Trach's in Home Care

  1. OK, here is my question. I opened a case last weekend, a young man with a trach, a plastic Shiley type, placed for sleep apnea. So he says, I got a very poor history, and on the weekend, it is hard to speak with anyone who knows anything about his case.

    The HMO sent twill "tapes" to tie his trach with. Now I have a critical care background, and I remember the days when that was the only choice anyone had, but why would that cheap HMO send something so difficult for even many nurses to do properly? I put in a request for the foam/velcro type of ties.

    I have not had many trach's in home care, and none in my own caseload, so I am wondering, are we suypposed to tecah the pt to change the ties themselves? I have one pt who I am in e-mail contact with, she was a nursing school instructor, and she has had a trach for quite some time. She agreed with me that this would be nuts to teach a pt. I also felt that no one should be alone when an airway is changed, heck, I am sure someone else is nearby when I change trach ties in the ICU for heavens sake. Is anyone out there teaching pt's to do this for themselevs? If not, how often do you change the ties? My other pt/rn says q 2 weeks or prn.

    Any insight?
    And where the heck is everyone?? No posts in this forum for a while, wake up HH nurses!!!
  2. Visit hoolahan profile page

    About hoolahan

    Joined: Dec '99; Posts: 3,786; Likes: 129
    Quality Nurse & Home Health Nurse


  3. by   LoisJean
    Hi, Hollihan! In my ABUNDANT experience of providing care and assistance for in home patients with trachs, I can tell you that trach ties were changed on the average of every three days. Of course this depended on the amount of goo (sorry, drainage) created from suctioning, coughing, etc.. I seldom see the velcro tapes--but probably because most of the patients I see are on Medicaid assistance. Anyhow, maybe it's because I'm so old and so long at this stuff that the idea of a patient changing his own trach, (without someone there to assist if needed), puts chills up my spine. We do a lot of reinforcement teaching with families and patients in the care of the trach--(acting in tandom with their primary care nurses): they teach the changing of ties every three days or more often if necessary and to never attempt changing of the trach unless there is someone else present to help if needed.

    But...I have had a few who have insisted on self-care. I even had one guy who used binder twine to hold his trach in place...his neck looked like one of the Sopranos had gotten ahold of it. Jeez.

    Does this help at all?
  4. by   NRSKarenRN
    From the "Respiratory Expert" (LOL):

    Things to consider re deciding type of trach tube anchoring device:
    1. New trach vs old.
    2. Medical DX: Any change for trach edema/neck swelling??
    3.Availability and willingness of caregiver to assist with trach tie change.
    4. Condition of skin around trach/neck and ammount of secretions.
    6. Payor source: willing to pay for velcro?
    7. Patient will remain long term agency client vs. teach and discharge.

    The answers to these questions will lead you decide type of trach anchoring device.

    If insurance will pay for velcro holder e.g. Dale tracheostomy holder, I say request that type. 2 per month is usual amount needed. Change q 3-5 days new...can leave on up to a week to 2wks. older; more frequent change if excessive secretions. HAND wash in warm soapy water and air dry-dries over night.---quickly dries with handheld hair dryer if needed. I have even bleached them if needed ( bloody open areas etc).

    Letter of medical necessity demonstrating why velcro holder only needed sometimes will get that product covered:
    eg: patient lives alone, dominent arm weakness; unable to change himself and caregiver unwilling to assist; patient with neck tumor that is increasing size and risk strangulation overnight--need quick adjustment etc.

    Re twill ties:
    1. Always try to teach care giver how to do if available.
    2. if new trach, prefer two pieces with bowtie on side vs one piece that is knotted.
    3. if no infection control/swelling concerns, ok to leave on as long as not soiled--- encourage cleaning beneath area q day.; otherwise do q three days.
    4. DOCUMENT and get DRS order that its OK for patient living alone to change trach ties himself---use stand mirror to visualize if unable get to BR mirror----even had one patient's family go to auto junkyard and buy side door mirror that sits flush--- he could swivel it easily!

    Newest anchoring device---Plastic IV tubing!!!!!!! Can be cut to size, easily cleaned, blends in with skin tones, not needing change for up to a month or more, softer even on neck for patients with long term older trach...LTC/extended rehab units using (seen in a nursing magazine).

    Edited for spelling.
    Last edit by NRSKarenRN on Sep 22, '01
  5. by   hoolahan
    THanks guys, and so prompt too!!

    Karen, I swear, you are a guru of HH! Thanks you for posting the name of that product. I was wracking my brain trying to remember it. Now, I asked my other pt about re-using those and she said they are disposable, so you shouldn't re-use. Probably what she was taught and she has Caid, so not a problem geting what she wants/needs.

    This guy, like I said gave a vague history. Lives alone, has an ex-wife willing to help, but more with IADL's and getting O2 set-up for him, etc. No neck diagnosis. I have only ever tied the twills in 2 peices. I cut a hole in the end and loop the tie thought it, the way you would do using a rubberband to secure and NG tube in the "olden"days. He is willing and motivated to learn, I just feel that for him to do it himself is risky. You know how often a pt will cough during this procedure, the trach is relatively new, what if he coughed it out? I just think IF he can learn to do it himself, ho can do it when his wife or teenaged dtr are there, using the velcro, at least they can call 911 even if he does it by himself in the BR, he should not be alone. B/c, if he looses the trach and can't speak, he's SOOL to make a call, though 911 would come anyway.

    Does anyone know if there is a standard on this for Home health? I have heard that there are HH standards for care put out by the ANA, anyone ever seen them? I am just interested in the official take on this as well.
  6. by   LoisJean
    Thanks, Karen, on the info regarding IV tubing to secure trachs!! What a fantastic idea! Hoolihan: there are, I am sure, Home Health standards for how to wash out your underwear--but if there is one for trach care and upkeep I haven't seen it. But, if anyone can find it I know Karen can!
  7. by   NRSKarenRN

    Took Resp ICU course in 1979. One night came on duty as charge LPN & ONLY nurse on 26 bed medical floor to discover the chief resident had admittted a vent dependent patient to my floor ---no experience and no inservicing staff. Promptly paged respiratory "Just make sure the bellows go up and down, call me to help suction him...bag him and page me stat is alarm goes off or bellows stops moving." Resident did this cause our nursing staff had great assessment skills " and he was tired of all his patients dying in telemetry" around the corner from my floor. Knew I needed to be knowledgable ASAP.....Lord talking about
    baptism by fire!!

    Just don't call me re birthin babies..... could only catch them, suction and give bath LOL!
  8. by   hoolahan
    Lois, I found the standards on the ANA site, gotta buy them of course. I hope it's worth $12!! I like that, washing your undies! LOL!

    Karen, I am with you when it comes to the OB stuff. My motto is
    ...."I don't know nuthin' 'bout birthin' no babies Miz Scahlett!"
  9. by   NRSKarenRN
    Needed a little time for finger search found these great sites re tracheostomy and respiratory care:

    1. Adult CEU article in Advance for nursing- Tracheostomy Patient Care :

    2.TRACHEOSTOMY CARE :An Introduction

    3. The tracheostomy tube change: a review of techniques

    4. Trach tube diagram + info on Passy-muir speaking valves

    5. Trach tube suppliers:

    6. Pediatric and TONS trach info @ Aaron's Tracheostomy page

    7. Size chart comparison for trach tubes + trach changing procedure

    8. Laryngectomee Stoma Care

    9. Vent users support page

    10. Respiratory resources @ Brownson's Nursing Notes

    Hoolahan---add these respiratory resources to your web site please, so I can find them again! ANA standards address nursing educational requirements and practice standards not care techniques.
    Last edit by NRSKarenRN on Sep 21, '01
  10. by   hoolahan
    Great idea! I'll make a trach page. But I have had trouble downloading the software lately! Taking forever! I wanted to add a flag or ribbon, like Google's, but gave up after it took longer than 45 min to download.

    Maybe I'll do a synopsis of your info and Loi's info, and put you on the page as co-authors, no last names, then you will be "published" you know!

    I'm on for the weekend, and nights on Monday, so maybe one day next week I can get it accomplished. Putting links is the most time-consuming part. I have to get my hemodynamics stuff together eventually too! And some wound stuff. I have big plans, but no time!

    Great suggestion!!
  11. by   nur20
    Originally posted by LoisJean
    Thanks, Karen, on the info regarding IV tubing to secure trachs!! What a fantastic idea! Hoolihan: there are, I am sure, Home Health standards for how to wash out your underwear--but if there is one for trach care and upkeep I haven't seen it. But, if anyone can find it I know Karen can!
    I have not heard of a standard of care for trachs. The physician usually write orders for care, changes, tie changes and site care. I find that velcro ties are the best. You can almost close them with one hand with a good fit in case something happens where you need another hand free A.S.A.P. Working with children they do not have inner cannulas so there is no margin for error
  12. by   hoolahan
    OK, so I'm not crazy then nur? That's good news!
    Glad you popped in, haven't seen you post in this forum before.
  13. by   NRSKarenRN
    What is outcome of your trach patient?
    Did you get needed supplies....don't keep me in suspense!
  14. by   hoolahan
    That's the thing about working weekends, I never find out!

    I did look for his chart, but never found it. I wondered which nurse they gave him to, but couldn't figure it out.

    I'd like to know too!!