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MED SURGE WINTER CLINICAL > w5 tracheostomy > Flashcards

w5 tracheostomy Flashcards

1
Q

what is a complete airway obstruction?

A

a medical emergency!! pt is not breathing

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2
Q

what is a partial airway obstruction?

A

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
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3
Q

what are S/S of partial airway obstruction?

A
  • stridor
  • use of accessory muscle
  • suprasternal and intercostal retractions
  • wheezing
  • restlenes
  • tachycardia
  • cyanosis
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4
Q

what are methods to re-establish a patent airway?

A

obstructed airway (Heimlich) manoeuvre

  • cricothyroidotomy
  • endotracheal intubation
  • tracheostomy
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5
Q

what is a tracheostomy?

A

a surgical incision into the trachea for the purpose of establishing an airway

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6
Q

when would we use a tracheostomy?

A

-used for pt requiring intubation longer than 7-10 days or when an airway is obstructed due to trauma, tumours, or dwelling

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7
Q

what are the indications for tracheostomy?

A
  1. bypass an upper airway obstruction
  2. facilitate removal of secretions
  3. permit long-term mechanical ventilation
  4. permit oral intake and speech in pt who require long-term mechanical ventilation
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8
Q

what are the benefits of tracheostomy?

A

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)
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9
Q

what are the complications of tracheotomies?

A
  • abnormal bleeding
  • tube dislodgement
  • obstructed tube
  • subcutaneous emphysema
  • trachesophageal fistula
  • tracheal stenosis
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10
Q

cause of bleeding tracheostomy

A

surgical intervention

  • erosion or rupture of blood vessel or both
  • nurse must monitor bleeding and notify physical if continues or excessive
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11
Q

cause of tube dislodgement

A

excessive manipulation or suctioning

-nurse must ensure ties are secure and keep obturator, hemostat, and new tracheotomy tube at bedside

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12
Q

cause of an obstructed tube?

A

dried or excessive secretions

  • nurse should assess pts respiratory status
  • suction if necessary
  • maintain humidification
  • perform trach care
  • ensure adequate hydration
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13
Q

what causes subcutaneous emphysema

A
  • air escapes from the incision to the subcutaneous tissue
  • mointor subcut emphysema
  • reassure pt and family
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14
Q

causes of tracheoesophageal fistula

A
  • tracheal wall necrosis, leading to fistula formation
  • monitor cuff pressure
  • monitor pt for coughing and choking while eating or drinking
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15
Q

causes of tracheal stenosis

A
  • 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
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16
Q

what should always be readily available by the bedside?

A

a spare tracheostomy set, obturator and tracheal dilator

-preferably taped at the head of the bed

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17
Q

how long should u suction for at a time?

A

-10 seconds

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18
Q

how often should the nurse assess the need for suctioning

A

q2h

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19
Q

what should the suction pressure be set as?

A

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

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20
Q

after a tracheostomy procedure how long should the ties not be changed for?

A

for the first 72hours!!

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21
Q

tracheostomy with inflated cuff

A

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

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22
Q

what is minimal leak technique (MLT)?

A

involves inflating the cuff w/ the minimum amount of air to obtain a seal and then w/drawing 0.1 mL of air

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23
Q

what are the disadvantages of MLT (minimal leak technique)

A

risk for aspiration from secretions leaking around the cuff and difficulty maintaining positive end-expiratory pressure

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24
Q

what should the pt do before cuff deflation?

A

-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

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25
Q

care of a new tracheostomy tube

A
  1. a replacement tube of equal or smaller size should be kept at the bedside (readily available for emergency reinsertion)
  2. trach tapes are not to be changed for at least 24-72 hours after the insertion procedure
  3. the first tube change is performed by a physician, usually no sooner than 7 days after the trach
26
Q

after the first tube change how often should the tube be changed approximately?

A

once a month

27
Q

patients who cannot protect the airway from aspiration require what kind of trach?

A

an inflated cuff trach

-pt may be able to swallow w/out aspirating when the cuff is deflated but not when it is inflated

28
Q

what is a fenestrated tube?

A

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
29
Q

what are the assessments before the use of a fenestrated tube?

A
  • 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
30
Q

what is a disadvantage of fenestrated tubes?

A

-potential development of tracheal polyps from tracheal tissue granulating into the fenestrated opening

31
Q

what is decannulation?

A

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
32
Q

How develop a laryngeal polyps?

A
  • -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
33
Q

Cuffed Tube with Disposable Inner Cannula

A

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.

34
Q

Cuffed Tube with Reusable Inner Cannula

A

-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.

35
Q

Cuffless Tube with Disposable Inner Cannula

A

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

36
Q

Cuffless Tube with Reusable Inner Cannula

A

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

37
Q

Fenestrated Cuffed Tracheostomy Tube

A

-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.

38
Q

Fenestrated Cuffless Tracheostomy Tube

A
  • 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).
39
Q

Metal Tracheostomy Tube

A

-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.

40
Q

what are your assessments for trach stoma?

A

-Assess for secretions, stoma skin around trach for redness, drainage, secretions, bleeding
With newly established trach, are sutures still in place?

41
Q

how often do trach ties get changed?

A

change only when wet, soiled, safety considerations

-ensure 1-2 fingers can fit beneath ties

42
Q

how many times can u pass the same catheter during suctioning?

A

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

43
Q

suctioning can lead to_?

A
  • 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)
44
Q

what are unexpected outcomes d/t trach stoma?

A
  • 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)
45
Q

what should you document

A
  • 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
46
Q

what are s/s of upper and lower airway obstruction requiring nasotracheal or orotracheal suctioning?

A

abnormal RR

  • adventitious sounds
  • nasal secretions
  • gurgling
  • drooling
  • restlessness
  • gastric secretions
  • vomitus in the mouth
  • coughing w/out clearing secretions from the airway
47
Q

what are S/S of hypoxia and hypercapnia?

A
  • 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
48
Q

was are contraindications to nasotracheal suctioning?

A

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
49
Q

what do you use to clean the stoma?

A

normal saline

hydrogen peroxide- this is an old practice we don’t use anymore (but is stated in potter & Perry)

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53
Q

how small should the inner cannula be?

A

should be 1cm smaller than the trach

54
Q

how long do we cork for?

A

2-4 hours, titrate it
until they have 24 hours tolerance of cork
-if pt has SOB, stop this process

55
Q

how long do we cork for?

A

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

56
Q

why do we not suction while inserting the catheter?

A

Increase risk for hypoxia** - don’t want to take away their oxygen at this time

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MED SURGE WINTER CLINICAL (8 decks)

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