Tracheostomy

A tracheostomy is a surgically-created opening called a stoma that goes from the

front of the patient’s neck into the trachea. A tracheostomy tube is placed through
the stoma and directly into the trachea to maintain an open (patent) airway.
Placement of a tracheostomy tube may be performed emergently or as a planned
procedure due to the following:
 A large object blocking the airway
 Respiratory failure or arrest
 Severe neck or mouth injuries
 A swollen or blocked airway due to inhalation of harmful material such as
smoke, steam, or other toxic gases
 Cancer of the throat or neck, which can affect breathing by pressing on the
airway
 Paralysis of the muscles that affect swallowing
 Surgery around the larynx that prevents normal breathing and swallowing
 Long-term oxygen therapy via a mechanical ventilator

Subjective Assessment
If appropriate, perform a focused interview collecting a brief history of respiratory
conditions and assess for feelings of shortness of breath (dyspnea), sputum
production, and coughing.

Objective Assessment
Prior to suctioning, a baseline assessment for indications of respiratory distress and
the need for suctioning should be obtained and documented, including, but not
limited to, the following:
 Secretions from the mouth and/or tracheal stoma
 Auscultation of lung sounds
 Heart rate
 Respiratory rate
 Cardiac rhythm
 Oxygen saturation
 Skin color and perfusion
 Effectiveness of cough
Prepare the patient by explaining the procedure and providing adequate sedation
and pain relief as needed. Place the patient in semi-Fowler’s position if conscious or
in a lateral position facing you if they are unconscious. While suctioning the patient,
if signs of worsening respiratory distress occur, stop the procedure and request
emergency assistance. The following should be monitored during and following the
procedure:
 Lung sounds
 Skin color
 Breathing pattern and rate
 Oxygenation (pulse oximeter)
 Pulse rate
 Dysrhythmias if electrocardiogram is available
 Color, consistency, and volume of secretions
 Presence of bleeding or evidence of physical trauma
 Subjective response including pain
 Cough
  Laryngospasm (spasm of the vocal cords that can result in airway
obstruction)
After completing suctioning, the outcomes from the procedure should be evaluated
and documented, including the following:
 Improvement of lung sounds
 Removal of secretions
 Improvement of pulse oximetry
 Decreased work of breathing
 Stabilized respiratory rate
 Decreased dyspnea
Be aware that the patient’s lung sounds may not clear completely after suctioning,
but the removal of secretions should improve the patency of the patient’s airway.
Potential complications resulting from this procedure include nasal
irritation/bleeding, gagging/vomiting, discomfort and pain, and uncontrolled
coughing. Potential adverse reactions include mucosal hemorrhage, laceration of
nasal turbinate, perforation of the pharynx, hypoxia/hypoxemia, cardiac
dysrhythmias/arrest, bradycardia, elevated blood pressure, hypotension, respiratory
arrest, laryngospasm, bronchoconstriction, bronchospasm, hospital-acquired
infection, atelectasis, increased intracranial pressure, and pneumothorax.

OROPHARYNGEAL AND NASOPHARYNGEAL SUCTIONING CHECKLIST &

SAMPLE DOCUMENTATION
Suctioning via the oropharyngeal (mouth) and nasopharyngeal (nasal) routes is
performed to remove accumulated saliva, pulmonary secretions, blood, vomitus,
and other foreign material from these areas that cannot be removed by the
patient’s spontaneous cough or other less invasive procedures. Nasal and
pharyngeal suctioning are performed in a wide variety of settings, including critical
care units, emergency departments, inpatient acute care, skilled nursing facility
care, home care, and outpatient/ambulatory care. Suctioning is indicated when the
patient is unable to clear secretions and/or when there is audible or visible evidence
of secretions in the large/central airways that persist in spite of the patient’s best
cough effort. Need for suctioning is evidenced by one or more of the following:
 Visible secretions in the airway
 Chest auscultation, gurgling breath sounds, rhonchi, or diminished breath
sounds
 Reported feeling of secretions in the chest
 Suspected aspiration of gastric or upper airway secretions
 Clinically apparent increased work of breathing
 Restlessness
 Unrelieved coughing
In emergent situations, a provider order is not necessary for suctioning to maintain
a patient’s airway. However, routine suctioning does require a provider order..
Follow agency policy regarding setting suction pressure. Pressure should not exceed
150 mm Hg because higher pressures have been shown to cause trauma,
hypoxemia, and atelectasis. The following ranges are appropriate pressure
according to the patient’s age:
 Neonates: 60-80 mm Hg
 Infants: 80-100 mm Hg
 Children: 100-120 mm Hg
  Adults: 100-150 mm Hg
Suction only when clinically indicated and for up to 15 seconds at a time to
decrease the risk of respiratory complications. Hyperoxygenation and
hyperventilation should be performed prior to the nasal and tracheal procedures to
avoid the most common hazards of suctioning (hypoxemia, arrhythmias, and
atelectasis). For nasal suctioning, increase the amount of O2 the patient is receiving
for a few minutes prior to the procedure and instruct the patient to take several
deep breaths. For tracheal suctioning, do the same. If the patient is on a ventilator,
you can either hyperoxygenate and ventilate with the Ambu bag or provide a few
extra machine assisted breaths prior to the procedure. Allow the patient to recover
and hyperventilate and hyperoxygenate between each passing of the suction
catheter. The patient should recover for 30-60 seconds between passes.
When performing nasal suctioning, have the patient lean their head backwards to
open the airway. This helps guide the catheter toward the trachea rather than the
esophagus.
Checklist for Oropharyngeal or Nasopharyngeal Suctioning
Use the checklist below to review the steps for completion of “Oropharyngeal or
Nasopharyngeal Suctioning.”
Steps
Always review and follow agency policy regarding this specific skill.
1.Gather supplies: Yankauer or suction catheter, suction machine or wall suction
device, suction canister, connecting tubing, pulse oximeter, stethoscope, PPE
(e.g., mask, goggles or face shield, nonsterile gloves), sterile gloves for suctioning
with sterile suction catheter, towel or disposable paper drape, nonsterile basin or
disposable cup, and normal saline or tap water.

2. Perform safety steps:

 Perform hand hygiene.
 Check the room for transmission-based precautions.
 Introduce yourself, your role, the purpose of your visit, and an estimate
of the time it will take.
 Confirm patient ID using two patient identifiers (e.g., name and date of
birth).
 Explain the process to the patient.
 Be organized and systematic.
 Use appropriate listening and questioning skills.
 Listen and attend to patient cues.
 Ensure the patient’s privacy and dignity.
 Assess ABCs.
3. Adjust the bed to a comfortable working height and lower the side rail closest to
you.
4. Position the patient:
 If conscious, place the patient in a semi-Fowler’s position.
 If unconscious, place the patient in the lateral position, facing you.
5. Move the bedside table close to your work area and raise it to waist height.
6. Place a towel or waterproof pad across the patient’s chest.
7. Adjust the suction to the appropriate pressure:
 Adults and adolescents: no more than 150 mm Hg
 Children: no more than 120 mmHg
 Infants: no more than 100 mm Hg
  Neonates: no more than 80 mm Hg

For a portable unit:

 Adults: 10 to 15 cm Hg
 Adolescents: 8 to 15 cm Hg
 Children: 8 to 10 cm Hg
 Infants: 8 to 10 cm Hg
 Neonates: 6 to 8 cm Hg
8. Put on a clean glove and occlude the end of the connection tubing to check
suction pressure.
9. Place the connecting tubing in a convenient location (e.g., at the head of the
bed).
10. Open the sterile suction package using aseptic technique. (NOTE: The open
wrapper or container becomes a sterile field to hold other supplies.) Carefully
remove the sterile container, touching only the outside surface. Set it up on the
work surface and fill with sterile saline using sterile technique.
11. Place a small amount of water-soluble lubricant on the sterile field, taking care
to avoid touching the sterile field with the lubricant package.
12. Increase the patient’s supplemental oxygen level or apply supplemental
oxygen per facility policy or primary care provider order.
13. Don additional PPE. Put on a face shield or goggles and mask.
14. Don sterile gloves. The dominant hand will manipulate the catheter and must
remain sterile.
15. The nondominant hand is considered clean rather than sterile and will control
the suction valve on the catheter.
 In the home setting and other community-based settings, maintenance of
sterility is not necessary.
16. With the dominant gloved hand, pick up the sterile suction catheter. Pick up
the connecting tubing with the nondominant hand and connect the tubing and
suction catheter.
17. Moisten the catheter by dipping it into the container of sterile saline. Occlude
the suction valve on the catheter to check for suction.
18. Encourage the patient to take several deep breaths.
19. Apply lubricant to the first 2 to 3 inches of the catheter, using the lubricant
that was placed on the sterile field.
20. Remove the oxygen delivery device, if appropriate. Do not apply suction as
the catheter is inserted. Hold the catheter between your thumb and forefinger.
21. Insert the catheter. For nasopharyngeal suctioning, gently insert the catheter
through the naris and along the floor of the nostril toward the trachea. Roll the
catheter between your fingers to help advance it. Advance the catheter
approximately 5 to 6 inches to reach the pharynx. For oropharyngeal suctioning,
insert the catheter through the mouth, along the side of the mouth toward the
trachea. Advance the catheter 3 to 4 inches to reach the pharynx
22. Apply suction by intermittently occluding the suction valve on the catheter
with the thumb of your nondominant hand and continuously rotate the catheter as
it is being withdrawn.
 Suction only on withdrawal and do not suction for more than 10 to 15
seconds at a time to minimize tissue trauma.
23. Replace the oxygen delivery device using your nondominant hand, if
appropriate, and have the patient take several deep breaths.
24. Flush the catheter with saline. Assess the effectiveness of suctioning by
listening to lung sounds and repeat, as needed, and according to the patient’s
tolerance. Wrap the suction catheter around your dominant hand between
attempts:
 Repeat the procedure up to three times until gurgling or bubbling sounds
stop and respirations are quiet. Allow 30 seconds to 1 minute between passes
to allow reoxygenation and reventilation.
25. When suctioning is completed, remove gloves from the dominant hand over the
coiled catheter, pulling them off inside out.
26. Remove the glove from the nondominant hand and dispose of gloves,
catheter, and the container with solution in the appropriate receptacle.
27. Assist the patient to a comfortable position. Raise the bed rail and place the
bed in the lowest position.
28.Turn off the suction. Remove the supplemental oxygen placed for suctioning, if
appropriate.
29.Remove face shield or goggles and mask; perform hand hygiene.
30.Perform oral hygiene on the patient after suctioning.
31.Reassess the patient’s respiratory status, including respiratory rate, effort,
oxygen saturation, and lung sounds.
32.Assist the patient to a comfortable position, ask if they have any questions,
and thank them for their time.
33.Ensure safety measures when leaving the room:
 CALL LIGHT: Within reach
 BED: Low and locked (in lowest position and brakes on)
 SIDE RAILS: Secured
 TABLE: Within reach
 ROOM: Risk-free for falls (scan room and clear any obstacles)
34. Perform hand hygiene.
35. Document the procedure and related assessment findings. Report any
concerns according to agency policy.

CHECKLIST FOR TRACHEOSTOMY SUCTIONING AND SAMPLE

DOCUMENTATION
Tracheostomy suctioning may be performed with open or closed technique. Open
suctioning requires disconnection of the patient from the oxygen source, whereas
closed suctioning uses an inline suctioning catheter that does not require
disconnection. This checklist will explain the open suctioning technique.
Indications for tracheostomy suctioning include the following:
 The need to maintain the patency and integrity of the artificial airway
 Deterioration of oxygen saturation and/or arterial blood gas values
 Visible secretions in the airway
 The patient’s inability to generate an effective spontaneous cough
 Acute respiratory distress
 Suspected aspiration of gastric or upper-airway secretions
 The need to obtain a sputum specimen
Similar assessments and monitoring apply when performing tracheostomy
suctioning compared with other types of suctioning with the addition of assessing
the stoma. The stoma should be free from redness and drainage. Hyperoxygenation
using a bag mask valve attached to an oxygen source may be required before and
during the open suctioning procedure based on the patient’s oxygenation status.
See Figure 22.8 for an image of an example of sterile tracheostomy suctioning kit.

Example of a Sterile Tracheostomy Kit

 To ensure patient safety, a replacement tracheostomy tube, an obturator, a
bag valve mask (Ambu bag), and suction catheter kit must always be
available in the room.
 Communication should be facilitated with the patient using writing when
possible.
 Follow agency policy regarding hyperoxygenation and hyperventilation prior
to and during suctioning.
 Do not suction for more than 15 seconds per pass.
 During the procedure, it is important to continually monitor the patient’s
pulse oximetry to determine if the oxygen saturation is maintaining at an
adequate level.
 Perform oral care after suctioning according to agency policy.

Steps
Always review and follow agency policy regarding this specific skill.
1. Gather supplies: sterile gloves, trach suction kit, mask with face shield, gown,
goggles, pulse oximetry, and bag valve device. It is helpful to request assistance
from a second nurse if preoxygenating the patient before suction passes.
2. Perform safety steps.
 Perform hand hygiene.
 Check the room for transmission-based precautions.
 Introduce yourself, your role, the purpose of your visit, and an estimate
of the time it will take.
 Confirm patient ID using two patient identifiers (e.g., name and date of
birth).
 Explain the process to the patient and ask if they have any questions.
 Be organized and systematic.
 Use appropriate listening and questioning skills.
  Listen and attend to patient cues.
 Ensure the patient’s privacy and dignity.
 Assess ABCs.
3. Verify that there are a backup tracheostomy and bag valve device available at
the bedside.
4. Assess lung sounds, heart rate and rhythm, and pulse oximetry.
5. Raise the head of the bed to waist level. Place the patient in a semi-Fowler’s
position and apply the pulse oximeter for monitoring during the procedure.
6. Turn on the suction. Set the suction gauge to appropriate setting based on age
of the patient.
7. Perform hand hygiene. Don appropriate PPE (gown and mask).
8. Open the suction catheter package faced away from you to maintain sterility.
9. Don the sterile gloves from the kit.
10. Remove the sterile fluid and check the expiration date.
11. Open the sterile container used for flushing the catheter and place it back into
the kit. Pour the sterile fluid into the sterile container using sterile technique.
12. Remove the suction catheter from the packaging. Ensure the catheter size is
not greater than half of the inner diameter of the tracheostomy tube.
13. Keep the catheter sterile by holding it with your dominant hand and attaching
it to the suction tubing with your nondominant hand. Note that your nondominant
hand is no longer sterile.
14. Test the suction and lubricate the sterile catheter by using your sterile hand to
dip the end into the sterile saline while occluding the thumb control.
15. Ask an assistant to preoxygenate the patient with 100% oxygen for 30 to 60
seconds using a handheld bag valve mask (Ambu bag) per agency protocol.
Alternatively, ask the patient to take two or three deep breaths if able.
16. Insert the catheter into the patient’s tracheostomy tube using your sterile
hand without applying suctioning:
 For shallow suctioning, insert the catheter the length of the
tracheostomy tube before beginning any suctioning.
 For deep suctioning, insert the catheter until resistance is met (at the
carina) and withdraw 1 centimeter before beginning suctioning.
 Do not force the catheter.
 Keep the dominant (sterile) hand at least one inch from the end of the
trach tube.
 To apply suction, place your nondominant thumb over the control
valve
17. Withdraw the catheter while continually rotating it between your fingers to
suction all sides of the tracheostomy tube. Do not suction longer than 15 seconds
to prevent hypoxia. Follow agency policy regarding the use of intermittent or
continuous suctioning. Do not contaminate the catheter as you remove it from the
trach tube.
18. Suction sterile saline each time the suction catheter is removed to flush the
catheter and suction tubing of secretions.
19. Assess the patient response to suctioning; hyperoxygenation may be required.
If dysrhythmia or bradycardia occur, stop the procedure.
20. Allow the patient to rest. After the patient’s pulse oximetry returns to baseline,
a second suctioning pass can be initiated if clinically indicated. Encourage the
patient to cough and deep breath to remove secretions between suctioning
passes.
21. Do not insert the suction catheter more than two times. If the patient’s
respiratory status does not improve or it worsens, call for emergency assistance.
22. Reattach the preexisting oxygen delivery device to the patient with your
noncontaminated hand.
23. Evaluate the effectiveness of the procedure and the patient’s respiratory
status. Assess patency of the airway and pulse oximetry.
24. Remove the catheter from the tubing and then remove gloves while holding
the catheter inside the glove. Perform hand hygiene.
25. Turn off the suction.
26. Perform proper hand hygiene and don clean gloves.
27. Reassess lung sounds, heart rate and rhythm, and pulse oximetry for
improvement.
28. Perform patient oral care.
29. Remove gloves and perform proper hand hygiene.
30. Assist the patient to a comfortable position, ask if they have any questions,
and thank them for their time.
31. Ensure safety measures when leaving the room:
 CALL LIGHT: Within reach
 BED: Low and locked (in lowest position and brakes on)
 SIDERAILS: Secured
 TABLE: Within reach
 ROOM: Risk-free for falls (scan room and clear any obstacles)
32. Perform hand hygiene.
33. Document the procedure and related assessment findings. Report any
concerns according to agency policy.

TRACHEOSTOMY SUCTIONING

 Introduction of a suction catheter through the tracheostomy tube to remove

mucus from the airway.

A. Learning Objectives
Students will:
o Discuss indications for tracheostomy suctioning
o Perform tracheostomy suctioning using aseptic technique
o Detect complications associated with tracheostomy suctioning

B. Equipment
o Suction catheters
o Suction apparatus
o Manual resuscitator to be connected to 100% oxygen source
o Container and water for flushing the suction tubing
o Receptacle for disposal
C. Procedure
EVIDENCE TO BE PRODUCED RATIONALE
1. Verifies doctor’s order To obtain specific instructions and
information of previous dressing.
2. Does handwashing/applying alcohol- Prevent transmission of microorganisms
based hand rub
3. Provides privacy
4. Introduce self to the client.
5. Check client’s identification using Ensures correct patient.
two patient identifiers
6. Explains the procedure Gains cooperation and allays anxiety
7. Informs that suctioning causes some To allay anxiety of the patient.
intermittent coughing and that it
assist in removing secretions.
8. Places in semi-fowler’s position (if For easy access.
not contraindicated)
9. Do pre-procedure assessment (get Provides baseline data
the RR, PR, auscultate for breath
sounds, get 02 saturation level,
assess for the color of the patient)
10. Attaches the AMBU bag to oxygen
source. Adjust oxygen flow to 100%
flush.
11. Places the sterile towel across the
client’s chest below the
tracheostomy.
12. Opens sterile supplies
13. Turns the suction and set the
pressure in accordance with agency
policy. For a wall unit, 100-120
mmHg is used for adults, 10-15
mmHg for a portable unit.
14. Put on goggles, mask and gown. To avoid cross contamination
15. Puts on sterile gloves. (Sterile glove
on the dominant hand and an
unsterile glove on the no-dominant
hand to protect the nurse)
16. Holding the catheter in dominant
hand and the connector in the non-
dominant hand, attach the catheter
to the Y-connector or straight
connector.
17. Using the dominant hand, place the
catheter tip in the sterile saline
solution.
18. Using the thumb of the non- Assesses the functionality of the suction
dominant hand, occlude the control machine.
and suction a small amount of sterile
solution through the catheter.
19. Summon an assistant if one is
available for this step.
20. Using your non-dominant hand, turn Ventilation before suctioning helps prevent
on the oxygen to 12-15 liters per hypoxemia.
minute
21. If the client is receiving oxygen, Prevents contamination of the connection
disconnect oxygen source from the
tracheostomy tube using your non
dominant hand.
22. Attach AMBU bag to the
tracheostomy tube
23. Compress AMBU bag 3-5x as the
client inhales.
24. Observe rise and fall of the client’s
chest with the connector facing up.
25. Remove AMBU bag and place it on
bed and or the client’s chest with the
connector facing up.
26. If the client has copious secretions,
do not hyperventilate with AMBU
bag. Instead: Keep the regular
oxygen delivery device on, and
increase the liter flow for few
minutes before suctioning.
27. With your non-dominant thumb off
the suction port, quickly but gently
insert the catheter into the trachea
through the tracheostomy tube.
28. Insert the catheter about 12.5 cm
(5in.) for adults or until the client
coughs or when you feel the
resistance.
29. To prevent damaging the mucus
membranes at the bifurcation,
withdraw the catheter about 1-2 cm
(0.4 – 0.8 in) before applying suction
30. Apply intermittent suction for 5-10
sec. by placing the non-dominant
thumb over the thumb port.
31. Rotate the catheter by rolling it in Failure to withdraw and rotate catheter
between your thumb and forefinger may result in damage to tracheal mucosa.
while slowly withdrawing it.
32. Withdraw the catheter completely
and release the suction
33. Hyperventilate the client The oxygen removed by suctioning must be
replenished before suctioning is attempted
again.
34. Suction again if needed.
35. Observe client’s respiration and skin
color. With your non-dominant hand,
check the pulse if necessary.
36. Encourage the client to breathe
deeply and to cough between
suctions.
37. Allow 2-3 minutes between suctions
when possible.
38. Flush the catheter and repeat
suctioning until the air passage is
clear and breathing is relatively
effortless and quiet.
39. After each suction, pick up the AMBU
bag with your clean hand and
ventilate the client with no more
than three breaths.
40. Flush the catheter and suction
tubing.
41. Turn off the suction and disconnect
the catheter from suction tubing.
42. Wrap the catheter around your
sterile hand and peel the glove off so
that it turns inside out over the
catheter.
43. Discard the glove and the catheter in Reduces contamination
moisture resistant bag.
44. Replenish the sterile fluid and
supplies so that the suction is ready
to be used again.
45. Be sure that the ventilator and
oxygen settings are returned to its
 pre suctioning settings.
46. Assist the client to a comfortable, If the person is conscious, a semi-fowler’s
safe position position is indicated. If the person is
unconscious, Sim’s position can assist the
drainage of the secretion from the mouth.
47. Record the suctioning Provides baseline data.
48. Including the amount and
description of suction returns and
any other relevant assessment.
49. Do post procedure assessment.

CHECKLIST FOR TRACHEOSTOMY CARE

Tracheostomy care is provided on a routine basis to keep the tracheostomy tube’s
flange, inner cannula, and surrounding area clean to reduce the amount of bacteria
entering the artificial airway and lungs.

Replacing and Cleaning an Inner Cannula

The primary purpose of the inner cannula is to prevent tracheostomy tube
obstruction. Many sources of obstruction can be prevented if the inner cannula is
regularly cleaned and replaced. Some inner cannulas are designed to be disposable,
while others are reusable for a number of days. Follow agency policy for inner
cannula replacement or cleaning, but as a rule of thumb, inner cannula cleaning
should be performed every 12-24 hours at a minimum. Cleaning may be needed
more frequently depending on the type of equipment, the amount and thickness of
secretions, and the patient’s ability to cough up the secretions.
Changing the inner cannula may encourage the patient to cough and bring mucus
out of the tracheostomy. For this reason, the inner cannula should be replaced prior
to changing the tracheostomy dressing to prevent secretions from soiling the new
dressing. If the inner cannula is disposable, no cleaning is required.

Checklist for Tracheostomy Care with a Reusable Inner Cannula

Use the checklist below to review the steps for completion of “Tracheostomy Care.”
Stoma site should be assessed and a clean dressing applied at least once per shift.
Wet or soiled dressings should be changed immediately. Follow agency policy
regarding clearing the inner cannula; it should be inspected at least twice daily and
cleaned as needed.
Steps
Always review and follow agency policy regarding this specific skill.
1. Gather supplies: bedside table, towel, sterile gloves, pulse oximeter, PPE (i.e.,
mask, goggles, or face shield), tracheostomy suctioning equipment, bag valve
mask (should be located in the room), and a sterile tracheostomy care kit (or
sterile cotton-tipped applicators, sterile manufactured tracheostomy split
sponge dressing, sterile basin, normal saline, and a disposable inner cannula or
a small, sterile brush to clean the reusable inner cannula).
2. Perform safety steps:
 Perform hand hygiene.
 Check the room for transmission-based precautions.
  Introduce yourself, your role, the purpose of your visit, and an estimate
of the time it will take.
 Confirm patient ID using two patient identifiers (e.g., name and date of
birth).
 Explain the process to the patient and ask if they have any questions.
 Be organized and systematic.
 Use appropriate listening and questioning skills.
 Listen and attend to patient cues.
 Ensure the patient’s privacy and dignity.
 Assess ABCs.

3. Raise the bed to waist level and place the patient in a semi-Fowler’s position.
4. Verify that there is a backup tracheostomy kit available.
5. Don appropriate PPE.
6. Perform tracheal suctioning if indicated.
7. Remove and discard the trach dressing. Inspect drainage on the dressing for
color and amount and note any odor.
8. Inspect stoma site for redness, drainage, and signs and symptoms of infection.
9. Remove the gloves and perform proper hand hygiene.
10. Open the sterile package and loosen the bottle cap of sterile saline.
11. Don one sterile glove on the dominant hand.
12. Open the sterile drape and place it on the patient’s chest.
13. Set up the equipment on the sterile field.
14. Remove the cap and pour saline in both basins with ungloved hand (4″-6”
above basin).
15. Don the second sterile glove.
16.Prepare and arrange supplies. Place pipe cleaners, trach ties, trach dressing,
and forceps on the field. Moisten cotton applicators and place them in the third
(empty) basin. Moisten two 4″ x 4″ pads in saline, wring out, open, and separately
place each one in the third basin. Leave one 4″ x 4″ dry.
17. With nondominant “contaminated” hand, remove the trach collar (if
applicable) and remove (unlock and twist) the inner cannula. If the patient
requires continuous supplemental oxygen, place the oxygenation device near the
outer cannula or ask a staff member to assist in maintaining the oxygen supply to
the patient.
18. Place the inner cannula in the saline basin.
19. Pick up the inner cannula with your nondominant hand, holding it only by the
end usually exposed to air.
20. With your dominant hand, use a brush to clean the inner cannula. Place the
brush back into the saline basin.
21. After cleaning, place the inner cannula in the second saline basin with your
nondominant hand and agitate for approximately 10 seconds to rinse off debris.
Repeat cleansing with brush as needed.
22. Dry the inner cannula with the pipe cleaners and place the inner cannula back
into the outer cannula. Lock it into place and pull gently to ensure it is locked
appropriately. Reattach the preexisting oxygenation device.
23. Clean the stoma with cotton applicators using one on the superior aspect and
one on the inferior aspect.
24. With your dominant, noncontaminated hand, moisten sterile gauze with sterile
saline and wring out excess. Assess the stoma for infection and skin breakdown
caused by flange pressure. Clean the stoma with the moistened gauze starting at
the 12 o’clock position of the stoma and wipe toward the 3 o’clock position. Begin
again with a new gauze square at 12 o’clock and clean toward 9 o’clock. To clean
the lower half of the site, start at the 3 o’clock position and clean toward 6
o’clock; then wipe from 9 o’clock to 6 o’clock, using a clean moistened gauze
square for each wipe. Continue this pattern on the surrounding skin and tube
flange. Avoid using a hydrogen peroxide mixture because it can impair healing.
25. Use sterile gauze to dry the area.
26. Apply the sterile tracheostomy split sponge dressing by only touching the
outer edges.
27. Replace trach ties as needed. (The literature overwhelmingly recommends a
two-person technique when changing the securing device to prevent tube
dislodgement. In the two-person technique, one person holds the trach tube in
place while the other changes the securing device). Thread the clean tie through
the opening on one side of the trach tube. Bring the tie around the back of the
neck, keeping one end longer than the other. Secure the tie on the opposite side
of the trach. Make sure that only one finger can be inserted under the tie.
28. Remove the old tracheostomy ties.
29. Remove gloves and perform proper hand hygiene.
30. Provide oral care. Oral care keeps the mouth and teeth not only clean, but also
has been shown to prevent hospital-acquired pneumonia.
31. Lower the bed to lowest the position. If the patient is on a mechanical
ventilator, the head of the bed should be maintained at 30-45 degrees to prevent
ventilator-associated pneumonia.
32. Assist the patient to a comfortable position, ask if they have any questions,
and thank them for their time.
33. Ensure safety measures when leaving the room:
 CALL LIGHT: Within reach
 BED: Low and locked (in lowest position and brakes on)
 SIDE RAILS: Secured
 TABLE: Within reach
 ROOM: Risk-free for falls (scan room and clear any obstacles)
34. Perform hand hygiene.
35. Document the procedure and related assessment findings. Report any
concerns according to agency policy.
TRACHEOSTOMY CARE

 A patient with a tracheostomy has had a surgically created opening made in

the lower airway, usually at the level of the 2 nd or 3rd tracheal ring.

 When a tracheostomy is inserted the upper airway is bypassed this also

includes bypassing the normal functions: humidifying, warning, and filtering
of air

A. Learning Objectives
Students will:
o Identify parts of a tracheostomy tube & their purposes
o Demonstrate safe & effective tracheostomy care

B. Equipment
o Hydrogen Peroxide
o Sterile saline
o Sterile gloves
o Disposable tracheostomy kit
o Clean scissors (if ties will be replaced)

C. Procedure
EVIDENCE TO BE PRODUCED RATIONALE
1. Verify the doctor’s order To obtain specific instructions and
information of previous dressing.
2. Apply alcohol based hand rub Infection control.
upon entering the client’s
room.
3. Prepare the client.

 Introduce self to the Ensures that the correct procedure is

patient. carried out on the correct patient
 Check the patient’s To allay anxiety and gain cooperation
identification For easy access during dressing
 Explain the procedure.
 Position the patient in
semi-Fowler’s position.
4. Prepare the equipment. Facilitates an efficient procedure.

 Wear masks and goggles Prevents secretions from getting into

 Open the sterile pack. the nurse’s eyes.
 Pour out the hydrogen
peroxide and sterile normal For removal of mucus and crust which
saline solution in separate promotes bacterial growth.
containers
 Prepare a moisture
resistant bag.
5. Put on clean gloves Prevent contamination of the wound
and also protect the nurse’s hands.
6. Unlock the inner cannula by
rotating it in a counter
clockwise direction while your
other hand supports the base
plate of the outer cannula.
7. Gently remove the inner
cannula by pulling it toward
you in line with its curvature
8. Soak the inner cannula in the Hydrogen peroxide may help loosen
hydrogen peroxide solution. dry crusted secretions.
9. Remove the dressing
10. Check the tracheostomy site For early detection and prompt
for signs of infection and treatment.
maceration
11. Change to sterile gloves
12. Remove the cannula from the
soaking solution using the
disposable pick-up forceps.
13. Clean the lumen and the entire
inner cannula thoroughly using
the nylon brush moistened with
sterile saline solution.
14. Inspect the cannula for
cleanliness. If encrustations are
evident, repeat cleaning.
15. Rinse the cannula thoroughly Ensures that all hydrogen peroxide is
by agitating in the saline removed
solution.
16. Gently tap it against the inside
edge of the sterile solution
container to remove excess
fluid.
17. Dry the lumen of the cannula.
Use the pipe cleaners to dry
the inner cannula.
18. Grasp the outer flange of the
inner cannula, and insert the
cannula in the direction of its
 curvature.
19. Lock the inner cannula in place
by turning the lock in clockwise
direction.
20. Gently pull the inner cannula to Stabilization of the tube helps prevent
ensure that it is secured. accidental dislodgement and keeps
irritation and coughing due to tube
manipulation at a minimum.
21. Pour out the sterile normal
saline solution in the
receptacle. *Discard the first
few drops. Note:*If using the
same solution from the same
container, this may be omitted.
22. Clean the incision site

 Clean around the incision

site with applicator sticks
dampened with sterile
normal saline. Start from the
inner to outer, using one
applicator per stroke.
 Dry by gently wiping the
area with gauze pad.
23. Apply a sterile dressing.

 Use a commercially
prepared sterile dressing if
available or open and refold
a 4x4 gauze.
 Avoid using a cotton-filled
gauze squares, and avoid
cutting the 4x4 gauze
 While applying the dressing,
ensure that the
tracheostomy tube is
securely supported.
24. Change the tie tapes.
 Fasten the clean ties before
removing the soiled ties.
 Apply the tie tape as follows:
 Thread one end of the
tape into the upper
half of the slot on one
side.
 Bring both ends of the
tape together, and
take them around the
client’s neck, keeping
them flat and
 untwisted.
 Ask the client to flex
the neck, if conscious
and coherent.
 Thread the piece of
tape closest to the
client’s neck from
back to front through
the other slot.
 Place one finger
underneath the tie
tape before tying.
 Tie it with double
square knots with the
loose tape ends.
 Cut off any long ends
 Cut old tie tape,
remove and discard.
25. Check the tautness of the Excessive tightness of tapes will
tracheostomy site. compress jugular veins, decrease
blood circulation to the skin under the
tape, and result in discomfort for the
patient.
26. Auscultate lung sounds. Provides a baseline
27. Determine client’s comfort
level
28. Identify unexpected outcomes
and intervene as necessary
29. Record and report intervention
and client’s response.
 TRACHEOSTOMY SUCTIONING

Instruction: Check under Correctly Done if identified skill is correctly performed;

Incorrectly Done if skill is not performed correctly; and Not Done if the student failed to
perform the skill.
Correctl Incorrectl Not Done
Procedur y y
e Done Done
1. Identify the patient.
2. Does handwashing/applying alcohol-based hand rub
3 Provides privacy

4. Introduce self to the client.

5 Check client’s identification using two patient
identifiers
6. Explains the procedure
7. Places in semi-fowler’s position (if not
contraindicated)
8. Attaches the AMBU bag to oxygen source. Adjust
oxygen flow to 100% flush.
9. Places the sterile towel across the client’s chest
below the tracheostomy
10. Opens sterile supplies
11. Turns the suction and set the pressure in accordance
with agency policy. For a wall unit, 100-120 mmHg is
used for adults, 10-15 mmHg for a portable unit.
12. Put on goggles, mask and gown.

13. Puts on sterile gloves. (Sterile glove on the

dominant hand and an unsterile glove on the no-
dominant hand to protect the nurse)
14. Holding the catheter in dominant hand and the
connector in the non-dominant hand, attach the catheter
to the Y-connector or straight connector.
15. Using the dominant hand, place the catheter tip in
the sterile saline solution.
16. Using the thumb of the non-dominant hand, occlude
the control and suction a small amount of sterile solution
through the catheter.
17. Summon an assistant if one is available for this step.
18. Using your non-dominant hand, turn on the oxygen
to 12-15 liters per minute
19. If the client is receiving oxygen, disconnect oxygen
source from the tracheostomy tube using your non
dominant hand.
20. Attach AMBU bag to the tracheostomy tube
21.Compress AMBU bag 3-5x as the client inhales.
22. Observe rise and fall of the client’s chest with the
connector facing up.

23. Remove AMBU bag and place it on bed and or the

client’s chest with the connector facing up.
24. If the client has copious secretions, do not
hyperventilate with AMBU bag. Instead: Keep the regular
oxygen delivery device on, and increase the liter flow for
few minutes before suctioning.
25. With your non-dominant thumb off the suction port,
quickly but gently insert the catheter into the trachea
through the tracheostomy tube.
26. Insert the catheter about 12.5 cm (5in.) for adults or
until the client coughs or when you feel the resistance.
27. To prevent damaging the mucus membranes at the
bifurcation, withdraw the catheter about 1-2 cm (0.4 –
0.8 in) before applying suction
28. Apply intermittent suction for 5-10 sec. by placing
the non-dominant thumb over the thumb port.
29.Rotate the catheter by rolling it in between your
thumb and forefinger while slowly withdrawing it.
30.Withdraw the catheter completely and release the
suction
31.Hyperventilate the client
32.Suction again if needed.
33.Observe client’s respiration and skin color. With your
non-dominant hand, check the pulse if necessary.
34.Encourage the client to breathe deeply and to cough
between suctions.
35.Allow 2-3 minutes between suctions when possible.
36.Flush the catheter and repeat suctioning until the air
passage is clear and breathing is relatively effortless
and quiet.
37.After each suction, pick up the AMBU bag with your
clean hand and ventilate the client with no more
than three breaths.
38.Flush the catheter and suction tubing.
39.Turn off the suction and disconnect the catheter
from suction tubing.
40.Wrap the catheter around your sterile hand and peel
the glove off so that it turns inside out over the
catheter.
41.Discard the glove and the catheter in moisture
resistant bag.
42.Replenish the sterile fluid and supplies so that the
suction is ready to be used again.
43.Be sure that the ventilator and oxygen settings are
returned to its pre suctioning settings.
44.Assist the client to a comfortable, safe position
45.Record the suctioning
46.Including the amount and description of suction
returns and any other relevant assessment.
47.Do post procedure assessment.
Comment:
Score:
Name of Student: _________________________________________
(Signature Over Printed Name)
Date Performed:

Evaluated by: Date of

Evaluation: ____