Example Charting: Trach Care

Notice how vital signs improve as excess secretions are removed…reducing risk for respiratory infection and
hypoxia.
0900 O2 sat 89% on room air, bilateral rhonchi to bases auscultated, unproductive cough, heart rate strong
and regular P-90, B/P-150/88, R-18 and T-99.3. Instruct need for prn trach suctioning to remove thick,
tenacious secretions and improve ventilation—nods head in agreement. Suctioning performed per
physician’s orders and according to policy and procedure using sterile technique and infection control.
Assistant nurse recruited for manual ventilation and to auscultated breath sounds; suction control set at
100 mm Hg vacuum. Client placed in semi-Fowler’s position, hyperventilated for one minute to 100%
O2 sat, suctioning performed using sterile technique, catheter inserted 1 to 2 cm beyond end of trach
tube until resistance met and cough elicited, intermittent suctioning performed while rotating the
catheter back and forth and withdrawing over a 5 to 10 second period resulting in moderate amounts of
white, tenacious, yellow tinged secretions. O2 sat 90% on room air, hyperventilated for one minute to
100% O2 sat, improved breath sound with diminished rhonchi auscultated, cough productive with scant
secretions escaping trach. Suctioning repeated resulting in copious amounts of white, thin secretions. O2
sat at 97% on room air, lungs clear to auscultation, heart rate strong and regular P-78, B/P 138/78, R-14,
and T-99.0. Scant amount of thick white oropharyngeal secretions suctioned. Supplies used for
suctioning discarded in biohazard bag. Client smiles when asked how he feels. Instruct need to turn,
cough, deep breath to facilitate removal of respiratory secretions, reduce risk for infection, and improve
ventilation—nods in agreement and returns demonstration 100%. Bed in low position, call light and
fluids in reach. RN Signature…………………………………………………………………………………

0930 P-78, B/P-128/70, R-14, T-98.3, lungs CTA, performs TCDB exercises. Instruct need for prn cleansing
of inner cannula and ostomy with tie change to reduce risk for infection, promote hygiene and skin
integrity—nods head and smiles. Cleaning performed using sterile technique per physician’s orders and
according to policy and procedure. Assistant nurse recruited to secure position of trach, and safety
observed using goggles and biohazard bag. Cleaning performed using sterile technique, inner cannula
unlocked and removed soaked in NS, dry secretions removed with brush and rinsed with NS, dried with
4x4 gauze and pipe cleaner, cannula replaced and locked in place. Cleansed tracheostomy site using NS
moistened cotton tip applicators and 4x4 gauzes and dried with 4x4 gauze. Ostomy site tissue intact, no
complications observed. Non-raveling, precut 4x4 gauze applied to trach site with flaps pointing up and
replaced soiled trach tie with clean ties allowing for about two fingers breadth of slack. Pt denies
discomfort, smiling after procedure completed. Bed in low position, call light and fluids in reach.
RN Signatuve………………………………………………………………………………………………………….