Utilize this comprehensive nursing care plan and management guide to provide nursing care for patients with tracheostomy. Enhance your knowledge of nursing assessment, interventions, goals, and nursing diagnosis, all meticulously tailored to meet the specific requirements of individuals with tracheostomy. This guide equips you with the essential information and resources to deliver effective and specialized care to patients navigating the challenges associated with tracheostomy.
Table of Contents
- What is Tracheostomy?
- Nursing Care Plans & Management
- Nursing Interventions and Actions
- 1. Improving & Maintaining a Patent Airway Clearance
- 2. Managing Breathing Pattern and Gas Exchange
- 3. Promoting Communication & Alternative Communication Methods
- 4. Preventing Aspiration Risk & Dysphagia
- 5. Promoting Safety & Preventing Injury Risk
- 6. Initiating Measures for Infection Control & Management
- 7. Reducing Anxiety & Preventing Caregiver Role Strain
- 8. Providing Patient Education & Health Teachings
- Recommended Resources
- See Also
- References and Sources
What is Tracheostomy?
Tracheostomy is a surgical procedure in which an opening is done into the anterior trachea to facilitate respiration. A tracheostomy may be required in an emergent setting to bypass an obstructed airway or may be placed electively to facilitate mechanical ventilation, to wean from a ventilator, or to allow more efficient management of secretions or a pulmonary toilet (Raimonde et al., 2022). Specifically, tracheostomy does not prevent aspiration of the airway or other secretions.
The indications for tracheostomy can be divided into emergent tracheostomy and elective tracheostomy. Emergent tracheostomy includes acute upper airway obstruction with failed endotracheal intubation, post-cricothyrotomy, penetrating laryngeal trauma, and LeFort III fracture. Indications for elective tracheostomy include prolonged ventilator dependence, prophylactic tracheostomy prior to head and neck cancer treatment, obstructive sleep apnea, chronic aspiration, neuromuscular disease, and subglottic stenosis (Raimonde et al., 2022).
The tracheostomy is preferred over an endotracheal tube (ET tube) when an artificial airway is needed for more than a few days. A tracheostomy provides a more secure airway, is less likely to be displaced, and is more readily replaceable than the traditional ET tube (Lindman & Soo, 2021). Methods can be instituted for the client to eat and speak, as well.
Nursing Care Plans & Management
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 Problem Priorities
The following are the nursing priorities for patients with tracheostomy:
1. Ensure a patent airway
2. Prevent infection at the tracheostomy site
3. Implement appropriate communication strategies
4. Provide emotional support, address concerns, and promote coping strategies
5. Provide education and support to the patient and their caregivers regarding tracheostomy care, emergency management, and signs of complications
Assess for the following subjective and objective data:
- Patient reports of difficulty of breathing or shortness of breath.
- Reports of pain or discomfort at the tracheostomy site.
- Presence of cough, excessive sputum production, or difficulty clearing secretions.
- Patient’s self-report of changes in voice or difficulty speaking.
- Patient’s description of any challenges or concerns related to tracheostomy care or daily activities.
- Visual observation of a tracheostomy tube in place.
- Auscultation of breath sounds to assess for any abnormal or adventitious sounds.
- Assessment of respiratory rate, depth, and effort.
- Inspection and palpation of the tracheostomy site for redness, swelling, or signs of infection.
- Assessment of the skin around the tracheostomy site for breakdown or irritation.
- Measurement of oxygen saturation (SpO2) levels to monitor oxygenation.
- Assessment of sputum characteristics, such as color, consistency, and volume.
- Evaluation of speech quality and ability to communicate effectively.
- Assessment of the patient’s ability to swallow and manage oral intake without signs of aspiration.
- Monitoring vital signs, including heart rate, blood pressure, and temperature.
Assess for factors related to the cause of problems for patients with tracheostomy:
- Copious secretions
- Decreased energy and fatigue
- Presence of artificial airway: tracheostomy
- Thick secretions
- Copious tracheal secretions
- Difficulty speaking
- Difficulty in maintaining the usual communication pattern
- Inability to cough and deep breathe
- Preexisting medical conditions
- Restricted lung expansion from immobility
- Tracheostomy leak
- Increased apprehension
- Fear of procedures to care for tracheostomy
- Uncertainty about possible respiratory status changes
- Expressed feelings of distress over the presence of tracheostomy
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with problems related to tracheostomy based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
- 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.
- The client will report the absence of or decreased dyspnea.
- The client will demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within acceptable ranges.
- The caregiver/s will verbalize and demonstrate proper care of tracheostomy: stoma care, suctioning techniques, tie and tube changes, and emergency protocols.
- The caregiver/s will use resources, such as rehabilitation team members, effectively.
- The client and caregiver/s will develop a plan for and schedule follow-up appointments.
Nursing Interventions and Actions
Nursing interventions for patients with tracheostomy include maintaining a patent airway through regular tube assessment and suctioning, preventing infection through meticulous tracheostomy site care and antibiotic administration when necessary, ensuring adequate nutrition and hydration, promoting effective communication using various strategies, facilitating proper positioning and mobility, and providing emotional support and education to the patient and their family. These interventions aim to optimize patient outcomes and prevent complications associated with tracheostomy. The following are the therapeutic interventions for patients with tracheostomy:
1. Improving & Maintaining a Patent 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).
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. Assess 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).
6. 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).
7. 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).
8. 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.
9. 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).
10. 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).
11. 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).
12. 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).
13. 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).
2. Managing Breathing Pattern and Gas Exchange
A client with a tracheostomy has an upper airway anatomical dead space that can be reduced by up to 50%. This space takes no part in gas exchange and adds to the work of breathing. Reducing this can help the client wean off a ventilator more easily. The natural warming, humidification, and filtering of air that usually takes place in the upper airway are also impaired (Physiopedia, 2020).
1. Assess the respiratory rate, rhythm, quality, depth, and effort.
Clients will alter breathing patterns over time to facilitate the gas exchange. Obstruction due to a crust or mucous plug can lead to atelectasis of lung abscess if aspirated. 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. (Mehta & Chamyal, 2017)
2. 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. Pneumonia can be a complication of tracheostomy if the aseptic technique is not used during suctioning. Pneumonia can also be associated with stoma infection (Mehta & Chamyal, 2017).
3. 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. Cardiac arrhythmia from endotracheal suctioning has been reported during tracheal suctioning (Mehta & Chamyal, 2017).
4. 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. Accumulation of secretions and airway compromise can impair the oxygenation of vital organs and tissues.
5. Monitor arterial blood gases and oxygen saturation.
Tracheostomy may be performed in clients experiencing respiratory distress syndrome, which presents significant clinical challenges. 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.
6. 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 the 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 an air leak occurs with the cuff pressure at the maximum recommended, the tracheostomy may have been displaced and may require changing (Lindman & Soo, 2021).
7. If a leak is present, try to reinflate the cuff, checking the pilot tube and valve for leaks. If unsuccessful, notify the healthcare provider.
An intact cuff is required to ensure the direction of air into the bronchial airways. If the client is mechanically ventilated and loses a large portion of the tidal volume because of a cuff leak, the tracheostomy tube will need to be replaced. Tracheostomy tube cuff pressure should be monitored using a manometer to reduce the risk of complications (Parker, 2014).
8. Place the client in a semi-Fowler’s to high Fowler’s position and reposition periodically.
This position promotes full lung expansion and improved air exchange. An upright position also prevents the aspiration of secretions and helps the client expectorate the excess secretions effectively. Repositioning promotes the aeration of all lung segments and mobilizes secretions.
9. Provide a calm and quiet environment, and encourage the client to express feelings.
Anxiety increases oxygen demand, and hypoxemia potentiates respiratory distress or cardiac symptoms, which in turn escalates anxiety. A quiet and calm environment may provide the client relaxation, conserving energy and reducing oxygen demand.
10. Instruct the client with deep breathing techniques and pursed-lip breathing, if indicated.
Deep breathing exercises help promote gas diffusion and expansion of small airways. This exercise also provides the client with some control over respiration, helping to reduce anxiety.
11. Provide support to family and caregivers.
The development of complications for a client with a tracheostomy is very frightening for the client and family because it may indicate the end-stage of the disease process or approaching death, especially if the client is in the hospice setting. Keeping the family informed may diminish their anxiety and minimize transmission to the client.
12. 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. The recently insulted trachea produces copious secretions, so suctioning every 15 minutes is not initially unreasonable. Suctioning should be performed under aseptic conditions with the client upright, when possible (Lindman & Soo, 2021).
13. 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. Humidified oxygen also prevents the inspissation of the secretions. If uncorrected, mucus that plugs the inner cannula can cause life-threatening obstruction (Lindman & Soo, 2021).
14. Maintain an adequate airway. If an obstruction is suspected, troubleshoot as appropriate.
Move the head and neck to correct any kinking of the tube or malpositioning. Attempt to deflate the cuff. This maneuver is important if there is a possibility of a herniated cuff. Try to pass a suction catheter to aspirate a mucus plug and assess for airway patency. Remove the inner cannula, and replace it with a backup inner cannula. A mucus plug can become lodged in the tube and obstruct the client’s airway. Remove and replace the tracheostomy tube if all else is unsuccessful to restore airway patency.
3. Promoting Communication & Alternative Communication Methods
Communication allows clients to better participate in their care and engage with family and healthcare professionals. The Joint Commission identified impaired communication as the number one root cause of sentinel events in hospitals nationwide. The inability to communicate is frustrating, resulting in decreased quality of life and feelings of fear, anxiety, and powerlessness (Pandian et al., 2019).
1. Assess the client’s communication ability.
As long as no edema is present, enough air should pass by the tube and through the vocal cords. This also encourages the client to re-establish normal airflow through the upper airway and diminishes psychological reliance on the lesser resistance of the tracheostomy (Lindman & Soo, 2021).
2. Assess the client’s knowledge base and level of comprehension.
Knowing how much to expect of the client can help avoid frustration and unreasonable demands for performance. However, having an expectation that the client will understand may help raise the level of performance.
3. 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 interpreting these nonverbal techniques. Each new method needs to be assessed for effectiveness and altered as necessary.
4. 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. Studies demonstrate that quality of life after tracheostomy is negatively affected for the first few months after surgery. Similarly, studies show that the presence of tracheostomy in clients predicts a worse quality of life (Haring et al., 2021).
5. Provide emotional support to the client and significant others.
Difficulty in communicating is a source of frustration for all involved. Prior articles described that up to 60% of ICU clients reported high levels of frustration associated with not having their communication needs met. These difficulties resulted in clients failing to share delusional experiences, with consequent feelings of loneliness, resentment, delirium, and violence (Modrykamien, 2019).
6. Place the client in a room close to the nurse’s station.
This ensures easy observation of the client by the nursing staff. Anticipate the client’s needs and let them know that the nurse will be immediately available should they require assistance.
7. Provide a call light within easy reach at all times. Answer the light promptly.
A prompt response decreases anxiety and feelings of helplessness. The client may be better able to relax and feel safe knowing that the nurse is vigilant and needs will be met.
8. 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. Establish eye contact with the client while doing so to assure them of the nurse’s interest in communicating. If the client is able to move their head, blink their eyes, or is comfortable with simple gestures, a great deal can be done with yes or no questions.
9. Provide alternative methods for communicating such as hand gestures, word-and-phrase cards, and picture boards for clients who are unable to write, or a writing pad.
Providing a variety of communication aids allows the client more channels through which information can be communicated. Low technology augmentative and alternative communication (AAC) strategies include pen and paper and communication boards. Clients with preserved cognition and fine motor abilities may be provided pen and paper to freely write. If fine motor abilities are preserved but the client is unable to write, communication boards are available. These boards consist of icons and pictures representing basic needs (Modrykamien, 2019).
10. Encourage the client to use an available mobile application that can help with communication.
The Society of Critical Care Medicine developed the “ICU Patient Communicator” application, which allows communication with the use of a handheld device. Particularly, the application allows the clients to select from a number of icons with the titles “I have pain”, “I need”, “I feel”, and “I want to see”. Once an icon is selected, a drop-down menu or body image appears, which allows the client to select specific messages or point toward a body area of pain.
11. Provide information about wearable communication devices, as appropriate.
Recently, a wearable personal communication device was developed (EyeControl, EyeFree Assisting Communication Ltd.), which avoids screen use. A head-mounted infrared camera tracks eye movements and sends information to a small processing unit that translates movements into communication. Once the message is selected, the device includes audio feedback to the user, and prior communication is transmitted to the output speaker or the connected Bluetooth device (Modrykamien, 2019).
12. 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. Notably, other reports showed that client-provider interactions usually focus on items perceived as relevant by clinicians but not so much by clients. These data show that ineffective communication between the client and providers may bring undesirable psychological outcomes (Modrykamien, 2019).
13. Collaborate with the healthcare provider 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 above the tracheostomy tube, allowing an air of phonation. In clients who are unable to tolerate cuff deflation, talking tracheostomy tubes are feasible in facilitating phonation. Moreover, this equipment improved overall QOL according to a study, allowing for phonation without cuff deflation, resulting in more opportunities for communication with the provider and family members (Pandian et al., 2019).
14. 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. Passy-Muir valves are special one-way valve caps that allow automatic occlusion with exhalation for speech. Negative pressure opens the valve. Fenestrations are rarely in the correct place. Simply deflating the cuff or, preferably, downsizing to a cuffless tracheostomy tube should suffice for audible speech (Lindman & Soo, 2021).
15. Coordinate with other medical teams for the client’s rehabilitation.
Special teams dedicated to speech and swallowing functions are usually involved to evaluate this process. They can recommend if the client is in good condition to start oral feeding, as well as an appropriate diet for the particular condition to prevent aspiration and further complications (Lindman & Soo, 2021).
4. Preventing Aspiration Risk & Dysphagia
It is well known that clients with a tracheostomy are at risk of dysphagia. The incidence of dysphagia is reported to be approximately 50% in this client population with a high risk of aspiration and silent aspiration. Without proper dysphagia management, clients are at greater risk of developing aspiration pneumonia which can lead to longer lengths of stay and increased hospital costs (Bartow, 2020).
1. Assess the client’s age and type of food consistency (solid or formula).
This provides detail about the risk of choking or aspiration. Some clients may be considered too medically fragile to begin oral intake and thus remain longer in NPO than necessary. Disuse atrophy can occur from limited use of the oropharyngeal musculature which may result in further exacerbation of dysphagia.
2. Assess the placement of the tube through imaging studies.
Infants and children have relatively short necks and are at high risk of tube displacement. Thus postoperative chest radiography is necessary for infants and children (Lindman & Soo, 2021).
3. Assess the client’s swallowing ability.
The clinical assessment of swallowing in children with a tracheostomy tube requires a complex understanding of the client’s overall health status. In the Blue Dye Test (BDT) the oral cavity of clients with tracheostomy tubes is dyed and they undergo orotracheal aspirations. This test is not recommended for clients with kidney problems, intestinal inflammatory disease, or an allergy to food colorings (Basso et al., 2021).
4. Encourage liquid initially in small amounts and gradually increase as tolerated; add cereal to infant formula or offer thick milkshakes to the child.
This provides fluids and nutrients of a consistency that is well-managed and swallowed to avoid choking. With timely speech-language pathology, clients could be placed on the most appropriate diet textures and liquid consistencies to decrease aspiration risk and, ultimately, improve the quality of client care (Bartow, 2020).
5. 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.
This promotes the flow of fluids and foods through gravity. Keep the head of the bed elevated at 30 to 45 degrees during feeding or at least 1 hour after feeding to reduce the risk of regurgitation or gastric reflux.
6. Suction fluids from mouth and airway once choking happen; limit suctioning procedure after feedings.
Suctioning prevents aspiration, however, suctioning after feedings may cause nausea or vomiting. When suctioning a tracheostomy, use a catheter that’s no more than half the inner diameter of the tube and insert it just beyond the end of the tube (Nakarada-Kordic et al., 2018).
7. Instruct caregivers on the type of foods and liquids allowed in the client.
This promotes nutrition requirements that are easier to tolerate and swallow with the tube in place. Individuals with tracheostomy tubes may need modified food or liquid consistencies to provide the safest and least restrictive diet. There is a standardized diet called the International Dysphagia Diet Standardization (IDDSI) which has different levels of food consistency (Tracheostomy Education, 2019).
8. Instruct the client on how to perform effective coughing exercises.
Clients with inflated cuffs are at high silent aspiration risk, with reduced ability to generate an effective cough reflex when material enters the airway. Once the cuff is deflated, some airflow may be able to escape around the tracheostomy tube and through the upper airway to clear some secretions or other material in the airway. Occlude the tube after cuff deflation to create subglottic air pressure which is necessary for an effective cough and can be achieved through finger occlusion, Passy-Muir valve, or capping (Tracheostomy Education, 2019).
9. Perform effective secretion management as indicated.
Clients with tracheostomy tubes have been found to have higher secretion levels compared to those without tracheostomy tubes. Secretion levels have been associated with aspiration for clients. Subglottic and tracheal suctioning can aid to lessen the number of secretions that enter the lungs (Tracheostomy Education, 2019).
10. Assist in placing a speaking valve or a Passy-Muir valve for the client.
A reduction of secretions has been demonstrated when a speaking valve is placed. A study reported a reduction in the frequency of suctioning following speaking valve use but did not provide objective data or direct visualization of secretions. Another study measured the amount of secretions suctioned both orally and via tracheostomy over a 24-hour period and found a 40% reduction in secretions when using the Passy-Muir valve (Tracheostomy Education, 2019).
11. Inform caregivers to notify the healthcare provider in the presence of respiratory distress.
This prevents life-threatening complications caused by suffocation. Apnea due to loss of hypoxic respiratory drive is mainly important in the awake client. Ventilatory support must be available. Pneumothorax or pneumomediastinum can result from direct injury to the pleura or the cupola of the lung or from high negative inspiratory pressures of clients who are awake and distressed (Lindman & Soo, 2021).
12. Collaborate with the healthcare and interprofessional teams for the care of the client.
A systematic review and meta-analysis of the literature regarding tracheostomy teams were conducted and the authors reported that multidisciplinary care leads to faster decannulation and increased speaking valve use resulting in improved quality of life (Bartow, 2020).
5. Promoting Safety & Preventing Injury Risk
Although tracheostomy is now commonly used, the complication rate remains high. The rate of complications with an emergency tracheostomy was two times as high as with an elective tracheostomy. This is usually due to haste, inadequate lighting, equipment, or assistance, and a client struggling for breath (Mehta & Chamyal, 2017). Individuals with tracheostomies are presented with a variety of functional, physical, and psychosocial challenges spanning from the point of insertion through hospital discharge to caring for the tracheostomy at home (Nakarada-Kordic et al., 2018). Here are some interventions to promote safety and prevent risk for injury:
1. Assess for proper tube placement, patency of the tube, and presence of an air leak around the tube.
This guarantees efficient tube function to provide an airway for oxygenation. A chest radiograph can be used to confirm the correct tube position within the trachea, which should be just below the level of the vocal cords and well above the carina (Schmölzer, 2018). Traditionally, the client is ventilated and correct tube placement is confirmed by observation of equal chest rise and auscultation of bilateral breath sounds (Parker, 2014).
2. Assess the security of tapes and knots, and the tightness of tapes by inserting a small finger between the tape and neck.
This promotes the safe use of ties to secure tubes, which should not be unraveled and should fit snugly without impairing circulation. Make sure the ties are not too tight and should be able to pass an index finger in between the ties and the neck (Parker, 2014).
3. Observe any change in breath sounds and respiratory rate, depth, and ease.
This determines the need to remove secretions to prevent occlusion and respiratory distress. Since there is no airflow through the upper airway with an inflated cuff, there is a lack of sensation of secretions that tend to pool above the level of the cuff. Since there is not an airtight seal, aspirated secretions may pass around the cuff into the lower airways and lungs (Tracheostomy Education, 2019).
4. Assess for postoperative bleeding around the stoma site.
Hemorrhage may occur during the operation but more frequently is delayed. A medium-sized vessel may be transected during the tracheostomy when the client is hypotensive and goes unrecognized. Later when normotensive levels return, brisk bleeding with aspiration may result. An irritating cough, aspiration of bloody secretions, or retrosternal discomfort may precede the hemorrhage (Mehta & Chamyal, 2017).
5. Hold the tube in place during a dressing change, and apply ointment under the wings of the tube, changing tapes, or suction tube.
This prevents manipulation of the tube that causes mechanical irritation and may dislodge the tube. Topical applications of corticosteroid creams, antibiotic preparations, and silver nitrate have been proposed for addressing granulation tissue (Johnson & Mosenifar, 2022). During tracheostomy tie change, the old ties are removed prior to securing the new ties, and one person is to maintain the airway by securing the tracheostomy tube in place and not removing the hand until the new tracheostomy ties are secured (The Royal Children’s Hospital Melbourne, 2022).
6. Suction gently and intermittently, using the proper catheter size and technique.
Suctioning clears the 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. Suctioning should be limited to the length of the tube to avoid tracheal ulceration and tracheitis. Suction should not be applied for more than 10 seconds. If any difficulty in passing the suction catheter is encountered, tube displacement and/or tube blockage should be suspected (Lindman & Soo, 2021).
7. Have a spare tracheostomy tube, scissors, bag, proper-sized mask and adaptor, an oxygen source, and suctioning equipment available at the bedside.
This provides emergency measures for airway obstruction or decannulation. These emergency supplies should be immediately available at the client’s bedside and accompany the client when they leave the room for any reason to protect the client from the complications associated with accidental decannulation or tube dislodgement (Parker, 2014).
8. Change tapes three days after surgery and tube two weeks after surgery per healthcare provider advice, with two nurses present or a respiratory therapist.
This ensures the safety of procedures with assistance if needed. The interval between the tracheostomy tube placement and the first tube change allows a tract between the skin and the trachea to develop. Confirming a safely healed tract allows nurses or other trained personnel to safely perform subsequent tracheostomy tube changes (Johnson & Mosenifar, 2022).
9. Change tube if obstructed, reinsert new tube if dislodged; have two personnel present.
One of the most commonly accepted indications for tracheostomy tube change includes tube malfunction. It is highly advisable to have two people present during any tracheostomy tube change and to ensure that the new tracheostomy tube is checked for integrity before the old one is removed (Johnson & Mosenifar, 2022).
10. Educate caregivers on the benefits of tracheostomy, such as reduced work of breathing, improved rest and feeding, and progress in developmental tasks.
This provides emotional support to parents and family. Most commonly, healthcare providers described the benefits of placing a tracheostomy, which includes a decreased length of hospital stay, not having to be permanent, providing a more stable airway, and allowing reduced sedation needs (Hebert et al., 2018).
11. Teach, demonstrate, and allow caregivers 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 is needed.
This encourages continuity of safe care by caregivers if able to execute skills and are approved by the healthcare team. This also promotes autonomy and control of the family in the client’s care. Using a low-cost anatomical trainer (LATT) during return demonstration provides the caregiver with the opportunity to practice the skills needed to care for a tracheostomy in a non-threatening environment. It also allows the caregiver to practice their skills as many times as they want to feel comfortable before they return the demonstration to their loved ones (Loerzel et al., 201).
12. Encourage caregivers to dress the client in loose-fitting clothing around the neck with no loose threads or frayed material, remove crumbs, beads, or dangerous toys, do careful bathing with the elimination of water near the tube; cover the tube with a bib when drinking or eating meals.
These measures prevent tube occlusion or entry of foreign materials. The easy access to the lower respiratory tract by the tracheostomy can allow the entry of unwanted foreign materials (Mehta & Chamyal, 2017). A child with a tracheostomy tube should be closely supervised when bathing or showering. They should also wear a heat moisture exchanger (HME) filter or tracheostomy bib filter to minimize the risk of aspiration (The Royal Children’s Hospital Melbourne, 2022).
13. Check the cuff pressure regularly.
The aim of tracheostomy cuff management is to use the minimum occlusive volume or minimum cuff pressure required. The cuff volume or pressure is to be checked at least every 8 hours and at any time to prevent complications associated with tracheostomy tube placement. If the cuff pressure is too high, this can lead to reduced capillary blood flow to the tracheal mucosa with the subsequent risk of tissue damage and tissue necrosis (The Royal Children’s Hospital Melbourne, 2022).
14. Provide humidification as indicated.
A tracheostomy tube bypasses the upper airway and therefore prevents normal humidification and filtration of inhaled air via the upper airway. Unless air inhaled via the tracheostomy tube is humidified, the epithelium of the trachea and bronchi will become dry, increasing the potential for tube blockage. Tracheal humidification can be provided by a heated humidifier or a heat and moisture exchanger (HME) (The Royal Children’s Hospital Melbourne, 2022).
6. Initiating Measures for Infection Control & Management
Tracheostomy is a surgical procedure by which a cannula is introduced into the trachea to establish a direct line of contact with the external environment. Clients with tracheostomy are at increased risk for tracheopulmonary infections as the tracheostomy tube bypasses the naturally protective nasal and oral airway passages and provides an open portal of entry for bacteria into the lower airway (Tan et al., 2020). Additionally, open or surgical tracheostomy is usually an aerosol-producing procedure with a high risk of contamination by exposing the secretions from the airway to the healthcare personnel (Swain et al., 2020). Early identification of the risk factors and diagnosis of tracheostomy-related infections is essential to avoid severe complications.
1. Assess the client’s temperature.
Fever may be a manifestation of an infection or inflammatory process. Clients with fever and at least one of the respiratory signs and symptoms of infection such as the new onset of or changes in purulent sputum, increased respiratory secretions, increased suctioning requirements, new onset worsening cough or dyspnea and bronchial breath sounds are considered to have pneumonia (Tan et al., 2020).
2. Assess skin integrity under tracheal ties.
This is a common site for infection and skin breakdown. Assess the peristomal skin for signs of infection or irritation, as well as the skin under the tracheostomy ties. One finger should fit between the client’s neck and the tie to avoid chafing and causing irritation (Parker, 2014).
3. 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. If the area appears red, tender, or smells foul, stoma cleaning may be performed more frequently. Culture and sensitivity reports guide antibiotic selection.
4. Monitor white blood cell (WBC) count.
An increasing WBC indicates the body’s effort to combat pathogens. Culture-proven or microbiologically positive bacterial pneumonia episodes can be defined as a WBC <4,000 or >12,000 mL, CRP >1 mg/dL, chest x-ray with a pneumonia patch, and positive sputum cultures. Non-bacterial pneumonia episodes can be classified as WBC 4,000-12,000/mL, CRP <1 mg/dL, and chest x-ray without a pneumonic patch (Tan et al., 2020).
5. Note risk factors for infection.
Intubation interferes with the normal defense mechanisms that keep microorganisms out of the lungs. Tracheostomy tubes, especially cuffed ones, interfere with the mucociliary transport system that helps clear airway secretions. Secretions that accumulate below and above the tube cuff are an ideal medium for pathogens. Other factors include prolonged mechanical ventilation, trauma, general debilitation, malnutrition, age, and invasive procedures.
6. Auscultate breath sounds.
The presence of rhonchi and wheezes suggests retained secretions requiring expectoration or suctioning. Rales and bronchial breath sounds are also symptoms of respiratory tract infections (Tan et al., 2020).
7. Encourage proper hand washing or alcohol-based hand rubs.
Hand washing is one of the simplest but most important keys to the prevention of hospital-acquired infection. If soap and water are not readily available, an alcohol-based hand sanitizer that contains at least 60% alcohol may be used.
8. Utilize appropriate personal protective equipment (PPE) when handling a client with a tracheostomy tube.
A client diagnosed with COVID-19 and has a tracheostomy tube is highly infectious. Healthcare professionals should wear PPE when handling a client with a tracheostomy. During suctioning, protective eyeglasses should be used for preventing exposure of the infection to the eye. The face mask must be FFP (N95) or FFP3. After the removal of the tracheostomy tube, the appropriate time to doff the PPE is at least 20 minutes. This doffing should be done at a designated area with the standard practice of current guidelines (Swain et al., 2020).
9. Maintain and screen visitors. Limit them as much as possible.
The client is already compromised and is at increased risk of exposure to infections. Limiting visitors and avoiding contact with persons with respiratory infections help decrease the client’s exposure to harmful pathogens.
10. 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. The pressure within the cuff should be checked regularly with a handheld pressure manometer and maintained ideally between 20 and 25 cm water. It should never exceed 25 cm water (Lindman & Soo, 2021).
11. Keep a tracheal obturator taped at the head of the bed for emergency use.
The tracheal obturator is used to reinsert the tracheostomy. This is a bevel-tipped shaft, which is placed inside the outer cannula of the tube during tube insertion. It has a smooth rounded tip that reduces trauma to the trachea during tube placement (Lindman & Soo, 2021).
12. Keep emergency supplies such as a spare tracheostomy tube of the same size and brand at the bedside.
Being prepared for an emergency helps prevent future complications. Certain emergency supplies should be immediately available at the client’s bedside and accompany the client during client transport for any reason to protect from the complications associated with accidental decannulation or tube dislodgement. Suction equipment, gloves, and a bag-valve mask, as well as tracheostomy tube ties or other securement devices, should also be immediately available (Parker, 2014).
13. Do not allow secretions to pool around the stoma. Suction the area, or wipe with an aseptic technique. Keep the skin under the tracheostomy ties and the 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. Closed or in-line suctioning helps maintain oxygenation during mechanical ventilation and also decreases the risk of aerosolizing secretions (Parker, 2014).
14. Provide stoma care.
Frequent stoma care is required for postoperative clients. Care for clients with long-term stoma placement is based on need. If applicable, clean the inner with hydrogen peroxide; rinse with sterile water or saline solution. Saline solution should be used for cleaning the skin around the stoma because hydrogen peroxide can damage the tissues. If a disposable inner cannula is used, dispose of the used inner cannula and replace it with a new inner cannula of the correct size. Keep the stoma clean and dry by using barrier creams or absorptive or hydrocolloid dressings around the tracheostomy and under its ties as needed. Use a dry dressing around the stoma if the skin is irritated or secretions are evident.
15. Secure the tracheostomy tube with twill tape, using a square knot on the side of the neck or specially designed foam tracheostomy ties.
Ties are loose enough that one finger can be inserted between the client and the ties to help reduce skin breakdown. If using twill tape, take a piece twice the diameter of the client’s neck, attach the ties to one flange, take both ends and place around the neck through the other flange, and knot it close to the flange using a square knot (Parker, 2014).
16. If signs of infection are present, administer an antifungal or antibacterial medication, as prescribed.
These agents are either toxic to the pathogen or retard its growth. One study showed that it is difficult to differentiate between bacterial and nonbacterial pneumonia episodes and, therefore, antibiotics overuse is difficult to avoid. However, it is supported that the practice of prescribing antibiotics may occur only when the client is symptomatic and when clinical evidence of bacterial infection is available (Tan et al., 2020).
7. Reducing Anxiety & Preventing Caregiver Role Strain
Individuals with tracheostomy are presented with a variety of functional, physical, and psychosocial challenges spanning from the point of insertion through hospital discharge to caring for the tracheostomy at home. Due to its influence on basic human needs such as respiration, communication, and nutrition, the presence of a long-term tracheostomy will likely impact the psychosocial well-being and quality of life of the individual concerned (Nakarada-Kordic et al., 2018).
1. Assess the level and manifestations of anxiety in the client and family members.
Gaining insights into the details and severity of anxiety is essential for implementing appropriate interventions. It is important to note that the responsibility of caring for an artificial airway can elevate caregiver anxiety, potentially resulting in inadequate client care (Loerzel et al., 2014).
2. Allow the client and caregivers to express fears and concerns and to ask inquiries about the disease and what to expect.
Providing an opportunity to release feelings and secure information to lessen anxiety. In a study, parents expressed fears related to caring for their child at home and were overwhelmed with technical skills such as caring for a tracheostomy and knowing that their child’s life depended on them (Loerzel et al., 2014).
3. Encourage family members to stay with the client, allow open visitation and telephone communications; encourage them to participate in planned care associated with common home routines.
Involvement of the client’s significant others in the care and common routines decreases anxiety. Early involvement in client-care activities, as well as sufficient education, has shown a positive effect on caregivers. Caregivers who have received information and support early in client treatment have demonstrated greater trust and confidence in the healthcare system, have fewer needs, and cope better in the later stages of the client’s illness (Loerzel et al., 2014).
4. Provide a nonjudgmental and supportive environment.
This promotes trust and reduces anxiety. In studies where participants said healthcare staff made them feel safe and cared for, they attributed this not only to competence and skill with procedures but also to the manner and sensitivity with which the staff performed the procedures (Nakarada-Kordic et al., 2018).
5. Assist the client in coping with changes in their body image.
Tracheostomy involves a prominent disfigurement in the anterior neck that is often permanent, and even if the stoma opening is no longer needed, a scar will most likely prevail. Suggestions have been made that hospital staff working with clients with disfigurement should have an understanding of their unique needs and there should be access to an identified staff member with counseling skills and a recognized route to a psychologist (Nakarada-Kordic et al., 2018).
6. If the client is a child, provide medical play objects such as a doll with a tracheostomy, suction catheters, tracheostomy tubes, and ties, as applicable.
This provides the 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.
7. Provide the client with a pencil and paper, pictures, and slate as age allows.
This provides means of communication and interaction with the child. The initial inability to communicate via speech causes anxiety, fear, frustration, and powerlessness. Additionally, ineffective communication has been suggested to be a barrier to ideal client treatment due to the client’s inability to voice their needs and wishes (Nakarada-Kordic et al., 2018).
8. Provide means to communicate with support groups that may help reduce stigma for the client with a tracheostomy.
The importance of social acceptance and support within the community has been highlighted in many studies. Social support has been associated with better adjustment levels in individuals with a range of disfiguring conditions. Social media sites such as Facebook have been found to be a promising source of support for teenagers with tracheostomies (Nakarada-Kordic et al., 2018).
9. Inform of all procedures and care and any updates on the client’s condition.
Providing individuals with the chance to establish trust and receive ongoing reassurance and support from clinical staff can effectively reduce anxiety stemming from the uncertainty of the situation. This is particularly significant in emergency cases where a tracheostomy is performed without the client’s prior consent, as it helps alleviate feelings of shock, fear, and anxiety (Nakarada-Kordic et al., 2018).
10. Explain to the client and caregivers the purpose of tracheostomy and how the procedure is done, and what to expect with having a tracheostomy.
Addressing anxiety stemming from fear of the unknown is crucial. Insights from hospital experiences indicate that clients and their families would greatly benefit from receiving additional information and counseling before and immediately following a tracheostomy procedure (Nakarada-Kordic et al., 2018).
11. Provide clarification to any misinformation in clear and easy-to-understand language.
Avoiding unnecessary misconceptions or false beliefs is important when it comes to tracheostomy tube care. Findings from a study revealed that participants initially found aspects of tracheostomy tube care to be intimidating due to the potential life-threatening problems and complications associated with it. The lack of comprehension regarding the procedure’s benefits and insufficient preoperative counseling further amplified these concerns (Nakarada-Kordic et al., 2018).
12. Identify and review with the client and family members the safety precautions being taken, such as backup power and oxygen supplies and emergency equipment at hand for suctioning.
This provides reassurance to help allay unnecessary anxiety, reduce concerns of the unknown, and pre-plan for response in emergency situations.
13. Refer to counseling, community groups, or agencies.
This provides the client and family members with the needed support and information from those with the same problems. An investigation into the presence and application of support groups both online and offline may inform further initiatives to reduce the stigmas that people with differences due to tracheostomy surgery are faced with (Nakarada-Kordic et al., 2018).
14. Refer the caregiver to educational programs related to tracheostomy care.
The Tracheostomy Care Anxiety Relief through Education and Support (T-CARES) program has a goal of allowing the caregivers to learn about and practice the skills needed to care for a client with a tracheostomy in a non-threatening environment away from the bedside to alleviate anxiety, enabling them to care for the client and reduce the risk of tracheostomy-related complications once the client is discharged home. It is a one-hour course based on unit protocols for teaching tracheostomy care (Loerzel et al., 2014).
8. Providing Patient Education & Health Teachings
Tracheostomy care involves a complex process that requires knowledge and skills for clients and their caregivers, especially because it is a challenging process for clients with different chronic diseases. Therefore, clients who are discharged from the hospital and their caregivers must be able to fully know and apply these practices, especially in long-term tracheostomy care (Karaca et al., 2019).
1. Assess the client’s knowledge regarding the purpose and care of a tracheostomy.
The provided information serves as a valuable foundation for education. To assess the level of tracheostomy care knowledge among caregivers, the Tracheostomy Care Knowledge Questionnaire can be utilized. This questionnaire encompasses multiple-choice questions covering various aspects, including the rationale behind tracheostomy opening, components of the tracheostomy cannula, the significance of handwashing, nutrition, humidification, aspiration techniques, inner cannula cleaning, stoma care, tracheostomy strings, communication, precautions, and potential complications that may arise (Karaca et al., 2019).
2. Assess the ability to manage care at home.
Both cognitive and technical skills are required for managing tracheostomy tubes. In descriptive studies conducted with caregivers of tracheostomy clients, caregivers have reported that they have been under a heavy burden due to the intense and complex structure of the caregiving role and that they needed guidance and knowledge/skill training to carry out this process (Karaca et al., 2019).
3. Assess the ability to respond to emergency situations.
This information is especially important because the lack of airway patency is a life-threatening problem. Tracheostomy has vital importance for providing airway patency, especially for clients experiencing numerous problems associated with tracheostomies such as pneumothorax, apnea, wrong placement of the tube, tracheal stenosis, tracheoesophageal fistula, and airway obstruction (Karaca et al., 2019).
4. Assess the level of anxiety related to the diagnosis and surgery.
Information provides clues to the client’s and caregiver’s postoperative reactions. Anxiety may interfere with the understanding of the information given before surgery. Tracheostomy is still socially stigmatized and can intimidate both the client and the family. The family’s understanding and comfort are most important, therefore, education must begin early, and preparations for discharge must be complete (Lindman & Soo, 2021).
5. Assess the caregiver’s ability to learn.
Identify concerns from the caregiver, such as feelings of fatigue, participation level, the best environment in which they can learn, how much content they can learn, and the best media and language to teach. Learning may depend on emotional and physical readiness and can be achieved at an individual pace.
6. Discuss the client’s need for a tracheostomy and its particular purpose. Repeat explanations at the client’s level of acceptance
Educational programs need to be individualized to the client’s specific situation and needs. Limited knowledge is often present and the presence of overwhelming stressors may impede understanding, therefore repetition of explanations may help the client and caregivers to digest the information given during a stressful time.
7. Provide instruction in sterile tracheostomy care and suctioning.
Empowering the client to regain control over their life is facilitated by this information. In long-term care scenarios, the client often assumes responsibility. By providing clear and focused teaching, the learner can concentrate fully on the subject matter. This approach allows the client or caregiver to gradually acquire skills without feeling overwhelmed. Suctioning should only be performed as necessary, ensuring the client is adequately oxygenated before and after the procedure. Closed or in-line suctioning techniques are recommended during mechanical ventilation as they help maintain oxygenation and reduce the risk of aerosolizing secretions (Parker, 2014).
8. Provide instructional videos about tracheostomy care.
The instructional video may be produced in a home environment to emulate the environment where the caregivers would be providing care. The video can be structured to allow caregivers time to practice the newly learned skills on a model or a low-cost anatomical trainer (LATT) (Loerzel et al., 2014).
9. Instruct the caregivers to perform a return demonstration on a provided model after the teaching.
Providing hands-on training and return demonstration in a group setting is a practical and cost-effective method to increase caregiver skills and reduce anxiety. The use of a LATT or an instructional model provides the caregiver with the opportunity to practice the skills needed in a non-threatening environment. It allows the family member to make mistakes and have them corrected at a comfortable pace to prevent errors at home. It also allows the caregiver to practice their skills as many times as they want to feel comfortable before they return the demonstration to the client (Loerzel et al., 2014).
10. Give short and easy-to-understand instructions, patterned with the caregivers’ 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. Caregivers can be given handouts about cleaning a tracheostomy tube and reinserting a tracheostomy tube. This can be routinely performed by the nurse in charge (Loerzel et al., 2014).
11. Instruct in the need to call a healthcare provider if the amount of secretions increases or a change in color or characteristic occurs.
Changes could signify the presence of an infection. Local infection at the tracheostomy site is fairly common and tracheitis occurs to some degree in every client having a tracheostomy. Tracheitis occurs most commonly at the stoma, the tip of the tube, and the area of the cuff. Tracheitis can be lessened by meticulous asepsis, frequent irrigation, and suctioning (Mehta & Chamyal, 2017).
12. Reinforce the client’s knowledge of emergency techniques such as tracheostomy reinsertion and obtaining an audiotape for home use that can be played when emergency service is called.
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. With the increasing number of clients with tracheostomy, safe caring requires knowledge and competencies in dealing with tracheostomy-related emergencies (Ng et al., 2022).
13. 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. The aim of weaning is to gradually return airflow to the upper airway and restore normal physiological functions. The process of weaning involves the manipulation of the tracheostomy tube which may increase the workload of breathing. (Physiopedia, 2020)
14. Provide written directions for the client and caregiver to read and be available for future reference. Provide a return demonstration of procedures before discharge
Written materials reinforce proper information and may be used as a home reference. Before leaving the hospital, all members of the household should feel comfortable with replacing the outer cannula. The most commonly overlooked or misunderstood item is the obturator, which is important in the atraumatic reinsertion of the outer cannula (Lindman & Soo, 2021).
15. Provide information on the reinsertion of a tracheostomy tube.
The first tube change is done by the healthcare provider. Thereafter the client or caregiver should be taught step-by-step reinsertion instructions and should complete a return demonstration. The indications for tracheostomy tube change include minimizing the risk of infection and granulation tissue formation, downsizing as part of a weaning or decannulation process, and verifying the formation of a mature tract for other healthcare professionals, particularly nurses and allied health members. Most manufacturers recommend that tracheostomy tubes be changed approximately 30 days after placement (Ng et al., 2022).
16. 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. Specialist nurses provide continuous coordination of care, education, and dissemination of knowledge, as well as ensure standards are always maintained or improved (Ng et al., 2022).
17. 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 airflow through the stoma site (Lindman & Soo, 2021).
18. Provide home care instructions as appropriate.
A loose scarf or shirt may be used over the tracheostomy site. This camouflages the area and may enhance body image. The stoma should be covered to prevent the inhalation of foreign materials. Swimming is contraindicated because aspiration is possible if water gets into the stoma. The client may shower with the stoma collar but should lean forward when shampooing. When securing the tracheostomy ties, only one finger should fit between the client’s neck and the tie, then place a clean pre cut dressing under the faceplate. Cut gauze is not used because the frayed edges can cause irritation. Peristomal care should be provided at least every 8 hours, but change the dressing only as needed (Parker, 2014).
19. Inform local utilities and paramedics about the client’s condition.
Advance notification of appropriate personnel promotes quick and active response. There is increasing evidence that coordinated care influences the safety and quality of care delivered to clients with tracheostomy and their families (Ng et al., 2022).
20. Facilitate arrangements with local home health nursing agencies, as applicable.
This promotes feelings of control and limits anxiety within the family; discharge is often a time of higher stress for caregivers and clients, and they can become easily overwhelmed. Specialist nurses provide continuous coordination of care, education, and dissemination of knowledge, as well as ensuring standards are always maintained or improved (Ng et al., 2022).
21. Facilitate the accessibility of supplies and equipment needed at home, including oxygen, pulse oximetry, suction apparatus, and so forth; provide the necessary instructions about using each piece of equipment.
This ensures supplies and equipment are available upon discharge and promotes an understanding of how the equipment works. The caregivers need to practice good habits when changing and cleaning the tracheostomy tube. They also need to know what to do in case of an emergency, such as when the tube dislodges accidentally or becomes obstructed. (Gillette Children’s, 2023)
22. Train all caregivers on how to perform CPR; provide written materials or videos for reinforcement.
This promotes an increased understanding of the emergency resuscitation needs of the client. Prior knowledge of CPR may reduce the stress felt by the family. If the caregiver is not confident in giving rescue breaths, they may use hands-only CPR. Hands-only CPR involves uninterrupted chest compressions of 100 to 120 per minute.
23. Demonstrate to family and other caregivers all guidelines of tracheostomy care for the client, including 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. The demonstration must include the standard education and instruction on basic airway anatomy, tracheostomy tube description, and operation, signs, and symptoms of respiratory distress, suctioning technique, tracheostomy tube cleaning and maintenance, stoma-site assessment and cleaning, emergency decannulation and reinsertion procedures, and equipment and supply use (Loerzel et al., 2014).
24. Teach and instruct the family to treat the child with tracheostomy as normally as possible, including information on growth and development, discipline, school, sibling reactions, the importance of play, and trip stress.
This promotes normalcy within the family which supports the well-being and development of the child. It also decreases anxiety and stress. In a study, individuals who were tracheostomized while in the ICU recommend how they used humor to get them through and tried to stay calm and informed about when their tube would be removed (Nakarada-Kordic et al., 2018). The child’s caregiver may use this technique to lift the child’s spirits and avoid stress within the family.
25. Teach the client with a tracheostomy about vocalization techniques as applicable.
This allows communication which enhances self-esteem and facilitates average growth and development. Participants in a study saw being able to speak again as a way of regaining control, regaining their ability to express their opinions, emotions, power, and independence. The return of voice is also associated with significant improvement in areas of self-esteem such as cheerfulness and the ability to be understood by others (Nakarada-Kordic et al., 2018).
26. Provide social support to the caregiver.
Caregivers report the positive results of receiving social support, such as boosting morale and increased tolerance of difficulties and ups and downs of client care. At home, one person is often responsible for most care as the primary caregiver, but one or more members of the family should also accept part of the care and help the primary caregiver in providing care. This indicates a distribution of care burden among caregivers and their support for each other in client care (Daraie et al., 2021).
27. Inform the client of the various roles of the members of the interprofessional healthcare team.
It is recognized that tracheostomy care outcomes are better when there is a concerted effort between various parties, including the client, surgeon, primary care provider, otolaryngologist, and interdisciplinary teams such as nurses and speech and language therapists (Ng et al., 2022).
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
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:
- Aspiration Risk & Aspiration Pneumonia
- Airway Clearance Therapy & Coughing
- Bronchopulmonary Dysplasia (BPD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Cystic Fibrosis
- Hemothorax and Pneumothorax
- Influenza (Flu)
- Ineffective Breathing Pattern (Dyspnea)
- Impairment of Gas Exchange
- Lung Cancer
- Mechanical Ventilation
- Pleural Effusion
- Pulmonary Embolism
- Pulmonary Tuberculosis
References and Sources
- Bartow, C. (2020, July 25). Can a multidisciplinary trach team improve swallowing in patients with a tracheostomy? Dysphagia Cafe. Retrieved January 28, 2023.
- Basso, C. S. D., da Silva Arroyo, M. A., Fucuta, P. d. S., & Maia, A. B. (2021). Feeding of children with tracheostomy at hospital discharge. Speech, Language, Hearing Sciences and Education Journal, 23(5).
- Daraie, S., Hasanvand, S., Goudarzi, F., & Rassouli, M. (2021, March 5). Gaining Experience Over Time: The Family Caregivers’ Perception of Patients with a Tracheostomy in Home Care. NCBI. Retrieved January 27, 2023.
- Gillette Children’s. (2023). Emergency Tracheostomy Care at Home | Gillette Children’s. Gillette Children’s. Retrieved January 27, 2023.
- Haring, C. T., Farlow, J. L., Leginza, M., Vance, K., Blakely, A., Lyden, T., Hoesli, R. C., Heft Neal, M. E., Brenner, M. J., Hogikyan, N. D., Morrison, R. J., & Casper, K. A. (2021, June). Effect of Augmentative Technology on Communication and Quality of Life After Tracheostomy or Total Laryngectomy. Otolaryngology-Head and Neck Surgery, 167(6).
- Hebert, L. M., Watson, A. C., Madrigal, V., & October, T. W. (2018, December 1). Discussing Benefits and Risks of Tracheostomy: What Physicians Actually Say. NCBI. Retrieved January 28, 2023.
- Johnson, W. A., & Mosenifar, Z. (2022, February 7). Tracheostomy Tube Change: Background, Indications, Contraindications. Medscape Reference. Retrieved January 28, 2023.
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