Ateneo de Zamboanga University

College of Nursing
NURSING SKILLS OUTPUT

TRACHEOSTOMY CARE

Definition

A tracheostomy is a surgically created opening in the trachea. A tracheostomy

tube is placed in the incision to secure an airway and to prevent it from closing.
Tracheostomy care is generally done every eight hours and involves cleaning around
the incision, as well as replacing the inner cannula of the tracheostomy tube. After the
site heals, the entire tracheostomy tube is replaced once or twice per week, depending
on the physician's order.

Tracheostomy care starts with suctioning the patient's airway, both via the
tracheostomy and orally. Sterile technique must be used when suctioning the
tracheostomy. The gauze dressing is removed from the tracheostomy site, and the
amount and color of drainage should be noted. Using sterile technique, the skin and
external portion of the tube are cleaned with hydrogen peroxide. Cotton-tipped
applicators should be used to clean closely around the stoma. The condition of the skin
and stoma should be noted. The area is then wiped with gauze dampened in 0.9%
sodium chloride and a new tracheostomy dressing is applied.

Purposes

The goals of tracheostomy care are to maintain the patency of the airway, prevent
breakdown of the skin surrounding the site, and prevent infection. Sterile technique
should be used during the procedure.

Objectives

1. Maintain airway patency by removing mucus and encrusted secretions.

2. Promote cleanliness and prevent infection and skin breakdown at stoma site.

Equipments

1) Sterile tracheostomy care kit containing:

i. - Two basins
ii. - Small brush or pipe cleaners
iii. - 4" × 4" gauze
iv. - Commercially available tracheostomy dressing
v. - Twill tape or tracheostomy ties
2) Hydrogen peroxide
3) Normal saline
4) Sterile gloves
 5) Scissors
6) Tracheostomy suction supplies

Procedures

 Explain procedure to client.

Rationale: Explanation facilitates cooperation and provides reassurance for
patient.
 If tracheostomy tube has just been suctioned, remove soiled dressing from around
tube and discard with gloves when they are removed.
Rationale: Suctioning prevents secretions from accumulating in inner cannula
and occluding airway
 Perform hand hygiene and open necessary supplies.
Rationale: Hand hygiene deters the spread of microorganisms.
Cleaning a Non disposable Inner cannula
 Prepare supplies before cleaning inner cannula.
a. Open tracheostomy care kit and separate basins, touching only the
edges.
If kit is not available, open two saline basins.
Rationale: Basins are sterile receptacles for cleaning solutions.
b. Fill one basin 0.5” (1.25 cm) deep with hydrogen peroxide).
Rationale: Hydrogen peroxide helps remove dry, encrusted secretions.
c. Fill other basin 0.5” (1.25 cm) deep with saline.
Rationale: Saline rinses and removes hydrogen peroxide and lubricates
the outer
surface of the inner cannula for easier reinsertion.
d. Open sterile brush or pipe cleaners if they are not already available in
cleaning
kit. Open additional sterile gauze pad.
Rationale: Sterile brush or pipe cleaner provides friction to clean inner
surface of
cannula.
 Don disposable gloves.
Rationale: Gloves protect against exposure to blood and body substances.
 Remove the oxygen source if one is present. Rotate the lock on the inner cannula
in a counterclockwise motion to release it.
Rationale: Releasing the lock permits removal of the inner cannula.
 Gently remove the inner cannula and carefully drop it in the basin with hydrogen
peroxide. Remove gloves and discard.
Rationale: Soaking in hydrogen peroxide loosens dry, hardened secretions.
 Clean the inner cannula.
a. Don sterile gloves.
Rationale: Sterile gloves maintain surgical asepsis.
b. Remove inner cannula from soaking solution. Moisten brush or pipe
cleaners in
 saline and insert into tube, using back – and – forth motion.
Rationale: Movement of brush creates friction and helps remove
accumulated
secretions.
c. Agitate cannula in saline solution. Remove and tap against inner surface
of basin.
Rationale: Saline rinses inner cannula. Tapping tube against basin
removes
excess saline in inner tube.
d. Place on sterile gauze pad.
Rationale: Placing on sterile gauze maintains sterility and frees both
hands for
suctioning.
 Suction outer cannula using sterile technique if necessary.
Rationale: Suctioning removes any remaining secretions
Replace inner cannula into outer cannula. Turn lock clockwise and check that inner
cannula is secure. Reapply oxygen source if needed.
Rationale: Clockwise motion secures inner cannula in place.
Replacing a Disposable Inner Cannula
 Release lock. Gently remove inner cannula and place in disposal bag. Discard
gloves and don sterile ones to insert new cannula. Replace with appropriately sized
new cannula. Engage lock on inner cannula.
Rationale: Disposable cannulas, although more costly, ensure that airways is
clean and patent.
Applying Clean Dressing and Tape
 Dip cotton-tipped applicator in sterile saline and clean stoma under faceplate. Use
each applicator only once, moving from stoma site outward.
Rationale: Saline is nonirritating to tissue. Cleansing from the stoma outward
and
using each applicator only once promotes aseptic technique.
 If secretions prove difficult to remove, apply diluted ½ strength hydrogen peroxide
to area around stoma, faceplate, and outer cannula. Rinse area with saline.
Rationale: Hydrogen peroxide may cause tissue damage and needs to be
removed from skin and surrounding area.
 Pat skin gently with dry 4”x4” gauze.
Rationale: Gauze removes excess moisture.
 Slide commercially prepared tracheostomy dressing or prefolded non-cotton
filled4”x4” dressing under faceplate.
Rationale: Lint or fiber from cotton-filled gauze pad can be aspirated into the
trachea and cause irritation.
Change the tracheostomy tape:
a. Leave soiled tape in place until new one is applied
Rationale: Leaving tape in place ensures that tracheostomy will not be
expelled if patient coughs or moves.
b. Cut piece of tape that is twice the neck circumference plus 4” (10cm).
Trim ends of tape on the diagonal.
 Rationale: This action provides for secure attachments with knot in front at
neckplate. Diagonal cut facilitates insertion of tape into openings
on faceplate.
c. Insert one end of tape through faceplate opening alongside old tape. Pull
through until both ends are even.
Rationale: Doing so provides attachment for one side of faceplate
d. Slide both tapes under patient’s neck and insert one end through
remaining opening on other side of faceplate. Pull snugly and tie ends in
double square knot. Check that patient can flex neck comfortably.
Rationale: A secure tape prevents accidental expulsion of the
tracheostomy tube. Allowing one finger breadth under tape permits
neck flexion that is comfortable and ensure that tape will not
compromise circulation to the area.
e. Carefully remove old tape. Reapply oxygen source if necessary.
Rationale: New tape provides for secure attachment.
 Remove gloves and discard. Perform hand hygiene. Assess patient’s respirations.
Document assessments and completion of procedure
Rationale: Assessment and accurate documentation provide for
comprehensive care

Nursing Responsibilities with Rationale

1.) Assess insertion site for any redness or purulent drainage; if present, these may
signify an infection.
2.) Assess patient for pain.
3.) Assess lung sounds and oxygen saturation levels.
4.) If tracheostomy is fresh, pain medication may be needed before performing
tracheostomy care.
5.) If mucus is plugging the tracheostomy tube, first irrigate and suction. If this is not
successful, remove the inner cannula and repeat the irrigation and suction. If there is
still obstruction, there may be mucus plugging the outer cannula and it should be
replaced.

Illustration:
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Clinical Instructor