Nursing Diagnosis for Tracheostomy and Care Plan

Nursing Diagnosis for Tracheostomy and Care Plan

This guide is about tracheostomy, nursing diagnosis for tracheostomy, and care plan. It can be used to create nursing care plans for educational purposes.

Nurses caring for patients with tracheostomies must have a thorough knowledge of the natural anatomy of the airway and how artificial appliances affect the breathing patterns and respiration of the patient. There is also a need to recognize the signs and symptoms of hypoxia and the skills necessary to provide effective nursing care should the tracheostomy tube accidentally dislodge. However, there is also a need to know what tracheostomy is all about and the conditions requiring a patient to have it.

Tracheostomy

What is a tracheostomy?

A tracheostomy is a surgically created opening in the cervical portion of the trachea. The procedure is quite common for patients who require an artificial airway, but it is not typically performed as an emergency procedure. This is because other procedures, such as oral intubation or cricothyrotomy, are much faster and less complicated than tracheostomy, especially in cases of respiratory arrest. Typically, an order is required for a tracheostomy to be performed for the following reasons:

  • To bypass an airway obstruction.
  • To help ensure airway patency in some patients
  • As an aid to removing secretions more efficiently
  • To provide better oxygenation to a patient (through mechanical ventilation or others) on a long-term basis.
Nursing Diagnosis for Tracheostomy and Care Plan
Tracheostomy

Because a tracheostomy (and related procedures such as suctioning or mechanical ventilation) is a high-risk procedure that patients must undergo, the nurse must adhere to accepted standards of practice or follow care protocols established by the health facility where they work. Furthermore, to ensure the quality of care, the nurse must be familiar with the equipment used on patients.

As mentioned previously, a tracheostomy is created to help patients with various health conditions that alter airway patency and affect gas exchange by providing an artificial airway. These are some examples:

  • Stroke or comatose patients
  • Patients who are suffering from laryngeal cancer
  • Patients who have suffered laryngeal edema and damage because of burns 
  • A patient with COPD and in need of mechanical ventilation
  • Pediatric patients who are suffering from congenital airway congestions

There are also anatomical abnormalities or problems that may necessitate the creation of a tracheostomy in the absence of a pathologic problem such as:

  • An inherent abnormality in the anatomy of the trachea or the larynx
  • Presence of a tumor or foreign object in the throat
  • Severe injuries in the airway, explicitly involving the neck, throat, or mouth
  • Inability to cough, swallow or expectorate sputum due to a variety of causes

Different Types of Tracheostomy Tube Insertion Procedures

How is a tracheostomy tube inserted?

The typical procedure for inserting a tracheostomy tube is performed in the operating room while the patient is under general anesthesia. However, the procedure can also be performed while the patient is awake. Sutures are usually placed in the tracheal cartilages between the second and third or fourth tracheal cartilages (see Figure 1). The ends of these sutures are also taped to the patient’s skin and serve to stabilize the tracheostomy.

Another approach, especially when the patient is admitted to the ICU, involves creating tracheostomies at the patient’s bedside. PDT stands for percutaneous dilatational tracheostomy. The PDT is performed with a local anesthetic or narcotic sedative and a guidewire to create a stoma where the tube is inserted in less time than other tracheostomies. This procedure takes about 15 minutes and has been shown to result in fewer scars and problems. This technique, however, cannot be performed on patients who have anatomical abnormalities or coagulation problems.

Nursing Diagnosis for Tracheostomy and Care Plan
Tracheostomy Tube Insertion

 

The mini tracheostomy is another procedure used to create a tracheostomy. Patients no longer need to be inside the operating rooms for tracheostomies. Therefore, this surgery is also done from the bedside as a compromise step to help decongest operating rooms. This also aids in ensuring that patients are continuously monitored while keeping healthcare costs low.

Nursing Diagnosis for Tracheostomy and Care Plan
Different Types of Tracheostomy Tubes (standard adult, cufless, pediatric, fenestrated tubes)

Benefits and Risks of a Tracheostomy

What are the pros and cons of tracheostomy?

Because tracheostomies can be performed either on a temporary or a permanent basis, it poses several benefits to the patients compared to other artificial airways created. Firstly, creating a tracheostomy will help keep the airway patent in case the tube gets dislodged. This is because the upper airway of the patient remains connected. Secondly, unlike a laryngectomy, which removes the larynx to create an artificial airway, no part of the larynx or trachea is removed.

There are also risks associated with creating a tracheostomy, ranging from those seen during the creation to those seen after the patient has been placed on long-term ventilation support. These dangers include:

  • Reaction to the medications and/or anesthetics used
  • Infection of the insertion site
  • Bleeding tendencies
  • Problems and issues with clotting
  • Severe respiratory problems
  • Potential of suffering from respiratory or cardiac arrest

Moreover, some patients experience other less severe complications, such as inflammation of the wound site. Some patients are also seen to suffer from an inability to expectorate sputum and difficulty adjusting to tracheostomy.

Care of the Patient After Tracheostomy Procedure

How do you care for a patient with a tracheostomy?

In the initial post-operative period, patients who have had a tracheostomy may experience pain and other discomforts. The patient is expected to be in a period of trying to recuperate from the trauma of the procedure and adjusting to the tube’s existence while trying to find better ways to communicate for the first 48 hours after the operation. The following can help the nurse in providing better post-procedure care to the patient:

  • Assess the breathing and ability of the patient to communicate. Note for rate, rhythm and respiratory sounds, and sputum characteristics to determine potentials for complications.
  • Provide patients with other means to communicate, such as writing pads.
  • Monitor vital signs and document them, especially when determining when patients can be transferred to their rooms. Note for any irregularities and inform the physician.
  • Avoid excessive manipulation of the tube to prevent dislodgement, especially since the stoma has the potential to close shut in the immediate post-op period.
  • Assist the physician on the first tube change, which usually happens a week after creating the stoma.
  • Refresh your memory on the symptoms and findings that patients who have had a tracheostomy can expect to see, such as:
    • A slight increase in the respiratory secretions after the procedure
    • Signs indicating imbalances in gas exchange (this can be corrected once patients are hooked to ventilation support, or taught deep breathing techniques)
    • Small amounts of bleeding in the tracheostomy site
    • Inflammation in the incision site in the immediate post-operative phase
    • Escape of small amounts of air in the incision site (this is no cause of alarm)

Nursing Diagnosis for Tracheostomy

What are the priority nursing diagnoses for patients requiring a tracheostomy?

Potential and actual nursing problems can be seen among patients who have a tracheostomy. These nursing problems can be identified using a thorough assessment of the patient, which involves considering the patient’s verbalization and symptoms and correlating these with the physical evaluation and laboratory data.

  • Ineffective airway clearance
  • High risk for aspiration
  • Ineffective breathing pattern
  • Impaired gas exchange
  • Inability to maintain spontaneous ventilation
  • High risk for infection
  • Impaired swallowing
  • High risk for impaired skin integrity
  • Altered oral mucous membrane
  • Fear
  • Anxiety
  • Situational low self-esteem
  • Knowledge deficit
  • Health seeking behavior

Nursing Care Plan with Rationale

What are eight important safety measures when caring for a client with a tracheostomy?

Intervention Rationale
Examine the trach tube, any tubing, and equipment connected to it, as well as the stoma site. Observe for redness, purulent drainage, and abnormal bleeding around the stoma. Note the amount, color, consistency, and odor of secretions. This step allows the nurse to determine the potential source of any problem or issues with the patient and the tubing set-up and help plan effective care.
Assess breath sounds, noting the depth, rate, and rhythm of respiration. Also, note for sputum production and characteristics of the expectorate. To determine the potential or presence of a complication of the procedure or improvement of the patient’s condition.
If a patient needs humidification, ensure the type of humidification the patient needs and administer it according to facility protocols. Patients may need different forms of humidification, and these may differ in administration from one another. Ensuring the type of humidification required by the patient allows the nurse to plan for more effective care.
Perform measures to mobilize secretions:

  • Increase fluid intake (if not contraindicated)
  • Repositioning regularly
  • Deep breathing and coughing
  • Chest physiotherapy
  • Postural drainage
These measures help ensure that secretions are mobilized and easier to expectorate.
If the patient needs suctioning, ensure that the steps for proper suctioning are followed:

  • Position patient in semi-Fowler’s. Time the suctioning procedure to occur prior to eating.
  • Select the appropriate size suction catheter based on the size of the tracheostomy tube used.
  • Hyperoxygenate before each pass with the catheter, although some initial suctioning should be done using bag ventilation to not drive secretions deeper toward the lungs. (Exceptions to hyperoxygenation are children and those with long-term tracheostomies.)
  • Insert the catheter to a pre-measured depth matching the length of the tube and only to the point of resistance if deeper suctioning is necessary.
  • Supply suction intermittently while rotating unless the catheter has side holes.
  • Limit suctioning to 5 seconds for pre-measured depth and 10-15 seconds for deep suctioning
  • Use suction pressure between 80 and 120 mmHg.
  • Limit suctioning to 3 passes and discontinue if heart rate drops by 20, increases by 40, produce arrhythmias, or decreases oxygen saturation to less than 90%.
  • Suction mouth after trach suctioning to remove secretions above a cuffed tube. Do not contaminate the trach by going from the mouth back to the trach.
  • Reassess the patient’s condition after suctioning and recommence oxygen therapy as soon as possible, ideally within 10 seconds of completing suctioning
Following these steps ensures that the nurse performs suctioning appropriately. The patient does not suffer from hypoxia as a complication from applying too much pressure or taking too long to suction secretions.
Ensure that the ties are properly secured and are changed at least once every 24 hours. This prevents dislodgement of the tubes and maintains the integrity of the tracheostomy. Follow the facility protocols in changing the tracheostomy ties.
Use a sterile technique to clean the reusable cannula with half-strength hydrogen peroxide, standard saline solution, or normal saline. This prevents the buildup of mucus and other sediments in the cannula and prevents infections.
Cuff pressure should be maintained in a range from 20 mmHg to 25 mmHg. Complications can arise quickly from the excessive pressure that can inhibit capillary perfusion.
Clean the stoma with a Q-tip or gauze square moistened with normal saline solution (NSS). Avoid using hydrogen peroxide unless the site is infected. Using hydrogen peroxide can impair the healing of the stoma site.

Patient Education

What can you teach a patient about tracheostomy?

The goal of tracheostomy for patients is to help improve oxygenation, ventilation, and gas exchange. While some of these are created temporarily, some patients require to have the tracheostomy on a long-term basis. Therefore, patient education is an essential aspect of care and should include both the patient and his significant others. Below are some patient education reminders to help ensure that the goal of creating a tracheostomy is met:

  • Prior to health education, allow the patient to verbalize his thoughts and feelings related to the tracheostomy as this would help facilitate better patient education.
  • Include alternative ways for communication in the teaching plan, such as using pens and paper, writing slabs and flashcards to allow the patient to convey his thoughts.
  • Demonstrate to the patient and significant others the process of cleaning the stoma, changing the ties and tube replacement, and asking them to demonstrate it back to ensure that they can do it with the correct technique.
  • Stress the importance of properly securing the appliance/tube in the stoma and not pressing on other structures to prevent impeding circulation and ulceration along with the insertion site.
  • Remind the patient to cover the hole with a cloth when outside to prevent dust, powder, and pollen from entering the site.
  • Teach proper ways of humidifying the air.
  • Remind the patient that he cannot engage in swimming or anything else that poses a risk of aspiration.
  • Include in the teaching signs of a healthy stoma and what symptoms should be reported to the physician.

Nursing Diagnosis for Tracheostomy and Care Plan Example

Scenario:

A patient is admitted post-opt on your unit after having a procedure for a tracheostomy. The patient is a little drowsy but slowly becoming more alert but is unable to communicate with you due to the inability to produce speech from the tracheostomy. The surgical site is moistened with petroleum jelly and has multiple sutures around the site. You have orders to administer saline drops every 2-4 hours to keep secretions from building up around the site and to apply petroleum jelly around the stoma every 3 hours to keep the stoma clean. In addition, the patient has a trach collar on with humidified oxygen at 30%. At the bedside, you have endotracheal suction to suction the patient as needed. The patient’s vital signs are BP 115/82, HR 85 (sinus rhythm), oxygen saturation 99%, respiratory rate 16, and temperature 99.6 ‘F. The patient’s wife is with him. The wife states she thinks her husband is getting mad at her because he can’t communicate with her.  During your assessment, while asking the patient questions he became agitated because of his inability to communicate with you and his wife. You note he throws his hands up in the air and shakes his head in frustration. As the day progresses you note that he is starting to produce more secretions around his stoma and at times starts to cough to remove the secretions but is unable to completely remove them. You have suctioned him 3 times and the mucous is thin and clear in nature.

Nursing Diagnosis:

Risk for ineffective airway clearance related to increased secretions secondary to tracheostomy as evidenced by the patient is post-opt from tracheostomy placement and is having increased secretions and difficulty removing them.

Risk for infection related to excessive pooling of secretions and bypassing of upper respiratory defenses as evidenced by the patient having a tracheostomy and increased secretions.

Impaired verbal communication related to the inability to produce speech secondary to tracheostomy as evidenced by patient unable to verbally communicate on assessment.

Subjective Data:

The wife states she thinks her husband is getting mad at her because he can’t communicate with her.

Objective Data:

The patient is a little drowsy but slowly becoming more alert but is unable to communicate with you due to the inability to produce speech from the tracheostomy. The surgical site is moistened with petroleum jelly and has multiple sutures around the site. You have orders to administer saline drops every 2-4 hours to keep secretions from building up around the site and to apply petroleum jelly around the stoma every 3 hours to keep the stoma clean. In addition, the patient has a trach collar on with humidified oxygen at 30%. At the bedside, you have endotracheal suction to suction the patient as needed. The patient’s vital signs are BP 115/82, HR 85 (sinus rhythm), oxygen saturation 99%, respiratory rate 16, and temperature 99.6 ‘F. The patient’s wife is with him. The wife states she thinks her husband is getting mad at her because he can’t communicate with her.  During your assessment, while asking the patient questions he became agitated because of his inability to communicate with you and his wife. You note he throws his hands up in the air and shakes his head in frustration. As the day progresses you note that he is starting to produce more secretions around his stoma and at times starts to cough to remove the secretions but is unable to completely remove them. You have suctioned him 3 times and the mucous is thin and clear in nature.

Nursing & Patient Outcomes/Goals:

The patient will not experience aspiration during his hospitalization.

The patient will demonstrate correctly how to properly clear the airway by discharge.

The patient will report risk factors that are associated with infection and perform proper precautions when needed.

The patient will demonstrate an improved ability to express themself by discharge.

Nursing Interventions:

The patient and all hospital staff will demonstrate meticulous hand washing techniques throughout hospitalization.

The patient and his wife will describe 2 methods of transmission of infection by discharge.

The nurse will maintain and assess for adequate humidity of inspired air every 2 hours.

The nurse will keep stoma-free from any debris or mucous buildup as needed.

The nurse will deep suction the patient as needed.

The nurse will educate the patient on how to properly cough and deep breathe throughout the hospitalization.

The nurse will provide the patient will alternative methods of communication per his preference example: flashcards, pencil and pad, eye blinks.

References

  1. Basavanthappa, B., (2015). Medical-Surgical Nursing. New Delhi: Jaypee Brothers Medical Publishers.
  2. Billings, D. and Hensel, D., 2019. Lippincott Q & A Review For NCLEX-RN. 13th ed. St. Louis, MO., USA.: Wolters Kluwer Medical.
  3. Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia: Wolters Kluwer.
  4. Morton, P., & Fontaine, D. (2018). Critical Care Nursing. Wolters Kluwer.
  5. Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2019). Essentials for Nursing Practice (9th ed.). St. Louis: Elsevier.

 

Nursing Diagnosis for Tracheostomy and Care Plan

 

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