7.9 : Tracheostomy Care I: Pre-procedural Steps

A tracheostomy is a surgical technique that involves making an incision in the neck to provide access to the trachea. It is frequently used in medical conditions such as airway obstruction and prolonged mechanical ventilation. Effective nursing management is crucial for the long-term success of a tracheostomy.

Required Equipment

The equipment necessary for tracheostomy care includes:

1. Disposable and sterile gloves
2. Goggles and mask or face shield
3. Additional PPE, as indicated
4. Sterile normal saline
5. Sterile cup or basin
6. Sterile cotton-tipped applicators
7. Sterile gauze sponges
8. Disposable inner tracheostomy cannula, appropriate size for the patient
9. Sterile suction catheter and glove set
10. Commercially prepared tracheostomy or drain dressing
11. Commercially prepared tracheostomy holder
12. Plastic disposal bag
13. Additional nurse for assistance

Stepwise Procedure with Rationale

1. Preparation: The nurse gathers all necessary equipment and places it on the bedside stand or overbed table to save time and energy. Hand hygiene is performed, and PPE is donned to prevent the spread of microorganisms.
2. Patient Identification and Privacy: The nurse identifies the patient to ensure the correct patient receives the intervention and to prevent errors. Privacy is provided by closing curtains around the bed and the door to the room, if possible.
3. Pain Assessment and Explanation: The nurse determines the need for tracheostomy care, assesses the patient's pain, and administers pain medication if indicated. For new tracheostomies, pain medication may be necessary before care is performed.
4. Explanation and Patient Positioning: The nurse explains the procedure and its purpose to the patient, even if the patient is not alert, to reduce anxiety. The nurse reassures the patient that the procedure will be stopped if any respiratory difficulty is indicated. The bed is adjusted to a comfortable working position, and the patient is placed in a semi-Fowler's position if conscious or in a lateral position if unconscious.
5. Pre-cleaning: The nurse puts on a face shield or goggles and mask, and suctions the tracheostomy, if necessary, to clear secretions, maintaining sterility throughout the process.
6. Changing the Inner Cannula: The nurse replaces the old inner cannula with a new one, maintaining sterility throughout the process and ensuring continuous O₂ supply.
7. Post-cleaning: The nurse cleans the stoma under the faceplate with sterile saline, moving from the stoma site outward. The area is then gently patted dry with a sterile gauze sponge to remove excess moisture.
8. Applying Clean Dressing and Holder: The nurse slides a commercially prepared tracheostomy or pre-folded non-cotton-filled dressing under the faceplate to prevent aspiration into the trachea and irritation or infection.
9. Changing the Tracheostomy Holder: With the assistance of a second nurse, the old collar is replaced with a new one to ensure that the tracheostomy tube remains securely in place, even if the patient coughs or moves.
10. Reassessment: The nurse reassesses the patient's respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds, to determine the effectiveness of the interventions and the presence of any complications.