Refusing trach care

[FROGGYLEGS, LPN]

Hi.

I don't really have a specific question. I'd like to post a bit of information in hopes that someone might have some input or advice on it.

A resident has a tracheostomy. No trach tube just the stoma, but it does function as their airway. No oxygen system - room air- no added humidification. No suctioning ordered. Does have orders to 'flush stoma q shift with saline'.

Resident is confused and very combative at times when attempts made to examine area or assess. Frequently refuses any care of area and any interventions. Refuses to allow nurse to even look at it sometimes and will pull shirt over it to conceal it.

Generally able to expel any mucous by coughing and the main need is to keep stoma clean, but sometimes refuses care completely until airway is affected by built up mucous and dried secretions. This is my biggest concern, that there is usually a problem before anyone is allowed to intervene and I am afraid that it will lead to an emergency situation.

I do document his agitation and refusals, any tidbits of an assessment I can get, and the care measures that I am able to provide.

I have little experience with trachs, but that probably shows right? :stone

If anyone has any suggestions for this I would love to hear them.

[barefootlady, ADN, RN]

I would chart as much of the appearance of the stoma and patients breathing ablility, IE, no redness, swelling or purulent drainage from stoma noted, no bleeding or scabbing noted. Patient's breathing is even, nonlabored. Patient has refused trach care, no s/s of acute distress.

[CapeCodMermaid, RN]

Hi.

I don't really have a specific question. I'd like to post a bit of information in hopes that someone might have some input or advice on it.

A resident has a tracheostomy. No trach tube just the stoma, but it does function as their airway. No oxygen system - room air- no added humidification. No suctioning ordered. Does have orders to 'flush stoma q shift with saline'.

Resident is confused and very combative at times when attempts made to examine area or assess. Frequently refuses any care of area and any interventions. Refuses to allow nurse to even look at it sometimes and will pull shirt over it to conceal it.

Generally able to expel any mucous by coughing and the main need is to keep stoma clean, but sometimes refuses care completely until airway is affected by built up mucous and dried secretions. This is my biggest concern, that there is usually a problem before anyone is allowed to intervene and I am afraid that it will lead to an emergency situation.

I do document his agitation and refusals, any tidbits of an assessment I can get, and the care measures that I am able to provide.

I have little experience with trachs, but that probably shows right? :stone

If anyone has any suggestions for this I would love to hear them.

Hmmmm...is it the standard of practice to flush a trach q shift? I've had patients with old trachs...no cannula or anything, but we never flushed the trach...just wondering.

[FROGGYLEGS, LPN]

Thanks for the input. :) I do try to document as much as possible to show at least that I have made attempts to provide needed care and am monitoring closely.

I have never heard of anyone having their trach flushed q shift. This particular order doesn't specify a certain amt of saline. I think the whole thing seems a bit odd, but then again I don't have much experience with hands-on trach care.

I have been reading a lot about tracheostomies lately and doing CE units that apply to it. What I've read seems to discourage instilling saline into the trach unless it is necessary during suctioning d/t tenacious mucous. I believe the reason given was that the saline actually stimulated mucous production.

[suzanne4, RN]

Never heard of instilling saline into an old stoma every shift. What is the reason behind that? I would definitely check with the doctor on that one. As stated above, it is only going to cause more secretions.