A nurse is performing tracheostomy care for a client who has a chronic tracheostomy. Which of the following actions should the nurse take?
A.
Allow space for one finger to be placed under the tube ties.
B.
Apply suction pressure while inserting the catheter into the trachea.
C.
Suction the client for 20 seconds with each pass.
D.
Cleanse around the stoma with povidone-iodine.
The correct answer and Explanation is :
The correct answer is A. Allow space for one finger to be placed under the tube ties.
Explanation:
Tracheostomy care is critical for clients with a chronic tracheostomy to ensure proper airway management and to prevent complications such as infection, obstruction, and skin breakdown. Among the options presented, allowing space for one finger to be placed under the tube ties is essential for maintaining airway patency and comfort for the patient.
A. Allow space for one finger to be placed under the tube ties.
This action is vital because it ensures that the ties are secure enough to hold the tracheostomy tube in place while also preventing excessive pressure on the skin around the stoma. If the ties are too tight, they can cause skin irritation, pressure sores, or even necrosis. The “one finger” rule is a commonly accepted practice in tracheostomy care to promote comfort and safety.
B. Apply suction pressure while inserting the catheter into the trachea.
This option is incorrect because suction should only be applied when withdrawing the catheter, not while inserting it. Applying suction during insertion can cause trauma to the airway and discomfort to the patient.
C. Suction the client for 20 seconds with each pass.
This statement is also incorrect. While suctioning, it is recommended to limit each pass to 10-15 seconds to prevent hypoxia and to allow the patient to recover between passes. Prolonged suctioning can lead to complications like airway trauma and hypoxemia.
D. Cleanse around the stoma with povidone-iodine.
Using povidone-iodine may not be appropriate as it can cause irritation or allergic reactions in some patients. Typically, a saline solution or sterile water is preferred for cleaning the stoma to maintain skin integrity and reduce the risk of irritation.
In summary, option A is the most appropriate action for tracheostomy care, ensuring patient safety and comfort while preventing potential complications.