The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?
A) Deflate the cuff overnight to prevent tracheal tissue trauma.
B) Inflate the cuff to the highest possible pressure in order to prevent aspiration.
C) Monitor the pressure in the cuff at least every 8 hours
D) Keep the tracheostomy tube plugged at all times.
Ans: C
Feedback:
Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.
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