Skill 77 A tracheostomy is a 51- to 76-mm (2- to 3-inch) curved metal or plastic tube inserted into a stoma through the neck and into the trachea to maintain a patent airway. Some patients with a tracheostomy tube are able to cough secretions out of the tube completely, whereas others are only able to cough secretions up into it. Standards for care include
properly securing the tube, inflating the cuff to an appropriate pressure, maintaining patency by suctioning, and providing oral hygiene. A tracheostomy tube can cause granulation tissue to form on the vocal cords, epiglottis, or trachea secondary to inappropriate cuff inflation. The skill of performing tracheostomy care is not routinely delegated to nursing assistive personnel (NAP). In some settings,
patients who have well-established tracheostomy tubes may have the care delegated to an NAP. The nurse is responsible for assessing a patient and evaluating for proper artificial airway care. The nurse directs the NAP to:Tracheostomy Care
Delegation Considerations
Equipment
Feb 19, 2017 | Posted by in NURSING | Comments Off on 77 Tracheostomy Care
1.1.ID: 18668360366
A patient has an endotracheal tube inserted orally. When should the nurse expect to perform
endotracheal tube care?
A. Whenever the patient begins to cough.
B. On a routine schedule according to agency policy to reposition the
tube. Correct
If endotracheal tube is inserted orally, the tube is often repositioned on the
opposite side of the mouth or center of mouth according to agency protocol to
prevent prolonged pressure and ulceration. Endotracheal tube care is usually
performed on a routine schedule. Coughing, especially continued coughing,
usually indicates a need for more frequent suctioning. Endotracheal tube care is
indicated if the depth of the tube has changed.
C. Only when the depth of the tube has changed from its original position (as
indicated by a marking at the lip or gum line).
D. According to health care provider orders.
Awarded 0.0 points out of 1.0 possible points.
2.2.ID: 18668360364
Which situation can be delegated to nursing assistive personnel (NAP) in regard to
endotracheal tube care?
A. Endotracheal care may be delegated to NAP only if the patient is on a
ventilator.
B. Assisting the nurse during a tape change by holding the endotracheal
tube. Correct
NAP can help with reporting signs that the tube is loose, the tapes are soiled, or
the patient is uncomfortable and assisting in holding the tube during a tape
change. Assessment requires the skill and knowledge of the nurse and should
not be delegated to NAP.
C. Performing respiratory assessments before and after endotracheal tube
care.
D. If the tapes are soiled, the NAP may change the tapes.
Awarded 1.0 points out of 1.0 possible points.
3.3.ID: 18668360354
Which of the following is an unexpected outcome during or after endotracheal suctioning and
endotracheal tube care?
A. A sudden drop in oxygen saturation. Correct
The nurse should stop suctioning and administer oxygen. The other items are
expected outcomes of performing endotracheal tube care.
B. Depth of tube is the same as when started or as ordered (same centimeter
marking at gums or lips).
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