Tracheostomy is a surgical procedure in which an opening is done into the trachea to prevent or relieve the airway obstruction and/or to serve as access for suctioning and for mechanical ventilation and other modes of oxygen delivery (tracheostomy collar, T-piece).
A tracheostomy can facilitate weaning from mechanical ventilation by reducing dead space and lowering airway resistance. It also improves client comfort by removing the endotracheal (ET) tube from the mouth or nose.
The tracheostomy is preferred over an ET when an artificial airway is needed for more than a few days. Methods can be instituted for the client to eat and speak, as well.
Nursing care plan goals and objectives for a client who had undergone tracheostomy include maintaining a patent airway through proper suctioning of secretions, providing an alternative means of communication, providing information on tracheostomy care, and preventing the occurrence of infection.
Nursing Care Plans
Here are nine nursing care plans and nursing diagnoses for tracheostomy:
- Ineffective Airway Clearance
- Impaired Verbal Communication
- Deficient Knowledge
- Risk for Impaired Gas Exchange
- Risk for Infection
- Deficient Knowledge
- Risk for Aspiration
- Risk for Injury
Ineffective Airway Clearance
May be related to
- Copious secretions
- Decreased energy and fatigue
- Presence of artificial airway: tracheostomy
- Thick secretions
Possibly evidenced by
- Abnormal breath sounds (crackles, rhonchi)
- Ineffective cough
- Increased breathing effort: nasal flaring, intercostal retractions, use of accessory muscles
- Shortness of breath
- Tachypnea and/or changes in breathing pattern
- Client will maintain a clear, open airway as evidenced by normal breath sounds, normal rate, and depth of respiration, and the ability to effectively cough up secretions.
|Assess changes in BP, HR, and temperature.||Tachycardia and hypertension may be related to an increased work of breathing. As the hypoxia and/or hypercapnia become severe, BP and HR drop. Fever may develop in response to retained secretions.|
|Assess respirations: note the quality, rate, rhythm, nasal flaring, and any increased use of accessory muscles of respiration.||These abnormalities indicate a respiratory compromise. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction. The breathing pattern may alter to include the use of accessory muscles to increase chest excursion.|
|Auscultate the lungs, noting areas of decreased ventilation and for the presence of adventitious breath sounds.||Decreased or absent breath sounds may indicate the presence of a mucus plug or other airway obstruction; wheezing may indicate partial airway obstruction or narrowing coarse crackles and/or rhonchi may indicate the presence of secretions along larger airways.|
|Assist the effectiveness of cough. Observe the color, consistency, and quantity of secretions.||Abnormalities may be a result of infection, bronchitis, long term smoking, or other conditions. A sign of infection is discolored sputum. Thick, tenacious secretions increase hypoxemia and may be indicative of dehydration.|
|Encourage the client to cough out secretions. If the cough is ineffective, Institute suctioning of the airway as needed.||Coughing is the most helpful way to remove most secretions. The client may be able to perform independently. Suctioning removes secretions if the client is unable to effectively clear the airway. Frequent suctioning should be based on the client’s clinical status, not on a present routine, such as every hour. Over suctioning can cause hypoxia and injury to bronchial and lung tissue.|
|Provide warm, humidified air.||A tracheostomy bypasses the nose, which is the body area that humidifies and warms inspired air. A decrease in the humidity of the inspired air will cause secretions to thicken. Also, cool air may decrease the ciliary function. Providing humidification of inspired air will prevent the drying and crusting of secretions.|
|Transport the client with portable oxygen, Ambu bag, suction equipment, and extra tracheostomy tube.||Being prepared for an emergency helps prevent future complications.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans related to respiratory system disorders:
- Asthma | 8 Care Plans
- Bronchiolitis | 5 Care Plans
- Bronchopulmonary Dysplasia (BPD) | 5 Care Plans
- Chronic Obstructive Pulmonary Disease (COPD) | 7 Care Plans
- Cystic Fibrosis | 5 Care Plans
- Hemothorax and Pneumothorax | 3 Care Plans
- Influenza (Flu) | 5 Care Plans
- Lung Cancer | 5 Care Plans
- Mechanical Ventilation | 6 Care Plans
- Near-Drowning | 5 Care Plans
- Pleural Effusion | 6 Care Plans
- Pneumonia | 11 Care Plans
- Pulmonary Embolism | 4 Care Plans
- Pulmonary Tuberculosis | 5 Care Plans
- Tracheostomy | 5 Care Plans