VISION

“MABINI COLLEGES shall

cultivate a CULTURE of
EXCELLENCE in Education.”

PERFORMANCE
CHECKLIST
TRACHEOSTOMY CARE

Name of Student______________________________________________________________________
Year/ Group : _____________________ School Year : ___________________________________
Semester /Term : First Semester _____________ Second Semester __________ Summer
____________

Competency Rate

1 - Unsatisfactory (75- 80) 4 - Very Satisfactory ( 91 – 95)

2 - Fair (81 – 85) 5 - Outstanding (96 – 100)
3 - Satisfactory (86 – 90)

Performance Points 5 4 3 2 1 CI’s Remarks

I – KNOWLEDGE (40%)
1. Defines Tracheostomy Care
2. State the purposes
3. Enumerate special considerations.
4. Identify materials/equipments needed.
5. State preparation of the patient.
6. State the principles/rationale behind specific
action.
II – SKILLS / ABILITY (40%)
1. Assess condition of stoma: [ redness, swelling,
character of secretions, presence of purulence
or bleeding].
2. Examine neck for subcutaneous emphysema
evidenced by crepitus around the ostomy site.
3. Explain procedure to the patient and teach
means of communication such as eye blinking or
raising a finger to indicate pain or distress.
4. Assist patient to a fowlers position and place
waterproof pad on chest.
5. Wash hands thoroughly
6. Assemble equipment’s;
a. Open the sterile tracheostomy kit, pour
Hydrogen peroxide and sterile normal
saline in separate gallipots.
b. Open other sterile supplies as needed
including sterile applicators, suction kit
and tracheostomy care kit
c. Put on face mask and eye shield.

7. Do sterile gloves. Place sterile towel on

patient's chest
8. Unlock the inner cannula and remove it by
gently pulling it out towards you in the line with
its curvature. Place the inner cannula in the bowl
with hydrogen peroxide suction
9. Remove the soiled tracheostomy dressing,
discard the dressing and gloves.
10. Clean the flange of the tube using sterile
applicators or gauze moistened with hydrogen
peroxide and then with normal saline. Use each
applicator once only.
11. Clean the stoma tube with the gauze Half
strength hydrogen peroxide may be used.
Thoroughly rinse the cleaned area using gauze
squares moistened with sterile normal saline.
12. Dry the stoma tube with dry sterile gauze. An
infected wound may be cleaned with gauze
saturated with an antiseptic solution, then
dried. A thin layer of antibiotic ointment may be
applied to the stoma with a cotton swab.
13. Cleaning the inner cannula
• Remove the inner cannula from the
soaking solution.
• Clean the lumen and entire cannula
thoroughly using the brush.
• Rinse the cleaned cannula by rinsing it
with sterile normal saline.

14. Replace the inner cannula and secure it in place

• Insert the inner cannula by grasping the
outer
• Lock the cannula in place by turning the
lock into position.
15. Apply sterile dressing.
• Open and refold a 4*4 gauze dressing
into a 'V' shape and place under the
flange on the tracheostomy tube. Do not
cut gauze pieces.
• Ensure that the tracheostomy tube is
securely supported while applying
dressing.
16. Change the tracheostomy ties.
• Leave the soiled tape in place until the
new one is applied
• Grasp slit end of clean tape and pull it
through opening on one side of the
tracheostomy tube.
• Pull the other end of the tape securely
thoroughly the slit end of the
tracheostomy tube on the other side.
• Tie the tapes at the side to side of the
neck in a square knot.
17. Document all relevant information in the chart
• Tracheostomy care carried out.
 • Dressing change and Observations.
III – ATTITUDE (20%)
1. Demonstrate preparedness, readiness and
confidence in the performance of the
procedure.
2. Accepts corrections/suggestions and shows
willingness to improve performance.
3. Answers questions politely and tactfully.
4. Shows respect and consideration of the
recipient of care.
5. Observe proper decorum and behave as a
mature student nurse.

Evaluated by: Conforme:

_____________________________ ______________________________
Signature over Printed Name / Date Signature over Printed
Name/Date
Clinical Instructor Student