Caring for your Child with a Tracheostomy at home

Transcription

1 Caring for your Child with a Tracheostomy at home This information is intended as a training guide for families. Information contained in this booklet is not intended to be a substitute for professional medical advice or recommendations. In case of a medical emergency, always call 911.

2 Introduction This manual is a guidebook for helping you to care for you child s tracheostomy. This book describes the different tasks you will need to do to keep your child healthy. This book will be used as a reference guide for you during your training on all the respiratory equipment your child will use. You will have different training sessions with our healthcare staff, depending on the equipment your child needs. Day one training includes introducing you to suctioning and travel bag supplies. Day two training includes apnea monitor set up. Day three training includes setting up your home with your equipment and supplies. Other training may be needed depending on what services your child needs. On the day that you are discharged from the hospital we will meet you at home to make sure everything is ready to go for you and your child.

3 What is a tracheotomy? A Tracheotomy is a surgically created hole (stoma) in the neck that leads directly into the trachea (wind pipe). The hole is kept open by inserting a tracheostomy tube in place, also called a trach tube. A tracheostomy bypasses the nose and mouth.

4 Tracheostomies There are several brands and styles of trach tubes. There are also cuffed and uncuffed trachs. Although the type of trach tube may vary, all tracheostomies need daily care to keep them clean and functioning properly. The most common trach tubes for tracheostomies are Shiley and Bivona. Some trach tubes have cuffs that can completely seal off the airway. There are also metal trachs called Jackson trachs, but are not usually used on pediatric patients.

5 Tracheostomy Tubes There are 3 main parts of a tracheostomy tube: Obturator- piece inserted in tracheostomy tube during insertion of tube. Helps to guide the tracheostomy tube into place. This is removed immediately after insertion. Flange- the top part of the tracheostomy tube where the trach ties will hold the tube in place. The brand and size of the tracheostomy tube will be written here. Cannula- the shaft of the tracheostomy tube that is inserted into the wind pipe. If your child s trach is cuffed there is a small balloon at the end of the cuff that can be inflated to seal off the airway for help with maintaining secretions.

6 Breathing Normally When breathing normally, to inhale and take a breath in, our muscles work together. A muscle called the diaphragm moves down and causes the rib cage to expand and acts as a vacuum to cause the air to move into our lungs. As the air passes through the nose it is heated, filtered, and moisturized. When we breathe out the diaphragm moves up causing the rib cage to constrict and the air in the lungs to be exhaled.

7 Breathing with a Tracheostomy When a tracheostomy is in place the child breathes a little differently. The air goes directly into the wind pipe and lungs, so the natural moisturizing, filtering, and heating through the nose is bypassed. We will go into more detail of how to add this process back in later in this book.

8 Care of Tracheostomy Site Keeping the tracheotomy site or stoma (opening in neck) clean is very important. It helps to ensure that your child s stoma will not get infected. This care should be done daily and as needed. Supplies Needed: gloves, sterile cottontipped applicators, sterile water, 2x2 sterile IV sponge dressing, and a blanket roll Procedure Prepare clean work area and wash hands Assemble supplies Place blanket roll under child s shoulders to hyperextend neck area, allowing for access to trach site Apply gloves Hold trach in place during entire procedure Remove old trach dressing Clean around trach stoma with sterile cottontipped applicators dipped in sterile water, using a rolling motion away from the opening

9 Care of Tracheostomy Site Use a new applicator with each pass of the stoma Apply new sterile 2x2 trach dressing underneath trach wings. Apply doctor prescribed ointment with cotton tipped applicators if needed

10 Changing Trach Ties Your child s tracheostomy tube is held in place by ties called trach ties. These trach ties are usually cloth with Velcro so that there is no irritation to your child s skin. These need to be changed daily and as needed. Your supply is for one trach tie per day, however, you can wash the trach ties in warm soapy water and let them air dry so that you have extras if needed. Supplies needed: new trach tie, scissors, soap and water to clean skin and washcloths, gloves Procedure: - Wash hands - Measure the size needed for your child by placing the new trach tie behind your child s neck and cut off any extra length. If you have a previously cut trach tie, you can use this to measure.

11 Changing Trach Ties Procedure: -Place blanket roll under child s shoulders to hyperextend the neck area, allowing for access to trach and trach ties. -Apply gloves. -Remove Velcro tab on one side of old trach tie, making sure to stabilize trach tube with other hand. -Clean the skin underneath the trach tie with the soap and water and allow the skin to dry. -Thread Velcro tab of new trach tie through hole in wing of tracheostomy tube. -Remove Velcro tab on other side of old trach tie and thread Velcro tab of new trach tie through hole in wing of the other side of the tracheostomy tube. -While continuing to stabilize the trach, reach around and secure both ends of the trach ties behind the neck leaving about a finger widths space between the tie and your child s neck.

12 Humidification The moisture in the air has an effect on your child s secretions or mucus that your child produces. As stated earlier, with a tracheostomy the nose and mouth are bypassed, so the air inhaled is not heated or humidified. Because of this; extra humidification is needed. If your child is not receiving enough humidity, his or her secretions will become very thick and hard to suction out, which can cause respiratory distress. If your child is receiving too much humidity, the secretions will be very thin and watery. Once your child begins receiving humidity, you can base his or her necessity of humidity on how his or her secretions look.

13 Ways to Provide Humidification There are many ways to provide humidification for your child. Two main types of humidification that CHHC uses are the 50 psi with a trach mask and the heat moisture exchanger. These should be used throughout the day to ensure that secretions do not become too thick. Heat Moisture Exchanger (HME)/ Artificial Nose -The HME is an easy way to provide humidification. It is a filter that fits right onto the trach tube. There are adapters available to provide oxygen through the HME if needed. The HME should only be used when your child is awake.

14 Ways to Provide Humidification 50 psi with trach mask -The 50 psi is an air compressor. A bottle of sterile water or distilled water is connected to it, so that the air being received is humidified. Blue tubing is connected from water bottle to a trach mask. The trach mask is connected around your child s neck and fits right over the trach to provide humidification. In between the trach mask and the water bottle is a water trap jar placed in line with the blue tubing. This jar collects the extra water that forms in the tubing. It is important to keep your child higher than the water trap so that the water does not spill into the trach mask.

15 Suctioning One of the most important exercises you will do is suctioning your child s trach. Suctioning is a procedure used to remove secretions from the airway. It requires the insertion of a small plastic tube called a catheter into the airway to remove the secretions. If your child is sick you may need to suction more frequently than normal. Signs that your child needs to be suctioned -shows signs of difficulty breathing -has a weak cough and cannot remove secretions -Makes a whistling noise when breathing -Color appears blue or dusky around the mouth -gurgling sound while breathing -thick secretions that plug the tube -restlessness or agitation -increased respiratory rate not due to activity

16 Suctioning What to watch for -It is important to pay attention to the color of your child s mucus. This will be important for knowing your child s normal and the difference of when your child is sick. Mucus -Clear or white: normal secretions -Yellow, green, or foul smelling: infection. Call your doctor and you may need to suction more often -Bloody or blood spotted: not enough humidity. Increase humidity -Pink and frothy- too much fluid. Call your child s doctor immediately If your child is able to cough up the mucus, so that it is coming out of the trach, you can use a suction adapter to suction the top of the trach tube. Do not suction with the Sims adapter for more than 3 seconds each pass.

17 Safe Suction It is important to know what is your child s safe suction number. This is a number that is pre-measured so that your child has the least amount of irritation as possible. To measure the proper safe suction number take a suction catheter and insert it into a new trach tube. -Insert the catheter until it reaches the opposite tip of the trach tube. -Advance the catheter until the end of the catheter is exposed to reveal the side port openings of the catheter.

18 Safe Suction -Mark the catheter at the bell of the trach and then remove the catheter. -If the suction catheter has numbers on it, record the number at the bell of the trach and that is your safe suction number. -If the suction catheter does not have numbers, place the catheter next to a tape measure to see how many centimeters it is, and that is your safe suction number.

19 Clean Technique for Suctioning Clean suction is the technique we use at CHHC. This just means that it is clean suctioning rather than sterile suctioning. With this the catheter is cleaned in between different suctioning times. Supplies: Appropriately sized suction catheter, exam gloves, sterile saline vial, and suction machine set to appropriate setting Procedure: -Prepare clean work area and wash hands -Assemble equipment -Open suction catheter package -Put on exam glove and grasp sterile suction catheter at suction port end -Connect suction port end of catheter to suction tubing on suction machine -Insert the catheter into your child s tracheostomy tube and advance it to the safe suction number -While withdrawing the catheter from the tube, place your thumb over the suction port and use a circling motion while pulling out the catheter

20 Clean Technique for Suctioning After withdrawing the catheter from the trach tube, flush catheter with tap water, then flush with vinegar solution Keep catheter in vinegar solution bottle, until ready for next use Remove catheter from vinegar solution and flush tube with sterile water, now catheter is ready to be used

21 Emergency Procedures for Tracheostomy Children with a tracheostomy are more likely to have problems when they become ill. It is important to always be prepared, in case of an emergency. Supplies needed available at ALL times: -Extra trach tube of same size and extra tube one size smaller -Ambu bag -Suction machine and supplies -Saline -Oxygen if available Situations that can lead up to an emergency -trach tube comes out -trach tube is plugged with secretions or other objects -there is a lung problem like a cold or chronic disease -your child is not breathing -before and after suctioning

22 Emergency Procedures If you suspect that there is a problem the first thing to do is check your child. Is your child breathing? -check to make sure you can see chest rise -make sure nothing is blocking the trach tube -make sure he or she is in a good position Yes my child is breathing -Suction the trach tube -watch for the coloring of your child s skin-blue, grey, etc. -assist your child with breathing by using an Ambu bag -try to trouble shoot the problem, if the problem continues call for help No my child is NOT breathing Attempt to suction the trach tube Change the trach tube, Give 2 breaths with the Ambu bag, making sure there is visible chest rise, if your child responds to the breaths, continue assisting his or her breathing, if there is no response begin chest compressions at a rate of 100 bpm. The cycle of breaths to compressions is 2 breaths to 30 compressions.

23 Emergency Procedures If your child is experiencing difficulty breathing, you may need to help them with the Ambu bag. It is important to check your Ambu bag on a regular basis, so that if you need it, you know it is functioning properly. If you think that your child needs help breathing with an Ambu bag here are the steps to follow. -Attach the adapter on the Ambu bag to the trach tube and squeeze the bag gently as your child begins to take a breath in. Try to match your child s breathing pattern, and to only squeeze the bag when your child is inhaling. -Continue to squeeze the bag until the chest rises to what appears to be a normal breath (don t squeeze the bag too hard, because over expanding the lungs can be harmful) -Continue bagging your child until he or she is more comfortable and breathing on his or her own, or until help arrives -While you are bagging, you should also try to correct the problem that caused the episode. Try to suction the trach tube, if you suspect that it is plugged with secretions you should change the trach tube immediately.

24 Emergency Procedures If the tracheostomy tube comes out and you cannot insert the same size trach tube or the smaller size trach tube, place a suction catheter 1 inch into the stoma and perform mouth to mouth or bag mask ventilations. As you are providing ventilations, you also need to call for help, as your child will need a new airway

25 Changing the Tracheostomy Tube Your child s trach tube will need to be changed weekly and as needed. Normally the trach change should be on the same day every week. Sometimes, however, the tube will need to be changed sooner. Times to change before scheduled: Unable to pass the suction catheter down trach tube Respiratory distress continues after suctioning Trach tube accidentally comes out It is recommended having two people available to perform a trach change. Supplies needed: Appropriate sized trach tube with obturator Trach ties Blanket roll Gloves Saline Smaller size trach tube

26 Changing the Tracheostomy Tube Before the actual trach change, you should already have the trach ties pre-measured and cut to fit your child. After the ties are cut, you should have the new trach threaded with the new trach ties. Also the trachs used for back-up should also be pre-threaded with the trach ties. It is also recommended to suction your child before changing the trach. In order to pre-thread the trach ties in the new trachs, you need to have a glove on while threading the trach ties. Have the trach ties already pre-sized and cut prior to beginning to thread the ties. Thread one side of the trach tube. Then thread the other side.

27 Changing the Tracheostomy Tube Procedure: Prepare clean work area and wash hands Assemble equipment Position your child so that his or her neck area is hyper extended with a towel roll Apply gloves then moisten new trach tube stem with sterile saline Remove old trach ties, making sure to stabilize and secure old trach tube in place with one hand With the other hand, take new trach with obturator (keeping neck of trach angled downward)

28 Changing the Tracheostomy Tube In one motion, pull old trach out and insert new trach Immediately remove the obturator after insertion Attach the new trach ties together behind your child s neck

29 Tracheostomy Safety Clothing Keep all clothing away from the tracheostomy, as to not block the opening Don t wear Turtlenecks Necklaces Anything that blocks the trach tube Do wear V-neck shirts Clothes that open in front Cotton Bibs Food -Most children with a tracheostomy can eat normally. It will be up to your doctor to decide the limits of your child. -When your child is eating stay in the same room, if they are a baby burp them often, and always hold the bottle yourself, do not prop it and leave unattended.

30 Tracheostomy Safety Activity and Play -It is important to choose toys that are appropriate for your child. It is also important for child interaction, so it is ok to let other children play with your child. However, it is important to teach the other children to not touch the trach tube or other medical equipment. Toys to Avoid Toys with small parts like Legos, Polly Pocket, etc. Sand boxes Swimming pools and other water related activities Beads, Marbles Skin Care Products Do not use perfume, powders, or aerosols around your child. These will irritate your child s airway and make them cough. Do NOT smoke around your child.

31 Tracheostomy Safety Bath Time Children with tracheostomies should be bathed on a regular basis and as needed, just like any other child. It is important and crucial that you not allow any water to go into the trach tube. If water gets into the trach tube it will go directly into your child s lungs. Bath Rules Protecting the airway can be done with a Humidivent. Stay with your child at all times Use shallow water If water goes into the trach tube suction the trach tube IMMEDIATELY Dust/Pets Dust and hair should be kept to a minimum in your house. Routine dusting will help to cut down on chances of hair and dust entering the trach tube.

32 Tracheostomy Safety Illness If your child begins to show signs of sickness, it is important to inform your doctor. Changes in medications may be needed while your child is sick. Here are some things that you can do to help make sure your child stays healthy. Wash your hands before contact with your child Try to maintain a healthy diet for you child Keep your child s immunizations current Avoid other people who are sick When your child is sick you may need to: Increase suctioning frequency Increase humidity Increase oxygen use More frequent breathing treatments (if ordered by your doctor) If your child begins to vomit, you can use a bib to protect the trach from the vomit. If any vomit gets into the trach tube, suction the tube IMMEDIATELY, and call your physician.

33 Traveling With your Child Any time you travel it is important that you take a travel bag with you. In this bag is everything you could need, if an emergency happened. Also whenever you leave the house you should have an Ambu bag and portable suction machine with you. What to keep in your travel bag One appropriate size trach tube with trach ties attached One trach tube one size smaller with trach ties attached 10 Suction catheters 10 pairs of sterile gloves Ambu bag 2 Humidivents 2 IV sponges 20 saline vials Container of water to clean suction tubing Portable suction machine When you are out and about, you can use a Humidivent on your child s trach to protect the trach and also make sure his or her trach is kept moist. A passy-muir valve can also be used for humidity, protection, and speech. While out and about, the suction catheter can be reused if placed back in the wrapper without contamination for up to one hour after the initial use.

34 Travel Bag Here is everything that you need to have readily available to you in your travel bag.

35 Monitoring Children with tracheostomies often need to be monitored with medical equipment when they are not being directly supervised by a caregiver. Two of the most common types of monitors that are used are an apnea monitor and a pulse oximeter. The apnea monitor is a machine that monitors both your child s breathing rate and heart rate. This is to alert you to a heart rate that is too low or a breathing rate that is too low. Make sure to wash the apnea monitor belt and patches with soap and water and let air dry every 2-3 days and as needed.

36 Monitoring A pulse oximeter measures your child s oxygen level and heart rate. The pulse oximeter uses a probe that goes on your child s finger or foot. The pulse oximeter will help to alert you when your child s oxygen level is too low and may need supplemental oxygen.

37 Equipment Cleaning Also see Master Task Sheet It is important to keep the equipment clean to help with infection control and also to keep the equipment running smoothly. Each piece of equipment has its own recommended cleaning process. Most of the equipment supplies will be soaked in a solution that is 1 part vinegar to 3 parts water. Tracheostomy tubes Use the trach cleaning kit to clean the inside of the trach tube Shiley trach tube Wash with soap and water, rinse, soak in vinegar/water solution one hour and rinse well Let trach tube air dry Place in clean container Bivona trach tube Make sure to take off sleeve to outer portion of trach tube when cleaning, using white pick Wash with soap and water, rinse well Boil water, remove from heat, place trach tube in water, cover and let set until water cools Let trach tube air dry Place in clean container If trach tube becomes cracked, tears, or you cannot read the numbers for the size of trach tube, throw trach tube away

38 Equipment Cleaning Suction equipment Wipe machine down as needed Empty the canister daily, flushing contents down the toilet Clean suction canister daily and as needed with soap and water, then let soak in vinegar solution one hour, rinse, and let air dry Clean canister lid with soap and water daily and as needed, rinse, and let air dry After suction tubing is flushed with water, rinse tubing with water then soak in vinegar solution, rinse, and hang to air dry Suction bottles Three times a week wash tap water and vinegar bottle with soap and water and soak in vinegar solution for one hour, then let air dry Bottles may be reused for one month or until discoloration or damage occurs. Wash the lids with soap and water and soak in vinegar solution one hour, then let air dry

39 Equipment Cleaning Humidification equipment Trach mask: clean daily with soap and water, soak in vinegar solution one hour, rinse, and air dry Humidivents: use for 24 hours and throw away, do not wash 50 psi Change blue corrugated tubing twice a month or as needed, you do not need to wash and reuse the blue tubing Replace pre-filled humidity bottle as needed Clean water trap cup two times per month or if soiled. Wash with soap and water, rinse, soak in vinegar solution for one hour, let air dry. Do not wash water trap lid.

40 Oxygen Sometimes children with tracheostomies need supplemental oxygen. There are two main types of sources used to get oxygen in the home. They are oxygen tanks and a concentrator. It is important to know how much oxygen your child normally uses. For oxygen safety information please see the oxygen safety book. You will need to use different equipment pieces to get the oxygen to your child. Trach mask A plastic cover that hooks up to the 50 psi and has oxygen bled into it, that sits over the trach Oxyvent A green plastic piece that clips over the Humidivent to deliver oxygen Ventilator Oxygen can be added to the ventilator so that your child can receive oxygen Ambu bag The Ambu bag can be connected to oxygen to be used during an emergency

41 Oxygen Signs your child may need more oxygen: Breathing more quickly than usual Nasal flaring Retractions are seen Grunting while breathing Shortness of breath Gray or bluish coloring of lips Low pulse oximeter readings Check with your child s doctor if you think your child needs more oxygen

42 Speaking with a Tracheostomy Talking occurs during exhaling, when the air being exhaled is passed through the vocal cords. As the air is passed through the vocal cords it is shaped by the mouth to produce sounds. With a tracheostomy the passageway is shaped differently and can affect the sound of your child s voice. The amount of sound your child will be able to produce will depend on the actual shape and openness of their airway and the type of trach tube they have. If the tube is larger, most of the air will go through the tube and will be unable to pass around the tube to be exhaled through the mouth If the tube is smaller, your child should be able to force the air up and around the tube and are able to make sounds through the vocal cords,

43 Speaking with a Tracheostomy At first your child may accidentally force air through their vocal cords while laughing or crying, but once they feel how it feels they may be able to do it purposefully. Vocalization Some children place their finger over their trach or use a cap to force the air up through their vocal cords so they are able to talk. Most children are able to use a passy-muir valve. The passy-muir valve is a one way valve. The child is able to inhale through the valve, but during exhalation the valve does not let air out the trach tube so the air is forced upwards and through the vocal cords. Others forms of communication can be used such as sign language and using pictures to communicate.

44 Passy-muir Valve The passy-muir valve can be used with both cuffed and uncuffed trachs. If your child has a cuffed trach the cuff must be deflated while using the passy-muir valve. Your child should be awake and supervised when using the passy-muir valve. The passy-muir valve can be used inline with a ventilator and also with oxygen.

45 Common Signs Here are some commonly used signs for children.

46 Home Care Children s Home Healthcare makes visits to your house to make sure the equipment is working properly and also to check up on your child. What visitation schedule your child is on, will depend on your child s illness and what equipment your child uses. If your child has trach equipment only, such as a 50psi and suction machines, home visits will be every 90 days with a phone follow-up in between. If your child has oxygen and uses it on a regular basis after the 3 rd home visit, your child will be seen every month. If your child has a ventilator or a BiPap, home visits will be made every month. While at the visit, the clinician will check serial numbers and function of your equipment. The clinician will also do an assessment of your child as well as ask you questions regarding your child s health. Such questions include: Any changes in medications? What goals are you working on with your child? Any illnesses or hospitalizations?

47 Home Ventilator/BiPap If your child also needs assistance with ventilation, he or she may be placed on a BiPap or ventilator. It is up to your doctor what type and what settings your child will be on. Sometimes children are placed on the BiPap or ventilator just at night, so that they can rest from the day and it helps them to not get too worn out. If your child is placed on a BiPap or ventilator it is important that you never change a setting by yourself.

48 Home Ventilators There are many different types of ventilators. There are currently 3 main ventilators that we use in the home. All of the ventilators perform the same function of providing your child with breathing assistance. The three brands we use are LTV, LP-10, and T-Bird. The main settings that doctors set are pressures, volumes, peep, and breathing rate. The ventilator and settings your doctor chooses for your child will depend on what your child tolerates.

49 Words to Know Apnea monitor-a monitor that measures breathing and heart rate Artificial nose-also called a humidivent. A device that warms and moistens the air your child breathes in. Bacteria-germs that can cause sickness in your child. Catheter- a small tube connected to suction to clear secretions CPR- a method for getting someone to breath again if they have stopped. Also called cardiopulmonary resuscitation. Cuff- the inflatable balloon on some tracheostomy tubes Exhale-breathing out Inhale-breathing in Mucus-slippery fluid that is produced in the lungs and windpipe. This dries and sticks to any surface. Also called secretions. Obturator-the semi-rigid stick that you put into the tracheostomy tube to help guide it into the opening in the neck

50 Words to Know Peep-positive end expiratory pressure. This is a setting used on a ventilator. Saline-Solution similar to water used for suctioning, AKA bullets Stoma-surgically created hole in the neck where you insert a tracheostomy tube. Sterile-free of germs Suctioning-vacuuming up mucus in the tracheostomy tube with a catheter Trachea- wind pipe Tracheostomy- an operation where a hole is surgically created in the neck and a tube is placed to make breathing easier Trach mask- a device that fits around the neck and over the tracheostomy tube to provide humidification Trach tube-short for tracheostomy tube. The is the tube that is placed in the neck Wheeze- a whistling breath sound that can be heard during breathing

51 Children's Home Healthcare PDN/RT Master Task Sheet In Home Instructions: All items should be cleaned/disinfected using the following process: wash item with soap and water, rinse thoroughly to avoid soap being left on the item, place in a vinegar solutions (made 1 part vinegar to 3 parts water, change solution every 72 hours & label) soak in the vinegar solution for 1 hour, rinse well and allow to air dry, unless otherwise noted. Soaking items in Control III for 10 minutes may be substituted for placed in in the vinegar solutions per parent/caregiver request (and cost) and if appropriate for the item per manufacture's recommendations. Type of Equipment How Often Cleaned/Changed Suction Machine 1 After suctioning (each use) clear the tubing with water. Daily & prn 2 Clean tubing rinse tubing out thoroughly in water followed by vinegar solution or control III x 1 hour, rinse well, hang and let air dry. Daily & prn 3 When tubing becomes discolored, discard and replace with new. prn 4 Empty/rinse suction canister each shift, empty contents into the toilet and flush, wearing PPE. Daily & prn 5 Clean suction canister, wash with soap and water, rinse thoroughly then soak in vinegar solution or control III. Wash the suction canister lid daily and prn with soap and water, rinse thoroughly, air dry, Do not separate the parts of the lid. Daily & prn 6 7 Three times a week wash the tap water bottle used for cleaning the suction tubing with soap and water, soak in the vinegar solution, rinse thoroughly then air dry. The sterile water bottle is good for 72 hours once opened (label when opened) and then past the 72 hours this bottle can become the new tap water bottle for tube rinsing or replaced. Yankeur suction tube: rinse tube with water after each suctioning and clean daily in preferred solution. 3 x times per week Daily & prn 8 Simm s tip: rinse tube with water after each suctioning and clean daily in preferred solution. Daily & prn 9 Mushroom tip: rinse tube with water after each suctioning and clean daily in preferred solution Daily & prn 10 Bulb syringe: rinse tube with water after each suctioning and clean daily. Daily & prn 11 Change portable suction machine s filter when dirty or at least every 2 months. Every two months 12 Change stationary suction machine s filter when dirty or at least every 2 months. Every two months 50 PSI Humidifier Air Compressor 13 Cut and change blue corrugated tubing 2 times per month or prn if soiled and date the tubing. Two times per month & prn 14 Replace self-contained pre-filled humidity bottle when empty and as needed, and date the bottle. If using re-useable bottles, refill humidifier bottle with distilled water, daily and prn to keep level just above minimum mark. Replace when empty & prn but at a minimum of two times per month. Clean humidifier bottle & lid every 72 hours and prn. Change the blue tubing two times per month. Be sure to open entrainment collar on lid and leave open until dry so air gets inside, Humidifier bottle every 72 hours otherwise it will mildew. Dial should be at % when in use on entrainment collar. Do not Blue tubing tw o times per month & 15 wash lid in soap and water. prn 16 Replace humidifier bottle prn if not functioning properly. prn 17 Clean water trap cup 2 times per month & prn when changing tubing. Rinse lid with water only-do not soak. Two times per month & prn 18 Change water trap cup prn when not functioning properly. prn 19 Wash humidifier filter once a week with soap and water, rinse and let air dry (ensure filter is completely dry before reassembly!) Weekly 20 Check filter daily, if dirty clean PRN prn Trach Mask/Collars 21 Wash trach collars with soap and water. Do not disinfect in Control III solution. May be soaked in vinegar solution. Daily & prn 22 Replace trach collars prn when visibly soiled or no longer stay fastened. prn

52 Trach Ties 23 Wash VELCRO TRACH TIES daily and prn in soap and water if reusing. Daily & prn 24 Check METAL TRACH TIES daily & prn check to make sure links are not wearing down, rusted and that clasps are not worn and fastening properly (usually lasts about a month). Shiley Trach Daily & prn 25 Clean outer cannula according to physician order or when needed. prn 26 Clean trach with fragrance, oil, lanolin free soap, rinse well and soak in vinegar solution for 1 hour after it has been changed. Use a clean pipe cleaner to clean the inside of tube, then wash. Let air dry, then place in a sealed clean container or zip lock bag per physician s order. Do not use Control III. Bivona Trach 27 Clean trach after it has been changed per physician orders. Make sure to take off sleeve to outer portion of trach when cleaning, using white pick (comes with new trach do not throw away). Wash trach with fragrance, oil, lanolin free soap and water, rinse well. Use new pipe cleaner to clean inside the tube. Boil water, remove from heat, and place trach in water, cover and let set until water cools. Take trach out of water and allow trach to air dry then place in a clean sealed container or zip lock bag. Make sure completely dry before putting sleeve back on trach. Make sure to put ridge of sleeve to bottom of trach. The Omni-flex must connect to the trach correctly. prn Do not use alcohol, Control III or any other drying agents on trachs as it may cause the tube to crack. Other Trach 28 Clean trach after it has been changed per manufacture's directions. prn Passy Muir Valves 29 Swish PMV in pure, fragrance free soap (such as Ivory) and water, Do not soak, rinse well, allow to air dry before placing in sealed container or zip lock bag. Do not use hot water, hydrogen peroxide, alcohol, Control III, brushes or q-tips to clean valves. Daily & prn 30 Ensure valve works properly with each application, if valve is making a "honking" noise, sticky or vibrates then replace. Daily & prn 31 Replace Passy Muir valve as they are only guaranteed to last minimum of 2 months before being replaced. Every two months Trach Caps/Trach Plugs 32 Wash daily, trach caps/plugs are to fit tightly, if the plug becomes loose, give back to parents and replace. Daily & prn In-line Humidivent 33 Change weekly or prn if soiled. Weekly Humidivents 34 Use new Humidivents daily. Do not wash Humidivents, use x 24 hours, and then throw away. Daily & prn Aerochambers 35 Do not wash collapsible aerochambers, clean per manufacture's recommendations. per manufacture's recommendations 36 Clean Aerochambers (hard plastic) per manufacture's recommendations. per manufacture's recommendations Nebulizers 37 Following each treatment the medication cup and mask are to be rinsed with hot tap water and allowed to air dry. After each use 38 Once each day disassemble the nebulizer kit and wash with mild soap and water then rinse. Soak in vinegar solution for one hour, rinse well then allow to air dry. Do not soak or clean the nebulizer tubing. Daily & prn 39 Replace the nebulizer cup when the cup no longer makes a mist or the treatment takes longer than minutes. prn 40 Check nebulizer filter weekly, it should be white, if gray replace. Weekly 41 Replace nebulizer filter. prn prn

53 42 Nebulizer tubing, if condensation is present then replace tubing. prn Oxygen Humidity Bottles 43 Change pre-filled oxygen humidity bottle when empty. prn Oxygen Tubing 44 If using the oxygen tubing, change oxygen tubing first week of every month. If tubing has condensation present replace the tubing. If the tubing has not been in use, then do not change it such as back-up emergency oxygen. Every month & prn Oxygen Concentrator 45 Check the filter daily, if dirty wash. Daily Wash the filter weekly with water, rinse well and allow to air dry before reassembly. Do not put filter back on the unit wet. Oximeters Wipe flex probes with damp cloth weekly. (Do not use alcohol wipes -as they break down probe, do not stretch or pull wires, as they are very fragile and expensive! Be sure to change location of flex probe sites every 2-4 hours and prn). Weekly Weekly & prn 48 Wash Posey with fragrance, oil and lanolin free soap and water, rinse thoroughly and air dry prn soiling. prn 49 Replace posey as needed or when the Velcro no longer sticks. prn Apnea Monitor Wash apnea monitor belt with fragrance, oil and lanolin free soap and water every 2-3 days & prn when soiled and allow to air dry, prn. (Do not put belt in washer or dryer; as it will break down the fibers in the belt. ) Wipe off shiny side of black lead patches at least every 2-3 days and prn with a washcloth dampened with water. (Patches will not work properly if dirty.) Do not use alcohol or Control III. Every 2-3 days Every 2-3 days 52 Change sticky electrodes change every 2-3 days prn. Every 2-3 days 53 Conduct a self-test weekly on monitor to ensure equipment is functioning properly. Weekly Ambu Bags 54 An Ambu bag is required for emergency use. prn order new 55 Emergency Ambu bag : Check each shift to ensure ready for patient use. Each shift If the patient requires respiratory treatments a separate Ambu bag is needed. Two compatible respiratory medications may be mixed together (per pharmacy recommendations), label the Ambu bag with the medication and the date. If a third respiratory medication is needed, an additional Ambu bag is needed for that medication, do not mix three respiratory medications together for one treatment. All Ambu bags should be discarded when medication therapy is completed. Do not use the emergency Ambu bag with any medications. Example of Ambu bagged medications; bronchodilators, Tobramycin, Gentamycin and steroids. If bagging in respiratory treatments; (need an additional Ambu bag for each medication) check the valve with every treatment for proper functioning debris is seen in head of Ambu bag then wipe out with alcohol wipe or q-tip. On each Ambu bag: Check duck bill valve with each use. (This is not the pop-off valve, it is the orange/rubber valve which can be seen when squeezing bag.) If it sticks-replace the Ambu bag. prn after respiratory illness is resolved. Every Respiratory Treatment each use 59 Replace Ambu bag prn. prn Omni Flex 60 Replace Omni-flex monthly with ventilator circuit changes and on the Ambu bags replace prn if soiled. Monthly & prn

54 64 soiled. Monthly & prn 65 Wipe temperature probe with alcohol pad once each month with circuit change & prn. Monthly & prn 66 Have a clean extra back-up set assembled and ready for use in a large bag. Check daily or each shift to ensure ready for use. Daily 67 Check BiPap filter weekly. Weekly 68 Change BiPap filter monthly or prn when dirty. Monthly & prn 69 Change PAL/Bacteria filter monthly and prn. Monthly & prn Non-Heated Ventilator Circuit on the Back-up Ventilator For Patients Who Use The Back Up Daily If used daily or regularly during the month, place in a plastic bag until next use. Change out when visibly soiled or monthly. Always ensure the back-up ventilator has a Heat Moisture Exchanger (HME) (in-line Humidivent) in place. The HME needs to be changed each week. HME change weekly Ventilator Circuit Monthly & prn Non-Heated Ventilator Circuit on the Back-up Ventilator For Patients Who Do Not Use The Back Up Daily If used occasionally during the month, place in a plastic bag until next use. Change out when visibly soiled or every month. Always ensure the back-up ventilator has a Heat Moisture Exchanger (HME) (in-line Humidivent) in place. The HME needs to be changed HME change weekly each week (if used). Ventilator Circuit Monthly & prn Safety Measures/Checks for Emergency Equipment 72 PPE Kit present ( isolation gown, goggles, sterile gloves, face masks, CPR face mask). Every shift 73 Ambu bag connected to E tank for trach patients. Every shift 74 Extra trach at the bedside, a size smaller and one of the same size. Every shift 75 Travel bag is ready to go and is fully stocked and bag is checked daily. Every shift 76 Check the oxygen tanks to ensure enough oxygen is available for emergencies and easily flows from the tank. Every shift Infection Prevention Change Control III solution every 7-14 days & label (per manufacture's recommendations). To mix Control III, use 1 capful to 1 quart of water for small bottle or for large bottle 1 oz Control lll to 1 gallon of water. Remember to wash items in soap and water prior to disinfecting with Control III. When removing objects from solution use tongs or have gloves on, solution is harmful to hands. Do not keep items in Control III longer than 10 minutes. Always rinse items well after removing from solution. **If floating objects or debris is noted in the solution then replace the solution. When changing solution, dump the old solution in the toilet and flush afterwards using universal precautions, e.g. goggles and gloves, do not dump solution down the sink it can harm pipes. Change vinegar solution every 72 hours and label the container. To make vinegar solution, use 1 part white vinegar to 3 parts water. Store in container with lid. Be sure to rinse items well when removing equipment. All respiratory supplies should be changed or cleaned after the patient has a respiratory illness. Assess need every shift Assess need every shift prn

55 Syringes Wash syringes with soap and water after every use rinse well. This applies to syringes used for medication administration or feedings regardless if they are used orally, or via NG's and 80 GB. Syringes may be used as long as the plunger works and the markings are visible. Every use Feeding Pump 81 Change feeding bag daily, label feeding bag with date & formula mixture. Daily 82 Rinse out if doing bolus feedings or put bag in fridge between uses. Daily Wash feeding tube daily. Do not Control III any feeding tubes. Suggest to change out feeding 83 tubes monthly or sooner if milk deposits are unable to be removed with cleaning. 84 Charge the feeding pump every night. Do not leave plugged in all day. Urinary Catheters 85 Use the catheter and then discard into the trash. Miscellaneous Tasks 86 Clean up any mess made during the shift and take out the trash (if needed). 87 Restock supplies. 88 Make formula and label formula with date and time mixed. Equipment Failure Any time a piece of equipment breaks or malfunctions report if to the appropriate On-call staff member: Respiratory Equipment: and ask for the On-call RT. Enteral Feeding Pumps: call and ask for the Home Health Nurse On-call Infusion pumps: call and ask for either the Home Health Nurse On-call or the Pharmacist On-call. No need to complete an incident report unless harm is done to the patient as the staff members managing the equipment will report the equipment malfunction. Attach a label to the defective equipment DO NOT USE and describe what the 89 problem was with the equipment & then sign your name to the equipment label. Daily Nightly Discard after each use Every shift Every shift Every shift

56 Bibliography Children s Hospital Tracheostomy Tube Care Handbook Children s Home Healthcare Parent Handbook for Tracheostomy Patients. Blank Children s Hospital Tracheostomy Care Booklet. mages/spx jpg px?t=95&imageid= &productid= g SmartMonitor2.jpg 87p020.jpg JPG meda-3800-pulse-oximeter.jpg ne/pccu/vol18/lesson15/fig8.gif ages/ jpg