Week 2- Tracheostomy Flashcards
upper airway components
Nose
Oral Cavity
Pharynx
Larynx
functions of upper airway
5
Heating/cooling inspired gas to body temperature
Filtering
Humidification
Smell
Phonation
Passage for ventilation
lower airway anatomy
5
Larynx (below the vocal cords)
Trachea
Bronchi
Bronchioles
Alveoli
functions of lower airway
Conducting airway for ventilation gas exchange
types of artificial airways
4
1.oropharyngeal airway
2. nasopharyngeal airway
3. ET tube
4. Naso-endotracheal tube
how to verify placement of ET tube and Naso endotracheal tube
2
- assess bilateral breath sounds
- auscultate over stomach to verify that the tube didn’t enter esophagus
not RN scope of practice to insert, unless additional (rural) education
Tracheostomy is an
incision into the trachea, creating a stoma or through which the airway is managed
surgical tracheostomy usually performed in
the OR but sometimes bedside in ICU
percutaneous tracheostomy
tube inserted with use of
tube is inserted with the use of a scope with a light source via a needle and guidewire technique
cricothyroidotomy only performed in
emergency situations, not preferred due to proximity of the vocal cords
benefits of a trach tube vs endotracheal tube
- lower risk of
- shorter
- easier
- more
- easier
- easier
- may start
- lower risk of laryngeal and oral injury
- shorter ventilator weaning time
- easier communication
- more comfortable
- easier to secure
- easier to do mouth care
- may start oral feeding sooner
indications for a tracheostomy
- bypass
- provide
- faciliate
- protect
- _____paralysis
- prevention of
- Bypass airway obstruction at or above the level of the larynx
- Provide (long term) mechanical ventilation
- Facilitate the removal of secretions
- Protect the airway in patient at risk of aspiration
- Vocal cord paralysis
- Prevention of Ventilator Associated Pneumonia (VAP)
complications of a trach
(8)
- Abnormal bleeding
- Tube dislodgement
- Obstructed tube/mucous plug
- Infection
- Subcutaneous emphysema
- Tracheo-esophageal fistula
- Tracheal stenosis
- Tracheal dilation
Types of tracheostomy tubes
cuffed trach
uncuffed
cuffed trach
- incorporates
- when placed with initial surgery it provides
- most have ____ cuffs
- an inflated cuff helps
- Balloon on the interior distal end of the tube that isolates the lower airway from the upper airway
- a stable airway until tract is established, patient is weaned off ventilator and is able to control secretions
- have “barrel” shaped high volume low-pressure cuffs to minimize the pressure on the tracheal mucosa and complications that occur with pressure necrosis
- protect against aspiration
cuffless trach
- used once
- may allow the pt to
- may facilitate
- may be
- can be used
- Used once patient can protect airway from aspiration, and no longer requires mechanical ventilation (except for long term ventilated patients)
- May allow the patient to speak if enough air passes above the tracheostomy tube through the vocal cords
- May facilitate oral feeding when compared to cuffed tubes while still providing access for suctioning
- May be plugged (corked) periodically if patient doesn’t require ventilation nor have upper airway obstruction
- Can be used long-term; much less chance of causing trans-tracheal damage
ADVANTAGES
cuffless trach
4
More comfortable for patient
May facilitate speaking
May facilitate eating
Progression towards decannulation
DISADVANTAGES
cuffless trachs
4
- Does not provide protection against aspiration
- Cannot provide adequate ventilation in event of Code Blue, or with surgery
- May dilute O2 received through trach mask or T-piece by mixing with room air O2 from upper airway
- Increases air leak (when used in long-term ventilated patients)
outer cannula
- maintains
- can be
- Maintains patency of stoma
- Can be fenestrated (to allow
air into larynx and facilitate
speech
suction requires what type of cannula
non-fenestrated
inner cannula for suctioning
inner cannula
- can be
- what it is
- protects the
- ideal for
disposable, reusable, high or low profile, or fenestrated
A removable tube which secures inside the outer cannula
Protects the patency of the tracheostomy tube with proper cleaning and can be removed to restore patent airway if occluded
Ideal for safety purposes
obturator
- Blunt tip introducer to reduce trauma during tracheostomy tube insertion
- Fits inside the outer cannula
- Rounded tip
- Remove immediately after tracheostomy tube insertion
- Kept as part of emergency kit
tracheal plug
- Occludes tracheostomy tube to redirect air around instead of through tracheostomy tube for weaning
- May be a sealed inner cannula, a cap, or a separate plug
Flange/Face plate
- Stabilizes tracheostomy tube by preventing the outer cannula from descending further into the trachea
- Allows a place for ties/sutures to attach
- Has tracheotomy tube specs (tube code/type/size) written on it
- May have locking indicator
- Some tubes have adjustable flanges
pilot line/cuff inflation line
pilot valve
- Connects pilot balloon to cuff
- Spring loaded
Keeps air from leaking out of the
balloon/cuff
Spring needs to be depressed in order to add or remove air from cuff
pilot balloon
External balloon connected to the cuff via the pilot line
Indicates whether cuff is inflated or deflated
trach cuff
- Balloon at the distal end of the tube
- Provides a seal between the tube and the tracheal wall when inflated, protecting against aspiration
- Deflated during weaning process
Emergency Airway Equipment:
4
ambu bag, mask, oral airway
non disposable inner cannula (if patient has cuffless, plugged tube in situ)
TRACH EMERGENCY AIRWAY SUPPLIES
- Cuffed tracheostomy tube - same size and one size smaller
- Tracheostomy dilator set
- 10cc syringe
- Tracheostomy tube exchanger
- 1 pack water –soluble lubricant
- Obturator (for tube insertion)
IHA Tracheostomy Emergency Guide
Pt is in resp distress
Call RT on vocera STAT
pt alert, responsive breathing
no= call code blue (bagger ressus with O2)
YES= remove trach cap if present
try to pass suction catheter and/or remove inner cannula and replace with new one
no improvement
obstructed upper airway and/or cuff inflated?
* when in doubt bag through trach)
NO= connect bagger to oxygen. use bagger with mask over nose/mouth and give breaths
YES= connect bagger to O2. place bagger without mask, directly to trach and give breaths
Applying humidified air/oxygen to
loosen secretions and prevent mucous plugging and/or infection
Check the patency and cleanliness of the
inner cannula regularly to avoid airway obstruction.
. Change/clean inner cannula for patency Q
12 h (may need more if thick secretions)
PURPOSE OF SUCTIONING
- Maintain airway patency
- Promote optimal gas exchange
- Decrease chance of infection through retained secretions
- Should be done on prn basis when indicated
- Shared skill between various HCPs (RT & RN)
Indications for Suctioning:
- Rattling, gurgling respiratory sounds indicative of secretions in or below the tracheostomy tube
- Ineffective cough (i.e. muscle weakness, decreased LOC, thick secretions)
- Visible secretions (in tube itself)
- Change in respiratory status (decreased SpO2 or peak pressure changes with vented patient= indicates problems with ventilation)
- Dyspnea, restlessness, irregular breathing pattern and/or accessory muscle use
- Pale or dusky color, clammy - indicating poor perfusion/ oxygenation potentially due to decreased respiratory efficiency
- May be requested by patient or with physiotherapy treatments or swallowing assessments
suction level
120-150 mmHg
catheter size for suctioning
no larger than half the size of the airway
height of HOB for suctioning
45-90 degrees
Connect ambu bag to oxygen ( ) or use oxygen by loosened trach mask
100 %
ensure adequate _____ suctioning to
oxygenation before, during and after
reduce risk of hypoxia and cardiac arrythmias
how to hyperoxygenate
100% O2 (3 – 5 times with ambu bag or 3 - 5 deep breaths with oxygen)
insert suction catheter ___ cm
13-15 cm or until reaching resistance from hitting the bifurcation (insert with no suction)
withdraw 1-2cm after reaching bifurcation of trachea
each suction pass should not exceed
5-10 seconds (tip to hold your own breath while you suction)
wait __ min in between then
1 min, rinse catheter
3 passes often enough
reassess patient post suctioning (this includes______) watch for
auscultation
bronchospasm with procedure - may need to give bronchodilators post suctioning
what to document after suctioning
- pre suction assessment
- results of suctions
- how patient tolerated it
- post suction assessment
purulent sputum
- my be infection
- yellow, green, brown
mucoid sputum
- consistent with oral secretions in appearance
bloody sputum
may be frank blood or serosanguinous in appearance
frothy sputum
consistent with pulmonary edema and has a pinkish tinge
tracheal mucosal damage
- can result from vigorous, deep and prolonged suctioning at excessive pressures.
hypoxia secondary to
oxygen desaturation
dysrhythmia due to
2
lack of O2 or stimulation of vagus nerve from tracheal irritation
lung collapse due to
excessive suction pressure
infections due to
airway contamination
low BP due to
vagal stimulation
increased ICP, intra abdominal and intrathoracic pressures are generated with
2
-coughing
- stimulation or instillation of saline
- instillation of topical anesthetic for patient at risk may be considered
dressing changes and tracheostomy care should be done
at least twice daily and prn
check ______ with every dressing change and prn
inner cannula patency
a disposable inner cannula is changed a minimum of every
24 hours
position for trach dressing change
supine in semi fowlers
what to use if stoma is crusted
diluted hydrogen peroxide
tightness of trach securing
fit 2 fingers under
always make sure new tie are secured prior to
removing old ties or if two people changing ties
if two people changing ties,
make sure new ties are secured before letting go of flange
decannulation process can take from
a few days to several months
reason pt would have a trach instead of ET tube
6
1- longer timeframe anticipated for this type of airway support (greater then 7-10 days)
2- patient comfort, less obstructive, can eat, talk (with certain types)
3- Upper airway is obstructed due to trauma, tumour or swelling
4- SC trauma or neuromuscular diseases
5- weaning from a TT is easier then from an ET tube
6- decrease chance of trauma to vocal cords
ET tubes most often used for
2
general anesthetic and in emergency situations
why would an cuffed trach be used
- cant manage secretions
- difficulty coughing independently
- tight seal between TT and trachea
- prevents aspiration of oral secretions
- used immediately after insertion until trach is more established
- used when ventilating a pt
advantages of uncuffed trachs
- ease of swallowing
- speaking
- cuff can cause dysphagia because it interferes with swallowing muscles
A nursing student is caring for a client who is scheduled for surgery later that day. The student’s clinical teacher asks the student to review the medication administration record (MAR) and identify if there are any medications that should be held prior to surgery. What medications should the student tell the clinical teacher are usually held prior to surgery? Select all that apply.
atorvastatin
bisoprolol
ASA 650 mg
prednisone
warfarin
asa
warfarin
The surgeon orders Cefazolin (Ancef) 1 g to be given IV at 7:30 a.m. when the client’s surgery is scheduled at 8:00 a.m. What is the PRIMARY reason to administer the antibiotic exactly at 7:30 a.m?
a. The antibiotic is most effective in preventing infection if it is given 30-60 minutes before the operative incision is made
b. Legally, the medication must be given at the ordered time
c. The peak and trough levels are needed for this antibiotic therapy
d. The postoperative dose of Cefazolin (Ancef) needs to be given exactly 8 hours after the preoperative dose of Cefazolin
a
The reason that patients are sent to a PACU/PAR after surgery is:
a. To provide time for the pt to emotionally cope with the effects of surgery.
b. To remain near the surgeon immediately after surgery.
c. To be monitored while recovering from anesthesia.
d. To allow the medical-surgical unit time to prepare for transfer.
c
when do post op infections usually happen
5-7 days post op
priorities for receiving a post op patient are
- airway
- breathing
- circulation
- depth of consciousness
- everything from surgery (HTT)
- freedom from risk
- gather information and chart
A nurse is caring for a patient after abdominal surgery in the post-anesthesia care unit (PACU/PAR). The patient’s blood pressure has increased and the patient is restless. The patient’s oxygen saturation is 97%. The MOST LIKELY cause for the increase in blood pressure and restlessness is that:
pt is in pain
sympathetic stimulation
increase HR, BP, restless
Following admission of the post-operative patient to the surgical ward, which of the following assessment data requires the most immediate attention?
Respiratory rate of 13/min
Oxygen saturation of 80%
Blood pressure of 90/60 mm Hg
Temperature of 36.0°C
b
airway and breathing
pt not perfusing organs
