TRACHEOSTOMY S 1. Perform cardiopulmonary assessment: A. Auscultate lung sounds. B. Assess condition and patency of airway and surrounding tissues.

C. Note type and size of tube, movement of tube, and cuff size. 2. Explain the procedure to the client and family. 3. Position the client. Clients usually prefer to be lying down. A client with a long-term, well-established tracheostomy may be seated. 4. Place a towel across the clients chest. 5. Perform hand hygiene. 6. Perform airway care: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ ___________ ___________ ___________ ___________ ___________ U NP Comments

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B. Tracheostomy care: (1) Observe for signs and symptoms of the need to perform tracheostomy care: (a) Soiled or loose ties or dressing (b) Nonstable tube (c) Excessive secretions (2) Suction tracheostomy. Before removing gloves, remove soiled tracheostomy dressing and discard in a glove with the coiled catheter. 7. Assess for signs and symptoms of upper and lower airway obstruction necessitating suctioning; abnormal respiratory rate; adventitious sounds; Nasal secretions, gurgling, drooling; restlessness; gastric secretions or vomitus in the mouth; and coughing without clearing secretions from the airway. __ __ __ ___________ __ __ __ ___________ __ __ __ __ __ __ __ __ __ __ __ __ ___________ ___________ ___________ ___________

8. Assess for signs and symptoms associated with hypoxia

S and hypercapnia: decreased SpO2, increased pulse and blood pressure, increased respiratory rate, apprehension, anxiety, decreased ability to concentrate, lethargy, decreased level of consciousness (especially acute), increased fatigue, dizziness, behavioural changes (especially irritability), dysrhythmias, pallor, and cyanosis. __

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9. Determine factors that normally influence upper or lower airway functioning: fluid status; lack of humidity; pulmonary disease, chronic obstructive pulmonary disorder, and pulmonary infection; anatomy; changes in level of consciousness; and decreased cough or gag reflex. 10. Identify contraindications to nasotracheal suctioning: occluded nasal passages; nasal bleeding, epiglottitis, or croup; acute head, facial, or neck injury or surgery, coagulopathy, or bleeding disorder; irritable airway or laryngospasm or bronchospasm; gastric surgery with high anastomosis; or myocardial infarction. Examine sputum microbiology data. Assess the clients understanding of the procedure. Obtain a physicians order if indicated by agency policy. Explain to the client how the procedure will help clear the airway and relieve breathing problems and that temporary coughing, sneezing, gagging, or shortness of breath is normal. Encourage the client to cough out secretions. Have the client practise coughing, if able. Splint surgical incisions, if necessary. Help the client to assume a position comfortable for you and the client (usually semi-Fowlers or sitting upright with head hyperextended, unless contraindicated). Place a pulse oximeter on the clients finger. Take a reading, and leave the pulse oximeter in place.

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S 18. 19. Place a towel across the clients chest. Perform hand hygiene. Put on a face shield if splashing is likely. __ __

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20. Turn on the suction device, and set the vacuum regulator to appropriate negative pressure (120150 mm Hg). Appropriate pressure may vary; check agency policy. 21. If indicated, increase supplemental oxygen therapy to 100% or as ordered by the physician. Encourage the client to breathe deeply. Preparation for all types of suctioning: A. Open the suction kit or catheter, using aseptic technique. If a sterile drape is available, place it across the clients chest or on the overbed table. Do not allow the suction catheter to touch any nonsterile surfaces. B. Unwrap or open a sterile basin and place it on the bedside table. Fill it with about 100 mL of sterile normal saline solution or water. Connect one end of connecting tubing to suction machine. Place other end in convenient location near client. Check that equipment is functioning properly by suctioning a small amount of water from basin. C. Turn on suction device. Set regulator to appropriate negative pressure: 120150 mm Hg for adults. 23. Suction airway. __ __ __ ___________

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Artificial airway suctioning: (1) Put on face shield. (2) Put one sterile glove on each hand, or put a nonsterile glove on your nondominant hand and a sterile glove on your dominant hand. (3) Pick up the suction catheter with your dominant hand without touching nonsterile surfaces. Pick up the connecting tubing with your nondominant hand. Secure the catheter to the tubing. __ __ __ __ __ __ ___________ ___________

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S (4) Check that equipment is functioning properly by suctioning a small amount of saline from the basin. __

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__ (5) If the client is receiving mechanical ventilation, open swivel the adapter or, if necessary, remove the oxygen or humidity delivery device with your nondominant hand. (6) Without applying suction, gently but quickly insert the catheter, using your dominant thumb and forefinger, into the artificial airway (it is best to time catheter insertion with inspiration) until resistance is met or the client coughs; then pull back 1 cm. (7) Apply intermittent suction by placing and releasing your nondominant thumb over the vent of the catheter; slowly withdraw the catheter while rotating it back and forth between your dominant thumb and forefinger. Encourage the client to cough. Watch for respiratory distress. (8) If the client is receiving mechanical ventilation, close the swivel adapter or replace the oxygen delivery device. (9) Encourage the client to breathe deeply, if able. Some clients respond well to several manual breaths from the mechanical ventilator or Ambu bag. (10) Rinse the catheter and connecting tubing with normal saline until clear. Use continuous suction. (11) Assess the clients cardiopulmonary _status. Repeat steps 17C(5) through 17C(11) once or twice more to clear secretions. Allow adequate time (at least 1 full minute) between suction passes for ventilation and reoxygenation. Perform oropharyngeal and nasopharyngeal suctioning __

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S (Steps 23 5, 6). After oropharyngeal and nasopharyngeal suction is performed, the catheter is contaminated; do not reinsert it into the tracheostomy tube. 24. While client is replenishing oxygen stores, prepare equipment on bedside table: __ __

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(a) Open sterile tracheostomy kit. Open three 4 4 gauze packages, using aseptic technique, and pour normal saline (NS) on one package and hydrogen peroxide on another. Leave the third package dry. Open two packages of cotton-tipped swabs and pour NS on one package and hydrogen peroxide on the other. Do not recap hydrogen peroxide and NS. (b) Open the sterile tracheostomy package. (c) Unwrap the sterile basin and pour approximately 0.52 cm of hydrogen peroxide into it. (d) Open the small sterile brush package and place it aseptically into the sterile basin. (e) Prepare a length of twill tape long enough to go around the clients neck two times, approximately 6075 cm for an adult. Cut ends on the diagonal. Lay aside in a dry area. (f) If using a commercially available tracheostomy tube holder, open the package according to the manufacturers directions. (25) Put on gloves. Keep your dominant hand sterile throughout the procedure. (26) Remove the oxygen source from the kit. Apply the oxygen source loosely over the tracheostomy if the client desaturates during the procedure. (27) If a nondisposable inner cannula is used:

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(a) While touching only the outer aspect of the tube, remove the inner cannula with your nondominant hand. Drop the inner cannula into the hydrogen peroxide basin.

S (b) Place the tracheostomy collar or T tube and ventilator oxygen source over or near the outer cannula. (Note: T tube and ventilator oxygen devices cannot be attached to all outer cannulas when the inner cannula is removed.) (c) To prevent oxygen desaturation in affected clients, quickly pick up the inner cannula and use a small brush to remove secretions from inside and outside the cannula. (d) Hold the inner cannula over the basin and rinse with NS, using your nondominant hand to pour. (e) Replace the inner cannula and secure the locking mechanism. Reapply the ventilator or oxygen sources. (28) Using hydrogen peroxideprepared cotton-tipped swabs(3) and 4 4 gauze(3), clean the exposed outer cannula surfaces and stoma under the faceplate, extending 510 cm in all directions from the stoma. Clean in a circular motion from the stoma site outward, using your dominant hand to handle sterile supplies. (29) Using NS-prepared cotton-tipped swabs and 4 4 gauze, rinse the hydrogen peroxide from the tracheostomy tube and skin surfaces. (30) Using dry 4 4 gauze, pat lightly at skin and exposed outer cannula surfaces. (31) Secure tracheostomy. __

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(a) Tracheostomy tie method: (a1) Apply new ties before removing the old tie.

(a2) Take the prepared tie and insert one end of the tie through the faceplate eyelet, and pull ends even. (a3) Slide both ends of the tie behind the clients head and around the neck to the other eyelet, and insert one tie through the second eyelet. (a4) Pull snugly.

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(a5) Tie ends securely in a double square knot, allowing space for only one finger in the tie. Remove the old tie.

S (a6) Insert fresh tracheostomy dressing under the clean ties and faceplate. 32. 33. 34. Position the client comfortably, and assess respiratory status. Replace any oxygen delivery devices. Remove and discard gloves. Replace the caps on the hydrogen peroxide and normal saline. Perform hand hygiene. Compare respiratory assessments made before and after the procedure. Observe depth and position of tubes. Assess the security of the tape or commercial ET or ET tube holder by tugging at the tube. Assess the skin around the mouth and the oral mucosa (with ET tube) and the tracheostomy stoma for drainage, pressure, and signs of irritation. Compare the clients vital signs and SpO2 saturation before and after suctioning. Ask the client whether breathing is easier and whether congestion is decreased. Observe airway secretions. __ __ __ __ __ __

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