Intact skin behind the ears c. The first tube change is done by the physician. A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. Regular skin inspection is important to prevent complications. Mitchell et al recommend that a plastic tracheostomy tube be used for initial placement. The nurse should set aside enough time to attend to all of the details of client care. Do not clean or re-use single use tubes.
Teach parents to suction airway if choking, perform after other measures have failed. Call the operating room to inform them of a pending emergency case. Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. Covering the stoma prevents the inhalation of foreign materials. Protective dressings can be used as needed to provide a cushion, collect secretions, and encourage timely healing.
Assist the patient in seeking an evaluation of their home and work setting. The client should have a sound communication method to ease frustration. Refer to medical social services as necessary. The client may be able to perform independently. Use central nervous system depressants cautiously; elderly clients may have an increased incidence of aspiration with altered levels of consciousness. The referral should be made as soon as possible following tracheostomy tube insertion to allow adequate time for the planning of in-home health care support prior to the patients discharge.
The nurse will maintain and assess for adequate humidity of inspired air every 2 hours. How do you develop a nursing care plan? These methods should be documented in the medical record and verbally handed over to staff to ensure adequate communication and appropriate understanding of the patient and their needs. Methods can be instituted for the client to eat and speak, as well. Nursing Interventions Rationale Assess level and manifestations of anxiety in parents and child. Document results of coughing and suctioning, particularly client tolerance and secretion characteristics such as color, odor, and volume.
Stand close, within patient's line of vision generally midline. The patient will report risk factors that are associated with infection and perform proper precautions when needed. Studies have shown that in mechanically ventilated clients receiving enteral feedings, there is a decreased incidence of nosocomial pneumonia if the client is positioned at a 45-degree semirecumbent position as opposed to a supine position Torres, Serra-Battles, Ros, 1992; Drakulovic et al, 1999. Being prepared for an emergency helps prevent future complications. See interventions for for further information on positioning a respiratory client.
A person with a tracheostomy is at risk for many different medical issues due to the in ability to clear secretions and the amount of care it takes to care for a tracheostomy etc. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties. Auscultate the , noting areas of decreased ventilation and for the presence of adventitious breath sounds. The surgical site is moisten with petroleum jelly and has multiple sutures around the site. Use of pink tape as opposed to clear tape or butterfly tape increases the length of time a tube stays taped Burns et al, 1995.
Position client to optimize respiration e. White et al suggest that indications for changing a tracheostomy tube include the need for a different size tube, tube malfunction, need for a different type of tube, and routine changes for ongoing airway management and prevention of infection. You need to assess your patient, collect data then find a diagnosis. How do you develop a nursing care plan? Special safety considerations Some patients may require assisted ventilation before and after suctioning. If we give them too much oxygen and raise their oxygen levels they will stop breathing. Administer humidified oxygen as needed.
. If you have a metal inner cannula do not use hydrogen peroxide, as it can cause damage to the cannula. Always wash your hands with soap and water before cleaning. This increases the patient's sense of frustration and feelings of helplessness. . It is preferable for the client to cough up secretions. Before discharge, patients and their caregivers should receive a checklist of supplies that should be taken with the patient at all times.
What action by the nurse is best? Tie the tapes at the side of the neck in square knot and alternate the tie every time tapes are changed. Is the the patient having pain? Not all children will be able to produce a vocal sounds or voice when the speaking valve is first used. Bleeding at the site and the vessels surrounding the incision may be a concern. Tying a square knot at the back of the neck d. If you are instructed to use a hydrogen peroxide mixture on your skin, be sure to rinse the area with normal saline afterward. Provide a nonjudgmental and supportive environment. Make sure the ties are snug enough to keep the neck plate from moving too much, yet loose enough to be comfortable.
These steps keep the stoma clean and dry. Give the patient ample time to respond. Your health care team will teach you how to do this. Try loose-fitting shirts with collars. Difficulties communicating are a source of frustration to all involved. Start making a list of abnormal data which will now become a list of their symptoms.