Fundamentals of Nursing Q 23
While changing the tapes on a tracheostomy tube, the client coughs, and the tube is dislodged. Which is the initial nursing action?
A. Call a respiratory therapist to reinsert the tracheotomy.
B. Cover the tracheostomy site with a sterile dressing.
C. Call the physician to reinsert the tracheotomy.
D. Grasp the retention sutures to spread the opening.
Correct Answer: D. Grasp the retention sutures to spread the opening.
If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if necessary. Once replaced, tie the tube securely, leaving one finger space between ties and the patient’s neck.
Option A: Ask the patient to breathe normally via their stoma while waiting for the doctor. Check tube position by (a) asking the patient to inhale deeply – they should be able to do so easily and comfortably, and (b) hold a piece of tissue in front of the opening – it should be “blown” during the patient’s exhalation.
Option B: Covering the tracheostomy site will block the airway. Use tracheostomy covers to protect the airway from outside elements (such as dust, cold air, etc.). All trach tubes have an outer cannula (main shaft) and a neck plate (flange). The flange rests on the neck over the stoma (opening). Holes on each side of the neck plate allow you to insert trach tube ties to secure the trach tube in place.
Option C: Calling a respiratory therapist or the physician will delay treatment in this emergency situation. Accidental dislodgement of the tracheostomy tube during the first several days is not uncommon and can be life-threatening, particularly in patients with severe oxygenation problems and/or high demands for pressure and volume from the ventilator.