Module 7: Trach Care and Discharge Planning

Question 1

What is transition?

Answer 1

• in relation to timing, transition implies process rather than event and, in this way, provides a broader, more continuous way of thinking about discharge planning. As a transitional process, discharge planning can and ought to begin on admission and extend beyond discharge.
• In relation to the integration of discharge planning with other relevant aspects of family life, transition suggests change, movement, and adjustment of life patterns, rather than focusing on discharge as an isolated occurrence.
• Finally, regarding the concern that discharge planning often occurs without sufficient parental participation, transition is a concept that focuses our attention on infants and families, in that they are the ones experiencing a transition. Discharge planning can easily be thought of as an activity that health care professionals engage in, whereas transition focuses on the lived experience of infants and families.

Question 2

What are the Recommendations for Nursing Practice in the NICU (3)?

Answer 2

• Support staff and student education on the needs of parents in the NICU
• Provide parents with clear and accurate information concerning their infant’s condition
• Collaborate effectively with parents and other members of the healthcare team when making decisions concerning the infant’s care
• Establish an emotionally safe and supportive NICU environment to help build trust
• Provide unlimited parent access to the infant and an open visitation policy whenever possible
• Provide individualized family centered care
• Assist parents to provide care for their infants through guided participation whenever appropriate
• Provide nursing support and facilitate the establishment of parent-to-parent support groups

Question 3

What is partnership is all about?

Answer 3

• The journey in the NICU can sometimes be a long and rough road.
• Envision yourself walking beside these parents and supporting them through this journey

Question 4

What does empowerment mean?

Answer 4

• By empowerment, she means that, as health care professionals, we must begin to acknowledge and promote the capacity of families to increase control over and to improve their own health (p. 68) and
• that a family’s health may be enhanced without solving its members’ health problems (p. 68).

Question 5

How should we approach family: with a sense of what?

Answer 5

• we approach families with a “sense of uncertainty” rather than a “sense of knowing” what they need
• appreciate that each family is unique and we are there to support them not fix their problems.
• We’re not suggesting you disregard previous experiences or discount your knowledge
• rather appreciate that this family’s experience is unique to them.

Question 6

Who knows baby best?

Answer 6

• There is a considerable shift in knowledge as parents become expert on the care of their baby.
• I used to assume to be the expert in neonatal care and would tell the parents what we were doing and why.
• Now, instead of telling them what is happening with their baby, I let them tell me.
• Providing nursing care that helps a family adapt to their experience requires learning how to support them in using their knowledge to make informed decisions about how their infant is cared for.

Question 7

What are families’ learning needs?

Answer 7

• What about families’ learning needs? What are they? How are they determined? How are they met? In keeping with our view that the way a particular family makes their transition from hospital to home is unique,
• I would suggest that, similarly, what a family’s learning needs are and how they are determined and met will depend on the individual characteristics of the family, their infant, and their situation.

Question 8

What is the key to partnership with a family?

Answer 8

The key is to work in partnership with a family as community resources are accessed in order that the family’s needs - not our perception of their needs are met.

Question 9

Why is it important to partner with families in the initial phase?

Answer 9

• Families of children with long-term challenges eventually become “case-managers” for their child as they coordinate the various specialists, equipment suppliers, therapists, etc.
• Partnering with families in the initial phase of seeking out and setting up resources provides them with valuable training in coordinating these resources in the future.

Question 10

Community Health Nurses/Public Health Nurses

Answer 10

• All newborn infants going home from hospital, those with long-term health challenges as well as those without, are referred to Community/Public Health and are contacted by their local
• Community/Public Health Nurse within the first few days at home.
• Infants going home with long-term health challenges are usually seen in their home the day after discharge.
• These nurses will provide breastfeeding support, assess weight gain, answer questions, and provide whatever support is needed by the family.
• If further support is needed after the first visit, additional visits can be arranged.

Question 11

Home Care Nurse

Answer 11

• These nurses are an outgrowth of Community/Public Health and will provide home visits in order to perform specific tasks such as dressing changes, urethral catheterizations, feeding tube placements, etc.
• The Community/Public Health Nurse will often refer a family to Home Care if the family needs ongoing support beyond that provided by Community/Public Health.

Question 12

Infant Development Program

Answer 12

• Physiotherapists or Occupational Therapists are available through the Infant Development Program to provide ongoing support to any infant going home with documented or suspected developmental delays as well as infants requiring specific exercises due to muscular or orthopedic concerns.
• Therapists will go into the home to assess the infant and provide training for parents in exercises for the infant
• Unfortunately, due to limited funding, infants often have to wait several months before their first visit from the Infant Development Program.

Question 13

Nursing Support Services

Answer 13

• Infants who require very specialized care at home will sometimes qualify for respite nursing care through Nursing Support Services
• In order to meet the requirements for this program, infants must have needs that require assessments and decision making that would normally be done by a professional
• In this case, parents are unable to leave their infant with a “regular” babysitter and respite nurses are provided for a certain number of hours per week to provide respite for the family.

Question 14

At Home Program

Answer 14

• This program is designed to meet the needs of infants and children who are unable to perform age-appropriate activities of daily living.
• Because infants do not normally perform any activities of daily living at an independent level (they don’t get dressed, feed themselves, brush their teeth, etc.), they usually do not qualify for the At Home Program .
• If, however, they are approved for respite nursing, they are automatically admitted to the At Home Program .
• The program provides funds for equipment, medication, transportation to and from medical appointments, etc.

Question 15

Neonatal Follow-up Clinic

Answer 15

• Some tertiary centers, including BC Women’s Hospital, have clinics where they perform follow-up assessments and care at set intervals for infants and families with specific conditions.
• Extremely low birthweight infants and infants who have required ECMO are among those seen in follow-up.
• This provides very detailed information for families about their infant and also provides information to the NICU regarding the long-term effects of certain conditions and specialized treatments.
• Need for further support can be determined and arranged through these visits.

Question 16

Home Oxygen Program

Answer 16

Infants requiring oxygen at discharge are funded by the Home Oxygen Program who works with Oxygen vendors to ensure oxygen is available and appropriate follow-up assessments of respiratory status is provided by Respiratory Therapists.

Question 17

Home Tracheostomy and Ventilation Program

Answer 17

• This is a provincial program serving every province and territory.
• Once the patients are trained in tracheostomy care and discharged from the nursery, they will have access to and be followed by the Tracheostomy and Ventilation Program.
• They will return for clinical assessments of upsizing of the tracheostomies, and weaning or adjustments of their respiratory support as they grow and change.
• During a clinical appointment they will be able to address any concerns with their child’s current respiratory support, and any issues they may be encountering with the tracheostomy from a respirologist and specifically trained respiratory therapist.
• Victoria has their own respiratory clinic so those on the Island may be followed by them - however this program is still supported by those at Children’s and Women’s Health Center of BC.

Question 18

What are some Indications for a tracheostomy may include (3)?

Answer 18

Congenital or acquired airway obstruction
i.e subglottic stenosis

Airway constriction due to congenital malformations
i.e. TEF, tracheal stenosis, tracheomalacia, Pierre-Robin syndrome

Other reasons
Long term airway, neuromuscular disorders, neuromuscular injury, trauma

Question 19

What is part of the upper airway?

Answer 19

• the nose plays a very important role in the upper airway. As air enters the nostrils, large particles of dust and dirt are filtered. The mucus membranes of the nasopharynx further filter this air, warm or cool the inspired air, and humidify it. The column of inspired air travels down through the oral pharynx to the laryngopharynx. Here it passes through the larynx where the vocal cords are located. The larynx is located at the top of the trachea. When we breathe in, the vocal cords open, allowing air to pass freely into the trachea.
• The larynx is composed of several cartilage structures - nine in total consisting of three large single cartilages and three paired cartilages. The three large single cartilages are the epiglottis, the thyroid, and the cricoid. The three paired cartilages are the smaller arytenoids, cuneiforms, and the corniculates. The cricoid cartilage is the only circumferential cartilage of the trachea, and is an important landmark used during tracheostomy.
• The trachea is a tubular structure which extends from the larynx through the neck to the thorax, where it terminates at the carina, dividing into the right and left main stem bronchi. The trachea ends by dividing into the right and left main stem bronchi which extend to the lungs.

Question 20

What is a Tracheostomy?

Answer 20

• A tracheostomy is a surgically created airway, or stoma, in the neck that bypasses upper airway structures.
• The stoma allows a tracheostomy tube to be introduced into the trachea.
• The tracheostomy tube maintains the patency of the stoma and serves as a device to connect equipment such as ventilators and resuscitation bags.
• It allows inspiration and exhalation to occur from the tracheostomy tube to the trachea, bypassing the upper airway.

Question 21

How is tracheostomies performed?

Answer 21

• tracheostomies are performed in the operating room under general anesthesia.
• The incision in the skin is made between the thyroid isthmus and the sternal notch, the fascia is dissected, and a vertical incision is made in the trachea.
• The tracheal incision is made at the level of the second to fifth tracheal rings and requires incision through one to three tracheal rings (Figure 2).
• Sutures are often placed through the tracheal wall on either side of the tracheal incision which are used to help identify the incision in the event of a problem requiring reinsertion of the tube before healing of the tract.
• The tracheostomy tube is inserted in the opening under direct visualization and sutures and/or a tracheostomy tie is used to secure the tube in place.

Question 22

When would a cuffed tracheotomy tube be needed ?

Answer 22

for an infant requiring higher ventilatory pressures for chronic lung disease, or who may have a large leak but are too small for the next size up in tracheostomy tubes.

Question 23

What are three main components of tracheostomies:

Answer 23

• Tracheotomy tube - maintains patency of stoma
• Flanges - used to secure tracheotomy ties
• Obturator - guides tracheotomy tube into position and helps to reduce trauma to the trachea

Question 24

What 5 major functions of the upper airway does a tracheostomy bypasses:

Answer 24

• Humidification and warming of inspired air to body temperature
• Filtering dust particles
• Speech
• Conduction and passage of air from the upper airway to the lower airway
• Mucous is produced from tissues and cilia that line the upper and lower airway

Question 25

Does a presence of a tracheostomy decreases the stimulation of smell across the sensory neurons of the upper airway?

Answer 25

yes

Question 26

What are some nursing care following a tracheostomy during the first 24-72 horus?

Answer 26

• Check for bleeding and swelling around site
• Prepare to suction trach q15-30 min first few hours
• Routine suction q1-2 first 24 hrs then q 2-3 as tolerated
• Use measurements for suctioning supplied by RT
• Deep suctioning is not necessary
• Monitor for bleeding or swelling of chest
• As the patient will most likely be kept paralyzed for the first 5-7 days, it is important to change the patients position at least Q4H, so that pressure marks do not occur around the new tracheotomy site, and stoma.
• Ensure that the ventilator circuit in not putting undo pressure on the stoma.

Question 27

What are 2 potential complications that occur during the first 24-72 hours of post tracheostomy?

Answer 27

• Pneumothorax
  Ensure chest x-ray done immediately post-op
  Observe for signs and symptoms of pneumothorax
• Accidental Extubation
  Restrain hands prn during this immediate post op care
  Give sedation/analgesics as ordered
  Ensure tracheotomy ties are secure

Question 28

What are 2 common complications (that can result in death) of tracheotomy tube-dependent children?

Answer 28

• Plugging of the tube with mucus
• Accidental decannulation

Question 29

What is plugging the tube?

Answer 29

• Plugging of the tracheotomy tube with mucus occurs when thick, viscous mucus obstructs the lumen of the tracheotomy tube.
• Several factors may lead to this complication including: dehydration, infection, and lack of humidity (many children with BPD may have excess mucous).
• To avoid these problems, we can provide these infants with adequate hydration and humidification, chest physiotherapy, and frequents suctioning.
• If suctioning does not clear the secretions, the tube may need to be changed immediately to ensure a patent airway.

Question 30

When does accidental decannulation occur?

Answer 30

Another serious complication is accidental dislodgement of the tracheotomy tube.
- This may occur during play or during tracheotomy care (changing tracheotomy ties, for instance).
- Immediate reinsertion is required to maintain a patent airway.
- A child with a tracheotomy tube should never be left unattended.

**is for this reason, that you must ensure you have a spare tracheotomy tube, ( a tracheotomy tube of the correct size plus one that is one size smaller), and an obturator, and securing devices at the bedside at all times.

Question 31

What should be done if accidental decannulation happens?

Answer 31

• Call for help - The Physician/Respiratory Therapist needs to insert new tracheotomy tube
• Hyperextend neck by placing roll under shoulders
• Using purse string sutures, attached to either side of tracheotomy incision and apply lateral traction
• If not able to do above - place a pair of closed mosquito clamps into opening and open clamps
• Provide extra oxygen-direct flow to stoma
• Have a new tracheostomy tube inserted by a Physician or Respiratory Therapist.