CSCC – SRSN Nursing Clinical Skills Evaluation Sheet

Performing Tracheostomy Care

Student:
Evaluator:
Attempt: 1st, 2nd, 3rd
“S” indicates satisfactory performance; “U” indicates that criteria was not satisfactorily met. If procedural
steps are not satisfactorily met, the student will receive an overall grade of unsatisfactory.
S/U Procedure Steps
1 Determine the need for tracheostomy care, assess allergies, and gather supplies: : trach kit, sterile
normal saline, hydrogen peroxide, clean gloves, sterile gloves, pulse oximeter, additional PPE as
needed.
2 Introduce yourself, identify patient with two identifiers, provide a safe environment, explain procedure,
provide privacy, confirm allergies with patient, and perform hand hygiene.
3 Assess the patient’s respiratory status and signs indicating the need for suctioning before performing
tracheostomy care. Apply pulse oximeter.
4 Assess for pain or the potential to cause pain and administer medication as prescribed.
5 Adjust the bed and clean overbed table to appropriate height.
6 Place patient in semi-Fowler’s position if conscious; lateral position if unconscious. State rationale.
7 Perform hand hygiene.
8 Open the tracheostomy kit on the overbed table. Set up sterile field and fill two basins with ½ inch
sterile saline, and front large basin with half hydrogen peroxide and half sterile saline (based on facility
policy).
9 Don clean gloves.
10 Instruct patient to take 2-3 deep breaths and remove oxygen collar.
11 Support the face plate, remove the inner cannula and drop into basin with half hydrogen peroxide/half
sterile saline.
12 Remove old tracheostomy dressing and assess site for drainage, redness, or edema. Discard old
dressing.
13 Replace oxygen collar, discard gloves, perform hand hygiene, and check oxygen saturation.
14 Don sterile gloves.
15 Arrange sterile supplies on sterile field for ease of use.
16 Using dominant hand, pick up inner cannula. Clean with brush and hydrogen peroxide/saline solution.
17 Agitate the inner cannula in sterile saline solution basin. Tap inner cannula dry against the inner surface
of basin.
18 Assess inner cannula for dents, cracks, tears, or becoming too rigid.
19 With dominant hand, hold cannula by outer flange. Remove oxygen collar with non-dominant hand
and stabilize face plate. Insert clean inner cannula.
20 Replace oxygen collar with non-dominant hand and check oxygen saturation.
21 Clean the stoma site with sterile supplies using last basin of sterile saline. Use each applicator or
sponge only once, moving from stoma site outward. State rationale.
22 Thoroughly and gently, dry the stoma site with 4x4 gauze to prevent maceration and inhibit microbial
growth.
23 Apply sterile tracheostomy dressing, being careful not to touch inner “V” of dressing.
24 Apply new trach tie. Keep soiled tie in place until a clean tie is securely attached. State rationale.
25 Untie or cut off old trach tie, being careful not to cut tubing that inflates tracheostomy cuff.
26 Remove gloves; perform hand hygiene.
27 Dispose of equipment and supplies appropriately.

Revised 3/2012, 1/2013, 4/2013, 3/2015, 4/2019

 28 Reassess the patient’s respiratory status.
29 Answer any patient questions, position patient/bed for comfort and safety, call light in reach, open
privacy curtain, and document procedure.
Overall Grade  Satisfactory  Unsatisfactory
Comments:

Utilizes correct pronunciation of medical terminology: Yes, Needs to review

Able to state rationale for procedure steps:

Voluntarily stated throughout skill.
Able to answer rationale when prompted.
Unable to answer rationale to two or more questions when prompted.

Student Signature: Date:

Evaluator Signature: Date:

In the event of unsatisfactory performance:

The Evaluator has reviewed with me the reasons for my unsatisfactory performance and has advised me of the next
steps in the process. I was given the opportunity to ask questions. I understand why my performance was
unsatisfactory.

Student Signature: Date:

Evaluator Signature: Date:

Revised 3/2012, 1/2013, 4/2013, 3/2015, 4/2019