Trache care/suctioning

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  1. What is the definition of a tracheotomy?
    Surgical incision into the trachea for the purpose of establishing an airway.
  2. What is the definition of a Tracheostomy?
    a stoma (opening) that results from the tracheotomy.
  3. What are 4 reason for having a tracheostomy?
    • 1. bypass an acute or chronic upper airway obstruction
    • 2. facilitate removal of tracheobronchial secretions
    • 3. prevent aspiration of oral or gastric secretions in unresponsive clients
    • 4. permit long-term mechanical ventilation in client with chronic respiratory failure
  4. what is the purpose of a fenestration?
    • hole to allow air to pass out through
    • allows patient to speak
  5. if the patients trache gets dislodged from established tracheostomy what should he nurse do?
    • 1. call for help
    • 2. monitor VS, keep HOB elevated
    • 3. immediately attempt to replace it
    • or 4. insert suction catheter to allow passage of air and to serve as a guide for insertion
  6. When the trache has become dislodged and the nurse needs to replace it how is that done?
    • 1. insert obturator in replacement tube, lubricate with saline
    • 2. use hemostat to spread open
    • 3. insert tube into stoma at a 45-degree angle to neck
    • 4. if insertion is successful, remove obturator immediately
  7. If the nurse is unable to replace the trache back in what should the nurse do?
    • 1. assess level of respiratory distress
    • 2. if patient is having minor dyspnea-alleviate by positing in a semi-fowler's position
    • 3. if patient is having severe dyspnea and no upper airway obstruction-ventilate with BVM over mouth/nose (gentle/slow breaths or may cover stoma with gloved hand or gauze & tape to prevent loss of oxygen via stoma)
    • 4. if patient is having severe dyspnea and has an upper airway obstruction- ventilate with BVM over stoma
  8. What is the purpose of having a nebulizer/trache mask?
    • provided the client with moistened air
    • humidification
    • oxygenation
  9. What type of tubing is used with a trache mask?
    corrugated tubing
  10. What is the max for the oxygen flow meter on the trache mask? What should the Venturi style valve on the nebulizer bottle neck be set to?
    • 12 L
    • 40%
  11. If the nurse is using a two oxygen flow meter system what are the tubes attached to?
    • one attached to the BVM
    • one attached to the Trache mask
  12. If the nurse is using a one oxygen flow meter system with a Y attached what are the Y's attached to?
    • one Y to the BVM
    • one Y to the Trache mask
  13. What are 10 reasons why a patient would need to be suctioned?
    • wheezing/coughing
    • adventious breath sounds
    • noisy breathing due to secretions
    • increased/decreased respiratory rate
    • decreased Sa02/Pa02
    • increased work of breathing
    • patient unable to clear secretions
    • decreased level of consciousness
    • anxiety
    • cyanosis
  14. What are some expected outcomes for suctioning a patient?
    • 1. patients airways are cleared of secretions
    • 2. adventious breath sounds are decreased or cleared
    • 3. patient reports easier breathing
    • 4. increased Sa02/Pa02
    • 5. patient able to perform correct oropharyngeal suctioning
    • 6. indication of aspiration is absent
    • 7. decreased anxiety
    • 8. decreased wheezing
  15. What part of the suctioning can be delegated to UAP?
    • tracheal suctioning in non stable patients without a permanent tracheostomy cannot be delegated to UAP
    • oropharyngeal suctioning and trache suctioning in stable chronically ill patients with permanent tracheostomy can be delegated
  16. What instructions should the nurse give to the UAP in regards to suctioning the patient?
    • 1. avoid mouth sutures and to apply suction to sensitive tissue
    • 2. the difference with patients on ventilators
    • 3. report to the nurse changes in VS, pulse ox, bloody sputum, difficulty breathing, respiratory distress or if the patient complains of discomfort during or after the procedure
  17. When is hyperoxygenating done and what is the purpose of it?
    • done before suctioning
    • to decrease suctioning induced hypoxemia (keep 02 at a high level so when suctioning want decrease 02 as much)
  18. Is it recommended to hyperoxygenate COPD patients?
  19. tRUE/FALSE. when using the BVM you are hyperventilating the patient?
    False. BVM hyperoxygenates NOT hyperventilates
  20. How does the BVM deliver oxygen to the patient?
    oxygen flows to the patient when the bag is squeezed
  21. What is the proper way to deliver oxygen to the patient with a BVM?
    use on hand and squeeze bag half way
  22. When should the nurse squeeze the BVM when the patient inhales or exhales?
    patient inhales
  23. What are the proper clothing to wear when suctioning?
    • mask and face shield
    • gown
  24. What is the purpose of rotating the catheter while suctioning?
    prevents injury to tracheal mucosa lining
  25. Suctioning as you go into the trache is not to be done because it causes what?
    increases the risk of trauma to the tracheal mucosa
  26. When suctioning how many time should you suctioning and how long should you wait in between each suction?
    • no more than 2 times
    • wait 30 seconds
  27. What are some complications a nurse should monitor the patient for after suctioning?
    • hypoxemia
    • atelectasis
    • arrhythmia
    • decreased cardiac output
    • increased intracranial pressure
  28. If your patient becomes cyanotic or restless or develops tachycardia, bradycardia, or other abnormal heart rhythm while suctioning what is the priority of the nurse to do?
    • 1. discontinue suctioning; unless patient condition is deteriorating due to secretions in airway
    • 2. provide supplemental oxygen
    • 3. monitor VS and pulse ox
  29. If you suction up bloody secretions what is the nurse going to do?
    • 1. evaluate technique and frequency of suctioning
    • 2. bleeding continues, notify MD due to potential hemorrhage and monitor vital signs
  30. If your suctioning a patient and you get no secretions what should the nurse do?
    • 1. evaluate technique of suctioning
    • 2. tell patient to cough
  31. If your suctioning a patient and you get thick secretions or it becomes difficult to suction what should the nurse do?
    • 1. monitor patients hydration status. patient could be dehydrated
    • 2. increase fluids
  32. If you patient starts to cough while your suctioning what should the nurse do?
    • 1. nothing. it helps bring secretions up
    • 2. medicate for cough prn
  33. When you start to perform trache care and the tube is not secure and it moves in or out or is coughed out by the patient what is the nurses priority to do?
    adjust or apply new ties
  34. If the nurse auscultates unequal bilateral breath sounds with a endotracheal tube what should the nurse do?
    • 1. evaluate the endotracheal tube for proper depth
    • 2. obtain order for chest x-ray study to verify placement
    • 3. assess patients respiratory status and observe for the presence of mucus plugs
  35. When assessing the skin around the stoma and you notice breakdown, pressure areas, or stomatitis what should the nurse do?
    • 1. increase frequency of tube care
    • 2. make sure skin is clean and dry
  36. if the tube accidentally come out while your cleaning the patient what should the nurse do?
    • 1. call for assistance
    • 2. monitor VS
    • 3. keep HOB elevated
    • 4. maintain patient airway by replacing old tracheostomy tube with new tube for established tracheostomy. use obturator to insert new tube and then remove obturator
    • 5. cover the site with gauze and ventilate via BVM
    • 6. do not attempt to recannulate because of potential for damage to stoma or trachea
  37. What are the 3 different types of suctioning?
    • 1. Oropharynegeal
    • 2. Nasotracheal
    • 3. Endotracheal & Tracheostomy
  38. When is it necessary to perform nasotracheal suctioning?
    when patient is unable to cough forcefully enough to clear secretions
  39. Which type of suctioning can be done independently by the patient?
    Oropharyngeal suctioning
  40. What are the certain reasons to perform Trache Care?
    • Q shift and PRN
    • secretions accumulating around site, sutures, and tube
    • dressing is soiled
    • dressing is wet
    • signs of infection
    • client complains of discomfort at stoma site
  41. After you remove the dressing what should you first observe for?
    • condition and stability of trache tube
    • condition of trache ties
    • condition of skin around stoma
    • confirm pilot balloon is inflated
  42. Before performing trache care what should the nurse assess for?
    • auscultate lung sounds/respiratory assessment
    • assess clients knowledge and comfort with procedure
    • assess clients ability to perform own trache care
  43. What are some expected outcomes to performing trache care?
    • 1. patient's artificial airway/tube is in correct position and properly secured
    • 2. patient remains with a fever and no signs of infections
    • 3. patients oral mucous membrane/stoma remains free of breakdown or accumulation of secretions
    • 4. patients artificial airway is intact without persistent dried secretions
    • 5. patient cooperates with care
    • 6. patient is able to demonstrate correct technique of tracheostomy care when appropriate
  44. What part of the process of trache care can be delegated to the UAP?
  45. What things can the nurse delegate to the UAP to help with trache care?
    • report vital signs
    • how the patient should be postioned
  46. If the nurse is going to be suctioning and doing trache care which part should be done first?
    suctioning should be done before care
  47. When doing trache care when should the patient be hyperoxygentated?
    as necessary prior to performing trache care
  48. What is the proper way a patient should be positioned while performing trache care?
  49. When changing the trache ties how should it be done with or without an assistant?
    • WITH: have assistant hold trache while removing old ties and apply new ties
    • WITHOUT: put on new ties first, then remove old ties
  50. What is the purpose of the trache cuff?
    seal off space between tube and trache
  51. What is the purpose of having the trache cuff inflated?
    • to prevent aspiration in setting of dysphagia
    • to facilitate ventilation via BVM or mechanical ventilation
  52. Who can inflate the cuff on the trache?
    nurse with a MD order
  53. What is the max cuff pressure?
    < 20 mmHG or < 25 cm H20
  54. Is it best to use minimal amount of pressure or maximal pressure to make seal?
    use minimal pressure
  55. When is it necessary to deflate the trache cuff?
    • per MD orders
    • when secretions pool above cuff and cause potential for infection
    • Does NOT have to be deflated when suctioning
  56. What are the steps in deflating the trache cuff?
    • 1. suction the patient
    • 2. attach 10 ml syringe with plunger depressed completely to port on pilot balloon
    • 3. pull back on plunger on syringe until pilot balloon is flat
  57. When trying to inflate the cuff on the trache what are some things that happen that should ne reported to the MD?
    • 1. inability to keep cuff inflated
    • 2. need to use progressively larger volumes of air to keep cuff inflated
  58. What are the steps in inflating the trache cuff?
    • 1. pull plunger on 10 ml syringe to 10 ml
    • 2. attach syringe to port at end of pilot balloon
    • 3. slowly inject 0.5 ml of air at a time until:
    • >in a mechanically ventilated client: no sound is heard when a stethoscope is placed over trachea indicating air is not leaking at peak inspiratory pressure
    • >in a spontaneously breathing client: air cannot be felt or heard escaping from the nose or mouth, air is not heard moving past the cuff when a stethoscope is placed over trachea
  59. If a patient is able to talk would you thing that the cuff is inflated or not?
    Not inflated adequately as the air is vibrating vocal cords
  60. What is the purpose of cleaning the inner cannula?
    • removes surface debris to maintain patency
    • to decrease transmission of microorganisms into lower respiratory tract
  61. When should a disposable or reusable inner cannula be changed or cleaned?
    • disposable: changed daily, then PRN
    • reusable: cleaned every morning, every evening, and PRN
  62. What is the purpose of the gauze dressing?
    absorbs secretions that are coming out during suctioning or when patient coughs
  63. How often should the gauze dressing be changed?
    every shift and PRN
  64. What is the purpose of the tract ties?
    to stabilize the trace
  65. How often should the trache ties be changed?
    whenever trache care is performed
  66. What is the purpose of a stoma cover?
    • prevents small objects and dust from getting in
    • keeping clothes cleaner
    • stops mucus from getting coughed onto others
  67. What should stoma covers consist of and be made of?
    • a loose weave
    • lent free
    • washable
  68. What are certain things that will alarm a patient to call their MD in regards to their trache?
    • 1. fever > 101
    • 2. trouble breathing
    • 3. change in secretions color (not clear), amount (increased), odor (infection)
    • 4. red or breakdown of skin around stoma
  69. Having a trache increases the risk of ventilated acquired pneumonia. What are the best ways to prevent VAP?
    • 1. elevate the HOB 30 to 45 degrees to prevent aspiration
    • 2. change position every 2 hours to prevent atelectasis and pulmonary infections
    • 3. provide oral care with chlorhexidine to decrease colonization of bacteria
    • 4. use a toothbrush every 8 hours to remove dental plaque organisms
    • 5. keep trache cuff pressure at 20 cm of H20 to prevent movements of secretions to lower airway
    • 6. monitor patient for aspiration when enteral feedings are infused
    • 7. increase patients mobility to promote pulmonary function and decrease pooling of secretions
Card Set:
Trache care/suctioning
2013-12-10 10:33:44

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