INSTITUTIONAL POLICY AND PROCEDURE (IPP)

Transcription

1 HOSPITAL NAME INSTITUTIONAL POLICY AND PROCEDURE (IPP) Department: Manual: Section: TITLE/DESCRIPTION POLICY NUMBER TRACHEOSTOMY CARE EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES APPROVED BY APPLIES TO PURPOSE To outline the nursing management of the patient with a tracheostomy. RESPONSIBILITY Performed by an RN, or Respiratory Care Practitioner (RCP). CROSS REFERENCES POLICY SUPPORTIVE DATA: Indications for a tracheostomy include: bypass upper airway obstruction (anomalies, trauma, infection, edema, neoplasm) prophylaxis for anticipated airway problems provision of ventilation reduce the risk of aspiration retained tracheobronchial secretions chronic upper airway secretions Low pressure cuffed tracheostomy (trach) tubes are used in adult patients to reduce risk of aspiration and establish a seal for ventilation. Bivona trach tubes are custom-made, non-disposable and do not have an inner cannula. Cuffed tubes are not routinely used for patients under 8-years-old. Suctioning should not be performed on a pre-set schedule but based on respiratory assessment of the patient. The primary indication for suctioning is the patient s inability to adequately clear their airway due to ineffective cough.. The physician usually changes first set of ties post operatively. Most patients with a cuffed trach tube, in which the cuff is inflated, are either: 1) on a ventilator with the inflated cuff providing a seal for adequate ventilation or; 2) have a "fresh trach with the inflated cuff preventing the aspiration of blood. However, patients with chronic aspiration may also require cuffed trachs. If the cuff is inflated, cuff pressure should be checked every shift to insure it does not exceed the capillary occlusion pressure of the tracheal wall cm H 2 O. Cuff pressure exceeding the capillary occlusion pressure can cause necrosis and stenosis of the trachea. Once the cuff has been deflated, generally the first post-op day, cuff pressure is no longer an issue. Personnel who inflate trach cuffs should know to use the "minimally occlusive pressure" when inflating the cuff. Routine saline lavage use is not recommended to thin secretions but only when indicated. Patient hydration and humidification must be considered first to thin secretions as the instillation of saline has been shown to have little or no value, adversely effects oxygen saturation and may contribute to the development of nosocomial pneumonia. Standards Page 1 of 5

2 PROCEDURE STEPS: KEY POINTS: 1. Assemble general equipment and supplies. 1. Emergency equipment may be needed in the event of accidental decannulation. This equipment is required at the bedside at all times. NOTE: If the patient is admitted with a pre-existing tracheostomy tube contact Respiratory Therapy to evaluate patient. 2. Place the patient in semi-fowler s position. 2. This position will decrease abdominal pressure on the diaphragm, promoting lung expansion. 3. Perform hand hygiene, put on gloves. 4. Suction airway per Nursing Procedure Manual. 4. This assures airway patency and patient comfort. 5. Remove and discard the soiled trach dressing and gloves. 6. Wash hands with antimicrobial solution Open tracheostomy kit. 7. Place the barrier on the overbed table or use supplies directly from kit. 8. Remove the sterile drape and place on patient s chest. 9. Fill one section of the divided basin with one-half hydrogen peroxide and one-half normal saline. Fill the other section with normal saline. 10. Remove any humidification, oxygen or ventilator device from trach tube. 11. Put on sterile gloves. 12. Place the contents of the kit on the sterile barrier if desired. 10. If the patient is ventilator dependent and cannot tolerate being disconnected from the ventilator during inner cannula cleaning keep a duplicate inner cannula in a dry sterile closed container at the bedside and quickly exchange the inner cannulas. Standards Page 2 of 5

3 13. Clean stoma, skin and tracheostomy tube flanges. a. Dip cotton swabs in the hydrogen peroxide/normal saline mixture. 13. a. Swabs should be moist - excessive fluid increases the risk of accidental aspiration. b. Clean upper half of stoma in a clockwise motion, b. Use swabs only once and wipe gently. swabbing from left to right, one stroke with each swab. Repeat on lower half of stoma. Use extra swabs to clean surrounding skin and tube flanges. 14. Repeat stoma cleaning using only normal saline. 14. Hydrogen peroxide mixture may irritate skin and impair healing if allowed to remain on the skin. 15. Stabilize the trach flange with one hand, with the other hand grasp the outside of the inner cannula, turn the inner cannula counter clockwise and remove. 16. Drop the inner cannula into the hydrogen peroxide/normal saline mixture in basin. 17. Cleanse the inner cannula gently with the sterile nylon brush or sterile pipe cleaner. NOTE: It is the portion of the cannula that is inserted into the trachea that must remain sterile. 18. Rinse the inner cannula in normal saline, inspect for cleanliness. 19. Grasp the outer ring of the clean inner cannula, tap gently against the sterile container to remove excess liquid. 20. Hold the flange of the tracheostomy with one hand and, with the other hand, reinsert the inner cannula. Use a clockwise turning motion to lock the cannula. Verify the cannula is locked. 21. Place a seamed or pre-split 4x4 under the tracheostomy tube flanges if drainage or secretions are present. 16. NOTE: If the inner cannula is disposable discard inner cannula and go to Step # Do not rub the metal part of the brush against the bottom edge of the inner cannula. Over time this abrading can cause splitting of the plastic. Obtain a new inner cannula if the plastic is split. 19. Repeat cleaning of cannula if necessary. Do not attempt to dry the outer surface of the inner cannula, a thin film of moisture acts as a lubricant during insertion. 20. The colored dots on the cannulas align when the cannula is properly locked. 21. Do not use cotton-filled gauze or a trimmed gauze sponge due risk of inhaling lint and fibers. If necessary fold regular 3 x 3 s and place folded edges around stoma. Change dressing prn when soiled or wet; a wet dressing predisposes the patient to skin excoriation and infection. 22. Assess the condition and security of trach 22. Assess the condition of patient s skin at the nape Standards Page 3 of 5

4 ties/velcro holder. Change if soiled. 23. Replace humidification, oxygen, and ventilation device as needed. of the neck for any trach tie irritation. 23. Humidification of inspired air is necessary during the immediate post-operative period to facilitate the mobilization of secretions. 24. Assess patient s respiratory status. 24. Document physical assessment findings on PCR 25. Place call bell and communication aids within reach. DOCUMENTATION: Document in the progress notes or unit specific flow sheet: procedure time patient s tolerance appearance of secretions any complications or difficulties including nursing action taken pulmonary assessment skin integrity at the stoma site and nape of the patient s neck. family/ caregiver teaching on Patient Education Record. FORMS EQUIPMENT Keep at bedside/have readily available for emergency use: manual ventilation bag if indicated suction set-up suction catheters standard trach: 1-same-size as current trach and 1-one-size smaller Bivona trach: 1 extra same-size-trach tube (clearly labeled with patient s name from armband label) sterile lubricant extra Velcro collar or trach ties obturator: same-size as current trach tube taped at the head-of-bed (HOB) scissors sterile hemostat 10ml syringe GENERAL: sterile tracheostomy care kit additional cotton swabs, gauze, etc. Velcro tracheostomy holder/twill tape suction set-up suction catheters Saline note date and time as opened bottles expire after 24 hrs. Hydrogen peroxide note date and time as opened bottles expire after 24 hrs Standards Page 4 of 5

5 REFERENCES Guidelines for Otorhinolaryngology Head & Neck Nursing Practice. (1996). Society of Otorhinolaryngology & Head-Neck Nurses, New Smyrna Beach, FL. Wiegand, D., & Carlson, K. (Eds.) (2005). AACN Procedure Manual for Critical Care. St. Louis. Elsevier Saunders. APPROVAL: Prepared by Reviewed by Approved By Approved By Latest Revision Approved By Name Signature Date Standards Page 5 of 5