NIGHTINGALE INSTITUTE OF NURSING,

NOIDA

PROCEDURE
ON
TRACHEOSTOMY CARE
(SUBJECT: ADVANCED NURSING PRACTICE)

SUBMITTED TO: SUBMITTED BY:

MS. RAJI MS. DHAIRYA ARORA
ASSISTANT PROFESSOR MSC(N) 1st year
NIN,NOIDA NIN, NOIDA
GENERAL INFORMATION:
Name of student teacher : Ms. Dhairya Arora

Subject : Advanced Nursing Practice

Topic : Tracheostomy Care

Group : M.Sc. 1st year Nursing students

Date :

Duration : 45 min

Method of teaching : Demonstration cum discussion

Place : M.SC 1st year class room

Language : English

A V aids : PPT, Black Board, video assisted learning, Flash Cards, Handouts.

Name of the evaluator : Ms. Raji (Assistant Professor, NIN, Noida)

Previous knowledge of the group : Group has some knowledge about Tracheostomy Care as acquired in their undergraduate level.
GENERAL OBJECTIVES: At the end of teaching, group will be able to gain knowledge about the topic ‘tracheostomy care’, to face and

control the group effectively with motivation and enthusiasm and to make effective use of skills and practice tracheostomy care demonstration in

clinical settings and as a teaching method.

SPECIFIC OBJECTIVES: At the end of teaching, group will be able to:

 introduce the topic ‘tracheostomy care’.


S. TIME SPECIFIC CONTENT TEACHING EVALUATION
N OBJECTIVE LEARNING
O. ACTIVITY WITH
AV AIDS
1. 1min introduce the TRACHEOSTOMY CARE INTRODUCTION
topic. Tracheostomy care
is a procedure ,
generally done
every eight hours
and involves
cleaning around the
incision, as well as
replacing the inner
cannula of the
tracheostomy tube.
After the site heals,
the entire
tracheostomy tube
is replaced once or
twice per week,
depending on the
physician's order.
DEFINITIONS
2. 5min define & The student teacher Define
Tracheostomy : A tracheostomy is a medical procedure, either temporary or permanent
discuss the defines the terms Tracheostomy,
,that involves creating an opening in the neck in order to place a tube into a person's
terms related related to the topic. inner cannula
windpipe. The tube is inserted through a cut in the neck below the vocal cords. This
to the topic. and
allows air to enter the lungs. Conditions that may require a tracheostomy include:
tracheostomy
 anaphylaxis tube.
 birth defects of the airway
 burns of the airway from inhalation of corrosive material
 cancer in the neck
  chronic lung disease
 coma
 diaphragm dysfunction
 facial burns or surgery
 infection
 injury to the larynx or laryngectomy
 injury to the chest wall
 need for prolonged respiratory or ventilator support
 obstruction of the airway by a foreign body
 obstructive sleep apnea
 paralysis of the muscles used in swallowing
 severe neck or mouth injuries
 tumors
 vocal cord paralysis
Inner cannula —Smaller tube that fits inside the tracheostomy tube, which can be
removed quickly if it becomes obstructed. This is often used for patients who have
copious secretions.
Tracheostomy tube —An indwelling tube used to maintain patency of the
tracheostomy. It can be made of metal (for long term use) or disposable plastic. The
tube can be cuffed (a balloon is inflated to keep the tube in place) or uncuffed (air is
allowed to flow freely around the tube). It can also be fenestrated, which allows the
3. 2min discuss patient to speak. The student teacher Discuss the
the discusses the tracheostomy
tracheostomy TRACHEOSTOMY TUBE SIZE CHART : tracheostomy tube tube size chart.
tube size size chart.
chart
4. 2min state the The student teacher What are the
precautions to states the precautions to be
be taken for precautions to be taken for
performing taken for performing
tracheostomy performing tracheostomy
care tracheostomy care care?

5. 1min enlist the PRECAUTIONS

purposes for  Extra precautions should be taken when performing site care during the first few The student teacher What are the
Tracheostomy days after the tracheostomy is surgically created. enlists the purposes purposes for
care.  The site is prone to bleeding and is sensitive to movement of the tracheostomy tube. for Tracheostomy
 It is recommended that another health care professional securely hold the tube while Tracheostomy care. care?
6. 3min discuss about site care is performed.
the  Tracheostomy care should not be done while the patient is restless or agitated, since The student teacher What
assessment this increases the chance that the tube may be pulled out and the airway lost. discusses about the assessment
before doing assessment before should be done
tracheostomy PURPOSES doing tracheostomy before doing
care. 1. Maintain airway patency by removing mucus and encrusted secretions. care. tracheostomy
2. Promote cleanliness and prevent infection and skin breakdown at stoma site. care?

ASSESSMENT
 Assess for excess peristomal secretions, excess intra-tracheal secretions, or soiled
tracheostomy dressing and ties.
 Assess respiratory status: breath sounds, respiratory rate, skin color, labored
breathing, flared nares or sternal retractions, arterial blood gases.
 Identify factors that influence tracheostomy care:
o Inadequate nutritional status predisposes client to infection, poor healing,
and weak cough reflex.
o Respiratory infection: pulmonary secretions increase in amount. Note color,
amount, and odor.
7. 3min enlist the o Fluid status: inadequate hydration increases tenaciousness of secretions. The student teacher Enlist the
equipments Client may have difficulty coughing up thick secretions. enlists the equipments
required for o Humidity: tracheostomy collars deliver humidified air to prevent dry, equipments required for
tracheostomy cracked membranes and thickened secretions. required for tracheostomy
care.  Identify type of tracheostomy tube used and if inner cannula is present. Identify if tracheostomy care. care.
tracheostomy tube is cuffed and if the cuff is inflated.
 Assess client's ability to understand and perform independent tracheostomy care.

EQUIPMENT
 Sterile tracheostomy care kit containing:
o - Two basins
o - Small brush or pipe cleaners
o - 4" × 4" gauze
8. 3min explain the The student teacher Explain the
o - Commercially available tracheostomy dressing
preparation to explains the preparation to be
be done o - Twill tape or tracheostomy ties preparation to be done before
before  Hydrogen peroxide done before tracheostomy
tracheostomy  Normal saline tracheostomy care. care.
care.  Sterile gloves
 Scissors
 Tracheostomy suction supplies

PREPARATION
 All supplies needed for tracheostomy care should be at the bedside prior to
beginning the procedure. There are prepackaged tracheostomy care kits available
9. 20min demonstrate that contain gauze pads, cotton-tipped applicators, a tracheostomy dressing, and The student teacher Demonstrate and
and explain hydrogen peroxide. In addition, a container of 0.9% sodium chloride solution, a demonstrates and explain the
the procedure suction kit, and sterile gloves are needed. The velcro strap that holds the explain the procedure of
of tracheostomy tube in place may be soiled and need to be replaced as well. procedure of tracheostomy
tracheostomy  The patient should be preoxygenated with 100% oxygen prior to suctioning. If the tracheostomy care care.
care. patient is agitated, a sedative should be given or the procedure should be with the help of
 rescheduled for a later time when the patient is calm.  video assisted
 Pain medication may be offered, especially during the first few days after surgery learning.
when manipulating the incision can cause discomfort.

PROCEDURE
1. Verify the physician order and identify the client.
Rationale: Prevents potential errors.
2. Wash your hands and don gloves.
Rationale: Handwashing and gloves reduce transmission of
microorganisms.
3. Explain procedure to client. Place the client in semi- to high Fowler's position (Fig.
1).
Rationale: Teaching decreases client anxiety and increases compliance.

Fig. 1: Greet client and explain procedure.

4. Suction tracheostomy tube. Before discarding gloves, remove soiled tracheostomy
dressing and discard with catheter inside glove. When suctioning through a
tracheostomy tube, insert catheter about 10 to 12 cm (in an adult).
Rationale: Removing secretions maintains a patent airway while doing
tracheostomy cleaning.
5. Replace oxygen or humidification source and encourage client to deep-breathe as
you prepare sterile supplies. Do not snap in place.
Rationale: Maintain good oxygenation status. Promotes easy removal
prior to sterile procedure.
6. Open sterile tracheostomy kit (Fig. 2). Pour normal saline into one basin, hydrogen
peroxide into the second (Fig. 3). Put on Sterile gloves (Fig. 4). Open several sterile
cotton-tipped applicators and one sterile precut tracheostomy dressing and place on
sterile field (Fig. 5). If kit does not contain tracheostomy ties, cut two 15-inch pieces
of twill tape and set aside.
Rationale: Preparing equipment allows for smooth, organized
performance of tracheostomy care.

Fig. 2: Open sterile tracheostomy kit. Fig. 3: Pour sterile hydrogen

peroxide into basin.

Fig. 4: Put on sterile gloves. Fig. 5: Place items on sterile

field.

7. Remove oxygen source (Fig. 6). The hand that touches the oxygen source is no
longer sterile. Note: For trache ostomy tube with inner cannula, complete Steps 7 to
 25. For tracheostomy tube without inner cannula or plugged with a button, complete
Steps 14 to 25.
Rationale: Prevents contamination of sterile gloves.

Fig. 6: Remove oxygen source.

8. Unlock inner cannula by turning counterclockwise. Remove inner cannula (Fig. 7).

Fig. 7: Unlock inner cannula by turning counter-clockwise.

9. Place inner cannula in basin with hydrogen peroxide (Fig. 8).
Rationale: Hydrogen peroxide loosens and removes secretions from
inner cannula.
 Fig. 8: Place inner cannula into basin with hydrogen peroxide.
10. Replace oxygen source over or near outer cannula.
Rationale: Maintain a constant supply of oxygen to prevent respiratory
or cardiac distress. Note: Not all clients require a constant oxygen
supply during tracheostomy care.
11. Clean lumen and sides of inner cannula using pipe cleaners or sterile brush (Fig. 9).
Rationale: Mechanical force and friction are needed to remove thick or
dried secretions.

Fig. 9: Clean inner cannula with brush.

12. Rinse inner cannula thoroughly by agitating in normal saline for several seconds
(Fig. 10).
Rationale: Rinsing and agitation remove secretions and water from
cannula and provide lubrication for easy reinsertion.
 Fig. 10: Rinse inner cannula in normal saline.
13. Remove oxygen source and replace inner cannula into outer cannula. "Lock" by
turning clockwise until the two blue dots align (Fig. 11). Replace oxygen or
humidity source.
Rationale: Oxygen is reestablished to a secured inner cannula.

Fig. 11: Replace inner cannula, then lock into place.

14. Remove tracheostomy dressing from under faceplate (Fig. 12).

Fig. 12: Remove soiled tracheostomy dressing.

15. Clean stoma under faceplate with circular motion using hydrogen peroxide-soaked
 cotton applicators. Clean dried secretions from all exposed outer cannula surfaces
(Fig. 13).
Rationale: Dried secretions are a good medium for bacterial growth.

Fig. 13: Clean secretions from tracheostomy site with cotton applicator.

16. Remove foaming secretions using normal saline-soaked, cotton-tipped applicators.
Rationale: Hydrogen peroxide can be irritating to the skin.
17. Pat moist surfaces dry with 4" × 4" gauze.
Rationale: Moist surfaces support growth of microorganisms and skin
excoriation.
18. Place dry, sterile, precut tracheostomy dressing around tracheostomy stoma and
under faceplate (Fig. 14). Do not use cut 4" × 4" gauze.
Rationale: Frayed cotton fibers from cut gauze could be aspirated into
the trachea.

Fig. 14: Replace new precut tracheostomy dressing.

19. If tracheostomy ties are to be changed, have an assistant don a sterile glove and hold
the tracheostomy tube in place.
 Rationale: This action prevents accidental displacement of the
tracheostomy tube if the client moves or coughs when the ties are not
secure.
For Tracheostomy Ties, Follow Steps 20-24
20. Cut a 12-inch slit approximately 1 inch from one end of both clean tracheostomy
ties. This is easily done by folding back on itself 1 inch of the tie and cutting a small
slit in the middle.
21. Remove and discard soiled tracheostomy ties.
22. Thread end of tie through cut slit in tie. Pull tight.
Rationale: The tie is secured to the faceplate without using knots. Knots
are difficult to undo when ties become crusted with secretions.
23. Repeat Step 21 with the second tie.
24. Bring both ties together at one side of the client's neck. Assess that ties are only tight
enough to allow one finger between tie and neck. Use two square knots to secure the
ties. Trim excess tie length. Note: Assess tautness of tracheostomy ties frequently in
clients whose neck may swell from trauma or surgery.
Rationale: Ties must be taut enough to prevent accidental dislodging of
tracheostomy tube but loose enough not to cause choking or pressure
on the jugular veins. Ties at side of neck are more comfortable for the
client.
For Tracheostomy Collar, Follow Steps 25-27.
25. While an assisting nurse holds the faceplate, gently pull the Velcro tab and remove
the collar on one side. Insert the new collar into the opening on the faceplate and
secure the Velcro tab. (Figs. 15 and 16).
 Fig. 15: Insert new collar into opening on faceplate.

Fig. 16: Secure Velcro tab.

26. Hold faceplate in place as the assisting nurse repeats step on the second side (Fig.
17).
27. Remove the old collar and ensure that the new collar is securely in place (Fig. 18).

Fig. 17: Insert new collar on second side and secure Velcro tab.
 Fig. 18: Discard soiled collar, ensure new collar is securely in place.
28. Remove gloves and discard disposable equipment. Label with date and time, and
10. 1min explain the store reusable supplies.
aftercare of Rationale: Opened normal saline is considered sterile for 24 hours. The student teacher Explain the
tracheostomy 29. Assist client to comfortable position and offer oral hygiene. explains the aftercare of
care. Rationale: Promotes client comfort. aftercare of tracheostomy
30. Wash your hands. tracheostomy care care
Rationale: Maintains infection control and communicates with other
healthcare team members.

11. 3min enlist the

home care Enlist the home
modifications The student teacher care
for Sample Documentation enlists the home modifications for
tracheostomy 12/05/19 9:00 Planning: Impaired airway clearance. care modifications tracheostomy
care. Implementation: Trach care - large amount of thick secretions for tracheostomy care.
cleansed from inner cannula, skin around trach is intact but care.
slightly red. Client is able to expectorate secretions when
encouraged to do so. Mist collar in place to maintain
humidification.
Evaluation: Increase fluids and encourage pulmonary hygiene and
mobility to decreased pooling of secretions.
12. 1min state the AFTERCARE The student teacher State the
complication  After tracheostomy care is finished, the soiled dressing and supplies should be states the complication of
of discarded, either in the garbage or in a biohazard container if there is a large amount complication of tracheostomy
tracheostomy of blood . tracheostomy care. care.
care.  The patient may need to be suctioned again, and his or her respiratory status should
13. 1min state the result be reassessed. The student teacher State the result
of  Again, pain medication should be offered as appropriate. states the result of of tracheostomy
tracheostomy tracheostomy care. care.
care. HOME CARE MODIFICATIONS
14. 2min enlist the role
 Teach the client or caregiver the following: The student teacher Enlist the role of
of nurse and o Handwashing is the most important step before touching the tracheostomy. enlists the role of nurse and other
other health o The function of each part of the tracheostomy tube. nurse and other health care team
care team o To remove, change, and replace the inner cannula. health care team members in
members in members in tracheostomy
o To clean the inner cannula two or three times a day.
tracheostomy tracheostomy care. care.
o To clean the tracheostomy stoma.
care.
o To suction tracheal secretions.
15. 1min summarise the o To assess for symptoms of infection (i.e., increased temperature, increased The student teacher
topic. amount of secretions, change in color or odor of secretions). summarises the
o To use a mirror for better visualization. topic.
16. 1min conclude the  Encourage parents to participate with the procedure in an effort to comfort the child CONCLUSION
topic. and promote client teaching. Staff caring for
COMPLICATIONS patients with a
Tracheostomy care is a relatively benign procedure. The greatest risk is that the tube tracheostomy tube
may be inadvertently removed and the airway lost. should be able to
identify which
type of
RESULTS tracheostomy tube
The anticipated outcomes of tracheostomy care include continual patency of the airway, the patient has, and
prevention of skin breakdown around the stoma, and prevention of infection.
potential problems
that may arise.
ROLE OF NURSE AND OTHER HEALTH CARE TEAM MEMBERS
  The nurse has the primary role in tracheostomy care, as he or she is responsible for
doing it in the acute care setting.
 The respiratory therapist may assist the nurse during the procedure and during
respiratory assessment.
 Some patients may be sent home with a tracheostomy. In this case, the nurse and
respiratory therapist are both responsible for teaching the patient and the family how
to perform site care at home.

BIBLIOGRAPHY
http://downloads.lww.com/wolterskluwer_vitalstream_com/samplecontent/9780781788786_Craven/samples/mod09/topic7a/text.html
McGovern, Kate & Marguerite Ambrose. "Providing Tracheostomy Tube Care." In Critical Care Skills: A Nurse's PhotoGuide, edited by June
Norris. Springhouse: Springhouse Corporation, 1996, pp. 298-311.
Thelan, Lynne, et al. Critical Care Nursing: Diagnosis and Management. St. Louis, MO: Mosby, 1998.
Abby Wojahn, RN, BSN, CCRN