[solved]-Tracheostomy Nursing Care Plans
Tracheostomy is a surgical procedure in which an opening is done into the trachea to prevent or relieve airway obstruction and/or to serve as access for suctioning and for mechanical ventilation and other modes of oxygen delivery (tracheostomy collar, T-piece).
A tracheostomy can facilitate weaning from mechanical ventilation by reducing dead space and lowering airway resistance. It also improves client comfort by removing the endotracheal (ET) tube from the mouth or nose.
The tracheostomy is preferred over an ET when an artificial airway is needed for more than a few days. Methods can be instituted for the client to eat and speak, as well.
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Nursing care plan goals and objectives for a client who had undergone tracheostomy include maintaining a patent airway through proper suctioning of secretions, providing an alternative means of communication, providing information on tracheostomy care, and preventing the occurrence of infection.
Nursing Care Plans
Here are seven (7) nursing care plans (NCP) and nursing diagnosis for tracheostomy:
Nursing Care Plans
Ineffective Airway Clearance
Impaired Verbal Communication
Deficient Knowledge
Risk for Impaired Gas Exchange
Risk for Infection
Anxiety
Deficient Knowledge
Risk for Aspiration
Risk for Injury
Ineffective Airway Clearance
Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
May be related to
Copious secretions
Decreased energy and fatigue
Presence of artificial airway: tracheostomy
Thick secretions
Possibly evidenced by
Abnormal breath sounds (crackles, rhonchi)
Dyspnea
Ineffective cough
Increased breathing effort: nasal flaring, intercostal retractions, use of accessory muscles
Shortness of breath
Tachypnea and/or changes in breathing pattern
Desired Outcomes
Client will maintain a clear, open airway as evidenced by normal breath sounds, normal rate, and depth of respiration, and the ability to effectively cough up secretions.
Nursing Interventions Rationale
Assess changes in BP, HR, and temperature. Tachycardia and hypertension may be related to an increased work of breathing. As the hypoxia and/or hypercapnia become severe, BP and HR drop. Fever may develop in response to retained secretions.
Assess respirations: note the quality, rate, rhythm, nasal flaring, and any increased use of accessory muscles of respiration. These abnormalities indicate a respiratory compromise. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction. The breathing pattern may alter to include the use of accessory muscles to increase chest excursion.
Auscultate the lungs, noting areas of decreased ventilation and for the presence of adventitious breath sounds. Decreased or absent breath sounds may indicate the presence of a mucus plug or other airway obstruction; wheezing may indicate partial airway obstruction or narrowing coarse crackles and/or rhonchi may indicate the presence of secretions along larger airways.
Assist the effectiveness of cough. Observe the color, consistency, and quantity of secretions. Abnormalities may be a result of infection, bronchitis, long term smoking, or other conditions. A sign of infection is discolored sputum. Thick, tenacious secretions increase hypoxemia and may be indicative of dehydration.
Encourage the client to cough out secretions. If the cough is ineffective, Institute suctioning of the airway as needed. Coughing is the most helpful way to remove most secretions. The client may be able to perform independently. Suctioning removes secretions if the client is unable to effectively clear the airway. Frequent suctioning should be based on the client’s clinical status, not on a present routine, such as every hour. Over suctioning can cause hypoxia and injury to bronchial and lung tissue.
Provide warm, humidified air. A tracheostomy bypasses the nose, which is the body area that humidifies and warms inspired air. A decrease in the humidity of the inspired air will cause secretions to thicken. Also, cool air may decrease the ciliary function. Providing humidification of inspired air will prevent the drying and crusting of secretions.
Transport the client with portable oxygen, Ambu bag, suction equipment, and extra tracheostomy tube. Being prepared for an emergency helps prevent future complications.
Impaired Verbal Communication
Impaired Verbal Communication: Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols.
May be related to
Presence of artificial airway: tracheostomy
Possibly evidenced by
Difficulty speaking
Difficulty in maintaining the usual communication pattern
Frustration
Desired Outcomes
Client will use a form of communication to get needs met and to relate effectively with persons and environments.
Nursing Interventions Rationale
Assess the client’s communication ability. Standard tracheostomy tubes allow the vocal cords to move, but no airflow passes over them if the cuff is inflated; therefore vocalization is not possible.
Assess the effectiveness of nonverbal communication methods. The client may use hand signals, facial expressions, and changes in body posture to communicate with others. However, others may have difficulty in interpreting these nonverbal techniques. Each new method needs to be assessed for effectiveness and altered as necessary.
Assess for frustration and anxiety related to not being able to communicate needs. The inability to communicate enhances a client’s sense of isolation and may promote a sense of helplessness.
Provide emotional support to the client and significant others. Difficulties communicating are a source of frustration for all involved.
Place the client in a room close to the nurse‘s station. This ensures easy observation of the client by the nursing staff.
Provide a call light within easy reach at all times. Answer the light promptly. A prompt response decreases anxiety and feelings of helplessness.
If the client is able to nod or speak “yes” or “no” answers, try to phrase questions so that the client can use these responses. Clients can become easily frustrated when they cannot communicate in a simple manner.
Provide alternative methods for communicating:
Hand gestures
Word-and-phrase cards
Picture board for clients who are unable to write
Writing pad
Providing a variety of communication aids allows the client more channels through which information can be communicated.
Allow the client time to communicate his or her needs. The nurse should set aside enough time to attend to all of the details of client care. Care measures may take a longer time to complete in the presence of a communication deficit.
Collaborate with the physician and speech therapist on the possible use of a “talking” tracheostomy tube as indicated. The “talking” tracheostomy tube provides a port for compressed gas to flow in above the tracheostomy tube, allowing air of phonation.
If the client no longer requires mechanical ventilation, consider the use of a Passy-Muir valve or fenestrated tracheostomy tube. These adaptive devices can facilitate talking.
Deficient Knowledge
Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
May be related to
New procedure or intervention in hospital
Possibly evidenced by
Anxiety
Expressed need for more information
Increased questioning
Lack of questioning
Desired Outcomes
Client or caregiver will demonstrate the knowledge and skills appropriate for tracheostomy care.
Nursing Interventions Rationale
Assess the client’s knowledge regarding the purpose and care of a tracheostomy. This information provides an important starting point in education.
Assess the ability to manage care at home. Both cognitive and technical skills are required for managing tracheostomy tubes.
Assess the ability to respond to emergency situations. This information is especially important because the lack of airway patency is a life-threatening problem.
Discuss the client’s need of a tracheostomy and its particular purpose. Educational programs need to be individualized to the client’s specific situation and needs.
Provide instruction in sterile tracheostomy care and suctioning. This information enables the client to take control of his or her life. Long-term care may be the client’s responsibility. Clearly, focused teaching allows the learner to concentrate more completely on the material being discussed. The client or caregiver can begin to acquire skills at a pace that is not overwhelming.
Instruct in the need to call health care provider if the amount of secretions increases or a change in color or characteristic occurs. Changes could signify the presence of an infection.
Reinforce the client’s knowledge of the following emergency technique:
Tracheostomy reinsertion
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.
Discuss the weaning process, as appropriate, with the use of fenestrated tracheostomy tubes, tracheostomy buttons, or progressively smaller tubes. Preparation and explanation help reduce anxiety.
Provide information on the reinsertion of a tracheostomy tube. The first tube change is done by the physician. Thereafter the client or caregiver should be taught step-by-step reinsertion instructions and should complete a return demonstration.
Collaborate with the case manager or social worker as appropriate to attain equipment and arrange for home care nurses. Continuity of care is facilitated through the use of appropriate resources.
Explain the process of decannulation, as appropriate. When the client’s tracheostomy remains capped with the client effectively maintaining his or her own respirations and airway clearance, the tracheostomy tube can be removed. With removal, the stoma site is covered with a folded 4 x 4 bandage and tape. The opening will close in a few days. Until the site is healed, the client should be instructed to cover the site with two fingers while attempting to cough or talk to prevent outward air flow through the stoma site.
Explain home care as follows:
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.
Covering the stoma prevents the inhalation of foreign materials.
Swimming is contraindicated.
Aspiration is possible if water gets into the stoma.
Risk for Impaired Gas Exchange
Risk for Impaired Gas Exchange: At risk for excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
May be related to
Aspiration
Copious tracheal secretions
Inability to cough and deep breathe
Infection
Pneumothorax
Preexisting medical conditions
Restricted lung expansion from immobility
Tracheostomy leak
Possibly evidenced by
[not applicable]
Desired Outcomes
Client will maintain optimal gas exchange as evidenced by arterial blood gasses (ABGs) within the client’s normal range, oxygen saturation of 90% or greater, alert response mentation or no further reduction in the level of consciousness, and relaxed breathing.
Nursing Interventions Rationale
Assess the respiratory rate, rhythm, quality, depth, and effort. Clients will alter breathing patterns over time to facilitate gas exchange. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties. Rapid, shallow breathing patterns affect gas exchange. Hypoxia is associated with an increased breathing effort.
Auscultate lung sounds, noting any areas of decreased ventilation or the presence of adventitious sounds. Changes in lung sounds may reveal the cause of impaired gas exchange.
Assess for changes in the client’s HR and temperature. Tachycardia is associated with increased work of breathing or hypoxia. Fever may develop in response to retained secretions or atelectasis.
Assess for changes in the level of consciousness. Increased restlessness, confusion, and/or irritability are early indicators of insufficient oxygenation of the brain and require further interventions.
Monitor arterial blood gasses and oxygen saturation. Pulse oximetry is a useful tool to detect early changes in oxygen saturation. Oxygen saturation should be kept at 90% or greater. Increasing PaCo2 and decreasing PaO2 are signs of hypoxemia and respiratory acidosis.
Monitor the effectiveness of the tracheostomy cuff, and assess for signs of cuff leak (the client is able to vocalize while the cuff is supposed to be inflated, the low-pressure ventilator alarm is sounding, loud upper airway noises are audible, the feeling of air coming from around the nose or mouth). Collaborate with the respiratory therapist, as needed, to determine cuff pressure. Maximum recommended levels for cuff pressure range from 20 to 25 mm Hg (27 to 33 cm H2O), or less if the trachea can be sealed with less. Signs of cuff leak are caused by air escaping upward past the vocal cords instead of being directed to the lower airways.
If a leak is present:
Try to reinflate the cuff, checking the pilot tube and valve for leaks.
If unsuccessful, notify the physician.
An intact cuff is required to ensure the direction of air into the bronchial airways. If the client is being mechanically ventilated and is losing a large portion of the tidal volume because of a cuff leak, the tracheostomy tube will need to be replaced.
Place the client in a semi-Fowler’s to high Fowler’s position. This position promotes full lung expansion and improved air exchange.
If lung sounds are abnormal, use tracheal suction as needed. Suctioning is indicated when clients are unable to remove secretions from the airway by coughing because of weakness, thick mucus plugs, or excessive or tenacious mucus.
Administer humidified oxygen as needed. The appropriate amount of oxygen must be delivered continuously so that the client maintains an oxygen saturation of 90% or greater. Humidification of oxygen prevents the drying of mucosal membranes.
Maintain an adequate airway. If an obstruction is suspected, troubleshoot as appropriate:
Move the head and neck.
Moving the head and neck corrects 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.
This is an attempt to aspirate a mucus plug and to assess for airway patency.
Remove the inner cannula, and replace 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.
A new tube can restore airway patency.
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