Within the scope of practice

  1. 0 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 tracheostomie tube to be discontinued. None of the nurses on the floor including me do not want to remove it ourselves but the doctor who is here m-f 9-5 keeps insisting we remove it ourselves. I think that it might be beyond our scope of practice. Is it within a nurses scope of practice to discontinue a tracheostomie tube.
  2. Visit  GRUNGE profile page

    About GRUNGE

    Joined Jul '10; Posts: 86; Likes: 94.

    17 Comments so far...

  3. Visit  GreyGull profile page
    9
    Nurses in post op recoveries and ICUs remove endotracheal tubes. Nurses in subacutes remove and replace trachs. I have not heard of a state forbidding this but I have heard of facilities restricting the procedure to different professionals if they are available.

    Are there RTs anywhere in this facility? Who is responsible for that trach for care? Who is responsible for the routine changes? Who is responsible for emergent situations such as decannulations, blown cuff and plugging of a single cannula trach? Do you keep a spare trach and a tracheal ring hook at bedside or nearby? These should not be 911 calls unless the patient has become distressed or suffered other consequences before a trach is replaced. If you accept trachs at your facility you should have a P&P to cover them. The next step would be, do you know what to do after the trach is pulled? The care of the stoma? Recognizing that it was not time to pull or other complications.

    Pulling a trach is generally not a big deal unless you don't know what to expect or when to expect the unexpected. Some trachs that have cuffs are very difficult to remove. Some trachs that have fenestrations may have tissue growth attached to the tracheal wall which results in some bleeding and pain. But, over all it is not a complex procedure but you should read the P&P first and if there is not another nurse in the whole unit that can advise you, be honest with the physician. He should not be thought of as lazy for a procedure that should be covered by your staff is there is no other personnel available and he should also know for the safety of his patient if the staff is not familiar with trachs so he can defer accepting another one until the staff is adequately prepared. A sentinel event is a bad time to prompt an inservice or have your accrediting agency find out there are some missing pieces in your P&P or training for this level of care.

    There is also a saying for airways, "Don't pull out what you or someone near you can not put back in".
    canoehead, CrufflerJJ, HollyHobby, and 6 others like this.
  4. Visit  dthfytr profile page
    0
    Your State Board of Nursing has the ultimate say on what's in your scope of practice. I can apprciate your concern. In all my years I've never been asked to do this and would want some guidance from someone more experienced.
  5. Visit  clemmm78 profile page
    5
    whether it is within the scope or practice doesn't seem to be the important thing here. It is if any of you have ever done it before and/or are competent to do it. For one, I would not as it has been 20 years since I worked with trachs, so I could not do it - even if I am technically allowed.
    Leelee2, canoehead, dudette10, and 2 others like this.
  6. Visit  Hospice Nurse LPN profile page
    0
    Quote from clemmm78
    whether it is within the scope or practice doesn't seem to be the important thing here. It is if any of you have ever done it before and/or are competent to do it. For one, I would not as it has been 20 years since I worked with trachs, so I could not do it - even if I am technically allowed.

    I so agree! Even if something is in the scope of your practice, you must be trained before jumping in.
  7. Visit  GHGoonette profile page
    4
    Quote from clemmm78
    whether it is within the scope or practice doesn't seem to be the important thing here. It is if any of you have ever done it before and/or are competent to do it. For one, I would not as it has been 20 years since I worked with trachs, so I could not do it - even if I am technically allowed.
    Dead right, it's like asking your husband to fix the plumbing...
  8. Visit  GreyGull profile page
    0
    However, if you are taking care of a trach patient and assuming the responsibility for that airway, you should already have been prepared with some of these questions asked and answered. Who did the weaning assessment and trials? Who did the trach care? What emergency procedures were you inserviced on? This is not an "what if situation" since someone or many someones have already been accepting care for a patient that may be out of their training and comfort zone. This is no longer a "what if" but rather a situation where the appropriate ongoing care of an artificial airway has not been addressed. Since this is stated to be a rehab facility, it is usually the goal of that patient to be decannulated or at least evaluated for decannulation once in the rehab program which should have been addressed in the initial care plan. Your brochures advertising your facility may even boast this since it is a big part of a patient's rehab even if you do it infrequently. Thus, you should know your responsibilities on that unit and there should be a senior staff member to advise you since your post indicates there have been other trachs.
    Last edit by GreyGull on Aug 15, '10
  9. Visit  netglow profile page
    0
    OP, do not succumb to pressure. Do not do it. It's hard to think how simple your decision is when you get pressure from the doc. This when he sees that you guys are not feeling comfortable with it. There is a reason he is not doing it himself. It's the same reason you should not do it.

    This is a serious issue that your management needs to address. They need to handle the problem at hand by getting someone who can do it for this situation, and then to get everyone up to speed with supervised training.
  10. Visit  Zookeeper3 profile page
    0
    No, I'm seeing this from a different standpoint. Unfortunately, this is not common, it's an airway and you're rightfully worried and I respect that about your practice.

    The stoma (hole where the trach is), by now is patent, you have an airway to suction if needed. Should some crazy thing happen and the stoma suddenly closes (which it will not, I promise)... you insert a nasopharageal airway. Suction through that.

    A patient at this point is only getting suctioned about every 4 or more hours, has the ability to expectorate their secretions on their own and is ready to progress!!!! That's wonderful.

    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.

    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.

    This is not a check off, this is not a BON cert. Just pull the tube, suction prior and monitor. I promise it's that simple. If you work nights and there is no back up, and no one, no one on your unit has ever done it, I understand. But pulling a trach is simply deflating the cuff and pulling down like you change an innercannula.

    I understand your worry, but others here may have led you astray. Just my humble food for thought. Take it for what it's worth.
  11. Visit  GreyGull profile page
    0
    Quote from 2ndwind
    OP, do not succumb to pressure. Do not do it. It's hard to think how simple your decision is when you get pressure from the doc. This when he sees that you guys are not feeling comfortable with it. There is a reason he is not doing it himself. It's the same reason you should not do it.
    I disagree it is the doctor who is feeling uncomfortable about pulling a trach. He may just believe this is a common part of your practice which is why a trach patient is sent to rehab. Some rehab facilities decannulate 2 - 3 patient per week.

    Quote from 2ndwind
    This is a serious issue that your management needs to address. They need to handle the problem at hand by getting someone who can do it for this situation, and then to get everyone up to speed with supervised training.
    If they want to remain in the rehab business, this is a must.

    To the OP:
    Does this facility have a CARF accreditation?
  12. Visit  GreyGull profile page
    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.
  13. Visit  sunnycalifRN profile page
    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!!"
  14. Visit  Zookeeper3 profile page
    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)


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