Trach Care

Supplies needed
1. Disposable inner cannula
2. Trach care kit
  1. 2 cotton-tipped applicators
  2. 2 pipe cleaners
  3. Trach cleaning brush
  4. Gauze
  5. Split trach dressing
  6. Sterile gloves
3. New ties or velcro holder
4. An extra pack of sterile 4×4 gauze
5. Sterile saline
  1. Avoid using hydrogen peroxide unless infection is present – it can impair healing
6. Towel – place across patient’s chest
Follow your facility’s policy on frequency of dressing changes
Change whenever soiled as secretions can dry and cause maceration to skin

Assessment

Assess stoma for skin breakdown or signs of infection

Nursing Concepts

Steps and Nursing Considerations
1. Gather supplies
2. Explain procedure to patient
3. Perform hand hygiene
4. Raise bed to comfortable working height
5. Don clean gloves
6. Open sterile trach care kit and sterile pack of 4×4 gauze
7. Pour sterile saline solution into the pack of 4×4 gauze
8. Open the following supplies onto the sterile field using sterile technique:
  1. Split trach dressing
  2. New disposable inner cannula
  3. Trach ties or velcro holder
    1. *NOTE* if this is NOT sterile, simply ensure that it is open and available within arms reach
9. Remove inner cannula with non-dominant hand
  1. If not disposable, place on a towel or other area besides the sterile field
10. Carefully remove the existing dressing and discard
11. Remove gloves and perform hand hygiene
12. Carefully remove sterile glove pack from kit without touching other parts
13. Apply sterile gloves appropriately
  1. Keep dominant hand sterile throughout procedure
14. Use a combination of the cotton-tipped applicators and pipe cleaners to clean secretions from the outside flange of the tracheostomy – do not insert into the stoma
15. Use the saline-soaked gauze to clean under the flange.
  1. Ring out the saline, slip one end under the flange and pull it out the other side
  2. Carefully lift the flange to assess and clean the bottom of the stoma
16. Once satisfied with cleaning, replace inner cannula with new, clean disposable cannula and lock in place
17. Holding trach secure with your nondominant hand, remove one side of the ties with your dominant hand
  1. May require a small pair of scissors
  2. May require two hands to untie knot – but do NOT remove unless holding trach secure
18. Insert new ties through the now-empty flange and secure velcro or pull almost halfway through
19. With one hand, slide both new and old ties behind the patient’s head (still holding the trach with your other hand)
20. Pull the new ties snug, remove the old tie from the flange
21. Secure the new ties to the other side of the flange
  1. Should be tight enough to fit 2 fingers snugly
  2. Not so tight that it causes the patient to cough
22. Carefully place the new split dressing under the flange around the trach
  1. Should be high enough to be under the flange to prevent skin breakdown
23. Per facility policy – label dressing
24. Discard all used supplies in the appropriate waste container
25. Remove gloves
26. Perform hand hygiene
27. Return bed to low/locked position
28. Ensure patient is comfortable
29. Document procedure and patient response/tolerance

Patient Education

Purpose for and importance of trach care
Keep hands down to prevent contaminating sterile field
When performed at home, this is a clean procedure – patients will require education on how to self-care

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Transcript

In this video we’re going to look at trach care. Remember you should always suction the patient before trach care, so if you haven’t watched that skill video yet, make sure you watch it! And remember as you’re doing this, you want to be assessing the stoma for signs of infection or skin breakdown.

First you’re going to open your sterile trach care kit and a sterile 4×4 pack of gauze, then pour sterile saline solution into the pack of gauze. You’ll notice the nurse is wearing goggles. If the patient coughs, you could get exposed, so we always recommend goggles or a face shield for trach care.

Then you have some other supplies that you need access to, so you’re going to open those onto your sterile field inside your kit. The new dressing, the new inner cannula, and the trach ties. Now – if your trach ties, or trach holder ISN’T sterile, just open it and set it next to the sterile field so that you can reach it.

Now you need to remove the inner cannula – these are disposable, so this will just get tossed. And remove the old dressing as well. Then remove your gloves and perform hand hygiene.

Now you can grab the sterile glove pack from the kit and put on your sterile gloves. Again, go to the Sterile Gloves skill video if you need help here. You’re gonna keep your dominant hand sterile throughout the whole procedure.

To clean the secretions from the flange of the tracheostomy, you’ll use a combination of the cotton-tipped applicators and pipe cleaners. Just don’t insert them into the stoma itself. If needed, you can dip them into the saline solution.

To clean under the flange and around the stoma, you’re going to use the saline-soaked gauze. You’ll want to grab a piece of gauze and ring it out, then stick it under the flange and pull it out the other side – you can use the end of the cotton-tipped applicator to help push it through if you need to.

Repeat this with a clean piece of gauze each time, and use another piece to wipe off any excess secretions if you need to. Make sure you’re lifting the flange to clean underneath it.

Once you’re satisfied with cleaning, you need to replace inner cannula with new, clean disposable inner cannula and lock it in place.

If you have to clean your inner cannula, you’ll use the brush in the kit and sterile saline solution. Notice we do NOT use hydrogen peroxide unless there is an obvious skin infection – it prevents healing.

Now it’s time to change the trach ties. Make sure your new ties are ready to go and within arms reach. You want to always keep one hand on the trach itself and start by untying one side of the existing ties. If you have a velcro holder like this, simply undo the velcro and pull it out of the flange.

Then you’re going to insert the new ties through that flange hole and secure the velcro. Remember, you have to keep one hand on the trach in case the patient coughs – that thing could fly right out!

With one hand, slide both the new and the old ties behind the patient’s head (still holding the trach with your other hand) and pull the new ties snug.

Now you can remove the old ties from the other flange and secure the new ties to the other side. Just make sure they aren’t twisted.

Check to make sure you can fit 2 fingers snugly beneath the ties. Too loose and the trach could dislodge, too tight and it could irritate the patient and make them cough.

Last step – you will carefully place the new split dressing under the flange around the trach. Again, you can use the tip of the cotton-tipped applicators if you need help pushing it up under the flange. Make sure it’s high enough to be under the flange to prevent skin breakdown.

Then you’ll label the dressing per facility policy, discard all your supplies, and document the procedure.

Easy as that, right!? The big thing to remember is that the respiratory system is sterile, so anything going INTO the trach or around the stoma HAS to be sterile. And, of course, keep one hand on the trach at all times when you’re changing the ties!
We hope that was helpful! Now, go out and be your best selves today. And, as always, happy nursing!

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Outline

Overview

Nursing Points

General

Assessment

Nursing Concepts

Patient Education

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