Interment cath and trach suction per pt request limit

Nurses Relations

Published

So I recently switched jobs , and I went from acute care ( critical care and step down units) to long

term care but not your usual nursing home patients , these are Pts with mental and physical disabilities and considered young adults -ages 18-50 being oldest. The majority have CP and a few traumatic brain injuries. I have two patients that require prn nurse intervention one being str8 cath as needed per his request and one that has a trach. Requiring suctioning. Let's address first dude ... He will request that you straight cath him numerous times a shift despite timing between last cath times. Request we'll over what I think you would need to cath someone who is not able to urinate without nursing intervention ... Is there a limit to this the order states as needed within no limits and I have asked staff and they say they just do it when ever and how many ever times he request... Now here's the trach dudes story .... He request suctioning numerous times a shift. He request prior to neb tx , then after and then will request again in between the last neb and then again prior to ha neb and after and then again .. Each suctioning you hardly get anything but a scant amount of clear secretions , he wants you to hold the suction catheter down until he nods to pull it out. Is there a limit to this and how can I approach the fact that this seems to me as a behavior problem almost a stimulation type thing because he is a quad that doesn't feel anything from shoulders down. Any suggestions ???

Specializes in MICU - CCRN, IR, Vascular Surgery.
Example.....just remembered this patient :cautious: Said patient was a quadraplegic who had a blow type call light. However, instead of using it, pt would make this weird, squirrel-call sounding noise with their mouth/cheek EVERY SINGLE TIME someone passed by their room.

Got old REALLY quickly.

i know that sound. It makes me die inside.

Why are you giving the trach patient nebulizers? What medication? Frequency scheduled?

The extra cold air flow from the nebulizer is an irritant and if done regularly the airways will remain irritated especially if there is no indication for the medication. What about an MDI?

Is the trach mist heated or cool?

Yes you suction before and after a TX especially on a quad. Nothing more silly than trying to nebulize through secretions and on a quad they may not be obvious.

Quad coughing regularly? Would patient benefit from a cough assist machine?

What level is his injury? Complete or incomplete? Different sensations for different classifications.

Is his trach cuffed? Inflated or deflated? Pressure checks? Over and under inflated cuffs are problematic. Cuff clearance protocol every shift being done?

If cuffed but deflated, that is a major irritant.

Is the trach malpositioned? Ties too loose or too tight? The weight of a trach collar and tubing can put the tip of the trach against the wall?

Last trach change? Different brand or size? Downsizing also means shorter length. It is not uncommon to start with 8 mm post op and go to 7 mm for long term care.

Un cuffed or cuff deflated can give tickling sensation feeling like secretions for a few weeks.

Speaking valve trials or being used?

The patient or resident might be practicing what he has been taught for survival in a long term facility. He may also be going off experience since patients are too easily labeled as attention seekers. The word "dudes" could give one the wrong impression about your attitude. Quads will spend the rest of their life trapped in their body wondering, worrying and studying how others perceive them.

@ICURN3020

The clicking noise is taught to quads for a reason. Caregivers may forget to place the "sip and puff" close enough just like some forget to place a call bell within reach. Sometimes it just takes a few moments of your time to place the sip and puff and do a test call for reassurance. If these patients don't trust you, they will call just so they are not forgotten and not just to make you miserable. If they have had a near death episode because of a caregiver who wasn't paying attention or didn't care, don't expect trust to come easy. Hopefully you will not have to know what it is like to depend on a sip and puff to ask for help.

Specializes in Gerontology.

Maybe the patient requesting frequent caths should just get a permanent I dwelling cath.

@ICURN3020

The clicking noise is taught to quads for a reason. Caregivers may forget to place the "sip and puff" close enough just like some forget to place a call bell within reach. Sometimes it just takes a few moments of your time to place the sip and puff and do a test call for reassurance. If these patients don't trust you, they will call just so they are not forgotten and not just to make you miserable. If they have had a near death episode because of a caregiver who wasn't paying attention or didn't care, don't expect trust to come easy. Hopefully you wideciphering to know what it is like to depend on a sip and puff to ask for help.

Thanks for the insight. I understand their fears, albeit not completely; I have experienced respiratory failure and have been on a ventilator, restrained (that was the protocol at the time) with no way to call for help and can relate to the fear, worry and anxiety that one goes through. However, this patient was EXCESSIVELY using that clicking noise. Once in the room, pt would not need or want anything 95% of the time. But of course, we would check on pt regardless as, like you mentioned, he may actually need or want something that particular time. I've learned to be pretty good at deciphering between anxious, scared pts and manipulative ones.

Also, your last comment was unnecessary.....I think it's a given that none of us ever want to know what it's like to be a quad, ventilator-dependent, etc.

Kind of butchered the referenced "last comment" in previous post and can't go back and fix it....:dead: I'm tired.

What nurse do you know that goes down the hall administering neb medications just to random patients without orders ? Obviously a md order has been written to do so and further more I didn't post to be judged in English and how I refer to my patient in an informal environment .

-Dustin

You have a unrealistic view of a long term care environment you have 17 patients and 8 hours to complete ordered care. You tell me hoe many test calls you do lol

-Dustin

Auto correct how

-Dustin

Oh and I must of forgot to mention I'm a nurse not a doctor ... And I'm amused you really had to ask why I'm giving neb treatments to a patient ? I mean I'm not lazy but why would I create extra work by giving medications not ordered to random patients .... not only is that a medication error .. It's over stepping a nurses scope of practice I don't prescribe I administer and carry out orders from a provider.

-Dustin

Dustin, our attached subacute holds 64 trach patients with more than half on ventilators. The acute rehab is 50 beds and has 5 - 10 new quadriplegic patients at any given time. There may be only one Respiratory Therapist assigned to each area and the nurse/patient ratio is horrendous.

The acute rehab may get more RTs for the daytime since new quadriplegic patients will get a full protocol TX 3x per day each lasting 45 - 60 minutes.

Once the patient gains more knowledge and some physical ability they are put on a maintenance routine.

We protocol off unnecessary treatments initially ordered by a doctor. Just because it is ordered does not always mean it is necessary or the appropriate delivery choice. Nebulizers do not have to be given "just because" the patient has a trach. Unfortunately some doctors do order nebs "just because" or they think the patient won't get suctioned. We can also switch to MDIs_ which are sometimes tolerated better. And, we make trach recommendations or change out per protocol. All the nurses are involved and do appreciate it when we take their suggestions from their assessments to fit the appropriate therapy to each patient for the long haul. Most doctors are receptive also if you don't have protocols.

So, the question about what nebulized med and why is not an inappropriate one. Any medication should have an indication and just because there is a trach is not one of them. Even some patients with lung disease can be put on maintenance MDIs. This also decreases the work for nurses when it comes to cleaning the nebulizer after treatments and reduces infection risk.

Call bell and ventilator tests are expected for documentation and the patient's piece of mind as well as that of the RT and nurses. Sentinel events make for a bad work day for all. When you are responsible for that many patients you can not afford to be lax. It also pays to spend a few extra minutes instilling confidence to a new and frightened patient. It may mean a lot less call bell time later.

Our patients may go to a much larger trach/ventilator facility with even less staffing or to home. For the home situation we strive to have the patient ready for a somewhat normal life and these patients usually do well. Unfortunately we do know that some LTC facilities will go back to nebs "just because" it's a trach with the usual doctor's order and no one questions it.

My posts are to give whoever reads them more insight on troubleshooting problems with trach patients. There are also about 50 medications which can be nebulized or given by MDI.

You have a unrealistic view of a long term care environment you have 17 patients and 8 hours to complete ordered care. You tell me hoe many test calls you do lol

-Dustin

But the patients are doing "test calls" anyway. Do one while you're in there, and you can instill confidence to avoid 3 calls that are just to test you later. That SAVES TIME.

+ Add a Comment