Nursing Skill: Tracheostomy Care and Suctioning

Reflect on the nurse in the skill video you just viewed. The nurse in the skill video documented the following after performing tracheostomy care and suctioning. Highlight the incorrect information they documented.

Lungs clear in bilateral upper lobes Nasal cannula Disposable outer cannula

What information should be recorded in the Respiratory portion of the I-SBAR's Assessment section? Select all that apply.

Bilateral breath sounds clear after suctioning Continuous oxygen via trach collar tracheostomy care and suctioning were performed

The nurse is preparing to perform tracheostomy care. Which of these assessment findings require further follow-up before performing tracheostomy care? Drag the assessment findings that require follow-up prior to the skill being performed to the box on the right.

Client communicates they are having trouble breathing Visualization of thick secretions in tracheostomy tube SpO2 86% on 50% O2 via trach collar ​

As the nurse is suctioning the client's tracheostomy tube, the client develops significant respiratory distress. Which of the potential interventions are indicated or contraindicated for the client at this time?

Indicated: withdraw suction catheter Administer oxygen Notify healthcare provider

The nurse knows it is best practice to remove the old tracheostomy ties after (not before) the new ties have been secured in place. This helps to prevent dislodgement (not aspiration) of the tracheostomy tube.

The nurse knows it is best practice to remove the old tracheostomy ties after (not before) the new ties have been secured in place. This helps to prevent dislodgement (not aspiration) of the tracheostomy tube.

Before performing tracheostomy care and suctioning, what factors would be important for the nurse to consider? Select all that apply.

Fluid balance Infection Lack of humidity Respiratory assessment

Arrange the steps in the order they should be performed in tracheostomy suctioning. Please note these are not inclusive steps of tracheostomy suctioning.

Place client into semi-Fowler's or Fowler's position​ Adjust regulator to 80-150 mmHg Increase supplemental oxygen flow following facility policy for hyperoxygenation protocol​ Open suction kit​ Don sterile gloves​ Pour sterile normal saline into sterile basin​ Dip the tip of the catheter into the basin to flush and moisten for easier insertion​ Insert the suction catheter into the tracheostomy until resistance is met or the client coughs​ Withdraw suction catheter approximately 1/2 inch then apply suction intermittently and gently rotate the catheter while withdrawing the catheter

When reviewing the client chart, what cues indicate sterile tracheal suctioning is needed? Select all that apply.​​

Rhonchi Oxygen saturation Audible secretions

While performing tracheostomy care, the nurse accidentally dislodges the tracheostomy tube. What actions should the nurse take? Select all that apply.

Stay with the client while calling for help Assess for airway patency Ventilate client as needed

Upon assessment, the nurse noted all the following cues. Match each cue with its associated risk for the client

Thick secretions visible in the tracheostomy tube > Thick secretions could cause airway obstruction and should be suctioned. Client confused and picking at tracheostomy tube > This will put the client at risk for tube dislodgement. Distraction methods should be attempted before restraint use. ​ Client has a temperature of 101.7 °F (38.7 °C) Oral > A fever along with thick secretions could indicate a risk for infection. Client lying flat in bed > Risk of aspiration. Keeping the head of the bed raised 30-45 degrees reduces the risk of aspiration.