Effective Date: August 31, 2006 SUBJECT: TRACHEOSTOMY CARE: CLEANING OF INNER CANNULA

Transcription

1 COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 418 Effective Date: August 31, 2006 SUBJECT: TRACHEOSTOMY CARE: CLEANING OF INNER CANNULA 1. PURPOSE: To provide guidelines for care of the individual with tracheostomy and cleansing of inner cannula without compromising respiratory function, and preventing infection by using standard precautions. 2. POLICY: 1. Tracheostomy care shall only be provided by a Registered Nurse, LVN or Psychiatric Technician who has received training in and has demonstrated competency in tracheostomy care at Coalinga State Hospital. 2. Tracheostomy care does not require a physician s order. Nursing staff should always keep supplies at the individual s bedside for suctioning. Clean the new, recent tracheostomy stoma every 8 hours or more frequently if indicated by accumulation of secretions. The ties shall be changed every 24 hours or more frequently if soiled or wet. Care shall be taken to prevent accidentally dislodging the trach tube when changing the ties. 3. Sterile technique shall be maintained. Suction the trachea and pharynx thoroughly before providing tracheostomy care. 4. The blood & body fluids/substances of all individuals shall be treated as though they were infectious. Refer to Standard Precautions A.D. If accidental removal of tracheostomy tube occurs during care, immediately use Ambu bag and mask to ventilate the individual by mouth while covering the tracheostomy stoma. However, if the individual has complete upper airway obstruction, a gaping stoma or laryngectomy, mouth to stoma ventilation must be performed. 3. ASSESSMENT: 1. Identify the individual, using two forms of identification (e.g. individual s I.D. photo and one other form). -1-

2 2. Explain the procedure to individual regardless of the level of alertness or orientation. This helps to allay the individual s anxiety and elicits maximum cooperation. 3. Assess the individual s understanding/acceptance of this alteration to body image & his/her concerns regarding current treatment. Determine educational deficits when deciding what and how to provide health teaching to the individual. 4. Assess the tracheotomy for: a. Condition of the stoma e.g. redness, swelling, character of secretions, presence of purulence or bleeding. b. Examine neck for subcutaneous emphysema, which indicates air leaking into the subcutaneous tissue. c. Amount and color of exudate. d. Ability of individual to aerate the lungs successfully through the tube. 5. Assess the individual s breath sounds via auscultation and determine need for suctioning, (e.g. increased amount and viscosity of secretions and/or inadequate gas exchange and coarse adventitious breath sound, noisy breathing, prolonged expiratory sounds). 4. EXPECTED OUTCOME: 1. To facilitate the therapeutic exchange of gases 2. To prevent the transmission of pathogenic microorganisms 3. To prevent encrustation around the tracheostomy area. 4. To provide physical and emotional comfort for the individual 5. To allay the fears and anxieties of the individual concerning the altered breathing rout and loss of speaking ability. 6. To prevent accidental dislodging of the trach tube. 5. EQUIPMENT: Assemble the following equipment or obtain a prepackaged tracheostomy care kit: a. Hydrogen peroxide / 0.9% Sodium Chloride b. Tracheostomy cleaning tray c. Eye/face shield protection and gown d. Bottle of sterile water and sterile normal saline e. Packet of sterile 4x4 gauze pads f. Antiseptic skin solution or detergent g. Plastic bag h. Sterile towel i. Sterile gloves and sterile cotton tips swabs j. Tracheostomy tie tapes or available securing device -2-

3 6. INDIVIDUAL PREPARATION: 1. Observe the individual at all times. 2. Position the individual in supine position with head extended and a support under the shoulders. 3. Reassurance and clear explanations will help to allay the individual s anxiety. 4. Provide communication devices, such as writing materials, if individual is able to use. 7. IMPLEMENTATIONS AND INTERVENTIONS: CLEANING OF THE OUTER TRACHEOSTOMY (NECK PLATE) AREA: NURSING ACTION A. Wash hands before and after tracheostomy care, and wear sterile gloves. B. Open all equipment using sterile technique. C. Place sterile towel on individual s chest under tracheostomy site. D. Open 4x4 gauze and pour hydrogen peroxide and sterile water respectively while having the rest of the gauze dry. E. Put on eye/face shield and wear gown as needed. KEY POINTS A. Use Sterile Technique and Standard precaution. Keep ties in place during procedure to prevent dislodging trach tube. B. Tracheostomy care is a sterile procedure. C. Provide sterile field. D. To remove mucus and crust which promote bacterial growth. E. Follow Standard Precautions as well as sterile technique. F. Place tracheostomy tube tapes on sterile field. G. Clean the external end of the tracheostomy tube and stoma areas with gauze soaked in hydrogen peroxide twice and discard each time. G. Hydrogen peroxide will help to loosen dried secretions. -3-

4 H. Repeat step 7 above using gauze soaked with sterile water. Then repeat again using dry gauze. H. The ensures all hydrogen peroxide is removed and stoma area dried to prevent infection and irritation. 8. CLEANSING OF THE INNER CANNULA: NURSING ACTION A. Inner cannula shall be cleaned at least every 8 hours or more frequently if needed. B. Remove inner cannula and wash both inside and outside with hydrogen peroxide solution using brush or pipe cleaners. KEY POINTS A. If there is a build-up of secretions, the inner cannula may need to be cleaned more frequently to facilitate air exchange. B. Keep tapes tied to prevent accidental dislodging during cleaning. Change tapes only after all other cleaning is completed. C. Rinse with sterile saline solution and replace the obturator into inner cannula before reinserting back into outer cannula, turn cannula to lock in place. D. Two staff are required for this step: one staff to hold trach tube neck plate in place, and one staff to remove and replace to tape. Cut soiled tape and remove carefully then replace with clean tape and tie at the side of the neck in a square knot, allowing two fingers to fit between the tape and the neck. D. To prevent irritation, rotate pressure side. Tapes that are too tight will compress jugular veins, decrease blood supply to the skin. E. All disposable equipment and soiled articles are placed in plastic bags and disposed of per policy. 9. SPECIAL PRECAUTIONS: A tracheostomy cuff may be used to hold the tube in place. The soft balloon is inflated with air to prevent accidental removal, or air leaks. KEY NOTE: The cuff must be deflated at regular intervals, e.g. once each shift, to prevent damage to the trachea. -4-

5 Spontaneous extubation of the tracheostomy tube requires immediate attention. The outer cannula should be replaced under sterile conditions by a physician. KEY NOTE: Accidental dislodgement of the tracheostomy tube may occur as a result of forceful coughing, confusion, or excessive movement. This requires immediate intervention. An extra tube, obturator and hemostat shall be kept at bedside. 10. EVALUATION: Documentation should include: a. Date and time b. Problem number c. Procedure/intervention performed d. Condition, reaction, findings, and individual s response e. Health teaching with an appraisal of the individual s understanding and acceptance of altered condition f. Appearance and amount of secretions g. Follow up care needed e.g. suctioning, assessing cuff pressure, stoma care, etc. h. Use of any ancillary devices, e.g. oxygen/mist collar, C-PAP, Tracheostomy button. NOTE: The documentation should indicate that the nurse know and understood the possible side effects of tracheostomy care and took measures to ensure that individual safety and well-being was maintained. -5-