Master Tracheostomy Care with Picmonic for Nursing RN

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Tracheostomy Care

Trachea-star-mouth Care
Picmonic
A tracheostomy is a surgically created opening in the trachea that establishes an airway to bypass airway obstructions, help remove secretions, or allow long-term mechanical ventilation. The inner cannula of the tracheostomy tube should be removed and cleaned to prevent airway obstruction. The area around the stoma should be cleaned every 8 hours and the collar should be loose enough to fit two fingers underneath the band. Considerations include deflating the cuff while the patient speaks, allowing the patient to eat, and keeping a replacement tube nearby. The physician is responsible for changing the initial tube change after 7 days of placement.
8 KEY FACTS
Inner Cannula Removed and Cleaned
Inner Tube Removed to Clean

Some tracheostomy tubes have an inner cannula that should be removed during cleaning. If the inner cannula is disposable, it should be replaced with a new one. If it is non-disposable, the inner cannula is cleaned at least every 8 hours. Cleaning the inner cannula helps remove mucous accumulation inside the tube.

Clean Q8 Hours Around Stoma
(8) Ball Q-Clock with Cleaning Star-mouths

The area around the stoma should be cleaned every 8 hours. Frequent cleaning helps prevent skin breakdown and subsequent infection. If there is a tracheostomy dressing, do not cut the dressing or any 4 x 4s, as small bits of gauze could be aspirated through the tracheostomy tube.

Two Fingers Under Ties
(2) Tutu Fingers Under Tie

The tracheostomy ties should be changed as needed. During changes, the two person technique is recommended to prevent tracheostomy dislodgement. One person stabilizes the tracheostomy while the second person changes the ties. Afterwards, two fingers are placed underneath the ties to make sure they are not too tight around the neck.

CONSIDERATIONS
Speak with Deflated Cuff
Speaking with Deflating Cuff

Tracheostomies with inflated cuffs prevent patients from speaking. If patients are able to breathe spontaneously, deflating the cuff of the tracheostomy tube will allow exhaled air to flow over the vocal cords and facilitate the ability to talk. Occluding the tube will help facilitate speech. However, since this method may introduce bacteria from the fingers and cause infection, specialized tracheostomy tubes and speaking valves are encouraged to help with speech.

Can Eat with Tube in Place
Eating with Tube in Place

After tracheostomy insertion, the patient may experience difficulty swallowing. Have the patient in an upright position while eating and if possible, partially (or completely) deflate the cuff during meals. Patient should eat slowly and tuck their chin down and move the forehead forward while swallowing. Small volumes of liquid should be consumed, possibly using a spoon to control the volume. Sometimes, the patient may require a referral with a speech therapist to regain the ability to swallow.

Keep Replacement Tube Nearby
Replacement Tube Nearby

A replacement tube of equal or smaller size should be kept at the bedside in case of emergency reinsertion. If the tube is dislodged, immediately try to replace it with a new tube. Each tube has an obturator used to help ease insertion of the tube. Immediately after insertion, the obturator is removed to allow air flow and should be placed in an easily accessible location at the bedside for quick use in case the cannula is accidentally removed.

Immediately Replace if Dislodged
Trying to Replace Dislodged Tube

Since it takes 5-7 days for the stoma to fully heal, the tube may be easily dislodged and require a replacement tube. Use a curved Kelly clamp or a hemostat to spread the opening. Lubricate the tip of the replacement tube with saline and insert the tube into the stoma at a 45-degree angle to the neck. If the tube cannot be replaced, place the patient in the semi-Fowler's position and assess the patient's respiratory effort, ventilate the patient with manual resuscitation bag or bag valve mask (BVM or Ambu bag), and call the Rapid Response Team.

Physician Does First Tube Change
Physician giving First-place Tube Change

Since it takes 5-7 days for the stoma to fully heal, the first tube change is completed after at least one week following tracheostomy insertion. The physician is responsible to completing the first tube change in order to assess the status of the stoma. Afterwards, the tracheostomy tube should be changed one month after the first tube change.

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