A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? Select all that apply. A Apply the oxygen source loosely if the SpO2 decreases during the procedure. B Use surgical asepsis to remove and clean the inner cannula. C Clean the outer cannula surfaces in a circular motion from the stoma site outward. D Replace the tracheostomy ties with new ties. E Cut a slit in gauze squares to place beneath the tube holder.
The correct answer and explanation is:
The correct actions a nurse should take when providing tracheostomy care are:
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer cannula surfaces in a circular motion from the stoma site outward.
D. Replace the tracheostomy ties with new ties.
Explanation:
A. Apply the oxygen source loosely if the SpO2 decreases during the procedure.
This is not the correct approach. Oxygen should be administered carefully to maintain adequate oxygenation but applying the oxygen source loosely may not provide effective oxygen delivery. Instead, the nurse should monitor oxygen saturation and provide oxygen as prescribed, ensuring it is properly fitted.
B. Use surgical asepsis to remove and clean the inner cannula.
Correct. The inner cannula of a tracheostomy tube is considered a sterile device. Surgical asepsis (sterile technique) is required when removing and cleaning it to prevent infection. This helps reduce the risk of respiratory tract infections.
C. Clean the outer cannula surfaces in a circular motion from the stoma site outward.
Correct. Cleaning in a circular motion from the stoma outward helps prevent introducing bacteria into the stoma site. This technique maintains hygiene and decreases the risk of infection.
D. Replace the tracheostomy ties with new ties.
Correct. The nurse should regularly change the tracheostomy ties to maintain the tube’s position securely and prevent skin breakdown around the stoma. New ties should be applied before removing old ties to prevent accidental decannulation.
E. Cut a slit in gauze squares to place beneath the tube holder.
This is not recommended because cutting a slit in gauze can create lint or fibers that may be inhaled, increasing the risk of infection or irritation in the airway. Commercially made tracheostomy dressings without slits are preferred to protect the skin around the stoma.
Summary:
Providing tracheostomy care involves maintaining sterility (surgical asepsis) for the inner cannula, careful cleaning of the outer cannula, secure and regular changing of ties, and avoiding potentially harmful practices such as cutting slit gauze dressings. Proper technique reduces the risk of infection, maintains airway patency, and promotes client comfort and safety.