Within the scope of practice - page 2

by GRUNGE 3,404 Views | 17 Comments

I tried posting this before but there was a lot of confusion. Ill be more detailed this time. I am a new nurse work on a rehabilitation unit and we do not see many tracheostomies. Our doctor has written an order for the... Read More


  1. 1
    Quote from Zookeeper3
    They have already have the trach capped, maybe a pasey miur valve to speak and they are ready to have the stoma covered with a 4x4 and recover to the next step.
    If someone is capping the trach, it should have been of no surprise when the physician wrote the order for decannulation especially if it was the RNs who have been capping the trach.

    Unless you are suctioning frequently... it is SAFE. You can always pass a thin suction catheter through the stoma to clear secretions.... you don't need Resperatory at the bedside waiting to intubate... they are stable, and you have not one, but TWO airways, the stoma hole and NT suction.
    If the patient is having a secretion issue, this should have been addressed prior to decannulation or recannulation should be considered. The cough should also have been evaluated. If you must resort to NT suctioning or poking a catheter into the stoma, that patient may not have been ready.

    If this was a med-surg floor or another level of LTC, my posts probably would not have been written so harshly. But, a rehab facility that accepts trachs should be on top of things alittle better rather than assume it is the doctor's laziness that this patient is not being decannulated. (reference to previous thread by GRUNGE)
    Last edit by GreyGull on Aug 15, '10
    Zookeeper3 likes this.
  2. 0
    Quote from GreyGull

    There is also a saying for airways, "Don't pull out what you or someone near you can not put back in".
    Good advice!

    When you decannulate a patient (remove the trach), you must be fully prepared to replace it should the need arise. Keep several cuffed and uncuffed trachs in an array of sizes at the bedside, along with steri-lube, ambu bag, etc.

    Additionally, no one in your unit seems comfortable with decannulating a patient . . . and my policy has always been, "If I don't know what I'm doing, don't do it!!"
  3. 0
    No we are agreeing, but not, if that makes sense... I just wanted to make sure the OP, whom was uncomfortable recognized issues to not decannulate... make sense? Trying to assure that if it all falls into the right picture, it's time, even if we are hesitant. I was trying to explain the options of complications to explain that airway maintenence was possible . Are we on a different page and I'm not seeing it? I worked last night, so be patient with me. Patients may still need suctioning after a trach pull, but it should NOT be an expected part of care. I agree with you 100%, but stoma suctioning still is required... at a rare PRN, not a standard of care.

    I think we are voicing the same concerns from different view. Put them together and they might be the same Let me know your thoughts ....


    Quote from GreyGull
    If someone is capping the trach, it should have been of no surprise when the physician wrote the order for decannulation especially if it was the RNs who have been capping the trach.

    If the patient is having a secretion issue, this should have been addressed prior to decannulation or recannulation should be considered. The cough should also have been evaluated. If you must resort to NT suctioning or poking a catheter into the stoma, that patient may not have been ready.

    If this was a med-surg floor or another level of LTC, my posts probably would not have been written so harshly. But, a rehab facility that accepts trachs should be on top of things alittle better rather than assume it is the doctor's laziness that this patient is not being decannulated. (reference to previous thread by GRUNGE)
  4. 1
    I guess, if i re-read my post it sounds like blame to the MD. I didn't mean that, I meant more that he has expectations being the OP's facility accepts trachs. I still think that the Op and, sounds like others at the facility need some training, and there should be no roadblocks to getting that.

    You know, Some SNFs are getting pretty intense patients these days. I'm not referring to the OP's patient, but the conversations I have with people who work those places... Some hospitals are d/c patients so fast it seems these days to rehab just to get them emergently right back. I ponder that some SNF nurses might find hospital medsurg a bit easier?!
    scoochy likes this.
  5. 0
    Quote from 2ndwind
    You know, Some SNFs are getting pretty intense patients these days. I'm not referring to the OP's patient, but the conversations I have with people who work those places... Some hospitals are d/c patients so fast it seems these days to rehab just to get them emergently right back. I ponder that some SNF nurses might find hospital medsurg a bit easier?!
    Agree.

    Considering that in some parts of the country the SNF nurse to patient ratio is much higher than on med-surg and the fact that they are left hanging without additional resources on site, I definitely believe they are at a disadvantage. I have known some nurses to do PRN on med-surg to keep up with the latest and greatest as well as having a nice night with just 4 - 5 patients who can turn themselves.

    The other issue with patients getting tossed out into a Rehab before they are ready is the loss of rehab days which they may not get back depending on their insurance. Unfair to staff who wants to see their patient make progress and unfair to the patients who then may end up placed in a long term facility rather than home.
  6. 0
    Quote from Zookeeper3
    No we are agreeing, but not, if that makes sense... I just wanted to make sure the OP, whom was uncomfortable recognized issues to not decannulate... make sense? Trying to assure that if it all falls into the right picture, it's time, even if we are hesitant. I was trying to explain the options of complications to explain that airway maintenence was possible . Are we on a different page and I'm not seeing it? I worked last night, so be patient with me. Patients may still need suctioning after a trach pull, but it should NOT be an expected part of care. I agree with you 100%, but stoma suctioning still is required... at a rare PRN, not a standard of care.

    I think we are voicing the same concerns from different view. Put them together and they might be the same Let me know your thoughts ....
    Agree.

    This is the importance of a care plan and everybody being on the same page. Generally the RNs, RTs, SLP and PTs are telling the doctors it is time for the tubes of all kinds to come out since they have been running on protocols for that progression. The doctors just write the final orders.

    I do agree some pull tubes and don't realize there is more to follow. Even for stomas, if they don't look like they are closing within a reasonable amount of time, an ENT surgical consult may be requested by the RNs/RTs from the Primary doctor. There are also so many different types of trachs as well as how the surgical opening was made. Emergency procedures must be discussed for each type. Even when to use H2O2 and when not to can be an issue.
  7. 0
    Quote from 2ndwind
    I guess, if i re-read my post it sounds like blame to the MD. I didn't mean that, I meant more that he has expectations being the OP's facility accepts trachs. I still think that the Op and, sounds like others at the facility need some training, and there should be no roadblocks to getting that.

    You know, Some SNFs are getting pretty intense patients these days. I'm not referring to the OP's patient, but the conversations I have with people who work those places... Some hospitals are d/c patients so fast it seems these days to rehab just to get them emergently right back. I ponder that some SNF nurses might find hospital medsurg a bit easier?!
    I guess, if I re-read your posts, it sounds like you're backpedaling.
  8. 0
    Sylv,

    I guess if I re-read your post you don't know me.


Top