Fundamentals of Nursing Q 419
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? Select all that apply.
A. Apply the oxygen source loosely if the SPO2 increases during the procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer surfaces in a circular motion from the stoma site outward.
D. Replace the tracheostomy ties with new ties.
E. Cut a slit in gauze squares to place beneath the tube holder.
Correct Answer: A, B, & C
A tracheostomy is an opening (made by an incision) through the neck into the trachea (windpipe). A tracheostomy opens the airway and aids breathing. A tracheostomy may be required in an emergent setting to bypass an obstructed airway, or (more commonly) may be placed electively to facilitate mechanical ventilation, to wean from a ventilator, or to allow more efficient management of secretions (referred to as pulmonary toilet), among other reasons.
Option A: The nurse must be prepared to provide supplemental oxygen in response to any decline in oxygenation saturation while performing tracheostomy care. Nurses need to understand all aspects of tracheostomy care, including routine and emergency airway management, safe decannulation, weaning and safe discharge into the community. The patient’s airway requires close monitoring 24 hours a day using a tracheostomy care chart to record care.
Option B: The nurse should use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. The NTSP (2013) recommends that all patients with a tracheostomy have a bed-head label with information regarding their tube and airway, including whether it is surgical or percutaneous, the tube type, size and suction-catheter size, patency of the upper airway and whether the tracheostomy is temporary, permanent or involves a laryngectomy (removal of the larynx).
Option C: This action helps move mucus and contaminated material away from the stoma for easy removal. The stoma site should be checked at least once a day, or more frequently if required, and this requires two nurses: one to hold the tube and one to clean the stoma site. The site should be cleaned using a tracheostomy wipe or with 0.9% sodium chloride solution, and dried thoroughly.
Option D: To help keep the skin clean and dry, the nurse should replace the tracheostomy ties if they are wet or soiled. There is a risk of two dislodgements replacing the ties, so he should not replace them routinely. Leaving the old ties in place while securing the clean ties prevents inadvertent dislodging of the tracheostomy tube. Securing tapes in this manner avoids the use of knots, which can come untied or cause pressure and irritation.
Option E: The nurse should use a commercially prepared tracheostomy dressing with a slit in it. Cutting gauze squares can loosen lint or cause fibers the client could aspirate. Use a commercially prepared tracheostomy dressing of non-raveling material or open and refold a 4-in. X 4-in. Gauze dressing into a V shape. Avoid using cotton-filled gauze squares or cutting the 4×4 gauze. Cotton lint or gauze fibers can be aspirated by the client, potentially creating a tracheal abscess.