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WILD WORLD OF PDN

Private Duty   (628 Views 17 Comments)
by 3.24.95 3.24.95, LPN (Member)

3.24.95 has 23 years experience as a LPN and works as a Nurse.

207 Visitors; 17 Posts

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I am struggling to find a balance, where I can practice as the diligent nurse I am, following policy/protocol, vs becoming the enemy. If I hear “we’ve always done it this way” one more time, I think I’ll have a coronary!

I am not a “yes (wo)man” and I don’t do things based on archaic and dogmatic thinking. The whole cold weather/air conditioning causes colds myth makes me want to cry.

I very recently oriented with a nurse that firmly stated trach changes were “clean procedures.” She rolled her eyes as I was doing my best to maintain a “sterile field” and laughed out loud, literally, when I confirmed that she’d take out old trach, on my count of 3.

Her confusion re how to “sterilize” a Bivona was the scariest part. She’d been soaking them in H2O2, letting it air dry, and “packaging” it with no date, no #of times used...nothing.

No wonder a wicked “cold” had been traveling from nurse to family member, and vice versa, for weeks. I had to call out, my 1st solo shift, because I caught the dag-nab thing!

Clinical managers can’t complete the tasks expected of them, so “snitching” on someone will get you super unpopular, in a real hurry.

Real-life, honest and genuine responses, based on experience, education, etc are most welcome & appreciated.

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kp2016 has 20 years experience.

3,014 Visitors; 196 Posts

I have been the new kid on the block in a unit where I heard "I was always told that" or "we always" all day long. Needless to say none of it was evidence based or based on published industry standards. 

I countered it by volunteering when the manager was looking for someone to join the education committee. I collected articles, resource manuals and orientation manuals from our relevant nursing association and journals and brought them to work. I incorporated the information into our education updates, skills updates etc and started referencing the position statements from our nursing association and our own policy and procedure manual  (which apparently my co workers were not familiar with) when even I was challenged, even if the challenge was just eye rolling. 

I didn't happen overnight, but I did make significant changes at this unit over time. 

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NRSKarenRN has 40 years experience as a BSN and works as a Registered Nurse, Home Health.

5 Followers; 9 Articles; 159,659 Visitors; 14,438 Posts

PDN = Private Duty Nursing in patients own home or school setting.

Trach change in the home is a CLEAN procedure.... I've been doing it that way for 25+ years.  Cleaning with soak and water, rinse distilled water or using Hydrogen peroxide acceptable.

See:

Changing a Tracheostomy (Trach) Tube | Way to Grow | CHKD

Aaron's Tracheostomy Page- Changing Trach.  

Aaron's website has wonderful info regarding respiratory care for children, vents, eating with trach written by RN mother who's child had trach for 4 years.

Tracheostomy home care | University of Iowa Hospitals & Clinics

Quote

 

Cleaning the tracheostomy tube

Plastic and metal tubes may be cleaned with mild soap and clean tap water. Hydrogen peroxide may be used to clean plastic or stainless steel tubes. Do not use hydrogen peroxide with sterling-silver tracheostomy tubes.

If the tracheostomy tube is cuffed, clean the cuff using the manufacturer’s instructions found in the package. The cuff should not come in contact with any cleaning detergents or chemicals.

Supplies I will need to clean my tracheostomy tube are:

Clean tap water

Mild soap

Hydrogen peroxide- Do not use this with sterling-silver trachestomy tubes.

 

To clean my tracheostomy tube:

Place the dirty tracheostomy tube, obturator, and strap in a clean container.

Add clean tap water and mild soap.

Be sure the tube, obturator, and strap are covered by water.

Soak them for a few minutes to loosen any secretions.

Clean the tube and other parts using pipe cleaners and gauze sponges. Pass the pipe cleaner through the tube to remove all of the secretions.

Rinse well with clean tap water to remove all the soap.

Make sure the secretions and lint from the pipe cleaners are removed.

Place the tracheostomy tube parts on a clean towel in a safe place. Let them air dry all the way. It will take about two to three hours.

Note: Have an extra tracheostomy tube ready for use while the newly-cleaned tube dries.

When the tracheostomy tube is dry, look for cracks, a change in color of the tube, or any foul odor. The tube will need to be replaced if you find any of these.

Get the tube ready to be used again by adding ties and putting the obturator in the tube.

Place all of the tracheostomy tube parts in a closed, clean container. Keep this with you at all times.

Cleaning the inner cannula

To clean the inner cannula so it does not become plugged:

Unlock it by turning it until the notch is reached and then slide it out.

Use a small brush or pipe cleaners to clean it.

Rinse it under cool running water.

Look through the inner cannula to make sure it is clean.

Shake it or use dry pipe cleaners to remove moisture.

Put it back in and lock it into place.

 

 

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sirI has 30 years experience as a MSN, APRN, NP and works as a FNP/WHNP(E)/Educator/MedLeg Consul.

12 Followers; 18 Articles; 135,979 Visitors; 12,983 Posts

Thread has been moved to PDN forum.

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ventmommy works as a Respiratory Therapist.

10,074 Visitors; 387 Posts

Trach changes anywhere outside of the OR are clean procedures. 

Bivona has VERY SPECIFIC instructions for how to process their trach tubes in the home setting.  I would not recommend using generic trach processing instructions because Bivona trachs are silicone.  The information is in every box.

  @ThisIsMandy If you don't have any new boxes, I can scan the insert from one of the boxes I have at home.  Bivona is pretty clear on the number of times that a trach tube can be re-used (5 times) so it's important to keep track of that.

How involved/uninvolved are the parents?

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3.24.95 has 23 years experience as a LPN and works as a Nurse.

207 Visitors; 17 Posts

I guess technically “sterile procedure” isn’t appropriate terminology, but used more to encourage maintaining as sterile of a field as possible, not touching the cannula, etc. Based on a lot of research, my take is that trach care/changing is somewhere between aseptic<clean.

Semantics aside, I guess you had to be there to see how careless and nonchalant this nurse was. Despite Drs orders/POC, and our agencies policies — both based on manufacturer’s recommendations — she had no clue what she was doing. 

She inserted a Bivona with no obturator, positions clients trach collar upside down, and wonders why his SaO2s are so wonky, and why his secretions are so thick, flowing non-stop. As a direct result of this, his pulmonologist recently put him on Augmentin, which caused diarrhea, resulting in a drastic increase in sz activity. That’s nuts! 

Mom is somewhat involved, however not very hands-on at all. She’s nice and laid back, but clearly doesn’t like the thought of “rocking the boat.” She did back me when I was nearly accused of fudging my documentation of SaO2s of 99-100.

Anyway, I’ve just decided to follow protocol/policy, that way my butt is covered, regardless of how “unpopular” it makes me.

 

 

 

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3.24.95 has 23 years experience as a LPN and works as a Nurse.

207 Visitors; 17 Posts

5 hours ago, NRSKarenRN said:

PDN = Private Duty Nursing in patients own home or school setting.

Trach change in the home is a CLEAN procedure.... I've been doing it that way for 25+ years.  Cleaning with soak and water, rinse distilled water or using Hydrogen peroxide acceptable.

See:

Changing a Tracheostomy (Trach) Tube | Way to Grow | CHKD

Aaron's Tracheostomy Page- Changing Trach.  

Aaron's website has wonderful info regarding respiratory care for children, vents, eating with trach written by RN mother.

Tracheostomy home care | University of Iowa Hospitals & Clinics

 

I’m open to new ideas, and will definitely check our Aaron’s page, but as a policy-nazi, and germaphobe, I’m sticking to my agencies policy, until it changes, or I have a Drs order to do differently.

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ventmommy works as a Respiratory Therapist.

10,074 Visitors; 387 Posts

As a mom, I'd fire the nurse. 

Touching the tube is a no-no.  Her method isn't even a clean procedure.

The reasons that we use an obturator:
1.  A selling feature of Bivona is that they are super flexible.  A downside is that they are super flexible.  When you put it in without an obturator, you risk the tube bending back on itself.
2.  The obturator provides the proper shape/angle for insertion.
3.  Trach tubes are blunt.  Mucosal lining of the airway is fragile.  The smooth, rounded tip of the obturator prevents damage to the delicate mucosal lining.  No one wants to be suctioning out blood from a rough insertion.

Sadly, I see trach collars upside down all of the time in the hospital.  If the flow is right and it's positioned over the tube, it should not affect SpO2 negatively.

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ventmommy works as a Respiratory Therapist.

10,074 Visitors; 387 Posts

1 minute ago, ThisIsMandy said:

I’m open to new ideas, and will definitely check our Aaron’s page, but as a policy-nazi, and germaphobe, I’m sticking to my agencies policy, until it changes, or I have a Drs order to do differently.

The only reasonable policy your agency should have regarding trach tube processing is to follow the manufacturer's instructions for use.

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ventmommy works as a Respiratory Therapist.

10,074 Visitors; 387 Posts

I'm really unimpressed when an MD prescribes an antibiotic without a tracheal aspirate and subsequent sensitivity.  The MD needs a lesson in antibiotic stewardship.

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3.24.95 has 23 years experience as a LPN and works as a Nurse.

207 Visitors; 17 Posts

Exactly! 

Unfortunately his chubby chin will not allow this, leaving his trach wide open to RA, with a whiff of O2. Hand-to-heart, every time I walk in the door his SaO2s are in mid-90s. After I position collar as it should be, I’m able to turn his O2 down, by a liter or 2, and maintain 99-100.

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3.24.95 has 23 years experience as a LPN and works as a Nurse.

207 Visitors; 17 Posts

13 minutes ago, ventmommy said:

The only reasonable policy your agency should have regarding trach tube processing is to follow the manufacturer's instructions for use.

Agreed, but unfortunately Drs have the power to override manufacturer’s directions, although infrequent, and only after the PCG has worn them down, and insists on sticking with whatever technique their primary of 5 years “has always done it.”

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