3. Which nursing measures are aspects of proper tracheostomy care? Select all that apply.
. Securing the twill tape ties on the side of the neck.
. Cleaning or changing the inner cannula at least once a day.
. Inflating the tracheostomy cuff before tracheostomy care.
. Using peroxide and sterile saline to clean around the stoma.
. Suctioning when secretions or adventitious breath sounds are present.
. Ensuring a means of communication with the client.
Test-Taking Tip
Use a true-or-false approach to each option. Consider options that are safe and effective care.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Therapeutic Procedures
. . . . .
Answer 1 is correct because positioning the ties on the side of the neck makes it easier and safer to change. Answer 2 is correct because secretions will accumulate on the cannula and need daily cleaning. Answer 3 is incorrect because the cuff should have already been inflated to stabilize the tracheostomy tube. Answer 4 is correct because these solutions are effective in removing the remaining secretions, and reduce the risk of infection. Answer 5 is correct because accumulated secretions interfere with gas exchange. Answer 6 is correct because the inability to make credible speech sounds may be frustrating to the client and increase anxiety. If possible, it is best to establish an alternate means (flash cards, dry erase board) before the tracheostomy.