w5 tracheostomy Flashcards
what is a complete airway obstruction?
a medical emergency!! pt is not breathing
what is a partial airway obstruction?
may occur as a result of aspiration of food or a foreign body
- laryngeal edema following extubation
- laryngeal or tracheal stenosis, central nervous system (CNS) depression
- allergic reaction
what are S/S of partial airway obstruction?
- stridor
- use of accessory muscle
- suprasternal and intercostal retractions
- wheezing
- restlenes
- tachycardia
- cyanosis
what are methods to re-establish a patent airway?
obstructed airway (Heimlich) manoeuvre
- cricothyroidotomy
- endotracheal intubation
- tracheostomy
what is a tracheostomy?
a surgical incision into the trachea for the purpose of establishing an airway
when would we use a tracheostomy?
-used for pt requiring intubation longer than 7-10 days or when an airway is obstructed due to trauma, tumours, or dwelling
what are the indications for tracheostomy?
- bypass an upper airway obstruction
- facilitate removal of secretions
- permit long-term mechanical ventilation
- permit oral intake and speech in pt who require long-term mechanical ventilation
what are the benefits of tracheostomy?
no tube in pt mouth
- comfort and mobility are increase
- risk to damage vocal cords are decreased
- pt is able to eat and talk w/ a tracheostomy because the tube enters lower in the airway (unless an inflated cuff is used)
what are the complications of tracheotomies?
- abnormal bleeding
- tube dislodgement
- obstructed tube
- subcutaneous emphysema
- trachesophageal fistula
- tracheal stenosis
cause of bleeding tracheostomy
surgical intervention
- erosion or rupture of blood vessel or both
- nurse must monitor bleeding and notify physical if continues or excessive
cause of tube dislodgement
excessive manipulation or suctioning
-nurse must ensure ties are secure and keep obturator, hemostat, and new tracheotomy tube at bedside
cause of an obstructed tube?
dried or excessive secretions
- nurse should assess pts respiratory status
- suction if necessary
- maintain humidification
- perform trach care
- ensure adequate hydration
what causes subcutaneous emphysema
- air escapes from the incision to the subcutaneous tissue
- mointor subcut emphysema
- reassure pt and family
causes of tracheoesophageal fistula
- tracheal wall necrosis, leading to fistula formation
- monitor cuff pressure
- monitor pt for coughing and choking while eating or drinking
causes of tracheal stenosis
- narrowing of tracheal lumen owing to scarring caused by tracheal irritation
- nurse should monitor cuff pressure
- ensure prompt treatment of infections
- ensure ties are secure
what should always be readily available by the bedside?
a spare tracheostomy set, obturator and tracheal dilator
-preferably taped at the head of the bed
how long should u suction for at a time?
-10 seconds
how often should the nurse assess the need for suctioning
q2h
what should the suction pressure be set as?
between 100 and 150mmHg for adults w/ tubing occluded
-for infants and children pressure should read between 50 and 100mm Hg depending on the size of the child
after a tracheostomy procedure how long should the ties not be changed for?
for the first 72hours!!
tracheostomy with inflated cuff
is used if the pt is at risk for aspiration or needs mechanical ventilation
-inflated cuff exert pressure on tracheal mucosa
-it is important to inflate the cuff w/ the minimum volume of air required to obtain an airway seal
cuff inflation pressure should not exceed 20mm Hg or 25 cm H20 b/c higher pressure may compress tracheal capillaries, limit blood flow, and predispose to tracheal necrosis
what is minimal leak technique (MLT)?
involves inflating the cuff w/ the minimum amount of air to obtain a seal and then w/drawing 0.1 mL of air
what are the disadvantages of MLT (minimal leak technique)
risk for aspiration from secretions leaking around the cuff and difficulty maintaining positive end-expiratory pressure
what should the pt do before cuff deflation?
-cough up secretions
and trach tubę and mouth should be suctioned -important step to prevent secretions from being aspirated during deflation
-the cuff is deflated during exhalation b/c the exhaled gas helps propel secretions into the mouth
-pt should cough before and after cuff deflation
-cuff should be reinflated during inspiration
care of a new tracheostomy tube
- a replacement tube of equal or smaller size should be kept at the bedside (readily available for emergency reinsertion)
- trach tapes are not to be changed for at least 24-72 hours after the insertion procedure
- the first tube change is performed by a physician, usually no sooner than 7 days after the trach
after the first tube change how often should the tube be changed approximately?
once a month
patients who cannot protect the airway from aspiration require what kind of trach?
an inflated cuff trach
-pt may be able to swallow w/out aspirating when the cuff is deflated but not when it is inflated
what is a fenestrated tube?
has an opening on the surface of the outer cannula that permit air from the lungs to flow over the vocal cords
- this tube allows the pt to breathe spontaneously though the larynx, speak, and cough up secretions w/ the tracheostomy tube in place
- can be used by pt who can swallow w/out risk for aspiration but requires suctioning for secretion removal
- can also be used for pts who require mechanical ventilation for less than 24 hrs a day like during sleep
what are the assessments before the use of a fenestrated tube?
- before this tube is used, pt ability to swallow w/out aspiration must be determined
1. no aspiration- inner cannula is removed
2. cuff is deflated
3. decantation cap is placed in the tube
what is a disadvantage of fenestrated tubes?
-potential development of tracheal polyps from tracheal tissue granulating into the fenestrated opening
what is decannulation?
when pts can adequately exchange air and expectorate secretions, the trach tube can be removed
- stoma is closed w/ tape strips and covered w/ an occlusive dressing
- pt should be instructed to splint the stoma w/ the finders when cough, swallowing or speaking
- epithelial tissues begins to form in 24-48 hrs and opening will close after several days- surgical interventions is not required
How develop a laryngeal polyps?
- -may develop on the vocal cord from vocal abuse (excessive talking, singing) or irritation (intubation, cigarette smoking)
- most common symptom is hoarseness
- can be treated w/ voice rest
- for large polyps (may cause dyspnea and stridor) surgical intervention may be needed
- polys are usually benign but may be removed b/c may become malignant later
Cuffed Tube with Disposable Inner Cannula
Used to obtain a closed circuit for ventilation
-Cuff should be inflated just enough to allow minimal air leak.
Cuff should be deflated if patient uses a speaking valve.
Cuff pressure should be checked twice a day.
Inner cannula is disposable.
Cuffed Tube with Reusable Inner Cannula
-Used to obtain a closed circuit for ventilation
-Cuff should be inflated just enough to allow minimal air leak.
Cuff should be deflated if patient uses a speaking valve.
Cuff pressure should be checked twice a day.
Inner cannula is not disposable. You can reuse it after cleaning it thoroughly.
Cuffless Tube with Disposable Inner Cannula
Used for patients with tracheal problems
Used for patients who are ready for decannulation
-Save the decannulation plug if the patient is close to getting decannulated.
Patient may be able to eat and may be able to talk without a speaking valve.
Inner cannula is disposable
Cuffless Tube with Reusable Inner Cannula
Used for patients with tracheal problems
Used for patients who are ready for decannulation
-Save the decannulation plug if the patient is close to getting decannulated.
Patient may be able to eat and may be able tospeak without a speaking valve.
Inner cannula is not disposable. You can reuse it after cleaning it thoroughly
Fenestrated Cuffed Tracheostomy Tube
-Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak
-There is a high risk for granuloma formation at the site of the fenestration (hole).
There is a higher risk for aspirating secretions.
It may be difficult to ventilate the patient adequately.
Fenestrated Cuffless Tracheostomy Tube
- Used for patients who have difficulty using a speaking valve
- There is a high risk for granuloma formation at the site of the fenestration (hole).
Metal Tracheostomy Tube
-Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes. (Jackson)
-Patients cannot get a MRI.
One needs to notify the security personnel at the airport prior to metal detection screening.
what are your assessments for trach stoma?
-Assess for secretions, stoma skin around trach for redness, drainage, secretions, bleeding
With newly established trach, are sutures still in place?
how often do trach ties get changed?
change only when wet, soiled, safety considerations
-ensure 1-2 fingers can fit beneath ties
how many times can u pass the same catheter during suctioning?
no more than 2 passes with the same catheter
=allow at least one minute in between suction passes for ventilation and oxygen - ask the pt to deep-breathe and to cough
suctioning can lead to_?
- hypoxemia
- cardiac dysrthythmias
- laryngeal and bronchospasm
- changes in BP (can be HTN or hypo)
- pain
- infection
- bradycardia caused by vagal stimulation
- nasal, pharyngeal, or tracheal trauma and bleeding induced by the suction catheter
- respiratory or cardiac arrest can even occur as a result of tracheal suctioning
- nasal trauma (i.e bleeding)
what are unexpected outcomes d/t trach stoma?
- accidental extubation (call for help, maintain patent airway, replace w/ new tube, VS & monitor for resp distress)
- hard, reddened area w/ or w/out excessive or foul-smelling secretions (possible infection, inform MD, increase frequency of tube care)
- insecure tube, artificial airways moves in or out, coughed out by pt ( assess respiratory status, presence of mucus plugs, adjust or apply new ties)
- breakdown, pressure areas or stomatitis (increase tube care, ensure clean and dry skin)
what should you document
- resp assessment (before and after)
- pain management
- trach care (changing of inner cannula (size), how pt tolerated the suctioning or corking, suctioning frequency & secretions -ACCO, & LOC)
- assess pt nutrition-oral or NG feed, risk of aspiration
what are s/s of upper and lower airway obstruction requiring nasotracheal or orotracheal suctioning?
abnormal RR
- adventitious sounds
- nasal secretions
- gurgling
- drooling
- restlessness
- gastric secretions
- vomitus in the mouth
- coughing w/out clearing secretions from the airway
what are S/S of hypoxia and hypercapnia?
- decrease SP02
- increase pulse and blood pressure
- increase RR
- apprehension
- anxiety
- decreased ability to concentrate
- lethargy
- decreased LOC (esp acute)
- increased fatigue
- dizziness
- behavioural changes (esp w/ irritability)
- dysrhythmias
- pallor
was are contraindications to nasotracheal suctioning?
occluded nasal passages
- nasal bleeding
- epiglottitis
- croup (acute head, facial, or neck injury or surgery)
- coagulopathy
- bleeding disorders
- laryngospams
- bronchoaspams
- gastric surgery w/ high anastomoses
- myocardial infraction
what do you use to clean the stoma?
normal saline
hydrogen peroxide- this is an old practice we don’t use anymore (but is stated in potter & Perry)
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how small should the inner cannula be?
should be 1cm smaller than the trach
how long do we cork for?
2-4 hours, titrate it
until they have 24 hours tolerance of cork
-if pt has SOB, stop this process
how long do we cork for?
2-4 hours, titrate it
until they have 24 hours tolerance of cork
-if pt has SOB, stop this process
goal: is to remove the cannula
why do we not suction while inserting the catheter?
Increase risk for hypoxia** - don’t want to take away their oxygen at this time
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