Nursing How To’s: Tracheostomy Care and Suctioning
Lydia was reading the patient’s chart, taking down notes needed for case discussion. She browses the physician’s order sheer to check if there are new orders when she comes about a note stating that tracheostomy care must be provided to the patient and that suctioning should be done as needed. Tracheostomy care? Suctioning? What are those? She finds herself asking. Still a nursing student, she knows that she still has a lot to learn and reading this order then realizing that she is unfamiliar with those terms just prove how much she has to learn.
Both intrigued and curious, she makes a mental note to search and read about them tonight.
- Sterile disposable tracheostomy cleaning kit or supplies (sterile containers, sterile nylon brush or pipe cleaners, sterile applicators, gauze squares)
- Sterile suction catheter kit (suction catheter and sterile container for solution)
- Sterile normal saline (Check agency protocol for soaking solution)
- Sterile gloves (2 pairs)
- Clean gloves
- Towel or drape to protect bed linens
- Moisture-proof bag
- Commercially available tracheostomy dressing or sterile 4-in. x -in. gauze dressing
- Cotton twill ties
- Clean scissors
- Introduce self and verify the client’s identity using agency protocol. Explain to the client everything that you need to do, why it is necessary, and how can he cooperate. Eye blinking, raising a finger can be a means of communication to indicate pain or distress.
- Observe appropriate infection control procedures such as hand hygiene.
- Provide for client privacy.
- Prepare the client and the equipment.
- To promote lung expansion, assist the client to semi-Fowler’s or Fowler’s position.
- Open the tracheostomy kit or sterile basins. Pour the soaking solution and sterile normal saline into separate containers.
- Establish the sterile field.
- Open other sterile supplies as needed including sterile applicators, suction kit, and tracheostomy dressing.
- Suction the tracheostomy tube, if necessary.
- Put a clean glove on your nondominant hand and a sterile glove on your dominant hand (or put on a pair of sterile gloves).
- Suction the full length of the tracheostomy tube to remove secretions and ensure a patent airway.
- Rinse the suction catheter and wrap the catheter around your hand, and peel the glove off so that it turns inside out over the catheter.
- Unlock the inner cannula with the gloved hand. Remove it by gently pulling it out toward you in line with its curvature. Place it in the soaking solution. Rationale: This moistens and loosens secretions.
- Remove the soiled tracheostomy dressing. Place the soiled dressing in your gloved hand and peel the glove off so that it turns inside out over the dressing. Discard the glove and the dressing.
- Put on sterile gloves. Keep your dominant hand sterile during the procedure.
- Clean the inner cannula.
- Remove the inner cannula from the soaking solution.
- Clean the lumen and entire inner cannula thoroughly using the brush or pipe cleaners moistened with sterile normal saline. Inspect the cannula for cleanliness by holding it at eye level and looking through it into the light.
- Rinse the inner cannula thoroughly in the sterile normal saline.
- After rinsing, gently tap the cannula against the inside edge of the sterile saline container. Use a pipe cleaner folded in half to dry only the inside of the cannula; do not dry the outside.Rationale: This removes excess liquid from the cannula and prevents possible aspiration by the client, while leaving a film of moisture on the outer surface to lubricate the cannula for reinsertion.
- Replace the inner cannula, securing it in place.
- Insert the inner cannula by grasping the outer flange and inserting the cannula in the direction of its curvature.
- Lock the cannula in place by turning the lock (if present) into position to secure the flange of the inner cannula to the outer cannula.
- Clean the incision site and tube flange.
- Using sterile applicators or gauze dressings moistened with normal saline, clean the incision site. Handle the sterile supplies with your dominant hand. Use each applicator or gauze dressing only once and then discard. Rationale: This avoids contaminating a clean area with a soiled gauze dressing or applicator.
- Hydrogen peroxide may be used (usually in a half-strength solution mixed with sterile normal saline; use a separate sterile container if this is necessary) to remove crusty secretions. Check agency policy. Thoroughly rinse the cleaned area using gauze squares moistened with sterile normal saline. Rationale: Hydrogen peroxide can be irritating to the skin and inhibit healing if not thoroughly removed.
- Clean the flange of the tube in the same manner.
- Thoroughly dry the client’s skin and tube flanges with dry gauze squares.
- Apply a sterile dressing.
- Use a commercially prepared tracheostomy dressing of non- raveling material or open and refold a 4-in. x 4-in. gauze dressing into a V shape. Avoid using cotton-filled gauze squares or cutting the 4-in. x 4-in. gauze. Rationale: Cotton lint or gauze fibers can be aspirated by the client, potentially creating a tracheal abscess.
- Place the dressing under the flange of the tracheostomy tube.
- While applying the dressing, ensure that the tracheostomy tube is securely supported.Rationale: Excessive movement of the tracheostomy tube irritates the trachea.
- Change the tracheostomy ties.
- Change as needed to keep the skin clean and dry.
- Twill tape and specially manufactured Velcro ties are available. Twill tape is inexpensive and readily available; however, it is easily soiled and can trap moisture that leads to irritation of the skin of the neck. Velcro ties are becoming more commonly used. They are wider, more comfortable, and cause less skin abrasion.
Two-Strip Method (Twill Tape)
- Cut two unequal strips of twill tape, one approximately 25 cm (10 in.) long and the other about 50 cm (20 in.) long. Rationale: Cutting one tape longer than the other allows them to be fastened at the side of the neck for easy access and to avoid the pressure of a knot on the skin at the back of the neck.
- Cut a l-cm (0.5-in.) lengthwise slit approximately 2.5 cm (1 in.) from one end of each strip. To do this, fold the end of the tape back onto itself about 2.5 cm (1 in.), then cut a slit in the middle of the tape from its folded edge.
- Leaving the old ties in place, thread the slit end of one clean tape through the eye of the tracheostomy flange from the bottom side; then thread the long end of the tape through the slit, pulling it tight until it is securely fastened to the flange. Rationale: Leaving the old ties in place while securing the clean ties prevents inadvertent dislodging of the tracheostomy tube. Securing tapes in this manner avoids the use of knots, which can come untied or cause pressure and irritation.
- If old ties are very soiled or it is difficult to thread new ties onto the tracheostomy flange with old ties in place, have an assistant put on a sterile glove and hold the tracheostomy in place while you replace the ties. This is very important be- cause movement of the tube during this procedure may cause irritation and stimulate coughing. Coughing can dislodge the tube if the ties are undone.
- Repeat the process for the second tie.
- Ask the client to flex the neck. Slip the longer tape under the client’s neck, place a finger between the tape and the client’s neck and tie the tapes together at the side of the neck.Rationale: Flexing the neck increases its circumference the way coughing does. Placing a finger under the tie prevents making the tie too tight, which could interfere with coughing or place pressure on the jugular veins.
- Tie the ends of the tapes using square knots. Cut off any long ends, leaving approximately 1 to 2 cm (0.5 in.). Rationale: Square knots prevent slippage and loosening. Adequate ends beyond the knot prevent the knot from inadvertently untying.
- Once the clean ties are secured, remove the soiled ties and discard.
One-Strip Method (Twill Tape)
- Cut a length of twill tape 2.5 times the length needed to go around the client’s neck from one tube flange to the other.
- Thread one end of the tape into the slot on one side of the flange.
- Bring both ends of the tape together. Take them around the client’s neck, keeping them flat and untwisted.
- Thread the end of the tape next to the client’s neck through the slot from the back to the front.
- Have the client flex the neck. Tie the loose ends with a square knot at the side of the client’s neck, allowing for slack by placing two fingers under the ties as with the two-strip method. Cut off long ends.
- Tape and pad the tie knot.
Place a folded 4-in. x. 4-in. gauze square under the tie knot, and apply tape over the knot.Rationale: This reduces skin irritation from the knot and prevents confusing the knot with the client’s gown ties.
- Check the tightness of the ties.
Frequently check the tightness of the tracheostomy ties and position of the tracheostomy tube.Rationale: Swelling of the neck may cause the ties to become too tight, interfering with coughing and circulation. Ties can loosen in restless clients, allowing the tracheostomy tube to extrude from the stoma.
- Document all relevant information.
Record suctioning, tracheostomy care, and the dressing change, noting your assessments.
- Explain to the patient and their family that you are going to suction the tracheostomy tube.
- Hand hygiene
- Use personal protective equipment including non-sterile gloves and safety glasses.
- Suction using a clean, non-touch technique.
- Attach suction catheter to suction tubing
- Gently introduce the suction catheter into the tracheostomy tube to the pre-measured depth.3
- Apply suction & gently rotate the catheter while withdrawing. Each suction should not be any longer than 5-10 seconds.
- Assess the patient’s respiratory rate, skin color and/or oximetry reading to ensure the patient has not been compromised during the procedure. Repeat the suction as indicated by the patient’s individual condition.
- Rinse the suction catheter with sterile water decanted into bowl, not directly from bottle.
- Look at the secretions in the suction tubing – they should be clear or white and move easily through the tubing.
- Notify the parent team if the secretions are abnormal, and consider sending a specimen for culture and sensitivity.