Tracheostomy care (Adult)

Tracheostomy Care of adults
For BNS student

1. 7/24/2022 1

2. UNIT-1(1.1) RESPIRATORY SYSTEM TracheoStomy care PREPARED BY: Arpana B husal BNS 2

3. Content layout Definition Purpose Indication Contraindication Equipments for tracheostomy insertion. Goals of tracheostomy care. Equipments for tracheostomy care. 7/24/2022 3

4. Content Layout Components and Types of tracheostomy tube Care of patient with tracheostomy Daily care of patient with tracheostomy. Nursing management Complication. Preventing complication associated with tracheostomy tube 7/24/2022 4

5. DEFINITION Trachea = windpipe Ostomy = surgical opening in the body Tracheostomy is a surgical procedure which consist of making an artificial opening on the anterior aspect of neck and opening a direct airway through an incision in the trachea(2-3/3-4 tracheal rings). 7/24/2022 5

6. DEFINITION (1/4) A tracheostomy is a surgical opening into the trachea below the larynx through which an indwelling tube is placed to overcome upper airway obstruction, facilitate mechanical ventilatory support and/ or the removal of tracheobronchial secretions. 7/24/2022 6

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9. PURPOSE To maintain the airways to facilitate the therapeutic exchanges of gases. To remove trachea bronchial secretion. To maintain optimum physical comfort. To decrease airway resistance. 7/24/2022 9

10. PURPOSE To provide a method of mechanical ventilation. To improve respiratory insufficiency. To prevent from aspiration and transmission of pathogenic micro-organisms. 7/24/2022 10

11. INDICATION 1. Airway obstruction Hemorrhage after thyroid surgery or upper airway bleeding. Foreign bodies impacted in larynx. Trauma to larynx or pharynx. Acute edema of epiglottis e.g. diphtheria, Facial burns 7/24/2022 11

12. indication 2. Congenital cause Laryngeal weakness stenosis Inflammatory disease conditions Tracheal laryngeal fracture Need for continuous mechanical ventilation Tumor in the respiratory airway 7/24/2022 13

13. indication 3. Retained secretions in tracheo-bronchial tree Unconscious patient following head injury and poisoning. Chest injury patient who is unable to cough. Paralysis of the muscles of respiration. Tetanus For radical surgery in the neck e.g. laryngectomy. 7/24/2022 14

14. INDICATION 4. Others To protect / minimize risk of aspiration in the patients with poor or absent cough reflex Neurologic conditions (Amyotrophic lateral sclerosis) Severe sleep apnea Laryngeal hypoplasia 7/24/2022 15

15. CONTRAINDICATION No absolute contraindications exist to tracheostomy. Relative contraindication is Laryngeal CA. Tracheo-esophageal fistula. Cancer in upper GI or respiratory tract 7/24/2022 16

16. EQUIPMENTS FOR TRACHEOSTOMY INSERTION Tracheostomy tube (size 6-9 mm for most adults) Sterile instruments: blade, forceps, suture material, scissors Sterile gown and gloves Cap and face shield Antiseptic preparation solution Gauze pads 7/24/2022 17

17. EQUIPMENTS FOR TRACHEOSTOMY INSERTION Shave preparation kit Sedation Local anesthetic and syringe Resuscitation bag and mask with oxygen source Suction source and catheters Syringe for cuff inflation Respiratory support available for post tracheostomy (mechanical ventilation, tracheal oxygen mask, CPAP ) 7/24/2022 18

18. TRACHEOSTOMY CARE GOALS To maintain airway patency by removing mucous and encrusted secretions. To maintain cleanliness and prevent infections to the tracheostomy site. To facilitate healing and maintain skin intergrity . To promote comfort and prevent displacement. 7/24/2022 19

19. EQUIPMENTS FOR TRACHEOSTOMY CARE Sterile disposable tracheostomy cleaning kit or supplies ( sterile containers, sterile nylon brush or pipe cleaner) Sterile applicators ( gauze squares) Sterile suction kit and Sterile normal saline Sterile gloves and clean gloves 7/24/2022 20

20. EQUIPMENTS Towel to drape to protect bed linens Sterile gauze dressing, cotton twill ties and clean scissors Moisture proof bag 7/24/2022 21

21. D isposable tracheostomy cleaning kit

22. BED SIDE EQUIPMENTS Spare tracheostomy tubes same size and type as the patient is wearing Tracheal dilator Suctioning equipment Oxygen equipment with humidification Gloves (non sterile) Gloves (sterile) for suctioning Infectious waste bag 7/24/2022 23

23. Tracheal dilator

24. Tracheostomy tube Tracheostomy tube is a curved tube that is inserted into the tracheostomy stoma made of plastic rubber or metal. Tracheostomy tubes have an outer cannula that is inserted into the trachea and a flange that rests against the neck and allows the tube to be secured in place with tape or ties. 7/24/2022 25

25. TRACHEOSTOMY TUBE Tracheostomy tubes also have an obturator which is used to insert the outer cannula which is then removed afterwards. The obturator is kept at the client's bedside in case the tube becomes dislodge and needs to be reinserted. 7/24/2022 26

26. COMPONENTS OF TRACHEOSTOMY TUBE Outer cannula Inner cannula: fits snugly into outer tube, can be easily removed for cleaning Flange: Flat plastic plate attached to outer tube –lies flush against the patient’s neck 15mm outer diameter termination: Fits all ventilator and respiratory equipment. 7/24/2022 27

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28. PARTS OF TRACHEOSTOMY TUBE 7/24/2022 29

29. TYPES OF Tracheostomy TUBE Metal Tube 2.Plastic tube 7/24/2022 30

30. TYPES OF TRACHEOSTOMY TUBE 3 . Cuffed and uncuffed 4. Fenestration 7/24/2022 31

31. TYPES OF TRACHEOSTOMY TUBE 5. Single and double lumen 7/24/2022 32

32. CARE OF PATIENT WITH TRACHEOSTOMY PREPARATIVE PHASE Assess the condition of the patient . Bathing or scrubbing the local skin area with antiseptic procedures. Keep the patient in NPO. Promote rest and sleep Collect informed consent, report of diagnostic test . 7/24/2022 33

33. CARE OF PATIENT WITH TRACHEOSTOMY Provide the preoperative medications. Instruct patient to remove jewellery , dentures, contact lenses Perform mouth care Place the identification band. 7/24/2022 34

34. CARE OF PATIENT WITH TRACHEOSTOMY 2 . PERFORMANCE PHASE Explain the procedure to the patient. Discuss a communication system with the patient Obtain consent for operative procedure Shave a neck region Assemble equipments. Using aseptic technique. 7/24/2022 35

35. CARE OF PATIENT WITH TRACHEOSTOMY Position the patient (in a supine position with head extended and a support under the shoulders) Obtain an order for and apply soft wrist restraints if the patient is confused. Give medication if ordered Position the light source 7/24/2022 36

36. CARE OF PATIENT WITH TRACHEOSTOMY Assist with antiseptic preparation Assist with gowning and gloving Assist with sterile draping Put on face shield 7/24/2022 37

37. During procedure, monitor the patient’s vital signs, suction as necessary , give medication as prescribed, and be prepared to administer emergency care. Immediately after the tube is inserted , inflate the cuff. The chest should be ausculted for the presence of bilateral breath sounds. 7/24/2022 38 CARE OF PATIENT WITH TRACHEOSTOMY

38. CARE OF PATIENT WITH TRACHEOSTOMY Secure the tracheostomy tube with tapes or other securing device and apply dressing Apply appropriate respiratory assistive device(mechanical ventilation. Tracheostomy, oxygen mask, CPAP) Check the tracheostomy tube cuff pressure 7/24/2022 39

39. 3. Follow up phase/ Post-operative phase Check the symmetry of chest expansion. Auscultate the breathe sound of anterior and the lateral chest bilaterally . Obtain order for chest x-ray to verify proper tube placement. Check cuff pressure every 8-12 hrs 7/24/2022 40 CARE OF PATIENT WITH TRACHEOS TOMY

40. CARE OF PATIENT WITH TRACHEOS TOMY Monitor the sign and symptoms of aspiration Assess vitals signs and breath sounds; note tube size used, physician performing procedure, type, dose, and route of medications given. Assess and chart condition of stoma: bleeding, swelling, subcutaneous air 7/24/2022 41

41. CARE OF PATIENT WITH TRACHEOSTOMY Administer oxygen concentration as prescribed by physician Secure the tube to the patient face with the tape, and mark the proximal end for position maintenance. 7/24/2022 42

42. Use the sterile suction technique and airway care to prevent iatrogenic contamination and infection. Continue to reposition patient every 2 hours and as needed to prevent atelectasis and to optimize lung expansion. Provide oral hygiene and suction the oropharynx whenever required. 7/24/2022 43 CARE OF PATIENT WITH TRACHEOSTOMY

43. CARE OF PATIENT WITH TRACHEOSTOMY Maintain patency of tracheostomy tube and airway Frequent atraumatic suction. Humidification of inspired air and oxygen Fowler’s position to aid in breathing Maintain adequate fluid intake 7/24/2022 44

44. CARE OF PATIENT WITH TRACHEOSTOMY Provide frequent mouth wash Mucolytic agents Coughing and physiotherapy 7/24/2022 45

45. CARE OF PATIENT WITH TRACHEOSTOMY Prevent infection and complication: Aseptic tube suction, handling and tube changing Prophylactic antibiotics An extra tube, obturator, and tracheostomy kit should be kept at the bedside. In the event of tube dislodgement, reinsertion of a new tube mat be necessary . 7/24/2022 46

46. DAILY CARE OF PATIENT WITH TRACHEOSTOMY 1. Assessment An increased monitoring of the patient’s blood pressure, respiratory rate, pulse and color is necessary An increased in the respiratory rate, wheezes ,an increased pulse rate may indicate the need for suction 7/24/2022 47

47. DAILY CARE OF PATIENT WITH TRACHEOSTOMY Cyanosis and distress not relieved by suctioning should be reported promptly Increasing restlessness with a rapid pulse rate may indicate hypoxia or bleeding Observe the wound for bleeding and then check daily for signs of infection 7/24/2022 48

48. DAILY CARE OF PATIENT WITH TRACHEOSTOMY 2. Maintain an open airway : Assess the patient regularly for excess secretions and suction and clean the tube as indicated. The trachea is suctioned using a sterile glove and a sterile suction catheter moisture in sterile water or normal saline with aseptic technique . 7/24/2022 49

49. DAILY CARE OF PATIENT WITH TRACHEOSTOMY Frequent repositioning of the patient 3 . Suctioning 7/24/2022 50

50. DAILY CARE OF PATIENT WITH TRACHEOSTOMY Suctioning raises the risk of hypoxemia, bronchospasm , and other adverse reactions, so suction only when needed, not on a set schedule, and suction for the shortest time necessary to clear secretions. Suctioning can be an uncomfortable and scary experience for the patient, so thoroughly explain the procedure to him before start . 7/24/2022 51

51. Indications for suctioning include coughing, secretions in the airway, respiratory distress, presence of rhonchi on auscultation, increased peak airway pressures on the ventilator, and decreasing SaO 2  or PaO 2 . Comfortable position of the patient.  Maintain aseptic technique . 7/24/2022 52 DAILY CARE OF PATIENT WITH TRACHEOSTOMY

52. DAILY CARE OF PATIENT WITH TRACHEOSTOMY 4. Cleaning of the tracheostomy tube and wound care: Tracheostomy care includes cleaning or changing the inner cannula, changing the dressing and tracheostomy tube holder, and suctioning if needed. Never clean and reuse a disposable cannula. 7/24/2022 53

53. DAILY CARE OF PATIENT WITH TRACHEOSTOMY Unlock and remove the inner cannula and place it in a solution of equal parts hydrogen peroxide and 0.9% sodium chloride unless the manufacturer directs otherwise. The inner cannula of the tracheostomy tube is carefully removed, cleansed every 3-5 hours or as often as necessary(perhaps even hourly) 7/24/2022 54

54. Remove encrusted secretions from the lumen with sterile pipe cleaners. After cleaning, rinse the cannula thoroughly with sterile 0.9% sodium chloride solution. 7/24/2022 55 DAILY CARE OF PATIENT WITH TRACHEOSTOMY

55. DAILY CARE OF PATIENT WITH TRACHEOSTOMY Reinsert the inner cannula and securely lock it into place. Stoma should be cleaned everyday carefully without dislodging tube. 7/24/2022 56

56. DAILY CARE OF PATIENT WITH TRACHEOSTOMY 5 . Humidification : Maintaining humidification is another key nursing responsibility. Provide constant airway humidification to avoid thickening and crusting of bronchial secretion . 7/24/2022 57

57. DAILY CARE OF PATIENT WITH TRACHEOSTOMY Ensure humidification of inspired air placing a piece of moist gauze over the tracheostomy tube so that the air takes up the moisture. Humidifier is useful. In addition, patient must be properly hydrated; for example, with I.V. fluids. 7/24/2022 58

58. DAILY CARE OF PATIENT WITH TRACHEOSTOMY 6. Mouth care : Provide frequent mouth care in every 2 hours for the patient’s comfort and to reduces the possibility of infection. 7/24/2022 59

59. DAILY CARE OF PATIENT WITH TRACHEOSTOMY 7 .Nutrition : If the patient eats by mouth, it is recommended that the tracheostomy tube be suctioned prior to eating. This often prevents the need for suctioning during or after meals, which may stimulate excessive coughing and could result in vomiting 7/24/2022 60

60. DAILY CARE OF PATIENT WITH TRACHEOSTOMY Encouraging fluid intake is helpful for a patient with a tracheostomy. Increased fluid intake will thin and loosen secretions making coughing and suctioning easier. Always observe the patient while eating to be sure food does not get into the trachea. 7/24/2022 61

61. DAILY CARE OF PATIENT WITH TRACHEOSTOMY 8. Communication 9 . Documentation Document the patient's response each time you suction, including his vital signs, cardiac rhythm, oxygen saturation, amount and consistency of secretions, breath sounds, and the frequency of needed suctioning 7/24/2022 62

62. NURSING MANAGEMENT 7/24/2022 63

63. NURSING ASSESSMENT Frequent monitoring of the patients blood pressure , respiratory rate, pulse and color is necessary. An increased in the respiratory rate , wheezes, an increased pulse rate may indicate the need for suction. Cyanosis and distress not relieved by suction should be reported promptly. 7/24/2022 64

64. NURSING ASSESSMENT Increasing restlessness with a rapid pulse rate may indicate hypoxia or bleeding. Observe the wound for bleeding in the immediate post-operative period and then check daily for signs of infection and sloughing. Assess patient ability to understand the spoken word. 7/24/2022 65

65. NURSING ASSESSMENT Assess patients ability to expression. Assess and observe swallowing reflexes , gag reflexes. Assess mental status confusion , lethargy , restlessness. Assess amount, color, consistency of secretion. 7/24/2022 66

66. NURSING DIAGNOSIS Ineffective airway clearance related to presence of artificial airway (tracheostomy) as evidenced by tachypnea and changes in breathing pattern. Impaired verbal communication related to presence of artificial airway as evidenced by difficulty in maintaining the usual communication pattern. 7/24/2022 67

67. Nursing diagnosis Anxiety related to threat to self concept as evidenced by expressed feeling of distress over the presence of tracheostomy. Knowledge deficit related to new procedure or intervention in hospital as evidenced by increased questioning. 7/24/2022 68

68. Nursing diagnosis Risk for infection related to surgical incision of tracheostomy. Risk of aspiration related to presence of tracheostomy. 7/24/2022 69

69. GOALS AND OUTCOME Patient will maintain a clear ,open airways and ability to effectively cough up secretion. Patient will use a form of communication to get needs met and to relate effectively with persons and environment. Patient will verbalize their own feeling. 7/24/2022 70

70. GOALS AND OUTCOME Patient or caregiver will demonstrate the knowledge and skills appropriate for tracheostomy care. Patient will remain free of infection. Patient will swallow meals without coughing, choking or changing color. 7/24/2022 71

71. NURSING INTERVENTION 1 . Maintaining airway clearance Assess changes in BP, Heart rate and temperature. Auscultate the lungs , presence of breathe sounds. Observe the color , consistency , and quantity of secretion Provide warm humidified air 7/24/2022 72

72. Nursing intervention Administer O2 as needed. Encourage patient to cough out secretion. Keep suction equipment and AMBU bag at bed side. Keep the patient in semi fowlers position. 7/24/2022 73

73. Nursing intervention 2 . Promoting verbal communication Assess the clients communication ability. Assess the effectiveness of non verbal communication methods. Place the patient in a room close to the nurses station. Provide a call light within easy reach at all times. 7/24/2022 74

74. Nursing intervention Provide alternative methods for communicating. Hand gestures Word and phrase cards Picture board Writing pad Pencil or pen 7/24/2022 75

75. Nursing intervention 3 . Reducing anxiety Assess the level and manifestation of anxiety in patients. Allow patient to express fears and concerns to ask, inquiries about disease and procedure. Inform of all procedure and care to the patient as well as visitors. Provide psychological support. 7/24/2022 76

76. Nursing intervention 7/24/2022 77 4. Enhancing knowledge Assess the patients knowledge regarding the purpose and care of tracheostomy. Provide instruction in sterile tracheostomy care and suctioning. Instruct in the need to call health care provider if the amount of secretion increases or change in color and characteristics occurs.

77. NURSING INTERVENTION 5. Preventing infection Assess patients vital sign. Assess skin integrity under tracheal ties. Monitor white blood cell count. Observe the stoma for color, crusting lesions 7/24/2022 78

78. NURSING INTERVENTION Provide stoma care. Do not allow secretions to pool around the stoma , suction the area , wipe with aseptic technique. 7/24/2022 79

79. NURSING INTERVENTION 6. Preventing aspiration Assess the ability to swallow and type of food consistency. Encourage liquid initially in small amounts and gradually increase as tolerated. Maintain in an upright sitting position during feeding. Suction fluids from mouth and airway. 7/24/2022 80

80. COMPLICATIONS Immediate (at the time of operation): hemorrhage , air embolism, cardiac arrest apnea, aspiration, pneumothorax, injury to laryngeal nerves and esophagus, local damage (thyroid cartilage, cricoid cartilage, recurrent laryngeal nerve). 7/24/2022 81

81. complications 2. Intermediate(during first few hours or days) bleeding, displacement of tube, blocking of tube, subcutaneous emphysema, pneumothorax, scabs, tracheal necrosis, tracheitis, local wound infection and dysphagia 7/24/2022 82

82. COMPLICATIONS 3 . Late (with prolonged use of tube for weeks and months ): laryngeal stenosis, tracheal stenosis, tracheo - esophageal fistula. 7/24/2022 83

83. Preventing complications WITH TUBE Administer adequate warmed humidity: steam inhalation, nebulization, keeping wet gauze piece over the tracheostomy site and changing it as per need. Maintain cuff around tube Suction as needed per assessment findings Maintain skin integrity. Change tape and dressing as needed or per protocol 7/24/2022 84

84. Preventing complication WITH TUBE Ascultate lungs sounds Monitor for signs and symptoms of infection, including temperature and white blood cell count Protein rich diet should be provided for early healing of incision site. Administer prescribed oxygen and monitor oxygen saturation 7/24/2022 85

85. PREVENTING COMPLICATION WITH TUBE Monitor for cyanosis Maintain adequate hydration of the patient Use sterile technique when suctioning and performing tracheostomy care Emergency drugs should be ready 7/24/2022 86

86. REFRENCES Smeltzer.S.G. Bare.B.G. Hinkle.J.G. Cheezer K.H.(2010) “Brunner & Suddarth’s textbook of Medical- Surgical Nursing", Volume 1. (12 th edition). New Delhi, Kluwer India. Pvt. Ltd. 2078/04/10 at 1 pm Mandal G.N (2016) “A Textbook Of Medical Surgical Nursing”. 5 th edition. Kathmandu. Makalu Publication House.2078/04/11at 3 pm. 7/24/2022 88

87. REFRENCES 2019. Mayo Foundation Of Medical Foundation And Research. Tracheostomy care https://www.mayoclinic.org@2021/08/02 at 3pm. Nov4,2019,tracheostomy care https://www.slideshare.net/gamandeep@2021/08/03 at 5pm 7/24/2022 89

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