PROBLEM SOLVING 2020 Jane Hutchins & Jessica
Description: PROBLEM SOLVING 2020 Jane Hutchins Jessica Parkes ENT Nurse Specialists Potential O2 saturations JVHSCH2020 Monitor O2 Saturation continuously O2 sats 95 in air via swedish nose No intervention required O2 sats 95 in air via
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slide1. PROBLEM SOLVING 2020 Jane Hutchins
&
Jessica Parkes
ENT Nurse Specialists<br>
slide2. Potential < O2 saturations JVH/SCH/2020 Monitor O2 Saturation continuously O2 sats > 95% in air via swedish nose No intervention required O2 sats 95%< in air via swedish nose Check trache tube patency – suction – if blocked change trache tube O2 sats >95% in air via swedish nose – no further action required O2 sats 95%< in max % via humidified O2 there is the potential to change to cuffed trache tube following discussion with ENT. REMEMBER to check O2 saturation probe is attached correctly BEFORE following this plan O2 sats 95%< in 1L via swedish nose change to humidified O2 as you can give a higher % O2 Wean O2 back to air via swedish nose. When O2 sats >95% in air via swedish nose for 24hrs change back to uncuffed trache tube<br>
slide3. Problem: Tracheostomy tube. Difficulty suctioning Irrigate with 0.5mls normal saline Difficulty inserting suction catheter Unable to breath through trache tube Change trache tube Monitor trache secretions Thick secretions Normal secretions Observe trache secretions Normal secretions Continue usual trache care Continue usual trache care Seek medical advice from G.P., Community nurse they will then inform the ENT Team at Sheffield Children’s hospital. Normal breathing resumed Not breathing Dial 999 & commence Basic Life Support JVH/SCH/2020 Offensive smelling tracheal secretions seek advice from Doctor or nurse Nebulise with 5ml 0.9% sodium chloride Unable to breath through trache tube change inner canular if present Remember for irrigation use 0.9% Saline!
0.5 ml – Below 1 year
1ml – 1 year and above<br>
slide4. Treatment for thick secretions Suction tube and if child’s tracheostomy tube is completely blocked by secretion, change tracheostomy tube immediately.
If secretions are BEGINNING to block tracheostomy tube then:
Irrigate with 0.9% sodium chloride (0.5ml for under 1 year and 1ml for over 1 year) this may need to be repeated once more providing the child's condition remains unchanged.
If following the second irrigation the secretions remain thick then use Nebulised saline.
If secretions slightly improve Commence patient on humidified air or oxygen and continue 4 hourly nebulised saline.
If Tracheostomy completely blocks, Change Tracheostomy Tube.<br>
slide5. Suction & Irrigation<br>
slide6. Established tracheostomy( located SCH trachesotomy care plan)<br>
slide8. Problem: Tracheostomy Secretions (colour change). Tracheostomy Secretions Continue current care Clear, minimal , easily obtained NAD - Seek advice from the ENT Team at Sheffield Children’s hospital & follow their plan ? Internal/External grannulation tissue, “Too dry” increase humidification / irrigation Treat with prescribed medication Suction too deep Normal secretions continue usual trache care Check suctioning technique - correct depth Good technique & correct depth Continue usual trache care & request ENT review & follow their prescribed treatment Seek advice from the ENT Team at Sheffield Children’s hospital. Obtain & send trache secretion specimen for M,C&S Offensive/Green/Yellow secretions SCH/JVH/2020 HIGH RISK of trache tube blocking – Irrigate more frequently +/- nebulised saline, change inner tube more frequently – Increased risk of EMERGENCY tube change Re-eductate instructing/documenting correct suction depth Blood stained Continue usual trache care Clear, minimal , easily obtained secretions Blood stained<br>
slide9. Causes of Blood Stained Secretions Suction depth is too deep resulting in trauma to the trachea (potential internal granulation tissue)
Infection
Over-granulation
Inadequate humidification – too dry<br>
slide10. Over Granulation Bivona tubes (Silicone)
Apply Mepilex Ag dressing and leave insitu for 7 days without changing.
If no improvement after 7 days change from silicone to plastic tube (e.g. shiley)
Follow guidelines for over granulation of plastic tube. (This is found in the next slide). REMEMBER – PETROLEUM BASED PRODUCTS MUST NOT BE USED WITH SILOCONE TUBES (BIVONA)<br>
slide11. Shiley (plastic tube)
Apply a ring of Vaseline around the stoma site (with tracheostomy insitu) as shown on the diagram and treat with sliver nitrate stick.
The following day apply Maxitrol onitment (petroleum based) and continue twice a day for 2 weeks.
If not improvement after 2 weeks, apply Mepilex Ag dressing and leave insitu for 7 days without changing. REMEMBER – PETROLEUM BASED PRODUCTS MUST NOT BE USED WITH SILOCONE TUBES (BIVONA) Ring of Vaseline Over Granulation, treat with sliver nitrate stick. Over Granulation<br>
slide12. Problem: Need to change Tracheostomy tube change Routine trache tube change every 7 days
Once only use Shiley Cuffed Tracheostomy tube change Cuffed Tube preparation & change
Instill 5mls air into cuff and check it inflates equally and remains so for a few minutes.
Remove the air & thread cotton tracheostomy tapes into the flange on the tracheostomy tube
Insert the introducer into the trache tube & apply a small amount of lubricant
Prepare the uncuffed size …… tracheostomy tube in the same way
Ensure suction machine is working with the appropriate size suction catheter attached
Position with a role under shoulders (neck extended)
Cut the old cotton tapes.
Step 1
Suction mouth.
Deflating the cuff
Remove the trache tube and insert the clean cuffed trache tube, remove the introducer, secure with cotton tapes & instill 5mls air into cuff tube,attach swedish nose, check pressure of cuff with monitor. Needs to be in the green area. Unable to insert clean cuffed trache tube
Reposition & insertion cuffed trache tube
Follow step 1 Unable to insert clean cuffed trache tube
Reposition and insertion cuffed trache tube
Unable to insert cuffed tube insert uncuffed smaller tube & contact ENT Unable to insert uncuffed smaller tube
Ring 2222/999
Stay with patient & monitor condition Unable to insert uncuffed smaller tube
Ring 2222/999
Stay with patient & monitor his condition
If patient stops breathing commence basic life support remember to take the roll out from under shoulders JVH/SCH2020<br>
slide13. Problem: SHILEY Tracheostomy tube cuff. Problem solving with Shiley tracheostomy cuff issues Cuff partially/fully deflated Check cuff pressure monitor 6 hourly NB Do not exceed 10-15mmgh Reinflate with cuff pressure monitor NB Do not exceed 10-15mmgh Cuff will not inflate Cuff inflated Change trache tube & return old tube to supplier JVH/SCH/2020 Increased watery, food or drink coloured tracheal secretions Stop Eating and Drinking and Contact ENT Cuff inflated Check cuff pressure monitor 6 hourly NB Do not exceed 10-15mmgh<br>
slide14. Problem: Need to change Bivona (silicone) TTS (cuffed) Tracheostomy tube change Routine trache tube change every 28 days or as child’s condition dictates Tracheostomy tube change Tube preparation & change
Instill 5mls normal saline into cuff and check it inflates equally and remains so for a few minutes.
Remove the normal saline & thread cotton tracheostomy tapes into the flange on the tracheostomy tube
Insert the introducer after checking on template & apply a small amount of lubricant
Prepare the uncuffed ½ size smaller tracheostomy tube
Ensure suction machine is working with the appropriate size suction catheter attached
Position child with a role under there shoulders (neck extended)
Cut the old cotton tapes.
Step 1
Suction childs mouth & nose.
Deflate the cuff by removing the saline
Remove the trache tube and insert the clean Cuffed tube, remove the introducer, secure with cotton tapes & instill …mls saline into cuff remove or add saline as required to ensure no symptoms of aspiration or “leak” are present. Unable to insert clean Cuffed trache tube
Reposition child and insertion Cuffed trache tube
Follow step 1 Unable to insert clean cuffed trache tube
Reposition child and insertion cuffed trache tube
Unable to insert cuffed tube insert smaller uncuffed tube & seek medical advice immediately Unable to insert uncuffed tube
Ring 2222 or 999
If child stops breathing commence basic life support JVH/SCH/2020<br>
slide15. - Problem: Bivona (silicone)
Tracheostomy tube cuff. Problem solving with tracheostomy cuff issues Cuff partially/fully deflated Check cuff pressure visually 6 hourly Instil 0.5mls of saline until there is no leak. This can be repeated in 0.5mls but no more than 3mls additional in total Recheck visually after 1 hour Cuff will not inflate Cuff inflated Change trache tube & return old tube to supplier Check cuff pressure visually 4 hourly Seek medical advice by contacting the ENT team at Sheffield Children’s Hospital
Send Secretions for MC&S Cuff partially/fully deflated Cuff inflated SCH/JVH/2020 Increased tracheal secretions Visually check cuff is inflated & check no “leak” is present Seek medical advice.
Send Secretions for MC&S
Then contact the ENT team at Sheffield Children’s Hospital if necessary NB Check cuff is inflated visually DO NOT remove the saline to check how much is in the cuff – use “ minimal leak technique” NB It is expected that saline will evaporate over a period of time especially if the child is ventilated.<br>
slide16. “Does & Don’t” of different types of tubes<br>
slide17. “Does & Don’t” of different types of tubes<br>
slide18. “Does & Don’t” of different types of tubes<br>
slide19. “Does & Don’t” of different types of tubes<br>
&
Jessica Parkes
ENT Nurse Specialists<br>
slide2. Potential < O2 saturations JVH/SCH/2020 Monitor O2 Saturation continuously O2 sats > 95% in air via swedish nose No intervention required O2 sats 95%< in air via swedish nose Check trache tube patency – suction – if blocked change trache tube O2 sats >95% in air via swedish nose – no further action required O2 sats 95%< in max % via humidified O2 there is the potential to change to cuffed trache tube following discussion with ENT. REMEMBER to check O2 saturation probe is attached correctly BEFORE following this plan O2 sats 95%< in 1L via swedish nose change to humidified O2 as you can give a higher % O2 Wean O2 back to air via swedish nose. When O2 sats >95% in air via swedish nose for 24hrs change back to uncuffed trache tube<br>
slide3. Problem: Tracheostomy tube. Difficulty suctioning Irrigate with 0.5mls normal saline Difficulty inserting suction catheter Unable to breath through trache tube Change trache tube Monitor trache secretions Thick secretions Normal secretions Observe trache secretions Normal secretions Continue usual trache care Continue usual trache care Seek medical advice from G.P., Community nurse they will then inform the ENT Team at Sheffield Children’s hospital. Normal breathing resumed Not breathing Dial 999 & commence Basic Life Support JVH/SCH/2020 Offensive smelling tracheal secretions seek advice from Doctor or nurse Nebulise with 5ml 0.9% sodium chloride Unable to breath through trache tube change inner canular if present Remember for irrigation use 0.9% Saline!
0.5 ml – Below 1 year
1ml – 1 year and above<br>
slide4. Treatment for thick secretions Suction tube and if child’s tracheostomy tube is completely blocked by secretion, change tracheostomy tube immediately.
If secretions are BEGINNING to block tracheostomy tube then:
Irrigate with 0.9% sodium chloride (0.5ml for under 1 year and 1ml for over 1 year) this may need to be repeated once more providing the child's condition remains unchanged.
If following the second irrigation the secretions remain thick then use Nebulised saline.
If secretions slightly improve Commence patient on humidified air or oxygen and continue 4 hourly nebulised saline.
If Tracheostomy completely blocks, Change Tracheostomy Tube.<br>
slide5. Suction & Irrigation<br>
slide6. Established tracheostomy( located SCH trachesotomy care plan)<br>
slide8. Problem: Tracheostomy Secretions (colour change). Tracheostomy Secretions Continue current care Clear, minimal , easily obtained NAD - Seek advice from the ENT Team at Sheffield Children’s hospital & follow their plan ? Internal/External grannulation tissue, “Too dry” increase humidification / irrigation Treat with prescribed medication Suction too deep Normal secretions continue usual trache care Check suctioning technique - correct depth Good technique & correct depth Continue usual trache care & request ENT review & follow their prescribed treatment Seek advice from the ENT Team at Sheffield Children’s hospital. Obtain & send trache secretion specimen for M,C&S Offensive/Green/Yellow secretions SCH/JVH/2020 HIGH RISK of trache tube blocking – Irrigate more frequently +/- nebulised saline, change inner tube more frequently – Increased risk of EMERGENCY tube change Re-eductate instructing/documenting correct suction depth Blood stained Continue usual trache care Clear, minimal , easily obtained secretions Blood stained<br>
slide9. Causes of Blood Stained Secretions Suction depth is too deep resulting in trauma to the trachea (potential internal granulation tissue)
Infection
Over-granulation
Inadequate humidification – too dry<br>
slide10. Over Granulation Bivona tubes (Silicone)
Apply Mepilex Ag dressing and leave insitu for 7 days without changing.
If no improvement after 7 days change from silicone to plastic tube (e.g. shiley)
Follow guidelines for over granulation of plastic tube. (This is found in the next slide). REMEMBER – PETROLEUM BASED PRODUCTS MUST NOT BE USED WITH SILOCONE TUBES (BIVONA)<br>
slide11. Shiley (plastic tube)
Apply a ring of Vaseline around the stoma site (with tracheostomy insitu) as shown on the diagram and treat with sliver nitrate stick.
The following day apply Maxitrol onitment (petroleum based) and continue twice a day for 2 weeks.
If not improvement after 2 weeks, apply Mepilex Ag dressing and leave insitu for 7 days without changing. REMEMBER – PETROLEUM BASED PRODUCTS MUST NOT BE USED WITH SILOCONE TUBES (BIVONA) Ring of Vaseline Over Granulation, treat with sliver nitrate stick. Over Granulation<br>
slide12. Problem: Need to change Tracheostomy tube change Routine trache tube change every 7 days
Once only use Shiley Cuffed Tracheostomy tube change Cuffed Tube preparation & change
Instill 5mls air into cuff and check it inflates equally and remains so for a few minutes.
Remove the air & thread cotton tracheostomy tapes into the flange on the tracheostomy tube
Insert the introducer into the trache tube & apply a small amount of lubricant
Prepare the uncuffed size …… tracheostomy tube in the same way
Ensure suction machine is working with the appropriate size suction catheter attached
Position with a role under shoulders (neck extended)
Cut the old cotton tapes.
Step 1
Suction mouth.
Deflating the cuff
Remove the trache tube and insert the clean cuffed trache tube, remove the introducer, secure with cotton tapes & instill 5mls air into cuff tube,attach swedish nose, check pressure of cuff with monitor. Needs to be in the green area. Unable to insert clean cuffed trache tube
Reposition & insertion cuffed trache tube
Follow step 1 Unable to insert clean cuffed trache tube
Reposition and insertion cuffed trache tube
Unable to insert cuffed tube insert uncuffed smaller tube & contact ENT Unable to insert uncuffed smaller tube
Ring 2222/999
Stay with patient & monitor condition Unable to insert uncuffed smaller tube
Ring 2222/999
Stay with patient & monitor his condition
If patient stops breathing commence basic life support remember to take the roll out from under shoulders JVH/SCH2020<br>
slide13. Problem: SHILEY Tracheostomy tube cuff. Problem solving with Shiley tracheostomy cuff issues Cuff partially/fully deflated Check cuff pressure monitor 6 hourly NB Do not exceed 10-15mmgh Reinflate with cuff pressure monitor NB Do not exceed 10-15mmgh Cuff will not inflate Cuff inflated Change trache tube & return old tube to supplier JVH/SCH/2020 Increased watery, food or drink coloured tracheal secretions Stop Eating and Drinking and Contact ENT Cuff inflated Check cuff pressure monitor 6 hourly NB Do not exceed 10-15mmgh<br>
slide14. Problem: Need to change Bivona (silicone) TTS (cuffed) Tracheostomy tube change Routine trache tube change every 28 days or as child’s condition dictates Tracheostomy tube change Tube preparation & change
Instill 5mls normal saline into cuff and check it inflates equally and remains so for a few minutes.
Remove the normal saline & thread cotton tracheostomy tapes into the flange on the tracheostomy tube
Insert the introducer after checking on template & apply a small amount of lubricant
Prepare the uncuffed ½ size smaller tracheostomy tube
Ensure suction machine is working with the appropriate size suction catheter attached
Position child with a role under there shoulders (neck extended)
Cut the old cotton tapes.
Step 1
Suction childs mouth & nose.
Deflate the cuff by removing the saline
Remove the trache tube and insert the clean Cuffed tube, remove the introducer, secure with cotton tapes & instill …mls saline into cuff remove or add saline as required to ensure no symptoms of aspiration or “leak” are present. Unable to insert clean Cuffed trache tube
Reposition child and insertion Cuffed trache tube
Follow step 1 Unable to insert clean cuffed trache tube
Reposition child and insertion cuffed trache tube
Unable to insert cuffed tube insert smaller uncuffed tube & seek medical advice immediately Unable to insert uncuffed tube
Ring 2222 or 999
If child stops breathing commence basic life support JVH/SCH/2020<br>
slide15. - Problem: Bivona (silicone)
Tracheostomy tube cuff. Problem solving with tracheostomy cuff issues Cuff partially/fully deflated Check cuff pressure visually 6 hourly Instil 0.5mls of saline until there is no leak. This can be repeated in 0.5mls but no more than 3mls additional in total Recheck visually after 1 hour Cuff will not inflate Cuff inflated Change trache tube & return old tube to supplier Check cuff pressure visually 4 hourly Seek medical advice by contacting the ENT team at Sheffield Children’s Hospital
Send Secretions for MC&S Cuff partially/fully deflated Cuff inflated SCH/JVH/2020 Increased tracheal secretions Visually check cuff is inflated & check no “leak” is present Seek medical advice.
Send Secretions for MC&S
Then contact the ENT team at Sheffield Children’s Hospital if necessary NB Check cuff is inflated visually DO NOT remove the saline to check how much is in the cuff – use “ minimal leak technique” NB It is expected that saline will evaporate over a period of time especially if the child is ventilated.<br>
slide16. “Does & Don’t” of different types of tubes<br>
slide17. “Does & Don’t” of different types of tubes<br>
slide18. “Does & Don’t” of different types of tubes<br>
slide19. “Does & Don’t” of different types of tubes<br>