MEDICAL-SURGICAL NURSING

Nursing Care with Tracheostomy Tube (lectures) - Mrs Rosy Shrestha

NURSING CARE OF CLIENT WITH TRACHEOSTOMY TUBE

Definition

  • A Tracheostomy is an artificial opening /or surgical opening made into the trachea.
    Or
  • The Tracheostomy means making an artificial opening in the trachea to cope with respiratory insufficiency.
 
Tracheotomy is a surgical procedure that is usually done in the operating room under general anesthesia. A tracheotomy is an incision into the trachea (windpipe) that forms a temporary or permanent opening which is called a Tracheostomy. Sometimes the terms "tracheotomy" and "Tracheostomy" are used interchangeably. The opening, or hole, is called a stoma. The incision is usually vertical and runs from the second to the fourth tracheal ring. 
 

Anatomy

  • Trachea lies in midline of the neck extending from cricoid cartilage (C6) superiorly to the tracheal bifurcation at the level of sternal angle (T5).
  • Comprises 16-20 C shaped cartilage rings.
  • Length 10-12cm.
  • Diameter 15-20mm.
 
 

Tracheostomy
 

Purpose

  • To maintain the airways to facilitate the therapeutic exchanges of gases
  • To facilitate Bronchial toilet; to remove tracheal bronchial secretion
  • To maintain Optimum physical comfort
  • To decrease airway resistances
  • To provide a method of mechanical ventilation
  • To improve respiratory efficiency
  • To prevent from aspiration & transmission of pathogenic micro–organism
 

Indication of Tracheostomy

Airway obstruction:

  • Hemorrhage after thyroid surgery or Upper airway bleeding
  • Need for long term airway management.
  • Foreign bodies impacted in the larynx.
  • Acute Odema of epiglottis e.g. diphtheria, facial burns.
  • Trauma to the pharynx or larynx.
 

Congenital causes

  • Laryngeal weakness stenosis
  • Traumatic cause
  • Inflammatory causes, diseases condition
  • Decrease level of consciousness
  • Inability to clear lower air secretion
  • Tracheal laryngeal fracture
  • Need for continuous mechanical ventilation
  • Tumor in respiratory airway
 

Retained secretion in the tracheo-bronchial tree:

  • Unconscious pt following head injury and poisoning.
  • Chest injuries pt unable to cough.
  • Paralysis of the muscles of respiration
  • Tetanus
  • To reduce dead space air by 30%
  • For radical surgery in the neck e.g. Laryngectomy.
 

Types

  • Temporary
    Permanent

Method:
Elective / Emergency

  • Tracheostomy instrument tray includes Tracheostomy tube, tracheal hook,trachal dialtor,tape,etc.
  • Tray must be autoclaved and kept in the casualty room, post op. ward and OT.
  • Patient’s head is kept extended by a pillow under the shoulder.
  • Local 2% xylocain is enough.
  • A vertical incision is made below the cricoid cartilage. The strap muscles separated and the isthmus of the thyroid gland retracted downwards.

 
 

Types of Tracheostomy tubes:

  • Metal, Plastic, Silver, Stainless steel
  • Outer cannula, Inner cannula, Obturator
    Place – Made vertically incision in the level of 2nd, 3rd, 4th tracheal ring.
 

Care of Tracheostomy patients

  • Pre- operative: Explain about procedure and take consent.
  • Post-operative care:
    • Suction with no 8 fr catheter every ½ hrly.
    • Humidify the air by boiling water in a kettle in front of the pt.
    • Clean the inner tube as frequently as necessary.
    • Clean the tube frequently as necessary.
    • Prophylactic antibiotic should be administered.
 

Nursing dx:

Risk of ineffective airway clearance

  • Assess for evidence respiratory distress tachypnea rate pattern
  • Auscultate chest every 2 hourly
  • Assess mental status confusion, lethargy restlessness/ABG analysis
  • Assess/observe amount colour, consistency of secretion.
 

Intervention

  • Positioning – semi- fowler’s
  • Keep suction equipment & ambu lag at bedside
  • Provide warm humidified air
  • Administer O2 as needed
  • Encourage patient to cough out secretion
 

Tracheostomies pt with wearing a thermovent (type of humidifier)
  • Institute suctioning airway as needed to clear secretion (instill 2-5 cc normal saline
  • Administer stoma care (aseptic technique) keep stoma clean and dry by using sterile gauze dressing around tracheotomy side
  • Hydration
 

Suction Technique:
 

Tracheostomy Tube Suctioning
 

Risk of aspiration

  • Assess swallowing reflexes, gag reflexes
  • Maintain fluid food – I/V, (24 hrs) NG tubes, parental feeding – test “swallow’
  • Before feeding inflate the cuff of tube leave it at lest 1 hrs after the feeding
 

High risk for infection

  • Assess and observe – stoma erythema, odor irritation inflammation pus
  • Assess vital sign
  • Assess laboratory value WBC/fever, chill, blood culture.
 

Intervention

  • Provide routine Tracheostomy care, careful hand washing, appropriate use of gloves, use of supplies, solution; maintain aseptic technique topical antibiotic, antibacterial ointment
  • Do not allow secretion to pool around stoma
 

Impaired verbal communication

  • Assess patient ability to understand the spoken word
  • Assess patents ability to expression
 

Intervention

  • Provide call light
  • Paper pencil
  • Keep patient near the nursing station
  • Consult speech therapist
 

Risk for constipation

  • Stool softeners, laxatives, enema, suppository

Fear and anxiety

  • Support, reassurance
  • Counseling, frequent observation

 

Complications

  • Tracheoesophageal fistula – tracheal wall necrosis
  • Tracheal dilation
  • Tracheal stenosis (at least 1 to 2 yrs)
  • Airway obstruction – due to excessive secretion
  • Infection bronchial pulmonary infection
  • Accidental decannulations
  • Subcutaneous emphysema,pneumothorax.
  • Injury to ant. jugular vein leading to hemorrhage.