TRACHEOSTOMY CARE

MODULE DESCRIPTION

It is the nurse responsibility to either changed or cleanse the inner cannula of a tracheostomy,
thus preventing mucus accumulation that may hinder good oxygen exchange, and may also obstruct the
airway. Tracheostomy dressings, collar and ties that is smudge by drainage may put the patient in the
likelihood of disintegration and infection around the skin of the tracheostomy. This module will provide
a step by step guide in performing tracheostomy care using aseptic technique, and is presented in the
manner of nursing process, thereby enhancing the capability to care for a patient with tracheostomy as
well as developing a nursing care plan.

COURSE LEARNING OUTCOMES

At the end of the course, you will be able to:

1. Perform tracheostomy care using aseptic technique with minimal supervision.
2. Identify the different parts of a tracheostomy
3. Determine the presence of abnormality at the site of tracheostomy insertion.
4. Plan the care of a patient with tracheostomy
5. Assess and evaluate the effectiveness of the care rendered.

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LET’S TRY THIS

Choose the best answer:

1. A fenestrated tracheostomy tube means?

a. The outer cannula has two openings
b. The outer cannula has precut opening
c. The inner cannula has two openings
d. The inner cannula has precut openings
2. Upon assessment you noticed a sudden change in the level of your patient’s consciousness,
which of the following should be done?
a. Administer oxygen
b. Determine factors that may have affected the patient’s status
c. Immediately report the patient’s condition to the doctor
d. Observe for further changes, then report to the doctor.
3. Which of the following action will determine the patient’s response to effectiveness of
tracheostomy placement?
a. Assessing the patient’s understanding to perform own care.
b. Assessing patient’s vital signs and ability to clear airway.
c. Assessing the presence of infection to the site of insertion.
d. Assessing the tube if it is snugly fit.
4. Which of the following nursing diagnoses reflects possible problem?
a. Impaired gas exchange
b. Impaired spontaneous ventilation
c. Ineffective airway clearance
d. Risk for impaired skin integrity
5. To optimize delivery of oxygen through tracheostomy, which of the following should the nurse
do?
a. Ensure that the tube is tied in a double knot
b. Help the patient in a comfortable position
c. Ensure that the tube is free from secretions
d. Assess patient’s understanding of the tracheostomy care [Date]

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TOPIC

A tracheostomy (stoma into the trachea) is created either temporary or permanent through a
surgical procedure through the neck beneath the larynx, into the trachea (between 2-3 /3-4 tracheal
rings) that serves as a place for tracheostomy tube to maintain an artificial airway.
Tracheostomy tubes is either metal or plastic hollow tube that is curved, and is inserted into the
tracheotomy stoma to ease mechanical ventilation, elimination of tracheal secretions and promote
patent airway. Also for patient
A. Parts of the Tracheostomy Tube
1. Flange – the flat plastic plate that helps hold the tracheostomy tube (outer tube) to the patient’s
skin on the neck to stabilize tracheostomy tube placement.
2. Outer cannula /outer tube – the tube that bear the tracheostomy open. Serves as the main
airway.
3. Inner tube – the removable part for easy cleaning. It snugly fit into the outer tube
4. Obturator – it guides the tracheostomy tube into the trachea then it is removed quickly

Indications for tracheostomy

1. To enable long term airway management due to airway obstruction, airway clearance needs.
2. To secure and maintain airway to patient with face, head, neck injury
3. For patient who are at risk for aspiration

Types of Tracheostomies
1. Fenestrated tube – a tube with an opening on the outer cannula to allow movements of air
through the mouth and nose. Deflated cuff and without the inner cannula the patient can speak.
2. Cuffed tracheostomy tube – resembles an endotracheal tube, the end is with soft balloon to be
inflated sealing the airway. Necessary for patient on positive pressure ventilation or when there
is an increase oral or gastric secretion are present that may put the patient at risk for aspiration.
3. Uncuffed tubes – commonly used to patient with good gag and coughing reflex in order to clear
the secretions thus protecting them from aspiration. No balloon to seal the airway.

Image credit: uihc.org

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Image credit: Clinical Nursing Skills and Techniques, Perry, Anne and Griffin

Note: observe aseptic technique when providing tracheostomy care: Respiratory tract is sterile.

EQUIPMENTS:
1. Disposable gloves
2. Sterile gloves
3. Googles, mask or face shield
4. PPE if indicated
5. Sterile normal saline
6. Sterile cup of basin
7. Sterile cotton tip applicator
8. Sterile gauze sponges
9. Disposable inner tracheostomy cannula, ensure appropriate size
10. Sterile suction catheter and glove set
11. Commercially prepared tracheostomy or drain dressing
12. Commercially prepared tracheostomy holder
13. Pulse oximeter
14. Tape and scissors
15. Plastic disposable bag
16. Obturator
17. Additional nurse
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ASSESSMENT
1. Assess for the need to perform tracheostomy care
2. Assess for any skin redness or purulent discharge at the insertion site
3. Assess presence of pain (especially for the new tracheostomy), administer prescribed analgesic
before performing the procedure
4. Check that lung sounds are equal in all lobes and with an oxygen saturation level above 93%
5. Assess for any signs of skin breakdown around the posterior portion of the neck due to pressure
from tracheostomy ties or holder

DIAGNOSIS: Identify the factors for nursing diagnosis base on the present situation of the patient.
1. Impaired skin integrity
2. Ineffective airway clearance
3. Risk for infection
4. Risk for aspiration

OUTCOME IDENTIFICATION AND PLANNING

1. Tracheostomy tube (inner and outer cannula) and site are free from to secretions, drainage, and
skin irritation and breakdown
2. Oxygen saturation level will be within normal/acceptable level
3. No signs of respiratory distress
4. Tube ties are clean and properly secured
5. Stoma site is free from any secretions and bleeding, with no signs of infection.

IMPLEMENTATION
1. Prepare and bring all the necessary equipment to the bedside or overhead table.
2. Perform hand hygiene and put on PPE if necessary
3. Identify the patient
4. Place pulse oximeter on the patient’s finger
5. Ensure patient’s privacy is observe
6. Assess the need for tracheotomy care, and presence of pain (administer prescribed pain
medication if needed)
7. Explain the rationale for performing the procedure. Reassure patient that any signs of
respiratory difficulty you will immediately stop.
8. Adjust the bed to a comfortable position, possibly at elbow height
9. Position the patient
a. Semi-fowler’s for conscious patient
b. Lateral position facing you for unconscious patient
10. Ensure that your equipment is close to the working area and is at your waist level. Trash
receptacle should be within your reach.
11. Wear google/face shield and mask
12. Suction tracheostomy secretion if needed, if suctioning had just been done, removed soiled
dressing and discard before removing your gloves used for suctioning.

Cleaning the disposable inner cannula

13. Open the package of the new cannula, and sterile cotton-tipped applicator observing aseptic
technique, ensure not to contaminate its content.
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a. Carefully pour 0.5 inch. deep of sterile saline to the sterile cup or basin.
14. Open and place the plastic disposable bag within reach.

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15. Don on disposable gloves.

16. If the patient is on oxygen remove and secure properly.
a. With your non-dominant hand, steady the outer cannula and faceplate of the
tracheostomy.
b. with your dominant hand hold the locking mechanism of the inner cannula.
c. Press the tabs and release lock

d. Gently and carefully remove the inner cannula and the site dressing and dispose into the
disposable trash bag.
17. Remove and dispose gloves and don on new sterile gloves.
a. With your dominant hand, take the sterile new inner cannula, keep the faceplate steady
using your non dominant hand, and carefully insert the inner cannula into the outer
cannula. Remember to press the tab to ensure the lock hold the outer cannula.
b. Put in place the oxygen source if necessary.

Applying Clean Dressing and Holder

18. Disconnect the oxygen source if needed.

a. Soak the sterile cotton applicator or gauze in the sterile saline, and cleansed the area of
the stoma under the faceplate. Using the principle of from inner to outer and use the
applicator or gauze once only, discard every after use
19. Pat the skin dry carefully and gently using a 4 x 4 gauze
20. Slip the commercially prepared tracheostomy dressing under the faceplate. Ensure that the
dressing is not cotton-filled.
21. Replace the tracheostomy holder
a. Ask for assistance to grasp the tracheostomy tube in place while removing the old collar
and replaced with a new one.
b. Carefully open the package of the new tracheostomy collar.
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c. Ensure that both nurses are wearing clean gloves.

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d. While one of the nurses is holding the faceplate, the other nurse pulls the Velcro tabs
and carefully remove the collar.
e. While one of the nurses still securing the tracheostomy faceplate in place, the other
nurse should set the collar around the patient’s neck, inserting the first tab then the
other into the faceplate opening and secure the Velcro tabs to the tracheostomy holder.
f. Check that the tracheostomy collar properly fits.
i. Remember that a finger should fit between the neck and the collar.
ii. Ensure that the patient can flex his/her neck comfortably.
iii. Place the oxygen back if needed.
22. Take off gloves and assist the patient to a comfortable position.
a. Ensure that the side rails are raise and the bed is in the lowest position if possible.
23. Remove PPE if used, as well as face shield, googles and mask.
24. Reevaluate the patient’s respiratory status, oxygen saturation and lung sound.

EVALUATION: The expected outcome is met if the following are observed:

1. Absence of drainage, secretions and skin breakdown or irritation at the insertion site as well as
the tracheostomy tube.
2. Oxygen saturation level is within acceptable parameters
3. No evidence of respiratory distress
4. Posterior portion of the neck is free from skin irritation or breakdown.

DOCUMENTATION;

1. Ensure to document the before and after assessment

a. Site assessment
b. Presence of pain if any
c. Lung sounds and oxygen saturation levels
2. Document if there is a resulting skin breakdown or irritation due to tracheostomy collar pressure
on the skin.
3. Document the care rendered

Example documentation:

10/ 19/2020 2:30 PM Tracheostomy care done; lung sounds in all lobes are clear; oxygen saturation
level 97 %; unlabored respiration; noted absence of edema or erythema at tracheostomy site; small
amount of thick yellow mucus noted at the site, cleaned and removed. --- J. Dela Cruz, RN
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UNEXPECTED SITUATIONS AND INTERVENTIONS

1. Dislodgement of tracheostomy due to hard coughing

a. Ensure that a spare tracheostomy tube and obturator is kept at bedside
b. Slip the obturator into the new sterile tracheostomy and insert into the stoma.
c. Remove the obturator.
d. Fix the ties and auscultate lung sounds on all lobes.
e. Assess presence of subcutaneous emphysema by palpation.
2. Presence of subcutaneous emphysema at the insertion site
a. Assess if the tracheostomy tube is dislodged or displaced
b. Notify the physician for the presence of subcutaneous emphysema

SPECIAL CONSIDERATION

1. Nurse is working alone

a. Remember to insert the new tracheostomy ties in place before removing the old one, to
prevent accidental removal of tracheostomy.
2. If the old ties need to be removed first ask for assistance to secure the tracheostomy tube in
place, then you removed the old ties and replaced it with new.
3. Ensure that emergency equipment is always accessible at bedside
a. Bag-valve mask
b. Oxygen
c. Obturator
d. Spare tracheostomy tube of the same size, and another one size smaller
e. Suction equipment
f. Endotracheal tube
4. Keep spare tracheostomy with cuff at the bedside for patient who is currently using
tracheostomy without a cuff, ensure that the tracheostomy is of the same size of the patient’s
currently using.
5. Home care consideration:
a. Demonstrate and give instruction to the patient and caregiver on how to accomplished
tracheostomy care.
b. Let the care giver perform return demonstration and ensure to give feedback.
6. Clean technique can be used in the home setting
7. Give instruction on how to make sterile saline solution
a. 1 teaspoon of table salt
b. 1 quart of water
c. Mix the salt with water and let it boil for 15 minutes
i. Cool and store in a clean dry container
ii. Instruct to discard the saline solution at the end of each day.
8. For a patient who is going to cleansed the tracheostomy site, instruct to use a mirror when
performing the procedure.
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CLEANING NONDISPOSABLE INNER CANNULA:

Note for additional equipment: sterile tracheostomy cleaning kit or 3 sterile basins; sterile pipe cleaner
or brush; sterile cleaning solution of hydrogen peroxide and normal saline solution.

1. Prepare and bring all the necessary equipment to the bedside or overhead table.
2. Perform hand hygiene and put on PPE if necessary
3. Identify the patient
4. Place pulse oximeter on the patient’s finger
5. Ensure patient’s privacy is observe
6. Assess the need for tracheotomy care, and presence of pain (administer prescribed pain
medication if needed)
7. Explain the rationale for performing the procedure. Reassure patient that any signs of
respiratory difficulty you will immediately stop.
8. Adjust the bed to a comfortable position, possibly at elbow height
9. Don disposable gloves
10. If the patient is on oxygen remove and secure properly.
a. With your non-dominant hand, steady the outer cannula and faceplate of the
tracheostomy.
b. with your dominant hand, in a counterclockwise motion, revolve the inner cannula to
release the lock.
11. While you are holding the faceplate, carefully remove the inner cannula and drop in the basin
with hydrogen peroxide solution.
a. Put in place the oxygen source of the patient on the outer cannula.
12. Remove and properly dispose gloves and don on sterile gloves.
a. Pull out the inner cannula from the basin of hydrogen peroxide solution.
b. Clean the tube using a back and forth motion, ensure to dip the brush so the saline
solution before inserting into the tube.
13. Perturb the cannula in in saline solution, pull it out and tap it against the inner surface of the
basin.
a. Set the cannula on a sterile gauze pad.
b. Assess if secretions accumulated in the outer cannula and suction using aseptic
technique.
14. Return the inner cannula to the outer cannula with your dominant hand while your
nondominant hand is securing the faceplate and outer cannula.
a. Rotate clockwise, ensure that the inner cannula is fastened securely.
b. Appraise the need for reapplication of oxygen, reapply if needed.
15. Continue with the site care and follow the site care procedure with disposable inner cannula.

NOTE:
When changing the dressing or the drain sponge of your patient DO NOT cut gauze sponge to be used in
changing or cleaning the tracheostomy site, the possibility of the fiber to lodge into the stoma will place
the patient into the risk of infection and irritation, or causing respiratory distress when inhaled into the
trachea.
[Date]

https://www.youtube.com/watch?v=R54v1YDrmxM

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POST TEST

Time for Mental Exercise

1. The patient cough so hard that an accidental extubating of the tracheostomy tube
happened. Which of the following is the most appropriate thing to do?
a. Cover the stoma with a gauze and instruct the patient to hold it in place
b. Reinsert the tracheostomy tube into the stoma with an obturator
c. Pick the tracheostomy tube cleanse and reinsert immediately back into the stoma
d. Immediately notify the physician
2. Which of the following needs an emergency management and evaluation?
a. Accidental extubating of tracheostomy tube
b. Copious and very thick secretions that is hard to remove
c. Patient is unable to speak and keep on communicating through sign language
d. Bleeding at the site of tracheostomy tube
3. In the nursing note the nurse signify that there is an infection. Which of the following
assessment findings by the nurse verify this data?
a. Very soiled dressing and holder
b. Presence of pain as verbalized by the patient
c. Purulent discharge
d. Diminished air flow
4. Which of the following nursing diagnosis is appropriate for thick secretion that is hard to
cough out?
a. Impaired coughing reflex
b. Risk for aspiration
c. Ineffective airway clearance
d. Risk for infection
5. The nurse will perform tracheostomy care to an unconscious client. Which of the following
is not appropriate?
a. Explain the procedure and the reason for performing it.
b. Close the curtain and the door of the room before performing the procedure.
c. Place the patient in a semi-fowlers position to promote comfort
d. None of these
6. In stabilizing the outer cannula and faceplate which hand should the nurse use?
a. Dominant hand
[Date]

b. Nondominant hand

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c. Both hand
d. Hand nearest to the cannula

7. Which of the following will attest that the collar is properly fitted?
a. The patient can move the head sideways
b. One finger can slip between the neck and the collar
c. The patient is not complaining that the collar is too tight nor too loose.
d. The patient can create sound from the tube
8. You are to evaluate if the caregiver of your patient understands the instruction in
performing tracheostomy care at home. Which of the following will show an understanding
of the instruction?
a. Able to perform the procedure without assistance
b. Able to identify all the equipment needed for the procedure
c. Able to recite all the step by step procedure
d. Able to identify the emergency situations that may arise during the procedure
9. Which of the following action will ensure that the non-disposable inner cannula is locked in
place?
a. Rotate the inner cannula on a clockwise motion
b. Rotate the inner cannula on a counterclockwise motion
c. The tie and the holder are not loose nor tight
d. Inner cannula can be inserted back and forth freely
10. All of the following are necessary for tracheostomy care EXCEPT?
a. Sterile and non-sterile gloves
b. Sterile sponge gauze with raw edges
c. Sterile cotton-tipped applicator and sterile basin
d. Commercially prepared drain sponge

[Date]

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REFERENCE

Taylor’s Clinical Nursing Skills, 3rd Edition

Clinical Nursing Skills and Technique, Perry, Anne, Griffin

Brunner and Suddarth’s Textbook of Medical and Surgical Nursing, 12 th Edition, Lippincott, Williams,
and Wilkins (2020)

https://www.youtube.com/watch?v=R54v1YDrmxM

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REFERENCE

https://nurseslabs.com/tracheostomy-nursing

www.healthline.com › health › tracheostomy

https://www.hopkinsmedicine.org/tracheostomy/about/what.html

https://www.criticalcarepractitioner.co.uk/tracheostomy-care/

https://uihc.org/health-topics/tracheostomy-home-care

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