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Name some S/S of complications for a patient on a trach?
- Coughing
- Unable to suction
- Dyspnea
- Restlessness
- Low SpO2
- Tube/cuff displacement
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How can we prevent trach tube obstruction?
- Humidification
- Hydration
- Routine trach care Q2H
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What are some tracheostomy post-op complications?
- tracheomalacia
- tracheal stenosis
- tracheoesophageal fistula
- trachea-innominate artery fistula
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What is tracheomalacia?
- pressure from the cuff causes
- tracheal dilation and erosion of cartilage
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What are manifestations of tracheomalacia?
- more pressure is needed in the cuff
- suctioning food particles
- Breathing machine would see the tidal volume is changing.
- Best thing to do – get them on a trach that is non cuffed ASAP
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What is Tracheal Stenosis?
- narrowed tracheal lumen
- due to scar formation from irritation of tracheal mucosa by the cuff
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What is Tracheoesophageal Fistula?
- erosion of posterior wall of trachea
- usually seen when the pt has NG tube
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What are S/S of tracheoesophageal fistula?
- Increased coughing and choking
- will see food particles with suction
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What is Trachea-innominate artery fistula?
Necrosis of the innominate artery due to constant pressure (necrosis and erosion)
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What are S/S of Trachea-innominate artery fistula?
- Trach tube that pulsating – REMEMBER THIS
- Do not leave the patient
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If a tracheostomy tube dislodges in an immature stoma, what does the nurse do?
- Emergency!
- Have another nurse call RRT
- Ventilate using bag and mask
- Skilled provider must replace
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If a tracheostomy tube dislodges in a mature (>72 hours) stoma, what does the nurse do?
the nurse can slip it back in
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How do we prevent dislodgement of trach tubes?
- Keep old ties in place when attaching a new one, then remove old ties
- Safest way is to have two people change ties
- One finger width in between tie and skin
- Make sure all items are at bedside for emergency
- Tube replacement (same size and one size smaller)
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Name some potential complications of tracheostomy surgery
- Pneumothorax (in OR)
- Subcutaneous emphysema (crepitus)
- bleeding (oozing normal)
- infection
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What does the nurse do if crepitus is found?
- within the first 72 hours – EMERGENCY – trachea is sending air into the tissues
- After 72 hours it’s still a big deal but not emergent
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How can we prevent infection of trach's?
- Trach care – aseptic technique
- Don’t cut gauze – small bits will be aspirated
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A patient on a mechanical vent - the trach tube must be?
cuffed
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What does a fenestrated trach tube do?
allows patient to talk
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What is critical to know when working with fenestrated trach tubes?
- deflate the cuff BEFORE capping
- patient will suffocate!!!
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What should the cuff pressure be on a trach tube?
20-30 cm H2O
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What is the temperature range of air entering a trach?
>98.6 but below 104
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What is the best practice for QSEN on suctioning the artificial airway?
- Assess the need to suction
- Wash hands
- Explain SOB and coughing are expected
- Check suction source (between 80-100 mm Hg)
- Set up sterile field
- preoxygenate with 100% O2 (30s - 3m)
- Quickly insert suction cath until resistance
- Withdraw cath and apply suction (NEVER longer than 10-15s)
- Hyperoxygenate 1-5m until baseline HR and O2 sat WNL
- Repeat for up to 3 passes
- suction mouth, provide oral care
- remove gloves, wash hands
- document secretions and patient's response
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How long do we suction?
- TOTAL of 10-15 seconds (going down and back)
- ONLY suction on the way out
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What is the suction set at for trach care?
80-100 mmHg
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What are two complications during trach suctioning?
- Vagal stimulation
- Bronchospasm
Stop suctioning immediately and oxygenate with 100% O2
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Why do we never use ORAL suction for an artificial airway?
Introduce oral bacteria into the lungs
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How do we prevent decannulation during trach care?
- keep old ties on while applying new ties
- two nurses is best
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Best practice (QSEN) for Tracheostomy Care?
- Assemble equipment
- wash hands
- suction the trach tube if necessary
- remove old dressing and excess secretions
- set up sterile field
- remove and clean inner cannula or replace if disposable
- clean stoma site and trach plate with half-strength hydrogen peroxide followed by sterile saline (make sure non enters trach)
- change trach ties if soiled
- wash hands
- document
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When someone is choking or coughing what should the nurse consider?
Aspiration
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Best practice (QSEN) for preventing aspiration during swallowing?
- avoid meals when fatigued
- smaller more frequent meals
- don't hurry the patient
- supervision if self-feeding
- keep emergency suction equipment close
- avoid water and thin liquids
- position in most upright position
- if possible completely or partially deflate cuff
- suction first
- ...
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Risk factors for Obstructive Sleep Apnea?
- Obesity
- Smoking
- Male
- Sedation
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S/S of Obstructive Sleep Apnea?
- Daytime sleepiness
- Daytime somnolence
- fatigue
- Confusion
- Memory loss
- Cardiovascular problems
- HTN
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How do patients find out they have sleep apnea?
- Spouse
- Wake up with a HA
- Testing
- Cap CO2 monitoring
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What do we do about Obstructive Sleep Apnea?
- CPAP
- Humidification
- Nasal Sprays
- Adjust padding on mask
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A patient on CPAP must do what?
Wear every time, even for naps
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This is an autoimmune disorder caused by bronchoconstriction due to hyperresponsiveness
Asthma
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Name some symptoms of asthma
- Triggers cause hyperresponsiveness (inflammation)
- Mucosal edema
- Excessive mucus production
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Name some triggers of asthma
- Allergies (mold, pollen, roaches, feathers, sulfates, house cleaners, sinusitis, infection, temperature changes)
- Exercise
- Meds: ASA, NSAID’s, beta-blockers
- GERD
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What can be done to treat asthma?
- Change locations
- Cleaning dust, etc
- Avoid allergens
- Avoid those meds
- Take a reliever (SABA) before exercise
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Name some clinical manifestations of asthma
- SOB (dyspnea)
- Barrel chest
- Anxious, agitated
- Wheezing – if suddenly stops without intervention – emergent, they are not moving air
- Tachycardia
- Accessory muscle use, intercostal retractions
- Tachypnea
- Stridor
- LOC – confusion, somnolence
- Cough with phlegm
- Tripod position – KNOW THIS
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Nursing education for patient with asthma
- Keep a diary to know more about triggers
- Peak-flow meter is essential
- Comply with meds is essential
- Avoid infections
- Seek regular f/u care
- Goal is to have less attacks, sleep better…
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What is critical for patient education of peak flow meter?
- If in 50-80% (yellow zone) range below norm - use reliever drug and reassess peak flow after a few minutes.
- If continues in this range see MD (not emerg)
- If less than 50% (red zone) below norm - use reliever drug and seek emergency attention
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How to use peak flow meter? (twice daily)
- set to zero
- stand - no leaning or support
- deep breath
- wrap lips tightly around mouth piece
- blow out breath hard and fast
- reset and perform twice more
- the highest reading of the three is current peak flow rate
- keep a record for trends
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When should an asthma patient seek emergency treatment?
- gray or blue fingertips or lips
- difficulty breathing, walking or talking
- retractions of the neck, chest, or ribs
- nasal flaring
- failure of drugs to control worsening symptoms
- peak expiratory flow rate declining steadily after treatment
- peak expiratory flow rate 50% below usual
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Educate patient to use inhaler with spacer
- remove caps, put inhaler into spacer
- shake vigorously
- lips around mouthpiece and seal tightly
- press down on canister
- breath in slowly and deeply
- remove mouthpiece - hold breath 10 sec then breath out slowly
- wait 1 min between puffs
- replace caps
- clean inhaler daily, clean spacer once a week
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Educate the patient to use inhaler without spacer
- remove cap and shake
- tilt head back slightly and breath out
- open mouth - place mouthpiece 1-2 in away
- press canister
- breath in slowly and deeply (5-7 sec)
- hold breath (10 sec) breath out slowly
- wait 1 min between puffs
- replace cap
- clean inhaler once a day
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Educate the patient to use a dry powder inhaler
- Load or insert capsule or disk into device
- MD gives instruction on breathing rate
- place lips around mouthpiece and breath in forcefully
- remove from mouth as soon as inhaled in
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What is important regarding the use of dry powder inhalers?
- not propelled - breathing in is what pulls drug in
- never exhale into inhaler
- never wash or place in water
- never shake
- keep in a dry place at room temp
- if preloaded discard when empty
- may not feel, smell, or taste
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In COPD what happens with ABG's
- CO2 produced faster than eliminated
- chronic respiratory acidosis (advanced disease)
- low PaO2
- high PaCO2
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This is the "blue bloater" - narrowing of bronchioles, may see JVD, no tissue damage:
Chronic Bronchitis
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This is the "pink puffer" - blowing off acid, loss of elasticity and hyperinflation of lungs, tissue damage:
Emphysema
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What are some causes of Emphysema?
- age
- smoking
- air pollutants
- ATT (alpha anti trypsin) deficiency – helps body to fend off bad pollutants (familial)
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Name some S/S of Emphysema
- Clubbing
- Barrel chest
- Flattened diaphragm
- PFT’s to diagnose
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What do we do for patients with COPD?
- Positioning – what makes them feel improved
- Teach them to purse lip breath
- Hydration
- Humidifier
- Clear of secretions to help O2
- Diet:
- Infection control
- Home O2 delivery
- Immunizations
- When to seek medical care
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Nursing interventions regarding COPD patients regarding diet?
- carbs break down into CO2 which adds to CO2 retention
- tiring
- small meals (6 a day)
- eat slowly
- rest before and after meals
- healthy but tastes good to them
- involve dietitian
- no liquids with or before meal (makes full)
- avoid dry or gassy foods
- dense calories and high in protein
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How is purse lip breathing done?
- Close mouth, breathe in through nose
- Purse lips as if whistling
- breath out slowly, without puffing cheeks
- use abdominal muscles to squeeze out every bit of air
- use during any physical activity
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With COPD, what cardiac complication can be seen?
- cor pulmonale (RIGHT sided HF)
- caused by pulmonary disease
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Patients with Emphysema are blowing off ? to get to ?
- blowing off acid
- to get to a regular pH
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Risk factors for Lung Cancer
- Smoking
- Pollutants (asbestos)
- Radiation exposure
- Age
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S/S of Lung Cancer
- May not know until advanced – no early symptom
- Hoarsness
- Cough
- Sputum production
- Hymoptosis
- Dyspnea
- Activity intolerance
- Once these are found – already progressed
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Name the two type of lung cancer
- Non-small cell - most common
- Small cell – most lethal
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How much water is required for a water seal chest tube drainage system?
- 2 cm of water
- check every shift
- add sterile water if necessary
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What does the water seal tell us?
- how the lung is progressing
- if the leak is improving then less bubbles in chamber
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Why is suction used in a chest tube?
- To pull air or fluid out of the lung
- must have doctor's order to D/C
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What tidaling tell us on a chest tube?
breathing of patient
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Notify physician or RRT for the following in a patient with a chest tube:
- tracheal deviation
- sudden onset or increased intensity of dyspnea
- O2 sat less than 90%
- drainage <100 ml/hr (70 ml in Iggy)
- Visible eyelets on chest tube
- chest tube falls out of the patient
- chest tube disconnects from the drainage system
- drainage tube stops (in the first 24H)
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What to do if chest tube comes out of patient?
- cover with dry, sterile gauze with one flap up
- No petroleum dressing
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What to do if chest tube comes our of drainage system?
place end in sterile water and keep below the level of the patient's chest
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What can happen if the tubing is clamped for longer than a few seconds?
Tension Pneumothorax - trachea and organs shift to one side
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What is the purpose of negative pressure with the chest tube?
allows for lung expansion
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