Assisting in Tracheostomy and Its Immediate Care

7/30/2019 Assisting in Tracheostomy and Its Immediate Care

1/13

1

TRACHEOSTOMY CARE

Tracheostomy

It is an artificial opening made in the trachea into which a tube isinserted to establish and maintain a patent airway.

Purpose

1. To provide an airway when there is obstruction in the upper airway.2. To aid in removal of tracheobronchial, secretions3. To avoid aspiration of secretions, food and/or fluids into the lungs.4. To replace an endotracheal tube when long term or permanent

airway provision is required.

5. To facilitate the use of respirator to ventilate the lungs.

Supplies

1. A sterile tray containing

a) BP handle with blade1b)Sharp scissors, curved1, straight (pointed)1c) Sharp hook1, blunt hook1d)Double hook retractors2e) Sinus forceps1f) Haemostats, straight2, curved2g)Mosquito forceps2h)Blunt dissector1i) Dissecting forceps, toothed1, non toothed1j) Tracheal dilator1k) Needle holder1, suturing needles and suture materiall) Tracheostomy tubes (complete sets with ties tied to them), 3

sizes (large, medium, and small size) taped and with pilot

m)Syringe and needle for local anaestheian)Dressing towels and towel clipso) Sponge holding forceps, Cotton pad, gauze pieces and cotton


2/13

2

balls,

p)Gowns, gloves and masks2. A clean tray containing

a.Protective sheet and towelb.Local anaesthesia i.e lignocaine 2 percentc.Sterile vaseline gauze in containerd.Lifting forceps in sterile containere.Kidney tray and paper bagf. Suction machineg.

Sterile catheters in sterile container

a) h. Sterile normal saline in a sterile containerh.Spirit, iodine or betadin and other cleaning lotions.

Guidelines

1.Tracheostomy may be indicated ina) Conscious patients with upper airway obstruction e.g. tumours,

stenosis, oedema of larynx and trachea and foreign bodies.

b)Unconscious patients with inadequate ventialtion e.g. respiratorydepression.

c) Patients with severe burns especially around face and neck.d)Patients with head, neck and chest injuries. The airway obstruction

may result from haemorrhage, oedema, muscular and nerve

paralysis, sub mucosal haematoma, subcutaneous emphysema etc.

e) Patients with respiratory failure who require respiratory assistancefor periods longer than 1 to 2 days especially when a respirator is to

be used.

f) Patients with trauma and paralysis of larynx and trachea, severepulmonary oedema and emphysema.

g)Patients receiving irradiation therapy for laryngeal tumours.h)Patients with fulminating infections of the mouth, pharynx or throat

e.g. diphtheria, poliomyelitis and tetanus.

i) Patients with accumulation of secretions in the lower


3/13

3

tracheobroncheal tree causing hypoxia, atelectasis or both.

j) Patients with neurologic disorders impairing respiratory muscles e.g.head injuries, drug overdose, bulbar paralysis, cerebrovascular

accidents and prolonged convulsive seizures.k) Patients undergoing major surgeries of mouth and neck e.g.

hemiglossectomy, mandibulectomy, laryngectomy, radical neck

resection etc.

l) Post operative patients with laryngeal oedema due to prolongedintubation or when endotracheal tube cannot be inserted or it is

contraindicated. m. Weak, feeble or critically ill patients to reduce

the work of breathing.

2. Tracheostomy may be classified into

a) Emergency and planned according to the situation.b)Temporary and permanent according to the duration.c) High and low, according to the place of incision. If it is above

isthmus of thyroid, it is high and if it is below the isthmus of the

thyroid at the 3rd to 4th ring of trachea, it is low.

3. The principles of tracheostomy care are

a)Maintenance of patent airwayb)Promotion of cleaningc)Prevention of drying and crusting of mucus.

4. The appropriate sizes of tracheostomy tubes and suctioncatheters to be used according to the age groups are asunder

Age Size (internal Size of suctiondiameter) of tracheostomytube

catheter

New Born 4.5 mm 5-8 Fr.

uptol year 5.5 mm 8Fr.

1 to 3 ears 6.0 mm 10 Fr.3 to 6 ears 7.0 mm 12 Fr.6 to 12 8.0 mm 14 Fr.12 to 9.0 mm 16-18Fr.Adult 9-11 mm 18 Fr.


4/13

4

5. A variety of tracheostomy tubes are available eg. plastic,

nylon, stainless steel or sterling silver. Metal tubes and most of

the synthetic tubes have three parts which are kept together as

one set. The parts are.a) Outer tube or outer cannula It is held in place by a tie or tape

(ribbon), passed through the loops on either side of the opening

of the tube.

b) Inner tube or inner cannula It fits inside the outer tube. It is heldin place by a small flip lock which is located on the top part of the

outer tube. It is left in place except at times when removed for

cleaning.

c) Obturator or pilot tube It is used as a guide to the outer tubewhile it is inserted into the trachea. It should be kept at the

bedside to be ready for use at any time when the outer tube is

expelled from trachea and another tube set is not available.

6. Following complications can be seen in patients with

tracheostomy.

a) Poor ventilation due to the airway obstruction (complete orpartial) as a result of external pressure, foreign bodies, swelling

(oedema) of mucous lining, excessive secretions, blocking of

tracheostomy tube by accumulation of encrustations or by thick,

dry secretions or by both.

b)Respiratory insufficiency due to the tracheo-bronchial obstructionat a level lower than that of the tracheostomy tube. This is

evident from unequal respiratory movements on the two sides of

the chest, marked respiratory effort and retraction of tissues

over the supraclavicular, inter costal and substernal regions.

c) Accidental expulsion of a single can nula of tracheostomy tube orouter cannula of a double-walled tube during coughing and

suctioning.

d) Inflammation and infection of wound and lower respiratory tractdue to contact with secretions or contaminated supplies and


5/13

5

inhalation of unfiltered, unwarmed and unhumidified air.

e) Pulmonary infection and. atelectasis due to inability to cough outthe secretions as the tracheostomized patient is unable to cough

effectively.f) Tracheo-esophageal fistula due to erosion through the posterior

tracheal wall which may result from improper angulation of the

tube, improper cannula length, improper fixation of the tube and

incorrect tracheostomy site. It is evident from coughing and

choking while eating and drinking, aspiration of or leakage of

foods or liquids from tracheostmy tube,

g)Haemorrhage from the incision site into the respiratory tractcauses asphyxia. The reasons are same as for tracheo-

esophageal fistula

h)Subcutaneous emphysema due to escape of air into the tissues,i) Injury to the tracheal wall and adjacent structures due to rough

handling of tracheostomy tube during suctioning and changing

tube procedures,

j) Prolonged suctioning of tracheostomy tube reduces oxygencontent causing hypoxia and cardiac arrest.

7. Do not leave any plastic bags, papers, clothes etc. nearby, if

the patient is child as it may pull them over the tracheostomy

opening and obstruct the airway

Nursing Activity

1) Assemble and arrange the supplies urgently at the bedside if it isto be performed as an emergency procedure and screen the bed.

2) Explain the procedure to the patient and his or her relatives.3) Get the written consent from the relative.4) Cover the patient with a cover sheet and fanfold the top clothes

to the foot end of the bed.

5) Remove the upper garments and put on a gown.6) Adjust the position of the bed to a comfortable working height


6/13

6

and move the patient to the edge of the bed.

7) Position the patient flat on his or her back with a pillow under theshoulders to tilt the head and neck to hyperextend. Use

restraints, if necessary to maintain the position and keep thehead and neck in a straight line.

8) Place the protective sheet and towel under the head and neck ofthe patient.

9) Adjust the light to have sufficient light on the part10) Wash your hands11) Put on mask, gown and gloves.12) Assist the doctor as needed to perform tracheostomy.13) Assist to suck the secretions and blood thoroughly.

14) Assist to introduce the tracheostomy tube and tie to the neck.15) Wash the supplies thoroughly and treat as instruments,

procedure "Taking Care of Patient's Equipment"

16) Postoperativelya) Watch the patient continuously over a period of first 24 to 48

hours.

b)Suck the secretions every half to one hour on the first day ifnecessary.

c) Observe the vital signs and Complications that may ariseduring the post operative period and report.

d)Take care to prevent accidental expulsion of tracheostomytube. Emergency tracheostomy tube reinsertion supplies

should be available at the bedside at all times. These

supplies include

a) Tracheal dilator1


7/13

7

b)Pair of scissorsc) Extra tracheostomy tube (complete set) tied with tapesd)Double hook retractore) Small bowl, cleaning solutions and dressing materials.

e) Keep additional supplies ready for use at all times to meetemergency i.e.

Suction apparatus with sterile suction tubes Sterile bowl with sterile water Ambu bag, oxygen apparatus, respirator and humidifier (a

kettle with boiling water can be used if humidifier is not

available).

f) Maintain fowler position.g)Ensure warmth, filtration and humidification of the inspired air.

Keep a few layers of sterile wet gauze over the tracheostomy to

filter and humidify the air and change the gauze as necessary.

Keep the room warm. Give humidified oxygen, if necessary and

give steam inhalation at least twice a day.

h)Practice asepsis and avoid persons with respiratory diseases nearthe patient.

i) Keep the mucous membranes of respiratory tract moist by givingadequate fluids. Intravenous fluids can be given if oral intake is

not adequate. Maintain accurate intake and output chart.

j) Give frequent mouth care.k) Administer medications as ordered. Narcotics and sedatives are

avoided.

Recording

1)Note the following in the nurse's notes.a. The date and time of tracheostomy.b. Vital signs and breath sounds.c. Complications detected and treatment given.d. Time and frequency of suctioning, colour, amount,

consistency and odour of secretions.


8/13

8

e. Time and frequency of month care.f. Time and frequency of oxygen administration.g. Time and frequency of steam inhalation.

2. Note the time and amount of fluid intake in the intake andoutput chart.

GIVING TRACHEOSTOMY CARE

Purpose

1. To keep the airway patent.2. To reduce the respiratory infections.3. To help the patient learn to take care of tracheostomy especially

when permanent tracheostomy is performed.

Supplies

Sterile Supplies

1. Half way cut gauze pieces, ties/tapes, cotton swabs, cotton pads2. Applicators3. Bowls-24. Gloves-2 pairs5. Small brush with fine bristles.

Clean Supplies

1. Hydrogen peroxide (1/2 strength)2. Sterile sodium bicarbonate 2 percent or normal saline3. Any non-irritating cleansing solution4. Vaseline and antibiotic ointment e.g. soframycin5. Protective sheet, gloves-one pair6. Kidney tray and paper bag.

Guidelines

1)Change the tracheostomy dressing at least every 4 hours andties at least every 24 hours to keep the dressing and ties dry.

2)While changing ties, take the help of another person to prevent


9/13

9

dislodgement of the tracheostomy tube. Ties should be neither

loose nor too tight.

3)Remove and clean the inner caunula, at least every 8 hours.Never wash it with hot water as it coagulates the mucus whichmakes difficult to remove it.

4)Changing of the outer cannula is done by the doctors in theimmediate post operative period and later on by the nurses after

first week, as the tracheastomy tract is well established by then.

An extra tracheostomy tray is kept ready for the doctor to

change the outer caunula or tube.

5)Maintain strict aseptic technique during the procedure.6)Do not inflate the tracheostomy cuff unless ordered and inflate

only with air if ordered to inflate.

7) If respirator is in use, perform the procedure without disruptingits use.

8)Gauze pieces used for tracheostomy dressing are cut half waythrough and are inserted on either side of the tube to absorb the

secretions leaking around the tube. Never use cotton to prevent

its aspiration into the trachea.

9)As the patient with tracheostomy is unable to talk, specialattention should be paid to meet his or her needs. Anticipate and

meet his or her needs without any delay. Provide with a signal

light, a call bell and a paper and pencil to communicate.

Reassure him or her that his or her speech problem is only

temporary.

10) Consider the tracheal secretions contaminated and handle aswound isolation procedure.

11) In a temporary tracheostomy, remove the tube as soon as theunderlying cause is removed. Before removing, the opening is

closed for a varying length of time and observed for any

untoward signs. If the patient feels no difficulty, remove, the

tube. Observe the patient for 24-48 hours for any respiratory


10/13

10

distress following the tube removal.

12) A patient with permanent tracheostomy is given followinginstructions.

a) Take care of the tracheostomy tube. Demonstrate theprocedure to the patient and take return demonstration.

b)What to do in case the tube gets dislodged. Avoidaccidental entry and aspiration of water, hair, cotton into

the stoma while taking bath or soap and water while

washing the face and also avoid swimming.

c) Take care while using after shave lotions on neck, orpowder or spray on face, neck and chest.

d) Inform the barber about the stoma while getting hair cutdone.

e) Prevent respiratory infections by taking adequateprotection and avoiding contact with the patients suffering

from respiratory diseases.

f) Teach how to talk. Take a deep breath, close the stomawith a finger, and then speak one two words. Again take a

breath and do likewise.

g)Take well-balanced diet to improve health.

Nursing Activity

1)Take the supplies to the bedside and screen the bed.2)Explain the procedure to the patient and reassure.3)Position the patient in a semi fowler's position unless

contraindicated.

4)Wash your hands.5)Suction the tracheostomy. Refer procedure "Suctioning through

Endotracheal/Tracheostomy Tube".

6)Wash your hands.7)Open the sterile tray.8)Pour hydrogen peroxide into the sterile bowl and sodium


11/13

11

bicarbonate/normal saline into the other sterile bowl using sterile

technique.

9)Put on clean gloves and remove the soiled tracheostomy dressingand place in the paper bag.

10) Cut and remove the soiled ties. Take the help of the otherperson who will continually hold the tracheostomy tube with a

sterile gloved hand until new ties are securely placed. Place the

soiled ties in the paper bag.

11) Remove the clean gloves and put on sterile gloves.12) Clean and sterilize the inner cannula, if present.

a) Unlock the inner cannula and remove.b)Wash it under cold running water to remove the mucus

adhering to it.

c) Soak it in hydrogen peroxide and sodium bicarbonate 2percent or nor mal saline (477).

d)Clean it with soap and water using a small brush.e) Rinse it thoroughly under running water.f) Inspect the lumen of the tube to make sure that it is clean,g)Sterilize it by putting in the boiling water for five minutes.

13) Suction the outer caunula to remove secretions. Be careful notto remove it.

14) Rinse the inner cannula and lock securely to the outer cannula15) Reapply sterile precut ties or tapes to each side of the

tracheostomy tube. Secure them around the patient's neck with

a knot at the side of the neck. They should be tight enough to

allow only one finger to slide underneath. Trim off the excess

ties.


12/13

12

16. Apply little antibiotic ointment on the skin around thetracheostomy tube. (478).

17. Insert vaseline gauze (precut) around the tube. (480).18. Apply plain gauze (precut) over- the vaseline gauze (479).19. Remove gloves and place in the kidney tray.20. Wash your hands.21. Place the patient in comfortable position22. Discard the supplies to be discarded, wash the supplies to be

washed, dry and replace.

Recordings

Note the following in the nurse's notes

1. Date and time of the procedure.2. Colour, amount, consistency and odour of secretions.3. Condition of incision.4. Ointment applied to the skin around tracheostomy tube.5. Vital signs and breath sounds.6. Any instructions given to the patient and/or family and their level of

understanding.


13/13

13

BIBLIOGRAPHY

1)Theresamma. CP., 2006 Fundamentals of Nursing Proceduremanual for General nursing & Midwifery Course. 1st Edition,

Jaypee Brothers, Medical Publishers (p) Ltd., New Delhi.p:

412-415.

2) Nancy Sr., 2002, Principles & Practice of Nursing & Nursingarts procedures, 5th edition published & Printed by N.R.

Publishers, House, Indore.p:132-140.

3) LC Gupta US, Sahu, Priya Gupta, 2007 Practical NursingProcedure. 3rd Edition, Printed at Para Offset Pvt. Ltd. New

Delhi; p: 122-127.

4) Sagunthala Sharma Birpuri 1997 Principles and Practice ofNursing 1st edition Printed at Lordson Publishers (P) ltd., New

Delhi. p. 294-295.

5) Brunner & Siddarths, 2001, Text book of Medical- surgicalNursing- 12th edition, volume2, published by Wolters Kluwer

(India) pvt. Ltd New Delhi, Page No: 648-651

6) Lewis, collier, Heitkemper, 1996 Medicalsurgical Nursing,4th Edition, Mosby year book- Inc USA, Page no: 603-610

Websites

1) www.wikipedia.com2) www.pubmed.com3) www.scrbd.com4) www.googlebooks.com5) www.indianmedicine.com
http://www.wikipedia.com/http://www.pubmed.com/http://www.scrbd.com/http://www.googlebooks.com/http://www.googlebooks.com/http://www.scrbd.com/http://www.pubmed.com/http://www.wikipedia.com/

Assisting in Tracheostomy and Its Immediate Care

Documents