1. Tracheostomy Teaching Guidelines for Patients/Families
PICU

2. Tracheostomy Teaching Pathway
Pre-trach
Explain possible reasons for tracheostomy.
Discuss how the tracheostomy will work.
Post-op
Day 1-5
Ensure caregiver watches trach care video (EZTV 1093)
Provide caregiver with trach care booklet which is obtained from Family Resource Center (62558)
Day 5-7
Begin in the moment/bedside teaching with caregiver(s)
Obtain tracheostomy teaching record from eDocs (this will guide teaching expectations)
Consider teaching steps 3-7 located on teaching record
Post-Op
Day 7 until discharge
Continue in the moment/bedside teaching with caregivers
Provide CPR schedule and help coordinate class enrollment for families (see class schedule for contact information)
Collaborate with Case Management to ensure discharge supplies have been ordered

3. Key Points of Tracheostomy Teaching.
Reasons for tracheostomy
How does the tracheostomy work
Tracheostomy type and size
Suctioning
Cleaning
Stoma Care
Tracheostomy ties and changes
Tracheostomy change
Bagging
When to call the doctor
Please place check mark bedside item as completed

4. Pre-Op Discussion Reasons for a Tracheostomy
A tracheostomy may be temporary (used for a short time) or permanent.
Here are some possible reasons for a tracheostomy:
Need for long-term use of a ventilator (a machine that helps with breathing)
Obstruction in the airway due to an accident, paralysis, surgery, or malformation
The need for frequent suctioning of secretions in the airway
Obstruction of the airway during sleep (sleep apnea)

5. How Does the tracheostomy work
How Your Child’s Tracheostomy Works
The surgery is done in an operating room.
The surgeon creates a small opening in the neck, called a stoma.
The tracheostomy tube is put into the stoma.
One end of the tracheostomy tube rests outside the stoma. The other end rests inside the windpipe (trachea).
When your child breathes in, air goes through the tube into the trachea to the lungs.
When your child breathes out, air comes out of the tracheostomy tube.
Your child can still also breathe in and out through his or her nose.

6. Print this form from eDocs and keep at patient’s bedside until discharged. Please do not scan and file electronically until all sections are completed.
SUGGESTED TIMELINE:
Before trach placed 1 & 2
After first trach change 4, 5d, 6, 7, 8, 9, 11
Any time 3, 5 a/b/c, 6, 10

7. Tracheostomy Card

8. suctioning
1. Collect Your Supplies
Find a clean, well-lighted space. Collect your supplies: a suction machine, a clean suction catheter, and a small bowl of distilled water.
Wash your hands with soap and warm water. Then, put on clean, disposable, powderless gloves.
2. Prepare to Suction
Turn on the suction machine to _________ mm Hg.
Attach the suction catheter to the suction machine. Dip the catheter tip into the distilled water to assure the suction is working.
Do the following only if your health care provider tells you to: Put a small amount of sterile saline solution into the tracheostomy tube. This will help loosen mucus.

9. Suctioning (cont.) 3. Insert the Catheter
Allow your child to take a few deep breaths or provide manual breaths with the bag.
Gently insert the catheter into the tracheostomy tube. While you insert the catheter, do not suction. Stop inserting the catheter at the predetermined measurement.
4. Apply Suction
Apply suction. At the same time, slowly pull the catheter out of the tracheostomy tube. Move the catheter tip in a circle as you pull the catheter out.
The catheter should be out of the tracheostomy tube within 5–10 seconds. If you need to suction more, allow your child to relax and breathe for a few minutes before you start again.
When you have finished suctioning, turn off the suction machine. Discard the used catheter, water, and gloves. Parents may reuse catheter at home, but in the hospital it is one use only.

10. Cleaning/stoma care Keeping the Tracheostomy Clean
To take care of the skin and prevent infection, you need to keep your child’s tracheostomy clean.
Clean the tube and the skin around it at least once a day, or more often if instructed by your doctor. Follow these steps and any other guidelines you have been given. Choose a clean, well-lighted space.
Step 1
Collect the following supplies:
Gauze pads or other non-fraying material advised by your doctor
Cotton swabs
Tracheostomy tube brush
Bowl filled with the type of solution recommended by your doctor. Your doctor may recommend normal saline solution or a mixture of equal parts normal saline and hydrogen peroxide.
Wash your hands with soap and warm water. Put on clean, disposable, powderless gloves.

11. Cleaning/ Stoma care (cont.)
Step 2
Clean the neck plate and skin.
Remove the gauze from behind the neck plate. Check the area for signs of skin breakdown or infection.
Clean the neck plate and the skin under it. Use clean gauze pads or other non-fraying material dabbed in normal saline solution. A thorough cleaning technique you may consider involves cleaning the stoma in a step-wise fashion, one quarter at a time. This pattern can also be followed on the surrounding skin and tube flange.
Use a new gauze pad/cotton swab for each section.
Start at the 12 o'clock position and wipe to the 3 o'clock position
Next, clean from 12 o'clock to 9 o'clock
Next, clean the 3 o'clock to 6 o'clock position.
Lastly, clean from the 9 o'clock to 6 o'clock position.
Gently pat the skin dry.
Don't use a hydrogen peroxide mixture directly on your skin unless your doctor specifically tells you to do so. Hydrogen peroxide can irritate the skin and increase the risk for infection. If you are instructed to use a hydrogen peroxide mixture on your skin, be sure to rinse the area with normal saline afterward.
Put a clean, precut gauze pad under the neck plate. This pad protects your skin. Do not cut a gauze pad because the frayed edges will increase risk for infection and a loose thread could potentially be inhaled into the trach.

12. Tracheostomy ties Keeping the Tracheostomy Ties Clean
Tracheostomy ties fit around your child’s neck to hold the tube in place.
Fabric ties need to be changed when they are dirty.
Supplies:
Velcro ties
Blanket roll to place under your child’s shoulders
Suction equipment and catheter
Second caregiver
Step 1
Wash your hands
Step 2
Place blanket under the shoulders to allow you to see the tracheostomy better

13. Tracheostomy ties (cont.)
Step 3
Remove one side of the Velcro tie while the second caregiver holds the tube in place.
While the tie is removed, clean the neck with soap and water; dry thoroughly
Thread the clean Velcro tie into this side and attach
Repeat with the opposite side
Step 4
Check the tightness of the new ties (ties should be just tight enough to slip one to two fingers under the tie).
Gently pull on the tracheostomy to make sure it is snug.

14. Tracheostomy change
Some people find it helpful to set up and do changing and cleaning in the same place each time.
Choose a clean, well-lighted space near a sink. Supplies you will need for cleaning and changing include:
Collect Supplies
Rolled-up towel or pillow (to place behind child’s neck)
Liquid soap, alcohol, or disinfectant foam
Clean, disposable, powderless gloves
Gauze
Normal saline solution
Tracheostomy ties and scissors, cut to the right length
Tracheostomy tube
Two sterile or disposable cups
Small towel
Suction machine

15. Tracheostomy Change Replace the Tracheostomy Tube
Ask the doctor about whether or not to use an obturator, which may make it easier to insert the tube. Its rounded edges also protect the stoma during insertion.
If you need to use a lubricant, be sure to ask the doctor how much to use.
Have a suction machine ready, if needed.
Depending on the age of your child, explain the procedure as well as you can.
If two people are available, one person removes the old tracheostomy tube and the other secures the new one.

16. bagging The manual resuscitator bag is often called “the bag”.
It is used to give your child extra breaths.
How to bag
Place the bag on your child’s trachoestomy
As you squeeze the bag, watch your child’s chest rise
As soon as your child chest rises, release the bag
Repeat the cycle of squeezing and releasing until your child is back to their baseline or usual breathing

17. When to call the doctor
Call the doctor right away if your child has any of the following:
Red, painful, or bleeding stoma
Yellow or green, smelly, bloody, or thick mucus from the stoma
Fever of 100.4°F or higher
Swelling around the tracheostomy tube
Pain when you suction the tracheostomy tube
Shortness of breath or any trouble breathing
Vomiting
Tracheostomy tube or suction catheter that is difficult to insert

18. Tracheostomy Discharge Supplies.
Suction kits
Tracheostomy (type and sizes)
Sterile split gauze: 2x2’s or 4x4’s
Sterile cotton tipped applicators
Tracheostomy tube holders
Ambu bag (appropriate patient size)
Oxygen source (if needed)
Portable suction
Tracheostomy collar humidity
Pulse Oximeter (indication of alarm limits)
Little suckers
Home Medical Equipment (HME)
KY jelly
Flex and adaptors
Tracheostomy care kits (for cleaning)
Please place check mark bedside item as completed

19. Additional Information/Resources
Please check in with the patient’s Case Manager frequently to ensure all steps/processes are on target for discharge The topics they review with the family include:
2 competent/consistent/adult caregivers must be identified
Education participation by caregivers/rooming in/CPR
Home supplies/equipment/delivery
Insurance coverage
Private duty nursing
Home electricity – making the home a priority in power outage
No smoking in the home
Contacting the local EMS/fire station to notify them of a special needs child
Respiratory Therapists will continue to serve as a resource and integral part of caregiver teaching

20. CPR for Families: Class Schedule
Contact Person: Debra Hardy
Date: Every Monday and Thursday
Time: 1230
Place: 7A Expansion Area
Contact 7A CSL or RSL for same day registration (20361)
Parents can choose either class, depending of their scheduling needs

21. References
Krames Patient Education Material, retrieved November 18, 2013
Mosby’s Nursing Skills Consult, retrieved November 20, 2013