ADVERTISEMENTS
Tracheostomy is a surgical procedure in which an opening is done into the trachea to prevent or relieve 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 seven (7) nursing care plans (NCP) and nursing diagnosis for tracheostomy:
Ineffective Airway Clearance
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
- 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.
| Nursing Interventions | Rationale |
|---|---|
| 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. |
Impaired Verbal Communication
Nursing Diagnosis
- Impaired Verbal Communication
May be related to
- Presence of artificial airway: tracheostomy
Possibly evidenced by
ADVERTISEMENTS
- Difficulty speaking
- Difficulty in maintaining the usual communication pattern
- Frustration
Desired Outcomes
- Client will use a form of communication to get needs met and to relate effectively with persons and environments.
| Nursing Interventions | Rationale |
|---|---|
| Assess the client’s communication ability. | Standard tracheostomy tubes allow the vocal cords to move, but no airflow passes over them if the cuff is inflated; therefore vocalization is not possible. |
| Assess the effectiveness of nonverbal communication methods. | The client may use hand signals, facial expressions, and changes in body posture to communicate with others. However, others may have difficulty in interpreting these nonverbal techniques. Each new method needs to be assessed for effectiveness and altered as necessary. |
| Assess for frustration and anxiety related to not being able to communicate needs. | The inability to communicate enhances a client’s sense of isolation and may promote a sense of helplessness. |
| Provide emotional support to the client and significant others. | Difficulties communicating are a source of frustration for all involved. |
| Place the client in a room close to the nurse‘s station. | This ensures easy observation of the client by the nursing staff. |
| Provide a call light within easy reach at all times. Answer the light promptly. | A prompt response decreases anxiety and feelings of helplessness. |
| If the client is able to nod or speak “yes” or “no” answers, try to phrase questions so that the client can use these responses. | Clients can become easily frustrated when they cannot communicate in a simple manner. |
Provide alternative methods for communicating:
|
Providing a variety of communication aids allows the client more channels through which information can be communicated. |
| Allow the client time to communicate his or her needs. | The nurse should set aside enough time to attend to all of the details of client care. Care measures may take a longer time to complete in the presence of a communication deficit. |
| Collaborate with the physician and speech therapist on the possible use of a “talking” tracheostomy tube as indicated. | The “talking” tracheostomy tube provides a port for compressed gas to flow in above the tracheostomy tube, allowing air of phonation. |
| If the client no longer requires mechanical ventilation, consider the use of a Passy-Muir valve or fenestrated tracheostomy tube. | These adaptive devices can facilitate talking. |
Deficient Knowledge
Nursing Diagnosis
- Deficient Knowledge
May be related to
- New procedure or intervention in hospital
Possibly evidenced by
- Anxiety
- Expressed need for more information
- Increased questioning
- Lack of questioning
Desired Outcomes
- Client or caregiver will demonstrate the knowledge and skills appropriate for tracheostomy care.
| Nursing Interventions | Rationale |
|---|---|
| Assess the client’s knowledge regarding the purpose and care of a tracheostomy. | This information provides an important starting point in education. |
| Assess the ability to manage care at home. | Both cognitive and technical skills are required for managing tracheostomy tubes. |
| Assess the ability to respond to emergency situations. | This information is especially important because the lack of airway patency is a life-threatening problem. |
| Discuss the client’s need of a tracheostomy and its particular purpose. | Educational programs need to be individualized to the client’s specific situation and needs. |
| Provide instruction in sterile tracheostomy care and suctioning. | This information enables the client to take control of his or her life. Long-term care may be the client’s responsibility. Clearly, focused teaching allows the learner to concentrate more completely on the material being discussed. The client or caregiver can begin to acquire skills at a pace that is not overwhelming. |
| Instruct in the need to call health care provider if the amount of secretions increases or a change in color or characteristic occurs. | Changes could signify the presence of an infection. |
Reinforce the client’s knowledge of the following emergency technique:
|
Preparing ahead of time can reduce distress and complications. The client will feel more secure in the home environment with a means for rapid communication in an emergency. |
| Discuss the weaning process, as appropriate, with the use of fenestrated tracheostomy tubes, tracheostomy buttons, or progressively smaller tubes. | Preparation and explanation help reduce anxiety. |
| Provide information on the reinsertion of a tracheostomy tube. | The first tube change is done by the physician. Thereafter the client or caregiver should be taught step-by-step reinsertion instructions and should complete a return demonstration. |
| Collaborate with the case manager or social worker as appropriate to attain equipment and arrange for home care nurses. | Continuity of care is facilitated through the use of appropriate resources. |
| Explain the process of decannulation, as appropriate. | When the client’s tracheostomy remains capped with the client effectively maintaining his or her own respirations and airway clearance, the tracheostomy tube can be removed. With removal, the stoma site is covered with a folded 4 x 4 bandage and tape. The opening will close in a few days. Until the site is healed, the client should be instructed to cover the site with two fingers while attempting to cough or talk to prevent outward air flow through the stoma site. |
| Explain home care as follows: | |
|
This camouflages the area and may enhance body image. |
|
Covering the stoma prevents the inhalation of foreign materials. |
|
Aspiration is possible if water gets into the stoma. |
Risk for Impaired Gas Exchange
Nursing Diagnosis
- Risk for Impaired Gas Exchange
May be related to
- Aspiration
- Copious tracheal secretions
- Inability to cough and deep breathe
- Infection
- Pneumothorax
- Preexisting medical conditions
- Restricted lung expansion from immobility
- Tracheostomy leak
Possibly evidenced by
- [not applicable]
Desired Outcomes
- Client will maintain optimal gas exchange as evidenced by arterial blood gasses (ABGs) within the client’s normal range, oxygen saturation of 90% or greater, alert response mentation or no further reduction in the level of consciousness, and relaxed breathing.
| Nursing Interventions | Rationale |
|---|---|
| Assess the respiratory rate, rhythm, quality, depth, and effort. | Clients will alter breathing patterns over time to facilitate gas exchange. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties. Rapid, shallow breathing patterns affect gas exchange. Hypoxia is associated with an increased breathing effort. |
| Auscultate lung sounds, noting any areas of decreased ventilation or the presence of adventitious sounds. | Changes in lung sounds may reveal the cause of impaired gas exchange. |
| Assess for changes in the client’s HR and temperature. | Tachycardia is associated with increased work of breathing or hypoxia. Fever may develop in response to retained secretions or atelectasis. |
| Assess for changes in the level of consciousness. | Increased restlessness, confusion, and/or irritability are early indicators of insufficient oxygenation of the brain and require further interventions. |
| Monitor arterial blood gasses and oxygen saturation. | Pulse oximetry is a useful tool to detect early changes in oxygen saturation. Oxygen saturation should be kept at 90% or greater. Increasing PaCo2 and decreasing PaO2 are signs of hypoxemia and respiratory acidosis. |
| Monitor the effectiveness of the tracheostomy cuff, and assess for signs of cuff leak (the client is able to vocalize while the cuff is supposed to be inflated, the low-pressure ventilator alarm is sounding, loud upper airway noises are audible, the feeling of air coming from around the nose or mouth). Collaborate with the respiratory therapist, as needed, to determine cuff pressure. | Maximum recommended levels for cuff pressure range from 20 to 25 mm Hg (27 to 33 cm H2O), or less if the trachea can be sealed with less. Signs of cuff leak are caused by air escaping upward past the vocal cords instead of being directed to the lower airways. |
If a leak is present:
|
An intact cuff is required to ensure the direction of air into the bronchial airways. If the client is being mechanically ventilated and is losing a large portion of the tidal volume because of a cuff leak, the tracheostomy tube will need to be replaced. |
| Place the client in a semi-Fowler’s to high Fowler’s position. | This position promotes full lung expansion and improved air exchange. |
| If lung sounds are abnormal, use tracheal suction as needed. | Suctioning is indicated when clients are unable to remove secretions from the airway by coughing because of weakness, thick mucus plugs, or excessive or tenacious mucus. |
| Administer humidified oxygen as needed. | The appropriate amount of oxygen must be delivered continuously so that the client maintains an oxygen saturation of 90% or greater. Humidification of oxygen prevents the drying of mucosal membranes. |
| Maintain an adequate airway. If an obstruction is suspected, troubleshoot as appropriate: | |
|
Moving the head and neck corrects any kinking of the tube or malpositioning. |
|
This maneuver is important if there is a possibility of a herniated cuff. |
|
This is an attempt to aspirate a mucus plug and to assess for airway patency. |
|
A mucus plug can become lodged in the tube and obstruct the client’s airway. |
|
A new tube can restore airway patency. |
Risk for Infection
Nursing Diagnosis
- Risk for Infection
May be related to
ADVERTISEMENTS
- Increased secretions
- Suctioning of airway
- Surgical incision of tracheostomy
Possibly evidenced by
- [not applicable]
Desired Outcomes
- Client will remain free of infection, as evidenced by normal temperature, normal sputum culture, normal white blood cell (WBC) count, absence of purulent drainage around the stoma, and clear breath sounds.
| Nursing Interventions | Rationale |
|---|---|
| Assess client’s temperature. | Fever may be a manifestation of an infection or inflammatory process. |
| Assess skin integrity under tracheal ties. | This is a common site for infection and skin breakdown. |
| Observe the stoma for erythema, color, exudates, and crusting lesions. If present, culture the stoma and notify the physician. | The buildup of mucus and the rubbing of the tracheostomy tube can irritate the skin and serve as a site for infection. Culture and sensitivity reports guide the antibiotic selection. |
| Monitor white blood cell (WBC) count. | An increasing WBC indicates the body’s effort to combat pathogen. |
| Maintain an inflated tracheostomy cuff at the lowest pressure possible to maintain an adequate seal for ventilation. | An inflated cuff protects the airway and is required for mechanical ventilation. Cuffs should be kept at the lowest pressure to prevent tracheal erosion. Clients are not able to vocalize while the cuff is properly inflated. |
| Keep a tracheal obturator taped at the head of the bed for emergency use. | The tracheal obturator is used to reinsert the tracheostomy. |
| Keep a spare tracheostomy tube of same size and brand at the bedside. | Being prepared for an emergency helps prevent future complications. |
| Do not allow secretions to pool around the stoma. Suction the area, or wipe with aseptic technique. Keep the skin under the tracheostomy ties and back of the neck clean and dry. | These steps keep the stoma clean and dry. The back of the neck should be checked carefully in bedridden clients because secretions tend to flow to the back of the neck. Clean, dry skin helps prevent skin irritation. |
| Provide stoma care: | Frequent stoma care is required for postoperative clients. Care for clients with long-term stoma placement is based on need. |
|
|
|
Use a dry dressing around the stoma if the skin is irritated or secretions are evident. Creams can be used to prevent or treat skin breakdown. |
|
Ties loose enough that one finger can be inserted between the client and the ties help reduce skin breakdown. |
| If signs of infection are present, apply an antifungal or antibacterial medication, as prescribed. | These agents are either toxic to the pathogen or retard its growth. |
Anxiety
Nursing Diagnosis
- Anxiety
May be related to
- Threat to self-concept (tracheostomy); change in health status
Possibly evidenced by
- Increased apprehension
- Fear of procedures to care for tracheostomy
- Uncertainty about possible respiratory status changes
- Expressed feelings of distress over the presence of tracheostomy
Desired Outcomes
- Child and parents will verbalize reduced anxiety.
| Nursing Interventions | Rationale |
|---|---|
| Assess the level and manifestations of anxiety in parents and child. | Provides detail needed for interventions and clues to the severity of anxiety. |
| Allow parents and child to express fears and concerns and to ask inquiries about the disease and what to expect. |
Provides an opportunity to release feelings and secure information to lessen anxiety. |
| Encourage parents to stay with the child, allow open visitation and telephone communications; encourage to participate in planned care associated with common home routines. | Involvement of the child’s significant others in the care and common routines decreases anxiety. |
| Provide a nonjudgmental and supportive environment. | Promotes trust and reduces anxiety. |
| Maintain child’s position of comfort, allow the presence of a familiar object such as a blanket or toy. | Promotes comfort and safety. |
| Provide the child with medical play objects such as a doll with a have tracheostomy, suction catheters, tracheostomy tubes, and ties, as applicable. | Provides child the opportunity to have hands-on experience with equipment; enhances their understanding of procedures; allows medical professionals some idea into the child’s knowledge and understanding of the procedure. |
| Provide the child with a pencil and paper, pictures, slate as age allows. |
Provides means of communication and interaction with the child. |
| Provide a tour of the pediatric intensive care unit and the floor before the scheduled surgical procedures as applicable. | Allow familiarity with the environment which may help to lessen anxiety. |
| Inform of all procedures and care and any updates in the child’s condition. | Decreases anxiety brought about by the fear of the unknown. |
| Explain to parents and child (age appropriate) purpose for tracheostomy and how the procedure is done, and what to expect with having a tracheostomy. | Alleviate anxiety caused by fear of the unknown. |
| Provide clarification to any misinformation in a clear and easy to understand language. | Avoids any unnecessary thoughts resulting from inaccurate information or beliefs. |
| Refer to counseling, community groups or agencies. | Providing parents and child needed support and information from those with the same problems. |
Deficient Knowledge
Nursing Diagnosis
- Deficient Knowledge
May be related to
- Lack of knowledge about tracheostomy care
- Impending home discharge of the child
Possibly evidenced by
- Parents inquiry about the child’s home care
- Child readmits to the hospital due to problems encountered during/with caregiving at home
Desired Outcomes
- Parents will verbalize and demonstrate proper care of tracheostomy: stoma care, suctioning techniques, tie and tube changes, and emergency protocols.
| Nursing Interventions | Rationale |
|---|---|
| Give short and easy to understand instructions, patterned with the parents’ specific learning styles and needs; provide written guides after each session. | Short and individualized sessions will enhance understanding; written materials reinforce learning and improve comprehension. |
| Inform local utilities and paramedics about the child’s condition. | Advance notification of appropriate personnel promotes quick and active response. |
| Facilitate arrangements with local home health nursing agencies, as applicable. | Promotes feelings of control and limits anxiety within parents; discharge is often a time of higher stress for parents, and they can become easily overwhelmed. |
| Facilitate the accessibility of supplies and equipment needed at home, including oxygen, pulse oximetry, suction apparatus, and so forth; provide the necessary instructions about the use of each equipment. | Ensures supplies and equipment are available upon discharge; promotes understanding of how the equipment works. |
| Train all caregivers on how to perform CPR; provide written materials or video for reinforcement. | Promotes increased understanding of emergency resuscitation needs of the client; prior knowledge of CPR may reduce stress felt by the family. |
| Demonstrate to family and other caregivers on all guidelines of tracheostomy care for the child which includes site assessment, suctioning techniques, site care, tracheostomy changes, and emergency protocols. | Involving all family members and significant others may increase the level of support and reduces anxiety felt by the immediate family. |
| Teach and instruct the family to treat the child as normally as possible, including information on growth and development, discipline, school, sibling reactions, the importance of play, and trips stress. |
Promotes normalcy within the family which supports the well-being and development of the child; decreases anxiety and stress. |
| Teach the child with a tracheostomy about vocalization techniques as applicable. | Allows communication which enhances self-esteem and facilitates normal growth and development. |
Risk for Aspiration
Nursing Diagnosis
- Risk for Aspiration
May be related to
- Presence of tracheostomy or endotracheal tube
Possibly evidenced by
- [not applicable]
Desired Outcomes
- Client will swallow meals without coughing, choking, or changing color.
| Nursing Interventions | Rationale |
|---|---|
| Assess child’s age, ability to swallow, and type of food consistency (solid or formula). | Provides detail about the risk for choking or aspiration. |
| Encourage liquid initially in small amounts and gradually increase as tolerated; add cereal to infant formula or offer thick milkshakes to the child. | Provides fluids and nutrients of a consistency that is well managed and swallowed to avoid choking. |
| Maintain in an upright or sitting position during feedings (or place on the lap or in an infant seat); allow to remain in position for 30 minutes afterward. | Promotes the flow of fluids and foods through gravity. |
| Suction fluids from mouth and airway once choking happen; limit suctioning procedure after feedings. | Prevents aspiration; suctioning after feedings may cause nausea or vomiting. |
| Instruct parents the type of foods and liquids allowed in the child. | Promotes nutrition requirements that are easier to tolerate and swallow with the tube in place. |
| Instruct parents measures to take during choking; teach positions that are safest when feeding the child. | Prevents aspiration of fluid or food into the airway. |
| Teach parents to suction airway if choking, perform after other measures have failed. | Removes fluid or feedings from the airway. |
| Inform parents to notify the physician in presence of respiratory distress. |
Prevents life-threatening complication caused by suffocation. |
Risk for Injury
Nursing Diagnosis
ADVERTISEMENTS
- Risk for Injury
May be related to
- Complications of tracheostomy
Possibly evidenced by
- [not applicable]
Desired Outcomes
- Absence of respiratory distress.
- Tracheostomy tube will remain in place and patent.
| Nursing Interventions | Rationale |
|---|---|
| Assess for proper tube placement, patency of tube, and presence of an air leak around the tube. | Guarantees efficient tube function to provide an airway for oxygenation. |
| Assess security of tapes and knots, the tightness of tapes by inserting a small finger between tape and neck. |
Promotes safe use of ties to secure tube, which should not be unraveled and should fit snugly without impairing the circulation. |
| Observe for any change in breath sounds and respiratory rate, depth, and ease. | Determines the need to remove secretions to prevent occlusion and respiratory distress. |
| Assess stay sutures if new tracheostomy by noting security of tapes on side of the neck, any movement or dislodgement of the tube. | Ensures safe placement of the tracheostomy tube and avoids dislodgement. |
| Restrain if appropriate developmentally and if needed; inform parents and child of purpose. Monitor skin under restraints per protocol. |
Prevents the child from accidental pull out of the tube; prevents injury. |
| Hold tube in place during dressing changed, apply ointment under wings of the tube, changing tapes, or suctioning tube. | Prevents manipulation of the tube that causes mechanical irritation and may dislodge tube. |
| Suction gently and intermittently, use proper catheter size and technique. | Clears airway and pool of secretions without injury to the trachea, prolonged suctioning causes vagal stimulation and bradycardia and high pressure may damage the mucosa of the trachea. |
| Have spare tracheostomy tube, scissors, bag, and proper sized mask and adaptor, an oxygen source, and suctioning equipment available at the bedside. | Provides for emergency measures for airway obstruction or decannulation. |
| Change tapes 3 days after surgery and tube 2 weeks after surgery per physician advice, with 2 nurses present or respiratory therapist. |
Ensures safety of procedures with assistance if needed. |
| Change tube if obstructed, reinsert new tube if dislodged; have 2 people present. | Maintains effective tube functioning and airway patency. |
| Educate parents of the benefits of tracheostomy, such as reduce work of breathing, improved rest and feeding, progress in developmental tasks. |
Provides emotional support to parents and family. |
| Teach, demonstrate, and allow parents to return demonstration of the tube change (insertion and removal) to be done monthly or as needed, tube ties change, suctioning and cleansing of the tube if long-term care needed. |
Encourages continuity of safe care by parents if able to execute skills and approved by physician; promotes autonomy and control of family in child’s care. |
| Encourage parents to dress the child in loose-fitting clothing around the neck with no loose threads or frayed material, remove crumbs, beads or dangerous toys, careful bathing with the elimination of water near tube; cover tube with bib when drinking or eating meals. |
Prevents tube occlusion or entry of foreign materials. |
| Instruct parents to observe for any swelling or bleeding around the tube, labored breathing, change in skin color, absence of air moving in and out of the tube, inability to insert suction tube, excessive choking during feeding and notify health care provider immediately. | Avoids complications that may result in severe airway damage. |
See Also
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
Respiratory Care Plans
Care plans about respiratory system disorders:
- Asthma | 8 Care Plans
- Bronchiolitis | 5 Care Plans
- Chronic Obstructive Pulmonary Disease (COPD) | 5+ 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 | 8+ Care Plans
- Pulmonary Embolism | 4 Care Plans
- Pulmonary Tuberculosis | 5 Care Plans
- Tracheostomy | 5 Care Plans
Thank you very much I have learned better through your material in comparison to class. It is more interesting and easy to follow and understand. Truly appreciate.
Thanks alot