1. Tubes and Drains PN 3

2. Respiratory Tubes Tracheostomy

3.  opening in trachea-surgically created  Variety of tubes can be inserted- temp/perm, length of use, speak  Variation of tubes-double or single lumen, cuffed or not

4. Tracheostomy

5. Comparison of features- Cannula  Double lumen-both inner and outer cannula  Easy cleaning  Reusable or disposable  Shiley  Single lumen-no inner cannula  Short term use  Not anticipated to have copious secretions  Portex

6. Shiley

7. Portex

8. Cuff  Cuff-allows to be sealed off  Prevent air loss or prevent aspiration  Inflate with air using syringe to pilot ballon  No cuff-long term use  Don’t need mechanical ventilation  Low risk aspiration

9. Cuff  Cuffed

10. Fenestration  With-have holes in tube to allow air to flow between larynx and trachea  During weaning so client can regain ability to breath  Allows for speech  Non-no holes  Mechanical ventilation or for people who don’t speak

11. Fenestration

12. Nursing Responsibilities  HOB 30 degrees  Ambu bag at bedside  Spare set, clamps at bedside  Humidified O2  TCDB  Respiratory Assessment q 4 hrs  Suction-set up and procedure  Inspect stoma  Perform tracheostomy care q 8 hrs  Change ties daily  Monitor cuff pressure q 8 hrs  Alternate communication devices

13. Complications  Tube displacement-secure, keep spare at bedside, don’t pull  Tube obstruction-humidify O2, suction, TCDB, clean inner cannula  Tracheomalacia (dilation caused by high pressure cuffs)-monitor pressure, bleeding, air volumes, aspiration, get to uncuffed asap  Tracheoesophageal fistula (abnormal connection between trachea and esophagus from high cuff pressure)-Same as above but may have Gtube inserted  Tracheal stenosis (narrowing from scar tissue)-surgical dilation  Tracheal-innominate artery fistula (erosion of trachea into artery cause by pressure-monitor pressure, bleeding, pulsation in trach tube, prepare for immediate life-saving surgical repair

14. Removal  Accidental  Before 72 hrs-bag, call rapid response  After 72-insert new tube, ventilate with manual resuscitation bag, assess air exchange  Purposeful  Suction  Deflat cuff  MD-cuts sutures and withdraws tube during exhalation  Dry sterile dressing over stoma and tape gently  Close over next few days but leaves scar

15. Respiratory Tubes Endotracheal tube

16. Ambu Bag

17. ET tube

18. Overview  Short term use-10 to 14 days  Keep patent airway  Can use mechanical ventilation  Long tube  One end-adapter for O2  Other end-cuff for inflation

19. Insertion  Orotracheal  Larger tube  Rapid restore of air  Discomfort for pt, displacement with tongue, occlusion from biting  Nasotracheal  Smaller tube  Increase respiratory effect

20. Orotracheal Tube

21. Nasotracheal Tube

23. Nursing Management  Check placement every 8 hrs  Confirm placement with Chest X-Ray  Mark lip line for cm to insure placement  Ambu bag at bedside  Suction as needs  Check respiratory every 4 hrs  Inflate cuff  Insert oral airway to prevent biting  Position on one side of the mouth  Oral care every 2 hours  Provide alternative means of communication

24. Removal  Suction  Elevate HOB-semi fowlers to fowlers  Deflate cuff  Have client inhale and remove at peak inspiration  Encourage to cough  O2  Monitor closely for 30 min  Teach they will have a sore throat, hoarse voice

25. Closed Chest Drainage System Chest Tube

26. Chest tube insertion  Why are chest tubes placed?  3 types of drainage systems  single chamber-water seal and drainage collection in same chamber.  dual chamber-water seal and collection chamber separately  three chamber-water seal, collection drainage and suction control in separate chambers. Pneumothorax, hemothorax, pleural effusions, lung abscess, post-op chest drainage (thoracotomy or CABG)

27. Chest Tube-Nursing Care  Document vitals, breath sounds, oxygen sat and resp effort at least every 4 hours.  Tape all connections, secure to chest wall.  Keep chamber below chest level.  Check frequently for kinks or loops/ s/s of infection crepitus  If water seal system used, The water level should fluctuate with respiration. If it does not it may not be patent.  Keep device upright- monitor water level, add fluid as need to maintain 2cm water seal.  Measure drainage every 8 hrs marking the level  Keep 2 covered hemostats, bottle of sterile water and an occlusive dressing at bedside at all times.

28. Complications  Air leaks  monitor water seal chamber for continuous bubbling  Accidental disconnection ◦ check all connections ◦ instruct to exhale as much as possible & cough, cleanse tip and reconnect tubing  If tube accidentally removed..place Vaseline gauze immediately over site  Tension Pneumothorax  What can cause a tension pneumothorax?  When are chest tubes removed?

29. Chest Tubes

30. Chest Tube

32. Renal and Urinary Tubes

33. Nephrostomy/Ureteral Tube  Position tube so it maintain patency, don’t clamp  Monitor urine output  Don’t irrigate unless ordered then use surgical aseptic technique with a max of 5 mL  Report if patency is not restored

34. Nephrostomy

35. Indwelling Urinary Catheter  Insert with sterile techique, record amout of outflow  Position below bladder and secure to thigh  Accurate I and O  Routine cath care  Removal-explain to pt, empty and record, deflate balloon, withdraw while client exhales

36. Nasogastric Tubes

37. NG tubes  Insertion  High fowlers  Measure-nose to earlobe then to xiphoid process-apply tape  Lubricate  Tilt head downward  Insert naris and advance upward and backward until resistance is met then rotate catheter  Ask to take sips of water or swallow-stop if they start to cough or reach tape  Tape in place  Can start suction but no feedings unless placement is confirmed by chest x-ray

38. NG Tube

39. NG-Nursing Management  Check placement  Chest x-ray, check pH, insert air and listen for popping noise  Check every 4 hrs  Monitor residual  Prior to and regularly during feedings-q4hrs  Irrigate-check patency  Mouth care q 2 hrs  Monitor naris for ulceration  Removal  Remove tape, hold breath, withdraw in 1 smooth motion

40. NG Tube

41. Nasoenteric Tube

42. Nasoenteric (Intestinal) Tubes

43. Nasoenteric Tubes  Inserted in nare into stomach and passed into intestines bc the are weighted  Pt on rt side to facilitate passage  Placement checked by abdominal x-ray  Wait to tape until verified  Suction allows for bowel decompression and intestinal secretions  Perform abdominal assessment and measure girth

44. Combined Esophageal and Gastric Tubes

45. Combined  Pressure to bleeding esophageal varices  Sengstaken-Blakemore tube-3 lumen-low gastric suction, balloon applies pressure against bleeding blood vessels  Traction is needed to maintain position of inflated balloons  NG tube inserted to suction secretions above balloon  Minnesota is similar but 4 lumens-drain secretions

46. Combined

47.  Insertion  Upright position  Check all balloons before insertion  Complication