Tracheostomy, ECG, and CBG PDF

Reviewer in Tracheostomy, ECG, and CBG Tracheostomy care Tracheostomies require routine care to prevent infection and obstruction, as well as frequent suctioning to maintain a patent airway. Tracheostomy care and suctioning are performed collaboratively by nurses and respiratory therap...

Reviewer in Tracheostomy, ECG, and CBG Tracheostomy care Tracheostomies require routine care to prevent infection and obstruction, as well as frequent suctioning to maintain a patent airway. Tracheostomy care and suctioning are performed collaboratively by nurses and respiratory therapists. Tracheostomy Technically, the term tracheotomy refers to the incision (cut) that your surgeon creates in your windpipe. The term tracheostomy refers to the opening itself. (This opening is also called a stoma.) Who needs to have a tracheostomy? Have an obstruction in your upper airway (nose, mouth or throat). Have difficulty swallowing. Have trouble breathing due to injury, swelling or lung conditions is a surgical procedure in which your Undergo airway reconstruction surgeon creates a hole through your following surgery on neck and into your trachea (windpipe). your larynx (voice box) or pharynx It opens your airway and helps you (throat). breathe. Need mechanical Depending on the specific situation, a ventilation (breathing machine) for tracheostomy might be temporary or more than a week. permanent. What are the risks or complications Goals of tracheostomy? The goal is to deliver oxygen to your lungs Possible complications include: easily and safely. Bleeding. You might need a tracheostomy if you have Infection. an obstructed upper airway or an Damage to your esophagus. underlying health condition. Damage to your trachea (windpipe). Tracheostom  Tracheo-esophageal fistula (an Cleaning your trach tube is important for abnormal opening between your these reasons: trachea and esophagus). 1. Regular cleaning prevents skin irritation that Injury to your recurrent laryngeal can lead to infection around the stoma site. nerve (the nerve that moves your 2. It reduces the risk for respiratory infections. vocal cords). Cleaning prevents buildup of dried secretions Blocked tracheostomy. (Mucus that can block the tracheostomy tube. or blood clots can block your 3. Research has proved that secretions can be tracheostomy tube.) harmful to skin health and increase the risk for Air that becomes trapped in your infection. lungs, chest or under the skin around your tracheostomy. When cleaning your tracheostomy, it's Keeping your tracheostomy tube clean and important to be well prepared with the right following all recommended guidelines can supplies in case of an emergency. For reduce your risk of developing these example, have extra trach tubes, a manual complications. ventilator bag, an obturator that is your size, and a suctioning device with catheters available. Steps in tracheostomy suctioning not leave the suctioning catheter for more than 10 seconds. After suctioning, allow at least 10–15 seconds and allow the person to take deep breaths or to use oxygen if necessary. Rinse the catheter by suctioning saline or clean water in a separate bowl. Repeat steps 5–8 if necessary. Cleaning Your Tracheostomy Inner Cannula and Skin Maintain airway patency by removing mucus and encrusted secretions. Promote cleanliness and prevent infection and skin breakdown at stoma site. ASSESSMENT Assess for excess peristomal secretions, excess intra-tracheal secretions, or soiled tracheostomy dressing and ties. Assess respiratory status: breath The person performing the procedure sounds, respiratory rate, skin color, needs to ensure they have washed their labored breathing, flared nares or sternal hands properly and are wearing gloves. retractions, arterial blood gases. Attach the suctioning tube to the Identify factors that influence connecting tube of the suctioning tracheostomy care: machine. Turn the machine on. ○ Inadequate nutritional status Ensure the person receiving the predisposes client to infection, suctioning has their head and shoulders poor healing, and weak cough elevated slightly. Coughing before the reflex. procedure and wiping away the mucus is ○ Respiratory infection: pulmonary beneficial. secretions increase in amount. The individual receiving the suctioning Note color, amount, and odor. should take three to four deep breaths ○ Fluid status: inadequate hydration before inserting the catheter. increases tenaciousness of Gently insert the suction tube about 4–5 secretions. Client may have inches into the inner tube of the airway. difficulty coughing up thick They should apply no suction at this secretions. point. ○ Humidity: tracheostomy collars Once the catheter is in place or deliver humidified air to prevent resistance is felt, apply suction by using dry, cracked membranes and the thumb to cover the suctioning vent thickened secretions. (hole) of the tube. Identify type of tracheostomy tube used At the same time as applying the suction, and if inner cannula is present. Identify if gently start pulling out the catheter. Do  tracheostomy tube is cuffed and if the cuff 5. Replace oxygen or humidification source and is inflated. encourage client to deep-breathe as you Assess client's ability to understand and prepare sterile supplies. Do not snap in place. perform independent tracheostomy care. Rationale: Maintain good oxygenation status. Promotes easy removal prior to sterile procedure. EQUIPMENTS 6. Open sterile tracheostomy kit (Fig. 2). Pour Sterile tracheostomy care kit containing: normal saline into one basin, hydrogen peroxide ○ Two basins into the second (Fig. 3). Don Sterile gloves (Fig. ○ Small brush or pipe cleaners 4). Open several sterile cotton-tipped ○ 4" × 4" gauze applicators and one sterile precut tracheostomy ○ Commercially available tracheostomy dressing and place on sterile field (Fig. 5). If kit dressing does not contain tracheostomy ties, cut two 15- ○ Twill tape or tracheostomy ties inch pieces of twill tape and set aside. Hydrogen peroxide Normal saline Rationale: Preparing equipment allows for Sterile gloves smooth, organized performance of Scissors tracheostomy care. Tracheostomy suction supplies 7. Remove oxygen source (Fig. 6). The hand that touches the oxygen source is no longer sterile. Note: For trache ostomy tube with inner PROCEDURES cannula, complete Steps 7 to 25. For 1. Verify the physician order and identify the tracheostomy tube without inner cannula or client. plugged with a button, complete Steps 14 to 25. Rationale: Prevents potential errors. Rationale: Prevents contamination of sterile gloves. 2. Wash your hands and don gloves. 8. Unlock inner cannula by turning Rationale: Handwashing and gloves reduce counterclockwise. Remove inner cannula transmission of microorganisms. 9. Place inner cannula in basin with hydrogen 3. Explain procedure to client. Place the client in peroxide. semi- to high Fowler's position Rationale: Hydrogen peroxide loosens and Rationale: Teaching decreases client removes secretions from inner cannula. anxiety and increases compliance. 10. Replace oxygen source over or near outer 4. Suction tracheostomy tube. Before discarding cannula. gloves, remove soiled tracheostomy dressing and discard with catheter inside glove. When Rationale: Maintain a constant supply of suctioning through a tracheostomy tube, insert oxygen to prevent respiratory or cardiac catheter about 10 to 12 cm (in an adult). distress. Note: Not all clients require a constant oxygen supply during Rationale: Removing secretions maintains a tracheostomy care. patent airway while doing tracheostomy cleaning. 11. Clean lumen and sides of inner cannula using pipe cleaners or sterile brush Rationale: Mechanical force and friction are Rationale: The tie is secured to the faceplate needed to remove thick or dried secretions. without using knots. Knots are difficult to undo when ties become crusted with 12. Clean inner cannula with brush. Rinse inner secretions. cannula thoroughly by agitating in normal saline for several seconds. 3. Repeat Step 21 with the second tie. Rationale: Rinsing and agitation remove 24. Bring both ties together at one side of the secretions and water from cannula and client's neck. Assess that ties are only tight provide lubrication for easy reinsertion. enough to allow one finger between tie and neck. Use two square knots to secure the ties. 13. Remove oxygen source and replace inner Trim excess tie length. Note: Assess tautness of cannula into outer cannula. "Lock" by turning tracheostomy ties frequently in clients whose clockwise until the two blue dots align. Replace neck may swell from trauma or surgery. oxygen or humidity source. Rationale: Ties must be taut enough to Rationale: Oxygen is reestablished to a prevent accidental dislodging of secured inner cannula. tracheostomy tube but loose enough not to 14. Remove tracheostomy dressing from under cause choking or pressure on the jugular faceplate veins. Ties at side of neck are more comfortable for the client. 15. Clean stoma under faceplate with circular motion using hydrogen peroxide-soaked cotton applicators. Clean dried secretions from all For tracheostomy collar exposed outer cannula surfaces (Fig. 13). 25. While an assisting nurse holds the faceplate, Rationale: Dried secretions are a good gently pull the Velcro tab and remove the collar medium for bacterial growth. on one side. Insert the new collar into the 16. Remove foaming secretions using normal opening on the faceplate and secure the Velcro saline-soaked, cotton-tipped applicators. tab. Rationale: Hydrogen peroxide can be 26. Hold faceplate in place as the assisting irritating to the skin. nurse repeats step on the second side 17. Pat moist surfaces dry with 4" × 4" gauze. 27 Remove the old collar and ensure that the new collar is securely in place (Fig. 18). Rationale: Moist surfaces support growth of microorganisms and skin excoriation. 28. Remove gloves and discard disposable equipment. Label with date and time, and store reusable supplies. For Tracheostomy ties Rationale: Opened normal saline is 20. Cut a 12-inch slit approximately 1 inch from considered sterile for 24 hours. one end of both clean tracheostomy ties. This is 29. Assist client to comfortable position and offer easily done by folding back on itself 1 inch of the oral hygiene. tie and cutting a small slit in the middle. Rationale: Promotes client comfort. 21 Remove and discard soiled tracheostomy ties. 30 Wash your hands. 22. Thread end of tie through cut slit in tie. Pull tight. Rationale: Maintains infection control and Patient preparation. Before the ECG communicates with other healthcare team procedure, nurses are responsible for members. preparing the patient for the test.... ECG equipment setup.... Performing the ECG test.... ELECTROCARDIOGRAM (ECG) Documentation and reporting.... Patient Education.... Monitoring and follow-up. What are the nursing considerations before recording an ECG? Assess the client's medical record for information regarding the needs for an ECG. Assess the client's heart rate, heart sounds, and blood pressure. Assess the client's chest for areas of irritation, skin breakdown, or excessive hair growth that may interfere with the electrode placement. What should you instruct patients to do before an ECG? 1. removing any metallic objects such as jewelry. is a representation of the electrical 2. possibly shaving chest hair. events of the cardiac cycle. Each event 3. avoiding drinking cold water right before has a distinctive waveform, the study of test. waveform can lead to greater insight into 4. no exercising, or increasing your heart a patient's cardiac pathophysiology. rate, before the test. 5. keeping the room at a moderate temperature to avoid shivering. What does an ECG test for? An ECG can help detect problems with 12 Lead ECG Placement Guide your heart rate or heart rhythm. It can The correct positioning of leads is essential to help doctors tell if you're having a heart taking an accurate 12 lead resting ECG and attack or if you've had a heart attack in incorrect placement of leads can lead to a false the past. An ECG is usually one of the diagnosis of infarction or negative changes on first heart tests you will have. the ECG. This guide explains the common position for each of the 10 leads on a 12 lead resting ECG. Nursing Responsibilities in ECG  What are the nursing considerations before recording an ECG? Assess the client's medical record for information regarding the needs for an ECG. Assess the client's heart rate, heart sounds, and blood pressure. Assess the client's chest for areas of irritation, skin breakdown, or excessive hair growth that may interfere with the electrode placement. During the ECG test, nurses are responsible for monitoring the patient, ensuring that the electrodes are in the correct position, and recording the ECG data accurately. They should be knowledgeable about the various types of ECG tests and understand the appropriate lead placement for each test. CAPILLARY BLOOD GLUCOSE (CBG) A method used to check blood glucose levels of clients with insulin-dependent diabetes mellitus (IDDM) or Type I and non-insulin-dependent diabetes mellitus (NIDDM) or Type II. V1 - Fourth intercostal space on the right sternum V2 - Fourth intercostal space at the left sternum V3 - Midway between placement of V2 and V4 V4 - Fifth intercostal space at the midclavicular line V5 - Anterior axillary line on the same horizontal level as V4 V6 - Mid-axillary line on the same horizontal level as V4 and V5 PURPOSE Factors Affecting Laboratory Results To monitor or determine blood glucose Insufficient blood drop after the test levels of clients at risk for hyperglycemia Do not milk (massage) the finger. It can or hypoglycemia cause inaccurate result To promote blood glucose regulation by the client To evaluate the effectiveness of insulin NURSING IMPLICATIONS administration Obtain a history regarding the client’s glucose testing method, including past glucose testing results CLINICAL PROBLEMS Answer the client’s questions Decreased level: Insulin overdose Increased level: Diabetes mellitus, hyperalimentation, excessive stress Client Teaching Drugs that may Increase Glucose Value: Steroids, Thiazide, Diuretics Discuss the procedure with the client; have client demonstrate the procedure Discuss the course of action the client should take if the test result is abnormal Finger-Stick Capillary Method Instruct the client to take insulin or the 1. Check the procedure on the specific oral hypoglycemic agent at the glucose monitoring device prescribed time 2. Cleanse the finger site with alcohol; wipe Tell the client to report immediately signs dry and symptoms of hypoglycemia or 3. Puncture the lateral side of the finger; hypoglycemia wipe off the first drop of blood Instruct the client to keep accurate 4. Let large drop of blood drop onto the records of the glucose tests reagent strip; the blood should cover the Encourage the client to keep all medical pad of the strip appointments 5. Place the reagent strip into the meter for UNEXPECTED RELATED reading; follow the directions on the OUTCOMES INTERVENTIONS meter 1. The puncture site -Apply pressure 6. Apply pressure to the site until bleeding is bruised or -Notify the health care has stopped continues to bleed provider if bleeding continues -Continue to monitor Heel-Stick the patient 2. Blood glucose 1. Use the same method for obtaining a level is above or -Check if there are finger stick; however, hold the heel in a below the target medication orders for dependent position to allow the blood to range deviations in glucose accumulate level 2. A capillary tube to obtain the blood -Notify health care specimen may be necessary for blood provider glucose testing -Administer insulin or carbohydrate source as ordered,  depending on glucose level 3. Glucose meter -Review instructions malfunctions for troubleshooting glucose meters -Repeat test 4. Patient expresses -Repeat instructions misunderstanding of to the patient procedure and -Have the patient results demonstrate the procedure