Nursing model after tracheotomy: Nursing after tracheotomy: Careful, proper and thorough nursing after tracheotomy can effectively improve the ventilation function of patients, which is directly related to the success or failure of surgery and the prognosis of patients. Therefore, nurses must adapt to the development of holistic nursing, master and apply a wide range of relevant knowledge and skills, provide comfortable nursing for patients more scientifically and professionally, and alleviate their pain.
Tracheotomy; Nursing; Sucking sputum; take precautions against infection
Humanized nursing
After tracheotomy, the patient's breathing is maintained by tracheal intubation. Once this passage is blocked, it will often lead to suffocation and life-threatening. On the other hand, after the operation, the air enters and exits from the tracheal intubation without passing through the vocal cords, so the patient can't speak, let alone express his pain and needs, which is prone to impatience and fear. Therefore, nurses should fully understand patients' pain and take a series of measures to eliminate patients' psychological discomfort.
Explain the cause of voice loss to patients, tell them the expected extubation time and the improvement of their condition, and introduce the recovery of similar patients, so as to relieve their worries and enhance their confidence in recovery.
Teach patients simple sign language. Such as thumb defecation, little finger urination, index finger hunger, middle finger thirst, nose agitation-sputum aspiration, eyes closed-sleep and so on. And provide patients with tablets, paper and pens. , and express your needs in words [1].
Pay attention to humanistic care, pay attention to your words and deeds, and judge the patient's psychological and mental state. Although the patient can't talk during catheterization, the nurse should still take the initiative to talk to him and sincerely care for and consider the patient. Or communicate with them with their eyes and judge their physiological needs. It can make patients get the greatest physical and psychological comfort, and at the same time enhance their trust in nursing staff.
environment
Due to the establishment of artificial airway, tracheotomy patients lose the process of nasal cavity filtration, humidification and temperature regulation, which makes airway secretions sticky, sputum is not easy to be sucked out, sputum scab is easy to form, resulting in blockage [2]. Therefore, postoperative care needs special personnel and special rooms to keep the indoor air fresh. Room temperature is 18℃ ~ 20℃ and humidity is 50% ~ 70% [3]. Ward air can be disinfected by ultraviolet lamp. If conditions permit, patients can enter the advanced laminar flow room after operation. Strictly control visits, visitors wear isolation gown, masks and hats, and implement protective isolation for patients.
posture
After the operation, the patient should lie flat on the pillow and keep the head and neck straight to ensure the central position of the tracheal intubation in the trachea and prevent the intubation from moving, blocking or falling out to cause suffocation [4].
Observe vital signs
The ward is equipped with first aid equipment. Pay attention to wound bleeding and airway obstruction within 24 hours after operation, and suck out bloody secretions in trachea in time. Closely observe the changes of the disease, regularly measure blood pressure, body temperature, pulse, blood oxygen saturation, respiratory frequency and depth, and pay attention to local complications such as bleeding, subcutaneous emphysema and incision infection.
Keep the respiratory tract unobstructed
The most important nursing after tracheotomy is to prevent intubation blockage. Most patients with tracheotomy are in critical condition, with different degrees of consciousness disorder, weakened or even missing protective cough reflex, and obstacles in spontaneous expectoration. However, too frequent sputum aspiration will lead to unnecessary tracheal mucosal damage, increased secretion, and increased chances of infection and bleeding. Therefore, timely sputum aspiration to clear airway secretions is the key to ensure airway patency and therapeutic effect [5]. When you hear the sound of sputum in the respiratory tract, you should suck sputum in time, perform strict aseptic operation, and move gently to reduce the pain when sucking sputum. Observe the patient's nonverbal behaviors such as facial expressions and body movements during sputum aspiration to understand the degree of pain, so as to judge the improvement of hypoxia and stop sputum aspiration.
Increase the oxygen flow before and after sputum aspiration, and inhale oxygen 1 ~ 2 minutes to relieve the symptoms of holding your breath during sputum aspiration. Generally, sputum aspiration does not exceed 15 seconds. If the patient has symptoms of shortness of breath, cyanosis or convulsion, he should immediately stop sputum suction and give oxygen.
Special sputum suction tube or rubber or silicone tube with larger inner diameter 12 or 14 should be selected for sputum suction. Generally, 1 ~ 2 hours is used for deep sputum aspiration 1 time, and the insertion depth is 10 ~ 14 cm. The sputum suction tube must reach the depth of trachea to start the aspirator.
The sputum suction tube should be replaced every time, and it will enter the airway to suck sputum. Once it exits the endotracheal tube, it cannot be used again. The sputum suction tube entering the airway must not be contaminated. If it is suspected of being contaminated, it should be replaced in time. Replace the connecting tube and drainage tube [6] of the aspirator every day.
The effect of sputum aspiration was evaluated by auscultation before and after sputum aspiration.
Because the air breathed by tracheotomy patients has not been filtered and moistened by nasal mucosa, or the patient has a high fever. The respiratory tract is dry, and the disease fluid is easy to form a hard scab, which leads to tube blockage. Therefore, in order to alleviate the pain caused by sputum aspiration, the airway can be humidified to make the patient's sputum thinner and easier to suck out.
The suitable suction negative pressure is 6.7 kPa (50 mm Hg).
Take measures to prevent infection
Cover the tracheal intubation with double-layer wet gauze, and change it 1 time every day to prevent inhalation of dust and foreign objects.
Gentamicin 80 thousand U+ dexamethasone 5mg+? -chymotrypsin 4000u+ normal saline 20ml, 3 ~ 4 drops are dripped into tracheal intubation every 30 minutes. Reasonable airway humidification can dissolve and dilute sputum, make sputum discharged in time, keep respiratory tract unobstructed, diminish inflammation and bacteria, and effectively prevent lung infection.
Rinse the endotracheal tube with normal saline 1 ~ 2 times a day to wash off the mucus attached to it. When cleaning, take out the inner sleeve and insert another clean inner sleeve into the outer sleeve. When taking the inner casing, pay attention to the curvature of the inner casing. Fix the outer casing with one hand and unlock the pipe lock with the other hand, and take it out slowly along the curvature of the casing. Do not forcibly pull it out with rough force to prevent the outer casing from being pulled out at the same time, causing suffocation.
Generally, the dressing under the outer tube stent should be replaced 1 time/day. If the pollution is serious, it should be replaced in time, and the dressing should be replaced aseptically to prevent bacterial infection.
Pay attention to prevent tube detachment.
Check and adjust the tightness of the jacket lacing every day, only through one index finger. The patient should not change his posture too much to prevent the cannula from slipping out. Coma, unconsciousness and children should be properly restrained to avoid extubation. Once the tube is removed, the nurse should calm down, immediately notify the doctor, give oxygen to the patient, insert the tube core into the outer sleeve, press it in situ from the incision of the trachea wall along the midline depending on the elasticity of the trachea cartilage, touch the front and rear walls of the trachea with the index finger if necessary, and guide hemostatic forceps to open the trachea, and then intubate. After repositioning the tube, pull out the tube core and put in the inner tube.
Take out the inner sleeve and pull out the tube.
Hold the chassis of the outer sleeve, turn the flap on the nozzle with your right hand, and then slowly take out the inner tube according to the curvature. Don't lift your coat hard, or even pull it out at the same time. Moreover, the removal time of the inner tube should not be too long to prevent the secretion from sticking to the outer jacket and causing blockage. If the inner and outer coats are adhered, the diluent can be dripped 1 ~ 2 minutes before the secretion is loosened.
Before extubation, tube plugging test should be done, and breathing should be observed for 2 ~ 3 days. If you breathe smoothly and sound well, you can extubate. The wound after extubation was covered with sterile vaseline gauze to heal it.
refer to
Shao Jianli 1 leijin, Li Xiaoyu. Comfortable nursing care of patients with tracheotomy. Jilin Medicine, 2007,28 (4): 99.
Lang Meiling. Nursing care of patients with craniocerebral injury to prevent the formation of sputum scab after tracheotomy. China Community Physician, 2009, 1 1(2):97.
3 Lu Shuhua. Nursing care of respiratory tract management. Journal of Practical Nursing, 2007, 17(2):38.
4 Yang Xueyan. Talking about the nursing before and after tracheotomy. China Medical and Health, 2008,3 (9): 80.
5 confused. Clinical experience of timely sputum aspiration in patients with tracheotomy. Journal of Practical Nursing, 2007, 17(2):37.
6 Ling Wenjun. Nursing experience of 42 patients with laryngeal cancer before and after operation. China Journal of Otolaryngology, 2008, 16(3):238.
Nursing after tracheotomy Fan Wen II: Tracheotomy Nursing Abstract: Tracheotomy, as a traumatic artificial airway, is of great significance in rescuing critically ill patients. It can not only relieve respiratory crisis immediately, but also be used for respiratory dysfunction or paralysis and respiratory failure caused by various reasons. It is necessary to immediately relieve or eliminate the symptoms of dyspnea in patients who have been using ventilator and tracheotomy for a long time. However, this is only the first step to solve the problem. Because tracheotomy is an invasive treatment, from the completion of the operation to the successful removal of tracheal cannula, a little negligence may lead to complications and life-threatening at any time. Proper, meticulous and careful nursing after operation is a very important link for patients to pass through the critical period safely.
Trachea; Incision; nurse
China Library Classification Number R473 Document Identification Number B1004-4949 (2014) 01-0/48-01.
1 indications for tracheotomy
1. 1 Relieve upper respiratory tract obstruction
1.2 Clearing lower respiratory secretions
1.3 establishment of airway in patients undergoing head and neck surgery
1.4 respiratory failure caused by various reasons
1.5 check and treat some diseases
2 Complications of tracheotomy
2. 1 pipeline demolition
2.2 bleeding
2.3 subcutaneous emphysema
2.4 infection
2.5 Ulcer and edema of tracheal wall
2.6 pneumothorax
2.7 vocal cord dysfunction
2.8 suffocation
3 Nursing care of tracheotomy
3. 1 Nursing of Tracheal Incision Because Tracheal Incision is an invasive treatment, it is easy to be contaminated by surrounding skin bacteria and respiratory secretions, and it is easy to form tracheal incision infection. Sterile gauze cushion is often used in clinic to prevent tracheal incision infection. Strictly observe whether there is bleeding in the tracheal incision. If there is less bleeding, change the gauze in time and keep the incision dry and clean. If there is more bleeding, report it to the doctor. It is urgent to open the suture and find out the reason to stop the bleeding. Observe whether there is subcutaneous emphysema around the incision. If there is sputum pollution, change the gauze in time, usually twice a day, and scrub the wound and casing with 0.5% iodophor cotton ball for 5cm each time.
3.2 Nursing care of respiratory tract
3.2. 1 The environment keeps the indoor air fresh, with room temperature 18 ~ 20℃ and humidity of 50% ~ 70%. The tracheal cuff is covered with 2-4 layers of warm and wet gauze, and the ward is disinfected with ultraviolet air. At present, qualified hospitals are equipped with advanced laminar flow rooms, which create a good ward environment for tracheotomy patients. For patients with tracheotomy, the visit should be strictly controlled. Visitors should wear isolation gown, masks and hats, and patients should be placed in protective isolation.
3.2.2 Patients with airway humidification and tracheotomy lose humidification function, and are prone to complications such as airway obstruction, atelectasis and secondary infection. The main purpose of humidification is to dilute secretions to facilitate aspiration or cough. Humidifying oxygen can prevent secretion from scabbing and lead to airway obstruction. Airway humidification can be achieved by dripping physiological saline through trachea to humidify oxygen. In addition, airway administration can prevent respiratory tract infection, and also achieve the purpose of humidifying the airway, among which air atomization administration is more effective [1].
Aspiration of sputum
① It shows dyspnea; Secretion can be seen in tracheal catheter; Gasps; Unexplained decrease in oxygen saturation. ② Give adequate oxygen inhalation before and after sputum aspiration. Studies have shown that patients with tracheotomy often have symptoms of hypoxia during sputum aspiration [2], which leads to tissue hypoxia, aggravates organ function damage and even threatens the life of critically ill patients. Pre-oxygenation before and after sputum aspiration can prevent hypoxemia and tissue hypoxia caused by sputum aspiration, that is, pure oxygen is given 5 minutes before sputum aspiration and still within 5 minutes after sputum aspiration [3].
Methods One sputum aspiration should not exceed 15 seconds, and continuous sputum aspiration should not exceed 3 minutes. The sputum suction tube rotates left and right, pulls upward, and draws back while sucking. Before and after sputum aspiration, the oxygen flow rate is increased by 3 ~ 5 liters per minute according to the condition. The ultimate goal of sputum aspiration is to remove secretions and promote gas exchange. The American Respiratory Management Association regards the improvement of breath sounds, the reduction of inspiratory peak pressure, the reduction of respiratory resistance or the improvement of dynamic compliance, the increase of tidal volume and the increase of arterial blood gas value or oxygen saturation as the criteria for successful sputum aspiration [4].
3.2 Nursing care of tracheal cannula
3.2. 1 Take off the tube to prevent the head and neck from spreading, ensure the central position of the tracheal intubation in the trachea, and prevent the intubation from moving or falling off and causing suffocation. The measures to prevent the coat from falling off are as follows: coma patients need to bind their hands with restraint belts; The fixing belt should be densely packed, not thin gauze. Once the outer sleeve falls off, immediately separate the incision with hemostatic forceps, and insert the sleeve along the incision or perform intubation rescue.
3.2.2 Management of airbags The main function of airbags is to prevent oral secretions and stomach contents from being inhaled into the airway by mistake, prevent gas from flowing back from the upper respiratory tract, and ensure effective ventilation. Within 72 hours after operation, the balloon was inflated to prevent postoperative wound bleeding from flowing into the lungs. Generally, inflation is 8 ~ 10 ml. If mechanical ventilation is not needed, the airbag does not need to be inflated after 72 hours, which is beneficial to breathing; When eating, the airbag is inflated to prevent foreign bodies from entering the airway and affecting breathing.
3.3 Psychological Care For conscious patients, we should show more care and consideration to them and give them spiritual comfort. Especially for patients who are conscious and unable to pronounce after tracheotomy, we can tell some relevant knowledge and give psychological comfort by written conversation or action.
Prevent patients from pulling out the cannula by themselves because of impatience, and try to fix their hands when necessary. Special care should be given to patients with tracheotomy, and a chaperone should be left. Nurses' skillful skills, friendly attitude and the company of relatives give patients a strong sense of security and are conducive to the improvement of their condition.
3.4 Nutrition Due to swallowing problems and loss of appetite, tracheotomy patients are prone to complications such as aspiration and malnutrition. 24 hours after operation, patients can be fed with easily digestible foods such as rice soup and egg soup by nose, and carefully fed with foods such as milk and soybean milk that are easy to cause abdominal distension and diarrhea. 7- 14 days after operation, patients can try oral administration. Instruct patients to step by step, avoid severe cough and choking, and prevent complications such as aspiration pneumonia.
As a first aid method, tracheotomy is widely used in clinic. The operation is relatively simple, and postoperative nursing is particularly important. Improper nursing will cause many complications and even endanger life. Therefore, this kind of surgical patients need our careful care to achieve the expected recovery. In various nursing operations, how to effectively prevent respiratory tract infection is still an important topic for future research and discussion.
refer to
[1] Chejie, Lu Yushu, Wang Mingxin, et al. Comparative study on anti-infection effects of spraying and dropping drugs after tracheotomy. Journal of Nurse Training, 1998, 13 (6): 13.
[2]Guglielminotti J, Desmonts J M, Duruil B. Effect of tracheal sputum aspiration on respiratory resistance in patients with mechanical ventilation. Chest, 1998,113 (5):1335.
[3], Yang Yancheng, et al. Clinical observation of pre-oxygenation to reduce tissue hypoxia caused by sputum aspiration. China Journal of Nursing,1999,34 (12): 714.