VELEZ COLLEGE – COLLEGE OF NURSING (Nursing Care Management 112 Skills Lab)

SKILLS LABORATORY MODULE NO. 8

TRACHEOSTOMY CARE

Tracheostomy is the formation of an opening into the trachea into which a tube is inserted through which
the patient breathes.

LEARNING OBJECTIVES:
By the end of the module, the student will be able to:
1. Give the indications for a tracheostomy.
2. Give the complications of a tracheostomy.
3. Identify the parts of a tracheostomy tube.
4. Discuss the emergency nursing management in the event accidental extubation occurs.
5. Perform tracheostomy care.
6. Apply the principles of asepsis and infection control throughout the procedure.
7. Explain rationale for each step of the procedure.

Important Information related to this Module:

A. Indications for a Tracheostomy:

Acute respiratory failure

Anticipated upper airway obstruction from edema or soft tissue swelling due to head & neck
trauma
CNS depression
Facial or airway burns
Neuromuscular disease
Patients who require long-term ventilatory assistance (e.g., cervical spine injury)
Severe obstructive sleep apnea syndrome
Upper airway obstruction (tumor, inflammation, foreign body, laryngeal spasm)

B. Complications of a Tracheostomy: [consult textbook for clinical manifestations, prevention & management]

Early Complications
- Air embolism - Posterior tracheal wall penetration
- Aspiration - Recurrent laryngeal nerve damage
- Bleeding - Subcutaneous emphysema
- Pneumothorax

Long-Term Complications
- Airway obstruction (from accumulation of copious secretions)
- Laryngeal/tracheal injury (ulceration or necrosis of tracheal mucosa, postextubation tracheal
stenosis, tracheal dilation, tracheo-esophageal & tracheal-arterial fistula, innominate artery erosion,
tracheomalacia)
- Pulmonary infection & sepsis
- Dependence on artificial airway

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C. Parts of a Tracheostomy Tube:

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D. Emergency Nursing Management for Accidental Extubation

Things to keep at the client’s bedside always: (1) obturator, (2) forceps/hemostat, (3) extra
tracheostomy tube, (4) bag-valve-mask resuscitator/Ambu®-bag attached to oxygen source
In case tracheostomy tube is accidentally dislodged, HYPEREXTEND the client’s neck and grasp
retention sutures of stoma with sterile forceps to keep airway open.
Call for help.

Materials/Equipment Needed: [materials/items with an asterisk (*) are the materials the students should
bring during skills laboratory period]
- Sterile gloves*
- Cotton-tip applicators*
- Sterile 4x4 gauze (without cotton lining)*
- Hydrogen peroxide*
- Sterile water or sterile saline*
- Disposable inner cannula (if available)
- 2 basins (preferably sterile; e.g., carbolized carrier pans are commonly used)
- Tracheostomy brush
- Tracheostomy ties
- Sterile towel
- Personal protective equipment

Nursing Skill to Develop in this Module:

A. Performing Tracheostomy Care
1. Assess respirations for rate, rhythm & depth.
2. Auscultate lung fields.
3. Check ABG and pulse oximetry values.
4. Assess passage of air through tracheostomy tube.
5. Assess anxiety and restlessness.
6. Assess condition of stoma before tracheostomy care (note redness, swelling, character of secretions, and
presence of purulence or bleeding).
7. Examine neck for subcutaneous emphysema.
8. Explain procedure to the client.
9. Perform hand hygiene.
10. Suction trachea & pharynx thoroughly before tracheostomy care (refer to Module 9 for this procedure).
11. Assemble tracheostomy care equipment. Place hydrogen peroxide solution on one sterile basin and
sterile water or saline on the other. Put on personal protective equipment and don gloves. Open and
moisten cotton-tip applicators (some will be moistened with sterile water/saline, some with hydrogen
peroxide and some are kept dry)

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12. Remove soiled dressing and discard.

13. Change a disposable inner cannula, touching only the external portion, and lock it securely into place.
14. If inner cannula is reusable, remove it with your contaminated hand.
15. While holding external portion with your contaminated hand, immerse inner portion of reusable cannula
in the basin with H2O2 solution briefly.
16. Using a tracheostomy brush or cotton applicator, clean cannula with your sterile hand.
17. When clean, still holding external portion with contaminated hand, immerse inner portion of cannula
into basin of sterile water or saline solution. Agitate it to rinse thoroughly.
18. Tap inner cannula gently unto inner rim of sterile container to remove excess water but not dry enough
to facilitate reinsertion.
19. Reinsert reusable cannula and lock it securely into place.
20. Cleanse external end & neck plate of tracheostomy tube with cotton applicator moistened with H2O2.
21. Rinse external end & neck plate of tracheostomy tube with cotton applicator moistened with sterile
water or saline.
22. Wipe with dry cotton applicator.
23. Cleanse skin under neck plate of tube/stoma with cotton applicator moistened with H2O2. Make only a
single sweep with each applicator before discarding.
24. Rinse with cotton applicator moistened with sterile water or saline. Make only a single sweep with each
applicator before discarding.
25. Wipe with dry cotton applicator. Make only a single sweep with each applicator before discarding.
26. Change tracheostomy ties. Secure ties at the side of the neck in a square knot (ties should be tight
enough to keep tube securely in the stoma, but loose enough to permit two fingers to fit between the
tapes and the neck).
NURSING ALERT: It is important to obtain assistance from another nurse or a respiratory
therapist because of the risk of accidental tube expulsion during this procedure. Patient
movement or coughing can dislodge the tube.
If changing tracheostomy ties alone or without assistance, remove soiled ties one side at a time
as you attach the new tie on each eye of the flange. You may also ask the client to place his/her
fingers over the flange to secure tube as you change the tie.
In removing the soiled ties, DON’T cut it. Simply untie the square knot during removal.

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27. Change tracheostomy dressing. Place a gauze pad between the stoma site and the tracheostomy tube to
absorb secretions and prevent irritation of the stoma. [see illustration below]

28. Discard all used materials & perform hand hygiene.

Special Considerations:
Sterile technique is used for tracheostomy care of a fresh or newly-created stoma. Once healed, clean
technique may be used.
Tracheostomy care is routinely done every shift; inner cannula may be cleaned more frequently (as
often as every 2 hours)
Tracheostomy ties should be changed every 24 hours or more frequently if soiled or wet.
Assess tightness of tracheostomy ties at least once per shift.
In preparing a tracheostomy dressing, make sure to fold the gauze in such a way that loose fibers are
tucked in and away from contact into tracheostomy tube opening. Loose gauze fibers may result in
aspiration.
If the patient's neck or stoma is excoriated or infected, apply a water-soluble lubricant or topical
antibiotic cream as ordered. Remember not to use a powder or an oil-based substance on or around a
stoma because aspiration can cause infection and abscess.

References & Suggested Readings:

Altman, G.B. (2010). Fundamental & advanced nursing skills (3rd ed.). Clifton Park, NY: Delmar Cengage
Learning.
Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb’s fundamentals of nursing: Concepts,
process and practice (8th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
Nettina, S. & Mills, E.J. (2006). Lippincott manual of nursing practice (8th ed.). Philadelphia, PA:
Lippincott, Williams & Wilkins.
Schilling-McCann, J. (2009). Lippincott’s nursing procedures (5th ed.). Philadelphia, PA: Lippincott,
Williams & Wilkins.
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth’s textbook of medical-
surgical nursing (12th ed.). Philadelphia, PA: Wolter Kluwer Health/Lippincott, Williams & Wilkins.
Williams, L. & Hopper, P. (2003). Understanding medical-surgical nursing (2nd ed.). Philadelphia, PA:
F.A. Davis Company.