Open Resources for Nursing (Open RN) Show
Tracheostomy care is provided on a routine basis to keep the tracheostomy tube’s flange, inner cannula, and surrounding area clean to reduce the amount of bacteria entering the artificial airway and lungs. See Figure 22.9[1] for an image of a sterile tracheostomy care kit. Replacing and Cleaning an Inner CannulaThe primary purpose of the inner cannula is to prevent tracheostomy tube obstruction. Many sources of obstruction can be prevented if the inner cannula is regularly cleaned and replaced. Some inner cannulas are designed to be disposable, while others are reusable for a number of days. Follow agency policy for inner cannula replacement or cleaning, but as a rule of thumb, inner cannula cleaning should be performed every 12-24 hours at a minimum. Cleaning may be needed more frequently depending on the type of equipment, the amount and thickness of secretions, and the patient’s ability to cough up the secretions. Changing the inner cannula may encourage the patient to cough and bring mucus out of the tracheostomy. For this reason, the inner cannula should be replaced prior to changing the tracheostomy dressing to prevent secretions from soiling the new dressing. If the inner cannula is disposable, no cleaning is required.[2] Checklist for Tracheostomy Care With a Reusable Inner CannulaUse the checklist below to review the steps for completion of “Tracheostomy Care.” Stoma site should be assessed and a clean dressing applied at least once per shift. Wet or soiled dressings should be changed immediately.[3] Follow agency policy regarding clearing the inner cannula; it should be inspected at least twice daily and cleaned as needed. StepsDisclaimer: Always review and follow agency policy regarding this specific skill.
Sample DocumentationSample Documentation of Expected FindingsTracheostomy care provided with sterile technique. Stoma site free of redness or drainage. Inner cannula cleaned and stoma dressing changed. Patient tolerated the procedure without difficulties. Sample Documentation of Unexpected FindingsTracheostomy care provided with sterile technique. Stoma site is erythematous, warm, and tender to palpation. Inner cannula cleaned and stoma dressing changed. Patient tolerated the procedure without difficulties. Dr. Smith notified of change in condition of stoma at 1315 and stated would assess the patient this afternoon. When caring for a client with a tracheostomy the nurse would perform?When caring for a client with a tracheostomy, the nurse would perform which recommended action? Clean the wound around the tube and inner cannula at least every 24 hours. Assess a newly inserted tracheostomy every 3 to 4 hours. Use gauze dressings over the tracheostomy that are filled with cotton.
Which actions will the nurse include when doing tracheostomy care quizlet?Auscultate the lungs and check the heart rate.. Prepare by turning suction on to between 80 and 120 mm Hg pressure.. Hyper oxygenate using 100% oxygen.. Don sterile gloves.. Guide the catheter into the tracheostomy tube using a sterile-gloved hand.. Which action should the nurse take first when performing tracheostomy care?Which nursing action must be taken first? The first nursing action for a patient following an airway procedure is to assess the patient's respiratory status; this requires auscultation of the lungs. Suction is not needed if the lungs are clear to auscultation.
When suctioning a client with a tracheostomy which nursing intervention is correct quizlet?For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia.
|