NRSG 302 - Week 2

Parts of the upper airway

Nose, oral cavity, pharynx, larynx

Functions of upper airway

Heating/cooling inspired gas to body temp, filtering, humidification, smell, phonation, passage for ventilation

Components of the lower airway

Larynx (below the vocal cords), trachea, bronchi, bronchioles, alveoli

Functions of the lower airway

Conducting airway for ventilation gas exchange

Types of artificial airways

Oropharyngeal, nasopharyngeal, endotracheal tube, naso-endotracheal tube

Tracheostomy

Incision into the trachea, creating a stoma or through which the airway is managed

Surgical tracheostomy

Usually performed in OR, can be performed bedside in ICU

Percutaneous tracheostomy

Tube is introduced with the use of a scope with a light source, via a needle and guidewire technique

Cricothyroidotomy

Only performed in emergency situations

Not preferred due to proximity of vocal cords

Benefits of a tracheostomy vs endotracheal tube

Lower risk of laryngeal and oral injury, shorter ventilator weaning time, easier communication, more comfortable, easier to secure, easier to do mouth care, may start oral feeding sooner

Indications for a tracheostomy

Bypass airway obstruction at or below level of larynx, provide long-term mechanical ventilation, facilitate removal of secretions, protect airway in patient at risk of aspiration, vocal cord paralysis, prevention of ventilator associated pneumonia (VAP), total neck dissection, tumors of head/neck where swelling or airway obstruction is anticipated

Complications of a tracheostomy

Abnormal bleeding, tube dislodgement, obstructed tube/mucus plug, infection, subQ emphysema, tracheo-esophageal fistula, tracheal stenosis, tracheal dilation

Cuffed trach

Has a balloon at the interior distal end of the tube to isolate lower airway from upper airway

If placed with initial surgery, provides stable airway until trach is established, pt is weaned off ventilator and is able to control secretions

Inflated cuff helps protect against aspiration

Can use ambu bag

Cuffless trach

Used once pt can protect airway from aspiration and no longer requires mechanical ventilation

May allow pt to speak of enough air passes above the trach tube through the vocal cords

Easier to facilitate oral feeding

Can be plugged or corked if pt doesnt require ventilation or have an upper airway obstruction

Can be used long term

Less change of internal damage

CANNOT use ambu bag

Advantages of cuffless trachs

More comfortable, may facilitate speaking, may facilitate eating, progression towards decannulation

Disadvantages of cuffless trachs

Does not provide protection against aspiration, cannot provide adequate ventilation in Code Blue or surgery, may dilute O2 received via a trach mask or T-piece by mixing room air from upper airway, increases air leak

Components of a tracheostomy tube

Outer cannula, inner cannula, obturator, tracheal plug, flange/face plate, pilot line/cuff inflation line, pilot valve, pilot balloon, trach cuff

Function of outer cannula

Maintains patency of stoma, can be fenestrated (allows air into larynx and faciliates speech, but requires non-fenestrated inner cannula for suction_

Function of inner cannula

Disposable, reusable high or low profile, or fenestrated

Removable tube. which secures the inside of the outer cannula, protects patency of the tracheostomy tube with proper cleaning and can be removed to restore pt airway if occluded, ideal for safety purposes

Function of obturator

Blunt tip introducer to reduce trauma during tracheostomy tube insertion, fits inside the outer cannula, rounded tip, remove immediately after trach tube insertion, kept as part of emergency kit

Function of a tracheal plug

Occludes tracheostomy tube to redirect air around instead of through tracheostomy tube for weaning

May be a sealed inner cannula, a cap or a separate plug

Functions of a flange/face plate

Stabilizes tracheostomy tube by preventing the outer cannula from descending further into the trachea, allows a place for ties/sutures to attach, has the specs of the tube written on it, may have locking indicator, may have adjustable flange

Function of pilot line/cuff inflation line

Connects pilot balloon to cuff

Function of pilot valve

Spring loaded, keeps air from leaking out of balloon/cuff, spring needs to be depressed in order to add or remove air from cuff

Function of pilot balloon

External balloon connected to the cuff via the pilot line, indicates whether the cuff is inflated or deflated

Function of trach cuff

Balloon at the distal end of the tube, provides a seal between the tube and the tracheal wall when inflated, protecting against aspiration, deflated during weaning

Purpose of fenestrated trach

Allows for increased air to move into larynx at lower resistance, potentially facilitating speech

Can be considered when plugging trach is not tolerated

Must place non-fenestrated inner cannula for suctioning

"-otomy"

Cutting in to

"-ectomy"

Removal of

Emergency airway equipment

Ambu bag, mask, oral airway, non-disposable cannula (if pt has cuffless + plugged tube in situ)

Trach emergency airway equipment

Cuffed trach tube (same size and one size smaller), tracheostomy dilator set, 10cc syringe, tracheostomy tube exchanger, 1 pack water-soluble lubricant, obturator

How often should the inner cannula be changed or cleaned?

Q12h

Purpose of suctioning a trach

Maintain airway patency, promote optimal gas exchange, decrease chance of infection through retained secretions

How often should you suction a trach

PRN as indicated

Indications for suctioning a trach

Rattling or gurgling sounds from trach, ineffective cough, visible secretions, change in respiratory status, dyspnea, restlessness, increased WOB, irregular breathing, pallor, upon request

What kind of technique is used for suctioning

Aseptic

How long should each suction pass be

Up to 5-10 seconds

What suction pressure is typically used for adults

80-120 mm Hg

Complications of trach suctioning

Mucosal damage, hypoxia, dysrhythmias, lung collapse, infections, bronchospasm, low BP, increased ICP/intraabdominal/intrathoracic pressure

When should dressing changes and trach care be done?

Q12h and PRN

In IH, how often is a disposable inner cannula changed

q24h

2 ways that trachs can be secured

Ties or sutures

What is weaning off of a trach

Multi-step procedure with goal of decannulation and own airway maintenance

Can take from days to months

3 components of perioperative

Pre-op

Intra-op

Post-op

3 ways to classify surgeries

Seriousness, urgency and purpose

Types of seriousness of surgery

Major or minor

Types of urgency of surgery

Elective, urgent, emergency

Types of purpose of surgery

Diagnostic, ablative, palliative, reconstructive/restorative, procurement for transplant, constructive, cosmetic

Major surgery

Involves extensive reconstruction or alteration in body parts

Poses great risk to wellbeing

Examples of major surgery

CABG, colon resection, laryngectomy, lung resection

Minor surgery

Involves minimal alternation in body parts

Often designed to correct deformities

Involves minimal risks compared to major procedures

Examples of minor surgery

Cataract extraction, facial plastic surgery, tooth extraction

Elective surgery

Optional and may not be necessary for health

Examples of elective surgery

Bunionectomy, facial plastic surgery, breast reconstruction, removal of wart

Urgent surgery

Necessary for patient health

May prevent additional problems from developing, but not necessarily emergent

Examples of urgent surgery

Excision of cancerous tumor, cholecystectomy, vascular repair for obstructed artery

Emergency surgery

Must be done immediately to preserve body part or save life

Examples of emergency surgery

Repair of perforated appendix, repair of traumatic amputation, control of internal hemorrhaging

Diagnostic surgery

Surgical exploration that allows physician to confirm diagnosis

May involve removal of tissue for further testing

Examples of diagnostic surgery

Exploratory laparotomy, breast biopsy

Ablative surgery

Excision or removal of diseased body part

Example of ablative surgery

Amputation, appendectomy, cholecystectomy

Palliative surgery

Relieves or reduces intensity of disease symptoms

Does not cure

Examples of palliative surgery

Colostomy, necrotic tissue debridement, removal of brain tumor

Reconstructive/restorative surgery

Restores function or appearance to traumatized or malfunctioning tissues

Examples of reconstructive/restorative surgery

Internal fixation of fractures, scar revision

Procurement for transplant

Removal of organs or tissues from a person for the purpose of transplantation into another person

Person is usually deceased, but can be a living donor

Constructive surgery

Restores function lost or reduced as a result of congenital anomalies

Examples of constructive surgery

Cleft palate repair, closure of atrial septal defect

Cosmetic surgery

Performed to improve personal appearance

Examples of cosmetic surgery

Blepharoplasty to correct eyelid deformities, rhinoplasty

Why are older adults more likely to experience peri-op complications

Comorbidities, lower % of body water (fluid/electrolyte disturbances), reduced liver/kidney function, poor nourishment

What meds should be checked to ensure the Dr wants them given on day of operation

Glucocorticoids, antidiabetics, insulin, ACEIs, ARBs, diuretics, Bblockers (usually given but double check), blood thinners

Herbs and supplements that can cause peri-op complications

Echinacea, feverfew, garlic, ginger, gingko, ginseng, goldenseal, licorice, saw palmetto, St John's wort, valerian, vitamin E, Kava

What to check before sending pt for procedure

Identification, allergies, informed consent, blood products, NPO status, voided/has a catheter, skin prep, pre-op meds, check OR slate, removal of valuables/jewelry, pt hx

Important post-op teaching topics

Pain management, preventing atelectasis, DB&C, diet, wound care, common complications, d/c

Informed consent process

Review consent form, surgeon signs consent and discusses with patient, pt signs, RN to ask if they have all the info

3 elements of valid consent

Voluntary, has mental capacity, informed

When do you not need consent for surgery

Life or limb, but check policy

Pre-op meds that are usually given

Reducing stomach acid, anticholinergics, sedatives, prophylactic abx, pain meds, anti-emetics, bronchodilators

Post-op ax: airway

How is pt breathing, is the airway protected

Post-op ax: breathing

Resp ax

Start VS = RR, O2 sat

Post-op ax: circulation

Continue VS

HR, BP

Compare vitals with baseline

CVS ax

Post-op ax: depth of consciousness

Is the pt awake enough to maintain an airway, prevent aspiration if vomiting, call for help, refrain for pulling out tubes and drains

Post-op ax: everything from surgery

Inspect dressings, drains and equipment

Complete rest of H2T

Post-op ax: freedom from risk

Bed brakes, bed in lowest position with rails up, call bell within reach, safety equipment at bedside

Post-op ax: gather info and chart

Review chart, complete ax or interventions as required, chart, communicate with other team members as needed