Chapter 28
Respiratory Care
587
Skill 28.8 (continued)
tracheostomy. The dressing absorbs drainage and mucus from around the stoma. Safety: If a split dressing is not avail- able, avoid cutting a gauze 4 × 4 to make a tracheostomy dressing because the threads from the cut ends can enter the tracheostomy and cause infection and irritation. Instead, fold the gauze 4 × 4 in half and then each end at right angles to fit beneath the faceplate. 19. Ensure that the tracheostomy collar is in place over the tracheostomy if ordered and that oxygen is being delivered per order. 20. Follow the Ending Implementation Steps located on the inside back cover. Evaluation Steps 1. Determine the effectiveness of the procedure. Is the tracheos- tomy clean and patent? 2. Evaluate the patient’s response to the procedure. Did they complain of pain, discomfort, fatigue, or shortness of breath?
For Velcro Holders 4. Insert the Velcro ends through the slits in the faceplate from back to front. 5. Ensure that the foam holder is lying smoothly behind the patient’s neck. 6. Pull the Velcro through the slits and press it down against the foam, leaving about one finger space between the patient’s neck and the holder. Safety: Do NOT remove the old ties or hold- ers until the new ties or holders are in place and secured. The patient will cough as you work with the tracheostomy and can cough it out if it is not secured.
Sample Documentation
10/11/28 2100 Trach care performed. Suctioned for mod amt of thick white mucus. Inner cannula partially obstructed with sm amt thick white mucus. Tolerated without c/o discomfort or fatigue. Writes “can breathe better” after procedure completed. ___________________________________________________________________________ _______________________________________________ Nurse’s signature and credentials
Completion of Tracheostomy Care 18. Replace the tracheostomy dressing with a clean tracheos- tomy one. This is placed so that the open ends point toward the patient’s chin and are brought together above the
Skill 28.9 Maintaining Chest Tubes
Assessment Steps 1. Verify the physician’s order for the level of suction in the chest drainage system. 2. Assess for an emergency situation if chest tubes are being inserted at the bedside. Enlist the help of other staff members to help you gather and assemble all equipment as quickly as possible. Planning Steps 1. Gather needed equipment and supplies: chest tube with insertion tray, a drainage system, sterile water, connec- tors, petroleum jelly (Vaseline) gauze dressings, split drain sponges, an abdominal dressing pad, and padded Kelly clamps, in addition to sterile gloves, masks, gowns, and goggles as needed. 2. Organize your equipment. Set up the suction and water seal per order to have the drainage system ready when the tube is attached. Intervention Steps 1. Follow the Initial Implementation Steps located on the inside front cover. 2. Assist the physician as required by opening packages, hand- ing items, and pouring solutions. Reassure the patient during the procedure.
3. Once the tube is in place, attach it to the drainage system and remove the padded Kelly clamp. 4. Apply Vaseline gauze dressing or facility-recommended dress- ing around the chest tube site, sealing any area where an air leak could occur. Cover the gauze with drain sponges and abdominal dressing pads. Tape the dressing area completely to help prevent air from entering the chest cavity. 5. Tape all connections thoroughly, taping away from the patient first and then back toward the patient. Attach the chest tube to the patient with a loop of tape to prevent tension on the insertion site as you tape the connections. 6. Turn on suction as ordered until gentle bubbling is noted if it is a wet suction system. 7. Place the drainage system securely on the floor and arrange the tubing so that there are no kinks or downward loops so that drainage can flow by gravity to the collection chamber. 8. Maintain the drainage system in an upright position below the level of the chest at all times to prevent the water seal or suction fluids from being disturbed. 9. Frequently assess the tubes for kinks or loops and the drain- age in the tubing for clots, which could cause increased negative pressure in the chest cavity. Safety: If clots are block- ing the tubing, follow the facility’s policy and physician’s orders. Do NOT milk or strip the tubes unless you are specifically ordered to do so.
(skill continues on page 588)
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