Effective: Revised: April 15, 2016 SUCTIONING, MODIFIED STERILE TRACHEAL

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Norah Hunter
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1 SUCTIONING, MODIFIED STERILE TRACHEAL Purpose: Tracheal suctioning is performed to remove secretions and maintain a patent airway. Additional Authority: Nevada Revised Statute, Nevada Nurse Practice Act, School Nurse Advisory Opinion, CCSD Regulation Health & Welfare: Students Scope: School Nurses, Specialized Procedure Nurses, contracted licensed staff (RN, LPN) and qualified, trained unlicensed assistive personnel (UAP) Responsible Party: Health Services Director Distribution: Health Services Coordinators, School Nurses, Specialized Procedure Nurses, First Aid Safety Assistants, Health Services Department Secretarial Staff and other UAP trained to the procedure 1.0 Policy 1.1 Suctioning is performed using a modified sterile technique with a singleuse sterile catheter and clean gloves for each procedure. 1.2 New LHCP orders must be obtained annually and reviewed by school nurse prior to student returning to school Parent/guardian signature is required for every new and revised order Revised LHCP orders are recommended whenever there is a change in student s health status and are required if the student has undergone a medical procedure or hospitalization.

2 1.3 All equipment for suctioning must be assembled and ready for immediate use at all times Equipment must be checked daily by designated personnel prior to the child getting on the bus or upon arrival to school Student may not be on campus without all necessary equipment Equipment check must be documented on the Tracheostomy Equipment Checklist. 1.4 Single-use sterile catheters are required Sterile gloves are not required but may be used if provided with the suction catheters Students who require ventilator support while at school may have a closed suction catheter system in place. The closed suction catheter system must always remain in line with the ventilator tubing Inline catheter systems will be changed by the parent/guardian based upon the catheter manufacturer s recommendation. 1.5 Modified sterile tracheal suctioning is performed by a licensed nurse when a student with a tracheostomy cannot adequately clear respiratory secretions Qualified, trained unlicensed personnel may only perform this procedure in an emergency.

3 1.6 As an emergency measure, a licensed nurse may perform deep suctioning. This procedure cannot be delegated. Deep suctioning will be performed as follows: The insertion depth of the suction catheter may be up to a maximum of 1 ½ times the pre-measured suction catheter length or until resistance is met, whichever comes first. (e.g., Length of trach tube is 7 cm, emergency deep suctioning procedure would allow the insertion depth up to 10.5 cm) EMS Dispatch will be activated if emergency deep suctioning is employed Student must go home with parent/guardian if EMS does not transport following deep suctioning If deep suctioning has been performed, the school nurse must notify the Health Services Coordinator LHCP notification will be done, as appropriate. New orders and return to school clearance may be required Under special circumstances, the student may remain at school and a second deep suctioning episode may be allowed if ordered by the LHCP. Student must go home after 2 nd emergency suctioning intervention. 1.1 Only licensed nurses will use a manual resuscitation device such as a bag-valve-mask (BVM) or Ambu bag.

4 1.1.1 If CPR/AED certified, qualified UAP will provide mouth-to-stoma or mouth-to-mouth resuscitation using an appropriate barrier device. 2.0 General Guidelines 2.1 Indications for modified sterile tracheal suctioning include the following: Noisy, rattling breath sounds Secretions that are visible in the tracheostomy opening Respiratory distress (such as congestion, difficulty breathing, agitation, paleness, excessive coughing, cyanosis, nasal flaring or retractions) Obstructed airway 3.0 Procedure ESSENTIAL STEPS KEYPOINTS-PRECAUTIONS 1. Review current LHCP Orders 2. Conduct equipment checks 3. Wash hands. Use Universal Precautions 4. Auscultate breath sounds anteriorly and posteriorly (licensed nurses only) unless emergency suctioning required 5. Assemble the equipment and materials on a clean work surface: Suctioning machine Sterile, single-use suction catheters or sleeved catheters of prescribed size. Sterile saline or sterile water used to clear catheter, if available Container for saline or water, if available Listening to breath sounds before suctioning to determine need for suctioning Students, who self-suction and selfmanage their own care, may re-use their equipment per their routine care procedures. All suction catheter types can only be used during one suctioning session.

5 Disposable gloves Bag Valve Mask device (licensed nurses only) Saline dosettes (licensed nurses only) 6. Position student. Position may vary according to student need. 7. Explain procedure at student s level of understanding. 8. Turn on suction machine and check for suction 9. Open catheter suction kit. 10. Open a saline dosette as per LHCP orders, if dosettes are provided by parent (licensed nurses only) 11. Fill sterile cup/container with sterile saline/water (if available) 12. Put on gloves 13. Depth of suction catheter insertion is to be pre-measured. Do not insert suction catheter past the distal tip of the tracheostomy tube in place. 14. As an emergency measure, the depth of the suction catheter insertion may be increased up to a maximum of 1 ½ times the premeasured suction catheter length. 15. As an emergency measure, if oxygen is ordered and available, increase oxygen to 6-10 liters until saturation have returned to prescribed level. 16. While holding the end of the suction catheter in dominant hand, attach it to the suction machine tubing held in the non-dominant hand Depth of insertion can be premeasured from another tracheostomy tube of the same size that is in place for student. For example, length of the tracheostomy tube is 7cm, in an emergency when standard suction depth is ineffective, this would allow for an insertion depth up to 10.5 cm. 911 will be activated, student to go home. Once pulse oxygen level is maintained, flow of oxygen will be titrated down to maintain student s pulse oximetry measurement within the student s normal range. Maintain modified sterile technique. The dominant hand should remain clean. It should not touch anything but the catheter.

6 17. Turn on the suction machine with non-dominant hand 18. Test that the suction machine is functioning 19. Encourage the student to take a deep breath and cough 20. With thumb off of the vent hole, gently and quickly insert catheter into tracheostomy, to premeasured mark on suction catheter. 21. Cover vent hole with thumb while withdrawing catheter. Each insertion and withdrawal of the catheter must be completed within 5 to 10 seconds. 22. Perform a maximum of 3 passes per catheter use for each suctioning session. 23. Suction saline or sterile water again through catheter to rinse secretions from catheter and tubing as needed. 24. Disconnect catheter from suction tubing. Wrap catheter around gloved hand. Pull gloves off inside out. The non-dominant hand should be used to turn on switches or touch other objects. Leave the other end of the catheter in its cover until ready for use Hold suction catheter 2 3 inches from tip with dominant hand and insert tip in sterile saline/water (if available). Check for suction by holding nondominant gloved finger over vent hole of suction device. Do not apply suction during the catheter insertion; only apply suction during withdrawal of the catheter. Coughing may indicate that the suction catheter has passed the end of the tracheostomy tube. If resistance is met, do not advance the catheter further into the tube. Rotate catheter gently between thumb and index finger while suctioning and withdrawing. Prolonged suctioning blocks the student s airway and can cause a dangerous drop in the oxygen level. Allow student to rest and catch breath for seconds between passes. BVM-assisted breaths may be provided after 3 passes by licensed nurses only, if needed.

7 25. Discard used suction catheter in appropriate receptacle and wash hands. 26. Note color, consistency (e.g., thin, thick) and quantity of secretions. 27. Auscultate breath sounds anteriorly and posteriorly (licensed nurses only). 28. Be sure suction equipment and supplies are restocked and ready for immediate use. Report any changes from student s usual pattern to parent/guardian and school nurse. Listening to breath sounds before and after suctioning determines effectiveness in clearing airway. POSSIBLE PROBLEMS REQUIRING IMMEDIATE ATTENTION OBSERVATION 1. The student shows any of the following signs of respiratory distress: Coughing Color changes Wheezing or noisy breathing Agitation Retractions ACTION/REASON This may be due to a plugged tracheostomy tube from mucus, aspiration of foreign matter, or accidental dislodgement of the tube. Reassure student. Check air movement from tracheostomy. Check placement of tracheostomy tube. If tracheostomy is securely in place, suction. 2. If moist, gurgling noises or whistling sounds are heard, or if mucus is seen at the tracheostomy opening, repeat suctioning procedure. 3. Student has thick, difficult to remove secretions. If the above measures are unsuccessful in relieving respiratory distress, Activate EMS (9-1-1 dispatch) and provide CPR if necessary. If appropriate, ask the student if further suctioning is needed If prescribed, insert several drops of saline into tracheostomy with non-

8 4. Suction catheter will not pass, or there is no air movement from the tracheostomy tube. 5. Tracheostomy tube is dislodged and attempt to insert new tracheostomy tube is unsuccessful dominant hand. Manually ventilate with BVM to disperse saline (licensed nurses only).this helps to loosen and thin out thick or dry secretions. Remove tracheostomy tube and attempt to insert new tracheostomy tube (See Tracheostomy Tube Replacement) Activate EMS (9-1-1 dispatch). Closely monitor ventilation and perfusion. If student is spontaneously breathing, administer blow-by oxygen, if ordered. If indicated, begin pulmonary resuscitation, remove tracheostomy tube, pinch nose, cover stoma with gloved finger and proceed with mouthto-mouth breaths. If unsuccessful provide mouth-tostoma breaths while closing the mouth and pinching the nose. 6. Bleeding occurs during suctioning The secretions become blood-tinged and the student is not in respiratory distress. If student becomes unconscious, follow CPR guidelines. Stop suctioning and check vacuum pressure setting. Recommended: Children: mm Hg Adults: mm Hg If bleeding, adjust to lower setting than recommended. Continue suctioning as necessary to clear the airway. A large amount of blood is suctioned from the tracheostomy For excessive bleeding, activate EMS (9-1-1 dispatch). Begin CPR if necessary. 7. Student becomes hypoxic Use BVM and oxygen, if indicated and prescribed (licensed nurses only) 8. Aspiration of foreign material (e.g. Auscultate lungs, suction, then

9 food, sand) auscultate lungs again. Add saline, if available, and give breaths with BVM (licensed nurses only) after initial suctioning, if ordered. Repeat above steps until aspirated secretions are clear or gone. If tracheostomy tube remains blocked by foreign material, call 911 and remove the tracheostomy tube. Change tracheostomy tube and check air movement. Administer blowby oxygen if prescribed. Respiratory distress or arrest can occur with any aspiration. Begin CPR, if needed. 4.0 Documentation 4.1 Document procedure in the electronic medical record (Healthmaster) and electronic billing record (EdPlan). 5.0 References, Sources, Bibliography 5.1 See Reference List in Respiratory chapter. 6.0 Authorizations Health Services Director (Print) Signature Date Medical Consultant (Print) Signature Date

Effective: September, 2011 Revised: August 17, 2016 TRACHEOSTOMY TUBE REPLACEMENT

Effective: September, 2011 Revised: August 17, 2016 TRACHEOSTOMY TUBE REPLACEMENT TRACHEOSTOMY TUBE REPLACEMENT Purpose: Emergency tracheostomy tube replacement occurs when the tube becomes blocked, dislodged or has been unintentionally removed. Additional Authority: Nevada Revised