Download How to ease your fear of working with a tracheostomy patient

ALL ABOUT TRACHEOSTOMIES
WHAT IS A TRACHEOSTOMY?
• A TRACHEOSTOMY IS A MEDICAL PROCEDURE — EITHER TEMPORARY OR PERMANENT — THAT
INVOLVES CREATING AN OPENING IN THE NECK IN ORDER TO PLACE A TUBE INTO A PERSON’S
WINDPIPE.
• THE TUBE IS INSERTED THROUGH A CUT IN THE NECK BELOW THE VOCAL CORDS. THIS
ALLOWS AIR TO ENTER THE LUNGS. BREATHING IS THEN DONE THROUGH THE TUBE,
BYPASSING THE MOUTH, NOSE, AND THROAT.
• A TRACHEOSTOMY IS COMMONLY REFERRED TO AS A STOMA. THIS IS THE NAME FOR THE
HOLE IN THE NECK THAT THE TUBE PASSES THROUGH.
WHY A TRACHEOSTOMY IS PERFORMED
• A TRACHEOSTOMY IS PERFORMED FOR SEVERAL REASONS, ALL
INVOLVING RESTRICTED AIRWAYS. IT MAY BE DONE DURING AN
EMERGENCY WHEN YOUR AIRWAY IS BLOCKED. OR IT COULD BE
USED WHEN A DISEASE OR OTHER PROBLEM MAKES NORMAL
BREATHING IMPOSSIBLE.
•
CONDITIONS THAT MAY REQUIRE A TRACHEOSTOMY
INCLUDE:
• ANAPHYLAXIS
• OBSTRUCTION OF THE AIRWAY BY A FOREIGN BODY
• BIRTH DEFECTS OF THE AIRWAY
• OBSTRUCTIVE SLEEP APNEA
• BURNS OF THE AIRWAY FROM INHALATION OF
CORROSIVE MATERIAL
• PARALYSIS OF THE MUSCLES USED IN SWALLOWING
• CANCER IN THE NECK
• SEVERE NECK OR MOUTH INJURIES
• CHRONIC LUNG DISEASE
• TUMORS
• COMA
• VOCAL CORD PARALYSIS
• DIAPHRAGM DYSFUNCTION
• INJURY TO THE CHEST WALL
• FACIAL BURNS OR SURGERY
• INFECTION
• INJURY TO THE LARYNX OR LARYNGECTOMY
• NEED FOR PROLONGED RESPIRATORY OR VENTILATOR
SUPPORT
BASIC NURSING PRINCIPLES OF CARING FOR PATIENTS WITH A TRACHEOSTOMY
• AIRWAY OCCLUSION IS THE MOST SERIOUS COMPLICATION ARISING FROM A TRACHEOSTOMY. IT IS A
MEDICAL EMERGENCY AND CAN RESULT IN CARDIAC ARREST (WOODROW, 2002). PATIENTS WITH A
TRACHEOSTOMY SHOULD BE NURSED UNDER CLOSE OBSERVATION, IN AN AREA WITH FUNCTIONAL
OXYGEN AND SUCTION APPARATUS. BASIC VITAL SIGNS MONITORING, PARTICULARLY RESPIRATORY
RATE, SHOULD BE COMPLEMENTED BY MORE ADVANCED MONITORING SUCH AS PULSE OXIMETRY.
• NURSES CARING FOR TRACHEOSTOMISED PATIENTS SHOULD BE SKILLED AND COMPETENT IN ALL
ASPECTS OF CARE. THEY SHOULD BE ABLE TO DETECT PARTIAL AND TOTAL AIRWAY OBSTRUCTION AND
SHOULD ALSO HAVE THE NECESSARY SKILLS TO SECURE AN AIRWAY IF THIS OCCURS.
• THE MOST COMMON CAUSE OF OBSTRUCTION IS A BUILD-UP OF RESPIRATORY SECRETIONS IN THE TUBE.
SUCTION VIA THE TUBE CAN IMMEDIATELY REMEDY THIS.
CONTINUED……..
• MOST TRACHEOSTOMIES ARE OF AN ‘INNER TUBE DESIGN’ - WHERE A SMALL PLASTIC INNER TUBE SITS INSIDE
A LARGER ONE. IF PARTIAL/TOTAL OCCLUSION IS SUSPECTED, THIS INNER PART CAN BE REMOVED AND A
TEMPORARY SPARE INNER TUBE WILL REPLACE THE OCCLUDED ONE, CREATING A CLEAR ROUTE. THESE SPARE
TUBES SHOULD BE KEPT NEARBY IN THE PATIENT’S BED SPACE.
• IF THE TUBE IS NOT AN INNER TUBE DESIGN AND OCCLUSION IS EVIDENT, THE TUBE SHOULD BE REMOVED AND
THE PATIENT’S ABILITY TO BREATHE WITHOUT THE TRACHEOSTOMY SHOULD BE ASSESSED.
• IN SOME PATIENTS THE STOMA MAY BE PATENT, AND/OR THEY MAY BE ABLE TO BREATHE THROUGH THE
NORMAL ROUTE.
• HOWEVER, IF THIS IS NOT THE CASE - WHICH IS PARTICULARLY LIKELY IF THE TRACHEOSTOMY IS PERMANENT TUBE REINSERTION WILL BE REQUIRED. IF THE STOMA IS PATENT, A TUBE OF THE SAME SIZE CAN BE REINSERTED
WITHOUT DIFFICULTY. HOWEVER, IT MAY ONLY BE POSSIBLE TO INSERT A SMALLER TUBE UNTIL MORE
EXPERIENCED HELP ARRIVES. TRACHEAL DILATORS MAY BE OF SOME USE TO DILATE THE STOMA AND THESE
SHOULD BE KEPT NEARBY IN THE BED SPACE, ALONGSIDE SPARE TUBES OF THE SAME AND SMALLER SIZE.
CONTINUED…….
• THE MAJORITY OF PATIENTS WITH TRACHEOSTOMIES WILL BE UNABLE TO SPEAK, AS THE TUBE/STOMA IS
POSITIONED BELOW THE LEVEL OF THE VOCAL CORDS. HOWEVER, THIS IS NOT ALWAYS THE CASE. A PATIENT
MAY BREATHE AROUND THE TRACHEOSTOMY, PARTICULARLY IF THE TUBE DOES NOT HAVE A CUFF, OR THE CUFF
IS DEFLATED. IN SOME CASES EXHALED AIR PASSES THROUGH SPECIALLY DESIGNED HOLES IN THE TUBE
(FENESTRATIONS) AND THROUGH THE VOCAL CORDS. SPECIFIC ‘SPEAKING VALVES’ HAVE ALSO BEEN
DEVELOPED TO ALLOW PATIENTS TO TALK.
• EFFECTIVE COMMUNICATION CAN BE A CHALLENGE WITH PATIENTS WITH TRACHEOSTOMIES, AND WRITTEN
AND OTHER NON-VERBAL COMMUNICATION STRATEGIES ARE NECESSARY. MANY NURSES EXPERIENCED IN
CARING FOR THIS GROUP OF PATIENTS DEVELOP CONSIDERABLE ‘LIP-READING’ SKILLS, WHICH ARE OF GREAT
VALUE. REGARDLESS OF THE COMMUNICATION STRATEGIES USED, NURSES MUST ALWAYS CONSIDER HOW THE
LOSS OF SPEECH WILL AFFECT PATIENTS AND THE ANXIETIES THIS MAY EVOKE. IF PERMANENT TRACHEOSTOMY
IS PLANNED, AS IN THE CASE OF LARYNGECTOMY, SPECIFIC COUNSELLING AND PSYCHOLOGICAL SUPPORT
WILL NEED TO BE IN PLACE FOR SOME TIME BEFORE THE PROCEDURE.
WHAT RESPIRATORY THERAPISTS WISH NURSES WOULD UNDERSTAND.
• 1. PLEASE DON’T ASK US IF WE ARE RESPIRATORY. WE HAVE NAMES AND IT PROBABLY ISN’T “RESPIRATORY”. INSTEAD ASK US IF WE
ARE FROM RESPIRATORY IF YOU DON’T KNOW OUR NAMES. WE DON’T ASK YOU IF YOU ARE “NURSE”. PLEASE DON’T CALL US
“TECHS” EITHER. CHANCES ARE, UNLESS YOU HAVE YOUR BSN, WE HAVE HAD MORE SCHOOLING THAN YOU.
2. A WHEEZE…THAT BREATH SOUND THAT IS CAUSED BY BRONCHOSPASM…IS ALWAYS HIGH PITCHED. IF IT’S A LOW PITCHED
“WHEEZE” THAT YOU HEAR, IT’S RHONCHI AND A TREATMENT WILL DO NOTHING TO HELP. WHAT YOU HEAR IS THE SOUND OF
SECRETIONS IN THE LARGE AIRWAY. HAVE YOUR PATIENT COUGH. CALL THE DOCTOR TO ORDER A MUCOLTYIC.
3. BRONCHODILATORS DON’T DO ANYTHING FOR MOBILIZING SECRETIONS UNLESS THE PATIENT HAS ASTHMA AND THE MUCOUS IS
BEING BLOCKED BY SPASMING AIRWAYS. IT DOES NOTHING FOR ANYTHING UPPER AIRWAY. SEE #2.
4. IF THE PATIENT IS “WHEEZING” BECAUSE OF BEING FLUID OVERLOADED DUE TO PULMONARY EDEMA, BRONCHODILATORS WON’T
HELP. UNFORTUNATELY, SCIENCE HASN’T FOUND A WAY TO PUT SWIMMING ARMS ON THE BRONCHODILATOR TO ALLOW IT TO MAKE
IT PASS THROUGH ALL OF THE FLUID TO THE SMALLER AIRWAYS WHERE THE MEDICATION ACTUALLY WORKS. IF THE PATIENT DOES
HAVE ASTHMA, A BRONCHODILATOR MAY HELP A BIT, BUT THEY WILL STILL NEED A DIURETIC OR GET DIALYZED.
5. WE AREN’T THE ONLY ONES THAT KNOW HOW TO NT SUCTION. YOU WERE TRAINED TO DO IT AS WELL. DON’T CALL US TO DO IT
UNLESS YOU HAVE AT LEAST TRIED TO DO IT YOURSELF. CERTAINLY DON’T TELL US THAT YOU ALREADY TRIED AND NOT HAVE EVEN
BOTHERED TO MAKE SURE THAT THERE IS A SUCTION CANISTER SET UP IN THE ROOM FOR WHEN WE ARRIVE. MOST LIKELY IF WE
AREN’T ON YOUR FLOOR WE ARE BUSY IN A UNIT IN ANOTHER PART OF THE HOSPITAL.
CONTINUED………
• 6. PLEASE DON’T CALL US TO SAY THAT YOUR PATIENT NEEDS A TREATMENT. ASK US IF WE COULD COME ASSESS YOUR PATIENT. IF
THEY NEED ONE, WE WILL BE MORE THAN HAPPY TO ADMINISTER IT. YEARS AGO, I ARRIVED IN A PATIENT’S ROOM BY REQUEST OF A
NURSE TO GIVE A TREATMENT AND HE WAS IN OBVIOUS DISTRESS. HE HAD NO PULMONARY HISTORY PER HIS CHART (A BIG TIP OFF). I
LISTENED TO HIS LUNGS…RIGHT SIDE WAS TOTALLY CLEAR AND LEFT SIDE WAS ABSENT. I EXPLAINED TO THE NURSE THAT HE DIDN’T
NEED A TREATMENT BUT INSTEAD NEED A STAT CXR. I HAD TO CALL THE MD MYSELF AS THE RN WAS TOO BUSY BEING UPSET WITH ME
FOR REFUSING TO GIVE THE TREATMENT. THE CXR REVEALED A MASSIVE PLURAL EFFUSION. THE PATIENT WAS TAKEN TO THE UNIT AND
THE HAD ALMOST 3 LITERS OF FLUID REMOVED FROM HIS LEFT PLEURAL SPACE VIA THORACENTESIS. I NEVER GAVE THE TREATMENT.
7. DON’T TOUCH ANY BUTTON OR KNOB ON THE VENT EXCEPT THE FIO2. ONLY TOUCH IT TO GO UP IF THE PATIENT IS DESATURATING
AND CALL US TO LET US KNOW WHAT HAPPENED. DO NOT WEAN IT FOR US. WE ARE RESPONSIBLE FOR ALL SETTINGS IN THAT
MACHINE. WE DON’T TOUCH YOUR PUMPS.
8. CHANCES ARE, WE DO NOT GET ANOTHER RT TO COVER OUR ASSIGNMENT WHEN WE TAKE OUR LUNCH BREAK. WE ALWAYS
CARRY OUR PHONE OR PAGER AND ARE RESPONSIBLE FOR ANSWERING THEM EVEN WHEN WE FINALLY GET A CHANCE TO EAT.
9. IF YOUR PATIENT HAS A TRACH AND BECOMES ACUTELY DISTRESSED, PLEASE CHECK TO MAKE SURE THE INNER CANNULA IS PATENT.
IT CAN TAKE US 10 MINUTES TO GET TO BEDSIDE AND THAT’S LONG ENOUGH FOR YOUR PATIENT TO CODE. CHECKING THE INNER
CANNULA TAKES 5 SECONDS.
•
WHAT NOT TO DO WITH YOUR TRACH PATIENT!!!!