A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:
1. 1 minute
2. 5 seconds
3. 10 seconds
4. 30 seconds
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Tracheostomy
Description
A tracheostomy is an opening made surgically directly into the trachea to establish an airway; tracheostomy tube is inserted into the opening and the tube attaches to the mechanical ventilator or another type of oxygen delivery device.
The tracheostomy can be temporary or permanent.
Interventions
Assess respirations and for bilateral breath sounds.
Monitor arterial blood gases and pulse oximetry.
Encourage coughing and deep breathing.
Maintain a semi-Fowler’s to high Fowler’s position.
Monitor for bleeding, difficulty with breathing, absence of breath sounds, and crepitus (subcutaneous emphysema), which are indications of hemorrhage or pneumothorax.
Provide respiratory treatments as prescribed.
Suction fluids as needed; hyperoxygenate the client before suctioning.
If the client is allowed to eat, sit the client up for meals and ensure that the cuff is inflated (if the tube is not capped) for meals and for 1 hour after meals to prevent aspiration.
Monitor cuff pressures as prescribed.
Assess the stoma and secretions for blood or purulent drainage.
Follow the physician’s prescriptions and agency policy for cleaning the tracheostomy
site and inner cannula (many inner cannulas are disposable); usually, half-strength hydrogen peroxide is used.
Administer humidified oxygen as prescribed, because the normal humidification
process is bypassed in a client with a tracheostomy.
Obtain assistance in changing tracheostomy ties; after placing the new ties, cut and remove
the old ties holding the tracheostomy in place (some securing devices are soft and made with Velcro to hold the tube in place).
Keep a resuscitation (Ambu) bag, obturator, clamps, and a spare tracheostomy tube of
the same size at the bedside.
Complications of a tracheostomy
Tube Obstruction
Assessment
Difficulty in breathing
Noisy respirations
Difficulty in inserting the suction catheter
Thick, dry secretions
Unexplained peak pressures if client is on a mechanical ventilator
Prevention and Interventions
Assist the client to cough and deep breathe.
Provide humidification and suctioning.
Clean the inner cannula regularly.
The physician repositions or replaces the tube if obstruction
occurs as a result of cuff prolapse over the end of the
tube.
Tube Dislodgment
Prevention and Interventions
Secure the tube in place. Minimize manipulation and traction
on the tube. Ensure that the client does not pull
on the tube. Ensure that a tracheostomy tube of the
same type and size is at the client’s bedside.
Be familiar with institutional policy regarding replacement of
a tracheostomy tube as a nursing procedure.
During the first 72 hours following surgical placement of
the tracheostomy, the nurse manually ventilates the
client by using a manual resuscitation (Ambu) bag
while another nurse calls the Rapid Response team for
help.
After 72 hours following surgical placement of the
tracheostomy:
n Extend the client’s neck and open the tissues of the
stoma to secure the airway.
n Grasp the retention sutures (if they are present) to
spread the opening.
n Use a tracheal dilator (curved clamp) to hold the stoma
open.
n Prepare to insert a tracheostomy tube; place the obturator
into the tracheostomy tube, replace the tube, and
remove the obturator.
n Maintain ventilation by resuscitation (Ambu) bag.
n Assess airflow and bilateral breath sounds.
n If unable to secure an airway, call the Rapid Response
team and the anesthesiologist.