Definition
Tracheostomy care includes changing a tracheostomy inner tube, cleaning tracheostomy site, and changing dressing around the site.
Purposes
- To maintain airway patency.
- To prevent infection at the tracheostomy site.
- To facilitate healing and prevent skin excoriation around the tracheostomy site.
- To promote comfort
- To assess condition.
Equipment
A tracheostomy care kit containing the following:
- Gallipots (3 Nos.)
- Sterile towel.
- Sterile nylon brush/tube brush.
- Sterile gauze squares.
- Cotton twill ties or tracheostomy tie tapes.
- Sterile bowl for solution.
A clean tray containing the following:
- Sterile suction catheter.
- Hydrogen peroxide.
- Normal saline.
- Sterile gloves (2 pairs).
- clean scissors.
- Face mask and eye shield (optional).
- Kidney tray.
- Waterproof pad.
- Syringe to inflate and deflate tracheostomy tube Balloon.
- Suction apparatus
Procedure
| Nursing Action | Rationale | |
| 1 | Before procedure Assess the condition of stoma (redness, swelling, character of secretions, and presence of purulence or bleeding). | Presence of any of these indicates infection and culture test may be warranted. |
| 2 | Examine neck for subcutaneous emphysema evidenced by crepitus around the ostomy site. | indicates air leak into subcutaneous tissue. |
| 3 | Explain the procedure to the patient and teach means of communication such as eye blinking or raising a finger to indicate pain or distress. | Obtains cooperation from patient. |
| 4 | Assist patient to a Fowler’s position and place waterproof pad on chest. | Promotes lung expansion. Prevents soiling of linen. |
| 5 | During procedure Wash hands thoroughly. | Prevents cross-infection. |
| 6 | Assemble equipment: Open the sterile tracheostomy kit; pour hydrogen peroxide and sterile normal saline in separate gallipots.Open other sterile supplies as needed including sterile applicators, suction kit and tracheostomy care kit (dressing kit).Put on face mask and eye shield. | Hydrogen peroxide and saline remove mucus and crust which promote bacterial growth. Enhances the performance phase of the procedure. |
| 7 | Don sterile gloves. Place sterile towel on patient’s chest. | Maintains aseptic technique. |
| 8 | Suction the full length of tracheostomy tube and pharynx thoroughly. | Removes secretions. |
| 9 | Rinse the suction catheter and discard it. | |
| 10 | Unlock the inner cannula (if present) and remove it by gently pulling it out toward you in line with its curvature. Place the inner cannula in the bowl with hydrogen peroxide solution (applicable for tubes having inner and outer cannula). | Hydrogen peroxide moistens and loosens dried secretions. |
| 11 | Remove the soiled tracheostomy dressing, discard the dressing and gloves. | |
| 12 | Don a second pair of sterile gloves. | |
| 13 | Clean the flange of the tube using sterile applicators or gauze moistened with hydrogen peroxide and then with normal saline. Use each applicator once only. | Using the applicator or gauze once only, avoids contaminating a clean area with soiled gauze. |
| 14 | Clean the stoma area with gauze (make only a single sweep with each gauze sponge before discarding). Half strength hydrogen peroxide (mixed with normal saline) may be used. Thoroughly cleanse area using gauze squares moistened with sterile normal saline | Hydrogen peroxide helps to loosen dry crusted secretions. Hydrogen peroxide is irritating to the skin and inhibits healing if not removed thoroughly. |
| 15 | Dry the stoma with dry sterile gauze. An infected wound may be cleaned with gauze saturated with an antiseptic solution, then dried, A thin layer of antibiotic ointment may be applied to the stoma with a cotton swab. | Helps prevent wound infection. |
| 16 | Cleaning the inner cannula: Remove the inner cannula from the soaking solution. Clean the lumen and entire cannula thoroughly using the brush. Rinse the cleaned cannula by rinsing it with sterile normal saline (agitating the cannula in the container with saline cleans it well). Gently tap the cannula against the inside of the sterile saline container after rinsing. | Thorough rinsing is important to remove hydrogen peroxide from inner cannula. Removes solution adhering on the cannula. |
| 17 | Replace the inner cannula and secure it in place: insert the inner cannula by grasping the outer flange and pushing in the direction of its curvature. R Lock the cannula in place by turning the lock (if present) into position. | This secures the flange of the inner cannula to the outer cannula. |
| 18 | Apply sterile dressing: Open and refold a 4 x 4 gauze dressing into a “V” shape and place under the flange of the tracheostomy tube Do not cut gauze pieces. Ensure that the tracheostomy tube is securely supported while applying dressing. | Avoid using cotton-filled 4 x 4 gauze. Cotton or gauze fiber can be aspirated by the patient potentially creating a tracheal abscess. Excessive movement of the tracheostomy tube irritates the trachea. |
| 19 | Change the tracheostomy ties: Leave the soiled tape in place until the new one is applied. Cut a piece of tape that is twice the neck circumference plus 10 cm. Cut the ends of tape diagonally. Apply the new tape. Remove old tapes carefully. Grasp slit end of clean tape and pull it through opening on one side of the tracheostomy tube. Pull the other end of the tape securely through the slit end of the tracheostomy tube on the other side.Tie the tapes at the side of the neck in a square knot. Alternate knot from side to side each time tapes are changed. Ties should be tight enough to keep tube securely in the stoma and loose enough to permit two fingers to fit between the tape and neck. | Leaving tape in place ensures that tube will not be expelled if patient coughs or moves. This action provides a secure attachment with knot. Diagonal cut facilitates insertion of tape into openings of neck plate. Prevents irritation and aids in rotation of pressure site. Excessive tightness compresses jugular veins, decreases blood circulation to the skin and results in discomfort for patient. |
| 20 | After procedure Document all relevant information in the chart: Suctioning done Tracheostomy care carried out Dressing change and Observations. |
Special consideration
- Tracheostomy dressing should be done every 8 hours or whenever dressings are soiled.
- Tracheostomy tubes may come with disposable inner cannula or without the inner cannula. If disposable inner cannula is present, then replace the one that is inside with a new one.
- If only single lumen is present, then suction the tracheostomy tube and clean the neck plate and tracheostomy site.
- Before removing the tube, the cuff of an endotracheal tube/tracheostomy tube should be deflated.
- Removal of a tube with an inflate cuff may cause laryngeal edema and damage to vocal cords. In case of confused or agitated patients sedate if needed or apply restraints to prevent pulling the tube.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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