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so the area should be kept clean. Tracheostomies can also cause damage to the surrounding tissues through pressure and the presence of irritant secretions (Woodrow 2002), necessitating regular inspection and appropriate care of the area to prevent tissue damage and wound breakdown. Changing the dressing will ensure that the surrounding skin remains clean, dry and free from irritation and infection (Edgtton-Winn and Wright 2005).

Rationale

Indications

In some patients, dressing may not be indicated as it creates an ideal environment for bacterial colonization (Higgins 2009). The decision to dress a tracheostomy should be based on clinical need, although a thorough assessment of the stoma is indicated for all patients with altered airways (i.e. tracheostomy or laryngectomy). The dressing around the tracheostomy tube can be renewed without removing the tube which should be done twice a day or more frequently if necessary (Serra 2000).

Contraindications

Occasionally a surgical team may request that the original dressing remain intact for a period of time, usually 24–48 hours. There may be an increased risk of bleeding associated with the stoma formation and in this instance the dressing should not be changed until consultation with the surgeon has occurred.

Principles of care

Changing the tracheostomy dressing always requires two people (Woodrow 2002): one to secure the tracheostomy and the other to assess and dress the stoma site. When assessing the wound, if infection is suspected, that is, the area is reddened, excoriated, painful, discoloured or exudate is present, a microbiology swab should be sent for culture (Higgins 2009, ICS 2008, Woodrow 2002).

The stoma should be cleaned thoroughly with 0.9% sodium chloride (Woodrow 2002) and an appropriate dressing applied where indicated. This should be a foam dressing, usually manufactured with a cross-shaped incision to fit around the tracheostomy tube (Woodrow 2002). A moisturizing cream, such as E45, can be applied twice daily to the stoma once the tracheostomy tube and associated dressing are removed. For those patients with secretions that tend to accumulate around the stoma, a Cavilon wand can be used to prevent the skin becoming red and excoriated (Hampton 1998).

Stoma sutures (secured to the flange of the trachestomy tube) are removed on day 7 (day 7–10 if the tracheostomy has been inserted using a percutaneous technique). If the patient has previously received external beam radiotherapy to the neck, stoma sutures are removed on day 10.

Procedure guideline 10.3 Tracheostomy dressing change

This procedure requires two nurses. One is required to hold the tracheostomy in place, and the other to change the dressing.

Essential equipment

Sterile dressing pack

Tracheostomy dressing or keyhole dressing

Cleaning solution, such as 0.9% sodium chloride

Tracheostomy securing tapes

Bactericidal alcohol handrub

Medicinal products

Review a possible need for analgesia

Preprocedure

Action Rationale

1 Explain and discuss the procedure with the patient. To ensure that the patient understands the procedure and gives their valid consent (NMC 2008b, C).

2 Screen the bed or cubicle. To ensure the patient’s privacy. E

3 Wash hands using bactericidal soap and water or bactericidal alcohol handrub, and prepare the dressing tray or trolley. To minimize the risk of infection (Fraise and Bradley 2009, E).

4 Perform the procedure using aseptic technique. To minimize the risk of infection. E

Procedure

5 Remove the soiled dressing from around the tube, clean around the stoma with 0.9% sodium chloride using low-linting gauze. To reduce the risk of dressing fragments entering the altered airway (Russell 2005, E) and to remove secretions and any crusts.

6 Replace with a tracheostomy dressing or a comfortable foam-backed keyhole dressing (Action Figure 6). To ensure the patient’s comfort. E

To avoid pressure from the tube (Scase 2004, E).

7 Renew tracheostomy tapes, checking that 1–2 fingers can be placed between the tapes and neck. To secure the tube. E

To ensure that the tapes