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Care of a Patient With a Tracheostomy (102.109)

Care of a Patient With a Tracheostomy (102.109) - Policies, Clinical, UWMF Clinical, UWMF-wide, Clinical Policies and Procedures, Pulmonary

102.109

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UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE

TITLE: CARE OF A PATEINT WITH A TRACHEOSTOMY

Effective Date: April, 2002 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education

Reviewed October, 2003 March, 2005 February, 2008 May 2010 June 2012


PURPOSE: To provide guidelines for care of the patient with an artificial airway at UWMF Clinics.

POLICY: The clinical staff (RN or LPN) will utilize the following guidelines to care for patients with
tracheostomies.

The CMA may assist the RN or provider in providing tracheostomy care and suctioning a patient with a
tracheostomy, per the following procedure.

The CMA, under the direct supervision of the RN or provider, will utilize the following guidelines to provide
tracheostomy care and suctioning of a patient, only if the CMA has had specific training and has been deemed
competent in this task. However, responsibility for the procedure remains with the supervising RN or provider.

The RN, LPN, or CMA staff will utilize these guidelines to assist the provider when changing inner
tracheostomy cannulas and ties.

DEFINITION: The term “tracheotomy” refers to the incision into the trachea (windpipe) that forms a
temporary or permanent opening, which is called a “tracheostomy;” however; the terms are sometimes used
interchangeably. A tube is placed through this opening to provide an airway and to remove secretions from the
lungs. Breathing is done through the tracheostomy tube rather than through the nose and mouth.

SUPPLIES:
Suctioning:
Portable or wall suction, Y-connector, Standard sterile suction kit
OR individual supplies:
*Sterile suction catheter (appropriate size), Connecting tubing, Sterile water or saline, Sterile
gloves
Water-soluble lubricant, drape or towel, goggles, face shield or mask
Provider’s order, Patient’s record

*CATHETERS: Newborns 6-8 Fr
18 months 8-10 Fr
24 months 10 Fr
2-4 years 10-12 Fr
5-7 years 12 Fr
8-12 years 12-14 Fr
12+ years 12-16 Fr
Non-Disposable Inner Cannula Care:
Non-sterile gloves, sterile gloves, Tracheostomy Care Kit, Normal Saline,
Hydrogen peroxide (H2O2)


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Applying Clean Dressing:
Non-sterile gloves, cotton-tip applicator, sterile normal saline, hydrogen peroxide (H2O2),
Commercially-prepared tracheostomy dressing or pre-folded non-cotton-filled 4x4

Changing Ties:
Tracheostomy ties (Velcro or twill), scissors, fenestrated sterile 4x4 or 2x2.

PROCEDURE:

Suctioning a Tracheostomy

1. Check provider’s order and clarify any inconsistencies in the order.

2. Wash hands and gather equipment.

3. Introduce yourself and identify the patient. Include date of birth.

4. Provide good light and provide privacy by closing curtains or door.

5. Assess bilateral breath sounds, respiratory rate, and oxygen saturation (refer to pulse oximetry policy)-
do we want to note that they should document, in HL, these things?

6. Explain procedure and purpose for suctioning to patient.

7. Administer pain medication before suctioning (if indicated).

8. Assist patient to a semi-Fowler's or Fowler's position.

9. Turn suction to appropriate pressure:
a. Wall unit:
Adult: 100-120 mm Hg Child: 95-110 mm Hg Infant: 50 mm Hg

b. Portable unit
Adult: 10-15 mm Hg Child: 5-10 mm Hg Infant: 2-5 mm Hg

Note: Patients often have their own portable suction units and extra supplies.

10. Place clean towel, across patient's chest.

11. Put on goggles & mask or face shield, and gown.

12. Open sterile kit or set up equipment and prepare to suction:
a. Place sterile drape across patient's chest.
b. Open sterile container and place on table without contaminating inner surface.
c. Pour sterile saline into sterile container.
d. Hyper-oxygenate patient (to prevent hypoxia during suctioning): what should pulse ox reading be?
If patient is not receiving supplemental oxygen or aerosol, instruct him to take three to six
deep breaths.
If patient is receiving supplemental oxygen, evaluate his need for pre-oxygenation. If
indicated, instruct them to take three to six deep breaths while using his supplemental
oxygen.

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If patient is being mechanically ventilated, use the ventilator (rather than a handheld
resuscitation bag) to hyper-oxygenate and hyperinflate the lungs before suctioning.
e. Put on sterile gloves. Dominant hand that will handle catheter must remain sterile while nondominant
hand is considered clean (not sterile).
f. Connect sterile suction catheter to suction tubing with unsterile-gloved hand.

13. Moisten catheter by dipping catheter into saline filled sterile container.
Note: Unless catheter is silicone, which does not require lubrication.

14. Remove oxygen delivery setup with unsterile-gloved hand (if needed)

15. Turn suction machine on with non-sterile hand and test amount of suction by placing thumb over Y-port
opening at proximal end of suction catheter.

16. Using sterile gloved hand and with thumb off the Y-port, gently and quickly insert catheter into the
trachea. Advance about 10-12.5 cm (4-5 inches) or until patient coughs.

17. Apply intermittent suction by occluding Y-port with thumb of unsterile gloved hand. Gently rotate
catheter with thumb and index finger of sterile gloved hand as catheter is being withdrawn. Do NOT
allow suction to continue for more than 10 seconds.

18. Hyperoxygenate as described in section 12.b. between each suctioning or encourage patient to cough
and deep breathe.

19. Flush catheter with saline and repeat suctioning as needed or according to patient's tolerance. Allow
patient to rest at least 1 minute between each suctioning attempt, and replace oxygen delivery setup if
necessary.

20. When procedure is done, turn off suction macine and disconnect catheter from suction tubing.

21. Remove and dispose of gloves, catheter, and container in proper receptacle.

22. Adjust patient's position.

23. Wash hands.

24. Auscultate chest and breath sounds to assess effectiveness of suctioning.

25. Documentation (in Progress Notes section of HealthLink)
patient assessment prior to and after suctioning (character of patient's respirations, bilateral breaths
sounds, presence/absence of cough, etc.)
Patient vital signs; including oxygen saturation rate
patient education
time of suctioning, size of catheter
nature and amount of secretions
how patient tolerated procedure

24. Offer oral hygiene (if indicated).



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Replacing Non-Disposable Inner Cannula (if indicated).

1. Open tracheostomy care kit.

2. While maintaining sterility, fill both sections of the container with
normal saline
a. Only normal saline should be used for cleaning a metal
tracheostomy tube (H2O2 causes pitting of the metal inner
cannula)
b. Equal parts sterile normal saline and H2O2 may be used to loosen debris from inner cannulas of
reusable (not disposable) plastic inner cannulas, followed by normal saline rinse.

3. Apply sterile gloves.

4. Using your nondominant hand, remove and discard any dressing, disconnect the ventilator or oxygen
source (if applicable), and unlock the tracheosotmy tube’s inner annula by rotating it counterclockwise.
Place the inner cannula in the container sterile normal saline or 1:1 normal saline: H2O2 solution.

5. Working quickly, use your dominant hand to scrub the cannula with the sterile nylon brush. If the brush
doesn’t slide easily into the cannula, use a sterile pipe cleaner.

6. Immerse the cannula in the container of sterile normal rinse, and agitate it for about 10 seconds to rinse
it thoroughly.

7. Inspect the cannula for cleanliness. Repeat the cleaning process if necessary. If clean, tap it gently
against the inside edge of the sterile container to remove excess liquid and prevent aspiration. Do not
dry the outer surface because a thin film of moisture acts as a lubricant during insertion.

8. Reinsert the inner cannula into the patient’ tracheostomy tube. Lock it in place and then gently pull on it
to make sure it’s positioned securely. Reconnect the ventilator or oxygen source (if applicable).

9. Apply a new sterile tracheostomy dressing, if applicable

Note: If the patient can not tolerate being disconnected from the ventilator for the time it takes to clean
the inner cannula, replace the existing inner cannula with a clean one and re-attach the ventilator or
oxygen source. Then clean the cannula just removed form the patient, and store it in a sterile container
for use the next time.

10. Documentation (in Progress Notes section of HealthLink)
patient assessment and education
procedure performed and time of proceudre
how patient tolerated procedure

Applying Clean Dressing

1. Apply clean gloves.

2. Dip cotton applicator in saline and clean stoma under faceplate.

3. Use each applicator once, moving from stoma site outward.



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4. Apply hydrogen peroxide to area around stoma, faceplate, and outer cannula if secretions prove difficult to
remove.

5. Rinse area with saline.

6. Pat skin gently with a dry 4 x 4 gauze.

7. Slide commercially prepared tracheostomy dressing or pre-folded non-cotton-filled 4 x 4 dressing under
faceplate.

8. Documentation (in Progress Notes section of HealthLink)
patient assessment and education
procedure performed and time of procedure
condition of old dressing (presence of drainage, etc.)
how patient tolerated procedure

Changing Tracheostomy Ties

1. Obtain assistance from another nurse because of the risk of accidental tube expulsion during this procedure.
Patient movement or coughing can dislodge the tube. If you must perform the
procedure without assistance, fasten the clean ties in place before removing
the old ties to prevent tube expulsion.

2. Wash hands. Apply sterile gloves

3. Help the patient into semi-Fowler’s position

4. Velcro Ties:
a) Carefully remove the soiled ties from patient's neck while holding the tracheostomy tube steady. This is
done more easily with two people.
b) Thread fastener tabs through the flanges of the tracheostomy tube plate and secure to the soft material.
c) Place neck band around patient's neck. Secure Velcro strap so that it is secure to keep the tracheostomy
tube in place, but still able to place one finger between the patient's neck and the tie.
d) Apply clean, lint-free fenestrated dressing under tracheostomy site to absorb secretions. A thumb
forceps or a cotton swab applicator may be used to help slide the dressing into place.

5. Twill Ties:
a) Cut a length of twill slightly more than double the length of the back of the patient's neck from flange to
flange.
b) Carefully remove the soiled ties from patient's neck while holding the tracheostomy tube steady. This is
done more easily with two people.
c) Place the end of the clean tie under the flange and thread it through the hole from the bottom to top of
the flange. Thumb forceps can be used to pull the end of the tie through the hole. Pull the twill tie so
the ends are equal. Bring both ends around the back of the neck to the other flange


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d) Thread the end of the tie through the other side of the tracheostomy tube from underneath and tie using a
square knot (NEVER USE A BOW). The ties should be tight enough to keep the tracheostomy tube in
place, but loose enough to place one finger between the patient's neck and the ties.
e) Apply clean, lint-free fenestrated dressing under tracheostomy site to absorb secretions. A thumb
forceps or a cotton swab applicator may be used to help slide the dressing into place.
6. Documentation (in Progress Notes section of HealthLink)
patient assessment and education
procedure performed and time of procedure
how patient tolerated procedure

WRITTEN BY: Ronnie Peterson, R.N., M.S, Manager of Clinical Support

REVISED BY: Carol Decker, RN, MSN, Clinical Staff Educator

REVIEWED BY: Karen Rivera, RN, Pulmonary Clinic, 2010

REFERENCES:
Kowalak, J. P. (Ed.). (2009).Lippincott’s nursing procedures (5th ed.). Ambler, PA: Lippincott Williams & Wilkins.

UWHC Departmental Policy 7.19. (September 1, 2010). Care of the patient with a tracheostomy tube, adult and pediatric.
In Nursing Patient Care, Section: 7.

AUTHORIZATION:


Medical Director Date