9 Tracheostomy Nursing Care Plans

Ineffective Airway Clearance

Tracheostomy may be performed to provide a long-term route for mechanical ventilation in cases of respiratory failure or to provide pulmonary toilet when the client has inadequate cough due to chronic pain or weakness, or if the client experienced aspiration and has the inability to handle secretions (Lindman & Soo, 2021). However, the presence of artificial airways may also impair effective coughing and secretion removal, which may result in the need for periodic removal of pulmonary secretions (Stacy, 2020). 

Nursing Diagnosis

• 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)
• Dyspnea
• Ineffective cough
• Increased breathing effort: nasal flaring, intercostal retractions, use of accessory muscles
• Shortness of breath
• Tachypnea and/or changes in breathing pattern

Desired Outcomes

• The client will maintain a clear, open airway as evidenced by normal breath sounds, normal rate, depth of respiration, and the ability to effectively cough up secretions.
• The client will be free of aspiration.
• The caregiver will identify potential complications and initiate appropriate actions.

Nursing Assessment and Rationales

1. Assess airway patency.
Obstruction may be caused by the accumulation of secretions, mucus plugs, hemorrhage, bronchospasm, and problems with the position of the tracheostomy. The most frequent cause of obstruction was the plugging of the tracheostomy tube with a crust or mucus plug. These plugs can be aspirated and lead to atelectasis or lung abscess (Mehta & Chamyal, 2017).

2. 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. Apnea, severe hypotension, and cardiac arrhythmia can be very serious problems and may result in sudden death after tracheostomy (Mehta & Chamyal, 2017).

3. Assess respirations: note the quality, rate, rhythm, nasal flaring, and 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. Apnea due to loss of hypoxic respiratory drive is mainly important in the awake client. Ventilatory support must be available (Lindman & Soo, 2021).

4. Auscultate the lungs, noting areas of decreased ventilation and the presence of adventitious breath sounds. Evaluate chest movements.
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. Symmetrical chest movement with breath sounds through the lung fields indicates proper tube placement and unobstructed airflow.

5. 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. Local infection at the tracheostomy site is fairly common and tracheitis occurs to some degree in every client having a tracheostomy (Mehta & Chamyal, 2017).

Nursing Interventions and Rationales

1. 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. In acute cases, suctioning is always performed as a sterile procedure to prevent hospital-acquired pneumonia (Stacy, 2020).

2. Reposition the client regularly.
Repositioning promotes drainage of secretions and ventilation to all lung segments, therefore reducing the risk of atelectasis. Atelectasis may occur due to aspiration of crusts or plugs and when it occurs, it necessitates the removal of the plug with a bronchoscope (Mehta & Chamyal, 2017).

3. Encourage increasing fluid intake.
Fluids help liquefy secretions, thereby enhancing expectoration. Acute obstruction of the tracheostomy tube may be caused by blood or mucus and is more likely in the immediate and early postoperative periods (Raimonde et al., 2022). Increasing fluid intake may help prevent this complication.

4. Hyperoxygenate the client before and after suctioning.
Administering 100% oxygen persecution and post-suction reduces hypoxemia; however, it is not without risks such as absorption atelectasis. Administering 100% oxygen must be considered if the client has experienced a clinically significant reduction in oxygen saturation with suctioning, has high oxygen PEEP requirements, or has compromised cerebral circulation (Stacy, 2020).

5. Provide warm, humidified air.
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. Additionally, adequate systemic hydration and supplemental humidification of inspired gasses assist with thinning secretions for easier aspiration from airways (Stacy, 2020).

6. Avoid the instillation of sodium chloride before suctioning.
Routine instillation of 0.9% sodium chloride solution before suctioning is not recommended. Evidence shows an association between the instillation of 0.9% sodium chloride solution and ventilator-associated pneumonia and hemodynamic changes (Stacy, 2020).

7. Ensure that the client has a properly sized and shaped tube.
A tracheostomy tube is a hollow tube, with or without a cuff, that is electively inserted directly into the trachea through a surgical incision or with a wire-guided progressive dilatation technique. The ideal tube size for a client is one that maximizes the functional internal diameter while limiting the outer diameter to approximately three-quarters of the internal diameter of the trachea. This reduces airway resistance and the work of breathing while facilitating airflow around the tube (Lindman & Soo, 2021).

8. Transport the client with portable oxygen, an Ambu bag, suction equipment, and an extra tracheostomy tube.
Being prepared for an emergency helps prevent future complications. Several complications have been described during open and percutaneous tracheostomies. Most of the complications are life-threatening. For this reason, prevention, early diagnosis, and treatment are key factors during this procedure (Lindman & Soo, 2021).