🫁Assessments
This must be continuously monitored for all trach patients during admission
What is continuous SpO₂ monitoring?
This is how often trach care should be performed at minimum.
What is every 12 hours?
This service must be paged when a trach patient arrives to the floor.
What is Respiratory Therapy?
Each suction pass should be limited to this amount of time.
What is 10–15 seconds?
This is the first priority in any tracheostomy emergency.
What is maintaining airway patency?
This part of the assessment includes noting redness, edema, subcutaneous air, or irritation.
What is stoma appearance?
This item should be changed every 24 hours or sooner if wet or soiled.
What are tracheostomy ties?
This oxygen delivery method should be initiated on admission per orders.
What is humidified oxygen via trach mask?
This should be done before suctioning to prevent hypoxia.
What is pre-oxygenation?
This is the quickest way to assess if a trach is patent at the bedside.
What is attempting to pass a suction catheter?
This change in secretions should raise concern for infection or clinical deterioration.
What is a change in color, amount, or consistency of sputum?
This positioning helps reduce aspiration risk and improve ventilation unless contraindicated.
What is 45-degree (semi-Fowler’s) positioning?
This should be turned on for the patient's room to ensure staff arrive quickly to check on the patient when they call.
What is priority ring on the call bell?
This is the maximum number of suction passes per session.
What is three passes?
During bag-mask ventilation of a trach patient, this must be done to the stoma.
What is covering the stoma with gauze and fingers?
These two early warning signs can alert you to potential respiratory distress / hypoxia.
What are restlessness and tachycardia?
It is recommended to use a two-person technique during this procedure to prevent accidental decannulation.
What is changing tracheostomy ties?
This equipment must accompany the patient when leaving the unit.
What are portable suction and continuous SpO₂ monitoring? (as well as being accompanied by an RN/MD/RT/LIP)
This combination of findings strongly suggests suctioning is needed.
What are increased work of breathing, tachypnea, and ineffective cough?
Your patient suddenly desaturates and you cannot pass a suction catheter. This is your first intervention.
What is removing and replacing the inner cannula?
This assessment helps determine if a patient can tolerate a speaking valve.
What is ability to handle secretions and tolerate cuff deflation?
This is the correct tightness for tracheostomy ties.
What is allowing two fingers to fit between the tie and the neck?
These supplies should be in the room for any patient with a Tracheostomy, in case of emergency.
What are suction set ups, suction catheters, Yankauers, sterile water, masks w/ face shields, ambu bag, humidified O2, trach care kits, 10cc luer lock syringe, aerosol drainage unit, disposible inner cannulas, and extra trach tubes in patient's size and one smaller?
This cardiac change during suctioning is a sign to stop the procedure.
What is bradycardia or arrhythmia?
If a patient self de-cannulates, you are unable to reinsert the trach, and the patient is deteriorating, this is your next intervention.
What is initiating bag-mask ventilation over the mouth while covering the stoma and calling a Code Blue?