What must the nurse do when performing tracheostomy care quizlet?

Introduce self and verify the patient's identity using facility protocol.

Explain to the patient (parent) what you are going to do, why it is necessary, and how the patient can participate. Inform the patient (parent) that suctioning usually stimulates the cough reflex and that this assists in removing the secretions.

Perform hand hygiene and observe other appropriate infection control procedures (e.g., gloves, goggles).

Provide for patient privacy. An assistant or parent may be needed to hold the child gently and to keep hands out of the way. The assistant or parent should maintain the child's head in the midline position.

If not contraindicated, place the patient in the semi-Fowler position to promote deep breathing, maximum lung expansion, and productive coughing.

Apply pulse oximeter finger clip to monitor oxygen saturation values during procedure (optional).

Rationale: Deep breathing oxygenates the lungs, counteracts the hypoxic effects of suctioning, and may induce coughing. Coughing helps loosen and move secretions.

Open-Suction System: Prepare the equipment.

Attach resuscitation apparatus (BVM) to oxygen source. Adjust the oxygen flow to 100%.

Open the sterile supplies: Suction kit or catheter/Sterile basin/container.

Pour sterile normal saline or water in sterile basin.

Place the sterile towel, if used, across patient's chest below tracheostomy or ETT or on a workspace.

Turn on the suction, and set the pressure in accordance with facility policy. For a wall unit, a pressure setting between 80-120 mmHg is normally used for adults, 60 mmHg for children.

Apply goggles, mask, and gown if necessary.

Apply sterile gloves. Some facilities recommend putting a sterile glove on the dominant hand and an unsterile glove on the nondominant hand. Rationale: The sterile gloved hand maintains the sterility of the suction catheter, and the unsterile glove holds the suction connecting tubing and prevents the transmission of microorganisms to the nurse.

Holding the catheter in the dominant hand and the connector in the nondominant hand, attach the suction catheter to the suction tubing.

Using the dominant hand, place the catheter tip in the sterile saline solution.

Using the thumb of the nondominant hand, occlude the thumb control and suction a small amount of the sterile solution through the catheter. Rationale: This determines that the suction equipment is working properly and lubricates the outside and the lumen of the catheter. Lubrication eases insertion and reduces tissue trauma during insertion. Lubricating the lumen also helps prevent secretions from sticking to the inside of the catheter.

If the patient does not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning

Using your nondominant hand, turn on the oxygen to 12-15 L/min.

If the patient is receiving oxygen, disconnect the oxygen source from the tracheostomy tube or ETT using your nondominant hand.

Attach the resuscitator to the tracheostomy or ETT.

Compress the BVM device 3-5 times as the patient inhales. This is best done by a second person who can use both hands to compress the bag, thus providing a greater inflation volume.

Observe the rise and fall of the patient's chest to assess the adequacy of each ventilation.

Remove the resuscitation device and place it on the bed or the patient's chest with the connector facing up.

Suction the tracheostomy tube or ETT.

Remove oxygen source or, for closed system, unlock the suction control mechanism if required by manufacturer.

With dominant hand, advance the suction catheter or, for closed system, suction catheter in its plastic sheath. Steady the T-piece with the nondominant hand.

Depress the suction control valve and apply intermittent suction for no more than 10 seconds and gently withdraw the catheter. Replace oxygen source.

Repeat as needed, remembering to provide hyperoxygenation and hyperinflation as needed.

Flush and, for closed system, close the system.

When suctioning is complete, withdraw catheter or, for closed system, withdraw catheter into its sleeve and close the access valve, if appropriate. Rationale: If the closed system does not have an access valve on the patient connector, the nurse needs to observe for the potential of the catheter migrating into the airway and partially obstructing the artificial airway.

Flush the catheter by instilling normal saline into the irrigation port and applying suction. Repeat until the catheter is clear.

For closed system, close the irrigation port and close suction valve.

When the procedure is complete, discard disposable supplies in appropriate container, doff gloves, perform hand hygiene, and leave patient safe and comfortable.

Complete documentation using forms, checklists, or electronic dropdown lists supplemented by nurse's notes or additional comments as appropriate.

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