I.

ARTIFICIAL AIRWAYS: are inserted to maintain patent air passage for clients whose airway has become obstructed or
may become obstructed.

A. Endotracheal tubes: are most commonly inserted for clients who have had general anesthetics or for those in
emergency situations where mechanical ventilation is required.
B. Tracheostomy: is an opening into the trachea through the neck. The tube is usually inserted through this opening
and an artificial airway is created.
o PURPOSES:
~ To maintain patent airway.
~ Indicated to the following:

-Acute respiratory failure, CNS depression, neuromuscular disease, pulmonary disease, chest wall injury

-Upper airway obstruction (tumor, inflammation, foreign body, laryngeal spasm)

-Anticipated upper airway obstruction from edema or soft tissue swelling due to head and neck trauma,
some postoperative head and neck procedures involving the airway, facial or airway burns, decreased level
of consciousness

-Aspiration prophylaxis

-Fracture of cervical vertebrae with spinal cord injury; requiring ventilatory assistance.

o PRECAUTIONS & SPECIAL CONSIDERATIONS:

o Watch out for redness and irritation of the nasal and oral mucosa.

o Recognize that patient is usually apprehensive, particularly about choking, inability to communicate
verbally, inability to remove secretions, uncomfortable suctioning, difficulty in breathing, or mechanical
failure.
o Ensure adequate ventilation and oxygenation through the use of supplemental oxygen or mechanical
ventilation as indicated.
o Assess breath sounds every 2 hours. Note evidence of ineffective secretion clearance (rhonchi,
crackles), which suggests need for suctioning.
o Provide adequate suctioning of oral secretions to prevent aspiration and decrease oral microbial
colonization.
o Perform frequent oral care with soft toothbrush or swabs and antiseptic mouthwash or hydrogen
peroxide diluted with water. Frequent oral care will aid in prevention of ventilator-associated
pneumonia.
o Ensure that aseptic technique is maintained when inserting an ET or tracheostomy tube. The artificial
airway bypasses the upper airway, and the lower airways are sterile below the level of the vocal cords.
o Elevate the patient to a semi-Fowler's or sitting position, when possible; these positions result in
improved lung compliance. The patient's position, however, should be changed at least every 2 hours to
ensure ventilation of all lung segments and prevent secretion stagnation and atelectasis. Position
changes are also necessary to avoid skin breakdown.

(Nutritional considerations):

o Recognize that an ET tube holds the epiglottis open. Therefore, only the inflated cuff prevents the
aspiration of oropharyngeal contents into the lungs. The patient must not receive oral feeding.
Administer enteral tube feedings or parenteral feedings as ordered.
 o Administer oral feedings to a conscious patient with a tracheostomy, usually with the cuff inflated. The
inflated cuff prevents aspiration of food contents into the lungs, but causes the tracheal wall to bulge
into the esophageal lumen, and may make swallowing more difficult.
o Patients who are not on mechanical ventilation and are awake, alert, and able to protect the airway are
candidates for eating with the cuff deflated.
o To assess ability to protect the airway, sit the patient upright and feed the patient colored gelatin or
juice. If color from gelatin can be suctioned from the tracheostomy tube, aspiration is occurring, and the
cuff must be inflated during feeding and for 1 hour afterward with head of bed elevated.
o Patients should receive thickened rather than regular liquids; this will assist in effective swallowing.

o EQUIPMENT: Endotracheal Intubation

 Laryngoscope with curved or straight blade and working light source (check batteries and bulb
regularly)
 Endotracheal (ET) tube with low-pressure cuff and adapter to connect tube to ventilator or resuscitation
bag
 Stylet to guide the endotracheal tube
 Oral airway (assorted sizes) or bite block to keep patient from biting into and occluding the ET tube
 Adhesive tape or tube fixation system
 Sterile anesthetic lubricant jelly (water-soluble)
 10-mL syringe
 Suction source
 Suction catheter and tonsil suction
 Resuscitation bag and mask connected to oxygen source
 Sterile towel
 Gloves
 Face shield
 End tidal CO2 detector

o EQUIPMENT: Assisting with Tracheostomy Insertion

 Tracheostomy tube (sizes 6-9 mm for most adults)

 Sterile instruments: hemostat, scalpel and blade, forceps, suture material, scissors
 Sterile gown and drapes, gloves
 Cap and face shield
 Antiseptic prep solution
 Gauze pads
 Shave prep kit
 Sedation
 Local anesthetic and syringe
 Resuscitation bag and mask with oxygen source
 Suction source and catheters
 Syringe for cuff inflation
 Respiratory support available for post-tracheostomy (mechanical ventilation, tracheal oxygen mask,
CPAP, T-piece)

o COMPLICATIONS OF ENDOTRACHEAL AND TRACHEOSTOMY TUBES:

 Laryngeal or tracheal injury

o Sore throat, hoarse voice

o Glottic edema
o Ulceration or necrosis of tracheal mucosa
o Vocal cord ulceration, granuloma, or polyps
 o Vocal cord paralysis
o Postextubation tracheal stenosis
o Tracheal dilation
o Formation of tracheal-esophageal fistula
o Formation of tracheal-arterial fistula
o Innominate artery erosion

 Pulmonary infection and sepsis

 Dependence on artificial airway

o POSSIBLE NURSING DIAGNOSIS:

 Risk for infection
 Risk for injury(trauma)
 Risk for aspiration
 Risk for activity intolerance
 Impaired bed mobility
 Impaired social interaction
 Ineffective breathing pattern
 Disturbed body image

o TEACHINGS : Client, Community, and Home care

 Explain the function of the equipment carefully.

 Inform patient and family that speaking will not be possible while the tube is in place, unless using a
tracheostomy tube with a deflated cuff, a fenestrated tube, a Passy-Muir speaking valve, or a speaking
tracheostomy tube.
o A Passey Muir valve is a speaking valve that fits over the end of the tracheostomy tube. Air
that is inhaled is exhaled through the vocal cords and out through the mouth, allowing speech.
 Develop the best method of communication for the patient (eg, sign language, lip movement, letter
boards, paper and pencil, magic slate, or coded messages).
o Patients with tracheostomy tubes or nasal ET tubes may effectively use orally operated
electrolarynx devices.
o Devise a means for patient to get the nurse's attention when someone is not immediately
available at the bedside, such as call bell, hand-operated bell, rattle.
 Anticipate some of patient's questions by discussing “Is it permanent?” “Will it hurt to breathe?” “Will
someone be with me?”
 If appropriate, advice patient that as condition improves a tracheostomy button may be used to plug the
tracheostomy site. A tracheostomy button is a rigid, closed cannula that is placed into the tracheostomy
stoma after removal of a cuffed or uncuffed tracheostomy tube. When in proper position, the button
does not extend into the tracheal lumen. The outer edge of the button is at the skin surface and the
inner edge is at the anterior tracheal wall

 Community and Home Care Considerations

 Teach patient and/or caregiver procedure. Patient will need to use stationary mirror to visualize
tracheostomy and perform procedure.
 Suctioning patient in the home: whenever possible, patient and/or caregiver should be taught to
perform procedure. Patient should use controlled cough and other secretion clearance techniques.
 Preoxygenation and hyperinflation before suctioning may not be routinely indicated for all patients
cared for in the home. Preoxygenation and hyperinflation are based on patient need and clinical status.
  Normal saline should not be instilled unless clinically indicated (eg, to stimulate cough).
 Clean technique and clean examination gloves are used. At the end of suctioning, the catheter or tonsil
tip should be flushed by suctioning recently boiled and cooled, or distilled, water to rinse away mucus,
followed by suctioning air through the apparatus. The outer surface may be wiped with alcohol or
hydrogen peroxide. The catheter and tonsil tip should be air-dried and stored in a clean, dry place.
Generally, suction catheters should be discarded after 24 hours. Tonsil tips may be boiled and reused.
 Care of tracheostomy stoma: clean with half-strength hydrogen peroxide (diluted with sterile water),
and wipe with sterile water or sterile saline.

 PROCEDURE:

 ET INSERTION

Nursing Action Rationale

Preparatory phase
1. Assess the patient's heart rate, level of 1. Provides a baseline to estimate the patient's tolerance of the
consciousness, and respiratory status. procedure.
Performance phase
1. Remove the patient's dental bridgework and 1. May interfere with insertion. Will not be able to remove easily
plates. from the patient once intubated.
2. Remove the headboard from the bed 2. To provide room to stand behind patient's head.
(optional).
3. Prepare equipment. 3.  
  a. Ensure function of resuscitation bag with   a.The patient may require ventilatory assistance during
mask and suction. procedure. Suction should be functional because gagging
and emesis may occur during procedure.
  b. Assemble the laryngoscope. Make sure  
the light bulb is tightly attached and
functional.
  c. Select an ET tube of the appropriate size  
(6-9 mm for the average adult).
  d. Place the ET tube on a sterile towel.   d.Although the tube will pass through the contaminated
mouth or nose, the airway below the vocal cords is sterile,
and efforts must be made to prevent iatrogenic
contamination of the distal end of the tube and cuff. The
proximal end of the tube may be handled because it will
reside in the upper airway.
  e. Inflate the cuff to make sure it assumes a   e.Malfunction of the cuff must be determined before tube
symmetrical shape and holds volume placement occurs.
without leakage. Then deflate maximally.
  f. Lubricate the distal end of the tube liberally   f. Aids in insertion.
with the sterile anesthetic water-soluble
jelly.
  g. Insert the stylet into the tube (if oral   g.Stiffens the soft tube, allowing it to be more easily directed
intubation is planned). Nasal intubation into the trachea.
does not employ use of the stylet.
4. Aspirate the stomach contents if a 4. To reduce risk of aspiration.
nasogastric tube is in place.
5. If time allows, inform the patient of the  
impending inability to talk and discuss
alternative means of communication.
6. If the patient is confused, it may be 6. Restraint of the confused patient may be necessary to
necessary to apply soft wrist restraints. promote patient safety and maintain sterile technique.
7. Put on gloves and face shield. 7. Prevents contact with patient's oral secretions.
8. During oral intubation if cervical spine is not8. Upper airway is open maximally in this position.
 injured, place patient's head in a
“sniffing” position (extended at the
junction of the neck and thorax and flexed at
the junction of the spine and skull).
9. Spray the back of the patient's throat with 9. Will decrease gagging.
anesthetic spray.
10 Ventilate and oxygenate the patient with the 10.Preoxygenation decreases the likelihood of cardiac
resuscitation bag and mask before dysrhythmias or respiratory distress secondary to
intubation. hypoxemia.
11.Hold the handle of the laryngoscope in the 11.Leverage is improved by crossing the thumb and index
left hand and hold the patient's mouth open fingers when opening the patient's mouth (scissor-twist
with the right hand by placing crossed fingers technique).
on the teeth.
12.Insert the curved blade of the laryngoscope 12.Rolling the lip away from teeth prevents injury by being
along the right side of the tongue, push the caught between the teeth and the blade.
tongue to the left, and use right thumb and
index finger to pull patient's lower lip away
from lower teeth.
13.Lift the laryngoscope forward (toward ceiling) 13.Do not use teeth as a fulcrum; this could lead to dental
to expose the epiglottis. damage.
14.Lift the laryngoscope upward and forward at 14.This stretches the hypoepiglottis ligament, folding the
a 45-degree angle to expose the glottis and epiglottis upward and exposing the glottis.
visualize vocal cords.
15.As the epiglottis is lifted forward (toward 15.Do not use the wrist. Use the shoulder and arm to lift the
ceiling), the vertical opening of the larynx epiglottis.
between the vocal cords will come into view
(see accompanying figure).
16.Once the vocal cords are visualized, insert the tube 16.Make sure you do not insert the tube into the esophagus;
into the right corner of the mouth and pass the tube the esophageal mucosa is pink and the opening is
while keeping vocal cords in constant view. horizontal rather than vertical.
17.Gently push the tube through the triangular space 17.If the vocal cords are in spasm (closed), wait a few seconds
formed by the vocal cords and back wall of trachea. before passing tube.
18.Stop insertion just after the tube cuff has 18.Advancing the tube further may lead to its entry into a
disappeared from view beyond the cords. mainstem bronchus (usually the right bronchus) causing
collapse of the unventilated lung
19.Withdraw laryngoscope while holding ET tube in  
place. Disassemble mask from resuscitation bag,
attach bag to ET tube, and ventilate the patient.
20.Inflate the cuff with the minimal amount of air 20.Listen over the cuff area with a stethoscope. Occlusion
required to occlude the trachea. occurs when no air leak is heard during ventilator inspiration
or compression of the resuscitation bag.
21.Insert a bite block if necessary. 21.This keeps the patient from biting down on the tube and
obstructing the airway.
22.Ascertain expansion of both sides of the chest by 22.Observation and auscultation help in determining that tube
observation and auscultation of breath sounds. remains in position and has not slipped into the right
mainstem bronchus.
23.Record distance from proximal end of tube to the 23.This will allow for detection of any later change in tube
point where the tube reaches the teeth. position.
24.Secure the tube to the patient's face with adhesive 24.The tube must be fixed securely to ensure that it will not be
tape or apply a commercially available endotracheal dislodged. Dislodgement of a tube with an inflated cuff may
tube stabilization device. result in damage to the vocal cords.
25.Obtain a chest X-ray to verify tube position.  
26.Document and monitor tube distance from lips to end 26 Assures correct placement of the tube.
of ET tube.
Follow-up phase
1. Record tube type and size, cuff pressure, and patient 1. ABGs may be prescribed to ensure adequacy of ventilation
tolerance of the procedure. Auscultate breath sounds and oxygenation. Tube displacement may result in
every 2 hours or if signs and symptoms of respiratory extubation (cuff above vocal cords), tube touching carina
distress occur. Assess ABGs after intubation if (causing paroxysmal coughing), or intubation of a mainstem
requested by the health care provider. bronchus (resulting in collapse of the unventilated lung).
2. Measure cuff pressure with manometer; adjust 2. The tube may be advanced or removed several centimeters
pressure. Make adjustment in tube placement on the for proper placement based on the chest X-ray results.
basis of the chest X-ray results.
  ASSISTING WITH TRACHEOSTOMY INSERTION

Nursing Action Rationale

Performance phase

1. Explain the procedure to the patient. 1. Apprehension about inability to talk is usually a major concern of
Discuss a communication system with the tracheostomized patient.
the patient.
2. Obtain consent for operative procedure.  

3. Shave neck region. 3. Hair and beard may harbor microorganisms. If the beard is to be
removed, inform the patient or family.
4. Assemble equipment. Using aseptic 4. Ensures that the cuff is functional before tube insertion.
technique, inflate tracheostomy cuff and
evaluate for symmetry and volume
leakage. Deflate maximally.
5. Position the patient (in a supine position 5. This position brings the trachea forward.
with head extended and a support
under the shoulders).
6. Obtain an order for and apply soft wrist 6. Restraint of the confused patient may be necessary to ensure
restraints if the patient is confused. patient safety and preservation of aseptic technique.
7. Give medication if ordered. 7. Sedation may be needed.

8. Position the light source.  

9. Assist with antiseptic prep.  

10.Assist with gowning and gloving.  

11.Assist with sterile draping.  

12.Put on face shield. 12. Spraying of blood or airway secretions may occur during this
procedure.

. During procedure, monitor the patient's 13. Bradycardia may result from vagal stimulation due to tracheal
vital signs, suction as necessary, give manipulation, or hypoxemia. Hypoxemia may also cause cardiac
medication as prescribed, and be irritability.
prepared to administer emergency care.
14.Immediately after the tube is inserted, 14. Ensures ventilation of both lungs.
inflate the cuff. The chest should be
auscultated for the presence of bilateral
breath sounds.
15.Secure the tracheostomy tube with twill  
tapes or other securing device and
apply dressing.
16.Apply appropriate respiratory assistive  
device (mechanical ventilation,
tracheostomy, oxygen mask, CPAP, T-
piece adapter).
17.Check the tracheostomy tube cuff 17. Excessive cuff pressure may cause tracheal damage.
pressure.
18.“Tie sutures” or “stay 18. Should the tracheostomy tube become dislodged, the stay
sutures” of silk may have been sutures may be grasped and used to spread the tracheal cartilage
placed through either side of the apart, facilitating placement of the new tube.
tracheal cartilage at the incision and
brought out through the wound. Each is
 to be taped to the skin at a 45-degree
angle laterally to the sternum.

Follow-up phase

1. Assess vital signs and breath 1. Provides baseline.

sounds; note tube size used,
physician performing procedure,
type, dose, and route of medications
given.
2. Obtain chest X-ray. 2. Documents proper tube placement.

3. Assess and chart condition of stoma: 3.  

  a. Bleeding a. Some bleeding around the stoma site is not unusual for the first few
hours. Monitor and inform the physician of any increase in bleeding.
  b. Swelling Clean the site aseptically when necessary. Do not change tracheostomy
ties for first 24 hours, because accidental dislodgement of the tube could
result when the ties are loose, and tube reinsertion through the as yet
unformed stoma may be difficult or impossible to accomplish.
  c. Subcutaneous air c. When positive pressure respiratory assistive devices are used
(mechanical ventilation, CPAP) before the wound is healed, air may be
forced into the subcutaneous fat layer. This can be seen as enlargement
of the neck and facial tissues and felt as crepitus or “cracking”
when the skin is depressed. Report immediately.
4. An extra tube, obturator, and 4. The hemostat will open the airway and allow ventilation in the
hemostat should be kept at the spontaneously breathing patient. Avoid inserting the tube horizontally,
bedside. In the event of tube because the tube may be forced against the back wall of the trachea.
dislodgement, reinsertion of a new
tube may be necessary. For
emergency tube insertion:
  a. Spread the wound with a hemostat  
or stay sutures.
  b. Insert replacement tube  
(containing the obturator) at an
angle.
  c. Point cannula downward and  
insert the tube maximally.
  d. Remove the obturator.  
II. SUCTIONING: Is aspirating secretions through a catheter connected to a suction machine or wall suction outlet. Suction
catheters may be either open tipped or whistle tipped. The whistle tipped catheter is less irritating to respiratory tissues,
although the open tipped catheter may be more effective for removing thick mucous plug.

a. Oropharyngeal suctioning: removes secretions from the upper respiratory tract

b. Nasopharyngeal and Nasotracheal suctioning: provides closer access to the trachea and
requires sterile technique.

 PURPOSE:

- To remove secretions that obstruct the airway

-To facilitate ventilation
-To obtain secretions for diagnostic purposes
-To prevent infection that may result from accumulated secretions

 PRECAUTIONS AND SPECIAL CONSIDERATIONS:

- Watch out for: narrowing of the airway, respiratory insufficiency, and stasis of secretions.

- Special Considerations:

o Maintain sterile technique while suctioning

o Administer supplemental 100% oxygen through the mechanical ventilator or manual resuscitation bag
before, after, and between suctioning passes to prevent hypoxemia.
o Closed system suctioning may be done with the suction catheter contained in the mechanical ventilator
tubing. Ventilator disconnection is not necessary so time is saved, sterility is maintained, and risk of
exposure to body fluids is eliminated.
o Oral suctioning using a Yankauer suction tube and oropharyngeal suctioning using a suction catheter can
be delegated to UAP and to the client or family, if appropriate, since this is not a sterile procedure. The
nurse needs to review the procedure and important points such as not applying suction during insertion of
the tube to avoid trauma to the mucous membrane. In contrast, nasopharyngeal and nasotracheal
suctioning uses sterile technique and requires application of knowledge and problem solving and should be
performed by the nurse or respiratory therapist.

 EQUIPMENTS:

 Oral and Nasopharyngeal/Nasotracheal Suctioning

 Towel or moisture-resistant pad

 Portable or wall suction machine with tubing collection receptacle, and suction pressure gauge
 Sterile disposable container for fluids
 Sterile normal saline or water
 Goggles or face shield, if appropriate
 Moisture-resistant disposal bag
 Sputum trap, if specimen is to be collected
  Oral and Oropharyngeal Suctioning

 Yankauer suction catheter or suction catheter kit

 Clean gloves

 Nasopharyngeal or Nasotracheal Suctioning

 Sterile gloves
 Sterile suction catheter kit (#12 to #18 Fr for adults, #8 to #10 Fr for children, and #5 to #8 Fr for
infants)
 Water-soluble lubricant
 Y-connector

 COMPLICATIONS:
 Trauma of mucous membrane
 POSSIBLE NURSING DIAGNOSIS:
 Risk for injury (trauma)
 Risk for infection
 Fear
 TEACHINGS: Client, Community and Home care
o Explain to the client the purpose of suctioning
o Teach caregivers to suction in the home situation using clean technique, rather than sterile. Wash hands
well before suctioning.
o Put on fresh examination gloves for suctioning, and reuse catheter after rinsing it in warm water.
o Be aware that appropriate and aggressive airway clearance will assist in preventing pulmonary
complications, thus lessening the need for hospitalization.
 PROCEDURE:
 Nursing action Rationale

Performance Phase

1. Prior to performing the procedure, introduce self and verify -Knowing that the procedure will relieve
the client’s identity using agency protocol. Explain to the breathing problems is often reassuring
client what you are going to do, why it is necessary, and how and enlists the client’s cooperation.
he or she can cooperate. Inform the client that suctioning will
relieve breathing difficulty and that the procedure is painless
but may be uncomfortable and stimulate the cough, gag, or
sneeze reflex.

2. Perform hand hygiene and observe other appropriate

infection control procedures.

3. Provide client privacy.

4. Prepare the client.

 Position a conscious person who has a functional
gag reflex in the semi-Fowler’s position with the
head turned to one side for oral suctioning or with
the neck hyperextended for nasal suctioning.
.
 Position an unconscious client in the lateral position,
facing you.
 Place the towel or moisture-resistant pad over the
pillow or under the chin.
5. Prepare the equipment.
-These positions facilitate the insertion
of the catheter and help prevent
aspiration of secretions.
- This position allows the tongue to fall
forward, so that it will not obstruct the
catheter on insertion. The lateral
position also facilitates drainage of
secretions from the pharynx and
prevents the possibility of aspiration.

 Set the pressure on the suction gauge, and the turn

on the suction. Many suction devices are calibrated
to three pressure ranges.
 Wall init:
Adult: 100 to 120 mm Hg

Child: 95 to 110 mm Hg

Infant: 50 to 95 mm Hg

 Portable unit:
Adult: 10 to 15 mm Hg

Child: 5 to 10 mm Hg

Infant: 2 to 5 mm Hg

For Oral and Oropharyngeal Suction__

 Moisten the tip of the Yankauer or suction catheter

with sterile water or saline. -This reduces friction and eases
insertion.

 Pull the tongue forward, if necessary, using gauze.

 Do not apply suction (that is, leave your finger off the
port) during insertion. - Applying suction during insertion
Tracheostomy Care (Routine)
 PURPOSE:
- To maintain airway patency
-To maintain cleanliness and prevent infection at the tracheostomy site
-To facilitate healing ang prevent skin excoriation around the tracheostomy incision
-To promote comfort

 EQUIPMENTS
Assemble the following equipment or obtain a pre-packaged tracheostomy care kit:

 Sterile towel
 Sterile gauze pads (10)
 Sterile cotton swabs
 Sterile gloves
 Hydrogen peroxide
 Sterile water
 Antiseptic solution and ointment (optional)
 Tracheostomy tie tapes or commercially available tracheostomy securing device
 Face shield

PROCEDURE

Nursing Action Rationale

Preparatory phase
1. Assess the condition of the stoma before tracheostomy care (redness, 1. The presence of skin breakdown or
swelling, character of secretions, and presence of purulence or bleeding). infection must be monitored. Culture of the
site may be warranted by appearance of
these signs.
2. Examine the neck for subcutaneous emphysema. 2. Indicates air leak into subcutaneous tissue.
Performance phase
1. Suction the trachea and pharynx thoroughly before tracheostomy care. 1. Removal of secretions before
tracheostomy care keeps the area clean
longer.
2. Explain the procedure to the patient.  
3. Wash hands thoroughly.  
4. Assemble equipment: 4.  
  a. Place sterile towel on patient's chest under tracheostomy site.   a.Provides sterile field.
  b. Open 4 gauze pads and pour hydrogen peroxide on them.   b.For removal of mucus and crust, which
promotes bacterial growth.
  c. Open 2 gauze pads and pour antiseptic solution on them.   c. May be applied to fresh stoma or
infected stoma. Not necessary for clean,
healed stoma.
  d. Open 2 gauze pads; keep dry.    
  e. Open 2 gauze pads and pour sterile water on them.    
  f. Place tracheostomy tube tapes on field.    
  g. Put on face shield and sterile gloves.   g.Face shield prevents secretions from
getting into the nurse's eyes. Sterile
gloves prevent contamination of the
wound by nurse's hands and also protect
the nurse's hands from infection.
5. Clean the external end of the tracheostomy tube with 2 gauze pads with 5. Designate the hand you clean with as
hydrogen peroxide; discard pads. contaminated and reserve the other hand
as sterile for handling sterile equipment.
6. Clean the stoma area with 2 peroxide-soaked gauze pads. Make only a 6. Hydrogen peroxide may help loosen dry
single sweep with each gauze pad before discarding. crusted secretions.
7. Loosen and remove crust with sterile cotton swabs.    
8. Repeat step 6 using the sterile water-soaked gauze pads. 8. Ensures that all hydrogen peroxide is
removed.
9. Repeat step 6 using dry pads. 9. Ensures dryness of the area. Wetness
promotes infection and irritation.
10.(optional) An infected wound may be cleaned with gauze saturated with an 10.May help clear wound infection.
antiseptic solution, then dried. A thin layer of antibiotic ointment may be
applied to the stoma with a cotton swab.
11.Change a disposable inner cannula, touching only the external portion, and 11.Because cannula is dirty when you remove
lock it securely into place. If inner cannula is reusable, remove it with your it, use your contaminated hand. It is
contaminated hand and clean it in hydrogen peroxide solution, using brush considered sterile once you clean it, so
or pipe cleaners with your sterile hand. When clean, drop it into sterile handle it with your sterile hand.
saline solution and agitate it to rinse thoroughly with your sterile hand. Tap
it gently to dry it and replace it with your sterile hand.
12.Change the tracheostomy tie tapes: 12. 
  a. Cut soiled tape while holding tube securely with other hand. Use care not   a.Stabilization of the tube helps prevent
to cut the pilot balloon tubing. accidental dislodgement and keeps
irritation and coughing due to tube
manipulation at a minimum.
  b. Remove old tapes carefully.    
  c. Grasp slit end of clean tape and pull it through opening on side of the    
tracheostomy tube.
  d. Pull other end of tape securely through the slit end of the tape.    
  e. Repeat on the other side.    
  f. Tie the tapes at the side of the neck in a square knot. Alternate knot from   f. To prevent irritation and rotate pressure
side to side each time tapes are changed. site.
  g. Ties should be tight enough to keep tube securely in the stoma, but   g.Excessive tightness of tapes will
loose enough to permit two fingers to fit between the tapes and the neck. compress jugular veins, decrease blood
circulation to the skin under the tape,
and result in discomfort for the patient.
13.Place a gauze pad between the stoma site and the tracheostomy tube to  
absorb secretions and prevent irritation of the stoma according to institution
policy (see accompanying figure). Many clinicians believe that gauze should
not be used around the stoma. In their opinion, the dressing keeps the area
moist and dark, promoting stomal infection. They believe the stoma should
be left open to the air and the surrounding area kept dry. A dressing is used
only if secretions are draining onto subclavian or neck I.V. sites or chest
incisions.
Note: If only one clinician is available, the stoma is new (< 2 weeks), or the  
patient's condition is unstable, follow steps c through f before removing old
tapes. Two sets of ties will be in place at the same time. After completing step
f, cut and remove the old tapes. Also, a tracheostomy-securing device can be
used instead of the tracheostomy ties.
Follow-up phase
1. Document procedure performance, observations of stoma (irritation, 1. Provides a baseline.
redness, edema, subcutaneous air), and character of secretions (color,
purulence). Report changes in stoma appearance or secretions.
2. Clean the fresh stoma every 8 hours or more frequently if indicated by 2. The area must be kept clean and dry to
accumulation of secretions. Ties should be changed every 24 hours, or prevent infection or irritation of tissues.
more frequently if soiled or wet.
A Written Report in
NCM 202 SKILLS
Topics:
I. Artificial airways
-Endotracheal tube
- Tracheostomy tube
~Trache care
II. Suctioning
-Oropharyngeal
-Nasopharyngeal
-Trache tube(Nasotracheal)

Submitted by :

GROUP 4
Olivar, Joan Christine D.

Paguio, Unica Q.

Ramirez, Zola Belle P.

Rufo, Arzel C.

Sevilla, Maria iara Arlene L.

Supranes, Princess Charmaine E.

Tariga, Gestine U.

Tuzon, May B.

Villalobos, Guia S.

Yumang, Ryan Isaac K.