Assisting Tracheostomy Insertion

Description:
A tracheostomy is the formation of an opening into the trachea usually between the
second and third rings of cartilage.
Purpose:
Facilitate weaning from mechanical ventilation by decreasing
Anatomical dead space.
Prevention / treatment of retained tracheo-bronchial secretions.
Chronic upper airway obstruction
Bypass acute upper airway obstruction
Materials:
Tracheostomy Tube (6-9 for most adults), sterile instruments: hemostat, scalpel and
blade. Sterile gowns, drapes and gloves. Cap, face shield, antiseptic solution and gauze pad,
shave prep kit. Sedation, local anesthetic and syringe. Resuscitation bag, mask with oxygen
source. Suction for cuff inflation, respiratory support and available for post-tracheostomy
(mechanical ventilation tracheal oxygen mask CPAP, T- piece).
Procedure Rationale
Performance phase
1. Explain the procedure to the patient.
Discuss a communication system with
the patient
Apprehension about inability to talk is usually
a major concern of tracheostomized patient
2. Obtain consent for operative
procedures
For legality purposes
3. Shave neck region Hair and beard may harbor microorganism. If
the bears is to be remove, inform the patient
or family
4. Assemble equipment. Using aseptic
technique, inflate tracheostomy cuff
and evaluate for symmetry and volume
leakage. Deflate maximally
Ensure that the cuff is functional before
insertion
5. Position the patient in a supine
position with head extended and a
support under the shoulders.
Position brings that trachea forward
6. Obtain an order for and apply soft
wrist restraints if the patient is
confused
Restraints of the confused patient may be
necessary to ensure patient safety and
preservation of aseptic technique
7. Give medication if ordered Sedation may be needed
8. Position the light source For proper visualization
9. Assist with antiseptic preparation Anticipate needs of co-workers
10. Assist with gowning and gloving Anticipate needs of co-workers, make
procedure easier
11. Assist with sterile draping Anticipate needs of co-workers, help maintain
sterility
12. Put on face shield Spraying of blood or airway secretions may
occur during this procedures
13. During procedures, monitor the
patient vital signs. Suction as
necessary, give medication as
prescribed, be prepared to administer
emergency care
Bradycardia may result from vagal stimulation
due to tracheal manipulation, or hypoxemia.
Hypoxemia may also cause cardiac irritabilty
14. Immediately after the tube is inserted,
inflate the cuff. The chest should be
auscultated for the presence of
bilateral breath sounds
Ensure ventilation of both lungs
15. Secure the tracheostomy tube with
twill tapes or other securing device and
apply dressing
To secure and avoid dislodgement of
tracheostomy tube
16. Apply appropriate respiratory
assistance devices (mechanical
ventilation, tracheostomy, oxygen
mask CPAP, T piece adapter)
Assurance and to give proper ventilation to
patient
17. Check the tracheostomy tube cuff
pressure
Excessive cuff pressure may cause tracheal
damage
18. Tie sutures or stay sutures of silk
mau have been placed through either
side of the tracheal cartilage at the
incisiom and brought out through the
wound. Each is to be tapped to the skin
at 45 degrees angle laterally to the
sternum
Should the tracheostomy tube become
dislodge, the stay sutures may be grasped and
used to spread the tracheal cartilage apart,
facilitating placement of the new tube
Follow-up phase
1. Assess vital signs and breath sounds:
note tube size used, physician
performing procedure, type, dose and
route of medication given
Provide baseline
2. Obtain chest x-ray Document proper tube placement
3. Assess and check condition of stoma
a. Bleeding


a. Some bleeding around the stoma site is
not unusual for the first few hours.


b. Swelling







c. Subcutaneous air
Monitor and inform the physician of
any increase in bleeding.
b. Clean the site aseptically when
necessary. Do not change
tracheostomy ties fir first 24 hours,
because accidental dislodgement of
the tube could result when the ties are
loose and the tube reinsertion through
the al yet unformed stoma may be
difficult or impossible to accomplish
c. When positive pressure respiratory
assistive devices are used (mechanical
ventilation, CPAP) before the wound is
healed, air may be seen as
enlargement of the neck and facial
tissues and felt be seen as crepitus on
cracking when the skin is depressed,
report immediately
4. An extra tube, obturator and hemostat
should we kept at the bedside. In the
event of tube dislodgement,
reinsertion of a new tube may be
necessary. For emergency tube
insertion
a. Spread the wound with a hemostat
or stay sutures
b. Insert replacement tube(containing
the obturator) at the angle
c. Point cannula downward and insert
the tube maximally
d. Remove the obturator
Hemostat will open the airway and allow
ventilation in th spontaneously breathing
patient. Avoid inserting the tube horizontally
because the tube may be forced against the
back of the trachea







CARDIOPULMONARY RESUCITTATION
DEFINITION: Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies,
including heart attack or near drowning, in which someone's breathing or heartbeat has stopped. CPR
can keep oxygenated blood flowing to the brain and other vital organs until more definitive medical
treatment can restore a normal heart rhythm.
PURPOSE: CPR is performed to restore and maintain breathing and circulation and to provide oxygen
and blood flow to the heart, brain, and other vital organs.
MATERIALS: > AED > Ambbubag > First aid kit
PROCEDURE RATIONALE
1. Check the scene for dangers. If you come across
someone who is unconscious, you need to
quickly make sure there are no dangers to
yourself if you choose to help them. Is there a
car exhaust running? A gas stove? Is there a fire?
Are electrical lines down?
This is to ensure your safety as well as your client
As you go on with the procedure. This is also to
Prevent further harm to the client.
A. If there is anything that could endanger you and
your victim, see if there is something you can do
to counteract it. Open the window, turn off the
stove, or put out the fire if possible. Anything
you can do counteract the danger.
B. However, if there is nothing you can do to
counteract the danger, move the victim. The
best way to move the victim is by placing a
blanket or a coat underneath their back and
pulling on the coat or blanket.
To prevent further harm to the victim




Dragging the client promotes easy access in
moving the client from one place to another
2. Check the victim for the consciousness by
shaking or tapping their shoulder and saying in a
loud, clear voice, Are you okey? Are you okey?
This is to check if the victim is conscious in a
voice loud enough the client can hear
A. If they respond, they are conscious. They may
have just been sleeping or they could have been
unconscious. If it still appears to be an
emergency situation (e.g they are having trouble
breathing, they appear to be fading I between
consciousness and unconsciousness, they were
unconscious, etc.) call for help and begin basic
first aid and take measures to prevent or treat
shock.
B. If they do not respond, continue with the
following steps.
Conscious patient may dont need CPR
(depending on the situation).







No answer indicated the victim needs help.
3. Send for help. The more people available for this CPR is a basic life support. If further harm may be
step the Better, however, it can be done alone. Encountered along the way, the patient can be
send easily in the nearest clinic/hospital
4. Check the victims pulse. Do not check for more
than 10 seconds. If the victim does not have a
pulse, continue with the CPR and the next steps.
The absence of pulse indicates that the client
Needs an immediate CPR
A. To check the neck (carotid) pulse, feel for a pulse
on the Side of the victims neck closest to you by
placing the tips of Your first two fingers beside
his Adams apple
B. To check the wrist (radial() pulse, place your first
two fingers On the thumb side of the victims
wrist.
C. Other pulse locations are the groin and ankle. To
check the groin, (femoral) pulse, press the tips of
two fingers into the middle of the groin. To
check the ankle (posterial tibial) pulse, place
your first two fingers on the inside of the ankle.
To check the presence of carotid pulse



To check the presence of radial pulse


To check the presence of the femoral and the
post tibial pulse.
5. Remember CAB: Chest Compression, Airway,
breathing
These are the main focus and purpose in doing
CPR.
6. Make sure the airway is open. Place your hands
on the victims forehead and two fingers on their
chin and tilt the head back to open the airway (if
you suspect a neck injury, pull the jaw forward
rather than lifting the chin). If jaw thrust fails to
open the airway, do a careful head tilt and chin
lift.
Proper tilting of the head prevents further
injury to the neck bone of the patient.
7. If there are no signs of life, place a breathing
barrier (if Available) over the victims mouth.
To provide the care needed by the client.
8. Give two rescue breathes. Keeping the airway
open, take The fingers that were on the
forehead and pinch the victims Nose closed.
Make a seal with your mouth over the victims
Mouth and breathe out for about one second.
Make sure your Breathe slowly, as this will make
sure the air goes in the lungs Not the stomach.
Make sure you keep your eye on the victims
chest.
*INFANT: one rescue breath. Rescue breaths are
delivered using a mouth-to-mouth seal, instead of
mouth-to-mouth-and-nose.
*CHILDAGED (1-8): one rescue breath. Rescue
breaths are delivered using a mouth-to-mouth seal,
instead of mouth-to-mouth-and-nose
Rescue breathes supports the clients respiration.
*CHILDAGE (8 and OLDER): two Rescue breaths are
delivered with a mouth-to-mouth seal
A. If the breath goes in, you should see the chest
slightly rise And also feel it go in. if the breath
goes in, give a second Rescue breathe.
B. If the breath does not go in, re-position the head
and try Again. If it does not go in again, the
victim may be choking. Do abdominal thrusts
(Heimlich Maneuver) to remove the Obstruction.
Rising of chest indicates the entering of the
Rescue breathes into the clients chest.

Obstruction impedes the passing of air into the
Lungs.
9. Perform CPR for one minute (which is about
three cycles Of CPR) and then call the EMS
before resuming with the CPR.
CPR should be done in a right timing/pace to
avoid any complication. It is an immediate basic
life support that needs to be done immediately.
10. Give 30 chest compressions. Place your hands
on the top Of each other and place them on the
sternum, or in the center of the chest (o the
breastbone) between the two nipples. Your ring
finger should be o the top of the nipple (this will
lower the chances of breaking a rib or ribs)
*INFANT: Chest compressions are delivered by
placing two fingers of one hand over the lower half
of the infant's sternum slightly below the nipple line.
giving 5 chest compressions followed by one rescue
breath in successive cycles.
*CHILDAGED (1-8): Chest compressions are delivered
by placing the heel of one hand over the lower half
of the sternum. giving 5 chest compressions followed
by one rescue breath in successive cycles.
*CHILDAGED (8-ABOVE): two hands are used for
compressions, with the heel of one hand on the
lower half of the sternum and the heel of the other
hand on top of that hand. With 15 compressions
followed by two rescue breaths.
Chest compression brings back the beating of the
Heart.
A. Compress the chest with elbows locked, by
pushing Straight down at least 2 inches deep
*INFANT: Press down about 1/2 inch to one inch.
*CHILDAGED (1-8): depressing about 1 to 1 1/2
inches per compression.
*CHILDAGED (8-ABOVE): The chest is compressed
about 1 1/2 to 2 inches per compression.
Right pushing and positioning of the arm
prevents the breaking of a rib/ribs
B. Do 30 of these compressions, and do them at a
rate of at Least 100 compressions per minute
*INFANT: Compressions are delivered at a rate of
100 times per minute, giving 5 chest compressions
This is the standard/right timing I rendering CPR.
followed by one rescue breath in successive cycles.
*CHILDAGED (1-8): Compressions are delivered at a
rate of 100 times per minute, giving five chest
compressions followed by one rescue breath in
successive cycles.
*CHILDAGED (8-ABOVE): The compression rate is 80
to 100 per minute delivered in cycles of 15
compressions followed by 2 rescue breaths.
C. Allow complete chest recoil after each
compression
Chest recoil indicates the forming back of ribs
Into its original shape before being compressed.
This is to prevent the breaking of a rib/ribs.
D. Minimize pauses in chest compression that
occur when Changing providers or preparing for
a shock. Attempt to limit Interruption to less
than 10 seconds.
To provide continuation of care
11. If an AED comes available, turn on the AED, place
the pads As instructed (one over the right chest
and other over the left Side), allow the AED to
analyse the rhythm, and give one Shock if
indicated, after clearing everyone from the
patient. Resume chest compression immediately
after each shock for Another five cycles before
reassessing.
This apparatus provides electrical impulse to
bring back the beating of the heart.











Administering Tube Feeding and Medication via Nasogastric Tube
Definition: A feeding tube is a medical device used to provide nutrition to patients who cannot
obtain nutrition by swallowing. The state of being fed by a feeding tube is called enteral feeding
or tube feeding. Placement may be temporary for the treatment of acute conditions or lifelong
in the case of chronic disabilities.
Purpose:
To restore or maintain nutritional status
To administer medication
Materials: Stethoscope, gloves, correct amount of feeding solution, 20 to 50 ml syringe with an
adapter, emesis basin, large syringe with plunger or calibrated plastic feeding bag with tubing
that can be attached to the feeding tub, pH test strip or meter, water ( 60 ml unless otherwise
specified) at room temperature.
Procedure Rationale
1. Explain Procedure to patient. Use
stethoscope to assess bowel sounds.
Promote fluid trust and reduce anxiety. Assist
for delayed gastric empty, indicates presence
of peristalsis and ability of G.I tract to digest
nutrients.
2. Assemble equipment. Check amount,
concentration, type and frequency of
tube feeding on patients chart. Check
expiration date of formula.
Ensure efficiency when initiating feeding.
3. Perform hand washing. Don disposable
gloves.
Reduce transmission of pathogen from gastric
contents.
4. Position patient with head of bed
elevated at least 30 degrees or near
normal position for eating as possible.
Reduce risk of pulmonary aspiration in the
event of client vomit or regurgitate formula
5. Unpin tube from patients gown and
check to see that Nasogastric tube is
properly located in stomach
To check position of tube.
6. Aspirate all gastric contents with
syringe and measure. Return
immediately through tube, saving small
amount to measure gastric pH. Flush
tube, with 30 ml of sterile water for
irrigation. Proceed with feeding if
amount of residual does not exceed
policy of agency or physicians
guidelines. Disconnect syringe from
tubing.
To check if the tube is position at the stomach.

7. For feeding:
a. Remove plunger from 30-60 ml
syringe.
Establish pathway for intervention.
b. Attach syringe to feeding tube, poor
premeasured amount of tube into
syringe, open clamp and allow feeding
to enter tube. Regulate the rate by
raising or lowering the height of the
syringe. Do not push formula with
syringe.
Prevents air from entering the formula.
Decreased risk for diarrhea.
c. Add 30 to 60 ml f water for irrigation to
syringe when feeding is almost
completed and allow it to run through
the tube.
Ensure that the remaining formula in the
tubing is administered and maintains patency
of tube.
d. When syringe has empties, hold the
syringe high and disconnect from tube.
Clamp the tube and cover end with
sterile gauze secured with a rubber
band or apply a cap.
Prevents air from entering stomach and
reduce risk of gas accumulation.
For medication:
a. Prepare the patient and medication. Ensure efficiency.
b. Lift the dressing around the tube. To have pathway for intervention.
c. Remove the dressing that covers the
tube. Then removed the dressing or
plug at the tip of the tube, and attach
the syringe or funnel to tip.
To have pathway for intervention.
d. Release the clamp and instill about 10
ml of water into tube through the
syringe.
To irrigate tubing.
e. If water flows in easily, the tube is
patent. If it flows slowly, raise the
funnel.
To check patency.
f. Pour up 20 ml of medication, pour in
about 30 ml of water.
Provide client with the prescribe medication.
g. After giving the medication, pour
about 30 ml of water.
To irrigate the tubing.
h. Tighten the clamp, place a 4x4 gauze
pad on the end of the tube and secure
it with a rubber band.
To prevent air going to the stomach.
i. Keep the head of the bed elevated for
at least 3o minutes after the
procedure.
To prevent aspiration.