of the Philippines

SAN NG LUNGSOD NG MAYNILA

y of the City of Manila)
na Street corner Muralla Street
Intramuros, Manila

COLLEGE OF NURSING
(Dalubhasaan ng Narsing)

INTENSIVE CARE NURSING – SKILLS CHECKLIST

PROVIDING TRACHEOSTOMY CARE

PURPOSE:
The nurse is responsible for either replacing a disposable inner cannula or cleaning a non
disposable inner cannula. The inner cannula requires replacement or cleaning to prevent
accumulation of secretions that can interfere with respiration and occlude the airway. Because
soiled tracheostomy dressings place the patient at risk for the development of skin breakdown
and infection, regularly change dressings and tracheostomy collar or ties. Use gauze dressings
that are not filled with cotton to prevent aspiration of foreign bodies (e.g., lint or cotton fibers)
into the trachea. Clean the skin around a tracheostomy to prevent buildup of dried secretions and
skin breakdown. Exercise care when changing the tracheostomy collar or ties to prevent
accidental decannulation or expulsion of the tube. Have an assistant hold the tube in place during
the changing of a collar. When changing a tracheostomy tie, keep the soiled tie in place until a
clean one is securely attached. Agency policy and patient condition determine specific
procedures and schedules, but a newly inserted tracheostomy may require attention every 1 to 2
hours. Because the respiratory tract is sterile and the tracheostomy provides a direct opening,
meticulous care is necessary when using aseptic technique.

EQUIPMENT:
• Disposable gloves
• Sterile gloves
• Goggles and mask or face shield
• Additional PPE, as indicated
• Sterile normal saline • Hydrogen Peroxide
• Sterile cup or basin
• Sterile cotton-tipped applicators
• Sterile gauze sponges
• Disposable inner tracheostomy cannula, appropriate size for patient
• Sterile suction catheter and glove set
• Commercially prepared tracheostomy or drain dressing
• Commercially prepared tracheostomy holder
• Plastic disposal bag
• Additional nurse

ASSESSMENT

Assess for signs and symptoms of the need to perform tracheostomy care, which include soiled
dressings and holder or ties, secretions in the tracheostomy tube, and diminished airflow through
the tracheostomy, or in accordance with facility policy. Assess insertion site for any redness or
purulent drainage; if present, these may signify an infection. Assess patient for pain. If
tracheostomy is new, pain medication may be needed before performing tracheostomy care.
Assess lung sounds and oxygen saturation levels. Lung sounds should be equal in all lobes, with
an oxygen saturation level above 93%. If tracheostomy is dislodged, lung sounds and oxygen
saturation level will diminish. Inspect the area on the posterior portion of the neck for any skin
breakdown that may result from irritation or pressure from tracheostomy holder or ties.

NURSING DIAGNOSIS

Determine the related factors for the nursing diagnosis based on the patient’s current status.
Appropriate nursing diagnoses may include:
• Impaired Skin Integrity
• Ineffective Airway Clearance
• Risk for Infection
• Risk for Aspiration

OUTCOME IDENTIFICATION AND PLANNING

The expected outcome to achieve when performing tracheostomy care is that the patient will
exhibit a tracheostomy tube and site free from drainage, secretions, and skin irritation or
breakdown. Other outcomes that may be appropriate include the following: oxygen saturation
levels will be within acceptable parameters, and patient will have no evidence of respiratory
distress.
 Implementation of the Procedure/Steps with Rationale

STEPS/PROCEDURE RATIONALE
Preparatory Phase:

1.Bring necessary equipment to the bedside
stand or overbed table.
2. Perform hand hygiene and put on PPE, if
indicated.
Performance Phase:
Ensures all required tools are readily
available, minimizing interruptions during
the procedure.
Reduces the risk of infection for both the
healthcare provider and the patient.

3. Identify the patient. Ensures that the correct individual is

receiving the intended care.
4. Close curtains around bed and close the Provides privacy for the patient and
door to the room, if possible. maintains a focused environment.
5. Determine the need for tracheostomy Allows for the assessment of the patient's
care. Assess patient’s pain and administer condition and the administration of pain
pain medication, if indicated. medication if required.
6. Explain what you are going to do and the Fosters communication, promotes
reason to the patient, even if the patient does understanding, and helps alleviate anxiety.
not appear to be alert. Reassure the patient
you will interrupt procedure if he or she
indicates respiratory difficulty.
7. Adjust bed to comfortable working Ensures a comfortable and safe environment
position, usually elbow height of the for both the patient and the caregiver.
caregiver. Lower side rail closest to you. If
the patient is conscious, place him or her in
a semi-Fowler’s position. If patient is
unconscious, place him or her in the lateral
position, facing you. Move the overbed
table close to your work area and raise to
waist height. Place a trash receptacle within
easy reach of work area
8. Put on prescribed institutional PPE. Protects against potential infections and
Suction tracheostomy, if necessary. If maintains a clear airway.
tracheostomy has just been suctioned,
remove soiled site dressing and discard
before removal of gloves used to perform
suctioning.
Cleaning the Tracheostomy: Disposable Ensures the sterility of the new inner
Inner Cannula cannula, minimizing the risk of infection

9. Carefully open the package with the new
disposable inner cannula, taking care not to
contaminate the cannula or the inside of the
package (Figure 1).
Carefully open the package with the sterile
cotton-tipped applicators, taking care not to
contaminate them.
Open sterile cup or basin and fill 0.5 inch
deep with saline or hydrogen peroxide, per
hospital policy or doctor’s order
Open the plastic disposable bag and place
within reach on work surface.
10. Put on disposable gloves.
11. Remove the oxygen source if one is
present. Stabilize the outer cannula and
faceplate of the tracheostomy with your
nondominant hand. Grasp the locking
mechanism of the inner cannula with your
dominant hand. Press the tabs and release
lock (Figure 2). Gently remove inner
cannula and place in disposal bag. If not
already removed, remove site dressing and
dispose of it in the trash.
when it is introduced into the tracheostomy
site.
Opening the package with care ensures the
maintenance of sterility. Contaminating the
cotton-tipped applicators can introduce
microorganisms, potentially causing
infection when used for cleaning or applying
substances around the tracheostomy site.
The use of a sterile cup or basin serves as a
container for the liquid solution required for
cleaning. Filling it to a specified depth
ensures an adequate amount for the
procedure. Filling with saline or hydrogen
peroxide aligns with hospital protocols,
providing a standardized, effective cleaning
solution for the tracheostomy site.
Opening and placing within reach facilitates
efficient disposal of used items, ensuring a
clean and organized workspace and adhering
to infection control practices.
The rationale for putting on disposable
gloves during tracheostomy care is rooted in
infection prevention, patient safety,
healthcare provider safety, adherence to
standard precautions, and the overall
maintenance of a clean and sterile
environment.
This step prioritizes patient comfort and
safety by temporarily removing the oxygen
source and stabilizing the outer cannula. The
use of aseptic technique during inner cannula
change minimizes infection risk, and proper
disposal practices maintain a hygienic
environment. Together, these measures
contribute to a safe and effective
tracheostomy care process.
12. Discard gloves and put on sterile gloves.
Pick up the new inner cannula with your
dominant hand, stabilize the faceplate with
your nondominant hand, and gently insert
the new inner cannula into the outer
cannula. Press the tabs to allow the lock to
grab the outer cannula (Figure 3). Reapply
oxygen source, if needed.
Applying Clean Dressing and Holder
13. Remove oxygen source, if necessary.
Dip cotton-tipped applicator or gauze
sponge in cup or basin with sterile saline
and clean stoma under faceplate. Use each
applicator or sponge only once, moving
from stoma site outward (Figure 4).
14. Pat skin gently with dry 4 x 4 gauze
sponge.
15. Slide commercially prepared
tracheostomy dressing or prefolded non–
cotton-filled 4x4-inch dressing under the
faceplate
16. Change the tracheostomy holder:
a. Cut trach ties length you desire, if not
precut.
b. Fold ends of the trach ties over 11 ⁄2
in., and cut a slit in the piece starting at the
This process prioritizes infection prevention
by transitioning from non-sterile to sterile
gloves during the insertion of a new inner
cannula. The technique ensures precision
and patient comfort while securing the lock
to prevent dislodgment. Swift reapplication
of the oxygen source maintains
uninterrupted respiratory support,
collectively promoting a safe and effective
tracheostomy care procedure.
This step prioritizes patient comfort and
safety by temporarily removing the oxygen
source. The use of aseptic technique,
including single-use applicators, ensures a
clean and hygienic cleaning process. The
methodical cleaning approach contributes to
maintaining a sterile environment, reducing
the risk of infections or skin issues around
the tracheostomy site.
gently patting the skin with a dry gauze
sponge is a simple yet crucial step in
tracheostomy care. It promotes skin health,
reduces infection risk, enhances patient
comfort, allows for observation, and
contributes to overall hygiene around the
tracheostomy site.
to protect the skin, absorb secretions,
enhance patient comfort, and maintain
hygiene. This step is integral to preventing
complications and ensuring the well-being of
the patient during tracheostomy care.
Changing the tracheostomy holder and
cutting tracheostomy ties to the desired
length is driven by the need for
customization to enhance patient comfort,
prevent skin irritation, optimize
tracheostomy tube positioning, facilitate
daily care, prevent complications, enhance
patient safety, and adhere to established best
practices in tracheostomy care.
Cutting trach ties to the desired length
allows for a personalized and comfortable
folded edge.
c. Pass the slit end of the ties through
the flange loop of the trach tube about 2–3
in. (you may use Kelly forceps to grab tie).
Leave the old trach tie in place if you are
changing the ties without assistance. This
prevents accidental dislodging of the trach
tube.
d. Thread the other end of the tie all the
way through the slit. Pull it firmly in place.
Rationale: This action anchors the tie around
the flange loop.
e. Repeat steps 4 and 5 on another
flange loop.
f. Bring ties around client’s neck and
tie in a square knot to one side of neck,
leaving one finger-breadth slack under tie.
Rationale: Slack prevents pressure on the
neck and jugular vein.
g. Cut off soiled trach ties if not already infection.
done and discard.
17. Remove gloves. Assist patient to a
comfortable position. Raise the bed rail and
place the bed in the lowest position.
fit, ensuring that the holder provides
adequate support without causing
discomfort to the patient.
Folding and passing the slit end of the ties
through the flange loop of the trach tube and
leaving the old tie in place during the
process (if changing without assistance)
prevent accidental dislodgment. This step
enhances patient safety.
The action of threading the other end of the
tie through the slit and pulling it firmly in
place anchors the tie around the flange loop.
This ensures a secure and stable positioning
of the tracheostomy tube.
Cutting off and discarding soiled trach ties
ensures the maintenance of hygiene,
preventing the accumulation of
contaminants and reducing the risk of
Removing gloves is essential to maintain
infection control practices, preventing
potential cross-contamination between
different patient care activities.
Assisting the patient to a comfortable
position ensures their well-being and
contributes to a positive and respectful
patient experience during and after the
procedure.
Lowering the bed to the lowest position
makes it easier for the patient to get in and
out of bed, promoting mobility and reducing
the risk of falls.
18. Remove face shield or goggles and
mask. Remove additional PPE, if used.
Perform hand hygiene.
19. Reassess patient’s respiratory status,
including respiratory rate, effort, oxygen
saturation, and lung sounds.
Follow-up Phase
20 The expected outcome is met when the
patient exhibits a tracheostomy tube and site
that are free from drainage, secretions, and
skin irritation or breakdown; oxygen
saturation level within acceptable
parameters; and is without evidence of
respiratory distress. In addition, the patient
verbalizes that site is free of pain and
exhibits no evidence of skin breakdown on
the posterior portion of the neck
21 Document your before and after
assessments, including site assessment,
These steps are essential to protect
healthcare providers from exposure to
respiratory secretions, minimize cross-
contamination, and prevent the spread of
pathogens. Performing thorough hand
hygiene after PPE removal further ensures
the safety of both healthcare providers and
patients, aligning with established guidelines
and protocols for standardized and evidence-
based care.
the rationale for reassessing a patient's
respiratory status lies in the early detection
of changes, monitoring the effectiveness of
interventions, adjusting treatment plans,
identifying signs of distress, optimizing
oxygenation, preventing complications,
ensuring patient safety, and adhering to
established standards of care. Regular
assessment is an integral component of
providing high-quality respiratory care
To achieve optimal tracheostomy care,
expected outcomes include maintaining a
tracheostomy tube and site free from
drainage, secretions, and skin irritation.
Additionally, the patient's oxygen saturation
level should be within acceptable
parameters, and there should be no evidence
of respiratory distress. Furthermore, the
patient should verbalize a pain-free
tracheostomy site and exhibit no signs of
skin breakdown on the posterior neck. These
outcomes are crucial for infection
prevention, ensuring respiratory stability,
promoting patient comfort, and preventing
complications. Overall, attaining these goals
reflects a patient-centered and
comprehensive approach to tracheostomy
care, evaluating both physiological
indicators and patient-reported experiences.
Documenting both before and after
assessments, especially focusing on site
 presence of pain, lung sounds, and oxygen
saturation levels.
Document presence of skin breakdown that
may result from irritation or pressure from
tracheostomy collar.
Document care given.
assessment in tracheostomy care, is essential
for individualized care, continuity of care,
monitoring changes, quality assurance, legal
compliance, communication among
healthcare providers, patient safety, and
educational purposes. It serves as a
comprehensive record that supports
effective and informed healthcare delivery.
Documenting the presence of skin
breakdown from tracheostomy collar
irritation and detailing the care provided is
crucial for patient safety and effective
healthcare delivery. This documentation
supports early issue identification,
individualized care planning,
communication among healthcare providers,
legal compliance, quality assurance, and a
patient-centered approach. Additionally, it
facilitates monitoring trends, analysis for
continuous improvement, and serves
educational purposes for healthcare training.
Overall, thorough documentation enhances
the quality, safety, and responsiveness of
tracheostomy care.

SCORE: 63/63

UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS

Patient coughs hard enough to dislodge tracheostomy: A spare tracheostomy and obturator
should be kept at bedside. Insert obturator into the new tracheostomy and insert tracheostomy
into stoma. Remove obturator. Secure ties and auscultate lung sounds. Palpate for any
subcutaneous emphysema. • On palpating around insertion site, you note a moderate amount of
subcutaneous emphysema in tissue: Assess for dislodgement of the tracheostomy tube. If the
tube has become displaced, a buildup of air in the subcutaneous portion of the skin is likely.
Notify physician if the subcutaneous emphysema is a change in the status of the tracheostomy.

SPECIAL CONSIDERATIONS General Consideration

• One nurse working alone should always place new tracheostomy ties in place before
removing old ties to prevent accidental extubation of tracheostomy. If it is necessary to remove
old ties first, obtain the assistance of a second person to hold the tracheostomy tube in place
while the old tie is removed and the new tie is replaced.
• Emergency equipment should be easily accessible at the bedside. Keep a bag-valve mask,
oxygen, the obturator from the current tracheostomy, spare tracheostomy of the same size, spare
tracheostomy one size smaller, and suction equipment at the bedside of a patient with an
endotracheal tube at all times.
• If the patient is currently using a tracheostomy without a cuff, keep a spare tracheostomy
of the same size with a cuff at the bedside for emergency use.

Home Care Considerations

• Instruct the patient and home caregiver on how to perform tracheostomy care. Observe a return
demonstration and provide feedback.
• Clean, rather than sterile, technique can be used in the home setting.
• Sterile saline can be made by mixing 1 teaspoon of table salt in 1 quart of water and boiling for
15 minutes. The solution is cooled and stored in a clean, dry container. Discard saline at the end
of each day to prevent growth of bacteria.
• The patient who is performing self-care should use a mirror to view the steps in the procedure.

GRADING:
2 POINTS – Correct/Complete Rationale 1 POINT - Incomplete Rationale 0 POINT -
Incorrect Rationale

TOTAL: 63 POINTS = 100% (Score / 63) x 100 = Score in Percentage

References:
➢ Hudak,et al. Critical Care Nursing: A Holistic Approach
➢ Schumacher & Chernecky. Critical Care and Emergency Nursing
➢ Lippincott. Manual of Nursing Practice
➢ Emergency Nurses Association of the Philippines. BLS & ACLS Handbook

Prepared By: Prof. Roison Andro Narvaez, MSN RN CMCS LGBH, PhD NS Student For
AY 2021-2022, First Semester

Reviewed and Modified By: Prof. Aris S. Santos, RN, RM For AY 2022-2023

Total score: _____________

I fully understand how I was graded for this skill and it was properly explained to me.
______________________________
Student’s FULLNAME & Signature
Date: ______________

I have explained and discussed how I have graded my student for this particular skill.
___________________________
Clinical Instructor FULLNAME & Signature
Date: _________

FIGURE 1. Carefully opening package with new disposable inner cannula.

FIGURE 2. Releasing lock on inner cannula.

FIGURE 3. Locking new inner cannula in place

FIGURE 4. Cleaning from stoma site, outward.

FIGURE 5. Securing tabs on tracheostomy holder

FIGURE 6. Reapplying oxygen source

SAMPLE DOCUMENTATION

10/26/2021 1300 Tracheostomy care completed; lung sounds clear in all lobes; respirations
even/unlabored; site without erythema or edema; small amount of thick, yellow secretions noted
at site. —R. Narvaez, MSN RN