Guideline on Documentation for the Tracheostomy /Ventilator Dependent Patient

PURPOSE: To outline the responsibilities for documenting nursing care on the

Tracheostomy and Ventilator Flow Sheet delivered to patients requiring

mechanical ventilation and /or tracheostomy tube (trach) support.

BACKGROUND:

Children with chronic tracheostomy are at risk for potentially life-threatening events related to airway com-

promise. No published standards are available to guide the healthcare professional in their care (Sherman et

al., 2000). The most common indications for a tracheotomy are upper airway obstruction, subglottic steno-

sis and the need for prolonged mechanical ventilation (Mahadevan, Barber, Salkeld, Douglas & Mills,

2007). Indications for home mechanical ventilation include neuromuscular disorders, lung and upper respi-

ratory diseases, hypoxic encephalopathy and abnormal ventilation control (Racca et al., 2011).

HEALTHCARE

PROFESSIONAL: Healthxare professional is credentialed (RN, LPN) and licensed with

documented knowledge and demonstrated competencies in the care of patients

requiring mechanical ventilation and/or tracheostomy tube support (Kohorst,

Blakely, Dockter & Pruit, 2007).

CONTENT: Includes shift responsibilities and documentation requirements.

SHIFT RESPONSIBILITIES

Physician Order (Kohorst, Blakely, Dockter, & Pruit, 2007)

1. Physician orders are documented on the Physician Plan of Care and/or the Physician Order form. 2. Nurses are responsible for checking physician orders prior to the start of care on each shift.

3. Physician orders include the type and size of tracheostomy tube and frequency of suctioning and tube changes.

4. Physician orders include type of ventilator, ventilator settings, alarm limits, and oxygen requirements.

5. Changes to ventilator settings require a physician order.

Physical Assessment

The nurse assesses the following parameters upon arrival (at start of care) and documents findings in all applicable items on the corresponding Flow Sheet (Kohorst, Blakely, Dockter, & Pruit, 2007; Royal Children’s

Hospital Melbourne, 2009):

 Temperature, heart rate, respiratory rate, breath sounds, oxygen if in use, pulse oximeter

reading,

 Tracheostomy tubeinformation: tube type, tube size, un-cuffed or cuffed, tracheostomy type,

string change, inner cannula change, neck care, trach stoma, snugness of tracheostomy tube fit and

date tracheostomy tube last changed and number of decannulations (if any).

 Ventilator information: ventilator name , type and location, source in use, external battery charg-

ing, clean or change fan filter, clean or change the inlet filter, ventilator charging and ventilator

settings (if in use).

1. Documentation must be legible and completed by the end of each shift. Copies of the flow sheet and progress

notes are retained in the patient home chart. Shifts vary in length. Shifts that exceed 8 hours may require a sec-

ond flow. 2. The nurse must notify the Clinical Manager (during business hours) or the on-call associate (after business

hours) for any significant change in or concern about the patient’s condition and/or equipment problems. Doc-

ument changes or concerns in the progress notes.

Monitoring Equipment (Sherman et al., 2000; Royal Children’s Hospital Melbourne, 2009)

1. Monitoring devices are commonly ordered by physicians for patients with chronic tracheostomies who are

at risk for airway complications. Nurses are responsible for complying with physician-ordered monitoring

and ensuring that the monitoring devices are clean and functional. Examples include:

 Pulse oximeter, alarm limits, oxygen saturation levels and frequency of use are ordered by the physician.

 Ventilator settings and weaning schedules are ordered by the physician.

 End -tidal CO2 monitoring may be ordered by the physician to establish trends in CO2 levels.

 Use of a heart rate/apnea monitor, alarm limits and frequency of use requires a physician order.

Ventilator Equipment Check

1. All ventilators and ventilator equipment must be checked at the beginning of each shift for accurate set-

tings, proper function and cleanliness(Kohorst, Blakely, Dockter, & Pruit, 2007).

2. Ventilator checks must be done(Kohorst, Blakely, Dockter, & Pruit, 2007).

a. At the beginning of each shift b. Prior to placing a patient on the ventilator

c. At least every two hours while on the system

d. After changes in ventilator settings ordered by a physician

e. After ventilator equipment cleaned

f. After any tubing or equipment change

g. After resolution of any problem with the ventilator equipment

3. Assure that the self-inflating bag/valve system and attachments for the emergency manual ventilation is

readily available, clean and functional(Kohorst, Blakely, Dockter, & Pruit, 2007).

4. If a ventilator-related equipment problem cannot be immediately resolved by troubleshooting the ventilator

set-up, the patient must be placed on a back-up ventilator or alternative respiratory system (Lewarski &

Gay, 2007) until the problem can be corrected. Notify the medical equipment company and document ven-

tilator equipment problem and outcome in the progress notes. Notify the Clinical Manager (during busi-

ness hours) or the on-call associate (after business hours) if problem cannot be resolved.

5. Three-pronged electrical outlets must be used for ventilator equipment. All ventilator equipment must be

plugged directly into the wall outlet unless use of grounded power strips have been approved by the durable

medical equipment vendor ( Pulmonetic Systems, 2005; T. Mozzone, personal communication, August 12,

2010).The surge protector functions by absorbing and then shunting the excess electrical current to the

grounded line (Harris, 2010).

6. Pediatric patients requiring mechanical ventilation should be maintained in a semi-recumbent position. A

physician order may specify the degree of elevation. National guidelines recommend the elevation of bed at

30 - 45 degrees in pediatrics and 15 - 30 degrees in infants (Massachusetts Department of Public Health,

2008). Positioning should be documented in the Progress Notes. Emergency Management (Sherman et al., 2000)

1. The nurse checks the contents of the tracheostomy tube bag every shift.

2. If a second (backup) ventilator is provided, it should be plugged into an outlet to continuously charge. If it

is necessary to use the back -up ventilator, the settings should be checked to ensure consistency with physi-

cian orders.

3. Where frequent power outages occur a portable generator may be recommended (Kohorst, Blakely, Dock-

ter, & Pruit, 2007).

4. An external battery may provide as much as eight hours of battery life and should be connected to the ven-

tilator in a power outage and should be available during transport (Pulmonetic Systems, 2005).

NOTE: The internal battery of the LTV ventilator provides approximately 10 minutes of power

depending on the factors such as the settings and the condition and age of the battery (Pulmonetic

Systems, 2005).If use of the backup respiratory systems become unsustainable, manually ventilate

the patient’s lungs (as necessary) with the self- inflating bag/valve system and call 911 to transport

the patient to the nearest hospital emergency department until power is restored. The nurse should

notify the Clinical Manager (during business hours) or the on-call associate (after business hours)

as time permits.

5. A functional phone line should be available so that medical personnel may be contacted in the event of an

emergency (Sherman et al., 2000; Kohorst, Blakely, Dockter, & Pruit, 2007). DOCUMENTATION

1. The nurse documents on all items listed on the flow sheet. If there is insufficient information available to

make an assessment, circle the item and write an explanation in the Progress Notes. If an item is not perti-

nent to the care or condition of the patient, indicate by N/A (not applicable). Do not leave any section on

the flow sheet blank.

2. The patient’s response to treatments must be documented on the Progress Notes since there is no space on

the Flow Sheet in which to document these observations.

3. If the patient does not require ventilator support during the shift, indicate by writing N/A on the line enti-

tled “Ventilator Parameter” in that section of the form .

Nurse/Client Information

1. Document Patient Name and Client # (if known).

2. Document Date of Visit.

3. Document Nurse Name.

4. Document Actual Arrival Time in.

5. Document Actual Departure Time out.

6. Document Total Hours Worked. Note: If shift is over 12 hours, the use of 2 flow sheets will be neces-

Tracheostomy Tube Data (Sherman et al., 2000; The Royal Children’s Hospital Melbourne, 2009)

1. Document the Type of tracheostomy tube, including manufacturer (e.g., Bivona, Shiley, etc.), whether sin- gle lumen or with inner cannula. Verify that information matches physician orders.

2. Document the tracheostomy tube Size in mm internal diameter and verify that it matches physician orders.

3. Document if tracheostomy tube is Cuffed or Un-cuffed. Check un-cuffed or cuffed. Indicate inflation vol-

ume on cuffed tracheostomy tube and verify that it matches physician orders. Adjust inflation volume with

air perphysician order, if necessary. Report findings of a significant variation from ordered amount to

Clinical Manager and document in progress notes.

4. Document String Type such as Velcro or twill tape.

5. Document String Change (check yes or no) if performed and document the outcome and/or problems in

the progress notes.

6. Document Inner Cannula Change (check yes or no) and document the outcome and/or any problems in

the progress notes.

7. Document whether Neck Care was provided (check yes or no) and describe care provided in the progress

notes.

8. Document the condition of the Tracheostomy Stoma. Describe appearance such as, dryness, redness, or

presence of excoriation or drainage (color, odor, consistency of secretions). Concerns or problems should

be written in the progress notes. Alteration in skin integrity around the stoma and the area around the neck

that is covered by the tracheostomy tube string must be documented.

9. Document whether Tracheostomy Stoma Care was provided (check yes or no) and describe care provided in the progress notes.

10. Document Snug Fit of the tracheostomy tube at start of care. The “rule of thumb” is “tight enough to slip

one finger beneath the tie.” Check yes to signify that tightness was assessed. If “no” box checked, provide

written explanation for response.

11. Document date of Last Tracheostomy Tube Change. A physician orders frequency of tracheostomy tube

change. A planned tracheostomy tube change is performed by two competent individuals. In an emergency,

only one person may be present to change the tube.

 If the tracheostomy tube is changed on the date of visit, document this date on the flow sheet.

Document the patient’s response to the procedure in the progress notes.

 Document the reason to Postpone the Scheduled Tube Change in progress notes. For example

write: “tracheostomy tube change not performed because no family member was available to as-

sist.” Document your discussion with family member to schedule the next tracheostomy tube

change. DO NOT leave this area blank.

12. Document the number of Accidental Decannulations specific to the shift on the flow sheet. An accidental

decannulation is an emergency event with possible life-threatening consequences. Documentation in the

progress notes includes a description of circumstances surrounding the event, whether the decannulation

was witnessed (by whom) or unwitnessed, whether the same tracheostomy tube was reinserted or a new

tracheostomy tube was placed and patient’s response. If a new tube was inserted, inspect the used tube and

document whether a mucous plug was visible (The Royal Children’s Hospital Melbourne, 2009).The cir-

cumstances surrounding the event must be reported to the Clinical Manager and/or the on-call associate by

the end of the shift. Tracheostomy Tube Bag Contents

Document the Tracheostomy Tube Bag contents. To ensure patient safety the tracheostomy bag accompanies the patient at all times. The nurse checks the tracheostomy bag contents at the beginning of each shift to ensure that all items listed on the flow sheet are present. The contents include: same size tracheostomy tube with Velcro tie threaded through flange, next size smaller tracheostomy tube with Velcro tie threaded through flange, extra Velcro ties, drain sponge, gloves, scissors, 5cc syringe, suction catheters, lubricant and saline (The Royal Children’s

Hospital Melbourne, 2009; Sherman et al., 2000).

1. Missing Supplies must be replaced. If an item cannot be replaced by the end of the shift, the nurse notifies

the parent and a plan is developed to restore the contents of the tracheostomy tube bag. It may be necessary

for the parent or the nurse to contact the medical equipment company. If the item cannot be replaced, the

nurse contacts the Clinical Manager (during business hours) or the on-call associate (after business hours)

and documents discussions in the progress notes.

2. Contents of the tracheostomy bag include:

. Tracheostomy tube size and type threaded with Velcro ties

. Tracheostomy tube one size smaller threaded with Velcro ties

. Extra Velcro ties

. Extra drain sponges (if worn)

. 5cc Syringe (if trach cuffed)

. Suction catheters

. Water based lubricant

. Gloves, Scissors, NSS

3. Although a self-inflating bag/valve system cannot fit in the tracheostomy tube bag, it should be in close

proximity to the patient. Ventilator Information(Kohorst, Blakely, Dockter, & Pruit, 2007;Massachusetts Department of Public Health,

1. Document the Ventilator Name (i.e. LTV 950).

2. Document the main Ventilator Location at Time of Assessment (i.e. bedroom, living room, physician of-

fice).

3. Document the Power Source in Use on the main ventilator. Check the A.C. or the internal battery or exter-

nal battery.

4. Check the External Battery Charging.

5. Document if the Fan Filter was cleaned or changed on the main ventilator.

6. Document if the Inlet Filter was cleaned or changed on the main ventilator.

7. Document whether the Back-Up Ventilator is plugged into an electrical outlet to ensure continuous

charge. If it is necessary to use the back-up ventilator, perform all checks prior to use.

8. Document that 02 Concentrator Power On Self-Test was performed if an O2 concentrator is used for patient

9. Document the date of the Last Ventilator Tubing changed.

10. Document that Portable Suction is available. Empty and clean suction canisters at end of each shift. Patient Care (Kohorst, Blakely, Dockter, & Pruit, 2007;Sherman et al., 2000; The Royal Children’s Hospital

Melbourne, 2009 )

1. Document Temperature and method upon arrival and at least every four hours.

2. Document Heart Rate and Respiratory Rate upon arrival and at least every four hours.

3. Document Breath Sounds upon arrival and at least every four hours. If other than clear, document findings in progress notes.

Clear = Cl Coarse = C Rales = R Rhonchi = Rh Diminished = D Absent = A Wheeze =

4. Document O2 in liters per minute with all ventilator setting checks and any changes in ventilator set-

tings or liter flow of oxygen.

5. While ventilator in use, document the Pulse Oximeter reading upon arrival and at least every two

hours. Document pulse oximeter with ventilator setting checks, changes in ventilator settings.

Document pulse oximeter at the start of oxygen administration or with change of oxygen flow. Maintain

the pulse oximeter reading within physician ordered limits.

6. When no ventilator is in use, but child is dependent on a tracheostomy tube, document pulse oximeter

upon arrival and at least every four hours or more often as ordered by a physician. Maintain the pulse

oximetry reading within physician ordered limits. 7. Document whether CPT , Vest or Cough-a-lator is performed. Document patient response to treatment

in the progress notes.

8. Document number of suction events (suction = x). The pressures applied during suctioning typically

range from 80 - 100mm Hg for most pediatric patients who are dependent on a tracheostomy tube. An

episode of suctioning should not exceed 5 - 10 seconds.

9. Document Secretion Color using the key below.

Clear = Cl White = Wh Yellow = Y Green = Gr

10. Document suction Amount using the key below.

Scant = Sc Small = S Moderate = M Copious = C

11. Document suction Consistency using the key below.

Thin = T Thick = Th

Ventilator Parameters (Kohorst, Blakely, Dockter, & Pruit, 2007; Branson, Campbell, Chatburn, & Covington,

1992; Massachusetts Department of Public Health, 2008)

Follow Physician Orders and Document Relevant Parameters, including:

1. Ventilator is in use (Main or Back-Up) 2. Type of Ventilation in use (Pressure or Volume)

3. Mode of ventilator in use (A-C, SIMV, CPAP)

4. Patient’s Actual Observed Breath Rate. Document the Set Breath Rate on the ventilator.

5. Patient’s (f) Breath Rate shown on the ventilator screen.

6. Tidal Volume

7. Patient’s Exhaled Tidal Volume (VTE)

8. Pressure Control

9. Inspiratory Time

10. Pressure Support

11. PEEP (Positive End Expiratory Pressure)

12. PIP (Peak Inspiratory Pressure)

13. MAP (Mean Airway Pressure)

14. Sensitivity 15. High Pressure Limit

16. Low Pressure Limit

17. Low Minute Volume

18. ET CO2(End Tidal CO2maintained within range according to physician orders)

19. O2 Tank Level and the Liquid O2 Tank Level. Inform the durable medical equipment (DME) vendor

when the levels indicate need to replace the tanks. Document whether or not you spoke with the DME rep-

resentative and outcome of discussion in progress notes.

20. Humidifier Temperature and Full H2O Level. Temperatures should be maintained at approximately 33

degrees centigrade (+/- 2 degrees). Follow the physician orders, if written. If there are no written physi-

cian orders, follow directions from the Respiratory Therapist at the durable medical equipment company.

21. Check (√) when the H2O Traps have been emptied along the ventilator circuit tubing. The condensation

along the corrugated tubing should be removed regularly to ensure that no water trickles into the airway.

Contaminated condensate should be emptied to prevent entry into the tracheostomy tube or inline medica-

tion nebulizers. 22. Document any other settings pertinent to the patient’s ventilator.

23. Sign and Date the Tracheostomy/Ventilator Flow Sheet.

24. Reference List

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Lewarski, J. S., & Gay, P. C. (2007). Current issues in home mechanical ventilation. Chest, 132,

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