NICU Basics for Tracheostomy Care

NICU 3/2010

Skills Day Education

Compiled by,

June Amling RN, MSN

Pamela Allen RN

Pam Dozier RN, BSN

Signs, Guidelines, & ‘Ready to Go Bag’

Signs, Guidelines, & ‘Ready to Go Bag’

Hyperextension & Off-loading Hyperextension & Off-loading

1. Copy of the NPG (found under Nursing Policies on the Intranet)

2. ‘Critical Airway Sign’ for fresh post-op trach patient.

3. “I have a Tracheostomy”sign at bedside & must be kept updated

4. Respiratory card on the ventilator with tracheostomy specifications

5. ‘Ready to Go’ Bag 6. Keep the yellow/green label on

the front package of a customized Bivona tracheostomy box. The cover lists the specific re-ordering info for that patient’s trach. Tuck this in the patient’s “Ready to Go” bag.

The “Musts” for Tracheostomy Patients

Important Points to Remember with the

Fresh Post-op Tracheostomy Patient

*Keep patient’s head midline & hyperextended at all times.

*Trach care must be done with cluster cares ie: q3-4hrs.

* Assess stoma site with each cluster cares. Look for any skin breakdown around neck or at stoma site.

*Ties are not to be changed until after the first trach change has been done by ENT (usually 5-7days post-op)

*‘For preventative reasons & upon returning from OR apply 2 pieces of Replicare Thin’ inferior & superior to trach stoma. Replace as needed.

* Do not cut the stay sutures that are secured to the chest. Add additional Tegaderm if the tape appears loose.

*Notify ENT if you feel at any time the trach ties are too tight or loose during the first week. It is not uncommon for swelling post-op which may create tightness with ties. Call ENT!

*Take care with ventilator tubing minimizing tension to stoma site & that it s not directly resting on patient’s skin. See photo to right.

1. SAME SIZE TRACHEOSTOMY TUBE

2. ONE SIZE SMALLER TRACHEOSTOMY, OR AN APPROPRIATE ETT

1. NEXT SIZE SMALLER THAN A 3.0PED/NEO IS A 2.5 ETT OR 8 FR SUCTION CATHETER

3. 8 FR SUCTION CATHETER (FOR EMERGENCY DECANNULATION)

4. SURGILUBE

5. SUTURE REMOVAL KIT

6. VELCRO TIES

‘Ready-to-Go’ BagIncludes the Following Items & must be checked by RN at the beginning of the

shift.

CRITICAL AIRWAY Fresh Post-Op Tracheostomy

1. The first week is very crucial in preserving the integrity of the stoma, therefore you must keep the patient’s head midline & hyperextended at all times. You must do a thorough assessment to occipital area for pressure ulcers with routine cares Q 3-4 hours. Do not place infant on the full body size Z-Flo mattress , but it is acceptable to use the small 7 X 7 inch Z-Flo directly under the head. When using the Z-Flo, continue to maintain midline positioning & hyperextension with the use of a neck roll.

2. Please be very diligent with trach care. Trach care must be done with cluster cares (ie: q 3-4 hours). Spray the tips of the ‘Qtips with wound cleanser and clean around the stoma and underneath the trach ties. Assess superior & inferior aspects of stoma site with each cluster care as to be certain trach is not applying too much pressure to skin. Document assessment in Powerchart (Ongoing Assessment→Tracheostomy →Stoma site).

3. Make certain that intact Replicare Thin pieces are superior & inferior to the trach stoma at all times. If Replicare becomes soiled, or loose, be sure to change Replicare Thin to areas previously stated, as well as underneath the stay sutures. Avoid additional tension to the stay sutures by carefully applying Replicare Thin underneath stay sutures. Notify ENT if you feel at any time the trach ties are too tight or loose during the first week.

4. After ENT performs the first trach change, ties are to be changed qd & prn if moist. If copious secretions are present change Replicare Thin & ties BID. Be certain to assess and cleanse back of neck during trach cares.

5. A small air leak is acceptable if the patient is ventilating satisfactory. If not, please notify ENT.

6. Must have Ready-to –Go bag at bedside, a tracheostomy sign with a copy of the CNMC Tracheostomy Nursing Practice Guideline within easy reach.

_____________*If you have any questions regarding trach care, please contact June Amling pg #0183, Pam Allen pg

#4676 &/or any other team member of the NICU Skin/Wound Care committee. List of member names are posted in the team room on the leadership board.

1. RESPIRATORY DISTRESS??A. ATTEMPT TO SUCTION TRACH

B. ATTEMPT TO VENTILATE TRACH WITH AMBU BAGC. CHANGE TRACH IF SUCTIONING/ VENTILATION UNSUCCESSFUL

2. NO SPONTANEOUS RESPIRATIONS/CARDIOPULMONARY ARREST??A. PRESS CODE BUTTON

B. ATTEMPT TO VENTILATE WITH AMBU BAGC. IF VENTIALTION UNSUCCESSFUL, SUCTION TRACH TUBE. IF PATIENT REMAINS

OBSTRUCTED, PERFORM EMERGENCY TRACH CHANGE.

3. CRITICAL CARE: ACCIDENTAL DECANNULATION WITH STAY SUTURES STILL INTACT??

A. CALL FOR HELPB. LIFT STAY SUTURES OFF CHEST AND MAINTAIN A GENTLE PULLING PRESSURE

UPWARDC. INSERT SAME SIZE TRACH TUBE

Emergency Interventions

BIVONA FLEXTEND TRACH BIVONA FLEXTEND TRACH TUBESTUBES

Benefits:

Silicone remains soft and flexible in the trachea

Can be used for 3 months, as with all Bivona trachs

Kink resistant

Atraumatic, contoured neck flange (causing less device related pressure directly to the neck).

Recommended for some of the NICU patients having chubby neck s or short necks.

Disadvantages:

Tube is composed partially of metal, therefore, needs to be changed out prior to going to MRI. Substitute with a non-metal Bivona (same size) or a Shiley equivalent for the scan.

‘

Bivona Fome-Cuf Trach Tube

‘

Bivona Fome-Cuf Trach Tube

Tight To Shaft (TTS) Cuffed Trach Tube

Tight To Shaft (TTS) Cuffed Trach Tube

Cuffed Bivona Tracheostomy Tubes

Bivona Un-Cuffed Tube

Bivona Un-Cuffed Tube

Bivona Tracheostomy Tubes

Hyper-Flex Bivona Tracheosotmy Tube

Hyper-Flex Bivona Tracheosotmy Tube

*Treat Skin Irritations/Redness using Protective Measures:

A. For minimal irritation (pink skin and irritated), keep area clean & dry, apply treatment as ordered by NNP/MD.B. For moderate irritation (red, excoriated skin) Cleanse area well with Wound Cleanser, pat dry, & apply Replicare Thin.C. For significant irritation (full skin breakdown), apply a small piece of Algisite dressing directly inferior & superior at trach stoma & secure with Replicare Thin. Change Algisite M when it becomes gel-like.

Trachesotomy Care

1. Trach care is to be done with cluster cares every 3-4hours. Spray the tips of the Q-Tips with Wound Cleanser and clean around the stoma and underneath the trach ties. Assess superior and inferior aspects of the stoma site. Replace Replicare Thin if loose. Use Exudry if patient has excessive secretions noted peri-stoma. This will help to wick away the moisture. Do not tuck guaze sponges under the trach tu as this may displace the trach tube.

2. Trach ties are changed q day and prn if soiled or damp. Cleanse & assess the neck for any skin breakdown. If neck red or excoriated, apply Replicare to back of neck, before applying new Velcro ties.

A Few Additional Items to Always Have Handy at the Bedside……

1. Wedge Popper

2.Obtruarator

3. Neck Roll

4. Twill Tie

If the Tracheostomy Tube is Customized to CNMC or Customized to the Patient. it will have a special yellow/green label. It will state ‘CUSTOMIZED.’

If the Tracheostomy Tube is Customized to CNMC or Customized to the Patient. it will have a special yellow/green label. It will state ‘CUSTOMIZED.’

Keep this Label in the ‘Ready-To-Go’ Bag. Label with patients label & dated as to when it was opened.

Keep this Label in the ‘Ready-To-Go’ Bag. Label with patients label & dated as to when it was opened.

Tracheostomy tubes may be a standard size but or customized to meet patient needs. If a customized tracheostomy tube is deemed necessary it may take up to one week to receive. It is always important not to lose this label as this is helpful in the re-ordering process.

There are some CNMC customized tracheostomy trach tubes in-house (kept in Trach Pyxis in the OR), but are limited in availability. It is important not to throw out the tracheostomy tubes. Bivonas are to be sent to SPD & the Shiley trachs are to be cleansed at the bedside. If you are in need of a CNMC customized trach please notify J. Amling, P Allen, or your charge nurse.

Customized Tracheostomy Tubes???

Insertion Guide for Suction Catheters

This sheet is a part of the Tracheostomy Nursing Practice Guidelines.

_________

Record suction length on the patient’s “I Have a Tracheostomy” sign at the bedside. Update as trach size changes.

__________

Bivona Flextend: Add an additional 2cms on top of the standard sx length quoted on the Insertion Guide

Powerchart Documentation

I-View / ICU Ongoing Assessment / Tracheostomy

Document q shift & prn with cares

Do

NEVER EVENT

Stage III

Pressure Ulcer

Tissue erosion from tracheostomy ties cutting into skin

What went wrong here?

Tracheostomy ties must never be too tight. One should be able to slide only one index finger up under the trach tie at any given time. Also keep in mind, if Velcro ties are too loose, the trach can easily fall out or can move about the trachea which may cause tissue erosion peri-stoma & or within the trachea itself.

_______

Device Related Skin Excoriation & Granulomas Peri-Trach Stoma

What can we do to prevent skin breakdown around the tracheostomy site??

There needs to be special attention given to the skin condition at the neck , as well as the inferior and superior aspects of the trach stoma. Assessment of stoma needs to be made with each patient cares & tie changes

What are Granulomas?

An overgrowth of inflammatory tissue, which is caused by tissue irritation from the tracheostomy tube or infection. Some granulomas become so enlarged that it may be difficult to pass a trach tube through the stoma.

.

Bivona Tracheostomy Tubes1.Rinse tracheostomy tube under water as to dislodge any mucous from the trach..

2. Place trach tube in a clear bag along with 2 patient stickers.

3. Nursing must take to SPD as soon as possible. SPD is located in the back of Central Supply.

4. Complete the sigh in sheet at desk & physically hand the bag over to an SPD employee.

5. SPD’s turn-around from drop off to pickup is 2-3hours. Make certain it is picked up within that time frame. You will need to sign the trach out when picking up. This particular trach tuve is most likely your only same size trachestomy tube.

It is the responsibility of each nurse to have all supplies in the Ready-to-Go bag. It should be checked at the beginning of each shift.

Cleansing the‘Shiley’ TracheostomyTube for re-use at the bedside

1.Rinse ‘ Shiley’ trach tube under running water.

2. Cleanse at bedside with ½ strength Hydrogen peroxide.

3.Rinse well w/ sterile NS .

4. Air dry on paper towel.

5.Place in sterile container.

6.Label w/ pt’s name , type of trach tube, date original package opened, & dates cleansed.

__________________

No peroxide if Shiley tube is cuffed, use only sterile saline as peroxide is destructive to the cuff.

May be used for 29 days before discarding. Label container accordingly .

Change q Monday & prn

*DOCUMENT ANY & ALL TRACHEOSTOMY PARENT TEACHING IN AD HOC UNDER PATIENT/FAMILY

EDUCATION. THERE IS A DESIGNATED AREA SPECIFIC FOR TRACHEOSTOMY EDUCATION.

TAKE OPPORTUNITIES TO EDUCATE WHEN PARENTS VISIT. INVOLVE THEM IN TRACH TIE

CHANGES, SUCTIONING, MONDAY TRACH CHANGE SCHEUDLE, ETC.

It is Everyone’s Responsibility to Provide Tracheostomy

Education to Families

Yikes!!!…And let’s hope we never see any one doing this!!

References

CNMC Nursing Practice Guidelines 7/2009 “Tracheostomy Management”

Tracheostomy Care Handbook: A Guide for the Healthcare Provider - Portex, Inc./ Product Literature

Pediatric Tracheostomy Care Handbook: An instructional Booklet for Home Care of your Child with a Tracheostomy/ Portex IncProduct Literature

‘Christmas in the BPD Ward’ Photo from the Life of Chevalier Jackson, An Autobiography (Slide 1)

Shiley (2009) “Tracheostomy Tube Home Care Guide”

Bivona (2009) www.smith-medical.com/catalog/ bivona-tracheostomy-tubes/neonatal