Page 2427 - Saunders Comprehensive Review For NCLEX-RN

blood or purulent drainage.
k. Follow the PHCP’s prescriptions and
agency policy for cleaning the
tracheostomy site and inner cannula
(many inner cannulas are disposable);
usually, half-strength hydrogen
peroxide is used.
l. Administer humidified oxygen as
prescribed, because the normal
humidification process is bypassed in a
client with a tracheostomy.
m. Obtain assistance in changing
tracheostomy ties; after placing the
new ties, cut and remove the old ties
holding the tracheostomy in place
(some securing devices are soft and
made with Velcro to hold the tube in
place).
n. Keep a resuscitation (Ambu) bag,
obturator, clamps, and spare
tracheostomy tube of the same size at
the bedside.
4. Complications of a tracheostomy (Table 69-5)

Never insert a plug (cap) into a tracheostomy tube until the cuff

is deflated and the inner cannula is removed; prior insertion prevents
airflow to the client.

Priority Nursing Actions

Tracheal Suctioning
1. Assess the client and explain the procedure.
2. Assist the client to an upright position.
3. Perform hand hygiene and don personal protective equipment.
4. Prepare suctioning equipment and turn on the suction.
5. Hyperoxygenate the client.
6. Insert the catheter without suction applied.
7. Once inserted, apply suction intermittently while rotating and
withdrawing the catheter.
8. Hyperoxygenate the client.
9. Listen to breath sounds and reassess oxygen saturation.
10. Document the procedure, client response, and effectiveness.

Reference

Lewis et al. (2017), p. 488.

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