Over the past few years, the number of patients with tracheostomy being cared for in the ward setting has increased dramatically as a direct result of an increased demand for critical care beds (Russel C., 2005). As a consequence, ward staffs are providing the specialist care required by these patients more frequently. However, there is evidence to suggest that there is a lack of knowledge, skills and confidence required to meet the unique needs of these patients safely and adequately (Paul F., 2010). This essay aims to discuss the nursing care required to effectively care for a patient with tracheostomy as well as the psychological impact of nursing a patient on isolation.
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To effectively care for a patient with tracheostomy, staff nurses will require a combination of complex skills such as appropriate respiratory assessment, an in-depth understanding of humidification, knowing when and how to suction, stoma care and management of tube blockage or displacement. In preparing to care for such patients the nurse must obtain information about the type and size of the cannula, the method of humidification required and details of any ventilatory support. Emergency equipments must also be within reach. This includes tracheal dilators, resuscitation equipment, suction equipment, stitch cutter, humidified oxygen and a call bell within patient’s reach (Barnett, 2005). The nurse must closely observe the patient’s respiratory function, assess their cough reflex and monitor their oxygen saturation frequently as this may signal occlusion which demands specialist medical help (Paul F., 2010).
Tracheal suctioning is a necessary intervention in the management of a patient with tracheostomy. However, Russel C. (2009) stated that it should not be done routinely but only after the nurse has identified the need for suctioning through proper patient assessment. The indications for suctioning includes audible or visible secretions, increased coughing, rise in airway pressure, suspected aspiration, reduced airflow and deteriorating peripheral oxygen saturation. Regan & Dallachiesa (2009) recommends hyperoxygenation before and after suctioning to prevent the occurrence of suction induced hypoxemia. This can be achieved by asking the conscious patient to take some deep breaths or by using manual resuscitation bag for unconscious patients. The procedure should take no longer than 10-15 seconds (Lewis,2005). The patient’s response must be documented each time suctioning is done, including the vital signs, oxygen saturation, amount and consistency of secretions, cardiac rhythm, breath sounds, and the frequency of needed suctioning.
Humidification is also an important aspect of tracheostomy care which can reduce the need for suctioning if assessed and delivered appropriately (Edgtton, 2005). The indication for the use of humidification includes thick and tenacious secretions which is difficult to clear.
Most standard adult tracheostomy tube has an inner cannula that can easily be removed and cleaned. Care of the inner cannula involves removing and cleaning it with warm running water. Trundle and Brooks (2004) identified that sterile water is not required in cleaning the inner cannula and warm running water would be enough. The dressing must be changed regularly which will require two person to ensure that one person is always holding the tube thus preventing accidental decannulation. The area around the stoma must be cleaned with normal saline and a pre-cut gauze must be used.
Furthermore, cuff pressure must be constantly monitored to prevent mucosal damage. A manometer may be used to measure the pressure of the cuff. The recommended maximum cuff pressure is 25 mmHg (Russel, 2005).
Effective communication can be challenging for patients with tracheostomy, thus, written and other non-verbal communication should be implemented. Example of non-verbal communication techniques that can help facilitate communication includes gestures, sign language, pointing, lip reading, eye blinking or facial expressions. Simple devices can also be used such as magic slates, pen and paper, symbol boards and flashcards.
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Patient’s nutritional status may also be impaired. Patients with tracheostomy would usually be on a nil by mouth diet which compromise the patient’s nutritional status. A referral to a nutritionist would help ensure his nutritional needs are being met.
A patient who has tracheostomy is at an increased risk of infection by reason of bypassing the natural defense mechanism offered by the cilia and mucous membrane in the nose and upper respiratory tract. Infections such as methicillin resistant staphylococcus aureus (MRSA) can easily be acquired thus, requiring patient isolation. It should be acknowledged that this could have a negative effect on the patient’s psychological status. In a systematic review of the impact of isolation on a patient’s well being conducted by Abad et al. (2010), the majority of studies showed a negative impact on patient’s mental well being and behavior including lowered self esteem, anxiety, depression, low sense of control, negative alterations in mood, anger, traumatic feeling of confinement and thought that contact with nurses and doctors lessen, thus decreasing the quality of care as perceived by the patients. Participants in a study conducted by Skyman et al. (2010) stated that they had an overwhelming feeling of alienation, unwelcome and shut out from treatment and care. On the contrary, Wassenberg et al (2010) found out that short term isolation does not have any negative influence on the patient’s psychological status but rather result to a positive attitude towards the precaution taken. They argued that higher levels of depression and anxiety usually result from long-term isolation rather than short term.
Patient education may be an important step to lessen the adverse psychological effects of isolation by helping the patients to understand the necessity for isolation thus giving them the opportunity to cope better (Morgan et al., 2009).
Caring for a patient with tracheostomy can be challenging. Since such patients are becoming more common in acute areas, nurses must ensure that their knowledge and skills in caring for such complex patients are maintained both from a theoretical and practical perspective. Nurses who care for this group must have access to appropriate training to ensure that care is delivered appropriately and with confidence. Furthermore, nurses should also be sensitive to the negative impact of isolation on a patient’s psychological status and must ensure that patients understand the need for isolation through thorough patient education to help alleviate the patient’s fear and anxiety.
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