NUR 232: SKILL 25-4 PERFORMING TRACHEOSTOMY CARE

Illustration of a tracheostomy tube & placement The anatomy is shown in cross- section

INTRODUCTION: A tracheostomy is a 51- to 76- mm (2- to 3-inch) curved metal or plastic tube inserted into a stoma through the neck and into the trachea to maintain a patent airway. It is place in patients who require long-term airway management because of airway obstruction, airway clearance needs, and long term intubation. A tracheostomy offers advantages over long-term endotracheal (ET) tube placement such as decreased laryngeal and tracheal tissue injury, ease of breathing, and access for better oral hygiene. Some patients with tracheostomy tubes are able to cough secretions out of the tube completely, whereas others are only able to cough secretions up into it. A tracheostomy tube has a flange that fits against a patient’s neck and an outer cannula or primary airway. It may have a removable inner cannula for cleaning and an inflatable cuff that surrounds the outer cannula.

INTRODUCTION – CONT’D An inflation tube and valve connect to the cuff for inflation. The pilot balloon expands and contracts on inflation and deflation. An inflated cuff keeps the tube stable within the trachea. Standards for care include properly securing the tube, inflating the cuff to an appropriate pressure, maintaining patency by suctioning, and providing oral hygiene. A tracheostomy tube can cause granulation tissue to form on the vocal cords, epiglottis or trachea secondary to inappropriate cuff inflation. An intubated patient is unable to speak because of placement of a tracheostomy tube which prevents normal airflow over and vibration of the vocal cords.

INTRODUCTION – CONT’D Use verbal and non-verbal communication skills when you care for an intubated patient. Alphabet charts, pen and paper, slates or chalkboards, or magnetic pen doodle boards are some common communication tools. You may place a speaking valve over some tracheostomy tubes, which allows a patient to speak. One type of tracheostomy tube is fenestrated, which means that the outer cannula has precut openings. When the inner cannula is removed and the cuff is deflated, patients can speak. A speech pathologist must evaluate patients for aspiration risk before cuff deflation and inner cannula removal.

ASSESSMENT 1. Observe for excess peri-stomal secretions, excess intra-tracheal secretions, soiled or damp tracheostomy ties, soiled or damp tracheostomy dressing, diminished airflow through tracheostomy tube, or signs and symptoms of airway obstruction requiring suctioning (see Skill 25-2) 2. Assess patient’s hydration status, humidity delivered to airway, status of existing infection, patient’s nutritional status, and ability to cough. 3. Assess vital signs, oxygen saturation, lung sounds, and patient’s ability to clear airway.

ASSESSMENT – CONT’D 4. Assess patient’s understanding of and ability to perform own tracheostomy care. 5. Check when tracheostomy care was last performed. Tracheostomy care is provided at least every 4 to 8 hours and more often if indicated (e.g., increased airway or stoma secretions, infection {airway or stoma}).

PLANNING 1. Expected outcomes following completion of procedure: Inner and outer cannulas of tracheostomy tube are free of secretions; ties are clean, secured snugly, and tied in double square knot. Tracheostomy tube is patent and secure, optimizing amount of oxygen delivered to patient and limiting risk of infection from retained secretions. Stoma is pink, does not bleed, and is free of secretions and signs of infection 2. Have another nurse or NAP assist in the procedure.

PLANNING – CONT’D 3. Explain procedure and patient’s participation. 4. Help patient to position comfortable for both nurse and patient (usually supine or semi-Fowler’s). Promotes patient comfort and prevents nurse muscle strain. 5. Place towel across patient’s chest. Reduces transmission of microorganisms.

IMPLEMENTATION 1. Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. 2. Perform hand hygiene. Apply clean gloves and face shield if applicable. 3. Apply pulse oximeter sensor. 4. Suction tracheostomy (see Skill 25-2). Before removing gloves, remove soiled tracheostomy dressing and discard in glove with coiled catheter. 5. Perform hand hygiene. Prepare equipment on bedside table. A. Open sterile tracheostomy kit. Open two 4 X 4 inch gauze packages using aseptic technique and pour normal saline on one package. Leave second package dry. Open two cotton-tipped swab packages and pour normal saline on one package. Do not recap normal saline.

IMPLEMENTATION – cont’d B. Open sterile tracheostomy dressing package. C. Unwrap sterile basin and pour about 0.5 to 2 cm (1/2 to 1 inch) of normal saline into it. D. Open small sterile brush package and place aseptically into sterile basin. E. Prepare length of twill tape long enough to go around patient’s neck 2 times, about 60 to 75 cm (25 to 30 inches) for an adult. Cut ends on diagonal. Lay aside in dry area. F. If using commercially available tracheostomy tube holder, open package according to manufacturer directions.

IMPLEMENTATION – cont’d 6. Hyper-oxygenate patient using ventilator settings or by applying oxygen source loosely over tracheostomy. 7. Apply sterile gloves. Keep dominant hand sterile throughout procedure. Clinical Decision Point: For tracheostomy tube with no inner cannula or Kistner button, continue with Step 9. 8. Care of Tracheostomy with Inner Cannula: A. While touching only outer aspect of tube, unlock and remove inner cannula with non-dominant hand following line of tracheostomy. Drop inner cannula into normal saline basin. B. Replace tracheostomy collar, T tube, or ventilator oxygen source over outer cannula. (Note: May not be able to attach T tube and ventilator oxygen devices to all outer cannulas when inner cannula is removed.)

IMPLEMENTATION – cont’d 8. Care of tracheostomy with inner cannula – cont’d C. To prevent oxygen desaturation in affected patients, quickly pick up inner cannula and use small brush to remove secretions inside and outside inner cannula. D. Hold inner cannula over basin and rinse with normal saline, using non-dominant (clean) hand to pour normal saline. E. Replace inner cannula and secure “locking” mechanism. Reapply ventilator after hyper- oxygenating patient if needed.

IMPLEMENTATION – cont’d 9. Tracheostomy with disposable inner cannula: A. Remove new cannula from manufacturer packaging. B. While touching only outer aspect of tube, withdraw inner cannula and replace with new cannula. Lock into position. C. Dispose of contaminated cannula in appropriate receptacle and reconnect to ventilator or oxygen supply. 10. Using normal saline-saturated cotton-tipped swabs and 4 X 4 inch gauze, clean expose outer cannula surfaces and stoma under faceplate extending 5 to 10 cm (2 to 4 inches) in all directions from stoma. Clean in circular motion from stoma site outward using dominant hand to handle sterile supplies.

A. Tracheostomy tie Method: IMPLEMENTATION – CONT’D 11. Using dry 4 X 4 inch gauze, pat lightly at skin and exposed outer cannula surfaces. 12. Secure tracheostomy. A. Tracheostomy tie Method: 1. Instruct assistant, if available, to apply clean gloves and securely hold tracheostomy tub in place. With assistant holding tracheostomy tube, cut old ties. 2. Take prepared tie, insert one end of tie through faceplate eyelet, and pull ends even.

IMPLEMENTATION – CONT’D 3. Slide both ends of tie behind head and around neck to other eyelet and insert one tie through second eyelet. 4. Pull snugly. 5. Tie ends securely in double square knot, allowing space for only one loose or two snug finger widths in tie. One finger width of slack prevents ties from being too tight when tracheostomy dressing is in place and also prevents movement of tracheostomy tube in lower airway.

IMPLEMENTATION – CONT’D 6. Insert fresh 4 x 4 inch tracheostomy dressing under clean ties and faceplate B. Tracheostomy tube holder method: 1. While wearing gloves, maintain secure hold on tracheostomy tube. This can be done with an assistant: or, when an assistant is not available, leave old tracheostomy tube holder in place until new device is secure. 2. Align strap under patient’s neck. Be sure that Velcro attachments are on either side of tracheostomy tube. 3. Place narrow end of ties under and through faceplate eyelets. Pull ends even and secure with Velcro closures. 4. Verify that there is space for only one loose or two snug finger widths under neck strap.

IMPLEMENTATION – CONT’D 13. Position patient comfortably and assess respiratory status. 14. Be sure that oxygen or humidification delivery sources are in place and set at correct levels. 15. Remove gloves and face shield and discard in appropriate receptacle. 16. Replace cap on normal saline bottles. Store reusable liquids, date container, and store unused supplies in appropriate place. 17. Perform hand hygiene.

EVALUATION 1. Compare assessments before and after tracheostomy care. Determines effectiveness of tracheostomy care. 2. Assess fit of new tracheostomy ties and ask patient if tube feels comfortable. Tracheostomy ties are uncomfortable and place patient at risk for tissue injury when they are too loose or too tight. 3. Inspect inner and outer cannulas for secretions. Presence of secretions on cannulas indicates need for more frequent tracheostomy care. 4. Assess stoma for inflammation, edema, or discolored secretions. Broken skin places patient at risk for infection. Stoma infection requires change in tracheostomy skin care plan.

UNEXPECTED OUTCOMES 1. Excessively loose or tight tracheostomy ties / tracheostomy holder. Adjust ties or apply new ties / tracheostomy holder. 2. Inflammation of tracheostomy stoma. Increase frequency of tracheostomy care. Apply topical antibacterial solution, allow it to dry, and apply bacterial barrier. Apply hydrocolloid or transparent dressing just under stoma to protect skin from breakdown. Consult with skin care specialist. 3. Patient has pressure area around tracheostomy tube. Increase frequency of tracheostomy care and keep dressing under faceplate at all times. Consider using double dressing or applying hydrocolloid or stoma adhesive dressing around stoma.

UNEXPECTED OUTCOMES – CONT’D 4. Accidental de-cannulation. Call for assistance. Replace old tracheostomy tube with new tube. Some experienced nurses or respiratory therapists may be able to quickly reinsert tracheostomy tube. Keep square tracheostomy tube or same size and kind at bedside in event of emergency replacement. Same-size ET tube can be inserted in stoma in an emergency. Insert suction catheter to confirm that new tube is in trachea. Be prepared to manually ventilate patients in whom respiratory distress develops with Ambu-bag until tracheostomy is replaced. Notify health care provider.

UNEXPECTED OUTCOMES – CONT’D 5. Respiratory distress from mucus plug in cannula. Remove inner cannula if applicable for cleaning or suction cannula. Notify health care provider if tracheostomy tube requires replacement.

RECORDING AND REPORTING Record respiratory assessments before and after care; type and size of tracheostomy tube; frequency and extend of care; type, color, and amount of secretions; patient tolerance and understanding of procedure; and special care in event of unexpected outcomes. Report accidental de-cannulation or respiratory distress to the health care provider.

SPECIAL CONSIDERATIONS – TEACHING Different types of tracheostomy tubes have different faceplates. Some are rigid; others are not. Instruct caregivers not to lift up rigid faceplates or they will dislodge the tube. Some commercial tracheostomy tube holders require removal of excess tie material to fit properly. If you anticipate long-term placement of tracheostomy, plan to teach patient and family tracheostomy care. Patients with new tracheostomy frequently have bloody secretions for 2 to 3 days after the procedure and for 24 hours after each tracheostomy tube change.

END OF SKILL This is the end of your skill. Your book has provided a video for this skill and the link is as follows: http://booksite.Elsevier.com/Perry- Potter/ClinicalSkills/video33.php Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques, 8e – 25.4 Performing Tracheostomy Care