Review indicators |
Indicator 1. The patient’s tracheostomy wound appears red, tender, swollen, inflammation, smell, high skin temperature, yellow-green secretions can be seen around the stoma, or the patient has fever, the nurse immediately informs the doctor. |
Indicator 2. The patient has signs of infection at the tracheostomy site, follow the doctor’s advice for bacterial culture. |
Indicator 3. When the patient has decreased blood oxygen saturation, decreased blood oxygen partial pressure, frequent coughing and respiratory distress, the nurse should perform airway suction for the patient. |
Indicator 4. When the patient needs to suck sputum, the airway pressure is low and the spontaneous breathing is weak, increase the cuff pressure appropriately. |
Indicator 5. After the patient turns over, wipes the bath, and transfers, the nurse should re-measure the cuff pressure. |
Indicator 6. Patients who have established artificial airways undergo continuous oxygen humidification and follow the doctor’s instructions to inhale 2 - 3 times per day. |
Indicator 7. The artificial airway humidification fluid uses 0.45% sodium chloride solution for continuous airway humidification. |
Indicator 8. When the patient has sputum in the airway, it should be sucked in time, and the sputum suction time is ≤15 s. Patients with no sputum or little sputum should perform a suction at least 8 hours. |
Indicator 9. Oral suction before turning over and after oral care. |
Indicator 10. Establishment of artificial airway patients use subglottic suction tracheal tube. |
Indicator 11. Use special tracheostomy gauze when changing dressings for tracheostomy wounds, and keep the skin at the tracheostomy site dry. |
Indicator 12. Patients with mechanical ventilation use chlorhexidine mouthwash for oral care once for 6 h - 8 h. |
Indicator 13. The nurse evaluated the skin of the patient daily and kept the wound clean and dry and replaced at any time in case of contamination. |
Indicator 14. Use a manual measurement cuff pressure gauge to monitor the airbag pressure every 6 - 8 hours and maintain it at 20 - 30 cm H2O. The inflation pressure should be higher than the ideal value 2 cm H2O during each measurement. |
Indicator 15. When monitoring the cuff pressure, clean the water in the pressure measuring tube in time. |
Indicator 16. The nursing class monitors and records the cuff pressure once after the tracheotomy wound dressing is changed. |
Indicator 17. Cuff pressure monitoring cannot use finger touch to determine the degree of inflation. |
Indicator 18. Nurses regularly evaluate airway humidification and adjust dynamically. |
Indicator 19. The patient has a large amount of secretions in the airway and the nurse needs to perform deep suction. |
Indicator 20. The nurse needs to measure the length of the suction tube inserted into the patient’s airway before suctioning 1) Insert into the carina and retract the suction tube 1 - 2 cm 2) Measure the same tracheal tube to estimate the length of the suction tube. |
Indicator 21. The nurse pre-oxygenated the patient with pure oxygen for at least 30 seconds before and after suction. |