Respiratory Care and Suctioning
Providing Tracheostomy Care
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- » Setting Oxygen Flow Rates
- » Applying a Nasal Cannula or Face Mask
- » Maintaining an Airway
- » Providing Tracheostomy Care
- » Performing Oropharyngeal Suctioning
- » Performing Nasotracheal and Nasopharyngeal Suctioning
Take the Review Test:
Safety
- When an assistant is helping replace neck ties, instruct him or her not to release the tracheostomy tube until the new ties are firmly in place. If you are working without an assistant, do not cut the old ties until the new ties are in place and have been securely tied.
- If accidental extubation occurs, call for assistance. Manually ventilate the patient with a resuscitation bag if needed. Keep a tracheostomy obturator at the bedside to facilitate reinsertion of a dislodged outer cannula. For emergency replacement, keep on hand an additional tracheostomy tube of the same size and shape as the one in use.
- Do not use scissors to cut 4 x 4–inch gauze pads to make a tracheostomy dressing. Cutting causes the pads to shed fibers that the patient could inhale. Instead, use a pad specifically designed for use as a tracheostomy dressing.
Equipment
(Roll cursor over items to see labels)
Pulse oximeter
Oxygen mask and tubing
Tracheostomy care kit (contents may vary)
- Sterile 4x4 inch gauze pads
- Sterile cotton-tipped applicators
- Cleansing brush
- Suction catheter
- Sterile basin
- Sterile gloves
- Sterile drape
Sterile tracheostomy dressing (precut)
Normal saline
New inner cannula (if appropriate)
Tracheostomy tube holder
Tracheostomy humidifier (optional)
Clean gloves
Face shield (optional)
PrintableDelegation
The skill of performing tracheostomy care is not routinely delegated to NAP. In some settings, care may be delegated to NAP for patients who have well-established tracheostomy tubes. In all cases, the nurse is responsible for assessing the patient and for providing proper artificial airway care. Be sure to instruct NAP to report the following immediately:
- Any changes in the patient’s respiratory status or level of consciousness
- Increased confusion, restlessness, irritability, or change in level of comfort
- Dislodgment or excessive movement of the tracheostomy tube
- Abnormal color of the tracheal stoma and drainage
Preparation
- Observe for excessive peristomal secretions, excessive intratracheal secretions, soiled or damp tracheostomy ties, soiled or damp tracheostomy dressings, diminished airflow through the tracheostomy tube, and signs of airway obstruction requiring suctioning.
- Assess the patient’s hydration status, humidity delivered to the airway, the status of any existing infection, nutritional status, the patient’s ability to cough, vital signs, oxygen saturation, lung sounds, the patient’s ability to clear the airway, and the patient’s understanding of his tracheostomy care and his ability to perform care.
- Check when tracheostomy care was last performed.
- Have another nurse or NAP assist in tracheostomy care.
- Explain the procedure to the patient, and explain what he or she needs to do.
- Help the patient into a position that is comfortable for both you and him or her. This is usually the supine or semi-Fowler’s position with a towel placed across the patient’s chest.
Follow-up
- Compare the patient assessments performed before and after tracheostomy care.
- Assess the fit of the new tracheostomy ties. Ask the patient if the tube feels comfortable.
- Inspect both inner and outer cannulas for secretions.
- Assess the stoma for inflammation, edema, and discolored secretions.
Documentation
- Record respiratory assessments before and after care. Record the type and size of tracheostomy tube and the frequency and extent of care.
- Record the type, color, and amount of secretions, the patient’s tolerance and understanding of the procedure, and any special care taken for unexpected outcomes.
- Report accidental decannulation or respiratory distress to the health care provider.
Review Questions
1. How can the nurse best minimize a patient’s risk for infection during tracheostomy care?
Adhere to sterile technique when appropriate.
Frequently assess for signs of local or systemic infection.- Monitor for indications that tracheostomy care is needed.
- Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage.
CORRECT. Adherence to sterile technique is the most important factor in minimizing the patient’s risk for infection during tracheostomy care.
INCORRECT. Proper assessment is important but will not reduce the patient’s risk for infection during tracheostomy care.
INCORRECT. Monitoring the patient for indications that tracheostomy care is needed will not reduce the patient’s risk for infection.
INCORRECT. Although the NAP would be instructed to report changes in tracheal drainage, such notification will not minimize the patient’s risk for infection.
2. Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy?
- Having a spare oxygen mask at the patient’s bedside
- Keeping an obturator and a tracheostomy tube at the patient’s bedside
- Reviewing the agency’s policy regarding tracheostomy care
- Instructing the family to call immediately if the patient has difficulty breathing
INCORRECT. Having a spare oxygen mask at the bedside does not constitute adequate emergency planning for a patient with a tracheostomy.
CORRECT. Keeping an obturator and a tracheostomy tube of the correct size at the patient’s bedside is the best way to plan for an emergency involving a tracheostomy, such as tube dislodgement.
INCORRECT. Reviewing the agency’s policy is important, but does not by itself constitute effective emergency planning for a patient with a tracheostomy.
INCORRECT. Instructing the family to call for help if the patient has difficulty breathing is appropriate, but does not by itself constitute effective emergency planning for a patient with a tracheostomy.
3. Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy?
- Cleaning the stoma with hydrogen peroxide and drying thoroughly
- Cleaning and assessing the skin around the stoma
- Assessing temperature and reporting skin breakdown immediately
- Allowing the patient to re-oxygenate after each tracheal suctioning
INCORRECT. Hydrogen peroxide is not used to cleanse the stoma and could injure the patient’s skin.
CORRECT. Frequently cleaning and assessing the skin in the tracheostomy area will reduce the patient’s risk for skin breakdown.
INCORRECT. Assessing for signs of infection and reporting skin breakdown will not reduce the patient’s risk for injury.
INCORRECT. Re-oxygenating after suctioning will not reduce the patient’s risk for skin breakdown.
4. Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy?
- Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago
- Removing the outer cannula and placing the obturator
- Holding the tracheostomy tube while the nurse changes the neck ties
- Monitoring oxygen saturation levels and placing oxygen if needed
INCORRECT. If agency policy allows it, the NAP may perform tracheostomy care only for a patient with an established tracheostomy.
INCORRECT. Removing the outer cannula would mean that the entire tracheostomy would come out. Placing an obturator is not within the NAP’s scope of practice.
CORRECT. NAP may hold the tube while the nurse changes the ties during tracheostomy care.
INCORRECT. NAP may take a pulse oximetry reading but may not monitor changes or administer oxygen.
5. Which technique would the nurse use to change a patient’s tracheostomy ties?
- Use a slipknot.
- Ensure that two fingers fit snugly under the tie.
- Knot the ends of the tie in the eyelets on the faceplate.
- Ask the patient to hold his or her breath while the ties are changed.
INCORRECT. A slipknot could become untied. Use a square knot on tracheostomy ties.
CORRECT. When the tie is secure, two fingers should fit snugly under it.
INCORRECT. The ends of the ties are not knotted at the eyelets on the faceplate. Doing so would make it difficult to change the ties when they become soiled.
INCORRECT. The patient is not asked to hold his or her breath during tracheostomy care.
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