Chapter 10. Tubes and Attachments Show
A tracheostoma is an artificial opening made in the trachea just below the larynx. A tracheostomy tube is a tube that is inserted through the opening, or stoma, to create an artificial airway. Patients who need long-term airway support (long-term patients who are intubated) or who have a need to bypass the upper airway may receive a tracheostomy. A tracheostomy (see Figure 10.1) can be very traumatic for a patient, and many find it difficult to adjust to having one. The tracheostomy may be permanent or temporary. It is created surgically through the trachea (upper airway remains intact), larynx (upper airway is not patent), or cricothyroid (usually for temporary emergency access to airway). Tracheostomy tubes are inserted for airway maintenance, ventilation, removal of secretions, or as an alternate airway (e.g., following laryngectomy). Figure 10.1 Cross-section view of a tracheostomy (on a model) inserted in the trachea anterior to the esophagusTracheostomy TubesTracheostomy tubes can be soft plastic, hard plastic, or, at times, metal. All tracheostomy devices are made up of an outer cannula, inner cannula, and an obturator used to insert the tube (see Figure 10.2). They come in different sizes and may have a cuff. A cuff tracheostomy produces a tight seal between the tube and the trachea. This seal prevents aspiration of oropharyngeal secretions and air leakages between the tube and the trachea. Tracheostomies are firmly tied and secured around the patient’s neck. The ties prevent accidental de-cannulation of the trachea. Sterile gauze and cleaning supplies are used daily to clean the trachea stoma and prevent infection to the site. Figure 10.2 Left to right: obturator, cuffed tracheostomy tube, non-cuffed tracheostomy tube, tracheal dilatorsHumidificationWhen a patient has a tracheostomy, air is no longer filtered and humidified as it is when passing through the upper airways. Most patients will have humidification and oxygen support. The following is a list of the special considerations of patients with a tracheostomy tube (BCIT, 2015c).
Potential ComplicationsEarly potential complications may include hemorrhage, pneumothorax, subcutaneous emphysema, cuff leak, tube dislodgement, and respiratory/cardiovascular arrest. Late potential complications may include airway obstruction, fistulae, infection, aspiration, and tracheal damage/erosion. Emergency supplies at the bedside must include the following: 1. Suction equipment 2. Oxygen equipment with humidification 3. An emergency bag containing (see Figure 10.3):
The emergency bag must accompany patients when they are transported off the unit. Table 10.2 outlines methods to prevent possible complications that may arise from tracheostomies, and how to intervene if they do occur. Table 10.2 Prevention and Interventions for Complications
Video 10.5Tracheal SuctioningThe purpose of suctioning is to maintain a patent airway, to remove secretions from the trachea and bronchi, and to stimulate the cough reflex (Vancouver Coastal Health, 2006). Patients with tracheostomies often have more secretions than normal and will require suctioning to remove secretions from the airway to prevent airway obstruction. Tracheostomy patients should be assessed every two hours and as required to see if suctioning is required. Sterile suction equipment is used each time tracheal suctioning is performed. Secretions can be aspirated using a suction catheter connected to a suction source. Tracheal suctioning is indicated with noisy respirations, decreased O2 sats, anxiousness, restlessness, increased respirations or work of breathing, change in skin colour, or wheezing or gurgling sounds. These are signs and symptoms of respiratory distress, and the patient should be suctioned immediately. Checklist 82 outlines the steps for tracheal suctioning. Checklist 82: Tracheal Suctioning
Special considerations:
Video 10.6Tracheostomy CareTracheostomy care is performed routinely and as required. Tracheostomy care is essential to avoid potential complications such as obstruction and infection. In addition to suctioning, tracheostomy care includes the following tasks:
If possible, these three tasks of tracheostomy care should be performed at the same time to minimize handling of the tracheal device. Collect all supplies at once and complete the procedure in the order listed above. However, there may be times when each task may be performed separately. Ongoing assessment is essential when caring for a patient with a tracheostomy. Additional care includes:
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. The inner cannula can be cleansed with half-strength hydrogen peroxide or sterile normal saline. Always check the manufacturer’s recommendations for tube cleaning. Some inner cannulas are designed to be disposable, while others are reusable for a number of days. Inner tube cleaning should be done as often as two or three times per day, 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, bringing mucous 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. Checklist 83 describes how to clean and replace an inner tracheal cannula. Checklist 83: Cleaning an Inner Tracheal Cannula
Video 10.7Cleaning Stoma and Changing the Sterile DressingThe stoma should be cleaned and the dressing changed every 6 to 12 hours or as needed, and the peristomal skin should be inspected for skin breakdown, redness, irritation, ulceration, pain, infection, or dried secretions. Patients with copious amounts of secretions often require frequent dressing changes to prevent maceration of the tissue and skin breakdown. Cotton-tip applicators can be used to get under the tracheostomy device, where cleaning can be done using a semi-circular motion, inward to outward. Always use aseptic technique. Checklist 84 provides a safe method to clean the tracheal stoma and replace the sterile dressing. Checklist 84: Cleaning Stoma and Changing a Sterile Dressing
Video 10.8Replacing Tracheostomy Ties (Velcro or Twill Tape)Tracheal ties will become dirty and require replacing. Ties should be replaced as required, according to agency policy. Ideally, one person should hold the tracheostomy tube in place while the tracheostomy ties are replaced by another person. Alternatively, secure the new tracheostomy ties prior to removing the old tracheostomy ties to avoid accidental dislodgement of the tracheostomy tube if the patient coughs or the tracheostomy is accidentally bumped out. Once the new tracheostomy ties are on, only one finger should fit between the tracheostomy ties and the neck. Ensure twill ties are knotted using a square knot. Checklist 85 lists the steps for replacing tracheostomy ties. Checklist 85: Replacing Tracheostomy Ties (Velcro or Twill Tape)
Video 10.9
Which nursing action will limit hypoxia when suctioning a client's airway?Administer 100% oxygen before suctioning to prevent a decrease in oxygen saturation during the suctioning procedure.
Which intervention would the nurse use to prevent hypoxia during suctioning in the patient with a tracheostomy?Remove oxygen mask to clean dressing but replace frequently as required by patient. Replace the tracheal oxygen mask frequently to prevent hypoxia.
Which nursing action is important when suctioning the secretions of a client with a tracheostomy quizlet?Which nursing action is appropriate when suctioning the secretions of a client with a tracheostomy? Initiate suction as the catheter is being withdrawn. A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen.
What is the action to patient during tracheostomy suctioning?Utilizing a non-touch technique gently introduce the suction catheter tip into the tracheostomy tube to the pre-measured depth. Apply finger to suction catheter hole & gently rotate the catheter while withdrawing. Each suction should not be any longer than 5-10 seconds.
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