- The client/caregiver can define a tracheostomy.
- It is the insertion of a tube into the trachea by making a surgical incision.
- The opening is called a “stoma.”
- It can be permanent or temporary.
- The client/caregiver can list indications for the use of a tracheostomy tube.
- Tumor occluding the airway
- Upper airway obstruction from a foreign body, edema, or mucus
- Radial neck resection surgery or laryngectomy
- Inability to maintain a patent airway
- To provide a method of mechanical ventilation
- The client/caregiver can describe a tracheostomy tube.
- The tracheostomy tube can be semiflexible plastic, rigid plastic, or metal.
- The tracheostomy tube consists of
- Outer cannula
- Inner cannula
- Obturator (used for initial placement and then removed)
- The tube may be cuffed or uncuffed.
- The tube is held in place by Velcro strips fastened around the neck. Usually sterile gauze pads (drain or pre-cut by manufacturer) are placed between the skin and edges of the tracheostomy cuff. Avoid cutting a gauze pad because fragments of gauze may enter the stoma.
- The client/caregiver can demonstrate cleaning the inner cannula.
- Wash hands. Put on clean gloves and remove soiled gauze dressing. Discard dressing inside of removed gloves.
- Wash hands and open tracheostomy cleaning kit without contamination.
- Put on sterile gloves.
- Add sterile normal saline in one side of the sterile kit basin and equal parts hydrogen peroxide and saline in the other side.
- If kit does not include sterile saline and peroxide, have assistants pour correct solutions.
- Unlock inner cannula and turn counter-clockwise. Remove and place in peroxide and saline solution to soak.
- Clean inside and outside the outer cannula with a brush or pipe cleaner.
- Rinse cleans the cannula in normal saline and removes excess liquid by tapping against the basin.
- Replace the inner cannula and turn clockwise until it clicks into place and dots on both cannula match.
- Cleanse around the stoma with Q-tips dipped into hydrogen peroxide.
- Then rinse with a normal saline soaked Q-tip.
- Replace drain (precut) gauze under the sides of the outer cannula.
- Check ties for fit and evaluate whether it needs to be changed due to soiling.
- After cleanup, place a pressure call bell, tap bell, or whatever method is used for the client to signal for assistance.
- The client/caregiver can demonstrate changing tracheostomy ties.
- Always have two people for this procedure so that one person can hold the tube firmly in place while the other person changes the ties.
- Use the Velcro strips provided in the tracheostomy care kit.
- Allow enough space for the little finger to fit between the strip and the client’s skin.
- The client/caregiver is aware of the need for skin care.
- Assess for signs and symptoms of infection (i.e., fever, redness, and irritation).
- Cleanse skin frequently, and place a dry gauze around the stoma.
- The client/caregiver can state the procedure to follow if the trach tube accidentally falls out.
- Remove the inner cannula from the dislodged tube.
- Insert the obturator into the outer cannula, and reinsert the tube.
- Remove the obturator and insert the inner cannula.
- The client/caregiver can list general precautions.
- Do not allow smoking in the same room.
- Avoid aerosol sprays and dust that may enter the trach.
- Provide adequate humidification.
- Keep a suction machine at the bedside at all times.
- Perform suctioning as needed, but avoid over-suctioning because it may increase secretions.
- Tape the obturator to the head of the bed, and keep an extra tracheostomy set and hemostat at the bedside.
- Prevent infection with good oral hygiene; avoid persons with respiratory infections. Use good hand-washing procedures.
- Avoid getting any water into the stoma.
- Use other communication techniques if speaking is impaired (call bell, sign language, pictures, etc.).
- Cover the stoma loosely if going out into very cold weather.
- Drink at least 3000 ml of water per day unless contraindicated.
- Avoid smoking.
- Wear a Medic Alert bracelet.
- Keep follow-up appointments with physician.
Resources
American Head and Neck Societywww.headandneckcancer.org/patienteducation/docs/tracheostomy.php
Speech therapist
Support groups
Medical supply company
References
Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care. St. Louis: Mosby Inc.Canobbio, M. M. (2006). Mosby’s handbook of patient teaching. St. Louis: Mosby Inc.Taylor, C., Lillis, C., & LeMone, P. (2005). Fundamentals of nursing. Philadelphia: Lippincott, Williams & Wilkins.Timby, B. K., & Smith, N. C. (2003). Introductory medical-surgical nursing (8th ed.). Philadelphia: J. B. Lippincott
Credits
Client Teaching Guides for Home Health Care, 2nd ed.© 2008 Jones and Bartlett Publishers, Inc.www.jbpub.com