Running head: CASE STUDY 1

CASE STUDY 2

Frist of all you should write the induction before the history – for example this is the case study about ….. and I will talk about the care intervention and tracstomy

Aftet the history you should write about family then about nursing care for patient and how to care about mr.jone then specific about tracstomy and what the definition of tracstomy what the producer …. Etc in one paragraph each point in one paragraph or 2 .. and how many time do it suctioning and what the size of the tracstomy .. you should make the case study as a nuse .. as something happen while you are in hospital for example .. every day when I go to the patient room i do …. Suctioning when I listen sounds .. or I do after the cleaning . then what the complication that effect for this patient like about cuff .. also how you should to care and what you should do to make comfortable and when you write something in some paragraph give the reason or study .. the case study I want it as a paragraph NOT point DON’T MAKE ANY POINT .. the references you should make between the sentence and if you mention any reframes in paragraph you should also mention it in list in the end .. that is my point and I want to do edit as soon as possible because you write the case in general not about patient and how to do ..

NO PLOGARISM .. at last just 5% and don’t check in any website .. I will do it this .. thank you

Case study of Patient with Tracheostomy

The patient is Mr. Jone an 83-year-old male patient who was diagnosed with chronic illness. The patient was admitted okn14-12-2018 due to acute pulmonary edema. Later he was admitted to Gama hospital on 4/3/2018 for long-term unit. Due to his illness, his family has not had an easy time. This illness has disrupted the whole family since Mr. Jone though old, he had a role to play. It has caused them to strain as a result of economic difficulties and disruptions in career development. His illness has caused his wife to be psychologically disturbed and due to her physical limitations associated with aging, she is suffering from being alone and missing the company of her husband who she is fond of. The children who are old with their families have been forced to alter their schedules to comfort their mother and be there for their father too. There has been a problem of who to take care of the patient since everyone is busy with his/her career and this has resulted in the contention in the family.

Mr. Jone requires a critical review of his critical problems and a comprehensive assessment, reassessment, and evaluation of interdisciplinary care. He requires the provision of significant value by reduction of disintegration and improvement of care transition for him. His family also requires significant education which is a critical component. He needs to be made comfortable and to be taught his own personal hygiene. He also needs to forget his cravings and be guarded so that he cannot overeat and be prevented from eating before meals.

Mr. Jone requires a risk nursing diagnosis because of the hospital risks are likely to develop unless nurses intervene. For him being old he has high chances of acquiring other infections, therefore the label for risk infection is supposed to be used to describe the risk for infection so as to describe the patient’s health status.

The nursing diagnosis that I identified and concentrated on is tracheostomy, this is a medical procedure that is either temporary or permanent, that pertains creating an opening in the neck in order to place a tube into a person’s neck. This tube is implanted through a cut in the neck below the vocal cords. This allows air to pass through the tube, avoiding the mouth, nose, and throat. A tracheostomy is done for many reasons. It is commonly used in patients who require long long mechanical ventilation, mainly to provide a more relaxed long-term airway and to enable weaning from ventilatory support (Brook, G, et al 2000).

The conditions that may require tracheostomy include anaphylaxis which is a severe allergic reaction to venom, food, or medication, birth defects of the way, diaphragm disfunction, chronic lung disease, coma, facial burns or surgery, infection, injury to the larynx, injury to the chest wall, need for prolonged respiratory or ventilator support, obstruction of the airway by a foreign body, obstructive sleep apnea paralysis of muscles used in swallowing, tumors, vocal cord paralysis and cancer in the neck (Huang, T. et al, 1963).

The patient to undergo tracheostomy will be told to prepare for the procedure. This may include fasting up to 12 hours before the procedure. Most scheduled tracheostomies are given a general anesthesia, which makes them fall asleep so as not to feel pain. In case, the patient case was an emergency he/she will be vaccinated with a local anesthesia. This anesthetizes the area of the neck where the whole is made. The procedure will start only after the anesthesia has begun working. The surgeon then makes a hole in the neck of the patient just below Adam’s apple. The cut will go through the cartilage rings of the outer wall of the trachea. Then a wide enough hole is opened to fit a tracheostomy tube. The doctor may connect the tube to a ventilator in case the patient is needed to breathe through a machine. The tube needs to be secured with a tube encircling a patient’s neck, this aids in keeping the tube in place while the skin around the wound heals (Ceriana, A, et al 2003).

The nurse and patient outcomes of tracheostomy are for the patient to stop suffering aspirations during his hospitalization, the patient to prove how to properly clear airway by discharge. The patient is supposed to report risk factors that are related to infection and perform proper safeguards when needed.

The main principles when looking after tracheostomy patients are based on maintaining a patient safety, easing communication and avoiding complications resulting from the procedure. Here airway is the sternest problem rising from a tracheostomy. It is a medical emergency and can lead to cardiac arrest (Woodrow, 2002). Patients with this condition should be taken care of with devotion in an area with operational oxygen and suction apparatus. Pulse oximetry should be used to monitor primary vital signs, mostly respiratory rate. Taking care of a tracheostomy patient one should be able to realize partial and total airway barrier and should contain the necessary skills to secure an airway in case it occurs. This was important for my patient since he was old and needed every kind of support

In my patient, the tracheostomy was of an internal tube design, where there is large tube outside covering a small one on the inside. In this condition, if the partial or complete occlusion is suspected the inner part is detached and a momentary spare inner tube will substitute the blocked one, thus creating a space. These spare tubes are supposed to be kept near the patient’s space.

While I was doing this I also made sure that washed my hands and applied alcohol gel before and after all actions. Also, I used a non-septic non-touch technique for all manipulations of the stoma. This was to avoid contaminating the tracheostomy tube and also protecting myself. The patient was required to be safe from all infections and the best way was for me to maintain cleanness since I handled the tube more often.

A tracheostomy avoids the ordinary upper airway mechanisms for humidification, purification, and warming of inhaled gases. Ander usual circumstances the point where air reaches 100% qualified humidity is just below the carina, but in a patient with tracheostomy this occurs in inferior breathing tract and can be further be occupied by the use of hazardous gases (Dawson, 2014). This gives rise to the high viscosity of mucous excretions, which depresses ciliary function; this may result in chest infections, reduced gas exchange, and atelectasis. Patients are characterized by dry coughs which may be related to tracheitis, an inflammation of the tracheal lining that can become diseased resulting in ulceration of tracheal mucosa. So, if adequate humidification is not provided to take care of this issue it can lead to tracheostomy tube blockage. Thus, these patients require close monitoring to always check for humidification.

Cuff monitoring is required at the start of each turn if a cuff seepage is overheard after any process where the tube might have moved position (Hess, 2005). Ischaemia can be caused by an over-inflated cuff which can result in the damage of the trachea whereas an under-inflated cuff may cause exhalations of gastric contents into the lungs and inhibit suitability of mechanical ventilation. Common causes of excessive cuff pressure include; small tracheostomy tube, poor tube placing and over-inflated cuff and lessened lung-compliance (St George’s healthcare, 2012). Four methods have been proposed for specialist care of the cuff; subjective estimation of cuff pressure by palpation of the pilot balloon, minimal occlusion volume (MOV), cuff pressure measurement and minimum leak technique (Rose and Redl 2010).Mostly an old person like Mr. Jone seems to mostly suffer from this condition hence he requires close attention with frequent visits and monitoring to observe his condition all the time. With him struggling to move when he has tired it becomes a difficult task due to his old age and this can lead him to alter or twist the tube due to this he requires someone to always stay by his side. I was very careful about this having just learned how serious it can turn out to be if in any case the tracheostomy tube is adjusted.

The patient is always assessed for sputum in the airways (Mullet et all 2013). The process called suctioning is supposed to be reserved for patients who are not able to secrete their own secretions. As the suction tube and suction pressure may cause tracheal injury and patients may find the process stressful (Sherlock et al 2009). Pre-oxygenate for 30–60 s particularly in those patients getting additional oxygen (AARC, 2010); in COPD patients this must be no more than 20% above zero (Day et al., 2002). It should be made sure that a non-fenestrated inner cannula is existing through suctioning. The suctioning tube should be no more than half the ID of the tube.

The tracheostomy tube is supposed to check at least once daily for trauma, infection or inflammation and results documented in the wound chart (St Georges healthcare, 2012). inflamed stomas should be changed. The stoma should be cleaned using 0.9% saline and a small cut dressing applied to dress the tube. Where the skin of the stoma has upbraided a film-making acrylate block such as Cavilon can be applied locally to prevent further corrosion. This task requires two people and thus called a two-person technique since the tracheostomy must be detached to sufficiently clean and asses the tube. The tracheostomy tube must be effectively be secured with a commercial tracheostomy holder. This prevents the patient from the pressure on the back of the neck and simply attuned. This helped Mr. Jone by maintaining his health and hygiene. It helped him to regain quicker and it made him comfortable.

Mr. Jone underwent a daily assessment of the mouth with the condition of the teeth, gums. Lips and mucous membranes (Berry et al. 2014). I did the oral inspection for Mr. Jone twice a day because he was not able to complete it for himself. I used a soft brush to brush both the surfaces of his teeth. And I gave him sterile water to rinse his mouth. This kept him free from bacteria that can cause infections by getting in touch with the tube. The patient is supposed to be educated on how to correctly cough and deep breathe throughout the hospitalization.

The patients of tracheostomy are subjected to loss of the ability to converse verbally which is a great frustration for these patients (Foster, 2010; Sherlock et al., 2009; Donnelly and Wiechula, 2006). The patient or the relatives should be made to understand that the patient might not be able to speak with the tracheostomy tube in place this is because the air is not passing through the vocal cords. They should find reassurance that the voice will be back after the tube is removed and as soon as the cuff reduction is tolerated. A one-way speaking valve or alternating finger blocking can be used to create a voice. In the conscious patients, different means of communication should be found using lip reading or electronic communication tools. One way speaking valve, if the patient tolerates tube occlusion then this method is applied so as to allow the patient breathing through the vocal cords, nose, and mouth. This may aid the patient to speak audibly. The duration of time the patient is able to bear a speaking valve will vary from one patient to the other and that can be the best know by observing the patient’s work of breathing. For other patients tolerance will not pose a problem, others may have to create the time they use the valves starting with a few minutes. The intention is to create tolerance to enable the patient to use the valve continuously.

For patients who have suffered upper airway obstruction, decannulation cap might provide the clinician and the patient with better assurance prior to decannulation. This cap occludes the tube completely requiring the patients to breathe through their nose and mouth. It is not normal to use the cap for more than 4 hours as it increases the work of breathing. And may make the patient get tired frequently. For my patient, all this methods dint apply since he was old even in a normal situation he would not have spoken correctly in a hurry so we just used the lips to communicate which proved to be effective with him since he didn’t have to speak.

Decannulation is supposed to be undertaken as soon as it is possible to minimize the risks accompanied by a long-term tube. However, it also avoids dangers such as airway blockage, exhalation, ventilatory failure, spectrum rendition and problem in oral retention. Therefore the decision to decannulate needs to be based on objective principles including:

· The original reasons for the insertion of the tracheostomy have been resolved (Heffner, 1995). And there are no signs weakening bronchopulmonary contamination( ICS, 2008).

· The patient can sustain enough gas exchange self-ventilating on oxygen treatment of less than 40%.

· The patients can steadily cough any emissions either to the mouth or to the tracheostomy tube. (O’Connor and White, 2010; Stelfox et al., 2008; ICS, 2008; Heffner, 1995).

· The patient is alert and interactive.

The other main problem for patients with the tracheostomy is the incapability to swallow efficiently (Foster, 2010; Sherlock et al., 2009).Some manage oral intake without aspiring with the cuff overblown. In the normal situation, the cuff should be fully deflated and a test of swallowing is introduced before oral intake is started. The risk of aspiration is highest in those patients with related or pre-existing neurological or mechanical sources of dysphagia, following head and neck surgery or in those ongoing significant breathing problems. Sips of sterile water should be given to the patient and if stood without coughing, desaturation or symptoms of aspiration on tracheal suctioning then the patient may eat and drink. Patients under the critical care unit are likely to have loosed appetite. A mixture of oral and enteral feeding may help inspire swallowing and appetite while preserving nutritional needs. If the patient does not swallow effectively he or she should be referred to speech and language professional for further evaluation (St. George Healthcare, 2012). Mr. Jone was one who had no appetite for any food, swallowing was difficult for him so I offered to try the oral and internal feeding, which is still under progress I could say he has not improved that much but there are mild signs of improvement.

There are many stages of weaning procedure that can be attained over time. This stages may be achieved using the tube in situ. However, when there in situ sufficient oxygen then downsizing a tube may be of importance. There is no any indication that if airflow the nose or mouth be enough, then regularly reducing or changing to a fenestrated tube helps with weaning. Cuff deflation: the cuff should be emptied using synchronous suction and depression to prevent the transfer of secretions at the top of the overblown cuff into the lungs. The cuff can be left permanently depressed once one is at a position to manage his or her own secretions without continuously coughing and does not get tired of breathing. Gloved finger occlusion: Once the patient can endure insistent periods of cuff deflation, a gloved finger can be applied towards the end of the tracheostomy tube to check the flow of air, flow within the tube and through the vocal cords to the nose and mouth. The finger being in the mouth the patient should be asked to count to three or provide a forced exhalation through the nose and the mouth. During obstruction, a patient should be monitored for symptoms of distress if this occurs then the process should be stopped. With my patient, I tried this method too but I had to abort the process since it caused obstruction. The patient experienced many complications as a result old age so I did not do many of the procedures. But he needed a close attention since he could not have done many of the tasks for himself. Breathing for him was hard due to asthma. So, the method of gloved finger occlusion would not do well in him.

As I stayed with Mr. Jone I realized he showed signs of trouble in breathing by breathing fast, pulling of skin between ribs when breathing, extreme fussiness, and restlessness and when this happened it is when I used to suction the tube. I taught his family on how to take care of him and since he was old he needed love and people being there for him. He required people to encourage him and to always speak words of hope. Reminding him of his happy moments.

This condition is distressful for an old person like Jone. All the time he was in the hospital wasn’t easy for him due to his chronic illness and combination of illness. But with the care and close supervision, there was hope. Since I followed the rules and procedure of caring for patients with tracheostomy it really showed results. I used to train the family different methods to take good care of him and it gave me hope of prolonging his life.

References

Brook, A. D., Sherman, G., Malen, J., & Kollef, M. H. (2000). Early versus late tracheostomy in patients who require prolonged mechanical ventilation. American Journal of Critical Care, 9(5), 352.

HUANG, C. T., COOK, A. W., & LYONS, H. A. (1963). Severe Craniocerebral Trauma and Respiratory Abnormalities: I. Physiological Studies with Specific Reference to Effect of Tracheostomy on Survival. Archives of neurology, 9(5), 545-554.

Ceriana, P., Carlucci, A., Navalesi, P., Rampulla, C., Delmastro, M., Piaggi, G., … & Nava, S. (2003). Weaning from tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical outcome. Intensive care medicine, 29(5), 845-848.

Dawson, D. (2014). Essential principles: tracheostomy care in the adult patient. Nursing in critical care, 19(2), 63-72.

St George’s Healthcare, N. H. S. Guidelines for the Care of Patients with Tracheostomy Tubes. Portex, 2000.

Lewis, T., & Oliver, G. (2005). Improving tracheostomy care for ward patients. Nursing Standard (through 2013), 19(19), 33.

Vyas, D., Inweregbu, K., & Pittard, A. (2002). Measurement of tracheal tube cuff pressure in critical care. Anaesthesia, 57(3), 275-277.

Butler, E. B., Teh, B. S., Grant, W. H., Uhl, B. M., Kuppersmith, R. B., Chiu, J. K., … & Woo, S. Y. (1999). Smart (simultaneous modulated accelerated radiation therapy) boost: a new accelerated fractionation schedule for the treatment of head and neck cancer with intensity modulated radiotherapy. International Journal of Radiation Oncology• Biology• Physics, 45(1), 21-32.

Dawson, D. (2014). Essential principles: tracheostomy care in the adult patient. Nursing in critical care, 19(2), 63-72.

Schmidt, M., Zogheib, E., Rozé, H., Repesse, X., Lebreton, G., Luyt, C. E., … & Ouattara, A. (2013). The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Intensive care medicine, 39(10), 1704-1713.

Simpson, T. P., Day, C. J. E., Jewkes, C. F., & Manara, A. R. (1999). The impact of percutaneous tracheostomy on intensive care unit practice and training. Anaesthesia, 54(2), 186-189.

Bouderka, M. A., Fakhir, B., Bouaggad, A., Hmamouchi, B., Hamoudi, D., & Harti, A. (2004). Early tracheostomy versus prolonged endotracheal intubation in severe head injury. Journal of Trauma and Acute Care Surgery, 57(2), 251-254.

Barquist, E. S., Amortegui, J., Hallal, A., Giannotti, G., Whinney, R., Alzamel, H., & MacLeod, J. (2006). Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study. Journal of Trauma and Acute Care Surgery, 60(1), 91-97.

Cameron, J. L., Reynolds, J., & Zuidema, G. D. (1973). Aspiration in patients with tracheostomies. Surg Gynecol Obstet, 136(1), 68-70.

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