College of Health Sciences Education

3rd Floor, DPT Building

Matina Campus, Davao City
Telefax: (082)
Phone No.: (082)300-5456/300-0647 Local 117

PROCEDURE CHECKLIST on
TRACHEOSTOMY CARE

Name of Student:________________________________ Rating:______________________

Year Level:__________________ Course / Code:____ Date Performed:______________

Procedure 5 4 3 2 1 Remarks
1. Prior to performing the procedure, introduce self and
verify the client’s identity using agency protocol. Explain
to the client what you are going to do, why is necessary,
and how he or she can participate. Provide for a means
of communication, such as eye blinking or raising a
finger, to indicate pain or distress. Follow through by
carefully observing the client throughout the procedure,
offering periodic eye contact, caring touch, and verbal
reassurance.
2. Perform hand hygiene and observe other appropriate
infection prevention procedures.
3. Provide for client privacy.
4. Assist the client to a semi – fowler’s or fowler’s position.
5. Open the tracheostomy kit / tracheostomy prepared items
(if kit is not available) or sterile basins. Establish a sterile
field. Open other sterile supplies as needed including
sterile applicators, suction kit, tracheostomy dressing,
and disposable inner cannula, if applicable.
6. Pour the soaking solution and sterile normal saline into
separate containers.
- Apply clean gloves
- Remove the oxygen source.
7. Unlock the inner cannula (if present) and remove it by
gently pulling it out toward in line with its curvature. Place
the inner cannula in the soaking solution, if not a
disposable inner cannula.
8. Based on the client’s respiratory assessments, place
oxygen source over or near the outer cannula.
9. Remove the soiled tracheostomy dressing. Place the
soiled dressing in your gloved hand and peel the glove off
so that it turns inside out over the dressing.
10 Remove and discard the gloves and the dressing.
Perform hand hygiene. Apply sterile gloves. Keep your
dominant hand sterile during the procedure.
11 Clean the inner cannula. Inspect the cannula for
cleanliness by holding it at eye level and looking through
it into the light. Rinse the inner cannula thoroughly in the
sterile normal saline.
12 Remove the inner cannula from the soaking solution.
Clean the lumen and the entire inner cannula thoroughly
using the brush or pipe cleaners moistened with sterile
normal saline.
13 After rinsing, gently tap the cannula against the inside
edge of the sterile saline container. Use a pipe cleaner
folded in half to dry only the inside of the cannula; do not
dry the outside.
14 Replace the inner cannula, securing it in place. Insert the
inner cannula by grasping the outer flange and inserting
the cannula in the direction of its curvature.
 College of Health Sciences Education
3rd Floor, DPT Building
Matina Campus, Davao City
Telefax: (082)
Phone No.: (082)300-5456/300-0647 Local 117
15 Lock the cannula in place by turning the lock (if present)
into position. Ties can loosen in restless clients, allowing
the tracheostomy tube to extrude from the stoma.
16 Thread one piece of the collar with Velcro end into the
slot on one side of the flange.
17 Take the Collar around the back of the client’s neck,
keeping it flat.
18 Thread the other piece of the collar with the Velcro end
into the slot on the other side of the flange.
19 Take the second piece of the collar around the back of
the client’s neck, keeping it flat.
20 Have the client flex the neck and secure the two pieces of
the collar together with the Velcro, allowing space for one
to two fingers between the collar and the client’s neck.
21 Check the tightness of the collar as with the tie method.
22 Remove and discard sterile gloves. Perform hand
hygiene.
23 Document all relevant information. Record suctioning,
tracheostomy care, and the dressing change, noting
assessments.
Total Score ÷ Raw Score x 85 + 15 =________ x 75 % +
25% Evaluation Rating = Final Rating

LEGEND:

1 - Poor (NOT What is EXPECTED)Unacceptable

2 - Below Average (SORT of What is EXPECTED)Poor
3 - Average (ALMOST What is EXPECTED)Satisfactory
4 - Above Average (What is EXPECTED)Good
5 - Excellent (MODEL performance)

Comments:________________________________________________________________
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________________________________ _____________________________
Name & Signature of Supervising CI Name & Signature of the Student
Date: ________________________ Date: _____________________