1. To provide the patient with an open air passage by preventing encrustation and obstruction.

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1 I. Care of the Patient with A Tracheostomy A. Purpose: 1. To provide the patient with an open air passage by preventing encrustation and obstruction. 2. To aid in bronchial hygiene by facilitating removal of secretions. 3. To promote healing of the wound, by keeping area clean. B. Special Notes and Precautions: 1. Precautions: a. anoxia as evidenced by air hunger, cyanosis and/or tachycardia. b. bronchospasm wheezing c. irritation to tracheal mucosa as evidenced by bleeding. d. coughing spasms 2. The critically ill patient may not be strong enough to cough vigorously and warn you of bronchial plugging. 3. Excessive secretions which may be slightly blood tinged can be expected during the first few days following a tracheostomy. Any fluids, blood, secretions, excretions must be removed by aspiration. Minimal amounts of secretions are essential. If not present, the humidification is not adequate. 4. A sterile catheter kit is needed for each suction procedure. 5. If naso-oral suction is indicated, then a second catheter will be needed for tracheal suction. Do not use the same catheter for both areas. I. Care of the Patient with A Tracheostomy (cont d) 6. Pre-oxygenate prior to suctioning. Aspirate only when necessary. Excessive suction may cause bleeding, spasm or increased secretions. Suction adults no longer than 15 seconds and children for 5 seconds. Keep an ambu-bag at bedside to provide rapid re-oxygenation following suction. 7. Inflate tracheostomy cuff while patient is on a ventilator or positive pressure machine, while being tube fed or when specified by the doctor. Low pressure cuffs (Portex and Shiley tubes) can be inflated for prolonged periods with minimal danger. Check with the doctor for specific orders. 8. Care of equipment: a. rinse suction tubing thoroughly.

2 b. empty and clean suction bottle when half full. 9. Charting Note time of procedure, condition of stoma, whether ties were changed, patient s respiratory rate, and character of sputum, on nurses notes. 10. Additional comments: a. Additional humidity may be given to prevent irritation of tracheal mucosa. This must be ordered by the physician. b. Oxygen may be given by tracheal collar or T-tube as ordered by the doctor. c. Only the physician may change the tracheostomy tube provide proper size trachea tube, sterile gloves and hemostat, dressing and ties. d. When tube feeding, inflate cuff of trachea and elevate head of bed to prevent aspiration keep cuff inflated via MLT (minimal leak technique) and bed elevated for 30 minutes following feeding. e. Suction mouth and pharynx area prior to deflating cuff to prevent trapped secretions from entering lower trachea. f. Tenacious secretions can best be removed by instilling sterile saline into the trachea prior to suction. Use 5-10cc for adults, and 1-3cc for children. Suction immediately. 5 ml single use ampules of sterile N/S may be obtained from Respiratory Therapy for lavage. h. Bottles of normal saline used for irrigating catheters must be changed every twenty-four hours. Bottle should be tagged and labeled with time and date changed. II. Tracheostomy Care (Disposable Inner Cannula) A. Equipment: Suction catheter kit Hyrdogen peroxide Ambu-bag Inner Cannula (appropriate size check for size number) B. Procedure: 1. Assemble equipment and wash hands. a. Open 4 x 4 s and moisten some with hydrogen peroxide and some with sterile saline. b. Open catheter suction kit. 2. Suction inner cannula. a. See suctioning procedure. 3. Remove inner cannula. a. Gently unlock inner cannula by pinching wings.

3 b. Remove inner cannula by pulling out support trachea with other hand if necessary. c. Disposable inner cannula can be discarded. 4. Suction outer cannula. a. Suction only to end of cannula-not necessary to suction trachea again. 5. Replace inner cannula with new cannula. Pinch wings to lock in place. 6. Change trachea dressing. a. Gently remove dressing while holding tracheostomy tube in place. If the dressing is adhered to the skin or tube, moisten with saline. b. Clean area with gauze moistened with peroxide solution. Rinse with gauze moistened with saline and dry. Apply an iodophor swab around trachea tube. (optional) c. Replace dressing. d. Check ties for cleanliness and looseness. Tie securely but loose enough to prevent choking or trauma to wound. When changing trachea ties-secure new ties before removing old ones. e. Do not change ties on new tracheas until after (72) hours. III. Tracheostomy Care (Non-Disposable Inner Cannula) A. Equipment: Disposable tracheostomy care kit Suction catheter kit Hydrogen peroxide Ambu- bag 1. Assemble equipment and wash hands. a. Open trachea care tray and pour hydrogen peroxide into sterile cup. Dilute with equal amount of sterile saline. b. Open catheter suction kit. 2. Suction inner cannula See suctioning procedures. 3. Remove and clean inner cannula. a. Gently unlock inner cannula, remove and place in cup containing peroxide. b. Clean inner cannula with pipe cleaner or sterile tracheostomy brush. Rinse thoroughly with sterile saline. c. Place in sterile cup or on tracheostomy care tray. 4. Suction outer cannula. a. Suction only to end of cannula not necessary to suction trachea again. 5. Replace inner cannula with new cannula. Lock in place. 6. Change trachea dressing.

4 a. Gently remove dressing while holding tracheostomy tube in place. If the dressing is adhered to the skin or tube, moisten with saline. b. Clean area with gauze soaked in peroxide solution. Rinse with gauze soaked in saline and dry. Apply Betadine (iodophor), swab around tracheostomy tube. (Optional) c. Replace dressing. d. Check ties for cleanliness and looseness. Tie securely but loose enough to prevent choking or trauma to wound. When changing tracheostomy ties secure new ties before removing old ones. e. Do not change ties on new tracheostomy until after (72) hours. IV. Tracheostomy Suction: A. Tracheostomy Suction (Disposable and Non-Disposable Inner Cannula) B. Equipment: Suction Catheter Kit Ambu bag C. Procedure: 1. Explain the procedure to the patient and family to allay their fears. 2. Assemble equipment and wash your hands. a. Open the sterile catheter kit without contaminating. b. Pour sterile saline into sterile cup for irrigating the catheter. c. Turn on suction. Use moderate suction (80mm 120mmHg for adults; 60mm 80mmHg for infants). d. Glove both hands with sterile gloves. e. Connect catheter to suction tubing Do not let tip of the catheter touch anything the but interior of the tracheostomy tube to prevent introducing infection deep into the lungs. f. With the gloved hand that will be the unsterile hand, pre-oxygenate the patient with 4-5 deep breaths. 3. Suction the inner cannula. a. Insert catheter without suction until resistance is met. Cough may be stimulated. Withdraw 1-2 cm and apply suction. Rotate the catheter as you withdraw. By doing so, mucous is aspirated from multiple areas in the trachea. If the catheter tip should adhere to the mucosal lining of the trachea, release suction immediately to prevent tissue trauma. b. Allow the catheter to remain in the trachea less than 15 seconds (5 seconds for infants) as suctioning decreases the patient s intake of air and obstructs the flow of expired air. c. AMBU the patient 4-5 deep breaths of 100% oxygen to replace O2 quickly or place patient back on ventilator. d. Clear the catheter by suctioning sterile saline through it. e. Repeat suctioning only if excessive secretions remain.

5 IV. Tracheostomy Suction (cont d): 4. Charting: a. Record frequency of suctioning. Character of secretions and any unwanted reactions of the patient on nurses notes. b. Report immediately signs of anoxia or other complications to physician. c. Care plan should include frequency and times of suctioning V. Care of Patient with Tracheostomy by Non-Nursing Areas A. Purpose: To provide continuity of care and minimize infection while the patient with tracheostomy is in non-nursing area. B. Procedure: Action Key Points/Rationale 1. If patient complains of difficulty 1.1 Maintain open airway on in breathing, choking or gagging, patient. IMMEDIATELY elevate head of bed and summon help from a physician, nurse, or a respiratory therapy. 2. DO NOT touch or remove a sterile 2.1 This may allow bacteria dressing or tracheostomy tube. to enter the area. 3. Be aware that the patient may not 3.1 Maintain communication be able to speak. Provide with with patient. pencil and paper if necessary to enable patient to communicate. 4. Patient may be unable to control 4.1 See Universal Precautions. secretions via the tracheostomy. Provide tissues for patient. Wear gloves when handling secretions. spread of 5. Proper handwashing is essential 5.1 To prevent the for all employees caring for the patient before and after patient contact. infection.

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