Last updated on April 30th, 2023 at 09:25 am
Tracheostomy Nursing Care Plans Diagnosis and Interventions
Tracheostomy NCLEX Review and Nursing Care Plans
A tracheostomy is an opening that is made through the neck and into the trachea. The tracheostomy tube is inserted into the opening for breathing purposes.
Uses of a Tracheostomy
Tracheostomy is performed due to several reasons concerning the airway. The following situations may call for a tracheostomy:
- The use of a breathing machine such as a ventilator for a long period, commonly more than one or two weeks.
- A medical condition that involves the airway such as blockage or narrowing of the air passage. Examples are throat cancer or paralysis of the vocal cords.
- Conditions that exhibit difficulty in clearing mucus out of the throat or lungs, that needs direct suctioning of the trachea to remove secretions.
- Preparation for major surgery involving the head or neck.
- Reconstruction of the airway after a tracheal or laryngeal surgery.
- Swallowing problems that require airway protection from the food and mucus.
- Trauma to the head or neck results in obstruction in the airway.
- In a situation where the breathing tube cannot be placed into the throat and mouth.
Risk of a Tracheostomy
Generally, Tracheostomy is safe. However, in some cases, complications happen most of the time while the surgery is ongoing or right after the procedure is done. The risk increases when the procedure is performed in an emergency.
Early complications may include the following:
- Bleeding. At the early stage of the tracheostomy procedure, bleeding commonly occurs in the windpipe or tracheostomy itself. In minor cases, it improves within a few days. But in a situation where bleeding persists, consult the physician immediately.
- Injury to the trachea, thyroid glands, and nerves found in the neck
- Placing or moving of the tracheostomy tube out of its proper position
- Subcutaneous emphysema. This is a condition where there is stuck air in the tissue below the skin of the neck. It can cause difficulty of breathing and injury to the windpipe (Trachea) or food pipe (Esophagus).
- Pneumothorax or collapsed lung. This occurs when there is an accumulation of air between the chest wall and lungs. Symptoms of the collapsed lung include chest pain, shortness, or difficulty of breathing. In some cases, pneumothorax can be a life-threatening situation.
- Hematoma. This condition happens when a collection of blood in the neck area, and compresses the trachea, resulting in difficulty of breathing.
Long-term problems may occur when the tracheostomy tube is longer in place. These complications include:
- Blockage in the tracheostomy tube
- Dislodgement of the tube from its proper position
- Blow, injury, or narrowing of the trachea.
- Formation of an anomalous passage in between the trachea and brachiocephalic artery, a blood vessel that originates from the top of the main area. This artery supplies blood to the right side of the head and neck down to the right arm. This is a life-threatening complication that may result in severe bleeding and emergency treatment is highly required.
- Tracheobronchitis. This is a condition in which the trachea and bronchial tubes become inflamed. Primarily due to bacterial or viral infection, and some are irritants like cigarette smoke.
- Pneumonia. A patient with a tracheostomy has a higher risk of developing frequent pneumonia, especially when staying in a hospital and long-term facility.
For long-term use of tracheostomy, it is recommended to set a schedule of regular appointments for monitoring, especially for any complications. Notify the physician immediately if any of the following arises:
- Bleeding at the tracheostomy site
- Difficulty breathing
- Pain at the tracheostomy site
- Redness or swelling may indicate inflammation
- Changes in the placement of the tube
Before the Procedure
At the time that the doctor determines if the patient needs to have a tracheostomy and the patient decides to undergo the procedure, informed consent must be obtained. Also, the doctor needs to assess the neck’s range of motion. The team of doctors who will perform the procedure, including a surgeon, anesthesiologists, and others need to deliberate the entire sequence and if there’s an alternative to the operation. An organized and strict procedure in preparation and actual surgery is applied and maintained to avoid any incidence of procedural complications.
During the Procedure
During the surgery, the anesthesiologist is in charge of airway management, facilitates intravenous sedation, and performs bronchoscopy. An intubation roll, cricoid hook, and tracheostomy set are also at hand. The patient is placed in a lying position, the neck is extended unless contraindicated. Anesthesia will be provided as directed by the anesthesiologist.
A small cut is performed onto the tissue to push down the thyroid isthmus. Next, bronchoscopy is performed to identify the best side to introduce the needle. The needle is placed at the lower edge of the light reflex, directed to the tracheal lumen to avoid the posterior tracheal wall. The tracheostomy tube is placed in the tracheal lumen under direct visualization.
To confirm the placement, the bronchoscope is introduced to the tracheostomy tube and placement is confirmed by seeing the carina.
To secure the tube, 2 sutures of 2-0 nylon on both sides of the flange. To make it more secure, tracheostomy tape is added to hold the tube in place.
Tracheostomy Nursing Care
- Routine Tracheostomy Care
The tracheostomy tube, the stoma and the skin surrounding it need special care to prevent complications. Before being discharged from the hospital, the nurse will demonstrate to the patient the proper way of taking care of the tracheostomy tube. Routine tracheostomy care should be done at least once a day or as necessary. The following are the step-by-step procedures in tracheostomy care.
- Prepare all the necessary supplies
- Wash hands with soap and water before doing the procedure, dry the hands using a clean towel.
- Put on sterile gloves.
- Suction the tracheostomy tube to remove secretions and clear the airway.
- Remove the inner cannula, put it in a basin, and pour hydrogen peroxide over it.
- Clean the inner cannula using a pipe cleaner or a small brush.
- Rinse the inner cannula thoroughly with normal saline solution
- Dry the cannula, both inner and outer surface using a clean gauze pad.
- Reinsert the inner cannula into the tracheostomy tube and secure it is locked in it.
- Remove the soiled gauze dressing around the stoma. Check the skin for any sign of inflammation. Inform the doctor if any of this is present.
- Clean the outer part of the cannula and the skin around the stoma using a cotton-tipped swab, soaked in a solution of half hydrogen peroxide and half water.
- Get a washcloth and wet with normal saline solution, wipe away the remaining hydrogen peroxide on the skin.
- Dry the exposed cannula and the skin around the stoma using a clean towel.
- Change the ties and secure them properly.
- Put a fine mesh gauze below the tracheostomy tie and neck plate by folding it in.
- Remove the gloves and throw them in the proper trash bin
- Wash the hands with soap and water. Wash the basins and small brush with water and soap. Dry them before keeping them away.
2. Suctioning a Tracheostomy Tube
Tracheal suctioning is done to remove mucus stuck in the tracheostomy tube to prevent blockage in the tracheostomy tube. It also removes secretion in the airway, to maintain clear and patent air passage. If done properly and cautiously, suctioning is a life-saving procedure by decreasing the risk of infection, build-up of secretions, and decreasing the level of oxygen. Indications of tracheal suctioning include the presence of secretions that can be visually or audible by hearing noisy respiration, signs of airway obstruction such as expanded breath sounds during expiration, an increase in respiratory effort, below-normal oxygen saturation, restlessness, and chronic cough.
Below is the step-by-step procedure when suctioning a tracheostomy tube:
- Prepare the supplies needed. The size of the suction catheter will depend on the inner diameter of the tracheostomy tube.
- Wash hands with soap and water. Put gloves on. As much as possible, wear an apron, goggles, and mask as protective equipment in cases of infection.
- Turn on the suction machine and connect the suction connecting tube.
- Connect the suction catheter to the suction connecting tube.
- Position the patient to flat on the back with a pillow under the shoulders. Some patients are more comfortable in a sitting position, it may also be done.
- Dip the catheter with the solution or tap water for lubrication and to check the suction machine and its circuit.
- Carefully remove the inner cannula of the tracheostomy tube and insert the suction catheter into the tracheostomy tube by following the natural curvature of the tube.
- Put the thumb over the suction vent intermittently while removing the catheter. Do not stay the catheter inside the tube for more than 10 seconds.
- Suction an amount of solution for irrigation or clean tap water to remove residuals from the tube.
- Clean the inner cannula before returning it to the tracheostomy tube.
- Turn off the suction machine, discard the catheter accordingly.
3. Emergency Care of a Tracheostomy Tube
- To provide safety to patients with tracheostomy, staff in charge of them must require themselves to be familiar with the procedures and equipment needed in an airway emergency. Each patient should keep an emergency tracheostomy bag which they carry during transfers and discharge. These contain pieces of equipment in inserting a new tube in the situation that the tube is dislodged or blocked.
- In cases of respiratory distress, urgent assessment of ABCs and calls for emergency help are needed. If indicated, perform CPR. High flow oxygen can be administered to the nose or mouth, and the stoma.
Nursing Diagnosis for Tracheostomy
Tracheostomy Nursing Care Plan 1
Ineffective Airway Clearance related to thick and copious respiratory secretions secondary to tracheostomy as evidenced by the patient being postoperative from tracheostomy placement, ineffective cough, shortness of breath, and presence of crackles and rhonchi on auscultation.
Desired Outcome: The patient will demonstrate clear airways and normal breath sounds by discharge.
|Tracheostomy Nursing Interventions||Rationale|
|Evaluate transition in vital signs.||An increase in heart rate and blood pressure may be connected to increase respiration. In situations of hypoxia and hypercapnia get severe, blood pressure and heart rate drop. Fever is an indication of infection|
|Note for any changes in respiration. Monitor the quality, rate, rhythm, expanded use of accessory muscles, and nasal flaring.||Changes may demonstrate compromised respiration. For example, increase respiratory rate and rhythm may indicate a compensatory mechanism in response to obstruction in the airway|
|The patient, relatives, and hospital staff will maintain frequent, proper handwashing||Patients with tracheostomy are at risk of developing an infection. Hand washing is one of the precautions to prevent transmission of infection.|
|Maintain and check for the humidity of air every 2 hours.||A decrease in air humidity will result in the thickening of secretions. Maintaining humidity in the air will prevent the thickening and drying of mucus.|
|Maintain the stoma free from mucus build-up and debris formation.||Keeping the stoma clean at all times may prevent the occurrence of blockage and infection.|
|Discuss the proper way of coughing secretions and deep breathing exercises.||The most effective way to expel mucus is through coughing. It can be done by the patient independently|
|Perform suction as needed.||Suctioning through tracheostomy will prevent build-up and blockage of mucus. Deep suctioning is sometimes required to maintain a clear airway, depending on the patient’s condition. The frequency of suction depends on the clinical status of the patient and not a routine-based procedure. Too much suctioning may result in injury to the bronchus and lung tissue.|
Tracheostomy Nursing Care Plan 2
Risk for Impaired Gas Exchange
Diagnosis: Risk for Impaired Gas Exchange related to thickened tracheal secretions secondary to tracheostomy.
Desired Outcomes: The patient will sustain a sufficient gas exchange, arterial blood gas result is within the normal range and will show no signs of desaturation, oxygen saturation is maintained at 90% and greater, relaxed breathing, and alert level of consciousness.
|Tracheostomy Nursing Interventions||Rationale|
|Evaluate respiration, rhythm, depth, effort, and quality.||Changes in respiratory rate and rhythm may indicate early respiratory distress. Fast, shallow breathing patterns may affect gas exchange. Increased breathing effort may be associated with hypoxia.|
|Auscultate breath sounds. Note any areas with decreased ventilation or extraneous sounds.||Impaired gas exchange can be manifested with changes in breath sounds.|
|Monitor any changes in heart rate and temperature.||An increase in heart rate is related to decreased oxygen levels in the blood. Developing fever can be a sign of atelectasis or secretion buildup in the lungs.|
|Evaluate the level of consciousness.||The presence of confusion, irritability, and restlessness can be an early indication of insufficient oxygen supply to the brain and requires an immediate response.|
|Check arterial blood gasses and monitor oxygen saturation.||Oxygen saturation can be monitored with the use of a pulse oximeter. It is a must to keep this at home. The normal oxygen saturation level should be at 90% or greater. Hypoxemia and respiratory acidosis are manifested by an increase in PaCo2 and a decrease in PaCo2.|
|Evaluate the effectiveness of the tracheostomy cuff and monitor for signs of cuff leak. Working with a respiratory therapist is recommended in determining cuff pressure||The recommended levels of cuff pressure are 20 to 25 mm Hg at maximum or lessen if the trachea can be sealed. The nurse can check if there’s a cuff leak is if there’s an air escaping upward past the vocal cords, instead of going to lower airways.|
Tracheostomy Nursing Care Plan 3
Risk for Infection
Diagnosis: Risk for Infection related to surgical incision of tracheostomy secondary to tracheostomy.
Desired Outcomes: The patient will be negative from any infection, as shown by normal body temperature, normal sputum culture, normal results in white blood cell count, clear breath sounds, and clean stoma without any presence of drainage.
|Tracheostomy Nursing Interventions||Rationale|
|Check the client’s temperature.||Fever can be a sign of an infection or the presence of inflammation|
|Check the skin’s integrity below tracheal ties.||Under the tracheal ties is a common site for infection and skin breakdown.|
|Monitor the stoma for redness, exudates, lesions. If any of these is present, inform the physician.||Mucus build-up and scratching of the tracheostomy tube may irritate the skin and can serve as a site for infection. Culture and sensitivity are advisable for antibiotic selection|
|Obtain white blood cell count.||Increased level of WBC can be a sign of the presence of infection, indicated by the body’s response to combat the pathogen.|
|Maintain the tracheostomy cuff inflated at the lowest pressure possible. To sustain adequate seal for ventilation.||To protect the airway and as required for mechanical ventilation, an inflated cuff is required. To prevent tracheal erosion, the cuff should be at the lowest pressure. It should be checked regularly, as patients are not able to vocalize while the cuff is properly inflated.|
|Keep the stoma clear from secretions. Wipe using an aseptic technique or suction the area if mucus accumulates in the area. Maintain the tracheostomy ties around the neck clean and dry.||A clean stoma helps in preventing skin irritation that may lead to infection. The back of the neck should be checked regularly, as secretions usually flow back.|
|Perform stoma care regularly.||For postoperative patients, regular stoma care is required to prevent complications. In long-term patients, stoma care is provided as needed|
Tracheostomy Nursing Care Plan 4
Risk for Aspiration
Diagnosis: Risk for Aspiration related to the presence of tracheostomy tube
Desired Outcomes: The patient will not have an instance of aspiration and can eat and drink without coughing, choking, or presence of skin discoloration.
|Tracheostomy Nursing Interventions||Rationale|
|Assess the patient’s capacity to swallow and the type of food they can tolerate.||To check if there’s any risk for choking or aspiration.|
|Evaluate airway patency.||Having an open and clear air passage is important to maintain airway clearance and prevent the risk for aspiration.|
|Give liquid first in small amounts and gradually increase the volume as tolerated.||Provides consistency in fluid and nutrients intake, that is well tolerated to avoid aspiration.|
|During feedings, place the patient in an upright or sitting position, and advise the patient to maintain in that position for 30 minutes after eating||Through gravitational force, it allows the flow of foods and fluids|
|If choking happens, suction fluids or foods from the mouth and air passage. After feeding, limit suctioning only when necessary.||Suctioning of food will prevent aspiration. On the other hand, suctioning after meals may cause vomiting.|
|Discuss which type of food and liquids are allowed to eat.||It promotes food that is not only tolerable and easier to swallow, but also nutritious.|
|Teach companions or relatives how to suction the airway if choking happens.||In an emergency, they can provide helpful measures to prevent further complications.|
|Check for any food particles in tracheal secretions||Presence of food in the tracheobronchial passages indicates aspirated material|
|Observe the effectiveness of the cuff in patients with tracheostomy tubes.||There is an increased risk of aspiration for the ineffective cuff. To verify cuff pressure, Collaborate with a respiratory therapist.|
|10 Evaluate the patient and family members’ willingness and capacity to learn and adjust with swallowing, feeding, and other related disorders.||Adjustment with the proper procedure results in successful coping.|
Tracheostomy Nursing Care Plan 5
Risk for Injury
Diagnosis: Risk for Injury related to tracheostomy care
Desired Outcomes: The patient will demonstrate the absence of restlessness, difficulty breathing and the tracheostomy tube will remain patent and in place.
|Tracheostomy Nursing Interventions||Rationale|
|Evaluate for proper tube placement, patency, and if there’s any presence of leakage of air within the tube.||This provides guarantee of the efficiency of the tube function, to give an airway for oxygenation.|
|Check the secureness of tapes and knots. The tightness of tapes by putting a small finger in between the tape and neck||This gives safety in using ties to secure tubes, that should not be unraveled and must fit firmly without impeding the circulation|
|Monitor for any changes in breath sounds and respiration, depth, and rhythm.||This identifies the need of removing secretions to prevent blockage and difficulty in respiration.|
|Evaluate sutures by noting security tapes on both sides of the neck, any movement or dislodgement.||This assures the safety of the tracheostomy tube placement and prevents dislodgement.|
|Hold carefully the tube when changing the dressing. Apply ointment under the wings of the tube, replacing tapes, or during suctioning||This prevents movement of the tube that results in irritation and dislodgement of the tube.|
|Gently suction, intermittently, using appropriate size and technique.||This clears the air passage and removes a pool of mucus without affecting the trachea. Suctioning over time stimulates the vagus nerve, bradycardia, and blood pressure that may damage the mucosa of the trachea.|
|Advise the patient to monitor any signs of swelling or bleeding around the tube. If there’s labored breathing, changes in skin color, absence of air in and out of the tube, inability to insert the suction tube, choking during feeding. If any of these occur, notify the physician immediately.||This prevents further complications that may lead to severe airway damage.|
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