A tracheostomy is an opening into the trachea through the neck just below the larynx through which an indwelling tube is placed and thus an artificial airway is created. It is used for clients needing long-term airway support. Show
Tracheostomy tubes have an outer cannula that is inserted into the trachea and a flange that rests against the neck and allows the tube to be secured in place with tape or ties. Tracheostomy tubes also have an obturator which is used to insert the outer cannula which is then removed afterwards. The obturator is kept at the client’s bedside in case the tube becomes dislodged and needs to be reinserted. Nurses provide tracheostomy care for clients with new or recent tracheostomy to maintain patency of the tube and minimize the risk for infection (since the inhaled air by the client is no longer filtered by the upper airways). Initially a tracheostomy may need to be suctioned and cleaned as often as every 1 to 2 hours. After the initial inflammatory response subsides, tracheostomy care may only need to be done once or twice a day, depending on the client.
Definition of Terms
Components of Tracheostomy Tube
All remaining features are optional
Providing Tracheostomy CarePurposes
Assessment
Planning Tracheostomy care involves application of scientific knowledge, sterile technique, and problem solving, and therefore needs to be performed by a nurse or respiratory therapist. Equipment
Procedure This well-organized, fixed, step-by-step sequence of the whole process of tracheostomy care is taken from Kozier & Erb’s Fundamentals of Nursing. 1. Introduce self and verify the client’s identity using agency protocol. Explain to the client everything that you need to do, why it is necessary, and how can he cooperate. Eye blinking, raising a finger can be a means of communication to indicate pain or distress. 2. Observe appropriate infection control procedures such as hand hygiene. 3. Provide for client privacy. 4. Prepare the client and the equipment.
5. Suction the tracheostomy tube, if necessary.
6. Clean the inner cannula.
7. Replace the inner cannula, securing it in place.
8. Clean the incision site and tube flange.
9. Apply a sterile dressing.
10. Change the tracheostomy ties.
Two-Strip Method (Twill Tape)
One-Strip Method (Twill Tape)
11. 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. Rationale: This reduces skin irritation from the knot and prevents confusing the knot with the client’s gown ties. 12. Check the tightness of the ties. Frequently check the tightness of the tracheostomy ties and position of the tracheostomy tube. Rationale: Swelling of the neck may cause the ties to become too tight, interfering with coughing and circulation. Ties can loosen in restless clients, allowing the tracheostomy tube to extrude from the stoma. 13. Document all relevant information. Record suctioning, tracheostomy care, and the dressing change, noting your assessments. Sample Documentation 12/23/2012 0900 Respirations 18-20/min. Lung sounds clear. Able to expectorate secretions requiring little suctioning. Large amount of thick secretions cleansed from inner cannula. Inner cannuLa changed. Trach dressing changed. Skin around trach is intact but slightly red in color 0.2 cm around entire opening. No broken skin noted in the reddened area. — G. Wayne, RN Variation: Using a Disposable Inner Cannula
Lifespan Considerations Infant and Child
Home Care Modifications
Suctioning a Tracheostomy TubeSuctioning of tracheostomy tube is only done as necessary. Sterile technique must be observed. Nurses should be aware that there is a frequency for the need of suctioning during immediate postoperative period. Purposes
Assessment
Planning Suctioning a tracheostomy or endotracheal tube is a sterile, invasive technique requiring application of scientific knowledge and problem solving. This skill is performed by a nurse or respiratory therapist and is not delegated to UAP. Equipment
Preparation Determine if the client has been suctioned previously and, if so, review the documentation of the procedure. This information can be very helpful in preparing the nurse for both the physiologic and psychologic impact of suctioning on the client Procedure This well-organized, fixed, step-by-step sequence of the whole process of tracheostomy suctioning is taken from Kozier & Erb’s Fundamentals of Nursing. 1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Inform the client that suctioning usually causes some intermittent coughing and-that this assists in removing the secretions. 2. Perform hand hygiene and observe other appropriate infection 3. Provide for client privacy. 4. Prepare the client. If not contraindicated because of health, place the client in the semi-Fowler’s position to promote deep breathing, maximum lung expansion, and productive coughing. Rationale: If necessary, provide analgesia before suctioning. Endotracheal suctioning stimulates the cough reflex, which can cause pain for clients who have had thoracic or abdominal surgery or who have experienced traumatic injury. Rationale: Premedication can increase the client’s comfort during the suctioning procedure. 5. Prepare the equipment.
6. Flush and lubricate the catheter.
7. If the client does not have copious secretions, hyperventilate the lungs with a resuscitation bag before suctioning.
Variation: Using a Ventilator to Provide Hyperventilation If the client is on a ventilator, use the ventilator for hyperventilation and hyperoxygenation. Newer models have a mode that provides 1 0 0 % oxygen for 2 minutes and then switches back to the previous oxygen setting as well as a manual breath or sigh button. Rationale: The use of ventilator settings provides more consistent delivery of oxygenation and hyperinflation than a resuscitation device. 8. If the client has copious secretions, do not hyperventilate with a resuscitator. Instead:
9. Quickly but gently insert the catheter without applying any suction.
10, Perform suctioning.
11. Reassess the client’s oxygenation status and repeat suctioning.
12. Dispose of equipment and ensure availability for the next suction.
13. Provide for client comfort and safety.
14. Document relevant data. Record the suctioning, including the amount and description of suction returns and any other relevant assessments. Sample Documentation 12/23/2012 1000 Coarse rales in RLL and LLL. Requires suctioning every 1-2 hrs. Obtain large amount of pinkish tinged white thin mucous via ETT. Breath sounds clearer after suctioning. Pt. signals when he wants to be suctioned. — J. Roberts, RN Variation: Closed Airway/Tracheal Suction System (In-Line Catheter)
Lifespan Considerations Infant and Child
Home Care Considerations
Dealing with EmergenciesIf the tracheostomy tube falls out
Patient is having Acute Dyspnea Acute dyspnea for patient with tracheostomy is most commonly caused by partial or complete blockage of the tracheostomy tube retained secretions. To unblock the tracheostomy tube:
It is possible that the tracheostomy may have become displaced. Stay with the patient until assistance arrives. Prepare for change of tracheostomy tube. Patient needing Cardiopulmonary Resuscitation In the event of cardiopulmonary arrest, treat tracheostomy patients as other patients:
Which nursing actions are included when providing tracheostomy care to a patient?Routine tracheostomy management consists of:. Equipment & environment.. Supervision and monitoring.. Humidification.. Suctioning.. Management of abnormal secretions.. Tracheostomy tube tie changes.. Tracheostomy tube changes.. Stoma care.. Which nursing actions are included when providing tracheostomy care to a patient quizlet?Terms in this set (19). Auscultate the lungs and check the heart rate.. Prepare by turning suction on to between 80 and 120 mm Hg pressure.. Hyper oxygenate using 100% oxygen.. Don sterile gloves.. Guide the catheter into the tracheostomy tube using a sterile-gloved hand.. What is the primary nursing responsibility with a trach patient?Nurses provide tracheostomy care for patients to maintain the integrity of the tracheostomy tube and lower the risk of infection. This is partly because air inhaled by the patient is no longer filtered by their upper airways.
Which action should the nurse take first when performing tracheostomy care?Which nursing action must be taken first? The first nursing action for a patient following an airway procedure is to assess the patient's respiratory status; this requires auscultation of the lungs. Suction is not needed if the lungs are clear to auscultation.
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