Tracheostomy care

Authors: Rednenko V.V., Rednenko L.I., Oladzko A.A.

Editor: Rednenko V.V.

Equipment for the practical skill:

• Tracheostomy simulator
• Tracheostomy tube

• Skin antiseptic
• 0.9% sodium chloride solution sterile 200 ml 
• 2% sodium bicarbonate solution 200 ml
• Tray (for washing the inner tube)
• Towel
• Sterile tweezers - 2 pcs.
• Scissors
• Zinc paste
• Medical spatula
• Electric pump (Janet syringe)
• Sterile suction catheter
• Syringe of volume 2-5 ml
• Sterile gauze pad - 2 pcs.
• Sterile gauze ball 
• Washing brush suitable for cleaning the inner surface of the inner cannula
• Non-sterile bandage (string)

• working solution of a chemical disinfectant in containers:
  • "Rinsing of MI"
  • "Disinfection of MI"
  • "Disinfection of dressings, PPE"
• medical waste container
  • "Plastic" 
    "Packaging" 

Clinical situation:

• Patient K, 48 years old, who is in the surgical department, after surgery for a tumor of the larynx, a tracheostomy tube was installed (3 days ago). Upon examination by a doctor, it was revealed: the patient often coughs, has difficulty breathing through the tracheostomy, due to thick sputum. The doctor prescribed sanitation of the tracheostomy 2-3 times a day with the insertion of a catheter to a depth of 10 cm, with preliminary introduction of 2 ml of sterile isotonic sodium chloride solution into the lumen of the tube to dilute sputum.
• You are a nurse in the surgical department. Care for the patient's tracheostomy.

Order of the skill performance:

Preparatory stage:

• Greet the patient, introduce yourself, identify the patient (specify the last name, first name and patronymic of the patient)
• Inform the patient about the procedure, get consent to giving it
• Prepare your workplace
  • Check the integrity of the packages of sterile medical items, dressings, protective paste  and expiration dates
  • Arrange items for the procedure on a manipulative table
• Prepare the patient for the procedure
  • Assist the patient to get into a comfortable position: the upper half of the body should be at an angle of 30-45 degrees (half-Fowler or Fowler position)
• Put on your protective equipment
  • Put on your apron, mask
  • Perform hygienic hand antisepsis
  • Put on non-sterile gloves
• Prepare the MI for the procedure
  • Open the package with gauze pads and balls
  • Open the package with suction catheter
  • Open the package with a spatula
  • Open the package with tweezers
  • Open the bottle with 0.9% sodium chloride solution
  • Prepare 2% sodium bicarbonate solution
    • take a container large enough to soak and wash the inner cannula of the tracheostomy tube (tray, glass, etc.)
    • take 120 ml of warm boiled water and dissolve 1 teaspoon of sodium bicarbonate in it
    • pour this solution into the prepared container

Maine stage:

• Cover the area around the tracheostomy with a towel
• Sanitize the trachea with an electric suction (if it is not available with a Janet syringe):
  • withdraw 1-2 ml of sterile 0.9% sodium chloride solution into the syringe
  • inject this solution into the lumen of the tracheostomy tube without a needle
  • ask the patient to clear their throat
  • take the sterile suction catheter from the cover and connect it to the electric pump
  • lubricate (wet) the suction catheter
    • take a bottle with isotonic sodium chloride solution
    • take a tray
    • pour over the distal end of the suction catheter over the tray, without touching it with the bottle
  • insert the catheter into the tracheostomy inner cannula to a depth, usually the length of the inner tube (5-8 cm), a deeper insertion of the suction catheter should be directed by the doctor
  • ask the patient to hold his breath, turn on the electric suction (pressure not higher than 25 mm Hg)
  • continue suction during which the patient can hold his own breath (within 5-10 s) and remove the catheter
  • turn off the electric pump
• remove the inner tracheostomy cannula:
  • turn the "lock-flag" of the outer tracheostomy cannula to the "up" position
  • grip the "ears" of the internal tracheostomy cannula with your thumb and forefinger
  • fix the neckplate with the thumb and forefinger of the other hand
  • pull the inner tracheostomy cannula out of the outer cannula by the "ears" in an arcuate movement
• treat the inner tracheostomy cannula 
  • dip the internal tracheostomy cannula into a container with warm 2% sodium bicarbonate solution
  • clean the outer surface and the canal of the internal tarcheostomy cannula with a brush
  • rinse the internal tracheostomy cannula under running water
  • rinse the internal tracheostomy cannula with sterile 0.9% sodium chloride solution by pouring it from a bottle over a tray
• place the internal tracheostomy cannula back
  • fix the outer tracheostomy tube plate with the thumb and forefinger of the non-dominant hand
  • take the "ears" of the inner tracheostomy cannula with the thumb and forefinger of your dominant hand and insert the inner cannula into the outer cannula
  • move the "lock-flag" to the down position
• dressing
  
  • take tweezers and gently remove the used pad from under the neckplate
  • place the pad and tweezers in the waste tray
  • take a gauze ball with another tweezers, moisten it with antiseptic and treat the skin around the tracheostomy
  • place the gauze ball and tweezers in the waste tray
  • take a spatula and lubricate the skin around the tracheostomy with zinc paste
  • place the spatula in the waste tray
  • take a sterile pad and cut it with sterile scissors by T-shape cut
  • place the pad under the neckplate
  • cut 2 strips of bandage of 15 and 30 cm long with scissors
  • tie them to the holes on the outer cannula neckplate and tie them on the side of the neck

Final stage:

• place the used MI in the appropriate containers
• remove the mask and place it in the  "Disinfection of dressings, PPE" container 
• take off the  apron and disinfect it using spray metod
• take off gloves, place it in the "Disinfection of dressings, PPE" container
• perform hygienic hand washing
• record the procedure in the medical records