OLIVAREZ COLLEGE

Dr. A. Santos Avenue, San Dionisio, Parañaque City

PACUCOA Accredited
COLLEGE OF HEALTH SCIENCES EDUCATION
NURSING DEPARTMENT
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Student Name: ___________________________________________ Score: _________________________

Level and Group No.: ______________________________________ Date: ________________________
Directions: Evaluate each step/task by putting (✔) under the proper heading. A numerical number may also be assigned &a minimum passing level determined.
Rate the students from 2 - 0, where:
(2) Performed Correctly Students performed the step according to the standard procedure or guidelines
(1) Attempted Not CorrectlyStudents unable to perform the steps/task according to procedure or guidelines
(0) Not Done Students did not do the step/task
(NO) Not Observed (NO) Evaluator unable to observe the step/task for various reasons like interruptions/inattentiveness.

Checklist on Tracheostomy Care

STEPS Performed Performed Not Done Not

Correctly but not (0) Observed
(2) Correctly (NO)
Done
(1)

1. Prior to performing the procedure, introduce self and verify

the client’s identity using agency protocol
2. Prepare the equipment. (Trach- Care Set )
● Tracheostomy gauze dressing
● Inner Cannula clean
● 34” Twill tape (Tracheostomy ties/Velcro )
● 4 gauze sponges, 4” x 4”
● 3 cotton-tipped applicators
● Tracheostomy brushes/pipe cleaners.
● 1 pair gloves
● 1 water-resistant towel
● 2 packets hydrogen peroxide, 30mL
● 2 Two small plastic containers or bowls
● Sterile water / Sterile NSS
● 1 Tracheostomy pad protects patient skin from irritation and absorbs
leakage around surgical sites.
3. Perform hand hygiene and observe other appropriate
infection control procedures (e.g., gloves, goggles).
4. Explain the procedure.

5.Ensure privacy, prepare & position the patient correctly for the
procedure.
6. Don clean gloves

7. Suction the tracheostomy tube, if necessary.

8. Open the Tracheostomy care set / prepare a sterile field

9. Pour hydrogen peroxide and sterile water or normal saline into one of the
clean containers. This makes a 1/2 strength solution. Pour sterile water or
normal saline into the second container. ( For Cleaning the inner cannula)
10. Remove the inner cannula securing it in place.
● Place two fingers of one hand on the neck plate of the trach. With
the other hand, unlock the inner cannula by turning it counter
clockwise or by unsnapping the side clips of a disposable type. Now
gently pull it out.
●
● Lock a disposable inner cannula by squeezing the side clips open
and snapping it into place.
11. Clean the inner cannula.
● Place the used inner cannula into the 1/2 strength solution of
hydrogen peroxide. Let it soak for a few minutes. Clean the inside
and outside of the inner cannula with the small brush or pipe
cleaners.
● Next rinse the inner cannula by putting it into the saline or water
container and gently swirl the tube for about 10 seconds. Shake off
excess water/saline. Place it on a clean white towel and allow it to
air dry.
12.Change the drain sponge/ dressing .
Change this daily but more often as it becomes wet, to avoid skin problems
13. Place the clean inner cannula
● The two blue dots should be lined up with each other when
correctly locked.
14.Clean the incision site and tube flange.
Clean skin around tracheostomy. Soak the cotton tipped applicators in the
hydrogen peroxide mixture for 10 seconds. Using the soaked cotton tipped
applicators, clean around the trach tube using a sweeping motion in one
direction.
15. Inspect the skin of the entire neck and throat area. Look for redness or
sores. Replace the tracheostomy dressing.
16. Change the tracheostomy ties.
● When changing a trach tie, never let go of the trach tube. Remove one side
of the tie at a time.
● Keep one hand on the neck plate while the other unfastens the tie. Remove
one side of the tie, thread the new one through this side and fasten.
● Unfasten the other side, remove, thread the rest of the new one and fasten
securely.
17. Tape and pad the tie knot.
Place a folded 4-in. x. 4-in. gauze square under the tie knot, and apply tape
over the knot.
18. Check the tightness of the ties.
Frequently check the tightness of the tracheostomy ties and position of the
tracheostomy tube.
19. Throw out used supplies and pour cleaning solutions into the toilet.

20. Clean containers or bowls with warm, soapy water and then rinse in
warm water. Allow them to air dry.
21. Remove gloves and wash hands

22. Document all relevant information.

Computation for student rating:
Raw score X 60 + 40
Perfect score
Student’s Signature and Date: _____________________________
Signature of Clinical Instructor and Date: ______________________

Remarks:
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