PEDIATRIC PATIENTS with tracheostomies may be cared for outside of the critical care setting in monitored or unmonitored units, depending on hospital policies. Regardless of location, every nurse who encounters a child with a tracheostomy must be prepared to handle the following emergencies: an immediate need for airway clearance, a need for additional oxygenation, and accidental dislodgement of the artificial airway. This article outlines the basic training, planning, and preparation nurses need to ensure the safety of hospitalized children with tracheostomies.
Knowledge and skills
A tracheostomy creates an opening through the neck into the trachea to establish an airway and remove secretions.1 Core knowledge about tracheostomy care is critical to building the skills nurses need to maintain a patent airway. Nurses must be prepared to plan interventions for various scenarios and emergencies, such as ineffective airway clearance (related to increased secretions secondary to presence of an artificial airway), or the potential for impaired gas exchange secondary to dislodgment of the tracheostomy tube.
Preceptors educate new hires on both general and hospital-specific tracheostomy care policies and procedures. During orientation to their unit, nurses should complete a tracheostomy care competency that addresses assessment, planning, implementation, and documentation, including evaluation (See Tracheostomy care competency [observed] for an example). Skills that target patient safety include identifying patient needs, ensuring that emergency replacement equipment is at the bedside, evaluating overall respiratory status, monitoring skin condition around the tracheostomy, and changing tracheostomy ties. Nurses should demonstrate their ability to provide proper securement by correctly threading the tracheostomy ties and tightening them properly-not too loose but not too tight. The standard of practice is to place one finger between the ties and the patient's neck.
Communicating with peers and patients
Individualized patient tracheostomy needs can be communicated orally, in writing, or both. For example, a written "trach card" can be placed at the head of the bed with the following information:
* present tracheostomy tube size
* present tracheostomy tube type including whether cuffed or cuffless
* suction catheter size appropriate for the child
* appropriate suctioning depth.
This visual communication tool aligns with the national patient safety goal of improving staff communication.2 One-way speaking valves can enhance communication with the patient. But to ensure patient safety, the tracheostomy tube cuff must be completely deflated when the speaking valve is in use to allow air to flow through the upper airway. Communicating with the patient and the patient's family can decrease anxiety associated with airway management. Explain the equipment and supplies focusing on preparedness and safety.
Monitoring safety
Visual monitoring and documentation are essential to ensuring that the best patient safety practices and policies are being implemented. Electronic medical record (EMR) management systems vary, but a location in the EMR should be designated to document tracheostomy assessment, including safety measures. Respiratory therapists and/or RNs document that safety measures are in effect and emergency equipment is kept at the patient's bedside (See Keeping equipment at hand).
Another aspect of monitoring includes collecting and reviewing data on rapid response team or code calls. Internal trending of adverse event reports and resuscitation events informs performance improvement activities to ensure the highest level of safety for hospitalized children with tracheostomies.
Final thoughts
Handling airway emergencies in children requires close cooperation between nurses and respiratory therapists. The roles and responsibilities of the RNs and respiratory therapists (RTs) may vary, depending on the unit and facility. The RT is often responsible for setting up equipment, but maintaining the equipment and/or supplies is a joint effort between the RNs and RTs. Along with collaboration, keeping essential equipment readily available at the bedside and during patient transport is critical for patient safety.
Tracheostomy care competency (observed)
Assessment
* need for tracheostomy care emergency replacement equipment is at patient's bedside
* respiratory status
* vital signs
* peristomal skin condition
Planning: Gather the following supplies
* tracheostomy cleaning kit (if available)
* normal saline solution
* hydrogen peroxide, depending on type of tracheostomy tube (Remember to check the manufacturer's cleaning instructions.)
* sterile gloves
* tracheostomy ties
* appropriate personal protective equipment
Implementation
* prepares equipment
* performs hand hygiene
* identifies patient using two identifiers
* determines if oral/tracheal suctioning is needed
* explains procedure to patient, parent, and/or guardian
* maintains standard precautions
* ensures privacy
* places patient in supine position if not contraindicated
* performs tracheostomy care according to policy and procedure
Documentation and verbalization (evaluation)
* date and time
* sterile technique used
* peristomal drainage amount and characteristics
* respiratory status
* peristomal skin condition
* complications and actions taken.
Source: Arnold Palmer Hospital for Children, Orlando, Fla. Used with permission.
Keeping equipment at hand
Supplies to replace a tracheostomy tube should be at the bedside or within reach.1 The following equipment should be at the patient's bedside at all times and travel with the patient when leaving the unit:
* oxygen source with flowmeter, nipple adapter, and tubing
* manual resuscitation bag attached to an oxygen source that is appropriate for the patient's size
* appropriately sized resuscitation mask
* suction source with tubing
* suction catheters
* vials of 0.9% sodium chloride solution for clearing the catheter
* disposable carbon dioxide (colorimetric) detector as appropriate
* current tracheostomy tube obturator at the head of the bed
* additional current size tracheostomy tube
* additional tracheostomy tube, one size smaller
* oropharyngeal or nasopharyngeal airway
* appropriate tracheostomy tube securement device
* sterile cotton-tipped applicators
* sterile 4" by 4" gauze pads and tracheostomy dressing
* gloves.
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