While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:
A. Call the physician to reinsert the tube.
B. Grasp the retention sutures to spread the opening.
C. Call the respiratory therapy department to reinsert the tracheotomy.
D. Cover the tracheostomy site with a sterile dressing to prevent infection.
Correct Answer: B. 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. If agency policy permits, the nurse then attempts immediately to replace the tube. Options A and C will delay treatment in this emergency situation.
Option A: When a tube is dislodged, a nurse is generally the first responder. At the first sign of a possible dislodged tube, another caregiver should send another individual to urgently summon a physician.
Option C: If the tracheostomy is new, only a physician should reinsert the tube, and a nurse or respiratory therapist should never attempt to reposition the tube. This is because it takes time for the tract to form, and repositioning before the tract has formed can lead to complications as severe as those caused by the failure to act.
Option D: Covering the tracheostomy site will block the airway. A dislodged tube also calls for immediate attempts at manual ventilation, and suction with a solution of sodium chloride. This will rule out a mucus plug. Once this is done, to prevent brain damage the nurse should immediately deflate the tracheostomy cuff and take out the tracheostomy tube.
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