The main aim of this assignment is to identify the problems that are associated with tracheostomy weaning in patients. The assignment deal with the understanding of the importance and usage of evidence in the High Dependency Unit and how the research and evidence can be incorporated into the nursing practice has been taken up. The case study deals with the problems that are faced by the patient with tracheostomy weaning. Two major problems that have been identified in the patient include anxiety and inappropriate airway clearance. Diagnosis by the nurse can help in the clinical judgment which has enabled them to perform a care plan for the patient. The analysis and the reflection on the nursing interventions that have provided relief to the patient have been discussed. It has been considered that the anxiety of the patient is due to the injury that has occurred due to tracheostomy insertion as well as feeding the patient via a nasogastric tube. The second problem is inappropriate airway clearance, which is conditions that produce excessive mucus, inflammation, or airway blockage,
The case study that has been chosen deals with the patient Mr. B who is 70 years old. He was admitted to the ICU due to a spinal cord injury after sustaining a fall. The main reason for performing a tracheostomy was that the patient had undergone fusion and anterior cervical discectomy (Vambheim et al., 2021). The patient was then weaned off of invasive ventilation and was switched to NIV. The discharge of the patient to the unit that deals with spinal problems was done for Mr. B. but soon’ after the transfer, the patient was readmitted to the ICU after a week. The holistic care could include encouraging the patient to cough out the secretions and suctioning the mucus if the patient is unable to do so own their own (Oyur Celik, 2017). The tracheostomy was done with 6 size tube. The toleration towards cuff deflation was negative for the patient. The transfer of the patient was done to HDU. This was done after the patient was weaned off from NIV from mechanical ventilation. The blockage in the patient's upper airway is the cause of the can be noticed in the patient as the tracheostomy have led to the improper technique of air reason has been seen. The patient was breathing shallowly and deeply at a rate of 24–28 breaths per minute. Mr. B required hourly suctioning due to his mucopurulent secretions through his tracheostomy line and weak cough. The selection of these two problems has been taken up for the critical analysis that is based on evidence. The problems that are faced by the patient include anxiety and a inappropriate airway clearance is problems that are prioritized in the critical analysis of evidence based practice. Other problems can include high blood pressure, shortness to breath, and mental pressure on the patient.
Removal of tracheostomy will cause anxiety for the patients. Thus, proper weaning and decannulation will require careful planning and this will however require support from various multiprotection team.the tracheostomy is just a surgical opening in the anterior wall of the trachea and this help in the process of breathing ((Bandelow et al., 2017)). The tracheostomy tube mainly enables the airflow. The aim of the weaning is to help the airflow to the upper way and this help in restoring physiological functions. Due to the whole complicated process that the patients go through the tracheostomies have high level of psychological distress and this will create high level of anxiety in patients (Copnell and Tume, 2015). A patient with respiratory distress will develop respiratory distress and this happen during the ward weaning process and this might lead to anxiety in the person. There ae severe chances of anxiety in the patients once after the removal of tracheostomy and this will lead to narrowing of larynx and in many cases, there are risk of severe aspiration pneumonia and thus the patients’ needs to be monitored regularly (Guia et al., 2021). Anxiety is very common in patient whenever the tracheostomy is being removed and this cause more problems to the person. The tracheostomy is very much essential as this will facilitate in the process of breathing (Breckenridge et al., 2014). The holistic care includes continued care and integration. The nurses can make the patient practice deep breathing as this will allow the patient to relax his body and mind. Placing the patients in quiet area can also help in reducing anxiety.
The patient experiences anxiety when weaning their tracheostomy because they are unsure of the process, what to expect, and what they ought to expect, and they also worry that they won't be able to breathe normally without their tracheostomy tube. This tension about breathing without the tracheostomy tube after the weaning processes increases the level of anxiety, because this tube provides a secure airway for the breathing process. Patients worry because of the thought difficulty in. The difficulty in breathing may also cause the respiratory failure and the condition of the patient can deteriorate within few minutes. Because of the pain and discomfort that are related to the weaning process, the patient's degree of worry and anxiety also rises as a result (Kwame and Petrucka, 2021). The tracheostomy place in the patient throat for extends period and that can be the reason of sore an irritation in throat. Sometimes the concerns about the setbacks as well as the potential complications also create the anxiety in the patient (Liney et al., 2019). The patient with a tracheostomy weaning experiences worry because of the potential for infection in their specific respiratory tract or other infections. Coughing, fever, and trouble speaking may be brought on by this.
The problems faced by the first patient were identified and there was ineffective airway clearance and this was mainly because of weak cough and secretions due to the tracheostomy and this has happened as the result of to cervical fracture. Respiratory muscle weakness creates more disturbances and it simply disturbs deep breathing (Krishnasamy et al., 2023). This creates more problems to the individual as the individual is unable to cough. The aspiratory muscles become paralyzed and this causes ineffective ventilation. There will be increase in breathing work. And in many cases, there are chances of atelectasis (Lynne Katz, 2018). The weakness of the expiratory muscles mainly results to impaired cough. This will create a situation where the person will not be able to clear secretions. Any disturbance in parasympathetic nervous system in the spinal will create an increase in bronchial secretion. This will create a situation where there will be accumulationof bronchial secretions and this will result in bradycardia and asystole due to the stimulation of nerve (Evans et al., 2014). There was one situation which happened due to bradycardia 40 beats / min during the whole suctioning process. Hence in this patient case the main thing that should be done is suctioning and this will help in assessing how the patient felt over trachea.
Safe endotracheal suctioning is done in order to prevent any kind of future infection among tracheostomy in patients. it will also include suction whenever it is necessary and this will involve preoxygenation in the patients if there is any drop in oxygen saturation (Gundogdu et al., 2016). The most important thing that should be noted that suctioning pressure should be between between 80 mm hg to 150 mm hg and this entire process should not last more than 15 seconds (Chaudary & Balasa, 2021) .the person MR b requires suctioning very single time in an hour as the person has a weak cough. In this case preoxygenated to 60% fio2 will help in preventing hypoxia and desaturation in the patient. Here closed suction was used and the exact amount of time that was providing to the patient was around 15 seconds and the pressure was around 150 mm hg in order to prevent any kinds of trauma (Howick et al., 2018).
Airway management involves continuous monitoring of the cuff pressure on the endotracheal tube. The consistently inflated cough guards against fluid aspiration into the trachea, shields the mucosal surface from tube tip abrasion, and ensures proper blood flow to the tracheal mucosa. The tracheal mucosa may suffer ischemia injury, scarring, and tracheal damage if the cuff has an excessive pressure (Kebapci and Ozkaynak, 2022). On the other side, when the cuff pressure is too low, air might escape around the tubes and affect the patient's ability to breathe and get oxygen. Due to excessive secretion and a weak cough, the individual was at a significant risk of aspiration. In order to maintain 25 to 30 cm H2O during in the shift, it was checked every fourth hour. The accurate pressure can be maintained with the help of continuous cuff pressure monitoring (Lee et al., 2017). Monitoring the cuff level helps to prevent the patient to receive the necessary ventilation and oxygen, as well as also preventing issues that are brought on by either a high or low cuff pressure. Mr. B. is a long-term patient with a tracheostomy who requires section, thus it was mentioned the necessity to detect and notify for suction because he is reliant on someone else to do it because he is quadriplegic.
The evidence-based research of Mr. B has shown that he has been suffering from two common problems anxiety and ineffective airway clearance due to tracheostomy weaning. It is observed that patients who undergo weaning of mechanical ventilation having tracheostomy can be due to several factors including suffocation, discomfort, and pain. The medical intervention that can treat the anxiety of Mr. B is mentioned below:
Providing emotional support: It is important to provide emotional support to Mr. B who has been undergoing weaning after the tracheostomy. This can result in the early recovery of Mr. B with support from family members, healthcare providers, and health professionals (Asan et al., 2021). Providing emotional support to Mr. B can help in alleviating his mental anxiety by addressing his fear and concern, information about the weaning process, and motivating Mr. B.
Good communication: Use of presence and good communication technique that will encourage the patient can be taken up by the nurses ( Pyeon et al., 2017). Therapeutic communication can be taken up so make the patient understand that they are not alone. The expression of the feelings of the client can also be taken up that will enable the nurse to assess the problems that the patient is facing. Interaction with the patients in a peaceful manner can also be taken up by the nurses.
Recommending relaxation technique: Relaxation techniques including guided imagery, deep breathing, and progressive muscles can help provide relief to Mr. B due to the weaning of the mechanical ventilation (Ncbi, 2023).
There are some interventions for Ineffective airway clearance, because this creates difficulty secretions, clearing mucus or other material from their airway, which can result in coughing, respiratory distress, and other complications.
Chest physiotherapy: Several approaches used in chest physical therapy aid in the mobilization of secretions from the airway and pulmonary systems (Dekker et al., 2020). This method could incorporate postural drainage, vibration, percussion, and breathing exercises.
Coughing and deep breathing: By assisting in the mobilization and elimination of mucus, deep breathing as well as coughing exercises can aid to enhance airway clearance (Chatwin et al., 2018). After chest physiotherapy, these exercises are frequently advised to be performed multiple times daily.
Suctioning: Using a suction catheter, the suctioning procedure is performed to remove extra secretions from the airway (McIlwaine et al., 2017). A doctor or other healthcare professional can carry out this. Suctioning can assist with elevating oxygenation levels throughout the body and lower the risk of hypoxia by eliminating secretions and increasing airway clearance. Ineffective airway clearing can result in issues like pneumonia that may be avoided by suctioning secretions out of the airway.
The chest physiotherapy is crucial for the inappropriate airway clearance of Mr.B because these large alterations are typical of the condition. Many approaches used in chest physiotherapy therapy can assist in mobilizing mucus as well as secretions, making it simpler to remove them from the airways. These methods include of breathing exercises, movement, percussion, and postural drainage (Wilson et al., 2019). The deep breathing exercises involve taking slow and deep breaths that helps to expand the lungs and increase the airflow. This helps to mobilize the secretions and mucus, make the coughing easy and clear the airways. By taking slow, deep breaths, the exercises for deep breathing assist in broadening the lungs and improve airflow (Hamdani et al., 2022). This facilitates coughing more easily and opens up the airways while also helping to mobilize mucus and discharges. This suctioning is also rational since it enables the evacuation of these fluids for ineffective airway clearance, enhancing airway patency as well as oxygenation (Trimble et al., 2022). Supporting the patient Mr. B emotionally is important because it makes sense to support the patient emotionally if they are experiencing anxiety because doing so will give them support and reduce their sense of loneliness. This helps the patient understand the value of taking care of them (Sands et al., 2023). A number of anxiety symptoms are also lessened by this emotional support. Also, it protects the patient from unexpected panic attacks (Long, 2018). Complications are less likely with this medication.
It can be concluded that the patient Mr. B had been admitted to the hospital due to spinal cord injury and was given a tracheostomy. This case study helped in the understanding of the evidence that is present and the way it has assisted in taking care of the patient. Two major problems that have been identified in the patient include anxiety and inappropriate airway clearance. Diagnosis by the nurse can help in the clinical judgment which has enabled them to perform a care plan for the patient. Inappropriate airway clearance why happen because of the various reasons and that also impact negatively to the patient. The care for patients who have undergone injuries like the spinal cord has been properly understood with the help of evidence-based practice. The interventions that are used in the case study to solve the problem of anxiety and inappropriate airway clearance have been supported by evidence. Increased mucus production, inflammation, and airway obstruction can be caused by diseases like as chronic lung disease, pneumonia, bronchitis, or pneumonia, which can impact airway clearance. It is important to provide emotional support to Mr. B who has been undergoing weaning after the tracheostomy. The problem-solving and the evaluation of the vase study have been possible with the help of evidence-based practice.
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