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Respiratory Procedures

Respiratory Procedures

Inhaler with Spacer

Things to consider

  • Attempt to provide the student with as much privacy as possible, given the urgency of the situation

Needed supplies

  • Inhaler
  • Spacer
  • Student’s Individualized Health Plan/Asthma Action Plan and/or healthcare provider’s order

Procedure

  1. Gather needed supplies and place on clean surface
  2. Position student providing for as much privacy as possible
  3. Wash hands
  4. If student will be administering medication, have student wash hands
  5. Check for authorization forms/record
    1. Medication Administration Form
    2. Medical provider
    3. Parent/guardian
  6. Check for the Five Rights
    1. Right student
    2. Correct time
    3. The medicine container matches authorization forms and medication administration record
    4. The dose on medication container matches authorization form and records
    5. The medication is in the correct route as identified on medication container, authorization forms and medication record
  7. Ensure that the medication has not expired
  8. Make sure the inhaler and spacer are free of foreign objects
  9. Shake the inhaler for 10 seconds to mix the medicine
  10. Remove the cap from the mouthpiece
  11. Prime the inhaler if indicated
    1. When the MDI is brand new or has not been used for a while, the medication may separate from the other ingredients in the canister and the metering chamber. Shaking the MDI will mix the ingredients in the drug reservoir but may not produce enough turbulence to re-blend the ingredients in the metering chamber. Priming, or releasing one or more sprays into the air, ensures your next dose will contain the labeled amount of medication
  12. Place the inhaler mouthpiece onto the end of the spacer
  13. Hold the inhaler between your index finger and thumb
  14. Have the student stand up and take a deep breath in, and breathe out
  15. Have the student put the end of the spacer into their mouth, between their teeth and above their tongue
  16. Have the student close their lips around the spacer
  17. Press down on the top of the inhaler once
  18. Instruct the student to breathe in very slowly until they have taken a full breath
    (If you hear a whistle sound instruct the student to breathe slower—the breath in should take at least 3-5 seconds)
  19. Instruct the student to hold their breath for 5 to 10 seconds
  20. Instruct the student to breathe out slowly through their mouth
  21. Wait 1 minute before having the student take a second puff (if ordered)
     
  22. Repeat steps 1 through 6 if taking a second puff
  23. Have student rinse out their mouth out with water and spit
  24. Wash hands
  25. Document medication administration in student’s medication administration log
  26. Follow up, as needed, with parents/guardian and healthcare provider 

Cleaning the spacer

  1. Remove the mouthpiece and the rubber piece that holds the inhaler
  2. Soak the mouthpiece, rubber piece and plastic chamber in a warm water and small amount of dish soap
  3. Rinse with clean water
  4. Shake off excess water and dry on clean surface in a vertical position, with the mouthpiece side up
  5. Do not dry with a cloth or paper towel
  6. Once dry, store in clean container or bag

Cleaning the inhaler

  1. Remove the canister from the actuator
  2. Run warm water through the top and bottom of plastic actuator (do not boil or place the actuator in the dishwasher)
  3. Shake off the excess water
  4. Allow the actuator to air dry on a clean surface prior to putting canister back in

Resources

AeroChamber Plus® Flow-Vu® Anti-Static Valved Holding Chamber: Instructions for Use http://www.aerochambervhc.com/instructions-for-use.aspx

American School Health Association: Asthma Resource Portal

Asthma and Allergy Foundation of America:  Success of the Asthma Management and Education Online Program

Asthma and Allergy Foundation of America:  Validated Programs for Children, Parents and Caregivers 

Children’s Hospital: University of Missouri Health Care
School Nurse Online Module

Merck Childhood Asthma Network and The National Association of School Nurses:  The Evolving Role of the School Nurse in Treating and Managing Childhood Asthma – At School and Home

National Heart, Lung and Blood Institute: Asthma Basics for Schools

National Heart, Lung and Blood Institute:  Management of Asthma Exacerbations: School Treatment Steps to Follow for an Asthma Episode in the School Setting When a Nurse is Not Available

National Heart, Lung and Blood Institute: Management of Asthma Exacerbations: School Treatment Suggested Emergency Nursing Protocol for Students with Asthma Who Don't Have a Personal Asthma Action Plan

National Heart, Lung and Blood Institute: Asthma Action Plan

Optichamber http://www.healthcare.philips.com/main/homehealth/respiratory_drug_delivery/optihalerdeliverysystem/default.wpd

References  

Allergy and Asthma Network.  Mothers of Asthmatics.  (2009).  Maximize the Mist – Keep Inhalers Clean, Primed and Ready.  Available at: http://www.aanma.org/2009/02/maximize-the-mist-keep-inhalers-clean-primed-and-ready/

American Lung Association.  How to Use a Metered-Dose Inhaler.  Available at: http://www.lung.org/assets/video/colorbox/pdfs/metered-dose-inhaler-spacer.pdf

Connecticut State Department of Education.  Clinical Procedure Guidelines for Connecticut School Nurses.  Available at:http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf

Corjulo, M. (2011). Mastering the metered-dose inhaler: an essential step toward improving asthma control in school. NASN School Nurse, 26, 285.

Acknowledgement of Reviewers:

Rachel Gallagher, RN, MSN, CPNP, NCSN
Director of Health Services
Milwaukee Public Schools

Jill Krueger, RN, BSN
Director/Health Officer
Forest County Health Department

Nebulizer

Things to consider

Attempt to provide the student with as much privacy as possible, given the urgency of the situation

Equipment

Medication
Nebulizer machine (air compressor)
Connecting tubing
Facemask, or a mouthpiece held in the mouth
Individualized Health Plan (IHP)/Asthma Action Plan and/or Healthcare provider’s orders

Procedure

  1. Position student
  2. Explain the procedure to the student at his/her level of understanding
  3. Encourage the student to assist in the procedure as much as he/she is able to help student learn self-care skills
  4. Review IHP/Asthma Action Plan and/or healthcare provider’s orders
  5. Check for authorization forms/record
    1. Medication Administration Form
    2. Medical provider
    3. Parent/guardian
  6. Check for the Five Rights
    1. Right student
    2. Correct time
    3. The medicine container matches authorization forms and medication administration record
    4. The dose on medication container matches authorization form and records
    5. The medication is in the correct route as identified on medication container, authorization forms and medication record
  7. Ensure that the medication has not expired
  8. Wash hands
  9. Set up and plug in the nebulizer machine in a location where the power source is close to a comfortable location for the medication to be administered
  10. Follow the directions for the specific brand of nebulizer machine and cup
  11. Unscrew top of nebulizer cup
  12. Add medication into the bottom half of the nebulizer cup
  13. Screw the top of the cup back on
  14. Attach the tubing from the cup to the nebulizer machine and the cup onto the facemask or mouthpiece
  15. Place either the facemask on the student or the mouthpiece in his or her mouth and turn on the machine
    1. A mist of medication should rapidly appear
  16. Instruct the student to take relatively normal slow deep breaths
  17. Keep the nebulizer cup in an upright position
  18. The cup may require some tapping on the sides toward the end of the treatment to optimize the completion of the dose
  19. The treatment is complete when there is no more mist from the cup (usually 10–15 minutes)
  20. Turn off the machine
  21. Remove the mask or mouthpiece
  22. Rinse nebulizer cup, mouthpiece  or mask under warm water
  23. Shake off excess water
  24. Place on paper towel to dry
  25. Reassess respiratory status
  26. Wash hands
  27. Document assessment, intervention and outcome in student’s healthcare record
  28. Update parents/guardian and healthcare provider, if needed

Cleaning and storing

  1. Take the nebulizer apart
  2. Set tubing aside
  3. Do not soak, wash or rinse tubing
    1. Replace it if it becomes cloudy, discolored or wet inside
  4. Wash the medicine cup and mask with warm, soapy water
  5. Rinse the medicine cup and mask in warm water
  6. Let all pieces air dry on a paper towel
  7. When dry, put pieces in a plastic bag or container

Disinfect weekly

  1. Soak medicine cup and mask in half strength vinegar for at least 10 minutes or overnight
  2. Rinse with water
  3. Let all pieces air dry on a paper towel
  4. When dry, put pieces in a plastic bag or container

Care of the machine

  1. Wipe with a damp cloth
  2. Check the filter monthly
    1. Change it every six months or sooner if discolored
  3. The machine should be serviced every five years

Resources

American School Health Association: Asthma Resource Portal

Asthma and Allergy Foundation of America:  Success of the Asthma Management and Education Online Program

Asthma and Allergy Foundation of America:  Validated Programs for Children, Parents and Caregivers 

Children’s Hospital: University of Missouri Health Care
School Nurse Online Module

Merck Childhood Asthma Network and The National Association of School Nurses:  The Evolving Role of the School Nurse in Treating and Managing Childhood Asthma – At School and Home

National Heart, Lung and Blood Institute: Asthma Basics for Schools

National Heart, Lung and Blood Institute:  Management of Asthma Exacerbations: School Treatment Steps to Follow for an Asthma Episode in the School Setting When a Nurse is Not Available

National Heart, Lung and Blood Institute: Management of Asthma Exacerbations: School Treatment Suggested Emergency Nursing Protocol for Students with Asthma Who Don't Have a Personal Asthma Action Plan

National Heart, Lung and Blood Institute: Asthma Action Plan

References

Children’s Hospital of Wisconsin.  (2010).  Using a Nebulizer with Mask.  http://www.chw.org/applications/TeachingSheets/5010EN.pdf

Connecticut State Department of Education.  (2012).  Clinical Procedure Guidelines for Connecticut School Nurses.  Available at:  http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf

Porter, S., Haynie M.D., Bierle, T., Caldwell, T. & Palfrey, J.  (1997).  Children and Youth Assisted by Medical Technology in Educational Settings.  Guidelines for Care.  Second Edition.  Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21285-0624

Acknowledgement of Reviewers

Marcia Creasy, BSN, RN
Retired School Nurse

Mary Kay Kempken, RN, BSN, NCSN
School Nurse
Randall Consolidated School

Changing Inner Cannula

Things to consider

  • Attempt to provide the student with as much privacy as possible, given the urgency of the situation
  • Should always have Emergency Travel Bag accessible when completing any tracheostomy procedure
  • Two people should be present during the procedure in the event of accidental decannulization
  • Some children have disposable inner cannulas and do not need to re-clean and reuse their inner cannula, if the child does not have a spare inner cannula in the emergency travel bag, their inner cannula should be cleaned and re-used

Supplies needed

(Emergency Travel Bag Equipment)

The essential equipment to be kept with the student at all times is as follows:

  • gloves
  • portable oxygen with appropriate sized Ambu-bag
  • appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube
  • portable suction machine that can operate with battery or electricity
  • sterile suction catheters
  • sterile saline vials
  • water-based lubricant
  • two spare tracheostomy tubes — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
  • obturator, if applicable
  • spare tracheostomy ties
  • blunt scissors
  • emergency phone numbers
  • pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation

Additional needed supplies

  • Student’s individual health plan/Healthcare provider’s order
  • Stethoscope
  • Sterile water
  • Hydrogen peroxide
  • Sterile pipe cleaners
  • Basin for cleaning
  • Personal Protective Equipment
    • gloves
    • goggles
    • mask

Procedure

  1. Assemble supplies and place on a clean surface
  2. Review student’s individual health plan/health care provider’s order
  3. Position student providing as much privacy as possible
  4. Explain the procedure at a level the student will understand
  5. Wash hands
  6. Assess student’s respiratory status to ensure it is appropriate to change tracheostomy cannula at this time
  7. Put on clean gloves
  8. Check emergency travel bag for disposable inner cannula
  9. If disposable inner cannula is available remove the inner cannula as per manufacturer’s instructions
  10. Reinsert the inner cannula by turning it 90 degrees from its usual position, introduce the tip into the outer cannula, slowly rotating it back 90 degrees to its final position
  11. If the student does not have a disposable inner cannula in emergency travel bag, follow the steps below for cleaning and re-inserting inner cannula
  12. Have person assisting with procedure wash hands and put on clean gloves
  13. Mix equal parts of sterile water and hydrogen peroxide in a clean basin
  14. Remove the inner cannula as indicated per manufacturer’s instructions
  15. Soak the inner cannula in a the basin of half-strength hydrogen peroxide solution
  16. Using sterile pipe cleaners, remove any dried secretions from inside the cannula
  17. Thoroughly rinse the cannula with sterile water
  18. Reinsert the inner cannula by turning it 90 degrees from its usual position, introduce the tip into the outer cannula, slowly rotating it back 90 degrees to its final position
  19. Lock the cannula in place per manufacturer’s instructions
  20. Assess student’s respiratory status
  21. Remove gloves
  22. Wash hands
  23. Document assessment, intervention and outcomes in student’s healthcare record
  24. Follow up with parents/guardian and healthcare provider, as needed

References:

  • American Thoracic Society. (2000). Care of the child with a chronic tracheostomy.  American Journal of Respiratory & Critical Care Medicine, 1, 297-308.
  • Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
  • Connecticut State Department of Education.  (2012).  Clinical Procedure Guidelines for Connecticut School Nurses
    Available at: http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf.

Acknowledgment of Reviewers:

Marcia Creasy, BSN, RN
Retired School Nurse

Cynthia C. Griffith, RN, BSN
Nurse Clinician
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin

Mary Kay Kempken, RN, BSN, NCSN
School Nurse
Randall Consolidated School

Cecilia Lang, MSN, CCRN, PNP-BC
Tracheostomy/Home Ventilator APN
Children’s Hospital of Wisconsin

Carole Wegner, MSN, RN
Clinical Nurse Specialist
Tracheostomy/Home Ventilator Program
Children's Hospital of Wisconsin

 

Changing Tracheostomy Tubes

Things to consider

  • When caring for a student who has a tracheostomy, the nurse should always know the reason for the tracheostomy, the child’s underlying health conditions and whether the child needs the tracheostomy to breathe
  • The changing of a tracheostomy tube in the school setting should be considered an emergency situation
  • Any concern that the situation is potentially life-threatening requires the activation of the EMS/911 system while the procedure is being performed. 
  • The two most common emergency scenarios are:
    • accidental decannulization; and
    • tracheostomy tube obstruction unrelieved by reasonable suction attempts. 
  • Obstruction can be caused by thick secretions/mucous plugging, foreign body, or airway granuloma tissue. Airway granuloma tissue can persist to obstruct a new tracheostomy tube, resulting in the highest degree of medical emergency.

Needed supplies

Emergency Travel Bag Equipment
The essential equipment to be kept with the student at all times is as follows:

  • gloves
  • portable oxygen ( if ordered)
  • appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube)
  • portable suction machine that can operate with battery or electricity
  • sterile suction catheters
  • sterile saline vials
  • water-based lubricant
  • two spare tracheostomy tubes — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
  • obturator, if applicable
  • spare tracheostomy ties
  • blunt scissors
  • emergency phone numbers
  • pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation

Additional Needed Supplies

  • Stethoscope
  • Medical tape
  • Personal protective equipment
    • goggles
    • mask
    • gloves

Procedure

  1. Activate EMS/911
  2. Reassure student
  3. Wash hands, if student’s condition permits
  4. Assemble equipment as student’s condition permits or utilize equipment in emergency travel bag
  5. If ordered, place pulse oximeter on student’s finger, toe or ear lobe during and after the procedure
  6. Ensure the presence of another responsible adult, preferably another nurse, if available, to assist with stabilizing the tracheostomy tube
  7. Put on gloves, goggles, and mask
  8. Have adult assisting with procedure put on gloves, goggles, and mask
  9. Suction the student’s tracheostomy tube, if indicated (see Tracheal Suctioning-Clean Technique)
  10. If able, position the student supine on the floor with a shoulder roll to gently hyperextend the neck
  11. Open the new tracheostomy tube kit that is the same size as is currently in the stu­dent
    1. Have the size smaller new tracheostomy tube readily available if needed
  12. If new tube is not available, clean the old tube as possible
  13. Take care to not touch the curved part of the tracheostomy tube, lubricate the distal end of the new tracheostomy tube with water-based lubricant
  14. Return the tracheostomy tube to the clean package that it was sealed in
    1. If the tube has an obturator, be sure the obturator is in the tube
  15. Remove tracheostomy mask, artificial nose or ventilator connection, as necessary
  16. Give student two to four breaths with resuscitation bag 
    1. If unable to pass suction catheter, do not attempt to give breaths to a plugged trach. CHANGE THE TRACH TUBE
  17. Have adult assisting with procedure hold old tracheostomy tube in place
  18. Assure tracheostomy tube cuff has been fully deflated, if applicable
    1. Deflate the cuff per manufacturer’s instructions
  19. Remove or cut old tracheostomy ties
  20. With one hand remove the old tracheostomy tube and set it out of the way
  21. Insert new tube
    1. If tube does not have an obturator, insert new tube at a right angle to the stoma, rotating it downward as it is inserted
    2. If tube has an obturator, insert tube straight into stoma
      1. Immediately remove the obturator and insert inner cannula
      2. Insertion of new tube should take no longer than 30 seconds
  22. Have adult assisting with the procedure hold the new tracheostomy tube in place
  23. Administer a minimum of three breaths with a manual resuscitator bag
  24. Secure the new tracheostomy tube in place by fastening the tracheostomy ties
    1. If this is a cuffed tracheostomy tube, inflate at this time per manufacturer’s in­structions
  25. Re-attach tracheostomy mask, artificial nose or ventilator connection, as necessary
  26. Position the student comfortably and observe to ensure he or she remains stable on their baseline level of supplemental or ventilator support (if any)
  27. Continue the respiratory assessment, using pulse oximetry, if available, until EMS has arrived
  28. Discard used equipment per school policy
  29. Remove gloves
  30. Wash hands
  31. Document assessment, intervention and outcomes in student’s healthcare record
  32. Notify parents/guardian and medical provider that student required a tracheostomy change procedure
  33. Replenish supplies in emergency travel bag

If unable to replace tracheostomy tube

  1. Reposition the student and re-attempt to place the tube
  2. If unsuccessful, attempt to place the smaller tube
  3. If unable to place a size smaller tube, assess child’s respiratory status to determine the need for rescue breathing
    1. If rescue breathing is needed
      1. Open the natural airway
        1. Be aware that some patients may not have a natural airway due to surgical procedures or anatomical abnormalities
      2. Tape over the tracheal stoma
      3. Give breaths using a manual resuscitation bag with a facemask
    2. If rescue breathing is not needed and child’s respiratory status is stable

      Observe the child and call 9ll for assistance.

References:

  • American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. American Journal of Respiratory & Critical Care Medicine, 1, 297-308.
  • Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
  • Children’s Hospital of Wisconsin.  (2006).  Tracheostomy Cares and Trach Tube Changes: Policy and Procedure.
  • Connecticut State Department of Education.  (2012).  Clinical Procedure Guidelines for Connecticut School Nurses. 
    Available at: http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf
  • Hootman, J.  (1996).  National Association of School Nurses.  Quality Nursing Interventions in the School Setting. 
  • Porter, S., Haynie, M.D., Bierle, T., Caldwell, T. & Palfrey, J.  (1997).  Children and Youth Assisted by Medical Technology in Educational Settings.  Guidelines for Care.  Second Edition.  Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21285-0624

Acknowledgement of Reviewers:

Cynthia C. Griffith, RN, BSN
Nurse Clinician
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin

Carole Wegner, MSN, RN
Clinical Nurse Specialist
Tracheostomy/Home Ventilator Program
Children's Hospital of Wisconsin

 

 

Changing Tracheostomy Ties

Things to consider:

  • Changing tracheostomy ties in the school setting is usually not done on a routine basis, rather it would be completed on an emergency situation such as an emergency tracheostomy change
  • When caring for a student who has a tracheostomy, the nurse should always know the reason for the tracheostomy, the child’s underlying health conditions and whether the child needs the tracheostomy to breathe
  • Two people should be present during the procedure in the event of accidental decannulization
  • Should always have Emergency Travel Bag accessible when completing any tracheostomy procedure
  • A shoulder roll is recommended to assist with the visualization and access to the tracheostomy site
  • The two most common forms of tracheostomy ties are a soft padded tie with Velcro tabs (most common) or a simple thin cloth or twill tie that requires tying to secure
  • Attempt to provide the student with as much privacy as possible, given the urgency of the situation

Needed Supplies:

Emergency Travel Bag Equipment:

  • gloves
  • portable oxygen with appropriate sized Ambu-bag
  • appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube)
  • portable suction machine that can operate with battery or electricity
  • sterile suction catheters
  • sterile saline vials
  • water-based lubricant
  • two spare tracheostomy tubes — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
  • spare tracheostomy ties
  • blunt scissors
  • emergency phone numbers
  • pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation

Additional Needed Supplies:

  • Student’s Individualized Health Plan and healthcare provider’s orders
  • Personal protective equipment
    • goggles
    • mask
    • gloves
  • Tracheostomy ties
  • Blunt scissors
  • Gauze
  • Stethoscope

Procedure:

  1. Gather supplies
  2. Review Individualized Health Plan and healthcare provider’s orders
  3. Position the student
    • If a shoulder roll is used, place it behind student’s shoulders
  4. Explain procedure at a level the student will understand
  5. Have person assisting with procedure wash hands and put on gloves
  6. Wash hands
  7. Put on gloves
  8. Remove the old ties while holding the tracheostomy tube in place
    • Removal of cloth ties requires the use of a blunt scissor
    • Removal of velcro tab ties is done by detaching each end of the tie
  9. Use caution not to occlude the tracheostomy tube
  10. Insert one end of the tie through the slit opening on the side of the tracheostomy tube
  11. Bring the other end of the tie around the back of the neck
  12. Repeat with the other end of the tie through the slit opening on the other side of the tracheostomy tube
  13. Fasten the tracheostomy ties
    • Velcro tabs are fastened back on themselves
    • Cloth ties are secured using a single square knot on the side or back of the neck
  14. The ties should allow enough space for one pinky finger between ties and neck
  15. If a dressing is used around the stoma, replace it now with a clean one
  16. Assess the student’s respiratory status to ensure that the tracheostomy tube remained in place and patent during the procedure
  17. Remove gloves
  18. Wash hands
  19. Documents assessment, procedure, and outcomes in the student’s healthcare record
  20. Follow up with parents/guardian and healthcare provider, as needed

References:

Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Children’s Hospital of Wisconsin.  Caring for Kids with Tracheostomies: Changing the Trach Ties

Cincinnati Children's Hospital Medical Center.  (2011).  Best evidence statement (BESt). Basic pediatric tracheostomy care.   Available at:  http://guideline.gov/content.aspx?id=34159&search=tracheostomy+stoma

Connecticut State Department of Education.  (2012).  Clinical Procedure Guidelines for Connecticut School Nurses.  Available at:  http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf

Porter, S., Haynie M.D., Bierle, T., Caldwell, T. & Palfrey, J.  (1997).  Children and Youth Assisted by Medical Technology in Educational Settings.  Guidelines for Care.  Second Edition.  Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21285-0624.


Acknowledgment of Reviewers:

Marcia Creasy, BSN, RN
Retired School Nurse

Cynthia C. Griffith, RN, BSN
Nurse Clinician
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin

Mary Kay Kempken, RN, BSN, NCSN
School Nurse
Randall Consolidated School

Cecilia Lang, MSN, CCRN, PNP-BC
Tracheostomy/Home Ventilator APN
Children's Hospital of Wisconsin

Carole Wegner, MSN, RN
Clinical Nurse Specialist
Tracheostomy/Home Ventilator Program
Children's Hospital of Wisconsin

 

Oxygen Administration

Things to consider:

When using nasal cannula, take care not to put undue pressure on the nasal tissue from tightening the attachment too much

Methods

Nasal Cannula:
  • Plastic tube that connects on one end to an oxygen source (tank) with the other end having two short prongs that each fit into the nostrils
  • Generally indicated as an option for planned use of continuous or intermittent oxygen
Mask 
  • A plastic facemask with tubing connected to an oxygen source
  • The two main sizes of oxygen masks are pediatric and adult. They are generally indicated for emergency situations
Tracheostomy Mask:
  • A plastic mask designed to fit over a tracheostomy cannula and secured by an elastic strap around the neck (over the tracheostomy ties)
  • This may be indicated for planned use of continuous or intermittent oxygen
Mechanical Ventilation:
  • A variety of portable mechanical ventilation devices may be used for children who attend school
  • They are attached to the student via a tracheostomy and may or may not involve the routine delivery of supplemental oxygen
Ambu Bag (Manual Resuscitation):
  • In a case of extreme medical emergency (i.e., severe oxygen desaturation, impending respiratory failure, or respiratory or cardiac arrest), oxygen can be delivered at full flow (> 10 L/min.) with an Ambu Bag using an appropriately sized sealed face mask or fitted directly onto a tracheostomy cannula
High pressure tanks (standard metal oxygen tanks): (standard metal oxygen tanks):

Require a regulator that has:
  1. A valve to turn the oxygen source on and off

  2. A flow meter to measure and adjust the flow of oxygen

  3. A pressure gauge to determine the amount of oxygen remaining in the tank
Procedure:
  1. Open the tank by turning the valve at the top counterclockwise until the needle on the pressure gauge moves

  2. Set the flow meter to the prescribed rate (liters/minute) by turning the dial to the number or until the ball rises to the correct level on the scale

If using a nasal cannula:

  1. Place prongs into nose so they follow the curve of the nostrils
  2. Loop the head attachment around the student’s ears  
  3. Adjust below the chin

If using a face mask:

  1. Place mask over nose and mouth
  2. Secure with elastic strap around the head and above the ears
  3. The mask needs to be comfortably, but firmly against the face:
    1. Tighten the straps until you can easily fit one finger between the strap and the student’s face
    2. Any space between the mask and face dilutes the intended concentration of oxygen
  4. For students unable to tolerate the elastic strap around their head, the mask can be held against the face without the strap (only appropriate for a limited period of time)

If using a tracheostomy mask:

  1. Follow the same procedure as a facemask, except cover the tracheostomy can­nula with the mask and secure it around the neck

If using an Ambu Bag:

  1. Turn oxygen flow rate > 10 L/min
  2. Administer by either face mask or tracheostomy connection:
    1. Either option requires a tight seal to the airway
  3. Rate and force of manual resuscitation breaths is determined by CPR certified personnel
To close the tank:
  1. Disconnect oxygen from the student
  2. Turn valve clockwise until it cannot go any further. The flow meter should steadily decrease to zero, indicating that no oxygen is flowing (or leaking) from the tank (referred to as “bleeding” the tank off)
  3. Turn the flow meter dial to zero
  4. Tank needs to be stored in a secured upright position to prevent it from falling or tipping over
  5. Storage area for oxygen tank must be free of petroleum products
Liquid oxygen tanks
  1. Portable liquid oxygen tanks can be refilled from a home-based liquid oxygen system
  2. These tanks are student specific and only indicated as part of an IHCP
  3. These tanks are used following the same procedural steps listed above and require the same safety considerations

References:

Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Connecticut State Department of Education.  (2012). Clinical Procedure Guidelines for Connecticut School Nurses.  Available at:  http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf.

 

Acknowledgement of Reviewers:

Rachel Gallagher, RN, MSN, CPNP, NCSN
Director of Health Services
Milwaukee Public Schools

Cynthia C. Griffith, RN, BSN
Nurse Clinician
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin

Jill Krueger, RN, BSN
Director/Health Officer
Forest County Health Department

Carole Wegner, MSN, RN
Clinical Nurse Specialist
Tracheostomy/Home Ventilator Program
Children's Hospital of Wisconsin

Tracheal Suctioning and Cleaning

Things to consider

  • When caring for a student who has a tracheostomy, the nurse should always know the reason for the tracheostomy, the child’s underlying health conditions and whether the child needs the tracheostomy to breathe
  • Attempt to provide the student with as much privacy as possible, given the urgency of the situation
  • Is suctioning necessary or can the student “cough out the secretions?”
    • Encourage the student to cough to expel the secretions
    • If secretions clear and there are no signs of respiratory distress, do not suction
  • Should always have Emergency Travel Bag accessible when completing any tracheostomy procedure
  • “Deep suctioning” up to or beyond the tracheal carina (point of bronchial bifurcation and tissue resistance) should not be indicated in a school setting, as it may cause epithelial damage
  • Each student will have an absolute length of catheter insertion, “measured length”
    • When suctioning, the catheter should not be inserted deeper than the absolute length of catheter insertion
  • When suctioning, determine what the family has been taught related to applying suction on insertion and when withdrawing catheter or just when withdrawing
  • The child can be suctioned with clean technique or sterile technique per child’s healthcare plan

Supplies

Emergency Travel Bag Equipment

The essential equipment to be kept with the student at all times is as follows:

  • gloves
  • portable oxygen with appropriate sized Ambu-bag
  • appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube
  • portable suction machine that can operate with battery or electricity
  • clean suction catheters
  • sterile saline vials
  • water-based lubricant
  • two spare tracheostomy tubes
    • one the size the student currently uses
    • one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
  • obturator, if applicable
  • spare tracheostomy ties
  • blunt scissors
  • emergency phone numbers
  • pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation

Additional needed supplies

  • Student’s individual health plan/healthcare provider’s order
  • Stethoscope
  • Cup of tap water
  • Personal protective equipment
    • Goggles
    • Mask
    • Gloves

Procedure

  1. Assemble supplies
  2. Review healthcare provider’s order/ Student’s individual health plan
  3. Wash hands
  4. Perform respiratory assessment
    1. The respiratory assessment should be an ongoing process to determine:
      1. How well the student is tolerating the procedure
      2. The amount of time and suction attempts that are clinically indicated
  5. Given the urgency and needs of the student; position the student to provide for the most privacy
    1. students in wheelchairs or other supportive seating devices can remain sitting upright or reclined up to, but not exceeding, semi-fowlers or 45 degrees
    2. students who are lying should be turned on their side (this position may be commonly associated with a student experiencing a seizure who may require supplemental oxygen and/or suctioning)
  6. Explain the procedure to the student at a level the student understands
  7. If ordered, place pulse oximeter on student’s finger, toe or ear lobe during and after the procedure
  8. Turn on suction machine and check for function
  9. For suction machines that have suction measurements in mm Hg
    1. Ensure the suction machine has the appropriate level of subatmospheric pressure:
      1. standard maximal pressure for children ranges from 80–100 mm Hg; and
      2. standard maximal pressure adolescents ranges 80-120 mm Hg
      3. maximal pressure may be determined by turning on suction and occluding extension tubing by folding it in half
      4. pressure reading on the gauge when the tubing is completely occluded is the maximal suction pressure
  10. For suction machines that have a dial with numbered suction settings (i.e. 1, 2, 3), use the lowest level of suctioning that will remove the secretions
    1. Start at the lowest suction level and increase as needed 
  11. Put on clean gloves
  12. Attach top of catheter to suction tubing
  13. Hold the suction catheter at the absolute length of catheter insertion, “measured length”
  14. Lubricate the catheter with normal saline
  15. The use of normal saline to lavage the tracheostomy tube is based on the Individualized Health Plan and, if indicated, to assist with the removal of thick secretions, needs to be used judiciously
  16. Remove tracheostomy mask, artificial nose or ventilator connection and promptly insert catheter while gently rotating within the cannula
  17. Advance catheter into tracheostomy tube to the “measured length” with or without suction (based on how the procedure is completed in the home setting and healthcare provider’s order)
  18. Twirl catheter between fingers as it is pulled out of tracheostomy tube, staying in no more than 5 seconds
    1. When suction catheter is inserted into tracheostomy tube, the student’s airway is occluded, total suction time should not exceed 5 seconds
  19. Suction a small amount of sterile saline with the suction catheter to clear any residual debris/secretions
  20. Allow student to rest and return to normal breathing
    1. If student was receiving oxygen and humidification by mask before the suctioning, reapplication of the mask between suctioning passes or 3-5 breaths with manual resuscitator bag with oxygen attached, may be warranted
    2. If student is not on oxygen, give 3 to 5 extra breaths with the resuscitator bag, if needed
  21. Repeat suctioning in above order (10-14) until secretions are removed
    1. Note the color, presence of odor, and consistency of secretions
  22. Suction nose and mouth with same catheter the same way
    1. If re-using catheter for tracheotomy suctioning, use a separate catheter to suction the mouth and nose
  23. Complete suctioning
  24. For students on oxygen
    1. Replace mask, artificial nose or ventilator connection on student
  25.  For students without oxygen:
    1. Give 3 to 5 extra breaths with the resuscitator bag, if needed                    
  26. Assess respiratory status
  27. Rinse suction catheter with ½ strength hydrogen peroxide or vinegar water; then rinse catheter with sterile water  (or procedure used by family)
  28. Place suction catheter in a clean container
    1. The suction catheter can be used up to 8 hours
  29. Remove gloves
  30. Rinse suction machine tubing with tap water
  31. Wash hands
  32. Document assessment, procedure, and outcomes in student’s healthcare record
  33. Report any concerns to parents/guardian and healthcare provider
    1. Such as green/yellow or foul smelling secretions
  34. Replenish supplies as needed

Procedure for cleaning suction catheter: See above #27

Resources

Ballard TRACH CARE: Solutions For The Home Care Patient
http://www.kchealthcare.com/media/67088/product%20information%20and%20tool_trach%20care_home%20care%20guide.pdf

UW Pediatric Pulmonary Center, American Family Children's Hospital, and Children's Hospital of Wisconsin

Pediatric Tracheostomy and Ventilator Care
http://www.uwppc.org/educational-resources/pediatric-tracheostomy-ventilator-care.html

References:

American Association for Respiratory Care. (2010).  AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respiratory Care, 55(6),758-64.

American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. American Journal of Respiratory & Critical Care Medicine, 1, 297-308.

Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Children’s Hospital of Wisconsin.  Caring for Kids with Tracheostomies: Suctioning Secretions

Cincinnati Children’s Hospital. (2011). Basic Pediatric Tracheostomy Care.  Accessible at: http://www.cincinnatichildrens.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=88057&libID=87745

Connecticut State Department of Education.  (2012).  Clinical Procedure Guidelines for Connecticut School Nurses.  Available at:  http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf

Hootman, J.  (1996).  National Association of School Nurses.  Quality Nursing Interventions in the School Setting

Porter, S., Haynie, M.D., Bierle, T., Caldwell, T. & Palfrey, J.  (1997).  Children and Youth Assisted by Medical Technology in Educational Settings.  Guidelines for Care.  Second Edition.  Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21285-0624.

Acknowledgment of Reviewers:

Marcia Creasy, BSN, RN
Retired School Nurse

Cynthia C. Griffith, RN, BSN
Nurse Clinician
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin

Mary Kay Kempken, RN, BSN, NCSN
School Nurse
Randall Consolidated School

Carole Wegner, MSN, RN
Clinical Nurse Specialist
Tracheostomy/Home Ventilator Program
Children's Hospital of Wisconsin

Tracheostomy Stoma Skin Care

Things to consider

  • When caring for a student who has a tracheostomy, the nurse should always know the reason for the tracheostomy, the child’s underlying health conditions and whether the child needs the tracheostomy to breathe
  • The frequency of stoma care and the care of the surrounding skin is based on the individual student’s current skin condition and associated factors, such as the amount of secretions and the degree of skin folds around the neck
  • Attempt to provide the student with as much privacy as possible, given the urgency of the situation
  • Should always have Emergency Travel Bag accessible when completing any tracheostomy procedure

Supplies

Emergency Travel Bag Equipment

The essential equipment to be kept with the student at all times is as follows:

  • gloves
  • portable oxygen (if ordered) with appropriate sized Ambu-bag
  • appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube)
  • portable suction machine that can operate with battery or electricity
  • sterile suction catheters
  • sterile saline vials
  • water-based lubricant
  • two spare tracheostomy tubes — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
  • obturator, if applicable
  • spare tracheostomy ties
  • blunt scissors
  • emergency phone numbers
  • pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation

Additional Needed Supplies

  • Student’s Individualized Health Plan (IHP) and/or healthcare provider’s order
  • Gauze
  • Cotton tip applicators
  • Mild soap
  • Water
  • Saline
  • Medicine cup
  • Stethoscope
  • Personal protective equipment
    • gloves
    • goggles
    • mask

Procedure

  1. Gather supplies
  2. Review IHP/Healthcare provider’s order
  3. Position student providing as much privacy as possible
  4. Explain the procedure to the student at his/her level of understanding
  5. Wash hands
  6. Put on gloves
  7. Ensure that tracheostomy ties are secure
  8. Remove dressing if applicable, dispose of per school policy
  9. Observe stoma for:
    1. Increased secretions or change in consistency or color of secretions
    2. Secretions that have an odor
    3. Redness or crusting
    4. Bleeding
    5. Indications of pain to stoma site
  10. Use gauze sponges and cotton-tipped swabs per IHP and healthcare provider’s orders
  11. Dip cotton dip applicator in saline and mild soap mixture per healthcare provider’s order
  12. Support the tracheostomy tube with your finger during cleaning
  13. Use cotton tip applicator to clean outer portion of tracheostomy tube and surrounding skin
    1. Start as close as possible to the tracheostomy tube then work away from it
  14. Make only one sweep with each cotton tip applicator before discarding
    1. Repeat the process until debris and/or mucus is removed
  15. Minimize direct moisture to the tracheostomy ties
    1. Use a dry cotton tip applicator to dry skin surrounding stoma starting at inner most part and moving outward
  16. Drying the skin is vital to maintaining skin integrity
  17. Place dressing on tracheostomy site, if ordered by healthcare provider
  18. Dispose of used supplies per school policy
  19. Remove gloves
  20. Wash hands
  21. Document assessment, intervention and outcomes in student’s healthcare record
  22. Follow up with parent/guardian and healthcare provider, as needed

References:

  • American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. American Journal of Respiratory & Critical Care Medicine, 1, 297-308.
  • Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
  • Children’s Hospital of Wisconsin.  Caring for Kids with Tracheostomies: Cleaning the Skin Around the Trach Tube
  • Cincinnati Children's Hospital Medical Center.  (2011).  Best evidence statement (BESt). Basic pediatric tracheostomy care.   Available at:  http://guideline.gov/content.aspx?id=34159&search=tracheostomy+stoma
  • Connecticut State Department of Education.  (2012).  Clinical Procedure Guidelines for Connecticut School Nurses.  Available at:  http://www.sde.ct.gov/sde/lib/sde/pdf/publications/clinical_guidelines/clinical_guidelines.pdf
  • Porter, S., Haynie, M.D., Bierle, T., Caldwell, T. & Palfrey, J.  (1997).  Children and Youth Assisted by Medical Technology in Educational Settings.  Guidelines for Care.  Second Edition.  Paul H. Brookes Publishing Co., P.O. Box 10624, Baltimore, MD 21285-0624.

Acknowledgment of Reviewers:

Marcia Creasy, BSN, RN
Retired School Nurse

Cynthia C. Griffith, RN, BSN
Nurse Clinician
Tracheostomy/Home Ventilator Program
Children’s Hospital of Wisconsin

Mary Kay Kempken, RN, BSN, NCSN
School Nurse
Randall Consolidated School

Carole Wegner, MSN, RN
Clinical Nurse Specialist
Tracheostomy/Home Ventilator Program
Children's Hospital of Wisconsin

 

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