OPEN TRACHEOSTOMY SUCTIONING - STERILE PROCEDURE Tayloers 751-763 Tracheostomy Care Requires 1. 2 people 2.

oxygen available -- oxygenated compression bag 3. both a sterile technique (dominat hand) and clean tecnique (nondominant hand) 4. Suctioning and cleaning the inner cannula is to remove the secretions to help pt breath easier, and reduce infection. 5. Risks to suction include 1. Increase risk of infection an invasive procedure 2. Increased risk to hypoxia this is reduced by providing O2 before, during, and after the suctioning. o Do not suction for more than 10 minutes 6. Dressing changes for tracheostomy reduces increased infection, assess skin, do not cut any dressing 7. Site care, cleaning inner canula to prevent clogging and accumulations of secretions. 8. Promote skin integrity, decrease risk of infection 9. Always assess pain level before and after suction. Treat pain for 30 min before procedure. SUCTIONING TRACHEOSTOMY Supplies Suction catheter tray 10 french with whistle tip, tray comes with sterile gloves Sterile normal saline Large tubing to connection to suction container Suction pressure should be 80-120 mmHg Chux Biohazard bag PPE eye shield/goggles, mask, gown O2 compression bag with connection to oxygen Extra pair of sterile gloves in case contaminates dominant hand. Procedure 1. Check order for frequency and type of suction, get supplies, ID patient, provide privacy, explain procedure wash hands 2. Assess patients pain level, if above 3 give patient PRN pain med, wait 30 minutes before suction 3. Make sure you have someone to assist another RN 4. Position conscious patient in fowlers position, raise bed height, place supplies on bedside table (if unconscious patient, place pt in lateral position facing you)

5. Set up O2 compression bag, make sure O2 is on, and place it next to patients head/shoulder 6. Connect large suction tubing to the suction container, place tubing hands reach (on bed) 7. Turn on suction to 80-120 mmHg 8. Put Chux under patients chin on chest 9. Put on PPE in order 1. gown 2. mask 3. eye shield/goggles 10. Open Sterile NS, place lid with top up 11. Open seal suction catheter tray, do not touch inside contents, edges 12. Push out gloves w/out touching inside of catheter tray or catheter. 13. Put on sterile gloves 14. With your non-dominant hand pour sterile NS into the catheter tray, THIS HAND IS CONTAMINATED/CLEAN, DO NOT TOUCH TUBE (inside tray) TRAY AT ALL 15. Give Pt a 3-5 breathes by pumping O2 compression bag over tracheostomy using the NONDOMINANT hand. (Patient or other RN removes oxygen delivery system tubing first). 16. Pick up catheter tubing with DOMINANT/Sterile hand. Position so the whistle tip is sticking out at end, and have suction end wrapped inside palm to protect 17. With NONDOMINANT hand, pick up tubing connected to suction 18. Connect tubing to suction catheter using NONDOMINANT hand 19. Moisten the catheter by placing the suction end of catheter into the saline solution with DOMINANT/STERILE hand, while placing thumb of NONDOMINANT hand over suction whistle (occlude Y port). Look for movement of water up catheter to tubing then into suction container. This indicates patency & proper suction. 20. Remove Oxygen deliver system connected to tracheostomy with NONDOMINANT Hand 21. With DOMINANT/STERILE hand insert suction catheter quickly but gently . Insert suction catheter, advance catheter by total of 4-5 inches. Advance tubing NO MORE than 1cm past the length of the tracheostomy tube. 22. Then apply INTERMITTANT suction with NONDOMINANT hand. 23. Rotate the catheter gently as you REMOVE it from tracheostomy. 24. LIMIT SUCTION TIME TO MAX OF 10 SECs 25. Hyperventilate patient. 3-5 O2 bag compressions with NONDOMINANT hand. 26. Place suction end of catheter into saline tray and apply suction to flush catheter. 27. Repeat steps 19-26 as needed to remove secretions. BUT pay attention to patients TOLERANCE. 28. Allow patient to rest between suctions. Rest for 1 minute between suctioning again. 29. During resting, have other RN replace oxygen delivery system onto tacheostomy.

30. Limit the # of suctioning to 3 per session. 31. After suctioning, make sure replace oxygen delivery system onto tacheostomy and patient is getting O2 perusion. Assess for signs + symptoms. 32. Turn off suction 33. Disconnect suction catheter from suction tubing, make sure you roll it up in your hand. 34. Clean up and Take off of PPE in order 1. gloves 2. eye shield/goggle 3. gown 4. mask 35. Clean hands 36. document what you did (how many suctions), assessment of tracheostomy 3. how patient reacted to treatment. TRACHEOSTOMY CLEAN & CARE CLEANING INNER CANNULA AND CHANGING DRESSING Done after Tracheostomy make sure patient has had time to rest first. Requires 2 RNs Supplies Tracheostomy Clean and Care Tray Sterile normal saline Suction pressure should be 80-120 mmHg Chux Clean gloves PPE eye shield/goggles, mask, gown O2 compression bag with connection to oxygen Extra pair of sterile gloves in case contaminate dominant hand. Disposable biohazard bag Scissors to cut tracheostomy ribbon ties *** Additional Inner Cannula*** Procedure 1. Check order for frequency and type of suction, get supplies, ID patient, provide privacy, explain procedure wash hands 2. Assess patients pain level, if above 3 give patient PRN pain med, wait 30 minutes before cleaning and changing dressing. 3. Make sure you have someone to assist another RN 4. Position conscious patient in fowlers position, raise bed height, place supplies on bedside table (if unconscious patient, place pt in lateral position facing you) 5. Set up O2 compression bag, make sure O2 is on, and place it next to patients head/shoulder 6. Place disposable biohazard bag next to pt arm 7. Put Chux under patients chin on chest

8. Put on PPE in order 1. gown 2. mask 3. eye shield/goggles 9. Open lid of Tracheostomy Clean and Care Tray, remove completely 10. Remove waterproof drape and create the sterile field 11. Dump contents into sterile field 12. Open Sterile NS, place lid with top up 13. Pour 0.5 inch of sterile NS into tray compartment/basin 14. Put on Clean gloves 15. Make sure 2nd nurse is on other side of patient to stabilize 16. Patient or other RN removes oxygen delivery system tubing first 17. Remove gauze around the tracheostomy site, throw in biohazard bag 18. Assess Tracheostomy site for inflammation, maceration, infection, bloody secretions, the amount and characteristics of the secretion (is it crusty?). If patient is sutured make sure sutures are intact. 19. Stabilize the the outer cannula and the base plate with NONDOMINANT hand 20. Rotate lock of inner cannula COUNTERCLOCKWISE motion with DOMINANT hand to release it from outer cannula 21. Continue to hold base plate, remove inner cannula slowly and smoothly. 22. Place inner cannula in the basin with sterile NS. 23. Take off clean gloves and throw in biohazard bag. 24. Don sterile gloves 25. Moisten brush in Sterile NS from basin 26. Insert brush into inner cannula, and use back and forth motion to remove secretions. Agitate the cannula in NS to clean out inside as well 27. Remove cannula from solution 28. Tap cannula on inner surface of basin to remove excess NS 29. Stabilize outer cannula and baseplate of tracheostomy with NONDOMINANT hand 30. Smoothly and quickly (without touching sides) replace the inner cannula inside outer cannula with DOMINANT hand, turn inner cannula CLOCKWISE to make sure it locks in place and is secured. ***Make sure 2nd nurse is on other side of pt. 31. Reattach O2 supply to tracheostomy. Assess patient 32. Allow rest period Patient or other RN replaces oxygen delivery system tubing 33. After resting, Patient or other RN removes oxygen delivery system tubing 34. With NONDOMINANT pour remaining NS into the OTHER basin 35. With Dominant hand place cotton tip applicator into NS to moisten 36. Clean around the stoma, throw away and biohazard bag **work in circular motion stoma site inside (stoma site) to outward ** BE GENTLE, irritation may cause pt to cough and eject inner cannula and dislodge baseplate 37. Allow rest period Patient or other RN replaces oxygen delivery system tubing 38. After resting, Patient or other RN removes oxygen delivery system tubing 39. Clean underneath baseplate, throw away and biohazard bag

**work in circular motion stoma site inside (stoma site) to outward ** BE GENTLE, irritation may cause pt to cough and eject inner cannula and dislodge baseplate 40. Pat dry area under base plate with gauze gently, make sure it is dry!! 41. Place new gauze under each side of base plate, fit around stoma. Make sure gauze is not cut (fibers can be inhaled into stoma and cause infection, or respiratory distress). If large gauze, fold to fit around the stoma 42. Allow rest period Patient or other RN replaces oxygen delivery system tubing 43. After resting, Patient or other RN removes oxygen delivery system tubing 44. Pull out new tape for tracheostomy. But leave old tape in place until after add new tape 45. Length of tape should be 2X the circumference of neck + 4 inches 46. Insert tape alongside baseplate the opening of the old tape 47. Pull all the way through on first side until both ends are even 48. Slide both tapes under patients neck ask pt to flex neck so can get tape around back of neck securely 49. Insert one through remaining opening on the other side of the baseplate 50. Pull tape snugly 51. Tie ends using double square not 52. ***Tape should be loose enough so can fit 1 finger between tape ties and neck 53. Snip end of excess new tape past knot 54. Once new ties are secured carefully remove the old ties, do not yank! 55. Patient or other RN replaces oxygen delivery system tubing 56. Clean up 57. Document procedure, assessment findings, how patient tolerated procedure.