Unit 1: Tracheostomy Care Flashcards
When placing a tracheostomy, initially an _______ tube is placed by the anesthesiologist to maintain the airway until the tracheostomy tube is inserted.
Endotracheal (ET) tube
How long can an Endotracheal (ET) tube be left in before we need to switch to the tracheostomy tube?
~2 weeks
What holds the tracheostomy tube in place?
The tracheostomy ties connected to the neck plate of the tracheostomy tube.
NOT the Cuff (inflated balloon); the cuff only prevents air from moving up around the tube.
How tight should the tracheostomy ties be?
What pressure should the tracheal cuff be maintained at and by who?
1 finger breadth
<14-20 mm Hg
Respiratory therapist (RT)
Tracheostomy care (cleaning) is performed using _____ technique; however, changing the inner cannula requires _____ technique
Clean; Sterile
How often should we replace the inner cannula?
What about Trach ties?
Twice daily (or once per shift)
Change trach ties AS NEEDED
Indications for a Tracheostomy (8)
- Trauma (facial/laryngeal trauma)
- Acute Airway obstruction
- Airway Protection (Copious secretions)
- Prolonged unconsciousness (vegetative state)
- Paralysis
- Inability to wean from mechanical ventilator
- Head/Neck surgery w/ airway involvement
- ARF (expected need for prolonged mechanical ventilation–*not done often; want to use ET tube for up to 2 weeks and hope they recover w/o need of a trach)
If a tracheostomy is planned, what preoperative education should we provide in conjunction with the multi-disciplinary team? (6)
- Critical care environment + Communication
- Airway self-management
- Trach Suctioning (uncomfortable)
- Pain control
- Nutrition support (feeding tube, risk for aspiration)
- Discharge plans
What preoperative teaching about communication should we provide? What can we utilize to promote communication?
Plan an acceptable communication method with the patient.
Dry erase board, picture board, yes/no questions
Patient teaching r/t Self-management of airway: (6)
● No swimming; use caution when showering/shaving
● Lean slightly forward and cover the stone when coughing or sneezing
● Clean stoma with mild soap and water
● Use non-oil-based lubricants around stoma
● Increase humidity by using saline in stoma as directed, a bedside humidifier, pans of water, &/or house plants
● MedicAlert bracelet
How do we verify tracheostomy location?
If misplacement occurs, where is the most likely location?
CXR
Misplacement generally occurs into subQ tissue
What is our #1 postoperative priority following a tracheostomy? What should you expect?
Maintaining a patent airway
Should expect better breathing–good deep breaths w/ normal amount of respirations, clear lung sounds, skin color
- Listen for bilateral lung sounds at least every 1 hr
- Clear any secretions (mucous/blood) if present
It’s consider a EMERGENCY if decannulation occurs in the first __ hours after surgery.
72 hours
What extra trach equipment should always be in the room?
Obturator
Tracheostomy insertion tray
Trach tube of the same size
Trach tube one size smaller
Ambubag
Suctioning equipment
Postoperative Assessment tool: “DOPE”
D = Dislodgment
O = Obstruction
P = Pneumothorax
E = Equipment Failure
If Dislodgement of the trach tube occurs within the first 72 hours, what do?
Call Rapid Response and Ventilate the patient w/ a manual resuscitation bag and face mask
If Dislodgement of the trach tube occurs after 72 hours, what do?
Place obturator
Replace trach tube with obturator still inserted
Remove the obturator
Listen for bilateral lung sounds
If Dislodgement of the trach tube occurs after 72 hours, and you’ve failed to reinsert a new trach tube, what do next?
CALL FOR HELP! (another RN, RT, etc.) and
Ventilate with a bag-valve-mask
If pt is in distress, call Rapid Response!
What can we do to prevent dislodgement of the trach tube?
Ensure the Trach Ties are secure
What are the two causes of trach tube obstruction?
- Secretions (mucous/blood)
- Cuff displacement
S/S + Indicators of Trach tube obstruction (5)
- difficulty breathing
- noisy respirations
- Thick, dry secretions
- Difficulty inserting a suction catheter
- High peak pressures (if on mechanical ventilator)
Interventions to prevent Obstruction
- Assessments every ~1 hr
- Pulmonary Hygiene
- Cough and deep breathing exercises
- Ambulation (or sit up/dangle if unable)
- Incentive Spirometer - Inner cannula care
- Humidified O2
- Suctioning PRN
What if the obstruction is due to cuff prolapse over the end of the tube?
Call RT to reposition or replace the tube!
What causes a pneumothorax to develop r/t a trach tube?
What might we see/hear that indicates this has occurred (4)
What should we do if we suspect this?
Develops during the tracheotomy procedure if the chest cavity is entered.
1. Subcutaneous Emphysema**
2. Pain
3. Unilateral breath sounds
4. Difficulty breathing (increased RR, etc.)
CALL THE PROVIDER!
What’s another cause of Subcutaneous Emphysema?
Opening or tear in the trachea that allows air to escape into the tissues of the neck and can progress to the face &/or chest.
How often should trach care be performed following placement? Why?
HOURLY for the first 24 hrs
LOTS of bleeding –> high risk for obstruction
Change dressing and clean site as needed based on the amount of bleeding
Bleeding in small amounts from the tracheotomy incision is expected for the first few days, but what if it’s constantly oozing?
NOT OKAY!
1. Wrap gauze around the tube and pack it gently into the wound to apply pressure.
2. Ensure trach cuff is properly inflated
3. Call the provider!
Can a patient develop a pressure ulcer from a trach tube?
OH YEAH.
Trach cuff applies pressure to the trachea and can cause damage
Other risk factors: nutritional status, use of steroids
What can we do to prevent trach tube pressure ulcers?
- Maintain the proper cuff pressure!
- Provide adequate nutrition
- Warm, humidified air
Suctioning is performed ___ for no more than _ passes lasting __-__ sec each, and should be done using ______ technique.
PRN for no more than 3 times for 10-15 sec
STERILE technique
What are some complications r/t to trach suctioning? (6)
- Hypoxia
- Pain
- Trauma/bleeding
- Vagal stimulation (bradycardia, hypotension, dysrhythmias)
- Infection
- Bronchospasm (coughing)
How to prevent complications from Trach suctioning? (10)
- Premedicate for pain Mx
- Sterile technique
- Hyperoxygenate (Ambubag + 100% FiO2)
- Use smallest suction catheter size
- Lubricate the catheter with saline
- Avoid prolonged suctioning
- Talk to your pt thru-out suctioning
- Monitor for dysrhythmias
- STOP if vagal stimulation occurs
How often do we perform oral hygiene?
At least every 2 hrs
- use sponge or soft-bristled toothbrush
- assess for oral mucosa breakdown
- rinse with normal saline q 4 hrs
What should we do if we want to begin weaning a patient off their trach?
CALL THE TROOPS!
- Interdisciplinary process that should include pt and family
How do we wean a patient off their trach?
● Deflate the cuff
● Change to an uncuffed tracheostomy tube
● Reduce size of tube
● Cap the tube (air moves through upper airway); WITH cuff DEFLATED!
● Tube can be removed after 24 hours of tolerating capped tube
Focused Tracheostomy Assessment:
- Note quality, pattern and rate of breathing compared to baseline
- Assess for cyanosis, esp. around lips which can indicate hypoxia.
- Auscultate lung sounds
- Ensure prescribed O2 is correct and has humidification
- Assess trach site for color, consistency, and amount of secretions in tube or externally.
- Assess trach ties condition + fit, and the skin under trach ties
- Call RT and check the cuff pressure once daily
- Ensure emergency trach equipment is in the room and the correct size.
Tachypnea can indicate ______.
Dyspnea (SOB) can indicate _____.
Tachypnea = hypoxia
Dyspnea = Obstruction
Trach tube + Aspiration prevention
- Serve meals when pt isn’t fatigued
- Position upright
- Small, frequent meals + adequate time
- Supervise self-feeding + encourage small, slow bites
- Keep suction equipment close and turned on
- Avoid thin liquids and straws
- Thicken ALL liquids (even water)
- thin liquids may be allowed after SLP eval - When possible, deflate tube cuff completely or partially during meals
- suction after cuff deflation
- encourage pt to dry swallow after each bite (aka double swallowing)
- Provide small volumes of liquids using a spoon.
- Avoid consecutive swallows of liquids
- Tell pt to “tuck” chin down and move forehead forward while swallowing
- allow pt to indicate when they’re ready for next bite
- if coughing occurs, stop feeding until pt indicates airway is clear.
- assess RR, ease of swallowing, pulse ox, and HR during feeding.
- Keep HOB elevated for 30 min after eating.
