Techniques for maintaining an airway that are not artificial airway?

A

Hydration, positioning, nutrition, chest PT techniques, suctioning, deep breathing, coughing, humidity, incentive spirometry, and noninvasive techniques help in maintaining an airway

• Artificial airway is needed when these do not clear secretions

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2
Q

What might be done before suctioning to limit hypoxia induced by this procedure?

A

• Preoxygenation and deep breathing sometimes referred to as hyperventilation, help to reduce suction-induced hypoxemia.

If mech vent, preoxygenation done by inc % of inspired oxygen breaths delivered by a mechanical ventilator

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3
Q

Hyperinflation is

A

the process of providing 100% oxygenation ot a patient before airway suctioning

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4
Q

T/F

all pt need preoxygenation before suctioning

A

F - not all - not needed unless hypoxemic

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5
Q

What to do after suctioning with O2 levels?

A

o Following suctioning, return a pt o2 level to presuctioning levels to avoid inc risk for o2 toxicity.

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6
Q

It is normal to do normal saline instillation (NSI) into artificial airways these days?

A

• Practice of normal saline instillation (NSI) into artificial airways is no longer recommended as standard practice. was thought to remove secretions
o Suctioning with ot without isotonic normal saline produces similar amounts of secretions and significant dec in o2 sat.

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7
Q

What sort of things are you assessing for prior to scuitoning? (including medical hx)

A
  1. Risk factors for upper or lower aiway obstr (COPD, infections, impaired mobility, sedation, dec LOC, seizures, presence of feeding tubes, dec gag or cough reflex, dec swallowing)
  2. SIgns of hypoxemia/hypercapnia
  3. Vitals
  4. S&S of upper and lower a/w obstr requiring airway suctioning, including qhezing, crackles, or gurgling on inspiration or expiration, restlessness, ineffective coughing, diminished breath sounds, tachypnea, HTN, hoTN, cyanosis, dec sec, drooling or gastric secretions
  5. Assess for additional factors that anatomically influence upper or lower airway function (surgery, tumors) …it impairs normal drainage of secretions and can impair or occlude airway
  6. Assess factors that affect vol and consistency of secretions
    a) fluid balance- fluid overload inc secretions
    b) lack of humidity- dehydration promotes thicker secretions
    c) infection-
  7. Examine sputum microbio data
  8. Assess pt understanding of procedure
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8
Q

Why is head injury a risk when suctioning?

A
  1. Use caution when suctioning pt with head injury. Inc iCP. Reduce this risk by presuctioning hyperventilation, which results in hypocarbia. This in turn induces vasoconstriction, thereby reducing risk of ICP
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9
Q

What sort of meds would need to be assessed prior to suctioning?

A
  1. Know SE of meds. Some meds such as beta-adrenergic blockers have side effect of bronchospasm. Resp depression for opiods. Too much o2 reduces drive to breath w pt w chronic hypercapnia
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10
Q

Difference between oropharyngeal + tracheal suctioning?

A
  • Major differences between oropharyngeal and tracheal airway suctioning are the depth suctioned, the potential for complications and the need for it to be a sterile procedure
  • Oropharyngeal- removes secretions from back of throat
  • Tracheal airway suctioning extends into the lower airway- indicated to remove resp secretions and maintain optimum ventilation and oxygenation in pt who are unable to remove secretions on own
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11
Q

Under what level of O2 is a good indicator that suctioning is needed?

A

When o2 is below 90% good indicator they need suction

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12
Q

Complications/problems with suctioning/

A
  • What is not suctioned can move into lungs- aspiration, infection,
  • Tracheal suctioning risks: hypoxemia often leading to cardiac dysrhythmias, laryngreal spasm or bradycardia (associated w stimulation of vagus nerve)
  • Nasal trauma and bleeding can develop from trauma from suction catheter
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13
Q

Endotracheal tubes + trachs protect the airway from gross aspiration in patients with…

A

impaired cough or gag reflexes.

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14
Q

Special consideration for metal trachs r/t safety?

A

• Metal TT are thermal sensitive and must be protected from extreme heat and cold to prevent tissue injury to the patient.

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15
Q

When is a closed system suction catheter used?

A

• Some use closed suction catheter system or in-klaw suction catheter device to minimize infections, especially in critically ill or immunosuppressed pts
• Use of a closed system catheter allows quickler lower airway suctioning without applying sterile gloves or a mask and oes not interrupt ventilation and oxygenation in critically ill patients.
o With a closed system the patients artificial airway is not disconnected from mechanical ventilation

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16
Q

S+S of hypercapnia/hypoxemia

A

presence of apprehension, dec ability to concentrate, dec LOC, inc fatigue, dizziness, behaviour changes, pallor, cyanosis, dyspnea or use of accessory muscles (can indicate hypoxia, hypoxemia, or hypercapnia)

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17
Q

First 3 steps for initiating suctioning?

A
  1. ID, HH, goggles or face shield if splashing, mask
  2. Connect suction and have end close to patient in convenient location. Set suction pressure s low as possible.
  3. Prepare suction catheter
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18
Q

How to prepare one time use catheter?

A

a) use aspetic twchnique, open suction kit or catherer. If sterile drape is available, place acorss patients chest or on over-bed table. Do not allow suction catheter to touch any nonsterile surfaces
b) unwrap or open sterile basi and place on bedside table. Be careful not to touoch inside of basil. Fill with 100ml of sterile water
c) open lubricant, squeeze small amount onto open catheter package (no neeed for artificial airway suctioning)

  1. Apply sterile gloves or nonsterile to nondominant and sterile to dominanant
  2. Pick up suction with dominant hand and pick up connecting tubing with nondominant hand
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19
Q

How do you hyperoxygenate a pt prior to suctioning?

A

Hyperozygenate pt with 100% o2 for 30-60 sec before suctioning by adjusting inspired o2 setting on mechanical ventilator or using an oxygen-enrichment program on microprocessor ventilators.

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20
Q

How do you insert the catheter for suctioning?

With or without suction on?

A

Without applying suction, gently but quickly insert catheter into artificial airway using dominant thumb and foreginger until you meet resistance or pt cough then pull back 1cm.

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21
Q

Why do you apply suction AFTEr putting catheter in?

A
  1. application of suction pressure without introducing catheter into trachea inc risk for damage to tracheal mucosa and inc hypoxia.
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22
Q

Why do you pull back after meeting resistance?

A

Pulling back stimulates cough and removes catheter from mucosal wall so catheter is no resting on it

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23
Q

How do you apply suction?

What do you want to encourage pt to do while suctioning?

A
  1. Apply continuous suction by placing nondom thumb over vent of catheter, slowly withdraw catheter while rotating it back ad forth between dom thumb and forefinger.

Encourage pt to cough. Watch for resp distresss

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24
Q

Do you want intermittent or continuous suction?

A

Use continuous suction

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25
Q

What to do with suction catheter when finished w patient?

What are you looking for with your pt?

A

Rinse catheter and connect tubing with normal saline until clear

  1. Assess vitals, cardiopulmonary srarus and ventilator measures for secretion learance. Repear steps to clear more secretions.
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26
Q

How long do you wait between suctioning?

A

at least 1 minute

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27
Q

What to encourage w pt following suctioning?

A
  1. Encourage deep breathing.

Hyperoxygenate for at least 1 min post suction to expand alveoli (???Just if hypoxemic?)

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28
Q

How to dispose of suction tubing?

A
  1. When suctioning complete, wrap glove around suction tubing and pull off clove and discard.
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29
Q

Max number of suctions w pt with head injury?

A

Limit suction to 2 times/ suction procedure.
(I think the general rule is 3?)

suctioning can cause elevation in ICP w pt with head injuries. Reduce this risk by presuction hyperoxygenation which results in hypocarbia which in turn induces vasoconstriction (dec ICP).

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30
Q

What to do if pt develops resp distress during suctioning?

A

if pt develops resp disress during procedure, withdraw suction and apply o2. In emergency admin o2 through catheter

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31
Q

Closed in line suction procedure.

I doubt we need to know this??

A

1) semi fowlers position
2) HH, gloves, face shield
3) TI usually attaches catheter to the mech vent circuit. If cather is not already in palce, open suction catheter package using aseptic tech and attack closed suction catheter to ventilator circuit by removing swivel adaptor and placing closed suction catheter apparatus on TT. Connect Y on mech vent circui to closed suction catheter with flex tubing
4) Connect one end of connecting tubing to suction machine and other end to closed system or in line suction atheter. Turn device on or set to neg preesure and check pressure.
5) Hyperoxygenate pt by adjusting FiO2 setting on the ventilator or by using temporary o2 enrichment program available on microprocessor ventilators
6) Pick up suction catheter enclosed in plastic sleeve in dom hand
7) Wait until pt inhales to insert catheter. Use a repeating maneuver of pushing catheter and sliding (or pulling) plastic sleeve back between thumb and foreginger until resistance felt or pt cough then pull back 1 cm before applying suction to avoid tissue damage
8) Encourage pt to cough and apply suction by squeezing on suction control mechanism while withdrawling catheter
9) Apply continuous suction for no longer than 10 seconds as you removes suction catheter.
10) Reassesss status
11) Repeat if needed and allow 1 min between
12) When airway is clear, withdraw catheter completely. Be sure that the colored indicator line on catheter is visible in sheath squeeze vial or push syringe when applying suction to rinse inner lumen of catheter. Use at least 5-10 ml of saline ro rinse catheter
13) Hyperoxygenate for at least 1 min post

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32
Q

How long is a trach?

A

51-76mm (2-3inch)

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33
Q

Advantages of trach over endotracheal?

A
  • dec laryngeal and tracheal tissue injury, ease of breathing, and access for better hygiene
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34
Q

Can pts with a trach cough effectively?

A

• Some patients with trach are able to cough up secretions out of the tube completely, whereas others are only able to cough secretions up into it.

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35
Q

Parts of a trach

A

• A trach tube has a flange that fits against a patients neck and an outer cannula or primary airway. Must have a removable inner cannula for cleaning and an inflatable cuff that surrounds the outer cannula

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36
Q

How do you know if the cuff is inflated?

A

The pilot balloon is also expanded

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37
Q

Why would you inflate the trach balloon?

A

An inflated cuff keeps the tube stable within the trachea

• A cuff on a tracheal tube prevents the escape of air between the tube and the walls of the trachea and reduces aspiration when pt is receiving ventilation

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38
Q

3 standards of care for trachs?

A

properly securing the tube, inflating the cuff to an appropriate pressure, maintaining patency by suctioning and providing oral care

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39
Q

What occurs when there is inproper inflation of the cuff? (damage done by the trach)

A

• A trach causes granulation tissue to form on the vocal cords, epiglottis, or trachea secondary to inappropriate cuff inflatin

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40
Q

Can pt’s with a trach tube speak?

A
  • An intubated pt is unable to speak bc of placement of a trach tube which prevents normal airflow over and vibration of the vocal cords.
  • May place a speaking valve over some trach tubes to allow pt to speak
  • When the inner cannula is removed and the cuff is deflated, patients can speak
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41
Q

What is the difference with a fenestrated trach tube?

A

• One type of trach tube is fenestrated, which means that the outer cannula has precut openings.

42
Q

Assessments prior to trach care?

A
  • Observe for excess peristomal secretions, excess intratracheal secretions, soiled or damp trach dressing, diminished airflow through trach tube or signs and symptoms of airway obstr requiring suctioning
  • Assess hydration status, humidity delivered to arway, status of existing infection, nutritional status and ability to cough (factors that affect amount and consistency of secretions)
  • Vitals, lung sounds
43
Q

First few steps in trach care?

A

1) ID, HH, clean gloves and face shield
2) Apply pulse oximeter sensor
3) Suction trach (previous skill). Before removing gloves, remove soiled trach dressing and sicard in glove with coiled catheter

44
Q

After suctioning, you get your equipment ready… what needs to be done?

A

o open sterile trach kit. Open 2 4x4s and pour normal saline on one package. Leave second package dry. Open 2 cotton tipped swab packages and pour normal saline on one package. Do not recap NS
o open sterile trach dressing package
o unwrap sterile basin and pour about .5-2cm (.5-1inch) of normal saline into it
o open small sterile brush package and place aspeptically into sterile basin
o prepare length of twill tape long enough to go around patients neck twice, about 25-30 inches for an adult. Cut ends on diagonal. Lay aside in dry area
o if using commercially available trach tube holder, open package according to manufacturer directions

45
Q

After you prepare your tray of sterile suplies for trach care, what might you need to do for the pt before removing the inner canula?
What kind of gloves are you wearing?

A

1) hyperoxygenate patient using ventilator settings or by applying oxygen source loosely over trach (required if pt o2 sat below 92%)
2) Apply sterile gloves. Keep dominant hand sterile throughout procedure

46
Q

1) care of trach with inner cannula (starting w removing the inner cannula)

A

o While touching only outer aspect of tube, unlock and remove inner cannula with nondominant hand following line of tracheostomy. Drop inner cannula into NS basin
o Replace trach collar, T tube, or ventilator o2 oxygen source over outer cannula (may not be able to attach T tube and ventilator oxygen devices to all outer cannulas when inner cannula is removed)
o To prevent desat in affected pt, quickly pick up inner cannula and use small brush to remove secretions inside and outside inner cannula
o Hold inner cannula over basin and rinse with NS, using nondominant hand to pour NS
(erin than dries it)
o Replace inner cannula and secure “locking’ mechanism. Reapply ventilator after hyperoxygenating patient if needed.

47
Q

How to change inner can of Trach with disposable inner cannula:

A

o Remove new cannula from manufacturer packaging
o While touching only aspect of tube, withdraw inner cannula and replace with new cannula. Lock into position.
o Dispose of contaminated cannula in appropriate receptable and reconnect to ventilator or o2 supply

48
Q

Once you have changed the inner canula of the trach…what do you do next?

A

1) Using NS saturated cotton ti[[ed swabs and 4x4, clean exposed outer cannula surfaces and stoma under faceplate extending 2-4 inches in all directions from stoma. Clean in circular motion
2) Using dry 4x4 pat dry
3) Secure trach

49
Q

How to change trach tie (last step in process of trach care)

A

o Instruct assistant to hold trach in place
o Take prepared tie, insert one end of tie through faceplate eyelet and pull ends even
o Slide both ends of tie behind head and aroud neck to other eyelet and insert one tie through second eyelet
o Pull snuggly
o Tie ends securely in double square knot, allowing spae for only one or two snug fingers
o Inert frech 4x4 trach dressing under clean ties and faceplate

50
Q

How to change a trach tube holder? (the velcro kind)

A

o While wearing gloves, maintain secure hold on trach tube. W or w/out an assistant. Leave old trach tube in place until new device is secured
o Align strap under pt neck. Besure that Velcro attachments are on either side of trach tube
o Place narrow end of ties underand through faceplate eyelets. Pull ends even and secure with Velcro closures
o Verify that there is space for only one loose or two sug fingers

  • I assume you put a 4X4 drain drsg on too.
51
Q

If the cuff pressure are too high….?

What is the correct P?

A
  • permamnent damage to the tracheal mucosa occurs

* Maintain cuff pressures between 20-25mmHg or less

52
Q

• Indications for cuff inflation?

A

1)Mechanical ventilation:
♣ Continuous airway pressure
♣ Positive end expiratory pressure (PEEP)
♣ Inability to meet ventilator requirements with cuff down
♣ Inability to meet oxygen requirements with cuff down

2)Risk of Aspirating Gastric Contents
♣	Feedin tube, especially large bore, in stomach
♣	GERD
♣	Hiatal hernia
♣	During and after meals
♣	Impaired gastric emptying 
♣	Decreased gag reflex
♣	Impaired swallowing
53
Q

Assessment prior to inflating cuff?

A

Observe for signs and symptoms of gurgling on expiration, decreased exhaled tidal vol (mechanically ventilated patient), spasmodic coughing, tense test balloon on tube, flaccid test balloon on tube, and unexpected phonation
Vitals, resp effort

54
Q

Procedure for inflating cuff on trach?

A

1) ID, HH, comfortable position
2) Suction secretions through trach tube and mouth
3) Connect syringe to pilot balloon
4) Place stethoscope in sternal notch or above trach tube and listen for minimal amount of air leak at end of inspiration
5) If you do not hear a leak, remove all air from cuff (releases excessive cuff pressure, which can reduce cap blood flow and increase tissue necrosis)
6) Reinfalte cuff according to agency policy
7) If you hear excessive air leak, slowly add air (may prevent adequate lung expansion and inc risk for aspiration)
8) Remove stethoscope remove syringe and resposition pt

55
Q

What is required constantly for pt with artificial airway and why?

A
  • Patients with an artificial airway require constant humidication to the airway
  • Artificial airway bypasses the normal filtering and humidification process of the nose and mouth
56
Q

How is O2 given through artificial airway (2)

A

The two deices that supply humidified gast o an artificial irway are a T tube and trach collar
• The T tube also called the Briggs adaptor- T shaped device with a ¾ inch connection that connects an o2 source to an artificial airway such as ET tube or trach

57
Q

What is a trach collar?

A

• Trach collar is a curved device with an adjsutabale strap that fits around a patients neck
o 2 ports- an exhalation port that remains patentnta ta all times and the port that connects to the oxygen source with large bore tubing

58
Q

What is the recommended flow rate for O2 into artifical airway?

A

• Recommended flow rate is 10L/min with nebuuizer set to Fio2

59
Q

Assessment for giving O2 into artificial airway?

A
  • resp status
  • obserce for patent airway and remove airway secretions by having pt couch and by suctioning
  • monitor pulse oximetry and note arterial blood gases
60
Q

Procedure for giving O2 through artifical airway?

A

1) HH, ID
2) Attach T tube or trach colar to large bore oxygen tubing and to humidified room air or oxygen source as indicated
3) If oxygen is ordered, adjust flow tate to 10ml/min or as ordered. Adjust neb to proper Fio2 sertting. Attach T tube to trach. Place trach collar over trach tube and adjust straps so it fits snug
4) Observe that T tube does not pull on trach. Observe for secretions within T tube or rach collar and suction as necessary
5) Observe o2 tubing freq for accum of fluid. Of present, drain tube aay from patients, disconnect color or T tube and discard fluid in receptable
6) Set up suction at bedside
7) Remove goggles, gloves, HH

61
Q

How is trach put in (pilitteri)

A
  • Cricoid cartilage of the trachea is swabbed with antiseptic and local anesthetic. Incision made just under ring of cartilage and trach tube with its obturator in place is inserted into opening
  • Few sutures may be necessary t the tube insertion site to halt bleeding or to reduce size of incision
62
Q

Consideations for trach in kid

A
  • Often will want to pull out. (child)
  • Assure them its ok and they cant speak.
  • Make sure parents know why this is happening
  • Breathing patterns for kids. (fearful)
  • Tell parents don’t give small toys that can fit in lumen of trach, keep use of sprays to a min, keep cold air from blowing against the trach cause can cause tracheal spasm, inspect stuffed toys, supervise children
63
Q

How are trach tubes different in children?

Do they need suctioning?

A
  • Most trach tubes are plastic and do not include an inner cannula which would require removal and cleaning
  • Do often need freq suctioning
  • Ineffective suctioning can cause more mucus. Know how to deeply suction
64
Q

How is a child weaned off trach tube?

A

• Tubes are generally sealed off partially by tape or occlusive for a day or 2 before removal then completely occuled before removal and slowly wean off.

65
Q

What occurs if pt coughs and trach tube is dislodged? Is this an emerg (in child)?

A

o Because the incision site usually does not close completely to occlude the tracheal opening when a tube is dislodged, the child still has a patent airway s as long as the child is not in distress, this is not an emergency. Always keep new tube at bedside. Slide the obturator into the tube and gently replace it in the tracheal opening. Remove the obturator and secure the new tube in place,

66
Q

Larynx CA
All always what kind of CA?
Risk factors?

A

• Almost all are squamous cell carcinoma
• Rates declining but incidence in women compared to men rising
• Risks:
o Assoc w EtOH + smoking.
o Chewing tobacco even worse than smoking as more potent
o Occup exposure to coal dust, steel dust, iron compounds + fumes, formaldehyde etc
o Diet of Western cultures
o Straining the voice, chronic laryngitis, nutritional def (riboflavin) + family predis

67
Q

How serious is laryngeal CA? Mets? Recurrence common?

A
  • Survival rate 75-95% if no spread to lymph nodes
  • Metastasis uncommon
  • Recurrence common in first 2-3yrs
68
Q

Clinical Manifestations of laryngeal CA?

A
  • Hoarseness (tumour impeding glottis) – not early sign
  • Persistent cough, burning + pain in throat (esp w hot fluids + citrus)
  • Palpable lump in neck
  • Late: dysphagia, dyspnea, unilateral nasal obbstr or discharge, peristnet ulceration + foul breath
  • Cervial lymph adenopathy, unintentional weight loss, general debilitated stae + pain radiating to ear may occur with mets
69
Q

Assessment + Diagnostic Findings of laryngeal CA?

A
  • Hx + Px
  • Laryngoscopy to eval tumour
  • Enlarged lymph nodes + thyroid gland
  • Mobility of vocal cords
  • Endoscopy, optical imaging, CT, MRI
  • Classify stage (size, histology, lymph node involve) + location are basis of tx
  • PET for determining tumour post tx
70
Q

Medical maangement of laryngeal CA?

A

• Goals: cure, preservation of safe, effective swallowing + voice, and avoidance of permanent tracheostoma
• Sx, radiation + chemo
• Depends on whether is recurrence or not
• Dental exam done to rule out oral disease (need to be resolved before radiation or sx)
• If early stage, radiation or sx likely effective
• Chemo followed by or concurrently w radiation has good effect
Surgical Tx – (details p. 563)
• Vocal cord stripping (removal of mucosa of edge of vocal cord)
• Cordectomy
• Laser sx
• Partial Laryngectomy (portion of larynx + one cord removed w tumour. Good if early stages)
Total laryngectomy:

71
Q

When is a total laryngectomy needed? What will be needed?

A

• for cure of advanced cases; results in permanent loss of the voice + need of permanent trach or laryngectomy tube (like trach but can’t speak or breath if occluded). Need tracheal stoma to prevent aspiration of food and fluid into lower resp tract. Has normal swallowing but no voice; breaths through opening in neck

72
Q

No more notes on details of treatment/speech therapy techniqeus because i doubt we would be tested on them!
(and I susepect the following cards aren’t too useful either)

A

…

73
Q

Assessment of pt undergoing laryngectomy?

A
  • Health hx + physical exam, focus on above symptoms
  • General state of nutrition, weight + BMI
  • Pre-op assess for speech therapy
  • Pt’s ability to hear, see + write essential
  • EtOh use
74
Q

Potential complications of laryngectomy?

A
  • Resp distress (hypoxia, airway obstruction, tracheal edema)
  • Hemorrhage
  • Infection
  • Wound breakdown
  • Aspiration
  • Tracheostomal stenosis
75
Q

Pre-op teaching for pt undergoing laryngectomy?

A

o Dx of this CA creates fear + misconceptions (assum loss of speech inevitable)
o Pt ability to sing, whistle + laugh will be lost
o Given written materials about procedure
o Coughing + deep breathing taught

76
Q

Use opioids + other resp depression drugs cautiously after laryngectomy…why?

A

leads to shallow breathing + ineffective cough

77
Q

What position to put pt in after laryngectomy?

A

o Position in semi or high fowler after recovery from anesthesia (reduced edema + allows lung expansion)

78
Q

Why do you see so many secretions after laryngectomy? Will this decrease? What can you do in the meantime?

A

o Tracheobronchial tree compensating b/c air most warmed + moistened in upper resp tract, so frequently cough large amounts of mucus; may have brassy-sounding cough (assure pt is temporary as will adapt)
♣ Wipe clean of mucus after coughing
♣ May want gauze or paper towel below trach opening to catch mucus at first
o Can suction but careful w sutures
o Clean stoma daily w soap + water
o If crusty, remove w sterile tweezers
o Humidification of environment very important (dec cough, mucous prod, crusting at stoma)! Mechanical humidifiers + nebulizers used.

79
Q

What is the primary rehab goal of pt after laryngectomy?

A

• Promoting Alternative Communication Methods

o Need call bell in reach
o Magic Slate often used for communication
o Use non-dominant hand for IV

80
Q

What sense may be altered for pt after laryngectomy? Is this permanent?

A

o Taste sensations altered b/c inhaled air goes right into trachea (and taste highly r/t smell) – olfactory system will adapt + eating will become pleasureable again

81
Q

WHy do you see wound breakdown in pt after laryngectomy + what is the risk here?

A

♣ d/t infection, poor wound healing, development of fistula, radiation, tumour growth
♣ Can be life-threatening as carotid artery close to stoma…may rupture

82
Q

How do you prevent aspiration in pt who has undergone laryngectomy?

A

♣ Suction nearby
♣ Asess for nausea + give antiemetics (don’t want vomit)
♣ Tube feeds: HOB at 30degrees or higher for 30-45min post feed; Check residuals

83
Q 
Tracheostomal stenosis (risk of laryngectomy) - what is it? 
Risks?
A

o abn narrowing of trachea or stoma
♣ Risks: infection at site, excessive traction on the tracheostomy tube by connecting tubing, persistent high tracheostomy cuff pressure
♣ Assess connecting tubing, stoma site – notify HCP if abn
♣ Ensure cuff deflated except short periods (when eating or taking meds)

84
Q

Promoting home care for pt with trach/ other tube from laryngectomy?

A
  • Pt needs to learn tracheostomy + stoma care, wound care + oral hygiene, dietary intake + safe hygiene + recreational activities
  • Stress importance of humidification, how to set up humidication. Air conditioning may be drying
  • Teaches how to respond to emerg (suctioning)
  • Safety in shower – need to ensure water not entering stoma – wear plastic bib or putting hand over is effective
  • Swimming not recommended as can drown without submerging face
  • Loose hairs + sprays need to not go into stoma – need caution with hair dressers
  • Use tissue to remove mucus, wash hands before care, dispose of soiled drsgs properly
  • S+S of infection
  • Avoidance of strenuous exercise + fatigue as will have greater difficulty speaking + this can be very frustrating
  • Need med bracelet to alert medical personel for special resuscitation measures –> direct mouth to stoma CPR needed
  • Freq oral care
  • If receiving radiation, may need synthetic saliva (as prod dec)
85
Q

Better cards now:..

A

x

86
Q

Where is a trach inserted?

A

Inserted between 2nd and 3rd tracheal rings

87
Q

Uses of a trach tube?

A
  • bypass upper airway obstr, allow removal of secretions, long term mech vent, prevent aspiration or oral or gastric secretions in unconscious or paralyzed pt (closes off trachea to esophagus), or replace an endotracheal tube
  • Performed in ICU or OR
88
Q

Complications of trach tube:

A

• Early: bleeding, hemothorax, air embolism, aspiration, subcut or mediastinal emphysema, recurrent laryngeal nerve damage + posterior wall tracheal wall penetration
• Long-term: airway obstr from accum of secretions or protrusion of cuff along opening of the tube, infection, rpuuture of innominate artery dysphagia, tracheoesophageal fistula, tracheal deviation, tracheal ischemia + necrosis
o After tube removed, can devel tracheal stenosis

89
Q

How to position pt after tracheostomy?

A

• Once VS stable, place in semi-fowler to facilitate vent, promote drainage, minimize edema, prevent strain on suture lines

90
Q

What to remember with giving meds to trach pt?

A

• Admin analgesia + sedation w caution as can suppress cough reflex

91
Q

Particularly important nursing intervention for trach pts?

A

CB in reach at all times

92
Q

Why is suctioning required for trach pt?

A

o Needed d/t dec effectiveness of cough mechanism

o Done when secretions present or adventitious lung sounds

93
Q

o Unnecessary suction causes

A

bronchospasm + trauma to trachea

94
Q

How is suctioning done if pt is mech vent?

Advnatages of this?

A

o If mech vent, in-line (aka closed suctioning) suction cath must be used to allow rapid suction owhen needed + minimize contamination

– allows suction w/o disconnected from vent. In-line dec hypoxemia, sustains PEEP, + dec pt anxiety about suctioning. Can be done w/o PPE on nurse.

95
Q

When is cuff inflated in trach?

A

pt requires mech vent or high risk of aspiration

96
Q

How does med-surg describe P needed in cuff?
how frequently checked?
WHen might you need a higher P?

A

o Want lower possible P in cuff that allows delivery of adequate tidal vol + prevents asp – usually <25mmHg to prevent injury + at >15mmHg to prevent asp
o Cuff P monitored at least q8h
o With long term intubation, may need higher P to maintain seal

97
Q

How often a trach dressing changed/

A
  • Trach dressing changed as needed ot keep skin clean + dry
98
Q

How do you prepare your tray for cleaning your inner canula?

A

One section 1/2 NS and 1/2 hydrogen peroxide + two with NS (one for rinsing + one for cotton swabs etc)

99
Q

How high should suction be when suctioning trach?

A

VIHA: 80-120mmHg
100-150mmHg (P+P)

Paul + Day say not higher than 120mmHg

100
Q

What safety equipment is required at the bedside with a trach?

A

Spare trachs, trach dilators, obturator, ambu bag with trach adaptor, suction equipment

N342 (5 decks)

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