Chapter 28
Respiratory Care
571
periodically to prevent erosion of the trachea caused by pressure. You can tell if the cuff is in fl ated or de fl ated by checking the “pillow” on the tracheostomy. If it is in fl ated, the cuff is in fl ated. 2. The obturator, which fi ts inside the outer cannula and forms a smooth end for inserting the tracheostomy tube into the tracheotomy. The obturator is removed once the tube is in place and kept at the bedside in case the tube comes out and must be reinserted. The blunt edge of the open tube could not easily be inserted into the trachea. The obturator fi lls the blunt edge with a smooth, rounded end for ease of insertion. 3. The inner cannula is inserted after the obturator is removed. It may be a disposable tube, or it may be designed to be cleaned and replaced every 8 hours. Mucus collects in the inner cannula and can block the patient’s airway if it is not suctioned frequently and cleaned or replaced regularly. Because the tracheostomy diverts air fl ow from going past the vocal cords, the patient with a tracheostomy is unable to make vocal sounds. A fenestrated tracheostomy tube has two cannulas with an opening in the outer cannula, on the posterior side, just above the cuff. When the inner cannula is removed, the patient can breathe through the mouth and nose and can vocalize. The inner cannula must be in place to suction a fenestrated tracheostomy tube. A Passy-Muir valve is placed on the hub of the trache- ostomy and allows air to move into the trachea and past the vocal cords when the patient inhales, enabling speech. The remainder of the time the valve is in a closed position, which prevents air leaks. SUCTIONING AND CLEANING A TRACHEOSTOMY. To clear a tracheostomy tube, you will use aseptic technique to insert a suction catheter into the inner cannula and apply suction as you withdraw it. When you are applying suction, you are also removing oxygen as you remove mucus. Therefore this procedure should be done quickly and effectively. The suction catheter may be sheathed or unsheathed. As with the sheathed catheter for suctioning an endotracheal tube, you do not have to wear sterile gloves to touch the sheath because the sterile catheter remains protected inside it. Skill 28.7 explains the process of suctioning a tracheostomy. When you clean a tracheostomy, you will remove the inner cannula and clean it in hydrogen peroxide mixed half- strength with saline and then rinse it in saline, dry it, and reinsert it. This is done every 8 hours using sterile tech- nique to prevent introducing pathogens into the trachea and lungs. If the inner cannula is disposable, you will remove it and reinsert a new one rather than cleaning and reinserting. When a patient has a permanent tracheostomy and is caring for it at home, the technique used may be a clean procedure rather than a sterile one. Tracheostomy ties are generally changed at this time. Safety: If possible, have an assistant hold the tracheostomy tube in place while you change the ties or holders. If you are
performing this procedure alone, do NOT loosen and remove the old ties until the new ties are in place and secured. The patient can easily cough the tube completely out of the trachea if it does not remain secured in place. You may use foam tra- cheostomy tube holders that are held in place by Velcro or twill ties that you thread through the slots on the tracheos- tomy tube and tie. Skill 28.8 gives the steps for cleaning a tracheostomy tube and changing tracheostomy ties.
KNOWLEDGE CONNECTION What is the difference between an oropharyngeal airway and a nasopharyngeal airway? What is the purpose of an endotracheal tube? What is an obturator, and how is it used?
Chest Tubes If the negative pressure in the pleural cavity is disrupted, the lungs can no longer fully expand. This causes dys- pnea, chest pain, hypoxia, and respiratory distress. It may be caused by secretions obstructing the airways or traumatic injuries that penetrate the chest wall, for example, gunshot or stab wounds. This disruption also occurs after surgery that involves opening the chest, such as surgery on the lungs or heart. To reestablish the negative pressure within the pleural space, also known as the pleural cavity, the physician will insert chest tubes. Placement of Chest Tubes When air enters the pleural space, it rises to the top of the cavity. As you learned earlier, this is referred to as a pneumo- thorax. A chest tube is inserted into the pleural space through an incision in the anterior superior surface of the chest in the second to fourth intercostal space to release this air. When blood and drainage are present in the pleural space, they pool in the lower portion of the cavity; this is called a hemothorax. The chest tube to drain this fl uid is inserted in the anterior inferior area of the chest, between the eighth and ninth intercostal space, and enters the pleural space. In situ- ations in which both air and blood are in the pleural cavity, two tubes are placed, one higher and one lower, joined by a Y-connector, and then attached to tubing leading to a drain- age system. Chest tubes may be inserted at the bedside or in the emer- gency department. They also may be placed in surgery during a thoracic procedure. When chest tubes are placed outside of surgery, a nurse must immediately connect them to the drainage system and tape all connections thoroughly to prevent leaks.
• WORD • BUILDING • hemothorax: hemo – blood + thorax – chest
Powered by FlippingBook