Tracheostomy care check off my version

TRACHEOSTOMY CARE Check M.D. order. Provide privacy.

Explain procedure to client.

Hi my name is Jennifer. I am your Nurse for today.

Can you tell me your name & DOB (check ID band)? Do you have any allergies to Latex? I will be providing you with some tracheostomy care and suctioning. This will help remove any secretions and make it easier for you to breathe. Some coughing and SOB are expected and normal, but any discomfort will be brief. Do you have any questions?

I am just going to raise your bed (HOB semi-fowler’s position 30 – 45 degrees) and check a few things before we get started.

Assess for: Tachypnea w/shallow depth, tachycardia, SpO2 < 90%, adventitious breath sounds in all lobes, cyanosis (especially around lips), is pt. getting correct amount of O2.

Assess trach site: color, consistency, and amt. of secretions; if it is sutured in place – is there any redness, swelling, or drainage from suture sites; if secured w/ties – are they moist w/secretions or perspiration, are the secretions dried on the ties, is the tie secure; look at skin around trach and neck – is there any skin breakdown related to pressure from the ties or excess secretions; assess behind faceplate – are there any secretions collected in this area.

Place towel across client’s chest.

Perform hand hygiene, and apply face shield if indicated.

Open sterile tracheostomy kit. Apply sterile gloves. Unfold sterile drape and lay over bed table.

Remove gauze, suction catheter, V-gauze, twill tape, pipe cleaners, and brush. Pour normal saline on two 4x4 gauzes. Open cotton – tipped swab and pour normal saline on swabs.

Keep dominant hand sterile.

Remove inner cannula touching only the outer aspects of the tube unlock and remove the inner cannula with the nondominant hand.

Hyperoxygenate the patient. 100% O2 for 30 seconds to 3 minutes.

Suction tracheostomy (pressure should be set between 80 and 120 mm Hg) while withdrawing the cannula in a circular motion. (Should suction for approximately 10 to 15 seconds – no longer).

Remove new cannula from manufacturer’s packaging.

Replace with new cannula. Lock into position.

Dispose of contaminated cannula in appropriate receptacle. Remove soiled dressing and discard.

Clean the exposed outer cannula surfaces and stoma with normal saline saturated cotton tipped swabs and 4x4. Clean in circular motion.

Pat lightly at skin and exposed cannula surface with dry 4x4 gauzes.

Secure tracheostomy with ties or tube holder, making sure two fingers fit between ties and client’s neck. Remove old ties.

Replace oxygen source. Apply V-gauze.

Position client comfortably and observe respiratory status.

Discard equipment and perform hand hygiene.

Document tracheostomy care completed any secretions, and size of inner cannula, and client’s tolerance of procedure.

Reassess lung sounds, SpO2, RR, HR, and ability to cough up secretions.

04/14/2015 0830 Tracheostomy care performed; Inner cannula replaced w/Size 6. Suctioned using a 14 Fr catheter. Obtained moderate amount of thin, yellow sputum. Stoma site is pink, w/no bleeding, free of secretions and no signs of infection. Lung sounds CTA, RR 18.

SpO2 93%. Tolerated procedure well.