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!