Trach Care Nursing Diagnosis: A Comprehensive Guide for Nurses

A tracheostomy, often referred to as a “trach,” is a surgical procedure that creates an opening in the trachea through the front of the neck to establish an airway. A tracheostomy tube is then inserted into this opening, which may be connected to a ventilator or other oxygen delivery systems to assist breathing. This intervention becomes necessary when the normal breathing passage is compromised, restricted, or when a patient requires prolonged mechanical ventilation. In emergency situations, a tracheotomy may be performed to address acute airway obstruction resulting from various causes like aspiration, foreign objects, trauma, or anaphylaxis.

Tracheostomies can be either temporary or permanent, depending on the patient’s underlying condition and recovery progress. While some tracheostomies are surgically closed or allowed to heal naturally when no longer needed, others may be lifelong. Early tracheostomy, typically performed within 5 to 7 days following intubation, is recommended for patients with severe closed-head injuries or those requiring extended ventilator support. This proactive approach aims to minimize complications associated with prolonged intubation, notably subglottic stenosis, which is the narrowing of the airway between the vocal cords and trachea. Similarly, for non-trauma patients who face challenges in ventilator weaning, tracheostomy is often considered within the same 5-7 day post-intubation timeframe.

The procedure is most frequently conducted in an operating room setting, where patients are under general anesthesia. However, if general anesthesia poses risks to the airway or if the procedure is performed outside of the operating room, a local anesthetic can be used to numb the neck and throat area.

Surgical vs. Percutaneous Tracheostomy: Understanding the Difference

Tracheostomies can be broadly categorized into two main types, each with distinct characteristics and application settings:

• Surgical (Open) Tracheostomy:

  • Typically performed in an operating room to ensure a sterile and controlled environment.
  • Involves surgical dissection to create a precise opening in the trachea.
  • Allows for direct visualization of the trachea during the procedure, enhancing accuracy and safety.
  • A tracheostomy tube is carefully inserted into the tracheal opening to facilitate ventilation.

• Percutaneous Tracheostomy:

  • Also known as minimally invasive tracheotomy or bedside tracheostomy, highlighting its less invasive nature and point-of-care application.
  • Often performed in a hospital room, eliminating the need for operating room transfer, which can be critical for unstable patients.
  • Employs a small incision, and specialized instruments are used to dilate and create an opening for tracheostomy tube insertion.
  • Typically performed without direct visualization of the trachea, relying on anatomical landmarks and procedural techniques.

The choice between surgical and percutaneous tracheostomy depends on several factors, including the patient’s clinical condition, urgency of the need for tracheostomy, available resources, and the expertise of the medical team. Percutaneous tracheostomy is often favored for its efficiency and reduced invasiveness, particularly in critical care settings.

Regardless of the method, both surgical and percutaneous tracheostomies involve creating an incision to allow for the insertion of a tracheostomy tube. Following insertion, the tube’s faceplate is securely fastened to the neck using tape, ties, or temporary sutures to prevent accidental displacement from the tracheal opening, ensuring the airway remains patent and functional.

The Nursing Process in Tracheostomy Care

Tracheostomy is recognized as a safe and effective procedure for maintaining a clear airway. However, achieving complication-free outcomes and ensuring patient well-being hinges significantly on meticulous post-operative and ongoing hygiene care. Nurses play a pivotal role in this aspect of care.

A tracheostomy significantly impacts a patient’s ability to communicate and eat. Initially, speaking and eating may be difficult or impossible. However, with time and appropriate rehabilitation, patients can be taught effective strategies to speak and eat with a tracheostomy in place. During the initial phase, and particularly if the patient is ventilator-dependent, nutritional needs and hydration are typically met through enteral or peripheral routes to prevent aspiration and malnutrition.

The nursing process for patients with a tracheostomy is comprehensive, encompassing assessment, diagnosis, planning, implementation, and evaluation. Each phase is crucial for delivering holistic and patient-centered care.

Nursing Assessment: Gathering Crucial Data for Trach Care

The initial step in providing nursing care for a patient with a tracheostomy is a thorough nursing assessment. This involves systematically collecting physical, psychosocial, emotional, and diagnostic data to form a complete picture of the patient’s needs and condition. This section focuses on both subjective and objective data pertinent to tracheostomy care.

Review of Health History: Uncovering the Need for Tracheostomy

1. Determine the Indications for Tracheostomy. Understanding why a tracheostomy was performed is fundamental to providing appropriate care. Common indications include:

• Airway obstruction: Conditions blocking the upper airway, preventing normal breathing.
• Trauma to the face or neck: Injuries that compromise or obstruct the airway.
• Prolonged ventilator dependence: Patients requiring long-term mechanical ventilation.
• Prophylaxis prior to head or neck cancer treatment: To secure the airway before treatments that may cause swelling or obstruction.
• Obstructive sleep apnea (OSA) with failed treatment: As a last resort for severe OSA unresponsive to other therapies.
• Neuromuscular diseases (ALS, stroke, MS, etc.): Conditions that weaken respiratory muscles and impair breathing.
• Management of secretions: Inability to effectively cough and clear airway secretions.

2. Review the Patient’s Medical History. Certain pre-existing conditions can predispose patients to needing a tracheostomy. These include:

• Facial and upper airway congenital anomalies: Birth defects affecting airway structure.
• Mechanical obstructions (foreign objects): Objects lodged in the airway.
• Upper airway defects or conditions:
  • Infection: Infections causing airway swelling and obstruction.
  • Edema: Swelling in the airway tissues.
  • Paralysis: Vocal cord or airway paralysis.
• Dysphagia: Difficulty swallowing, increasing aspiration risk.
• Sleep apnea: Especially severe or complex cases.

3. Determine the Patient’s Need for Long-Term Mechanical Ventilation. Tracheostomy provides a long-term airway solution for patients experiencing respiratory failure and requiring prolonged ventilator support. It is particularly beneficial for patients with ineffective coughing abilities and a high risk of aspiration.

4. Assess the Patient’s and Family’s Knowledge about Tracheostomy. It is crucial to gauge the patient’s and family’s understanding and perceptions of tracheostomy. Address any knowledge gaps or misconceptions, and discuss whether the tracheostomy is intended to be temporary or permanent. Ensure the family fully comprehends the level of care and commitment involved in maintaining a tracheostomy, especially for long-term management at home.

Physical Assessment: Identifying Tracheostomy-Related Issues

1. Assess the ABCs (Airway, Breathing, Circulation). Prioritize assessment of airway patency, breathing effectiveness, and circulatory status. Inspect the upper airway, including the nose, mouth, and throat, both before and after tracheostomy placement to establish a baseline and detect any changes or complications.

2. Monitor Vital Signs. Closely monitor vital signs—heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation—before, during, and after the tracheostomy procedure. Oxygen desaturation and bleeding are potential immediate complications. Continuously monitor oxygen saturation using pulse oximetry and promptly report any significant deviations from baseline.

3. Assess Respiratory Status. Evaluate the patient’s respiratory effort, rate, rhythm, and depth. Respiratory complications are a significant concern during and after tracheostomy. Be vigilant for signs of respiratory distress, such as:

• Tachypnea (rapid breathing): Increased respiratory rate.
• Retractions: Pulling in of chest muscles during breathing.
• Adventitious breath sounds: Abnormal sounds like wheezing, crackles, or rhonchi.
• Desaturation: Decreased oxygen saturation levels.
• Cyanosis: Bluish discoloration of skin and mucous membranes, indicating severe hypoxemia.

4. Observe for Tracheostomy-Related Complications. Tracheostomy, while beneficial, carries potential risks. Monitor closely for:

• Bleeding: From the stoma site or within the trachea.
• Infection: At the stoma site or in the trachea or lungs.
• Edema: Swelling around the stoma site.
• Obstruction: Blockage of the tracheostomy tube by secretions or displacement.
• Fistula: Abnormal passage between trachea and esophagus or skin.
• Pneumothorax: Air leakage into the pleural space.
• Decannulation: Accidental dislodgement of the tracheostomy tube.
• Necrosis: Tissue death around the stoma due to pressure or infection.

5. Assess Speaking and Swallowing Abilities. A tracheostomy tube can impact both speech and swallowing. Initially, patients may be unable to speak because airflow is diverted away from the vocal cords. Swallowing can also be affected, increasing aspiration risk. A speech-language pathologist can assist patients in regaining speech using speaking valves and in safely resuming oral intake. Nurses should assess swallowing ability before offering food or liquids.

6. Assess for Signs of Infection. Infection is a potential complication. Monitor the stoma site and surrounding area for:

• Redness (erythema)
• Swelling (edema)
• Warmth
• Granulation tissue (excessive tissue growth)
• Exudates (drainage)
• Pain or tenderness
• Foul odor
• Changes in secretions (color, consistency, amount)

Diagnostic Procedures: Confirming Placement and Assessing Status

1. Obtain Arterial Blood Gas (ABG). An ABG analysis post-tracheostomy is essential to evaluate the patient’s ventilation and acid-base balance. ABGs are typically ordered for patients on ventilators or if respiratory distress is suspected. They provide critical information about oxygenation, carbon dioxide removal, and pH levels.

2. Confirm Tracheostomy Placement. In certain situations, a chest X-ray may be performed to verify the correct placement of the tracheostomy tube within the trachea and to rule out complications such as pneumothorax.

Nursing Interventions: Implementing Trach Care Strategies

Nursing interventions are critical for the patient’s recovery and well-being following tracheostomy. These interventions are aimed at preventing complications, maintaining airway patency, promoting comfort, and facilitating communication.

Preparing for Tracheostomy: Ensuring a Smooth Procedure

1. Ensure Completeness of Informed Consent. As with any invasive procedure, obtaining informed consent is paramount. Ensure that the patient (if able) and family have a thorough discussion with the healthcare provider regarding the benefits, risks, and alternatives to tracheostomy. Encourage questions and address any concerns before obtaining written informed consent.

2. Prepare Equipment. For percutaneous tracheostomy, which is often performed at the bedside, the nurse is responsible for gathering the necessary equipment, including a tracheostomy kit and suction apparatus. Ensure all equipment is functioning correctly and readily available.

Preventing Tracheostomy Complications: Proactive Care Measures

1. Prevent Infections. Infection control is a top priority in tracheostomy care. While infections are not common with proper care, meticulous technique is essential. Appropriate wound care and adherence to sterile or clean techniques during trach care are key preventive measures.

2. Ensure Cuff Inflation (If Applicable). Cuffed tracheostomy tubes are used for patients requiring mechanical ventilation. The cuff creates a seal within the trachea, preventing air leakage and aspiration. Cuff pressure should be maintained between 20 to 25 mmHg to ensure an adequate seal without causing pressure necrosis. Regularly monitor cuff pressure using a manometer.

3. Pre-hyperoxygenate the Patient. Before procedures such as suctioning or tracheostomy tube insertion or changes, pre-hyperoxygenate the patient with 100% oxygen. This helps to prevent hypoxia by increasing the patient’s oxygen reserve. Hyperinflation can also reduce the risk of suction-induced atelectasis (lung collapse).

4. Maintain Sterility During Insertion and Care. Strict sterile technique during tracheostomy insertion and subsequent care procedures is crucial to minimize the risk of infection and stoma site skin breakdown. This includes using sterile gloves, dressings, and suction catheters.

5. Encourage Breathing and Coughing Exercises. Post-tracheostomy, encourage patients to perform deep breathing and coughing exercises, if clinically appropriate and able. These exercises help to clear secretions from the airway and promote lung expansion, reducing the risk of pneumonia and atelectasis.

6. Prevent Aspiration. Aspiration is a significant risk for patients with tracheostomies, especially those with swallowing difficulties or reduced consciousness. Strategies to minimize aspiration risk include:

• Elevating the head of the bed: Maintain the head of the bed elevated at least 30 degrees, especially during and after feeding.
• NPO status initially: Restrict oral intake until swallowing ability is assessed and deemed safe by a healthcare provider or speech pathologist.
• Cuff deflation considerations: Ensure the tracheostomy cuff is deflated (if appropriate and ordered by a physician and tolerated by the patient) before oral intake to improve swallowing and reduce aspiration risk. Cuff deflation should only be performed by trained personnel and when the patient can protect their airway.

Performing Post-Tracheostomy Care: Daily Maintenance and Monitoring

1. Secure Emergency Equipment at the Bedside. Always keep emergency equipment readily available at the patient’s bedside. This should include:

• Spare tracheostomy tubes: One of the same size and one size smaller than the patient’s current tube in case of accidental decannulation.
• Obturator: Used for re-inserting a tracheostomy tube.
• Tracheostomy insertion tray: Containing necessary instruments for tube re-insertion.
• Suction equipment: Functional and ready for immediate use.
• Manual resuscitation (Ambu) bag: For providing manual breaths if needed.

2. Provide Humidification. Humidified oxygen is essential for patients with tracheostomies because the upper airway’s natural humidification and filtering functions are bypassed. Humidification prevents the drying of tracheal mucosa and thinning of secretions, making them easier to clear. Various humidification methods can be used, including heated humidifiers and cool mist nebulizers, as prescribed. Mucolytics may also be prescribed to further thin thick secretions.

3. Provide Trach Care as Ordered. Routine tracheostomy care is a fundamental nursing responsibility. Frequency of care may vary based on institutional policy and patient needs, but typically includes:

• Stoma site care: Cleaning the skin around the stoma with sterile saline or prescribed solution to remove secretions and prevent skin breakdown.
• Dressing changes: Changing tracheostomy dressings regularly to maintain dryness and prevent infection.
• Cleaning dried mucus: Gently removing dried mucus from around the stoma and tracheostomy tube using sterile Q-tips or gauze moistened with sterile saline.
• Inner cannula care: Cleaning or replacing the inner cannula (if disposable or reusable) to prevent obstruction and maintain airway patency. Disposable inner cannulas are discarded and replaced, while reusable ones are cleaned, rinsed, and reinserted.
• Changing tracheostomy ties or Velcro collar: Securing the tracheostomy tube in place. Change ties when soiled or at least daily, ensuring two fingers can fit comfortably under the ties to prevent them from being too tight. Have assistance when changing ties to prevent accidental decannulation.

4. Suction as Needed. Suctioning is performed to remove secretions from the tracheostomy tube and airway when the patient is unable to cough effectively or if there are excessive secretions. Key points for suctioning include:

• Hyperoxygenate before suctioning: Administer 100% oxygen prior to suctioning.
• Sterile technique: Use a sterile suction catheter for each suctioning episode.
• Insert catheter without suction: Gently insert the suction catheter into the tracheostomy tube without applying suction.
• Intermittent suction and rotation: Apply intermittent suction while slowly withdrawing and rotating the catheter in a circular motion.
• Limit suction duration: Each suction pass should not exceed 10 seconds to prevent hypoxia and mucosal damage.
• Monitor patient response: Assess the patient’s respiratory status, oxygen saturation, and heart rate during and after suctioning.

5. Collaborate with a Respiratory Therapist (RT). Respiratory therapists are integral members of the tracheostomy care team. They play a crucial role in:

• Ventilator management: Setting up, monitoring, and adjusting ventilator settings.
• Oxygenation: Optimizing oxygen delivery and therapy.
• Tracheostomy care: Assisting with complex trach care procedures and troubleshooting issues.
• Airway management: Providing expertise in airway management strategies.

6. Aid in Communication. Tracheostomy significantly impacts verbal communication. Nurses should proactively address communication needs by providing various aids, such as:

• Pen and paper or whiteboard: For written communication.
• Alphabet board or letter board: To spell out words.
• Picture board: Using pictures to communicate needs and ideas.
• Electronic devices: Mobile phones, tablets with communication apps.
• Sign language: If the patient is familiar with sign language.
• One-way speaking valve attachment (Passy-Muir valve): Allows patients to speak by directing airflow over the vocal cords during exhalation. Requires physician order and patient assessment for suitability.

7. Support the Patient and Family. Living with or caring for someone with a tracheostomy can be challenging and emotionally taxing. Provide comprehensive support by:

• Education: Thoroughly educating the patient and family on all aspects of long-term tracheostomy care, including hygiene, suctioning, emergency procedures, and troubleshooting.
• Demonstration: Demonstrating trach care procedures and allowing for return demonstration to ensure competence and confidence.
• Emotional support: Acknowledging and addressing the patient’s and family’s emotional responses, anxieties, and fears. Provide reassurance and connect them with support resources as needed.

Trach Care Nursing Diagnosis: Identifying and Addressing Patient Needs

Nursing diagnoses provide a framework for identifying patient problems and guiding nursing care. Several nursing diagnoses are commonly associated with tracheostomy care. Understanding these diagnoses is essential for developing effective care plans.

Deficient Knowledge related to Tracheostomy Care

Nursing Diagnosis: Deficient Knowledge

This diagnosis applies when the patient or family lacks sufficient understanding of the tracheostomy procedure, care management, and potential complications.

Related Factors:

• Lack of exposure to information about tracheostomies.
• Misinformation or misconceptions about tracheostomy care.
• Fear and anxiety related to the procedure and its implications.
• Communication barriers hindering effective education.
• Challenges related to eating and speaking with a tracheostomy.

As Evidenced By:

• Expressed concerns and questions about tracheostomy and care.
• Anxiety about the procedure, outcomes, or lifestyle changes.
• Frustration with trach care routines.
• Development of preventable complications due to knowledge deficit.
• Uncooperative behavior stemming from lack of understanding.

Expected Outcomes:

• Patient/family will verbalize understanding of tracheostomy procedure and care management.
• Patient/family will actively participate in tracheostomy care.
• Patient will remain free from complications related to deficient knowledge.

Assessments:

1. Assess current knowledge: Evaluate the patient’s and family’s existing knowledge about tracheostomy, its function, and required hygiene care.
2. Identify learning barriers: Determine any factors that may impede learning, such as language barriers, cognitive impairments, or emotional distress.
3. Identify misconceptions: Explore and address any misconceptions or inaccurate beliefs about tracheostomy that the patient or family may hold.

Interventions:

1. Develop individualized care plan: Collaborate with the patient and family to create a personalized care plan that addresses their specific learning needs and preferences.
2. Involve family in education: Include family members in teaching sessions, as they often play a crucial role in long-term care.
3. Encourage questions: Create a welcoming and supportive environment that encourages questions and open communication.
4. Provide positive reinforcement: Offer positive feedback and encouragement as the patient and family demonstrate progress in understanding and managing trach care.
5. Clarify temporary vs. permanent: Clearly explain whether the tracheostomy is intended to be temporary or permanent to manage expectations and long-term planning.

Impaired Spontaneous Ventilation related to Artificial Airway

Nursing Diagnosis: Impaired Spontaneous Ventilation

This diagnosis is relevant when a patient is unable to maintain adequate breathing independently due to the presence of a tracheostomy or underlying respiratory compromise.

Related Factors:

• Presence of artificial airway (tracheostomy tube).
• Airway obstruction or compromise.
• Neuromuscular disease affecting respiratory muscles.
• Trauma to the face or neck impacting respiratory function.

As Evidenced By:

• Low oxygen saturation (SpO2).
• Decreased level of cooperation or increased agitation.
• Dyspnea (shortness of breath).
• Tachycardia (rapid heart rate).
• Restlessness or anxiety.

Expected Outcomes:

• Patient will demonstrate improved ability to wean from mechanical ventilation (if applicable).
• Patient will maintain a patent and effective airway.

Assessments:

1. Determine need for tracheostomy: Review the indications for tracheostomy to understand the underlying respiratory issues.
2. Monitor breath sounds and oxygenation: Regularly assess breath sounds for abnormalities and continuously monitor oxygen saturation.
3. Assess ventilator response: Evaluate the patient’s response to mechanical ventilation, noting any signs of distress or ventilator asynchrony.

Interventions:

1. Hyperoxygenate before suctioning: Pre-oxygenate the patient with 100% oxygen prior to suctioning to prevent hypoxia.
2. Effective communication: Establish alternative communication methods as the patient may be unable to speak initially.
3. Family education and demonstration: Instruct family members on proper trach care, emergency procedures, and when to seek medical help.
4. Respiratory therapist collaboration: Work closely with the respiratory therapist to optimize ventilator settings and tracheostomy care.

Impaired Verbal Communication related to Tracheostomy

Nursing Diagnosis: Impaired Verbal Communication

This diagnosis is used when a patient experiences difficulty or inability to communicate verbally due to the tracheostomy diverting airflow away from the vocal cords.

Related Factors:

• Altered airflow through the vocal cords (larynx).
• Potential laryngeal damage.
• Obstructed airway.
• Mechanical ventilation.

As Evidenced By:

• Difficulty speaking or aphonia (loss of voice).
• Inability to communicate verbally.
• Absence of voice sounds or hoarseness.
• Anxious appearance or signs of frustration.
• Fear of being misunderstood.

Expected Outcomes:

• Patient will establish and use effective alternative communication methods.
• Patient will be able to express needs clearly and effectively.
• Patient will demonstrate satisfaction with communication methods.

Assessments:

1. Assess communication ability: Evaluate the patient’s current ability to communicate verbally.
2. Determine best communication method: Identify the most effective alternative communication methods for the individual patient.
3. Note anxiety and frustration: Observe for and address any signs of anxiety, frustration, or helplessness related to communication difficulties.

Interventions:

1. Offer communication aids: Provide a range of communication aids and devices, such as writing materials, alphabet boards, picture boards, and electronic communication devices.
2. Provide emotional support: Offer empathy and emotional support to address the patient’s frustration and anxiety related to communication impairment.
3. Close monitoring: Closely monitor the patient for nonverbal cues that may indicate changes in their condition or needs, as verbal communication may be limited.
4. Call bell accessibility: Ensure the call bell is readily accessible so the patient can easily summon assistance.
5. Simple questions: Use simple questions that can be answered with “yes” or “no” initially.
6. Passy-Muir valve education: If appropriate, educate the patient on the use of a Passy-Muir speaking valve to facilitate verbal communication.
7. Speech-language pathologist consult: Consult with a speech-language pathologist for comprehensive communication and swallowing assessment and intervention.

Ineffective Airway Clearance related to Tracheostomy

Nursing Diagnosis: Ineffective Airway Clearance

This diagnosis is applied when a patient experiences difficulty clearing secretions or maintaining a patent airway due to the presence of a tracheostomy.

Related Factors:

• Excessive or thickened secretions.
• Misalignment or displacement of the tracheostomy tube.
• Decannulation.

As Evidenced By:

• Abnormal breath sounds (wheezing, crackles, rhonchi).
• Dyspnea.
• Irregular or ineffective breathing pattern.
• Difficulty coughing or weak cough.
• Use of accessory respiratory muscles.
• Cyanosis.

Expected Outcomes:

• Patient will maintain oxygen saturation within the normal range (95-100%).
• Patient will exhibit clear breath sounds upon auscultation.
• Patient will be free from signs of respiratory distress.

Assessments:

1. Assess respiratory status: Continuously monitor oxygen saturation, respiratory rate, and breathing pattern.
2. Determine tube placement: Assess and confirm proper tracheostomy tube placement.
3. Review placement confirmation: Review results of chest X-ray or other placement confirmation methods.
4. Check tracheal secretions: Assess the amount, color, consistency, and odor of tracheal secretions.
5. Inspect stoma site: Examine the stoma site for signs of bleeding, edema, or infection.
6. Auscultate breath sounds: Listen to breath sounds in all lung fields to identify abnormal sounds.
7. Obtain ABG: If indicated, obtain arterial blood gas analysis to assess oxygenation and ventilation.

Interventions:

1. Upright positioning: Maintain semi-Fowler’s position for conscious patients and side-lying for unconscious patients to promote drainage.
2. Suction secretions: Perform tracheostomy suctioning as needed to remove excess secretions and maintain airway patency.
3. Hyperoxygenate pre-suction: Always hyperoxygenate the patient before suctioning.
4. Maintain sterile technique: Adhere to sterile technique during tracheostomy care and suctioning.
5. Perform trach care regularly: Provide routine tracheostomy care as prescribed, including cleaning and inner cannula care.
6. Humidified oxygen: Administer humidified oxygen to keep secretions thin.
7. Change trach ties: Change tracheostomy ties regularly or when soiled, ensuring secure tube placement.
8. Emergency kit at bedside: Keep an emergency tracheostomy kit readily available at the bedside.
9. Deep breathing and coughing: Encourage deep breathing and coughing exercises when appropriate.
10. Respiratory therapist collaboration: Collaborate with a respiratory therapist for airway management and ventilation strategies.

Ineffective Breathing Pattern related to Tracheostomy

Nursing Diagnosis: Ineffective Breathing Pattern

This diagnosis is used when a patient exhibits changes in their breathing pattern that are ineffective or compromised, potentially related to the tracheostomy or underlying respiratory conditions.

Related Factors:

• Hypoxia.
• Airway obstruction.
• Infection.
• Neuromuscular impairment.
• Trauma to the face or neck.
• Secretions.

As Evidenced By:

• Bradypnea (slow breathing) or tachypnea (rapid breathing).
• Altered respiratory rate, rhythm, or depth.
• Dyspnea.
• Use of accessory respiratory muscles.

Expected Outcomes:

• Patient will maintain a respiratory rate and pattern within acceptable limits.
• Patient will maintain SpO2 levels within the normal range.

Assessments:

1. Assess for complications: Monitor for signs of respiratory distress or tracheostomy complications like tube malposition or stenosis.
2. Review underlying conditions: Review the patient’s medical history for conditions that may contribute to ineffective breathing patterns, such as COPD or ARDS.

Interventions:

1. Cuff management: Ensure proper tracheostomy cuff inflation pressure, avoiding overinflation or underinflation.
2. Humidification: Provide adequate humidification to prevent thick secretions.
3. Suction as needed: Perform suctioning to remove secretions and prevent mucus plugs.
4. Routine trach care: Provide routine tracheostomy care, including inner cannula cleaning or replacement.

By utilizing these nursing diagnoses and implementing appropriate assessments and interventions, nurses can provide comprehensive and patient-centered care to individuals with tracheostomies, promoting optimal respiratory function, communication, and overall well-being.

References

• Dougherty, L., & Lister, S. (2015). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. John Wiley & Sons.
• Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. Wolters Kluwer.
• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, K. H. (2020). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Barry, P. A., Goldsworthy, S., & Schneider, J. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• Lynn, P. (2019). Taylor’s Clinical Nursing Skills: A Nursing Process Approach. Wolters Kluwer.