Nursing 211

N211: Health Differences Across the Lifespan I

Nursing Interventions Avoid the offending substance. Nasal antihistamines, steroids and decongestant sprays. Allergy shots or immunotherapy may also help. Interventions for acute viral rhinitis are rest, increased fluid intake to help liquefy secretions, antipyretics, analgesics. Teaching clients that frequent hand washing is the best protection against the common cold. 2.35 Tracheostomy Tracheostomy is a surgical procedure that creates an opening in the trachea to establish a patent airway. A tracheostomy is an opening (stoma) that is surgically created. A variety of tubes can be inserted into the tracheostomy, depending on length of anticipated use, whether temporary or permanent, on whether mechanical ventilation will be used, and on need to be able to speak while in place. Variations in tubes include double lumen or single lumen (inner cannula or no inner cannula), cuffed or uncuffed, fenestrated or nonfenestrated, and talking tracheostomy tubes. A cuffed tracheostomy tube is inserted, and the cuff is inflated with air to create a seal. The tube is held in place by strips of gauze (trach ties). Clinical indications for a tracheostomy are to bypass an upper airway obstruction, to facilitate removal of copious tracheobronchial secretions, to allow for long term mechanical ventilation, and to facilitate oral intake and speech in the patient requiring long term mechanical ventilation. Nursing Assessment Includes assessment of respiratory rate, depth, and exertion. Auscultation of breath sounds, color of skin, nail beds and mucous membranes. Assess vital signs, patency and security of the tracheostomy tube. Assess tracheostomy stoma, noting color, edema, bleeding, drainage and odor. Evaluate diagnostic data: ABGs, pulse oximetry, chest x-ray and CBC with differential with sputum culture if infection is suspected. Nursing Diagnosis • Impaired gas exchange related to increased respiratory secretions • Ineffective airway clearance related to presence of tracheostomy tube and difficulty expectorating sputum • Impaired verbal communication related to use of artificial airway • Impaired swallowing related to mechanical obstruction • Risk for infection related to surgical incision directly into respiratory tract Nursing Inte ventions Include maintaining head of bed at 30 degrees; ensure that manual resuscitation (Ambu bag) is always at bedside . Keep spare tracheostomy set of same size, obturator, and clamps at bedside for

©2012

Page 79

of 148

Achieve