UNIT FOUR
586
Clinical Skills and Care
Skill 28.8 Performing Tracheostomy Care
Assessment Steps 1. Verify the health-care provider’s order for tracheostomy care. Standard orders are to perform the care every 8 hours. 2. Assess the type of tracheostomy the patient has. If the inner cannula is disposable, you will need to obtain a new replace- ment cannula. If it is reusable, you will need to obtain a kit for cleaning the inner cannula. Planning Step 1. Gather needed equipment and supplies: replacement can- nula or tracheostomy care kit, hydrogen peroxide, sterile saline, sterile gloves, clean gloves, goggles and a mask, or a mask and face shield. You will need a tracheostomy holder if the patient does not use ties. You will also need a suction catheter and glove kit. Intervention Steps 1. Follow the Initial Implementation Steps located on the inside front cover. 2. Suction the tracheostomy following the steps in Skill 28.7. This removes secretions and helps keep the tracheostomy patent during the cleaning of the inner cannula. 3. Don clean gloves. This will allow you to touch the inner can- nula to remove it without contaminating your sterile gloves or exposing yourself to blood or body fluids. Cannula Care To Replace a Disposable Inner Cannula 4. Open the package containing the new inner cannula, keeping the cannula on the sterile inner surface of the package. 5. Remove the inner cannula by unlocking it, either by turning it slightly to the side or by pinching the connecting flanges so that it will easily slide out. Also remove the old tracheostomy dressing from beneath the faceplate. 6. Dispose of the inner cannula and used dressing in the biohazard trash. 7. Insert the new inner cannula by turning it so that the end you are holding is at about the 9 o’clock position. Then, as you insert it into the outer cannula, turn it gently to the 6 o’clock position. Safety: Once the new inner cannula is inserted, ensure that it clicks into place or is tightened to stay in place. 8. Go to Steps 15 to 19. To Clean and Replace a Reusable Cannula 4. Open the tracheostomy care kit and set up your sterile field. Dump the contents of the kit onto the sterile field. This allows you to use the basin for your liquids. 5. Open and pour hydrogen peroxide into the larger compart- ment in the basin to a depth of 1/2 inch. Add saline to a depth of another 1/2 inch to dilute the hydrogen peroxide. Safety: Full-strength hydrogen peroxide can be irritating to the tissues. Follow facility policy regarding the use of hydrogen peroxide. 6. Pour sterile saline in the other two compartments in the basin to be prepared to clean and rinse the inner cannula. 7. Remove the inner cannula from the tracheostomy. Remember to unlock it by turning it slightly to the side or pinching the connecting flanges so that it will easily slide out. 8. Drop the inner cannula into the basin compartment contain- ing the peroxide and saline to allow the cannula to soak.
9. Remove the old tracheostomy dressing from beneath the faceplate and dispose of it in the biohazard trash. 10. Remove your clean gloves and sanitize your hands to pre- vent cross-contamination. 11. Put on sterile gloves and arrange your supplies on your ster- ile field so that you can easily obtain what you need as you complete the procedure. 12. Use the sterile small bottle brush to clean the inside and out- side of the inner cannula with the peroxide/saline solution. 13. Place the inner cannula in a basin compartment containing only sterile saline and agitate it to rinse off the peroxide. 14. Remove the inner cannula from the saline and use a ster- ile gauze 4 × 4 to dry the outside. Use both pipe cleaners together to dry the inside of the cannula by pulling them through it. Safety: It is important to dry the inside and outside of the cannula to prevent introducing saline into the trachea and causing choking. Be alert to any threads from the gauze 4 × 4 that could cling to the cannula. It should be dry and debris free. 15. Insert the cleaned inner cannula by turning it so that the end you are holding is at about the 9 o’clock position. Then, as you insert it into the outer cannula, turn it gently to the 6 o’clock position. Safety: Once the cleaned inner cannula is inserted, ensure that it clicks into place or is tightened to stay in place. To Clean the Faceplate 16. Dip a cotton-tipped applicator from your sterile field into the unused basin compartment containing sterile saline. Use the moistened applicator to clean around the stoma to loosen dried or crusted mucus. Get a new moistened swab for each swipe to prevent cross-contamination.
17. Dampen a sterile gauze 4 × 4 in the saline and clean the faceplate of the tracheostomy. Dry the faceplate with another gauze 4 × 4. To Change the Tracheostomy Ties or Tracheostomy Holder For Twill Ties 4. If you have an assistant, have that person hold the tracheos- tomy faceplate in place while you insert one end of the tie into the slit at the side of the faceplate. Safety: If you are work- ing alone, do NOT remove the existing twill ties until the new ones are in place. 5. Bring the other end behind the patient’s neck and pull it through the slit on the other side of the faceplate. 6. Tie the two ends together at the side of the patient’s neck so that they do not lie on a knot that could cause skin break- down. Safety: Ensure that you can fit one finger between the tie and the patient’s skin to avoid making it too tight.
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