COLLEGE OF NURSING

Silliman University
Dumaguete City

CARE OF PATIENT WITH TRACHEOSTOMY

Definition: The care of a patient with an opening into the trachea, usually between the third and the
fourth tracheal ring, with an insertion of the tracheostomy tube for the purpose of
alleviating respiratory obstruction as means of respiration, and/or to facilitate the
removal of tracheobronchial secretions. The tracheostomy may be temporary or
permanent.

Purposes:
1. To suction and clear the tracheostomy.
2. To provide correct and safe care.
3. To maintain functionality of the tracheostomy.

Equipment:

1. Content of tracheostomy care tray.

A. Sterile towel with supplies:

Several 4 x 4 inch gauze squares

2 small enamel basins
Cotton swabs/tracheostomy brush/pipe cleaners
Cleaning forceps
Suction catheter: Fr. 12 – 14 (adult)
Fr. 5 – 8 (child)

B. Outside tray:

Picking forcep
Sterile gloves
Waste receptacle
Ties
Small towel
Medicinal glass and dropper (or 2cc syringe)
Sterile cotton balls

2. In patient bedside:

Extra tracheostomy set or sterile hemostat

Bottle of hydrogen peroxide
Bottle of sterile water
Bottle of normal saline or Zephiran Chloride
Plaster
Portable suction machine with tubing and a bottle of sterile water for flushing suction catheter.
 STEPS RATIONALE
ASSESSMENT

1. Observe for signs and symptoms of need to Signs and symptoms are related to presence of
perform tracheostomy care: excess peristomal secretions at the stoma site or within the
secretions, excess intratracheal secretions, tracheostomy tube.
soiled or damp tracheostomy dressing,
diminish airflow through tracheostomy tube or
signs and symptoms of airway obstruction
requiring suctioning.

2. Observe for factors (eg. hydration, humidity, Allows nurse to accurately assess the need to
infections, nutrition and ability to cough) that perform tracheostomy care.
normally influence tracheostomy airway
functioning.

3. Assess patient’s understanding of and ability Allows nurse to identify potential need for
to perform own tracheostomy care. instruction.

4. Check when tracheostomy care was last Tracheostomy care is provided at least every 8 to
performed. 12 hours and more often if indicates (e.g. increase
airway secretions, infecton [airway or stoma],
increased sections around stoma).
NURSING DIAGNOSIS

Nursing Diagnoses

Ineffective airway clearance

Risk for aspiration
Ineffective breathing pattern
Impaired gas exchange
Risk for infection
Deficient knowledge regarding airway clearance
techniques and devices
Impaired swallowing
Impaired spontaneous ventilation

Related factors are individualized based on

patient’s condition or needs.

PLANNING

1. Identify expected outcomes:

Inner cannula and outer cannula of Tracheostomy tube is patent and secure.
Tracheostomy tube that is clear and free of
tracheostomy tube are free of secretions;
secretions optimizes the amount of oxygen
ties are clean, secured snugly and tied in delivered to patient and limits risk of infection
double square knot.
from retained secretions.
Indicates absence of infection and stoma site. Dry,
Stoma site is pink, does not bleed and is intact tracheostomy stoma reduces risk of
free of secretions. subsequent systemic infection.
Prevents accidental extubation of tracheostomy
2. Have another nurse or family member assist in tube.
the procedure.
Encourages cooperation, minimizes risks and
3. Explain procedure and patient’s participation. reduces anxiety.
 Promotes patient comfort and prevents nurse
4. Assist patient to position comfortably for both muscle strain.
nurse and patient (supine or semi-Fowler’s).
Reduces transmission of microorganisms.
5. Place towel across patient’s chest.

IMPLEMENTATION
Reduces transmission of microorganisms.
1. Wash hands. Don gloves and face shield if
applicable.
Removes secretions to avoid occluding outer
2. Suction tracheostomy. Before removing cannula while inner cannula is removed. Reduces
gloves, remove soiled tracheostomy dressing need for patient to cough.
and discard gloves with coiled catheter.
Prepares equipment and allows for smooth,
3. While patient is replenishing oxygen stores, organized completion of tracheostomy care.
prepare equipment on bedside table. Open
sterile tracheostomy kit. Open three 4 x 4 inch
gauze packages using aseptic technique and
pour normal saline on one package and
hydrogen peroxide on another. Leave third
package dry. Open two cotton-tripped swab
packages and pour normal saline on one
package and hydrogen on the other. Open
sterile tracheostomy dressing package.
Unwrap sterile basin and pour about 0.5 to 2
cm level (1/2 inch) hydrogen peroxide into it.
Open small sterile brush package and place
aseptically into sterile basin. If using large roll
of twill tape, cut appropriate length of tape
(see Step 14) and lay aside in dry area. Do not
recap hydrogen peroxide and normal saline.
Reduces transmission of microorganisms.
4. Wear gloves. Keep dominant hand sterile
throughout the procedure.

Critical Decision Point

For tracheostomy tube with no inner
cannula or Kistrier button, complete steps
10 to 22.
Removes inner cannula for cleaning. Hydrogen
peroxide loosens secretions from inner cannula.
5. Remove oxygen source and then inner cannula
with non-dominant hand. Drop inner cannula
into hydrogen peroxide basin. Maintains supply of oxygen to patient.
6. Place tracheostomy collar. T-tube on
ventilator oxygen source over outer cannula.

Critical Decision Point

T-tube and ventilator oxygen devices
cannot be attached to all outer cannulas
when the inner cannula is removed​. Tracheostomy brush provides mechanical force to
remove thick or dried secretions.
7. To prevent oxygen desaturation in affected
patients, quickly pick up inner cannula and
 use small brush to remove secretions inside
and outside inner cannula. Removes secretions and hydrogen peroxide from
inner cannula.
8. Hold inner cannula over basin and rinse with
normal saline, using non-dominant hand to
pour normal saline. Secure inner cannula and reestablishes oxygen
supply.
9. Replace inner cannula and secure “locking”
mechanism, if applicable. Reapply
tracheostomy collar, T-tukbe (Briggs), or
ventilator oxygen source.

TRACHEOSTOMY STOMA and

FACEPLATE
(includes with no inner cannula) Aseptically removes secretions from stoma site.
Moving in outward circle pulls mucus and other
10. With hydrogen peroxide-saturated contaminants from stoma to periphery.
cotton-tipped swabs and 4 x 4 inch gauze,
clean exposed outer cannula surfaces and
stoma under faceplate extending 5 to 10 cm (2
to 4 inches) in all directions from stoma.
Clean in circular motion from stoma site
outward using dominant hand to handle sterile Rinses hydrogen peroxide from surfaces. If not
supplies. removed from skin, hydrogen peroxide can
promote tissue injury.
11. With normal saline-saturated cotton-tipped
swabs and 4 x 4 inch gauze, rinse with
hydrogen peroxide tracheostomy tube and skin Dry surface prohibit formation of moist
surfaces. environment for microorganism growth and skin
excoriation.
12. With dry, 4 x 4 inch gauze, pat lightly at skin
and exposed outer surfaces.
Promotes hygiene and reduces transmission of
TRACH TIES AND DRESSING CHANGE microorganisms. Secures tracheostomy tube,
reduces risk of incidental extubation.
13. Instruct assistant, if available, to apply gloves
and securely hold tracheostomy tube in place.
With assistant holding tracheostomy tube, cut
ties. (Follow manufacturer’s guidelines for
Velcro ties. Be sure to cut off excess ties if
applicable)

Critical Decision Point

Assistant must not release hold on
tracheostomy tube until new ties are firmly
tied. If working without an assistant, do
Cutting ends of tie on diagonal aids in inserting tie
not cut old ties until new ties are in place through eyelet.
and securely tied.

14. Cut a length of twill tape and long enough to

go around patient’s neck two times (along 24
to 30 inches for an adult), cut ends on
diagonal.

15. Insert one end of tie through faceplate eyelet

and pull ends even.
16. Slide both ends of tie behind the head and Ensures tracheotomy will not come out.
around neck to other eyelet and insert one tie
to second eyelet. One finger-length of slack prevents ties from
being too tight when tracheostomy dressing is in
17. Pull snugly. place and also prevents movement of
tracheostomy tube in lower airway.
18. Tie ends securely in double square knot,
allowing space for only one loose or two snug
finger(s) in tie. (see illustration)

Absorbs drainage. Dressing prevents pressure on

clavicle heads.

19. Insert fresh tracheostomy dressing under clean

ties and faceplate.

Promotes comfort. Some patients may require

post-tracheostomy care suctioning.

Reduces transmission of microorganisms.

Contaminated gloves should not touch clean
20. Position patient comfortably and assess supplies.
respiratory status. Once opened, normal saline can be considered
free of bacteria for 24 hours, after which it should
21. Remove gloves and face shield and discard in be discarded.
appropriate receptacle.
Reduces transmission of microorganisms.
22. Replace cap on hydrogen peroxide and normal
saline bottles. Store reusable liquids and
unused supplies in appropriate place.
Determines effectiveness of tracheostomy care.
23. Wash hands.

EVALUATION Tracheostomy ties are uncomfortable and place

patient at risk of injury when they are too tight.
1. Compare assessment before and after Presence of secretions on cannulas indicates the
tracheostomy care. need for more vigorous tracheostomy care.
Broken skin places patient at risk for infection.
2. Assess comfort of new tracheostomy ties. Stomal infection necessitates change in
tracheostomy skin care plan.
3. Inspect inner and outer cannula for secretions.
4. Assess stoma for signs of infection or skin
breakdown.

RECORDING AND REPORTING

1. Chart in Kardex type and size of tracheostomy

tube, frequency of tracheostomy care, special
care in event of stomatitis.

2. Record in nurse’s notes assessments, supplies

used, frequency and extent of tracheostomy
care patient’s tolerance of procedure.

3. Report any changes in respiratory status.

UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS

Excessively loose or tight tracheostomy ties.

● Adjust ties or apply new ties.

Stomatitis
● Increase frequency of tracheostomy care.
● Consider intermittent application of heat to increase blood flow and promote healing.
● Apply topical antibacterial solution and allow it to dry and provide bacterial barrier.
● Apply hydrocolloid or transparent dressing just under the stoma to protect skin from
breakdown. Consult with a skin care specialist.

Pressure area around tracheostomy tube.

● Call for assistance.
● Replace old tracheostomy tube with new tube. Some experienced nurses or respiratory
therapists may be able to frequently reinsert tracheostomy tube. Be sure to keep spare
tracheostomy tube of the same size and kind at bedside in event to emergency replacement.
Same size ET tube can be inserted in stoma in an emergency.
● Be prepared to manually ventilate patients in whom respiratory distress develops.
● Notify the physician.

Respiratory distress from mucous plug of cannula.

● Remove inner cannula, if applicable for cleaning, or cannula can be suctioned.
● Notify physician or specially trained personnel if tracheostomy tube requires replacement.

TEACHING CONSIDERATIONS

Different types of tracheostomy tubes has different faceplates. Some are rigid, others are not.
Instruct caregivers not to lift up on rigid faceplates or they may dislodge tube.
Some commercial tracheostomy tube holders require removal of excess tie material to fit
properly.
If long-term placement of tracheostomy is anticipated, nurse should plan to teach patient and
family tracheostomy care.
Patients with new tracheostomy frequently have blood secretions for 2 to 3 days after procedure
or for 24 hours each tracheostomy change.
Student: _________________________________

Instructor: _______________________________

Instructor’s Signature: ____________________ Date: ____________

PERFORMANCE CHECKLIST CARE OF PATIENT WITH TRACHEOSTOMY

Preparation Excellent Satisfactory Below Needs Major Remarks

atisfactory Remediation

( 4) (3) (2) (1)

ASSESSMENT

1. Observes for signs and symptoms of

need to perform tracheostomy care:
excess peristomal secretions, excess
intratracheal secretions, soiled or damp
tracheostomy dressing, diminish airflow
through tracheostomy tube or signs and
symptoms of airway obstruction
requiring suctioning.
2. Observes for factors (eg. hydration,
humidity, infections, nutrition and
ability to cough) that normally influence
tracheostomy airway functioning.
3. Assesses patient’s understanding of and
ability to perform own tracheostomy
care.
4. Checks when tracheostomy care was
last performed.
NURSING DIAGNOSIS

Developed appropriate nursing diagnoses

based on assessment data.
PLANNING

1. Identifies expected outcomes:

Inner cannula and outer cannula of
tracheostomy tube are free of
secretions; ties are clean, secured
snugly and tied in double square
knot.
Stoma site is pink, does not bleed
and is free of secretions.
2. Have another nurse or family member
assist in the procedure.
3. Explains procedure and patient’s
participation.
4. Assists patient to position comfortably
for both nurse and patient (supine or
semi-Fowler’s).
5. Places towel across patient’s chest.
IMPLEMENTATION

1. Washes hands. Don gloves and face

shield if applicable.
2. Suctions tracheostomy. Before
removing gloves, remove soiled
tracheostomy dressing and discard
gloves with coiled catheter.

3. While patient is replenishing oxygen

stores, prepare equipment on bedside
table. Open sterile tracheostomy kit.
Open three 4 x 4 inch gauze packages
using aseptic technique and pour
normal saline on one package and
hydrogen peroxide on another. Leave
third package dry. Open two
cotton-tripped swab packages and pour
normal saline on one package and
hydrogen on the other. Open sterile
tracheostomy dressing package.
Unwrap sterile basin and pour about
0.5 to 2 cm level (1/2 inch) hydrogen
peroxide into it. Open small sterile
brush package and place aseptically
into sterile basin. If using large roll of
twill tape, cut appropriate length of
tape (see Step 14) and lay aside in dry
area. Do not recap hydrogen peroxide
and normal saline.
4. Wears gloves. Keep dominant hand
sterile throughout the procedure.
5. Removes oxygen source and then inner
cannula with non-dominant hand. Drop
inner cannula into hydrogen peroxide
basin.
6. Places tracheostomy collar. T-tube on
ventilator oxygen source over outer
cannula.
7. To prevent oxygen desaturation in
affected patients, quickly pick up inner
cannula and use small brush to remove
secretions inside and outside inner
cannula.
8. Holds inner cannula over basin and
rinse with normal saline, using
non-dominant hand to pour normal
saline.
9. Replaces inner cannula and secure
“locking” mechanism, if applicable.
Reapply tracheostomy collar, T-tukbe
(Briggs), or ventilator oxygen source.
 TRACHEOSTOMY STOMA and
FACEPLATE
(includes with no inner cannula)

10. With hydrogen peroxide-saturated

cotton-tipped swabs and 4 x 4 inch
gauze, cleans exposed outer cannula
surfaces and stoma under faceplate
extending 5 to 10 cm (2 to 4 inches) in
all directions from stoma. Clean in
circular motion from stoma site
outward using dominant hand to handle
sterile supplies.
11. With normal saline-saturated
cotton-tipped swabs and 4 x 4 inch
gauze, rinses with hydrogen peroxide
tracheostomy tube and skin surfaces.
12. With dry, 4 x 4 inch gauze, pats lightly
at skin and exposed outer surfaces.

TRACH TIES AND DRESSING

CHANGE

13. Instructs assistant, if available, to apply

gloves and securely hold tracheostomy
tube in place. With assistant holding
tracheostomy tube, cut ties. (Follow
manufacturer’s guidelines for Velcro
ties. Be sure to cut off excess ties if
applicable)
14. Cuts a length of twill tape and long
enough to go around patient’s neck two
times (along 24 to 30 inches for an
adult), cut ends on diagonal.
15. Inserts one end of tie through faceplate
eyelet and pull ends even.
16. Slides both ends of tie behind the head
and around neck to other eyelet and
insert one tie to second eyelet.
17. Pulls snugly.
18. Ties ends securely in double square
knot, allowing space for only one loose
or two snug finger(s) in tie.
19. Inserts fresh tracheostomy dressing
under clean ties and faceplate.
20. Positions patient comfortably and assess
respiratory status.
21. Removes gloves and face shield and
discard in appropriate receptacle.
22. Replaces cap on hydrogen peroxide and
normal saline bottles. Store reusable
liquids and unused supplies in
appropriate place.
23. Washes hands.
EVALUATION

1. Compares assessment before and after

tracheostomy care.
2. Assesses comfort of new tracheostomy
ties.
3. Inspects inner and outer cannula for
secretions.
4. Assesses stoma for signs of infection or
skin breakdown.
RECORDING AND REPORTING

1. Charts in Kardex type and size of

tracheostomy tube, frequency of
tracheostomy care, special care in event
of stomatitis.
2. Records in nurse’s notes assessments,
supplies used, frequency and extent of
tracheostomy care patient’s tolerance of
procedure.
3. Reports any changes in respiratory
status.