Term
| What materials are needed in a trach care kit? |
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Definition
sterile gloves
neck ties
cotton swabs
4x4's
sterile water/saline
hydrogen peroxide
FOLLOW FACULTY PROTOCOL |
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Term
| does the nurse use sterile technique |
|
Definition
|
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Term
| What is important to have by the bedside? |
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Definition
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Term
| When the cuff of the trach is inflated ... |
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Definition
| air will not go above the site of the trach, so patient will not be able to speak and will not aspirate. |
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Term
| How much room should be able to fit under neck ties? |
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Definition
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Term
| What is different about a fenestration trach? |
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Definition
It has holes in the out cannula. The holes allow air to passs from lungs through vocal cords.
It allow you to cough out secretions and talk.
Used before the removal of a trach (as a trial) |
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Term
| Parts of fenestration tubes... |
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Definition
| outter cannula, inner cannula, obturator , cuff, and plug |
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Term
| the outer canula is placed in the stoma to.... |
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Definition
| keep the hole from closing |
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Term
| The inner cannula fits into the outer cannula so that... |
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Definition
| it can be removed for cleaning |
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|
Term
| pasamural valve is used to... |
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Definition
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Term
| Risk associated with trachs... |
|
Definition
| loose the humidification feature of the nose, so more at risk for dried secretions. Also loose the ability to warm and filter are so there is an increase of upper respritory infections |
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Term
| Tracheostomy Post-Op complications? |
|
Definition
tube obstruction
tube dislodgement
accidental decannulation
pneumothorax
SC emphysema (snap, crackle, pop)
Bleeding
Infection |
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Term
| What should the nurse do when there is an accidental decannulation? |
|
Definition
make sure patient is getting O2
Early post-op (72h) this is a medical emergency, and nurse needs to call a code or anesthesia, or physican |
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Term
| Always keep supplies at patients bedside for... |
|
Definition
Suctioning
tube and stoma care
delivery of O2
humidity
tracheostomytube replacement with obturator
artifical ventilation (resuscitation bag) |
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Term
| Begin trach assessment by... |
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Definition
| inspecting stoma site (typically slightly larger than trach tube |
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Term
| What should be assessed of the stoma secretions? |
|
Definition
color
consistency and odor |
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Term
| What would indicate that pt's airway needs suctioning? |
|
Definition
course breath sounds
noisy breathing
prolonged expiratroy sounds |
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Term
| What is used to clean a reusable cannula? |
|
Definition
equal parts of hydrogen peroxide 0.9% (normal saline) or sterile water.
CLEAN USING STERILE TECHNIQUE. |
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Term
| The DO NOT's when providing trach care |
|
Definition
DO NOT
reuse disposable cannula
cut gauze (always use precut, or could aspirate particles)
lavage should only be done when suctioning to clear blockage
don't allow humidifier to empty
allow condinstion to accummulate in o2 delivery tubing.
insert trach button or Passe Muir valve without deflating cuff |
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Term
| the DO's of chest tube care |
|
Definition
DO
obtain baseline vitals
assess repiratory funcion, O2 saturation, immediatly after insertion of chest tube; CXR doen immediately following and per MD orders
-Routinely assess tube function and connection to dressing site
-record amount of drainage per orders
-keep 2 rubber tipped clamps at bedside
-keep vasoline gauze at bedside |
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Term
| Fluid in water seal chamber typically... |
|
Definition
rises on inspiration
decreases on expiration |
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Term
| If accidental dislodgement occurs the nurse should.. |
|
Definition
| insert end into a bottle of sterile water. |
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Term
| What does the nurse do if tube completely comes out of patient? |
|
Definition
| cover opening and assess ABC's |
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Term
| Things to avoid when using a chest tube. |
|
Definition
-loops, kinks or pressure in tubing
-lifting drainage system above patients chest.
-Never clamp chest tube unless there is a need to change out drainage system and if done then make sure it is done QUICKLY |
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