Tracheostomies

* Short-term reasons: * Anaphylactic shock * Trauma * Choking * Impaired airway baby drinking bleach throat is now swollen impairing airway needs trach * Croup cause upper airway swelling * If they couldn’t be intubated need an airway asap * Long-term reasons: * Syndrome have TEF an opening between trachea and esophagus unable to breathe * Cancer post surgery * Congenital abnormalities * Neuromuscular d/o’s MS, CP, spinal Cord injury or muscular dystrophy * Brain trauma/tumor or brain genetic disease (brain tells lungs to breathe so if its not working you’re not going to breathe)

***In pedi, there is only one cannula because if not the child will be taking the cannula out all day***

* Cuff will keep trach in place and will prevent aspiration. * Can be cuffed or uncuffed depending on the situation. * Keep scissors at bedside in case you need to cut the ties. ***DO NOT LET TRACH KID BE AROUND THE CHALKBOARD*** PARTICLES CAN ENTER THE TRACH.

* Put a filter on the trach if the child will be outdoors. * What kind of trach is most likely to be used in pedi? * Shiley 3.5, 4.0, 4.5 or 5.0 (the whole point is to always have a smaller half size replacement at the bedside at all times) * Example: Your patient currently has a 4.0 trach, need to have a 3.5 at bedside in case kid pulls out current trach. * Kids trachs are not stitched like adult trachs because they can pull the trach out and they’ll bleed out, that’s why we use ties in pediatric trachs.

***IF THE TRACH FALLS OUT, SHOVE IT BACK IN!!*** YOU CAN ALWAYS FIGHT THE INFECTION LATER BUT YOU CANNOT BRING THE KID BACK FROM THE DEAD.

Suctioning: Rule of 3’s for suctioning always hyper oxygenate first suction for 3 seconds on the way out for a maximum of 3 times.
***WHEN SUCTIONING THE TRACH DO NOT PASS THE “CARINA” ** The carina is the end of the trach tube. * Rationale: If you go passed the carina every time you suction you will begin breaking down the wall and it could cause injury to the area. Be sure to mark the spot to avoid this.

Trach care: * Clean using a clean technique with either sterile water or NS qshift or qday. * Change ties daily or qshift. * When suctioning, use sterile technique. * Do not suction for more than 3 seconds, use a twirling motion on the way out, continuous suction. * Bradycardia may occur during suctioning, this is expected. Just stop and oxygenate them.

When to suction: * If restless (when restless HR will increase, you suction but then baby can become bradycardic so stop and hyper oxygenate) * Infant will become cyanotic * If you hear lots of secretions

When choosing a catheter: * Choose a catheter that isn’t going to block too much of the airway.

* Fidgeting will always be the first sign of restlessness, you need to hyper oxygenate!

Suction power: * A little bit is best 40-60 power for premies 60 power for infants 80-100 power for bigger kids * Choose one that isn’t overpowering * NEVER deep suction! Bc it goes down to the lungs, that is outside of our practice * Change out suctioning tubing q29days! When changing tubing, use sterile technique * Be really careful with toddlers with trach, FOOD CAN GO INSIDE.

***KIDS WILL TRY TO FIT ANYTHING AND EVERYTHING DOWN THAT TUBE SO BE SURE TO MONITOR THEM WITH FOOD*** (risk for aspiration) They love putting peas or blue little medicine caps down their trach.

***Tiny little red dots around neck will indicate a yeast infection usually due to milk getting stuck there during feedings ***

*** #1 WAY TO PREVENT INFECTION IN TRACH KIDS IS HANDWASHING***

***SUCTION AS NEEDED, PRN! ***

*** TIE TIES TIGHT ENOUGH BUT NOT TOO TIGHT, but enough to prevent dislodgement***

***MAINTAIN SKIN INTEGRITY BY CLEANING WITH NS OR STERILE WATER***

***PASSY-MUIR VALVE Goes over trach, improves voice/speech, improves smell & taste, improves swallowing and may reduce aspiration ***

Growth and development ***SWADDLING Do not straighten the legs! It is not comfortable for the baby to have legs erect upon swaddling*** ***Jaundice = mental retardation…. the parent asks about it, what is your response? NEVER SAY YES YOUR BABY WILL HAVE MENTAL RETARDATION.*** School screenings: * Responding to parent if the test is negative, NEVER SAY THE KID HAS SOMETHING! You can just say that there is a possibility of a problem. Vision: Test question will ask about indicator of visual development being intact….these will be the options but you should only choose tracking!!! DO NOT PICK THE OTHER OPTIONS THEY DO NOT INDICATE THAT THE INFANT IS AT PROPER DEVELOPMENTAL STAGE. 1. Colorblindness (in infants, parent’s buy all of these colorful toys and baby can’t even see in color yet) 2. Infants should be able to track by 4 months (CORRECT ANSWER) 3. “Red reflex” retina is intact (doctor will do this but doesn’t indicate developmental stage is being met) 4. Pupillary neuro (DO NOT PICK THAT, just means the baby doesn’t have a brain bleed, yay horray but not the answer) The normal exam for an infant is the PRRL it’s the only test that you CAN do. * Nystagmus (never stops moving) NOT NORMAL * Strabismus (when eyes stay crossed or looks like a lazy eye and its normal in the beginning stages) NORMAL * Covered or uncovered test If the uncovered eye does not move, it is aligned. Vision screenings required by schools: Always ask child to start at the green line this will let us know if the child is colorblind if they still don’t know where to start * **4-5 year old they know letters and shapes so do HOTV chart (10 ft) * **5-6 year old Tumble-E chart (20-40ft) (bc they don’t know their alphabet yet) * **7 year old Snellen Chart (20ft) (bc they know their alphabet) Passing vs. Failing: * If 4 years old 20/40 line or better is passing * OR a 2 line difference * Example: 20/40 on left & 20/10 on right Failed bc it means the child is seeing poorly from one eye vs. the other. There is a 2 line difference. * If 5 years old and older 20/30 line or better is passing * If failed retest in 2-3 weeks (maybe it was a bad day for the kid) * If they fail after the retest refer to provider, there might be a problem. Hearing Screening: * *** What do you do if the A/C is too loud during the hearing test? YOU NEED TO MOVE THE HEARING TEST TO A DIFFERENT AREA, DO NOT PICK TO MOVE THE A/C ITSELF.*** Hearing test frequencies: * 1,000 25 * 2,000 25 * 4,000 25 * IF THEY MISS ANY THEY HAVE FAILED. * If the child does not raise their hand, stop the test and explain it again. * If the child fails, just try again next year. * Ear infections or cleanings can affect the childs hearing. Screening 8th graders: * Due to puberty * Ask girl when her period started * Conduct tests in privacy Scoliosis screening: * Bend over * Touch toes * Uneven hips and shoulders * If uneven, measure, record curvature and refer to provider. * Treatment might include a brace, surgery or watchful waiting. * 25 degree curvatures require surgery. * 10-25 degree curvatures require a brace. Acanthosis Nigricans: * Hyper pigmented velvety * Worse if detected in 4th grade versus 1st grade. * Insulin resistance related (NOT diabetes, the kid does NOT have diabetes) * Common in: * Boys * African Americans * Hispanics * Look at the neck measure or “grade it” talk in private record weight/height, BMI and growth chart take BP, wait 5 min and take it again. * Referral information includes: * Name * Age * 2 BP’s * BMI * Once referred to provider, the provider will perform an A1C test and a fasting BG test. I/V’s: * Facts about infants or children and their veins: * Smaller veins * More fragile * Blow easily * Harder to find * Use 22 and 24 gauges typically use 24 gauge in pedi. * Usually start I/V’s on hands or feet * Don’t start I/V’s on feet after 1 year age * ***Never start an I/V on the AC!!!*** * Put I/V on non-dominant hand * Use central line bc TPN can be super viscous and won’t fit through a regular I/V Distractions during an I/V start: * Infants “sweeties” sugar * Toddlers bubbles * Preschool t/v or a movie like “Frozen” * Have to have band-aid with you (avoid making trips and use the band-aid so that the kid doesn’t see any blood!) * Always give rewards!!! Feeding: * Oral feeds * NG tubes * OG tubes PO feedings: * **weight 108 cal/kg/day (108 x 3 = 324 cal/day) ** * 3 wk old infant = 3 kg * Stock formula 20 kilo/cal/oz = 90 kcal/day * Heart disorders require 120cal/kg/day How many ounces are needed per feeding if feeding Q3? 1. 108 (3) = 324 cal/day 2. 324 divided by 20 = 16.2 oz/day 3. 16.2 divided by 8 = 2 oz feed 4. The answer is 2 oz feed Different kinds of feeds: * If too concentrated dilute it!! * **Under 6 mo old doesn’t need ANY water until after 6 months Rules of 4 for milk 4hrs room temperature, 24 hours and 4 months in freezer -If you brake these rules, THROW IT AWAY. * NG or OG tube is chosen if the child is having trouble feeding. * OG tube usually short term * NG tube usually long term * Keep these points in mind when inserting the NG tube: * Swaddle before inserting NG tube * Sit infant up right before inserting NG tube * Head should be tucked forward * Pacifier so they can start the sucking motion * If you EVER meet or feel resistance when inserting the NG tube, STOP and pull it out. * Hyper oxygenate if turning blue or apneic using “blow-by” method * ***During an active seizure patients O2 will drop perform “blow-by” * Always use a small catheter and confirm placement by x-ray and pH paper 1. Only exception for not x-raying the placement is when child has Dobhoff tube instead because it has a weight at the end of it. * Flush NG tube with water 2. Usually only about 1ml since infants are so tiny 3. Feed over 30 min and teach feeding sensation through pacifier * ***REMEMBER- Babies do NOT need WATER*** only give the minimum required in the moment. * ***EVERYTHING GOES IN THE TUBE*** medications, formula and etc. You can put anything down the tube as long as placement has been confirmed! * ***Use douderm when taping NG tubing to infants face, you may place tape on top of the douderm. Douderm prevents skin breakdown.*** * ***If baby starts vomiting and gagging during NG tube insertion what will you do?! *** 4. STOP 5. SIT UP INFANT 6. SUCTION 7. OXYGENATE * Dumping syndrome can occur: * Symptoms include: 8. Sweating 9. Increased respirations 10. Increased heart rate 11. Severe cramping 12. EXPLOSIVE diarrhea * Clean you NG tube using sterile water or NS. Gavage method: * Order for Enfamil 90cc Q3hrs * PO feed x 10 min and gavage the rest * (gavage will usually be the remaining of the formula at the end) * Speech therapist will order how and how much to feed infant. Tips for NG? tube management: * Skin care infection – perform cleaning qshift or qday * Don’t leave it open * First initial NG tube feeding will be Pedialyte * Through pump? OG-tube: * ***Baby has new G-tube what will you do prior to feeding? * Check residual first, if >50% of feed is residual then hold feed and CALL the provider. *** PO feed (smoothly) 3 day old baby blood shifts to gut (colon) bacteria from colon will cause NECROTISING ENTEROCOLITIS *** ***KEEP WARM!!*** ***TICKLE/STIMULATE IF TURNING BLUE*** ***Premie baby has apnea order caffeine because they wont remember to breathe unlike full term babies*** * ***Review your respiratory module for this possible test question: Apnea of prematurity baby is usually placed on caffeine…answer should be Check the MAR for a caffeine order*** Medication administration in Pedi: ***LET THEM ADMIN MEDS IF THEY WANT TO!!*** Age doesn’t matter! *** Preschool let them choose which color they want green or blue!!*** ***Meds should be given with chasers NEVER MIXED into one (probably won’t finish the mixed beverage and now you have a bunch a medication left over in the mixed beverage)