Tracheostomy Skin Inspection Abnormalities
DESCRIPTION REASON PICTURE INTERVENTIONS DOCUMENTATION Apply gentle Fungal rash Fungal rash
B pressure to the Antifungal powder or area of redness. Heat from humidified cream (nsg to apply)
l This redness is oxygen Increase frequency of
a referred to as trach gauze dressing chg n Blanchable when InterDry textile (Nsg to you see a white c change every 5 days) RT flash of skin after can remove, inspect skin
h lifting up your and reapply same R a finger from the dressing. reddened area Humidified oxygen heat b E that you applied Remove source of the l pressure; NOT a problem (decrease D e pressure ulcer. temperature, when Blanchable (white flash) possible) N Maceration occurs Increase trach gauze
Maceration is because of excessive dressing changes. E white moisture. Under a Change trach ties if M waterlogged trach tie this may be excessively moist. S a tissue. due to humidifier or Use dry gauze or InterDry excessive sweating. c under trach collar elastic S Intertrigo (or Severe maceration e & trach tie to wick away fissure) is a linear results in the skin moisture in skin folds. r slit due to breaking down and
moisture in a fold. developing a fissure. a t
i
o n
with Fissure InterDInterdryry in use in place
Tracheostomy Skin Inspection Abnormalities
DESCRIPTION REASON PICTURE INTERVENTIONS DOCUMENTATION When there is an Stage I pressure ulcer S Remove the cause of P T area of redness that does NOT the pressure: R A blanch (see Consider switching from G description of Shiley to Bivona E E blanchable above) OR you have a S pressure ulcer. Place pad under I device/decrease friction: Partial thickness Stage II pressure S S Duoderm/Mepilex skin injury due to ulcer Intact or open serous-filled Allevyn trach foam T pressure. Intact U blister. If blister is open it is a Oxyears (nasal cannula) A or open blister shallow crater with a red, shiny Gel pad (Bipap/CPAP G (serous fluid). or dry partial thickness ulcer R mask) without slough or bruising. OR E
E II Decrease the weight of S Full thickness Stage III Pressure vent tubing from pulling wound (extending Ulcer on faceplate: T into the U Rolled towel under vent A subcutaneous tubing for support L G tissue) due to pressure.
E C
E III Purple Suspected Deep discoloration; Tissue Injury (sDTI) R s bruise. If pressure D damage is deep a T skin will open into Only true deep tissue I a wound after injuries will open into blistering. a wound. From Shiley faceplate Tracheostomy Skin Inspection Abnormalities
DESCRIPTION REASON PICTURE INTERVENTIONS DOCUMENTATION
Typically noted at Typically treatment is 9 and 3 o’clock or Incision is from the routine trach gauze care. at 6 o’clock. scalpel used during This may be increased to
I tracheostomy tube q4hrs to decrease the N placement. amount of moisture at site if excessive drainage. Most C 6 o’clock incisions will heal without I any treatment. S 3 and 9 o’clock I In some situations wound O HEALED? care dressings are ordered: If wound is not moist Allevyn foam N you may be seeing Alginate packing scar tissue of a healed incision.
Many surgeons Wounds from suture Wounds should resolve S W suture faceplate material where the quickly once the sutures have been removed. U O to skin with faceplate was insertion. RTs stitched to the skin. Gauze dressing Q shift T U remove these Duoderm, if edge of U N sutures. Standard practice at faceplate poking into Bethesda is to suture wound R D remove sutures on E S post-op day 5. Wound post Variable sizes, Routine care: Gauze/tape, change daily. T decannulation. depending on whether incisional R O wound has healed A U around trach prior to C T removal. H Tracheostomy Skin Inspection Abnormalities
DESCRIPTION REASON PICTURE INTERVENTIONS DOCUMENTATION Overgrowth of Occurs more If WOC APRN not RT: Change dressing applied over treated area approximately 1 hour after H granulation tissue commonly around a following, ask nsg to get (which is new foreign body, MD order for WOC APRN treatment to minimize risk of burn. Y blood vessels unstablized tube or to treat hypergranulation
P growing. Occurs due to excessive (minimizes scarring). E in response to an moisture. Continue gauze cover overly moist dressing after silver R wound bed). nitrate treatment. G May need to increase WOC APRN removes R If tissue is DRY dressing change to q4hrs A this is NOT the excessive tissue to keep dressing dry. hypergranulation. with silver nitrate. If N grey drainage from Stain treatment is left on after the skin patient can silver develop a chemical nitrate burn.
A Sometimes the Bunched skin can Routine trach care: happen when the Gauze dressing change healed tissue H T around tube has a tracheostomy tube is Hyperplasia every shift. E “bunched” inserted;especially if or bunched incision made is A T appearance, but skin tissue is dry, this is small. L R healed; not Hyperplasia is the E A hypergranulation. term used when skin D C has healed over
H hypergranulation tissue resulting in the tissue being elevated.
10/6/15 LB