Tracheostomy Teaching Guidelines for Patients/Families PICU

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

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

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)

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.

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

Tracheostomy Card

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.

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.

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.

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.

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

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.

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

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.

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

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

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

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

CPR for Families: Class Schedule Contact Person: Debra Hardy Email: debra.k.hardy@Vanderbilt.Edu 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

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