Trach patient!

[David Offenbaker, BSN, RN]

Hi all,

I recently got hired for peds home health and am due to orientate on Monday. I haven't had too much experience with trach patients (other than in the hospital where we do trach care, etc). Here are my questions:

• How do you do breathing treatments on a patient with a trach?

• In the home setting do you actually replace the entire trach, or just the inner cannula?

I know theses questions might sound silly, but I've yet to encounter this in the hospital setting.

Thanks!

Dave

[nursbee04]

I am by no means an expert, but I'll tell you what I know...

Breathing treatments - this depends on the trach and whether or not the patient is vent dependent - for example, my sister doesn't require 02, so she gets blow by treatments or a trach mask.

Replacing the trach - again, this depends on the type of trach. There are different kinds: cuffed, uncuffed, one piece disposable with no inner cannula and "permanent" trachs with inner cannulas. My sister has a one piece disposable uncuffed trach, so the whole trach is removed and a new trach put in with a new trach collar. Other patients may just require a new trach collar and cleaning the inner cannula (sterile technique).

To be honest, if you are going into peds, the parents can be a valuable source of the patient's routine and what works best for them, and probably are the best source to learn about trach care from (as long as they do it correctly), because they do it every day in most cases.

Will you be orienting with an experienced nurse?

pictures of several uncuffed trachs and a cuffed trach

(the skinny thing by the trach is the obturator, used to put in the trach and then immediately removed.)

adult trach with inner cannulas

[David Offenbaker, BSN, RN]

Thanks for the quick reply.

I'm still trying to figure out how to do breathing treatments VIA the trach. This particular patient isn't on a vent-- just gets treatmenets via nebulizer.

Does the nebulizer hook directly to the trach? Do you use a trach mask?

Thanks!

Dave

[TexasPediRN]

Thanks for the quick reply.

I'm still trying to figure out how to do breathing treatments VIA the trach. This particular patient isn't on a vent-- just gets treatmenets via nebulizer.

Does the nebulizer hook directly to the trach? Do you use a trach mask?

Thanks!

Dave

If the patient isnt on a vent, you will probably just do treatments via trach collar - kind of like a face mask, but goes over the trach. It doesnt hook to the trach, just has a strap that goes around the patients neck to hold the mask in front of the trach.

Since you are doing private duty, and this is a new case, you should be getting oriented to it, correct? Make sure the nurse that orients you makes sure you know how to change the trach, suction, what to do in case of emergency,etc.

Last question now that I think of it - I used to do private duty, and we had to learn trach/g-tube skills in the office, before we even went into the field and worked with patients. Does your company not do this?

Good luck!

-Meghan

[TexasPediRN]

Also:

For all trach related info (and then some!)

Try:

http://www.tracheostomy.com/

[suzanne4, RN]

Please be with what you plan to do. You are going to be working with what we call medically fragile kids and you are ultimately getting paid either by the state or a private insurance company in most cases. They are paying for someone with experience in this area; the parents should not be there to act as your resource, actually the other way around. You should be able to be a resource to them.

This is the same with adults at home on a vent or with a trach. The nurse should be the resource person, not the caregiver at the home to the nurse. Sure, there are things that are specific to that particular patient, and they will tell you that. But you are expected to know all procedures and feel comfortable with them and have experience in all of them before taking on a patient like this.

Example, have you changed out a complete trach? Many peds trachs do not have inner cannulas so they need to get changed out every so often and when they come out. Do you feel comfortable with that? Do you feel comfortable replacing a peg tube that has come out? Both of these must be done immediately, there is no time to wait for someone to come and assist you.

I am trying to be helpful and letting you know what you can be in for with taking on a patient like this and not having experience with the procedures that need to be done. Parents do not need to be around when there is a nurse there, they may be for the first day or so, but then you are completely on your own. You are also there to provide them some time off and out of the house.

Do you have peds experience in the hospital setting?

[David Offenbaker, BSN, RN]

Hi All,

Yes, I will be getting an orientation on Monday.

As for Peds experience, yes I have peds experience in the hospital setting, but in the hospital RT usually took care of the breathing treatments with trach patients-- we just did the trach care.

Sorry if my first post made me sound incompetent, I just hadn't had much experience with this and didn't want to look like a complete idiot before my orientation.

Thanks all,

Dave

[panamabrt]

The nebulizer will hook up to the corrugated tubing...you will see...it just runs inline with the oxygen tubing from the 02 source to the patient.

Put it inline b/t the T-piece OVER the trach and the corrugated tubing.

Many home trachs you just take out the inner cannula and clean them and put them back in.

Good Luck!

[NRSKarenRN, BSN, RN]

Check out these threads:

Vent Information

Suctioning ?

Please make sure orientation is just not policies and procedures. You should be familiar with all patient care needs prior to first day alone on a case.

Sounds like a discussion/in-service with RT at the hospital is indicated along with nurse educator re trach care.

Exact respiratory care should be spelled out in patient care plan or homecare orders. Often Trach care performed 8-12 hours by removing and cleaning inner cannula or replacing with new disposable cannula ( insurance reimbursement often drives cleaning or new one in homecare). Entire trach changed monthly by RN or MD if difficult/anatomy issue.

Read ALL the info at tracheostomy.com as most excellent resource for peds respiratory care. Remember YOU are totally responsible for care in the home, no back-up in 1-2min like in the hospital---typical response to pages/phone calls agency is 30-45 minutes.

It's your license that 's on the line. Being prepared for the unexpected in homecare is crucial.....memories of a new vent dependent patient just home 1 hour when electricity goes off ---and was off for 4 hours--- circles through my mind. No one had notified electric company that patient needed priority restoration service prior to leaving hospital.

Please make sure you are PREPARED to accept the responsibility associated with this case.

[jasnms]

You should also check with your state laws pertaining to private duty care with pediatrics. Some state laws require that an adult be present at all times.