Respiratory
*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.
Considerations:
- When caring for a student who has a tracheostomy, the nurse should always know the reason for the tracheostomy, the student’s underlying health conditions and whether the student needs the tracheostomy to breathe.
- The frequency of stoma care and the care of the surrounding skin is based on the individual student’s current skin condition and associated factors, such as the amount of secretions and the degree of skin folds around the neck.
- Attempt to provide the student with as much privacy as possible, given the urgency of the situation.
- There should always be a “GO BAG” (Emergency Travel Bag) accessible when completing any tracheostomy procedure.
- If the 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.
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 face mask (for emergencies when unable to reinsert a new tracheostomy tube)
- Portable suction machine that can operate with battery or electricity
- Battery should be fully charged
- 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
- 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 order
- Health care provider’s order should indicate how often stoma care should be provided and what specific cleansing items should be used
- Parent/Guardian authorization form
- Gauze
- Sterile cotton tip applicators
- Mild soap or student specific cleaning solution
- Water
- Saline
- Medicine cups
- Prepackaged sterile tracheostomy dressing, if ordered
- Stethoscope
- Personal protective equipment
- gloves
- goggles
- mask
Procedure:
- Gather supplies
- Clean the work station with soap and water or disinfecting wipe
- Review Individualized Health Care Plan (IHCP)/Health care provider’s order
- Ensure proper documentation of parent/guardian authorization to administer medication
- Position student providing as much privacy as possible
- Explain the procedure to the student at their level of understanding
- Wash hands
- Put on gloves
- Ensure that tracheostomy ties are secure
- Remove dressing if applicable, dispose of per school policy
- Observe stoma for:
- Increased secretions or change in consistency or color of secretions
- Secretions that have an odor
- Redness or crusting
- Bleeding
- Indications of pain to stoma site
- Clean the neck using gauze sponges and/or cotton-tipped swabs and cleaning solution (such as mild soap) per Individualized Health Care Plan (IHCP) and health care provider’s orders
- Allow the skin to dry
- Dip cotton dip applicator in saline/water mixed with cleaning solution (i.e. mild soap) ordered by the health care provider
- Support the tracheostomy tube with your finger during cleaning
- Use cotton tip applicator to clean outer portion of tracheostomy tube and surrounding skin
- Start as close as possible to the tracheostomy tube then work away from it
- Do not put the swab into the stoma
- Make only one sweep with each cotton tip applicator before discarding
- Repeat the process until debris and/or mucus is removed
- Minimize direct moisture to the tracheostomy ties
- Using cotton tip applicator to clean the outer portion of the tracheostomy and surrounding skin using just water
- Start as close as possible to the tracheostomy tube then work away from it
- Do not put the swab into the stoma
- Make only one sweep with each cotton tip applicator before discarding
- Use a dry cotton tip applicator to dry skin surrounding stoma starting at inner most part and moving outward
- Drying the skin is vital to maintaining skin integrity
- Place dressing on tracheostomy site, if ordered by health care provider
- Dispose of used supplies per school policy
- Assess student’s respiratory status, as needed
- Remove gloves
- Wash hands
- Document assessment, intervention and outcomes in student’s health care record
- Follow up with parent/guardian and health care provider, as needed
References:
Children’s Wisconsin. (n.d.) Tracheostomy care and suctioning the trach tube. Retrieved June 7, 2023, from https://childrenswi.org/medical-care/tracheostomy-home-ventilator/educational-resources
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 stoma and neck care. . Retrieved June 7, 2023, from https://youtu.be/ZR3TRrc8Yxc
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
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
Toothaker, R., & Cook, P. (2018). A review of four health procedures that school nurses may encounter. NASN school nurse (Print), 33(1), 19–22. https://doi.org/10.1177/1942602X17725885
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Acknowledgements 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
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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