Tracheostomy Nursing Care

 

Emergency Tracheostomy Scenarios

 

 

I first started looking after patients with trachys when I was a 3rd year student nurse and it is something I have always enjoyed.  I find it satisfying when you clear the patient's secretions...yes I know a lot of nurses hate it!

I always used to think it was amazing that a nurse was responsible for maintaining a patient's airway with an artificial tube and yet the patient was not in ICU but on a main ward.  I found it rewarding and in my opinion it felt like real nursing care.

I am going to talk about 3 scenarios which have stood out to me and highlight my reflections from each.

 

My First Trachy Change

My first trachy change was when I was a newly qualified nurse and it was on an 18 month old girl.  I always thrive on new opportunities and felt confident to change the trachy.  It was a planned change and I was prepared, or so I thought.  I changed the tube and the nurse who was supervising me suddenly shouted "dont forget to take the introducer out".  I was shocked at this as I had only just inserted the new trachy and was just about to take the introducer out.  I was really annoyed because I felt like she could have made me panic.  Luckily I am a calm person and continued with the procedure.  The nurse then told me she was a bit nervous supervising me as I was junior and that she did feel there was a bit of a delay in my removing the introducer.  I am not sure there was a delay but I took her word for it.

 

Reflection

I reflected on this incident and vowed that even though it is not in my nature to cause panic, I would never do what that nurse did to me.  After all, behaviours like this can affect a person and put them off looking after trachys or any other nursing procedures. Fortunately I wasn't phased and continued to look after patients with trachys throughout my nursing career.

 

Blocked Trachy

I was looking after a 4 year old boy who was in fact the first trachy I had looked after as a student nurse.  He had a complex health condition and had been admitted at 3 months old with a new trachy.

On this occasion I was at his bedside and could hear and see that his trachy was blocked.    I had the emergency bag at the bed side and was getting prepared to do an emergency change when help arrived.  I pulled the crash bell and waited for what seemed like an eternity for someone to turn up.  Finally a 3rd year student nurse arrived and took one look at the patient and panicked.  I told her to go and find a nurse or doctor and let them know that we would probably need to do an emergency tube change.  The poor student nurse was flapping but did go and get help by which time the child had coughed and I had cleared some secretions.  We decided that although I had been able to clear a lot of secretions it would be best to still change the tube.  We proceeded to change the tube and the child was fine.

I spoke to the student nurse after the scenario and she said she was in a panic and scared.  I reassured her that she was helpful and in fact played a key role in the scenario.  She had given a good handover to the doctor and had returned to help if she could.  

If we relate this scenario to my first trachy change and I had shouted at the student nurse she may have been put off ever running to a crash bell.  

 

Reflection

It is really important to support each other in times of emergency situations and remember to be civil even if you feel stressed or scared yourself.  I took the time to make sure the student felt supported and reassured her that she had done a good job.  We also talked about her learning and development for dealing with similar situations in the future.

New Tracheostomy

My final scenario I want to talk about involves a 15 year old boy with complex health needs.  This patient had a normal airway and needed suctioning at times to clear secretions. 

I was at the nurses station when the boy's mother called me into his cubicle as she felt something wasn't right and she thought he wasn't breathing.  I took one look and could see that he had desaturated and was definitely not breathing.  I asked the mum to pull the crash bell and to clear space around the bed.  Meanwhile I got the bag-valve-mask and started giving respiratory support.  It wasn't long before another nurse and doctor arrived and I handed over.  The doctor requested an emergency crash call be put out and soon the resus and outreach teams arrived.

I stepped back from the boy and looked after the mum who was clearly distressed.  We could both hear conversations about whether he would need a trachy.  I explained the best I could to the mum and we waited for the ENT team to arrive.  It seemed like a long time before the decision was made to perform an emergency trachy there and then.  I remember we seemed to be there for hours and all the time I was reassuring the mum and explaining things as they happened.  I am no expert so my explanations were very brief and in simple terms as I new the ENT consultant and other experts would explain everything after.

Fortunately the procedure went well and the boy went off to theatre and then ICU.  He recovered well and was discharged after a few weeks.  I continued to look after the boy over the next few years and felt a real bond with him and his parents.  He used to make me laugh when he knew he needed suction and would say "suction Netty!" in a husky voice.

 

Reflection

This scenario is a bit of a blur to me and I wished I had taken the time to get a debrief and fully understand what had happened and why the decision was made for a trachy.  I wished I had more involvement in his treatment during the emergency as this would have enabled me to understand the situation more.  It is not like me to not be more involved as I do tend to push myself into situations.  Maybe I could sense the enormity of what was happening and felt my place should be with the mum.  I do feel I played an important role because the mum had to be looked after and her son was in safe hands.  I regret not asking more questions following this emergency and I have since made sure that I reflect on all scenarios and where necessary will ask for a debrief or someone to at least explain what had happened. 

I carried on looking after patients with trachys for many years and the patients have been a variety of ages and conditions.  I have looked after one patient who was 3 months when she was first admitted and stayed with us for 3 and a half years before discharge.  This girl is now 18 years old and was successfully decanulated. 

When I first started looking after patients with trachys there were not many of them and they were deemed as higher level nursing care.  We would have the odd 1 or 2 patients with trachys whilst on the ward but by the time I left the ward it was not uncommon to have maybe 2 or 3 on the ward at a time.  

 

Trachy's are a lot more common now and the outcomes are far better than they used to be.  In my opininion this is due to the rapid advaces in health care.  What are your thoughts?

 

Take a look at my video!

 

 

 

 

Are we too quick to label parents?

We have all looked after patients where we feel that relatives can be very demanding.  

This is a story about a mum and daughter that I looked after on the ward several years ago.  I will call the mum Beth and the daughter Zara.

Zara was a 6 year old girl with complex health needs who was frequently admitted to the ward with seizures.  We knew the family well and due to her behaviours at times, Beth was soon labelled as "difficult".  She placed several demands on nurses and doctors and her behaviour  was bordering on the aggressive side.  Beth was devoted to Zara and would be by her side on every admission.  It was difficult to get Beth to leave the hospital and she would often say to me, she had to be by her side because she was Zara's voice.

Zara was sometimes very sick when she came to hospital and it was difficult to cannulate her at times.  I remember one time when the doctors really struggled and Beth was furious.  She started shouting at me to get a particular consultant who had managed to cannulate Zara first time on her previous admission.  I explained that the consultant was not around and there were doctors on the ward already who would be treating Zara.  Beth was not happy with this and kept demanding I get the consultant.  Luckily the ward doctors did manage to cannulate Zara and Beth eventually calmed down. This incident was not isolated and Beth would often request that only certain staff look after Zara.  She certainly wasn't afraid to speak out. 

Sadly Beth passed away a few years ago which was devastating to hear.  I had spent many shifts looking after Zara and I really got to know Beth well.  She would tell me her hopes and fears.  She would tell me how scared she was that if something happened to her who would look out for Zara.  The love she had for Zara was profound and that's what made it so hard to hear of her passing.  The way in which Beth advocated for Zara has stuck with me throughout my nursing career and it is something that I have always done for my patients.  Whilst I never agreed with Beth's behaviour, I did admire her strength and determination and the love she had for Zara.

You could argue that Beth was advocating for Zara and only had her best interests at heart.  Did Beth deserve to be labelled?  Could Beth have advocated in a more calm manner?

Nurses will come across many situations like this and will indeed start labelling parents when they display behaviours like Beth's.  Parents are vulnerable when their children are admitted to the ward as they feel they have no control over their children's condition and illness.  After all they are the ones that usually protect and keep their children safe.  This vulnerability can often be chanelled as fear which can lead to aggressive behaviours. Parents need to advocate for their children and in the case of Zara, Beth was her only voice and therefore she made demands on staff to get the best outcome for Zara.  It is difficult when faced with these behaviours as clearly nurses want the best outcome for patients too.  When parents are shouting it can be very distracting and sometimes cause panic amongst staff, we need the parents to calm down.

It is unacceptable for parents or relatives to shout at staff and make demands on them no matter what the situation is and therefore we need to set boundaries.  We need to foster open and honest communication and build a trusting relationship showing empathy and compassion.  Let's understand what is driving these behaviours and what we can do to support the parents.  However, we do need parents to also understand that nurses will not tolerate any form of aggressive behaviour.  Parents can still advocate for their children in a calm and civil manner.

Do you think Beth deserved to be labelled?

Feel free to leave a comment.