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Fundamentals of Primary Health Care B Tracheostomy Suctioning Chest Tube Feb. 28, 2009 2nd Semester A.Y. 2008-2009 TRACHEOSTOMY TRACHEOSTOMY – A surgical incision in the trachea just below the larynx . - maybe done under emergency conditions , but it is ideally performed in the operating room / to establish an airway - the universal or standard of a tracheostomy tube consist of an outer cannula , an inner cannula and an obturator . - other types of tracheostomy includes the following : fenestrated / non fenestrated/ talking tracheostomy / permanent a. Obturator – is inserted into the tube to guide the outer cannula during initial placement . It is kept at the bedside in case the outer cannula or a new one needs to be reinserted . ( obturator / kelly @ bedside for emergency) b. Outer cannula – is the “main shaft” that is inserted into the trachea . It has a flange ( neck plate ) at the external opening of the tracheostomy stoma . Tape or cloth is tied through the flange and around the client’s neck to hold the outer cannula in place c. Inner cannula – fits into the outer cannula; the inner cannula is removed for cleaning , while the outer cannula remains in place . UNCUFFED TUBE – maybe plastic or metal which allows air to flow around the tube / person with permanent tracheostomy may use an uncuffed tube . CUFFED TUBE – are surrounded by inflatable cuff that produces an airtight seal between the tube and trachea / use immediately after tracheostomy / client ventilating with mechanical ventilator Note – children do not require cuff tubes because their tracheas are resilient enough to seal the air space around the tube . Metal Trache FENESTRATED TRACHE TUBE – has holes in the outer cannula > the inner cannula is in place when the patient is on mechanical ventilator . > when the client is being WEANED (gradual discontinuation of mechanical support ) - inner cannula is removed - cuff deflated - external opening of the tube is plugged – client can now breathe around the tube and through the fenestration and also talk . When the client tires and needs to return to using the ventilator the nurse can easily do this by inserting the inner cannula (which occludes the fenestration ) , inflate the cuff unplugged the tube and attach the ventilator . INDICATIONS FOR A TRACHEOSTOMY 1.To maintain a patent airway . 2.To remove secretions especially when the client is unable to do so by coughing independently . 3.In the presence of head and neck burns or suspected laryngeal edema 4.Following surgical procedures . 5.Following irradiation procedures . INDICATIONS FOR A TRACHEOSTOMY 6. Removal of foreign body . 7. Intolerance to endotracheal tube or when endotracheal tube is in place for more than a week 8. Neurological disorders involving diaphragm , thoracic cavity , difficulty in swallowing , paralysis . 9. Apnea or unconciousness . 10. Respiratory failure . FOR DISCUSSION TODAY!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!! ADVANTAGES : 1.Improved client comfort 2.Decrease tracheal , pharyngeal , oral, nasal damage caused by long term E.T placement . 3.Use of nasoenteric tubes for nutrition may not be necessary , client can swallow effectively . 4.Oral secretions management improved 5.Adaptive devices > client able to speak GOALS OF COLLABORATIVE MANAGEMENT INCLUDE : Reestablishing and maintaining a patent airway Preventing dislodgement of the tracheostomy tube after insertion . Providing long term mechanical ventilation . Providing adequate nutrition and hydration . Helping the client to communicate . GOALS OF COLLABORATIVE MANAGEMENT INCLUDE : Preventing injury . Preventing bacterial contamination of the airway during suctioning . Preventing respiratory and cardiovascular complications from suctioning . Teaching client and family on how to take care for the tracheostomy at home if necessary . IMPORTANT NURSING DIAGNOSES (ACTUAL / POTENTIAL) ARE : Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Risk for injury – accidental extubation Risk for infection Impaired swallowing Impaired nutrition , less than body requirements Impaired verbal communication – (paper and pencil / magic slate / prepare list of needs e.g urinal , bedpan , pain medication etc. ) Constipation and other bowel dysfunction – ( valsalvas maneuver is not performed / glottis closed – vocal cords bypass ) Body image disturbance Anxiety and fear Ineffective management of therapeutic programs RISK FACTORS Tracheostomy is necessary when the airway is obstructed due to : Aspiration of foreign object or stomach contents upper airway bleeding cancer of the larynx tracheal tumors or strictures Tracheostomy is necessary when the airway is obstructed due to : enlarge thyroid oropharyngeal tumor excess mucous in airway vocal paralysis laryngeal edema epiglottitis severe obstructive sleep apnea need for continuous mechanical ventilation . SIGNS AND SYMPTOMS FOR NECESSITATING TRACHEOSTOMY Choking Loud snoring inspirations due to partial obstruction Stridor Decreased or absent phonation Ineffective cough Wet gurgling noise due to excess mucous Diminished breathe sounds Difficulty of swallowing Severe dyspnea Tachypnea Restlessness / fear / anxiety and cyanosis DIAGNOSTIC AND LABORATORY TEST 1. Fiberoptic bronchoscopy 2. Chest x – ray 3. ABG values 4. Pulse oximetry 5. Diagnostic test for specific tumors ( thyroid / laryngeal , oropharyngeal , mediastinal) THERAPEUTIC NURSING MANAGEMENT : 1. Prevention of complications from tracheostomy a. properly secure trache tube b. do not over inflate the cuff c. do not allow the tracheostomy tube to become occluded with excessive or dried secretions d. use aseptic technique when providing trache care to prevent infection e. provide adequate humidification f. Prevent complications from trache sunctioning – ( use careful suctioning technique to prevent tracheal trauma and possible infection . g. provide adequate hydration ASSESS / MONITOR : a.For signs of hemorrhage and shock following tracheostomy . b.Vital signs c.Assess for dyspnea / stridor / inspiratory effort / and signs of hypoxia d.Assess for excessive mucous in airway e.Assess for amount, thickness, quantity, color and odor of tracheal secretions ASSESS / MONITOR : f. Assess respirations for rate, rhythm and depth. g. Stoma and skin surrounding stoma for signs of inflammation or infection h. Clients ability to cooperate with trache care and suctioning . i. Assess the client’s arterial blood gases and oxygen saturation values j. Assess the movement of air through the tracheostomy tube ASSESS / MONITOR : k. Assess for tracheoesophageal fistula before feeding orally . j. Assess for constipation k. Assess oral mucosa for dryness l. Assess for anxiety, restlessness and fear m. Assess the client’s understanding of the procedure AGE RELATED CHANGES – GERONTOLOGICAL CONSIDERATIONS 1.Many elderly persons experiences less effective coughing , which can lead to an accumulation of secretions . The reduced airway clearance may result in accumulation of carbon dioxide and reduced oxygen exchange . Efforts to clear the tracheostomy are particularly important to prevent impaired gas exchange . GERONTOLOGICAL CONSIDERATIONS 2. Maintaining good hydration in the elderly is important to reduce the viscosity of secretions . Many older persons have decreased thirst and may risk for dehydration . Thick mucous compromises airway patency and increases the risk for pneumonia and atelectasis . Nursing interventions to improve hydration status are an important part of the care of the elderly client with tracheostomy . ATTENDING A PATIENT WITH TRACHEOSTOMY Procedure: 1. Identify client and introduce self. Explain procedure. 2. Wash hands. 3. Lower side rails near you. 4. Remove soild dressing from the tracheostomy site with a clamp and discard into the receptacle. Procedure: 5. Open tracheostomy set. 6. Pour hydrogen peroxide solution and sterile water in separate emesis basins. 7. Open sterile package of cotton-tipped applicator aseptically. 8. Wear clean gloves 9. Dip cotton-tipped applicator in the emesis basin of hydrogen peroxide. Cleanse neck plate, then rinse with a cotton applicator dipped in the emesis basin of saline Procedure: 10. Then, repeat procedure unto the skin underneath the neck plate. 11. Suctioning of secretions via tracheostomy tube before removing inner cannula may be done. 12. Remove inner cannula by unlocking from outer cannula. Procedure: 13. Remove inner cannula gently (counter clockwise then pull upward) 14. Immerse inner cannula in a basin of hydrogen peroxide. 15. Dry skin, then the neck plate with a dry cotton applicator 16. Use a sterile cotton applicator to clean the inner cannula with a hydrogen peroxide Procedure: 17. Place inner cannula in a basin of sterile water or saline. 18. Remove contaminated gloves. 19. Open to sterile packages of gauze pads 20. Wear sterile gloves 21. Rinse inner cannula with sterile water or saline. Dry inner cannula. Tap in sterile gauze pad to remove excess fluid. Return inner cannula clockwise CLEANING THE INNER CANNULA PLACING BACK THE INNER CANNULA Procedure: 22. Place the other sterile gauze pad around the cannula underneath the neck plate. 23. Remove gloves and wash hands Changing Tracheostomy Ties: 24. Measure the length of the tie around the neck and add 6cm to allow for tying of the knot. Procedure: 25. Insert end of the twill tape through the eye on one side of the neck plate. Pull the distal end of the tie through the cut and pull gently. 26. Insert the other end of the twill tape through the eye on the other side of the neck plate. Pull end of the tie and knot securely. Procedure: 27. Cut old tracheostomy ties and discard. 28. Insert one finger under the tracheostomy tapes to ensure fitting snugly. 29. Discard all used materials and washed hands. THERAPEUTIC NURSING INTERVENTIONS FOR ARTIFICIAL AIRWAY CARE 1. Check cuff pressure ( on some types of tubes ) 2. Assure that O2 is being delivered correctly and that it is warmed and humidified ( to prevent drying of secretions ) 3. Keep foreign objects ( apply protective dressing) 4. Suction to remove secretions . 5. Always have a suction set up and obturator / clamp at the bedside for emergency use . 6. Provide means of communications . 7. Keep call light / bell close at hand . 8. Provide frequent reassurance , explanations and anticipation of needs , to prevent anxiety . 9.Clean the inner cannula once or twice a day 10. Change the stoma dressing as often as needed 11. Deflate cuff tubes before oral feeding unless if the client is at high risk for aspiration SUCTIONING SUCTIONING OROPHARYNGEAL , NASOPHARYNGEAL, ET TUBE , TRACHEOSTOMY KEY POINTS : > Suction is performed to clear airways ; frequency is determined by the client’s condition . Suctioning irritates the mucosa and removes oxygen from the respiratory tract . Suctioning should be painless and relieve respiratory distress . It is normal for suctioning to cause coughing , sneezing , or gagging . Key Procedural Points : - Use sterile technique - Determine proper length of tube to insert - Hyperventilate or oxygenate client before suctioning - Do not apply suction while inserting the tube - Restrict suction time to 5 to 15 seconds - Encourage the client to cough and deep breathe between suctions . - Allow rest between suctions - Protect self against exposure to body fluid - Document the amount , consistency , color , and odor of sputum ; and respiratory status . SIGNS and SYMPTOMS of the NEED for SUCTIONING 1. Bubbling or rattling breath sounds . 2. Decrease breath sounds . 3. Dyspnea 4. Pallor and Cyanosis 5. Decreased O2 saturation level ( SaO2 level ) 6. Drooling , vomitus in mouth POTENTIAL COMPLICATIONS OF SUCTIONING Infection Cardiac arrythmias Hypoxia Mucosa trauma Death MODES OF SUCTIONING 1. Oropharyngeal Suctioning – is done to evacuate vomitus from patients having an altered gag reflex 2. Nasopharyngeal Suctioning – is intended to remove accumulated saliva, pulmonary secretions, blood, vomitus and other foreign material from the trachea and nasopharyngeal area that could not be removed by patient’s spontaneous cough or other less invasive procedures 3. Endotracheal Suctioning –is a component of bronchial hygiene therapy and mechanical ventilation and involves the mechanical aspiration of pulmonary secretions from a patient with an artificial airway in place. 4. Tracheostomy Suctioning PROCEDURE POINTS Use aseptic technique Hyperoxygenate the client by a resuscitation bag, increasing the oxygen flow rate, or by asking the client to take deep breaths Do not apply suction while inserting catheter Apply suction intermittently for 10 seconds; rotate catheter while withdrawing Hyperoxygenate client and encourage deep breaths Instruct client to take several deep breaths and then cough deeply to obtain sputum Lubricate the catheter with sterile water MATERIALS FOR SUCTIONING : SUCTION KIT Suction catheter – size depends on the client ( adult / pedia catheter available ) Saline solution or distilled water Sterile gloves ( clean and plastic gloves used due to unavailabity of sterile gloves ) Paper towel Suction machine ( portable or built in ) Oxygen ( tank portable or built in / identify the materials connected to the O2 apparatus ( e.g humidifier , etc ) Ambu bag / pediatric set Oropharyngeal and nasopharyngeal airways Procedure and policies varies / principle is observed THERAPEUTIC NURSING INTERVENTIONS : OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING - To remove secretions from the upper respiratory tract when the client can cough effectively , but unable to expectorate or swallow them . Assess the need for suctioning / provide privacy / promote client safety and comfort 1. Oral : semi fowlers with head turned to one side if conscious with a functional gag reflex . 2. Unconscious – side lying , facing the nurse 3. Place towel on pillow under the chin . 4. Proper suction pressure ( wall suction 110 – 150 mmHg for adults ) 5. Catheter ( tip of the nose to the earlobe ) 6. Check patency 7. Oral ( moisten catheter tip with water ) / nasal – ( lubricate the catheter tip with water soluble lubricant ) 8. Other part of the procedure follows Prevent fatigue and hypoxia ( allow resting period of 20 to 30 sec ) Prevent infection / protect against contact to body fluids Evaluate effectiveness of suctioning SPUTUM OR SPECIMEN COLLECTOR Assessment: 1. Assess respirations for rate, rhythm, and depth 2. Auscultate lung fields 3. Monitor arterial blood gases and oxygen saturation values 4. Assess for excessive secretions Assessment: 5. Monitor secretions for amount, color, consistency 6. Assess anxiety and restlessness 7. Assess for client’s understanding of the suctioning procedure. Procedure: 1. Identify client. Introduce self. Explain the procedure to the client. 2. Assess respirations and breath sounds. 3. Assemble materials needed. Open suction catheter and sterile bottle. 4. Position the client in high Fowler’s or semi-Fowler’s position. Procedure: 5. Hyperoxygenate client before suctioning. 6. Wash hands. 7. Put on gown, mask, and goggles or face shield. Wear gloves. 8. Designate one gloved hand as sterile and the other as clean Procedure: 9. Connect extension tubing to suction device using clean hand. 10.Using sterile hand, pick up the suction catheter. Grasp plastic connector end between your thumb and forefinger and coil the tip around your remaining finger. Procedure: 11. Pick up the extension tubing with your clean hand. Connect the suction catheter to the extension tubing. Do not contaminate the catheter. 12. Adjust suction control using clean hand 13. Position clean hand with the thumb over the catheter’s suction port 14. Rinse the catheter tip by dipping into the sterile solution and activate suction Procedure: 15. Observe the solution drawn into the catheter 16. Remove thumb from the suction port 17. Using clean hand, remove the oxygen delivery device and place it on a clean surface 18. Without occluding the suction control port, insert the catheter tip gently (in accordance to type of suctioning) Procedure: 19. Apply suction intermittently by occluding the suction control port with your thumb while rotating the catheter and withdrawing it. Apply suction no longer than 10 seconds 20. Repeat suctioning until all oral secretions have been cleared. Allow brief rest periods between episodes Procedure: 21. Rinse catheter with sterile water after each suctioning. 22. Administer oxygen after suctioning 23. Use separate catheter and sterile water for suctioning ET tubes, TT tubes and nasal / oral cavity. If using one catheter, suction ET or TT then nose and mouth respectively Procedure: 24.Disconnect the catheter from the extension tubing. Discard catheter and gloves in the appropriate container. 25.Wash hands. 26.Provide the client with oral hygiene if indicated or desired ATTACHING SUCTION CATHETER TO SUCTION TUBINGS NASOPHARYNGEAL SUCTIONING TRACHEOSTOMY SUCTIONING TRACHEOSTOMY MASK ENDOTRACHEAL INTUBATION The insertion of a tube into the trachea to allow air to enter the lungs. INDICATIONS FOR ET INTUBATION: a. Cardiopulmonary Arrest b. Patient in deep coma or unresponsive c. Shallow or slow respirations (less than 8 per minute) d. Progressive cyanosis INDICATIONS FOR ET INTUBATION: e. Surgical patients where body positioning or facial contours prevents the use of a mask f. To prevent loss of airway at a later time, i.e. a burn patient who inhales hot gases may be intubated initially to prevent his airway from swelling shut CONTRAINDICATIONS FOR ET INTUBATION: Obstruction of the upper airway due to foreign objects Cervical fractures The following conditions require caution before attempting to intubate: Esophageal disease CONTRAINDICATIONS FOR ET INTUBATION: Ingestion of corrosive substances Mandibular fractures Laryngeal edema Thermal or chemical burns PROCEDURAL POINT FOR ALL SUCTIONING 1.Use sterile technique 2.Determine the proper length of tube to insert . 3.Hyperventilate or oxygenate the client before suctioning . 4.Do not apply suction while inserting the tube . 5.Apply suction while rotating and withdrawing the catheter . PROCEDURAL POINTS FOR ALL SUCTIONING 6. Restrict suction time to 5 to 15 seconds to minimize oxygen lost . 7. Encourage client to cough and deep breathe between suctions . 8. Hyperventilate or oxygenate between suctions . 9. Let client rest between suctions . 10. Evaluate respiratory status before and after suctioning . 11. Protect against exposure to body fluids . CHEST TUBES CHEST TUBE ( WATER SEAL BOTTLE ) – Chest tubes are usually inserted through an intercostal space into the pleural cavity . Indications : 1.Following chest surgery 2.Trauma 3.Pneumothorax – collection of air or other gas in the pleural space that causes the lung to collapse . 4.Hemothorax – accumulation of blood and fluid in the pleural cavity , usually a result of trauma or surgery KEY POINTS Chest tubes are inserted in the emergency department , in the operating room via a thoracotomy incision , or the client’s bedside . The chest tube may be positioned anteriorly through the second intercostal space to remove air . The second tube maybe positioned posteriorly through the 8th and 9th intercostal space to remove fluid and blood . The tubes are sutured to the chest wall , an airtight dressing is placed over the puncture wound . The tubes are then attached to drainage tubing and drainage system THERE ARE 4 TYPES OF DRAINAGE SYSTEM : - One bottle system : water and collection of drainage in same bottle . - Two bottle system : water seal and collection drainage in separate bottles - Three bottle system : water seal , collection drainage and suction control in separate bottles . - Disposable single units that work the same as the three bottle system ( pleur- evac, atrium , thora – seal ) Air and fluid move from an area of high pressure ( intra – pleural space ) during expiration to an area of low pressure ( drainage system ) . The usual water depth in a water seal system is 2 cm . Chest tube are removed when the lungs have re-expanded and / or there is no more fluid drainage . it usually takes 2 or 3 three postoperative days of chest drainage for the lung to fully expand . Opening of incision with a Kelly clamp Kelly clamp guiding insertion of the chest tube Insertion of a trocar chest tube GOALS OF COLLABORATIVE MANAGEMENT : 1.Evacuating blood and fluid from the pleural cavity . 2.Preventing contamination of the pleural space . 3.Preventing accidental elevation or overturning of drainage bottles . 4.Re – expanding the collapse lung . GOALS OF COLLABORATIVE MANAGEMENT : 5. Re – establishing a satisfactory ventilation – perfusion ratio . 6. Preventing accidental removal of chest tubes . 7. Controlling client’s discomfort and anxiety . 8. Maintaining oxygenation and tissue perfusion . IMPORTANT NURSING DIAGNOSIS ( ACTUAL AND POTENTIAL ) 1. Impaired gas exchange . 2. Ineffective breathing pattern . 3. Anxiety and fear . 4. Risk for injury . 5. Risk for infection . 6. Impaired mobility . CLINICAL OVERVIEW : Chest tubes are inserted into the intrapleural space to remove air and fluid to reestablish negative intrapleural pressure . This allows the lungs to reexpand . Chest drainage which is collected in the drainage system , will be measured and sent to the laboratory for analysis . RISK FACTORS NECESSITATING CHEST TUBES 1. Blunt , crushing or penetrating chest injuries . 2. Tension pneumothorax – ( fluid shifting from unaffected area ) 3. Hemothorax – ( air ) 4. Hemopneumothorax – ( blood and air ) 5. Thoracic surgery 6. Invasive thoracic procedure SIGNS AND SYMPTOMS NECESSITATING CHEST TUBES: 1. Air hunger 2. Agitation 3. Hypotention 4. Tachycardia - 5. Severe diaphoresis 6. Absence or diminished breath sounds on the affected area 7. Tension pneumothorax 8. Cyanosis DIAGNOSTIC LABORATORY TEST 1. History and physical examination 2. Pleural fluid analysis 3. ABG analysis 4. Chest x-ray following removal of the chest tube THERAPEUTIC NURSING MANAGEMENT 1. ASSESS / MONITOR For blockage of drainage – note for oscillation For air leaks - continuous bubbling in the water seal chamber during inspiration and expiration rather than intermittent bubbling signifies that there is an air leak in the system THERAPEUTIC NURSING MANAGEMENT To determine the source of the air leak , - check for loose catheter and also thoroughly the tubing and all the connections To stop the air leak - place sterile petroleum gauze around the insertion of a loose chest tube , or re-tape the loose tubing connections . If these measures do not work , it may be necessary to change the entire system . THERAPEUTIC NURSING MANAGEMENT Vital signs / Breathe Sounds /Chest Wall for Unusual Chest Movements O2 saturations Chest tube insertion site for redness , pain , infection , crepitus Wound for excessive drainage or signs of infection following chest tube removal Client for signs of recurrent pneumothorax n NURSING ACTIVITIES : 1. Assist physician with the insertion of chest tube and set up of drainage system / emergency procedure is performed at the bedside . 2. Keep all tubing straight and coil loosely . 3. Prevent client from lying on tubing . 4. Make certain that connections between the chest tubes , drainage tubing , and drainage collection bottles are tight . NURSING ACTIVITIES : 5. Tape connections securely to prevent air leaks . 6. Tape tops of bottles . 7. Re – tape all connections if necessary . 8. Milk and strip the chest tubes if necessary to increase amount of negative pressure to the pleural space . NURSING ACTIVITIES : 9. Take precautions that drainage bottles are never elevated to the level of the clients chest . 10. Do not empty drainage bottles unless overflowing . 11. Never clamp chest tubes without a doctors order unless during emergency . 12. Encourage client to cough and deep breath , sit up in bed and ambulate . NURSING ACTIVITIES : 13. Provide pain medication one half hour before removing chest tube . 14. After removal of chest tube apply airtight sterile petroleum jelly gauze dressing . 15. Order chest x-ray as needed following removal of the chest tube . PHARMACOLOGY 1. Antiseptic solution to prepare site for chest tube . 2. Local anesthetic ( lidocaine ) 3. Sterile petroleum jelly gauze following chest tube removal . 4. Pain medication ( morphine and meperidine ) 5. Antibiotics ( if bacterial infection is present ) COMPLICATIONS : 1. Infection 2. Recurrent or new pneumothorax 3. Respiratory failure AGE RELATED CHANGES – GERONTOLOGICAL CONSIDERATIONS > Changes in fat deposition difficult to identify landmarks of insertion > Proper positioning for thoracotomy maybe difficult for the older person with impaired mobility or range of motion . THANK YOU AND GOD BLESS!!!!!!
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