a nurse is caring for an adult patient who is npo
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1 00:00:10,000 –> 00:00:23,600 Clinical Pearls: Tracheostomy Care for the Acute Care Nurse, by Janelle Nobrega. Hello, my name is Janelle Nobrega, I am a Clinical Nurse Specialist at Boston Childrens Hospital. This presentation is designed to give a broad overview of the care considerations for a patient with a tracheostomy. I will review safety checks, suctioning, humidification, site care, and emergency response. Safety Checks. All supplies that may be needed to change a tracheostomy tube should be readily available at the bedside or within reach. Your bedside safety checks should include a pulse oximetry monitor, a cardiac monitor if clinically indicated for your patient, a spare tracheostomy tube the same size currently in place, a spare tracheostomy tube one size smaller than currently in place, water-soluble lubricant and a syringe for cuffed tubes, humidification, oxygen setup if clinically indicated, suction equipment and supplies, bandage scissors, and a self-inflating ambu bag with a pop-off valve. 24 00:01:30,980 –> 00:01:34,750 An easy way to remember these items is the acronym MASHTT. M stands for monitor: cardiac and pulse oximeter. A stands for ambu bag with pop-off. S stands for suction. H stands for humidity. And the two Ts at the end stand for your spare trach the same size and your spare trach one size smaller. Suctioning. Suctioning a tracheostomy should be done at a minimum of every 8 hours, and as needed when clinically indicated by clinical assessment to ensure patency of the artificial airway. Depth of suction is determined
by adding the shaft length of the tracheostomy tube to the adapter/flextend length, and then adding one centimeter so that you can suction just below the end of the tracheostomy tube. Apply suction while withdrawing the catheter for no more than five to ten seconds per pass. Instillation of saline is not routine practice and should only be utilized for thick secretions. Here at Boston Childrens Hospital, we use clean technique for suctioning a tracheostomy in the inpatient areas, and sterile technique for suctioning a tracheostomy in the intensive care units. This is because patients with a fresh tracheostomy are at greater risk of infection than patients with mature stomas. Your institution may have different guidelines. Humidification. Our institutional policy at Boston Childrens requires that all patients with a tracheostomy tube have either an active or a passive humidification device. All patients use an active humidification device while sleeping. Do not use a passive device when the patient is unattended or unable to remove the device him or herself. An example of an active humidification device that we use here at Boston Childrens Hospital is a large volume nebulizer. If no supplemental oxygen is required and optimal aerosol output is desired, a large volume nebulizer can be operated utilizing a wall air flow meter. Set the dial to 0.35 to 0.40 to activate the Venturi effect. An example of a passive humidification device is a heat moisture exchange or an HME device. When utilizing an HME, check periodically and assure
that it is clear of secretions. Replace the HME if secretions are visualized. After applying an HME, assess for changes in respiratory status, including work of breathing and tachypnea. Consider decreasing the use of an HME or changing to an active humidification device if there is an increase in the viscosity of airway secretions. If supplemental oxygen is required you may utilize a large volume nebulizer or an HME. When utilizing a large volume nebulizer ensure use of an oxygen flow meter and adjust the FDO2 dial accordingly to maintain acceptable oxygen saturations for your patient per prescriber order. Note that if a FDO2 of greater than 50% is required, consult respiratory therapy to ensure proper oxygen delivery setup. If supplemental oxygen is required with an HME you must utilize an HME with an oxygen adapter. Connect the side port via oxygen tubing to a wall oxygen flow meter. Adjust the flow accordingly to the patients oxygen requirement per prescriber orders. Consult your institutions HME device manual to review the appropriate adjustment range of oxygen flow through an HME as this may vary according to the manufacturer of the device. 104 00:05:00,830 –> 00:05:03,700 Site Care. Tracheostomy site care should be performed daily at a minimum, and tracheostomy ties should be changed daily to allow for assessment of the tracheostomy stoma and the peristomal skin as well as the surrounding skin of the neck. Tracheostomy site care can be performed with sterile saline. Consider quarter strength hydrogen peroxide for sites
with drainage and consult your institutional experts for assessment as needed. Neck care can be performed with mild soap and water. Removing tracheostomy ties is always a two person procedure. This procedure can be performed by any combination of nurses, respiratory therapists, or caregivers. 119 00:05:43,210 –> 00:05:48,640 Ensure that only one small finger thickness can be inserted between the neck and the tracheostomy ties in the sitting or side lying position. The inner cannula of a double lumen tracheostomy tube is cleaned or replaced at least once a day and as needed. A nurse, respiratory therapist, or caregiver can change the inner cannula. Note that the first tracheostomy change is often done by the surgeon, a physician assistant, or a nurse practitioner. Routine tracheostomy change frequency is determined by the patients surgeon. That procedure will not be demonstrated in this video. Emergency Response. In the event of an unplanned decannulation, a tracheostomy obstruction, or if the patient is in any distress, call for help immediately and activate the emergency response per your institutional policy. Attempt to replace the tracheostomy tube one time if you are comfortable. Direct responders to your safety supplies, including the spare tracheostomy tubes present at the bedside. If the patient has a critical airway you may need to page advanced providers for assistance. Thank you very much for watching this video on care considerations for a patient with a tracheostomy. Please help us improve the content by providing us with some feedback. 149 00:07:00,720 –> 00:07:10,523
pediatrics, nursing, tracheostomy, trach, otolaryngology, respiratory, pulmonology, critical care, acute care, airway management, otohinolaryngology
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