Respiratory
Considerations:
- Changing tracheostomy ties in the school setting is usually not done on a routine basis, rather it would be completed in an emergency situation such as an emergency tracheostomy change.
- When caring for a student who has a tracheostomy, the school nurse should always know the reason for the tracheostomy, the student’s underlying health conditions and whether the student needs the tracheostomy to breathe.
- Two people should be present during the procedure in the event of accidental decannulation.
- There should always be a “GO BAG” (Emergency Travel Bag) accessible when completing any tracheostomy procedure.
- If student’s “GO BAG” contains a battery charged suction machine, the school nurse should check the battery charge level daily to ensure that it is fully charged.
- The school nurses should establish a schedule to periodically check the “GO BAG” to ensure all necessary supplies are available, not expired, and are in working condition.
- A shoulder roll is recommended to assist with the visualization and access to the tracheostomy site.
- The two most common forms of tracheostomy ties are a soft padded tie with Velcro tabs (most common) or a simple thin cloth or twill tie that requires tying to secure.
- Attempt to provide the student with as much privacy as possible, given the urgency of the situation.
*THIS PROCEDURE IS TYPICALLY PERFORMED BY A REGISTERED NURSE
The use of this procedure guideline assumes that the registered nurse has the nursing education and skills to perform this task. This procedure guideline does not replace nursing clinical judgment.
Supplies:
“GO BAG” (Emergency Travel Bag) Equipment:
The essential equipment to be kept with the student at all times is as follows:
- Gloves
- Portable oxygen (if ordered) with appropriate sized Ambu-bag
- Appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube)
- Portable suction machine that can operate with battery or electricity
- Battery should have a full charge
- Sterile suction catheters
- Sterile saline vials
- Water-based lubricant
- Distilled or sterile water
- 4×4 gauze
- Split gauze dressing (if student uses)
- Unscented and dye free soap
- Syringe, if needed for tracheostomy tube cuff
- Sterile water for cuffed trach filled with water
- Two spare tracheostomy tubes (including obturator) — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
- Obturator, if applicable
- Spare tracheostomy ties
- It is recommended to have spare tracheostomy ties already secured to spare tracheostomy to have a set of spare tracheostomy ties already secured to spare tracheostomy
- Blunt scissors
- Emergency phone numbers
- Pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation
Additional Supplies:
- Student’s Individualized Health Care Plan (IHCP) and health care provider’s orders
- Parent/Guardian authorization form
- Personal protective equipment
- goggles
- mask
- gloves
- Tracheostomy ties
- Blunt scissors
- Gauze
- Blanket role to place under the student’s shoulders, if needed
- Stethoscope
Procedure:
- Gather supplies
- Place on a clean surface
- Review Individualized Health Plan and health care provider’s orders
- Ensure proper documentation of parent/guardian authorization to perform this procedure
- Position the student
- If a shoulder roll is used, place it behind student’s shoulders
- Explain procedure at a level the student will understand
- Have person assisting with procedure wash hands and put on gloves
- Wash hands
- Put on gloves
- If tracheostomy tube dressing is present, remove
- One caregiver should hold the tracheostomy in place while the second caregiver (registered nurse) removes the tracheostomy ties
- Remove the old ties
- Removal of cloth ties requires the use of a blunt scissor
- Removal of Velcro tab ties is done by detaching each end of the tie
- Use caution not to occlude the tracheostomy tube
- Insert one end of the tie through the slit opening on the side of the tracheostomy tube
- Bring the other end of the tie around the back of the neck
- Repeat with the other end of the tie through the slit opening on the other side of the tracheostomy tube
- Fasten the tracheostomy ties
- Velcro tabs are fastened back on themselves
- Cloth ties are secured using a single square knot on the side or back of the neck
- The ties should allow enough space for one pinky finger between ties and neck
- If a dressing is used around the stoma, replace it now with a clean one
- Assess the student’s respiratory status to ensure that the tracheostomy tube remained in place and patent during the procedure
- Remove gloves
- Wash hands
- Document assessment, procedure, and outcomes in the student’s health care record
- Follow up with parents/guardian and health care provider, as needed
References:
Children’s Hospital St. Louis. (n.d.) Tracheostomy home care. Retrieved June 7, 2023, from https://media.bjc.org/sitelinks/tracheostomy/a001_introduction_welcome.html
Children’s Mercy Kansas City. (2018). Office of evidence based practice (EBP) – Critically appraised topic: Tracheostomy emergency supplies. Retrieved June 8, 2023 from https://www.childrensmercy.org/contentassets/878a471901cd4e858cc27ae0d82f441e/trach-go-bag-cat.pdf
Children’s Mercy Kansas City. (n.d.). Tracheostomy tube. Retrieved June 7, 2023, from https://www.childrensmercy.org/siteassets/media/departments-and-clinics/otolaryngology/tracheostomy-care-parent-card.pdf
Children’s Mercy Kansas City. (n.d.). Tracheostomy care-changing the ties and stoma and neck care. Retrieved June 7, 2023, from https://www.childrensmercy.org/siteassets/media/departments-and-clinics/otolaryngology/tracheostomy-care—changing-the-ties-and-skin-care-parent-card2.pdf
Lawrence, P. R., Chambers, R., Faulkner, M. S., & Spratling, R. (2021). Evidence-based care of children with tracheostomies: Hospitalization to home care. Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses, 46(2), 83–86. https://doi.org/10.1097/RNJ.0000000000000254
Lynn, P. (2019). Providing care of a tracheostomy tube. In Skill checklists for Taylor’s clinical nursing skills. A nursing process approach. (5th ed.). (pp. 331-333).
Pediatric Home Services. (2017). Trach stoma care (Cuidado del estoma). Retrieved June 7, 2023, from https://www.pediatrichomeservice.com/tips-how-tos/trach-stoma-care/?play=1
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Acknowledgment of Reviewers:
Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services
Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services
Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog
Debra Funk, BSN, RN
Director of Practice
Missouri State Board of Nursing
Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing
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Page last updated: February 16, 2024/no video
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The information and materials presented in this Website are intended for informational purposes only and are not designed to diagnose or treat a health problem or disease, or assist in diagnosis or treatment of the same. The information is not intended to substitute for, supplement or replace clinical judgment. If there are any concerns or questions about or relating to a nursing or medical procedure, contact the individual’s healthcare provider. The information provided on this Website is not intended to be a substitute for medical orders and persons without the proper education, training, supervision and/or licensure should not perform the procedures.
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