University of the East

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.

#64 Aurora Boulevard, Doña Imelda, Quezon City

COLLEGE OF NURSING

NCM 112 RELATED LEARNING EXPERIENCE:

NURSING SKILLS

Name:​ Hannah Micole Gaerlan ​Section:​ N3B ​Date:​ Nov. 16, 2020
Group Number:​ B6

Nursing Skill:​ Tracheostomy Care

Definition and Purpose:

● Tracheostomy care is done to keep your trach tube clean. It is to prevent a clogged tube
and decreases your risk of infection. It includes suctioning and cleaning parts of tube and
areas of the skin.

Assessment (Identify 3 or more data to assess before procedure):

● ​Assess changes in BP, HR, and temperature.
● Assess respirations: note the quality, rate, rhythm, nasal flaring, and any increased use of
accessory muscles of respiration.
● Auscultate the lungs, noting areas of decreased ventilation and for the presence of
adventitious breath sounds.

Identified Possible 3 Nursing Diagnoses:

1. Altered tissue perfusion
2. Impaired gas exchange
3. Impaired integrity

Planning (SMART Form):

● Client will maintain a clear, open airway as evidenced by normal breath sounds,
normal rate, and depth of respiration, and the ability to effectively cough up
secretions.
 Equipment (List down equipment to be used for the nursing procedure):
1. Sterile cloth
2. Sterile cotton tipped applicators
3. Pick up forceps
4. Sterile brushes
5. Sterile tracheostomy ties
6. Sterile pre-cut dressing

Implementation (Step by step procedure of the nursing skill with rationale):

Step # PROCEDURE RATIONALE

1 Greet patient and introduce yourself To establish rapport and promote

cooperation and understanding.

2 Verify physician order by checking the order sheet and To promote safety and to prevent error
counter check with nurses’ kardex/ Check the name
band and expiration date (if applicable)

3 Provide drapes and raise side rails To promote privacy

4 Assess respiratory status or breath sounds To obtain baseline, future assessment, and
comparison of data

5 Assess tracheostomy for presence of drainage, soiled or To assess need for care
loose ties or dressing

6 Perform handwashing To maintain sterility and to prevent

contamination and transient microorganism
transfer from the hand

7 Pour hydrogen peroxide in sterile container To maintain sterility

8 Pour sterile water in the sterile basin

9 Pour hydrogen peroxide in another basin

10 Open tracheostomy care set

11 Open the sterile tracheostomy care using sterile To maintain sterility and avoid
technique contamination

12 Wear sterile gloves To promote a sterile procedure

13 Prepare equipments for tracheostomy care To promote organized and timely

- Sterile cloth performance of the procedure.
- Pick up forcep
- Sterile cotton tipped applicators To avoid unnecessary interruptions
- Sterile brushes
- Steriles tracheostomy ties Pick-up forceps: To pick up cotton
- Sterile pre-cut dressing
14 Remove inner cannula

15 Soak inner cannula to hydrogen peroxide To aseptically clean inner cannula from
possible growth of
bacterias/microorganisms

16 Remove the soiled dressing

17 Done new sterile gloves To reduce transmission of microorganisms

18 Place the sterile cloth over client’s chest To prevent patient from being soiled

19 Dip the cotton applicator in sterile water

20 Clean stoma under faceplate and outer cannula To aseptically remove secretions from
surfaces stoma site

21 Repeat until it is well cleaned

22 Wipe it with dry sterile cotton applicator

23 Dress the stoma with a pre-cut sterile dressing

24 Brush the inside and outside of inner cannula

25 Dress the stoma with a pre-cut dressing

26 Rinse the inner cannula in sterile water To rinse hydrogen peroxide from surfaces,
preventing possible irritation

27 Wipe the inner cannula with a dry cotton applicator To prevent formation of moist environment
that can promote the growth of
microorganisms and skin excoriations

28 Replace the inner cannula

29 Insert it gently in a twisting motion then lock it

30 Remove the old tie To prevent spread of microorganisms from

the old tie

31 Untie it on one side then insert the new tie

32 Remove the other side of the old tie

33 Then insert the other end of the new tie

34 Secure the tie properly and comfortably for the patient To prevent dislodgement

35 Verify that there is a space for 1 to 2 snug finger widths To prevent skin necrosis
under neck strap

36 Cut the excess strap and tie it securely

37 Remove and discard gloves. Perform hand hygiene. Prevents transmission of microorganisms
38 Observe aftercare

39 Position the patient comfortably To promote comfort

40 Assess Respiratory Rate To ensure good patient outcomes and to

- Lung sounds provide clues to whether further
- Breathing pattern interventions are needed

41 Document the procedure

- Date
- Time

42 Document condition of the client To document abnormal and actual findings

43 Record the amount and consistency of secretions

44 Document the condition of the client’s skin