Tracheostomy: site care, suctioning, and readiness.
Patients with a tracheostomy are considered to be high risk and have numerous complexities for nurses to consider. In addition to understanding facility policy regarding tracheostomy care, nurses must possess the specific knowledge and skills to provide successful care for affected patients (Nance-Floyd, 2011). Nursing priorities for the patient with a tracheostomy must be supportive, lending focus to maintaining and improving respiratory function while preventing complications. Whether the nurse is a novice or experienced, caring for a patient with a tracheostomy can be an intimidating experience. In this article, a patient care scenario is incorporated to review tracheostomy site care, indications for suctioning, and potential emergent considerations associated with tracheostomy care.
A 44-year-old male has been hospitalized as a result of a severe chemical irritation of his airways. He collapsed 6 weeks ago while cleaning a hazardous spill at a local distribution plant. His admission to the intensive care unit was followed by insertion of a tracheostomy and mechanical ventilator support. He has a full code status and is alert and oriented in four spheres. His communication is achieved through use of pencil and paper, pictures, hand signals, and head nodding. He has been given nothing by mouth since admission. He initially was given continuous intravenous fluid (IV) therapy to support hydration and subsequently was prescribed total parenteral nutrition (TPN). His condition has improved over several weeks, and he has been removed from the ventilator and transferred to the medical-surgical unit. He has had a percutaneous endoscopic gastrostomy (PEG) tube placed in lieu of the TPN and IV fluids; he receives nutritional feedings and free water through the PEG. He is receiving 2 liters/minute of oxygen at 28% humidification via a tracheostomy collar. Although he has a good cough reflex, copious secretions present a constant airway management challenge. His current vital signs are as follows: temperature (T) 99.4[degrees] F, heart rate (HR) 86 beats/minute, respirations 18 breaths/minute, blood pressure (BP) 148/78 mm Hg, and pulse oximetry 99%. His pain is being managed, with a target of 3-4 on a 1-10 pain-intensity scale. One hour ago, he was medicated for complaints of pain in his neck and upper chest (6/10). Currently, he holds up three fingers as the nurse asks about his pain intensity. The nurse decides this is a great opportunity to perform tracheostomy site care.
Tracheostomy Site Care
Determining adequate respiratory function is always the top assessment priority, which begins as soon as the nurse sees the patient. A combination of inspection and auscultation can yield important assessment data (see Table 1). Another important consideration (and a continued struggle for nurses) is lighting. Appropriate lighting is essential for performing a quality assessment (Johnson et al., 2013). When the nurse is unable to visualize the tracheostomy stoma and surrounding skin areas clearly with the available room lighting, a penlight should be used.
Once the respiratory assessment has been completed, tracheostomy site care can become center stage. Experts recommend having two persons at the bedside for this nursing care task (Johnson et al., 2013; Nance-Floyd, 2011). Before the nurse begins the site cleaning, he or she should consider the nursing process and the corresponding points displayed in Table 2.
The skin around the stoma must be kept clean and dry to prevent maceration and infection. The nurse must assess the area for redness, tenderness, and firmness (The Cleveland Clinic, 2014). Skin integrity under the tracheostomy flange must be inspected closely for indications of pressure. New tracheostomies are at greater risk for bleeding; however, no site should have purulent drainage. Cellulitis also may form at the tracheostomy site (Lindman et al., 2014). Any of these problems, of course, should be reported to the health care provider immediately. The patient with copious secretions requires greater vigilance with airway assessments and skin care. While current guidelines do not specify when tracheostomy dressing changes should be scheduled, once per shift and as needed (when wet or soiled) is the common practice (Nance-Floyd, 2011).
The nurse must verify the type and size of tube being used. The tube may or may not have a double lumen, a cuff, or a fenestration (Johnson et al., 2013; Khan, 2012; Lindman et al., 2014). If the patient has a tracheostomy with a double lumen, the nurse should ensure the correct size inner cannula is available for the patient. Depending on the type of tracheostomy, the inner cannula may be removed and cleaned (for reuse) during tracheostomy care. Removing the inner cannula facilitates cleaning without compromising the airway, allows for secretions to be cleared, and helps decrease the risk of mucous plugging (Khan, 2012; Lindman et al., 2014).
The patient's size determines the tracheostomy size (neonatal, pediatric, adult). The tube size is printed on the flange (Khan, 2012), and should be approximately three-fourths of the patient's tracheal diameter. For example, an average-sized male commonly has a number 8 Shiley tube placed, while a female of average size may have a number 6 Shiley tube (Lindman et al., 2014). For securing the tracheostomy, Velcro[R] fasteners are softer than string ties and are a good choice for promoting skin integrity and patient comfort. The general rule is to be able to place two fingers between the patient's neck and the tracheostomy fastener (Frace, 2010; The Cleveland Clinic, 2014).
Humidification is another important consideration. Inspired air is not filtered, warmed, or humidified naturally when a tracheostomy is in place because the tracheostomy bypasses the upper-airway structures that perform these functions for the body (Frace, 2010). The nurse must monitor the patient's hydration and ensure supplemental humidification of oxygen is achieved, as both will aid in liquefying secretions (Khan, 2012; Nance-Floyd, 2011; The Cleveland Clinic, 2014). Normal saline should not be instilled in the tracheostomy in an attempt to loosen secretions (Nance-Floyd, 2011).
The need for suctioning must be based on an ongoing, individualized assessment. Close monitoring is essential for the patient who is at risk for ineffective airway clearance. The patient's respiratory status must remain the focus, and no set schedule should exist for tracheostomy suctioning (Nance-Floyd, 2011).
The suction device should be tested at the beginning of the shift and upon suction set-up to ensure it is operational. What could be worse than to need suction for a patient in respiratory distress, only to find the suction does not work? The recommended suction pressure for an open-system is up to 120 mm Hg; for a closed-system (with mechanical ventilation), the recommendation is up to 160 mm Hg (Nance-Floyd, 2011). Similar to tracheostomy tubes, suction catheters are available in a variety of sizes. According to Nance-Floyd, the following formula can be used to determine the correct-size French catheter needed for your patient:
(Internal tracheostomy tube size / 2) x 3 = Size of French catheter needed
Prior to suctioning, the nurse should oxygenate the patient through use of the hyper-oxygenation capability (if on a ventilator) or by giving four to six compressions with the manual ventilator bag. Sterility must be maintained during the suctioning procedure. No more than three passes with the catheter should be made, and the nurse must allow the patient to recover (20-30 seconds) after each pass (Nance-Floyd, 2011). Prior to each new pass, the nurse should clear the catheter by placing the tip into the sterile saline and applying suction. The distance for catheter insertion should not exceed the length of the tracheostomy tube, so the measurement must be confirmed. Tracheitis and tracheal ulceration may occur if the catheter is advanced too far (Lindman et al., 2014). Intermittent suctioning should be limited to 10 seconds during the extraction of the catheter, not only because the catheter obstructs the airway but also because the suction pulls the air from the lungs (Lindman et al., 2014; Nance-Floyd, 2011). With an assistant at the bedside, the nurse may perform hyperoxygenation between catheter passes.
Readiness to Respond
Providing care for a patient who has a tracheostomy can be a challenge. In an emergent circumstance, that challenge can intensify to a stressful or even fearful event for the patient and the nurse. Patient and family education, which must be specific and ongoing, is a mandatory inclusion. Rounding frequently, being prepared mentally, communicating with other staff members concerning the patient's tracheostomy tube, and having the right tools at the bedside (see Table 3) should provide the keys to successful emergency response (Frace, 2010; Nance-Floyd, 2011).
Continuing the Patient Scenario
During previous shifts, the nurse has provided tracheostomy care and suctioning for this patient without any difficulties. The nurse knows the facility policy, believes nursing skills have improved significantly by having the opportunity to care for such a unique patient, and feels confident. During shift report, the nurse is advised the patient has been very restless. The off-going nurse reports the patient was suctioned numerous times, and his secretions appeared to be a bit thicker than usual. As rounds begin, the nursing assistant presses the patient's call bell and calls for assistance. Current vital signs are documented as follows: T 99.8[degrees] F, HR 98 beats/minute, R 26 breaths/minute, and BP 152/82 mm Hg. His pulse oximetry reading is 89% and dropping. The patient's eyes convey the fear and anxiety he is feeling. His breathing is extremely labored, and his neck and upper chest are wet with a large amount of thick, white mucous. He is unsuccessful at clearing his airway by coughing, and his oximetry reading has dropped to 86%. At a quick glance, the nurse notices the humidification bottle is empty and quickly prepares to perform tracheostomy suctioning (using sterile technique). Three passes remove a significant amount of thick mucus. Although the patient is now able to cough more effectively, the nurse remains concerned as his oximetry is only 89%. The nurse decides to remove the inner cannula. Clinging to the cannula is a mucous plug, which has caused partial occlusion of the opening. The patient's oxygen saturation begins to rise (93%). The nurse inserts a replacement inner cannula just as the nursing assistant brings in the new humidification bottle. The patient now has a patent inner cannula, unlabored respirations at 20 per minute, humidification, and a pulse oximetry reading of 99%. A sense of calm reduces his heart rate, and his eyes communicate relief and gratitude.
The primary patient problem in this case is apparent. The patient's secretions had become increasingly viscous from lack of humidification. A thorough assessment would have revealed the empty humidification bottle. Upon recognizing that a patient's secretions have become thicker, the nurse immediately should consider if the patient's hydration is adequate and ensure the humidification system is working properly. Both are important, and a complete assessment must include support equipment critical to the patient's condition. Some patients may require an order for a mucolytic as well.
Airway management is a critical priority of patient care and requires a swift response (Johnson, 2013). The nurse must be knowledgeable and skilled in caring for patients with tracheostomies. Medical-surgical nursing requires readiness for crises. Being prepared to provide general tracheostomy care and suctioning and to apply critical thinking and skill during emergent circumstances are essential for successful patient outcomes.
Frace, M.A. (2010). Tracheostomy care on the medical-surgical unit. MEDSURG Nursing, 79(1), 58-61.
Johnson, W.A., Pinto, J.M., Paz, M., & Baroody, F.M. (2013). Tracheostomy tube change. Retrieved from http://emedicine. medscape.com/article/1580576-overview
Khan, M.K. (2012). Tracheostomy tubes. Retrieved from http://emed icine.medscape.com/article/2044774-overview
Lindman, J.P., Morgan, C.E., Peralta, R., & Elluru, R.G. (2014). Tracheostomy. Retrieved from http://emedicine.medscape.com/ article/865068-overview
Nance-Floyd, B. (2011). Tracheostomy care: An evidence-based guide to suctioning and dressing changes. American Nurse Today, 7(6). Retrieved from http://www.americannursetoday.com/tracheostomy -care-an-evidence-based-guide-to-suctioning-and-dressingchanges/
The Cleveland Clinic. (2014). Tracheostomy care. Retrieved from http://my.clevelandclinic.org/services/head-neck/treatmentsservices/tracheostomy-care
Mary L. Schreiber, MSN, RN, CMSRN, is Nursing Faculty Member, Orangeburg-Calhoun Technical College, Orangeburg, SC, and a speaker for PESI Healthcare.
Table 1. Key Points for the Respiratory Assessment * What is the patient's respiratory rate? * Is the patient exhibiting labored breathing? * Are there adventitious lung sounds on auscultation? * Can the patient cough effectively to clear secretions? * What is the quantity and characteristics of any secretions? * Are there any signs and symptoms of infection? * What is the pulse oximeter reading? * Is the supportive equipment working properly? Sources: Frace, 2010; Nance-Floyd, 2011 TABLE 2. Nursing Process and Key Points for Tracheostomy Care Nursing Process Key Points for Tracheostomy Care Assessment * Ensure adequate lighting. * Ensure proper patient positioning. * Perform a respiratory assessment. * Inspect the stoma site, area under the tracheostomy flange, and surrounding skin of the neck and upper chest. --Skin integrity: redness, tenderness, firmness, edema, drainage or bleeding, foul odor --Characteristics of mucous --Abnormalities related to the tube * Inspect the skin where the tracheostomy ties touch the neck Diagnosis * Potential for ineffective airway clearance * Potential for airway obstruction * Potential for alteration of skin integrity * Risk for infection Planning * Gather supplies. --Tracheostomy care kit (verify contents) --Suction kit and sterile saline (always available at bedside) * Ask a co-worker for assistance. * Ensure use of the appropriate personal protective equipment. --Goggles and gloves at a minimum --Additional precautions per patient condition * Ensure emergency supplies are available at the bedside. * Communicate the plan with the patient (and family). * Prepare mentally for the procedure. Implementation * Verify the patient's pulse oximetry result. * *** If needed, suction the patient at this time. *** * Ensure the patient remains adequately oxygenated. --Keep the tracheostomy collar in place as much as possible during the cleaning process (remove it while cleaning an area, replacing it while preparing to the clean the next area). * Maintain sterility during the process. * For double lumen tracheostomies, remove the inner cannula. --If changing, ensure the correct size is available for replacement. * Cleanse the stoma area using gauze dampened with sterile saline (a clean gauze for each wipe). * Cleanse the flange and tube in the same manner (dampened with sterile saline; a clean gauze for each wipe). --Most tracheostomy care kits have hydrogen peroxide, sterile saline, tiny brushes, and cotton swabs for cleaning. --After cleansing, rinse the flange well by wiping with moist gauze (use sterile saline). --An inner cannula must be rinsed free of hydrogen peroxide before reinsertion (use sterile saline). --Proceed cautiously in using hydrogen peroxide on the skin (very irritating). * Apply a clean dressing around the tracheostomy site and under the flanges. --Use only a manufactured fenestrated/split-drain or foam dressing. --Never cut gauze for use around the stoma, as the frayed fibers may be inhaled. * Change the ties or Velcro holder. --Ensure the tracheostomy tube is stabilized properly related to the risk for dislodgement as the ties are changed. Evaluation * Ask the following questions regarding the patient's status: --Is the tracheostomy in place properly? --Is the patient being oxygenated properly? ** What is the patient's pulse oximetry reading? --Is the humidification system working properly? --Is the tracheostomy site clean and dry? --What is the condition of the skin integrity around the stoma site? --How did the patient tolerate the procedure? --Is the patient comfortable? Sources: Frace, 2010; Nance-Floyd, 2011; The Cleveland Clinic, 2014 TABLE 3. Essential Bedside Equipment for the Tracheostomy Patient * Manual ventilation bag * Suction device and tubing (wall or bedside) * Suction catheters --Yankauer (rigid) --Flexible * Sterile saline * Additional tracheostomy tubes (for dislodged tracheostomy) --One to be the same size as the patient's current tube --One to be one size smaller than the patient's current tube * Obturator (for insertion ease in the event the trach becomes dislodged) Sources: Johnson et al., 2013; Lindman et al., 2014; Nance-Floyd, 2011
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|Title Annotation:||Clinical 'How To'|
|Author:||Schreiber, Mary L.|
|Date:||Mar 1, 2015|
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