tracheostomy care/suctioning documentation

  1. I have a lab practical on tracheostomy care/suctioning this upcoming Wednesday. I'm not worried about the actual "skill" part, but I'm kind of worried about the documentation. What kind of things should you document after performing trach care/suctioning? Sputum suctioned (type/color, maybe consistency or amount?), amount of suctioning used (we were told between 80-120mmHg), how many times you suctioned, how well the patient tolerated the procedure....I know I'm forgetting stuff!
  2. 2 Comments

  3. by   Nurse_Diane
    don't forget to chart the sputum's:

    1. consistency (viscous vs. watery)
    2. color
    3. any odors?
    4. amount

    how did pt tolerate procedure? What were the O2 sats before and after suctioning? How much 02 are they on? How many times did you suction them? (In real life, it usually takes more than one time to get all of the secretions).

    etc, etc.

    Good luck
  4. by   Daytonite
    (from nurse's 5-minute clinical consult: procedures, pages 503 and 509) document:
    • date and time
    • type of technique used (aseptic or sterile) and all procedures performed
    • amount, color, consistency and any odor of the secretions
    • appearance of the stoma and condition of the skin
    • record any changes made of the trach tube, inner cannula, or trach ties
    • record the duration of any cuff deflation
    • record the amount of cuff inflation
    • note any ability of the patient to speak
    • record respiratory status and breath sounds
    • document any patient teaching that you did