The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [369]
4 Once circuit is set up, run the system to check it is functioning correctly and the circuit is intact and check oxygen is delivered through oxygen analyser. To ensure that oxygen is being delivered through the circuit as set. E
To ensure the system is humidifying the oxygen and that no leaks exist (MDA 2000, C).
5 If the hot water system is in use, check it is running within recommended temperature range and attach to patient. To ensure no damage to the patient’s lungs if temperature above range. E
6 Check water is present in water source of system; do not allow to run dry. To aid adequate delivery of humidity to the patient and prevent damage to the humidifier. E
7 Position the circuit tubing below the patient. To ensure collection of humidity in the circuit is able to drain into the water trap or circuit rather than into the patient. E
8 Ask the patient if they find the humidification comfortable. To ensure patient comfort. E
Postprocedure
9 Monitor the running of the system. To ensure the system is functioning adequately and delivering humidity (MDA 2000, C).
10 Reassure the patient as they may find the system noisy and the excessive moisture in the circuit difficult to cope with. To allow patient to adjust to the feel of the mask, preventing anxiety and panic at the initial increase of work of breathing (Moser and Chung 2003, C).
11 Assess the tenacity of secretions on a regular basis, and document all findings. To assess how effective the choice of humidification device has been (E). This will enable the same care to be carried on or an alternative method to be evaluated. Documentation is imperative to the multidisciplinary approach to allow for ongoing best practice (Woodrow 2002, E).
12 Change the humidification and circuit on a weekly basis and document. To prevent contamination of equipment and minimize risk of infection (Demers 2002, E).
Problem-solving table 10.2 Prevention and resolution (Procedure guideline 10.2)
Complications
Possible contamination of water in humidification if tubing collects water and it is reintroduced into the humidification chamber. This chamber provides the perfect environment for contaminants to grow as it is moist and warm (Demers 2002).
Tracheostomy care
Definition
A tracheostomy is the surgical creation of an opening (stoma) into the trachea through the neck (Figure 10.11a). The opening is usually made at the level of the second or third cartilaginous ring (Woodrow 2002) and is kept patent with a tracheostomy tube, curved to accommodate the anatomy of the trachea. When a total laryngectomy (the surgical removal of the larynx) is performed, a permanent stoma is formed by stitching the end of the trachea to the skin of the neck (Woodrow 2002).
Figure 10.11 (a) Anatomy of the head and neck. (b) Temporary tracheostomy. (c) Permanent tracheostomy.
Anatomy and physiology
Figure 10.11a shows the anatomy of the neck. The larynx, situated at the top of the trachea, houses the vocal cords and is the point of transition between the upper and lower airways (Epstein 2009). It is made up of nine cartilage segments, the largest of which is called the thyroid cartilage. Inferior to this is the cricoid cartilage which attaches to the large cylindrical tube/elastic structure known as the trachea. This is usually approximately 11 cm long and is made up of rigid cartilage anteriorly and a posterior membranous portion (Epstein 2009). The trachea then divides at the carina to form the right and left mainstem bronchi of the lungs.
Related theory
The exact location of the stoma will be determined on an individual basis according to the patient’s neck and rationale for tracheostomy. Low stomas (i.e. beyond the third tracheal ring) increase the risk of bleeding from the brachiocephalic trunk, and a tracheostomy that is too close to the cricoid has an increased risk of subglottic stenosis, a condition that is difficult to treat (De Leyn et al. 2007).
Types of tracheostomy
A temporary tracheostomy