Goal: The patient exhibits a tracheostomy tube and site free from drainage, secretions, and skin irritation or breakdown.
1. Bring necessary equipment to the bedside stand or overbed table.
2. Perform hand hygiene and put on PPE, if indicated.
3. Identify the patient.
4. Close curtains around bed and close the door to the room, if possible.
5. Determine the need for tracheostomy care. Assess patient’s pain and administer pain medication, if indicated.
6. Explain what you are going to do and the reason to the patient, even if the patient does 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 position, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). 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 face shield or goggles and mask. Suction tracheostomy, if necessary. If tracheostomy has just been suctioned, remove soiled site dressing and discard before
removal of gloves used to perform suctioning.
Cleaning the Tracheostomy: Disposable Inner Cannula
(See the Skill Variation in your skills book for steps for cleaning a nondisposable inner cannula.)
9. Carefully open the package with the new disposable inner cannula, taking care not to contaminate the cannula or the inside of the package. 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. 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. Gently remove inner cannula and place in disposal bag. If not already removed, remove site dressing and dispose of it in the trash.
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. Reapply oxygen source, if needed.
Applying Clean Dressing and Holder
(See the Skill Variations in your skills book for steps for an alternate site dressing if a commercially prepared sponge is not available and to secure a tracheostomy with a tracheostomy ties/tape instead of a collar.)
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.
14. Pat skin gently with dry 4 4 gauze sponge.
15. Slide commercially prepared tracheostomy dressing or prefolded non-cotton-filled 4 4-inch dressing under the faceplate.
16. Change the tracheostomy holder:
a. Obtain the assistance of a second individual to hold the tracheostomy tube in place while the old collar is removed and the new collar is placed.
b. Open the package for the new tracheostomy collar.
c. Both nurses should put on clean gloves.
d. One nurse holds the faceplate while the other pulls up the Velcro tabs. Gently remove the collar.
e. The first nurse continues to hold the tracheostomy faceplate.
f. The other nurse places the collar around the patient’s neck and inserts first one tab, then the other, into the openings on the faceplate and secures the Velcro tabs on the tracheostomy holder.
g. Check the fit of the tracheostomy collar. You should be able to fit one finger between the neck and the collar. Check to make sure that the patient can flex neck comfortably. Reapply oxygen source, if necessary.
17. Remove gloves. Assist patient to a comfortable position. Raise the bed rail and place the bed in the lowest position.
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.
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