TRACHEOSTOMY CARE

Tracheostomy It is an artificial opening made in the trachea into which a tube is inserted 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, secretions 3. 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 blade1 b) Sharp scissors, curved1, straight (pointed)1 c) Sharp hook1, blunt hook1 d) Double hook retractors2 e) Sinus forceps1 f) Haemostats, straight2, curved2 g) Mosquito forceps2 h) Blunt dissector1 i) Dissecting forceps, toothed1, non toothed1 j) Tracheal dilator1 k) Needle holder1, suturing needles and suture material l) 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 anaestheia n) Dressing towels and towel clips o) Sponge holding forceps, Cotton pad, gauze pieces and cotton
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balls, p) Gowns, gloves and masks 2. A clean tray containing

a. Protective sheet and towel b. Local anaesthesia i.e lignocaine 2 percent c. Sterile vaseline gauze in container d. Lifting forceps in sterile container e. Kidney tray and paper bag f. Suction machine g. Sterile catheters in sterile container
a) h. Sterile normal saline in a sterile container

h. Spirit, iodine or betadin and other cleaning lotions.

Guidelines

1. Tracheostomy may be indicated in

a) 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. respiratory depression. 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 assistance for 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, severe pulmonary 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
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of

secretions

in

the

lower

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, resection etc. l) Post operative patients with laryngeal oedema due to prolonged intubation 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 mandibulectomy, laryngectomy, radical neck

a) Maintenance of patent airway b) Promotion of cleaning c) Prevention of drying and crusting of mucus.
4. The appropriate sizes of tracheostomy tubes and suction catheters to be used according to the age groups are as under Age Size (internal Size of suction diameter) of tracheostomy tube 4.5 mm 5.5 mm 6.0 mm 7.0 mm 8.0 mm 9.0 mm 9-11 mm catheter 5-8 Fr. 8Fr. 10 Fr. 12 Fr. 14 Fr. 16-18Fr. 18 Fr.

New Born uptol year 1 to 3 years 3 to 6 years 6 to 12 12 to years Adult 15years

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 held in 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 tube while 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 or partial) 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 obstruction at 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 or outer cannula of a double-walled tube during coughing and suctioning. d) Inflammation and infection of wound and lower respiratory tract due to contact with secretions or contaminated supplies and
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inhalation of unfiltered, unwarmed and unhumidified air. e) Pulmonary infection and. atelectasis due to inability to cough out the 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 tract causes asphyxia. The reasons are same as for tracheoesophageal 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 oxygen content 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 is

to 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
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and move the patient to the edge of the bed.

7) Position the patient flat on his or her back with a pillow under the

shoulders to tilt the head and neck to hyperextend. Use restraints, if necessary to maintain the position and keep the head and neck in a straight line.
8) Place the protective sheet and towel under the head and neck of

the patient.
9) Adjust the light to have sufficient light on the part 10) Wash your hands 11) 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) Postoperatively

a) 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 if necessary. c) Observe the vital signs and Complications that may arise during the post operative period and report. d) Take care to prevent accidental expulsion of tracheostomy tube. Emergency tracheostomy tube reinsertion supplies should be available at the bedside at all times. These supplies include a) Tracheal dilator1
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b) Pair of scissors c) Extra tracheostomy tube (complete set) tied with tapes d) Double hook retractor e) Small bowl, cleaning solutions and dressing materials. e) Keep additional supplies ready for use at all times to meet emergency 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 near the patient. i) Keep the mucous membranes of respiratory tract moist by giving adequate 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.
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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 and output 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 pads 2. Applicators 3. Bowls-2 4. Gloves-2 pairs 5. Small brush with fine bristles. Clean Supplies 1. Hydrogen peroxide (1/2 strength) 2. Sterile sodium bicarbonate 2 percent or normal saline 3. Any non-irritating cleansing solution 4. Vaseline and antibiotic ointment e.g. soframycin 5. Protective sheet, gloves-one pair 6. Kidney tray and paper bag. Guidelines 1) Change the tracheostomy dressing at least every 4 hours and ties at least every 24 hours to keep the dressing and ties dry. 2) While changing ties, take the help of another person to prevent
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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 which makes difficult to remove it. 4) Changing of the outer cannula is done by the doctors in the immediate 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 disrupting its use. 8) Gauze pieces used for tracheostomy dressing are cut half way through 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, special attention 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 as wound isolation procedure. 11) In a temporary tracheostomy, remove the tube as soon as the underlying 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
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distress following the tube removal. 12) A patient with permanent tracheostomy is given following instructions. a) Take care of the tracheostomy tube. Demonstrate the procedure to the patient and take return demonstration. b) What to do in case the tube gets dislodged. Avoid accidental 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, or powder or spray on face, neck and chest. d) Inform the barber about the stoma while getting hair cut done. e) Prevent respiratory infections by taking adequate protection and avoiding contact with the patients suffering from respiratory diseases. f) Teach how to talk. Take a deep breath, close the stoma with 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
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bicarbonate/normal saline into the other sterile bowl using sterile technique. 9) Put on clean gloves and remove the soiled tracheostomy dressing and place in the paper bag. 10) Cut and remove the soiled ties. Take the help of the other person 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 2 percent 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 not to remove it. 14) Rinse the inner cannula and lock securely to the outer cannula 15) 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.

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16. Apply

little

antibiotic

ointment

on

the

skin

around

the

tracheostomy 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 position 22. 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.

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BIBLIOGRAPHY 1) Theresamma. CP., 2006 Fundamentals of Nursing Procedure

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Nursing- 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.com 2) www.pubmed.com 3) www.scrbd.com 4) www.googlebooks.com 5) www.indianmedicine.com

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