Interment cath and trach suction per pt request limit

[Rvanurse2012]

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 ???

[iluvgusgus]

cant u get an order to cath over 250 or 300 ml? I'm sorry, i would refuse to cath someone every hour that is plain ridiculous. We have a protocol , if a pt requires straight caths for >48 hrs, they get an indwelling catheter. Suctioning someone that frequently may create more secretions. Both of these things are creating big risk for infections for these 2 pts, take control of it somehow.

[Rvanurse2012]

This patient isn't frightened , he can no longer control any other aspect of his life so you attempts to control us by under minding and directing his own care despite redirection and education attempts. he is very capable of calling for help as we have equipped him with a call light that works. I did not post this blog to have my nursing care judged on bias opinions that don't know all the details. This is sad health care has become a nick pick throw the professional under the bus and assume they are neglecting the patients. Pointing fingers at folks instead of backing our colleagues. We don't have doctors we have a doctor that practices at our facility only. As far as suggestions in tx I have being a CCRN made my suggestions and they have been shot down.

-Dustin

[GrannyRRT]

There really are so many things to address with the care of a trach.

Suctioning before and after is not excessive and even once in between can sometimes be expected with nebs. Depending on the medication this could the desired result. Doctors don't want mucus plugging and that is their usual justification for q 4 Albuterol and sx. Some doctors have been known to order scheduled q2 suctioning.

Instilling saline into the trach may result in more suctioning especially with a quadriplegic patient. You have literally had them aspirate fluid past where the sx cath reaches which may take awhile to absorb or be coughed up...difficult for a high complete SCI. Some patients prefer the saline and know it might lead to more suctioning. But, that preference was probably learned from a caregiver. Much of the behavior can be attributed to their post incident care or lack of.

Is single use sx kits or in line being used? Some people do go to deep and touching the soft tissue may create a wound or just enough irritation for the patient to feel discomfort as it heals like there is something that needs to come out. It just takes one rushed sx to ruin the next few days for you and the patient.

When learning just about trachs, our new nurses spend a minimum of 3 hours in the classroom and 5 hours with a Respiratory Therapist at the bedside. Even that just barely covers a good introduction to the trach itself and all the different patient conditions which make each trach care unique.

[GrannyRRT]

Dustin, no one is nitpicking you.

With the very few details you gave, it is hard to offer specifics. You got defensive even when asked about the nebulizer med.

I have written about reasons to use to get a nebulizer changed or suctioning issues addresed. But, it sounds like your facility has one way of dealing with trachs rather than fitting the therapy to the patients. If the nebulizer is part of the problem, it should be addressed but you need to be able to also involve the patient in their care. I believe once they enter long term they are now called resident. Giving them some choice in their therapy may improve their comfort.

Our LPNs don't have CCRN but have taken some of the things taught to them and have listened to the patients or residents to get what they needed from the doctors and Respiratory Therapists. You getting shot down would have depended on what you suggested and what you used to back it up with. Long term care and CCRN are very different which is why there is a specialty cert for nurses in this area also. You stated you just started in this area.

I would not back you in saying this patient is just a behavior problem without more clinical information. I prefer to assess a patient rather than just judge them.

[sistrmoon, BSN, RN]

Dustin, name calling is also unnecessary.

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.

Where was the name calling? There was an autocorrect of "how" to "hoe". Is that what you're talking about?

GrannyRRT: finding your posts very informative. Trachs are a weak area for me.

OP: sounds like a very trying situation and hope something can be found to remedy. I know on the floor at my hospital certain things can't be ordered every 1-2 hours because it's just not realistic with our patient load. If they really need q2h neuro checks or q1h pain meds, it's time for a higher level of care or a PCA. I know that's not an option in your environment but seriously! Cathing at least for less than 100ml each time that often is not necessary.

[JustBeachyNurse, LPN]

Where was the name calling? There was an autocorrect of "how" to "hoe". Is that what you're talking about?

GrannyRRT: finding your posts very informative. Trachs are a weak area for me.

OP: sounds like a very trying situation and hope something can be found to remedy. I know on the floor at my hospital certain things can't be ordered every 1-2 hours because it's just not realistic with our patient load. If they really need q2h neuro checks or q1h pain meds, it's time for a higher level of care or a PCA. I know that's not an option in your environment but seriously! Cathing at least for less than 100ml each time that often is not necessary.

Name calling was moderator edited per ToS (it was obvious for those who saw pre-edit)

It seems further evaluation may be needed for both patients Is a respiratory therapist available for consult?

[imintrouble, BSN, RN]

The simplest explanation is usually the correct one.

We could suppose for a dozen more pages, but it just looks to me like a case of control freakitis.

The worst case I ever cared for was a quadriplegic. I think it probably goes with the territory.

At first I bristled with being ordered around like a servant. I dug my heels in. It became a battle of wills. The end was inevitable. Of course the patient won. My days of emotional distress were pointless.

I started to see it less as a battle of wills, and more like a game of the mind.

I won't bore anybody with the lengthy details, but the formation of trust is a necessity. The helpless person must learn to trust the person caring for them. The jumping through hoops is the way they determine if you're going to do what they want when they want. Or even if you're going to be there when they need you.

I've found that once they trust me, we can negotiate certain aspects of their care. A give and take can develop.

It takes awhile, but it sounds like nobody in the OP is leaving any time soon.

I don't see anyway around the suctioning scenario, but time parameters on the cathing can be ordered by the MD. Every 4-6-8 hrs sounds reasonable to me.

[blondy2061h, MSN, RN]

I'm surprised at all of the recommendations to just convert the cathed patient to a foley. We're really pushing to avoid foleys except when absolutely necessary to decrease CAUTI rates.

[GrannyRRT]

The simplest explanation is usually the correct one.

We could suppose for a dozen more pages, but it just looks to me like a case of control freakitis.

The worst case I ever cared for was a quadriplegic. I think it probably goes with the territory.

At first I bristled with being ordered around like a servant. I dug my heels in. It became a battle of wills. The end was inevitable. Of course the patient won. My days of emotional distress were pointless.

I started to see it less as a battle of wills, and more like a game of the

I disagree about this being written off as freakitis.

Trachs are like shoes. They must fit properly.

Cuffed or unruffled play a huge role.

Depending on the level and completeness of injury, sensation will vary for each patient. Another example would be the quadriplegic requesting to be bagged when suctioned or larger tidal volumes on the ventilator.

The training and care they received at the previous facility plays a huge role. Many quadriplegic patients use the Cough Assist machine and are quad coughed. We spend a great deal of time with these patients especially if doing a nebulizer.

The training of the current care givers is a huge factor. This is not ICU or CCU. Managing long term patients is a specialty. While the quadriplegic patient can be challenging, nurses who want to specialize in this area will help resolve issues which might actually be part of the problem. If you are not yet experienced in long term care, you may not have patience for this. There is no comparison to the 2:1 ratio of ICU and all the people you can call.

The nebulizer and medication must best understood. It is not enough to say just because it's a trach or the doctor ordered it. If the patient has a pulmonary disease is it being properly treated?

The humidification system is another factor. Usually it is a cool mist and the flow varies per the device used. If the person has any airway reactivity, cool mist can increase it. Adding 6- 8 liters more of cold air delivering a medication can add more insult to the airways.

You could just label this patient as having freakitis but he will pick up on this quickly and you will be wearing a label also.

Bring the patient into a multidisciplinary care rounds which even long term care can have to address his needs. Even the psych issues can be addressed in most healthcare settings.

It takes a very special caregiver to work in long term care. Not everyone can or should be in that setting.

This discussion reveals some disturbing attitudes by a few. I will be stopping by the candy store today and buying the nurses in Subacute and Acute Rehab a couple of big boxes of chocolates for their attentiveness of getting problems addressed whether physical or psych and their hard work despite the nurse/patient ratio. For the large number of quadriplegic patients, even our troublemakers get their problems addressed and they know they so will they do not play games on important things concerning airway, bowel and bladder care. They are aware of the consequences.

[LadyFree28, BSN, LPN, RN]

I disagree about this being written off as freakitis.

Trachs are like shoes. They must fit properly.

Cuffed or unruffled play a huge role.

Depending on the level and completeness of injury, sensation will vary for each patient. Another example would be the quadriplegic requesting to be bagged when suctioned or larger tidal volumes on the ventilator.

The training and care they received at the previous facility plays a huge role. Many quadriplegic patients use the Cough Assist machine and are quad coughed. We spend a great deal of time with these patients especially if doing a nebulizer.

The training of the current care givers is a huge factor. This is not ICU or CCU. Managing long term patients is a specialty. While the quadriplegic patient can be challenging, nurses who want to specialize in this area will help resolve issues which might actually be part of the problem. If you are not yet experienced in long term care, you may not have patience for this. There is no comparison to the 2:1 ratio of ICU and all the people you can call.

The nebulizer and medication must best understood. It is not enough to say just because it's a trach or the doctor ordered it. If the patient has a pulmonary disease is it being properly treated?

The humidification system is another factor. Usually it is a cool mist and the flow varies per the device used. If the person has any airway reactivity, cool mist can increase it. Adding 6- 8 liters more of cold air delivering a medication can add more insult to the airways.

You could just label this patient as having freakitis but he will pick up on this quickly and you will be wearing a label also.

Bring the patient into a multidisciplinary care rounds which even long term care can have to address his needs. Even the psych issues can be addressed in most healthcare settings.

It takes a very special caregiver to work in long term care. Not everyone can or should be in that setting.

This discussion reveals some disturbing attitudes by a few. I will be stopping by the candy store today and buying the nurses in Subacute and Acute Rehab a couple of big boxes of chocolates for their attentiveness of getting problems addressed whether physical or psych and their hard work despite the nurse/patient ratio. For the large number of quadriplegic patients, even our troublemakers get their problems addressed and they know they so will they do not play games on important things concerning airway, bowel and bladder care. They are aware of the consequences.

THIS.

This is a great post on what Rehab entails seasoned Rehab nurses and personnel do.

Rehab nursing takes on a different holistic mindset, especially working with TBI and SCI pts; one has to work in the mindset of truly meeting where these pts are and then guiding them from those places to a better outcome or method, their adjustment state as well as a better locus of control.

Most are grieving in some or most ways; a optimal practice is to go with an objective mindset of what can be done, then to engage and guiding to a method of choice that is beneficial (ie the cessation of the "squirrel click") then to the expectation and flow of their needs being met successfully built on trust. Once trust is built, the ability for them to open up and understand the rationale as to WHY they needed to cope in their previous fashion helps them make the adjustments that they need for their benefit; it takes a team approach for them to get to that period of adjustment, some longer

than others.

[Surprised1, MSN, RN]

GrannyRRT, I appreciate your education about trachs. I've learned a lot from this thread.

[Karou]

Wow there is some amazing information on trach care here. Thanks guys!

As for the straight cath patient can you call the physician for parameters? Like to bladder scan for symptoms of retention and straight cath if over a certain amount only. Others mentioned UA to rule out UTI and possibly a urology consult. Maybe psych consult? Definitely discuss with the attending physician because straight cathing so frequently will probably cause a urinary tract infection... The patient needs education on the risks of frequent catheterization, if not already done.