George Patel, age 64, was admitted to your floor 3 days ago following surgical insertion of a tracheostomy tube. His diagnosis prior to surgery was acute upper airway obstruction. He has a medication (saline) lock. Currently, he is receiving oxygen via his tracheostomy at 40%. His pulse oximetry readings have been consistently running in the low 90s. He quickly becomes short of breath when his oxygen is interrupted during suctioning. During your shift, you will have to suction Mr. Patel as needed and provide routine tracheostomy care. You will also need to transport him with portable oxygen to radiology for his chest x-ray (AP and lateral).
Prescribed Interventions
- Morphine sulfate 1 to 4 mg IV q3h prn for pain
- AP and lateral chest x-ray
- Pulse oximetry every shift and prn
- Oxygen via trach Venturi mask at 40%
- Tracheostomy care every shift and prn
- Medication or saline lock, flush every shift
- Tracheal suctioning prn
Developing Clinical Reasoning and Clinical Judgment
- How would you determine when Mr. Patel needs to be suctioned?
- Describe expected outcomes when suctioning and providing tracheostomy care.
- How would you determine when Mr. Patel needs to have tracheostomy care?
- When transporting Mr. Patel to the radiology department, what interventions should you implement to ensure his safety?
Suggested Responses for Integrated Nursing Care
- To evaluate the need for suctioning, first assess Mr. Patel's respiratory status (refer to Chapters 3 and 14). Examine his oxygen saturation and compare it with his baseline (Chapter 14). If his oxygen saturation is decreased from his baseline, this may be an indication that he needs to be suctioned. Observe his respirations to determine if they are more labored than usual (refer to Chapters 2 and 3). Listen to his lung sounds for crackles or wheezes. Also, listen around his tracheostomy for gurgling. Does he have a productive cough? All of these signs and symptoms are indications that he needs to be suctioned.
- To assess the need for tracheostomy care (see Chapter 14), closely examine his tracheostomy as well as the tracheostomy holder/ties and precut gauze dressing. If it appears wet or moist, tracheostomy care would be indicated. If his tracheostomy dressing appears dry and intact, you may want to wait until later in your shift to do tracheostomy care. Suctioning and subsequent coughing will often soil the tracheostomy dressings, so wait until after suctioning to change the tracheostomy dressing.
- Your expected outcomes when suctioning a tracheostomy include minimizing hypoxia, discomfort, and fatigue. Hypoxia may be reduced by hyperoxygenating the patient before suctioning according to facility policy. When you suction Mr. Patel (using sterile technique), limit the length of suction time to 10 to 15 seconds and allow him to rest before suctioning him again (see Chapters 1 and 14). During tracheostomy care or repeat suctioning, quickly replace his oxygen source and limit the time his oxygen is interrupted. Since Mr. Patel has a new tracheostomy, it is very likely he will need to be premedicated with morphine for pain. Morphine may depress respirations, so continually assess Mr. Patel's respiratory status after administering the pain medication. In addition, adequate rest periods are needed to minimize fatigue from suctioning. Mr. Patel may require a rest period between suctioning the tracheostomy and his tracheostomy care.
- Important interventions when transporting Mr. Patel focus on providing adequate oxygenation. First, assess Mr. Patel's oxygen saturation and respiratory status prior to transport (Chapters 2 and 3). If indicated, suction Mr. Patel before he leaves his room. You must also check that the portable oxygen tank is full and the label says “oxygen.” Before turning off his wall oxygen, make sure the portable oxygen tank is working properly and that the equipment is ready. This avoids interruption of the oxygen supply while placing him on the portable oxygen.