Clinical Pearls: Tracheostomy Care for the Acute Care Nurse,
by Janelle Nobrega.
Hello, my name is Janelle Nobrega,
I am a Clinical Nurse Specialist at Boston Children's Hospital.
This presentation is designed to give
a broad overview of the care considerations for a patient
with a tracheostomy.
I will review safety checks, suctioning, humidification,
site care, and emergency response.
Safety Checks.
All supplies that may be needed to change a tracheostomy tube
should be readily available at the bedside or within reach.
Your bedside safety checks should include a pulse oximetry
monitor, a cardiac monitor if clinically indicated
for your patient, a spare tracheostomy tube
the same size currently in place, a spare tracheostomy
tube one size smaller than currently
in place, water-soluble lubricant and a syringe
for cuffed tubes, humidification,
oxygen setup if clinically indicated,
suction equipment and supplies, bandage scissors,
and a self-inflating ambu bag with a pop-off valve.
An easy way to remember these items is the acronym MASHTT.
M stands for monitor: cardiac and pulse oximeter.
A stands for ambu bag with pop-off.
S stands for suction.
H stands for humidity.
And the two T's at the end stand for your spare
trach the same size and your spare trach one size smaller.
Suctioning.
Suctioning a tracheostomy should be
done at a minimum of every 8 hours,
and as needed when clinically indicated
by clinical assessment to ensure patency
of the artificial airway.
Depth of suction is determined by adding the shaft
length of the tracheostomy tube to the adapter/flextend length,
and then adding one centimeter so
that you can suction just below the end
of the tracheostomy tube.
Apply suction while withdrawing the catheter
for no more than five to ten seconds per pass.
Instillation of saline is not routine practice
and should only be utilized for thick secretions.
Here at Boston Children's Hospital,
we use clean technique for suctioning
a tracheostomy in the inpatient areas,
and sterile technique for suctioning a tracheostomy
in the intensive care units.
This is because patients with a fresh tracheostomy
are at greater risk of infection than patients
with mature stomas.
Your institution may have different guidelines.
Humidification.
Our institutional policy at Boston Children's requires
that all patients with a tracheostomy tube
have either an active or a passive humidification device.
All patients use an active humidification device
while sleeping.
Do not use a passive device when the patient
is unattended or unable to remove
the device him or herself.
An example of an active humidification device
that we use here at Boston Children's Hospital
is a large volume nebulizer.
If no supplemental oxygen is required
and optimal aerosol output is desired,
a large volume nebulizer can be operated utilizing a wall air
flow meter.
Set the dial to 0.35 to 0.40 to activate the Venturi effect.
An example of a passive humidification device
is a heat moisture exchange or an HME device.
When utilizing an HME, check periodically and assure
that it is clear of secretions.
Replace the HME if secretions are visualized.
After applying an HME, assess for changes
in respiratory status, including work
of breathing and tachypnea.
Consider decreasing the use of an HME
or changing to an active humidification device
if there is an increase in the viscosity of airway secretions.
If supplemental oxygen is required
you may utilize a large volume nebulizer or an HME.
When utilizing a large volume nebulizer
ensure use of an oxygen flow meter
and adjust the FDO2 dial accordingly
to maintain acceptable oxygen saturations for your patient
per prescriber order.
Note that if a FDO2 of greater than 50% is required,
consult respiratory therapy to ensure proper oxygen delivery
setup.
If supplemental oxygen is required with an HME
you must utilize an HME with an oxygen adapter.
Connect the side port via oxygen tubing to a wall oxygen flow
meter.
Adjust the flow accordingly to the patient's oxygen
requirement per prescriber orders.
Consult your institutions HME device manual
to review the appropriate adjustment range of oxygen flow
through an HME as this may vary according to the manufacturer
of the device.
Site Care.
Tracheostomy site care should be performed daily at a minimum,
and tracheostomy ties should be changed daily
to allow for assessment of the tracheostomy stoma
and the peristomal skin as well as the surrounding
skin of the neck.
Tracheostomy site care can be performed with sterile saline.
Consider quarter strength hydrogen peroxide
for sites with drainage and consult
your institutional experts for assessment as needed.
Neck care can be performed with mild soap and water.
Removing tracheostomy ties is always a two person procedure.
This procedure can be performed by any combination of nurses,
respiratory therapists, or caregivers.
Ensure that only one small finger thickness
can be inserted between the neck and the tracheostomy ties
in the sitting or side lying position.
The inner cannula of a double lumen tracheostomy tube
is cleaned or replaced at least once a day and as needed.
A nurse, respiratory therapist, or caregiver
can change the inner cannula.
Note that the first tracheostomy change is often
done by the surgeon, a physician assistant, or a nurse
practitioner.
Routine tracheostomy change frequency
is determined by the patient's surgeon.
That procedure will not be demonstrated in this video.
Emergency Response.
In the event of an unplanned decannulation,
a tracheostomy obstruction, or if the patient
is in any distress, call for help immediately
and activate the emergency response
per your institutional policy.
Attempt to replace the tracheostomy tube one time
if you are comfortable.
Direct responders to your safety supplies,
including the spare tracheostomy tubes present at the bedside.
If the patient has a critical airway
you may need to page advanced providers for assistance.
Thank you very much for watching this video
on care considerations for a patient with a tracheostomy.
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