Fundamentals of Nursing Q 287
Nurse Trixie is preparing to perform tracheostomy care. Prior to the beginning of the procedure, the nurse performs which action?
A. Tells the client to raise two fingers to indicate pain or distress.
B. Changes twill tape holding the tracheostomy and place.
C. Cleans the incision site.
D. Check the tightness of the ties and knot.
Correct Answer: A. Tells the client to raise two fingers to indicate pain or distress.
Prior to starting the procedure, it is important to develop a means of communication by which the client can express pain or discomfort. Tracheostomy is a procedure where an artificial airway is established surgically or percutaneously in the cervical trachea. The term “tracheostomy” has evolved to refer to both the procedure as well as the clinical condition of having a tracheostomy tube. With the increasing number of patients with tracheostomy, safe caring requires knowledge and competencies in dealing with routine care, weaning, decannulation, as well as tracheostomy-related emergencies.
Option B: The twill tape is not changed until after performing tracheostomy care. Remove any sutures or ties attached to the tracheostomy tube and patient. When doing this, the assistant must stabilize the flange at all times to prevent premature removal.
Option C: Cleaning the incision should be done after cleaning the inner cannula. Inspect the stoma for signs of infection, presence of granulation tissue, bleeding, wound breakdown, and adequacy of a tract. Clean the area with moist gauze (with normal saline or hydrogen peroxide) followed by dry gauze while ensuring no foreign body enters the airway. Stay sutures, if present, may be used gently to pull up the trachea to provide exposure.
Option D: Checking the tightness of the ties and knot is done after applying new twill tape. Make sure the trach ties are not too tight and should be able to pass an index finger in between the trach ties and neck.