Tracheostomy Care

Posted
by ChelleBel (New) New

I am working on a case study which presents a question that has me puzzled and struggling. The scenario is this: The tissue surrounding the incision of a new tracheostomy is edematous. As you palpate the area, your fingers sink into the skin, and you auscultate a popping sound through your stethoscope. What does this mean?

I have searched through my book, PowerPoints, and the internet and can't find an answer as to what it means and what actions I'm supposed to take.

PLEASE HELP!!!

icuRNmaggie, BSN, RN

Specializes in MICU, SICU, CICU. Has 24 years experience. 1,970 Posts

Subcutaneous emphysema can cause temporary swelling and that palpable crackling of air under the skin.

Was there any mention of trauma or a chest tube?

ChelleBel

4 Posts

Unfortunately there wasn't any other information than that. Subcutaneous emphysema was basically the only thing I could find, but what would I do for the patient if that was the case? I've been told that it's not a major problem.

JustBeachyNurse, RN

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 12 years experience. 1 Article; 13,949 Posts

It depends. If the trach is not properly placed or there was additional trauma it's an urgent situation. Are oxygen saturations WNL? Respiratory distress? Significant edema?

Check lung sounds to ensure patient is ventilating. Check VS. Monitor edema. Contact surgeon.

ChelleBel

4 Posts

There was not additional information provided about trauma and such. I will go with what you suggested and move on. This is not being graded so I just want to get it done so I can start studying for my final. Nursing 4 is almost done!!! EEEKKKK!!!

Thank you so much for your help!

icuRNmaggie, BSN, RN

Specializes in MICU, SICU, CICU. Has 24 years experience. 1,970 Posts

The actions to take are:

Assess the patient and notify the MD.

Get a CXR on expiration.

Telling the patient to take a deep breath and hold it can obscure a pneumothorax.

A tracheal laceration can occur during open or percutaneous tracheostomy, this will heal without intervention.

As beachynurse said monitor for respiratory distress and tracheal deviation.

Needle decompression may be required. Prepare for chest tube insertion.

If on mechanical ventilation, is the pt receiving his tidal volumes and is the resp rate WNL.

If the patient already has chest tubes, check placement, connections, air leak, you may need to increase the suction to -25ml H20.

Edited by icuRNmaggie

ChelleBel

4 Posts

Thank you very much!!!

nurseprnRN, BSN, RN

2 Articles; 11,114 Posts

This is a new trach: This sounds like you have to think of the possibility of air escaping from a disruption in the anastomosis between the skin and the trachea. No mention of trauma? Of course there is. Never forget: Surgery is just expensive trauma.

Subcutaneous air (also called "subcutaneous emphysema") feels like microbubblewrap or Rice Krispies under the skin, although you might be able to hear it with a stethoscope. It is an indication of air in the soft tissues-- where it clearly ought not to be. Usually seen with rib fracture poking a hole in a lung (and that's trauma, for sure) or as a result of an air leak after thoracic surgery, but also seen in this kind of thing.

If there's no airway compromise, you don't have to do much besides notify the surgeon, who can come see if it's worth a revision or just watching carefully.

You can also feel this in gangrene, which isn't called "gas gangrene" for nuthin'. Same thing, only it's the gas produced by the Clostridium, not air, making the bubbles in the tissue. And while subq air isn't necessarily painful, gas gangrene is exquisitely agonizing.