Nursing Diagnosis for Tracheostomy: A Comprehensive Guide for Nurses

Overview of Tracheostomy and Nursing Care

A tracheostomy is a surgically created opening in the trachea, performed to establish an airway when the usual breathing route is blocked, restricted, or when prolonged mechanical ventilation is required. This procedure, often referred to as a “trach,” involves inserting a tracheostomy tube through an incision in the neck, directly into the trachea. This tube can then be connected to a ventilator or other oxygen delivery systems, facilitating respiration. Tracheostomies can be either temporary, used until the underlying condition resolves, or permanent, depending on the patient’s long-term needs. In emergency situations, a tracheotomy might be urgently performed to bypass acute airway obstructions caused by events like aspiration, foreign objects, trauma, or severe allergic reactions (anaphylaxis).

Early tracheostomy, typically performed within 5 to 7 days of intubation, is often recommended for patients with severe head injuries or those needing prolonged ventilator support. This proactive approach helps minimize complications associated with extended endotracheal intubation, such as subglottic stenosis, a narrowing of the airway below the vocal cords. For non-trauma patients who face challenges being weaned off ventilators, a tracheostomy around the same 5-7 day post-intubation mark is also frequently considered.

The safest setting for performing a surgical tracheostomy is usually an operating room, where patients can be under general anesthesia, ensuring they are completely unconscious and still during the procedure. However, in situations where general anesthesia poses risks to the airway, or when the procedure is done outside of an operating room environment, a local anesthetic can be used to numb the neck and throat area, providing patient comfort and cooperation.

Types of Tracheostomy Procedures: Surgical vs. Percutaneous

There are primarily two main types of tracheostomy procedures, each with its own setting and approach:

• Surgical (Open) Tracheostomy: This method is traditionally carried out in an operating room. It involves a surgical dissection to create a direct opening into the trachea. Through this opening, a tracheostomy tube is inserted to facilitate ventilation. This technique provides a clear surgical field and is often preferred in complex cases or when specific anatomical considerations are present.

• Percutaneous Tracheostomy: Also known as a minimally invasive or bedside tracheostomy, this procedure is often performed in a hospital room, often even at the patient’s bedside in the ICU. Percutaneous tracheostomy involves a smaller incision and the use of specialized instruments to create an opening for the tracheostomy tube without requiring a full surgical dissection or direct visualization of the trachea. This method is generally quicker and can be less invasive, making it suitable for certain patients and urgent situations.

The choice between surgical and percutaneous tracheostomy depends on several factors, including the patient’s condition, the urgency of the need for tracheostomy, and the clinical setting. Both procedures ultimately achieve the same goal: establishing a secure airway through a tracheal incision and the insertion of a tracheostomy tube. Once inserted, the tracheostomy tube’s faceplate is secured to the patient’s neck using ties, tape, or temporary sutures to prevent accidental displacement.

The Nursing Process in Tracheostomy Care

Tracheostomy is a vital procedure for maintaining a patent airway and supporting respiratory function. However, successful outcomes and the prevention of complications heavily depend on meticulous post-operative and ongoing nursing care. Nursing care is crucial for patients with tracheostomies, encompassing a broad spectrum of responsibilities from initial assessment to long-term management and patient education.

A significant impact of a tracheostomy is on the patient’s ability to communicate and eat. Speaking and swallowing can be significantly challenged or initially impossible. Over time, with dedicated support and therapy, many patients can learn to speak and eat effectively with a tracheostomy. Initially, to ensure adequate nutrition and hydration, patients on ventilators or those with swallowing difficulties typically receive nutrients and fluids either enterally (through feeding tubes) or peripherally (intravenously). This precaution is essential to prevent aspiration and malnutrition, common risks in tracheostomized patients.

Nursing Assessment for Patients with Tracheostomy

The foundation of effective nursing care begins with a thorough nursing assessment. This crucial first step involves systematically gathering physical, psychosocial, emotional, and diagnostic data. For patients with a tracheostomy, the nursing assessment focuses on both subjective and objective data to provide a holistic understanding of the patient’s condition and needs.

Reviewing Health History: Key Considerations

1. Indications for Tracheostomy: Understanding why a tracheostomy was performed is paramount. Common indications include:

• Airway Obstruction: Blockage of the upper airway due to various causes.
• Trauma to the Face or Neck: Injuries that compromise the airway.
• Prolonged Ventilator Dependence: Need for long-term mechanical respiratory support.
• Prophylaxis Before Head or Neck Cancer Treatment: To secure the airway before treatments that may cause swelling or obstruction.
• Obstructive Sleep Apnea (OSA) with Failed Conservative Treatment: When other treatments for severe OSA have been unsuccessful.
• Neuromuscular Diseases (e.g., ALS, Stroke, Multiple Sclerosis): Conditions that weaken respiratory muscles and impair airway protection.
• Management of Secretions: Inability to effectively clear airway secretions.

2. Patient’s Medical History: Certain pre-existing medical conditions increase the likelihood of needing a tracheostomy. These include:

• Congenital Anomalies: Facial and upper airway abnormalities present at birth.
• Mechanical Obstructions: Foreign bodies or growths obstructing the airway.
• Upper Airway Defects or Conditions: Infections, edema, or paralysis affecting the larynx or trachea.
• Dysphagia: Swallowing difficulties increasing aspiration risk.
• Sleep Apnea: Particularly severe or untreated obstructive sleep apnea.

3. Need for Long-Term Mechanical Ventilation: Assess the likelihood of prolonged ventilator support. Tracheostomy facilitates long-term ventilation in conditions causing respiratory failure and is also beneficial for patients with:

• Respiratory Failure: Inability of the lungs to adequately oxygenate the blood or remove carbon dioxide.
• Ineffective Coughing Ability: Compromising the ability to clear airway secretions.
• Risk for Aspiration: Increased risk of inhaling foreign material into the lungs.

4. Patient and Family Knowledge Assessment: It’s vital to gauge the patient’s and family’s understanding of tracheostomy. Identify any knowledge gaps or misconceptions about:

• Tracheostomy Purpose and Procedure: Lack of understanding can cause anxiety.
• Temporary vs. Permanent Nature: Misconceptions about the duration of the tracheostomy.
• Home Care Requirements: Understanding the level of care needed for trach maintenance at home.

Physical Assessment: Objective Data Collection

1. Assess the ABCs (Airway, Breathing, Circulation): Prioritize assessment of airway patency, breathing effectiveness, and circulatory status. Inspect the upper airway (nose, mouth, throat) both before and after tracheostomy placement.

2. Monitor Vital Signs: Closely monitor vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation, temperature) before, during, and after the tracheostomy procedure. Be vigilant for:

• Oxygen Desaturation: Drop in oxygen saturation levels.
• Bleeding: Excessive bleeding from the tracheostomy site.
• Significant Vital Sign Changes: Deviations from baseline values.
  Continuous pulse oximetry monitoring is essential.

3. Respiratory Status Evaluation: Observe respiratory effort and characteristics closely for signs of respiratory distress:

• Tachypnea: Rapid breathing.
• Retractions: Pulling in of chest muscles during breathing.
• Adventitious Breath Sounds: Abnormal sounds like wheezing, crackles, or rhonchi.
• Desaturation: Decreased oxygen saturation.
• Cyanosis: Bluish discoloration of skin and mucous membranes, indicating hypoxia.

4. Tracheostomy-Related Complications: Be alert to potential complications:

• Bleeding: From the surgical site or within the trachea.
• Infection: Local site infection or tracheitis.
• Edema: Swelling around the stoma site.
• Obstruction: Blockage of the tracheostomy tube.
• 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. Speech and Swallowing Abilities: Assess the impact of the tracheostomy on these functions. Note:

• Speaking Difficulty: Inability to speak due to airflow diversion.
• Swallowing Difficulties (Dysphagia): Risk of aspiration.
  Referral to a speech-language pathologist is often necessary for evaluation and management.

6. Signs of Infection: Monitor for local signs of infection at the tracheostomy site:

• Redness (Erythema)
• Swelling (Edema)
• Warmth
• Granulation Tissue (Excessive)
• Exudate (Purulent or Increased)
• Pain at the Site
• Foul Odor
• Increased or Change in Secretions

Diagnostic Procedures for Tracheostomy Patients

1. Arterial Blood Gas (ABG) Analysis: Obtain ABGs post-tracheostomy to evaluate:

• Ventilation Effectiveness: Partial pressure of carbon dioxide (PaCO2).
• Oxygenation Status: Partial pressure of oxygen (PaO2) and oxygen saturation (SaO2).
• Acid-Base Balance: pH, bicarbonate levels.
  ABGs are especially important for ventilated patients or those showing respiratory distress.

2. Chest X-Ray: May be ordered to:

• Confirm Tracheostomy Tube Placement: Ensure correct positioning within the trachea.
• Evaluate for Complications: Detect pneumothorax or other lung issues.

Nursing Interventions for Tracheostomy Care

Effective nursing interventions are crucial for preventing complications and promoting patient recovery and well-being following a tracheostomy.

Preparation for Tracheostomy Procedure

1. Informed Consent Verification: Ensure proper informed consent is obtained. This involves:

• Discussion of Benefits, Risks, and Alternatives: Open communication between the healthcare provider, patient, and family.
• Addressing Questions and Concerns: Providing opportunities to clarify doubts.
• Documentation of Signed Consent: Confirming informed consent is legally documented.

2. Equipment Preparation: For percutaneous tracheostomy, the nurse is often responsible for:

• Tracheostomy Kit Assembly: Gathering necessary sterile supplies and instruments.
• Suction Equipment Setup: Ensuring suction is functional and ready for use.

Prevention of Tracheostomy Complications: Proactive Measures

1. Infection Prevention: Implement strict infection control measures:

• Sterile Technique: During tracheostomy care and suctioning.
• Regular Stoma Care: Cleaning and dressing changes as per protocol.
• Wound Assessment: Monitor for early signs of infection.

2. Cuff Management: For cuffed tracheostomy tubes:

• Cuff Inflation Monitoring: Maintain cuff pressure within 20-25 mmHg to ensure an adequate seal for ventilation without causing tracheal necrosis.
• Pressure Monitoring Equipment: Utilize a cuff manometer to accurately measure pressure.
• Avoid Overinflation: Prevent pressure-induced tracheal damage.

3. Pre-hyperoxygenation: Before suctioning or procedures that might disrupt oxygenation:

• Administer 100% Oxygen: Preoxygenate with high-flow oxygen to prevent hypoxia.
• Hyperinflation: Can help reduce the risk of suction-induced atelectasis.

4. Sterility Maintenance: Uphold sterile technique during:

• Tracheostomy Insertion: If assisting with bedside procedures.
• Tracheostomy Care: Suctioning, dressing changes, inner cannula cleaning/replacement.

5. Breathing and Coughing Exercises: Encourage respiratory physiotherapy:

• Deep Breathing Exercises: Promote lung expansion.
• Coughing Exercises: Facilitate secretion mobilization and clearance.

6. Aspiration Prevention: Implement strategies to minimize aspiration risk:

• Elevate Head of Bed: Maintain a semi-Fowler’s or high-Fowler’s position (at least 30 degrees).
• NPO Status Initially: Withhold oral intake until swallowing is assessed and deemed safe.
• Cuff Deflation Precautions: Ensure cuff deflation is done only when appropriate and safe for swallowing, as per healthcare provider or speech pathologist orders.

Post-Tracheostomy Care: Ongoing Management

1. Emergency Equipment at Bedside: Ensure immediate access to:

• Tracheostomy Emergency Kit: Including spare tracheostomy tubes (same size and one size smaller), obturator, clamps.
• Suction Equipment: Functional suction apparatus.
• Manual Resuscitation Bag (Ambu bag): For immediate ventilation if needed.

2. Humidification Provision: Essential to maintain airway moisture:

• Humidified Oxygen: Administer humidified oxygen to prevent secretion thickening and mucus plug formation.
• Mucolytics (as prescribed): May be used to thin secretions.

3. Routine Tracheostomy Care: Perform regular care as ordered, typically including:

• Stoma Site Care: Cleaning around the stoma.
• Dressing Changes: Maintaining a clean and dry stoma site.
• Dried Mucus Removal: Gentle cleaning with sterile Q-tips or gauze.
• Inner Cannula Care: Cleaning or replacing the inner cannula (disposable or reusable type).
• Tracheostomy Tie Changes: Securely changing tracheostomy ties to prevent dislodgement.

4. Suctioning as Needed: Suction the tracheostomy tube when:

• Audible Secretions: Noisy respirations indicating secretions in the airway.
• Ineffective Cough: Patient unable to clear secretions independently.
• Increased Coughing: Signaling increased secretions.
• Oxygen Desaturation: Potentially due to airway secretions.
  Always hyperoxygenate before suctioning and limit suction duration to <10 seconds per pass.

5. Respiratory Therapist Collaboration: Work closely with respiratory therapists for:

• Ventilator Management: Optimizing ventilator settings.
• Oxygenation Strategies: Adjusting oxygen delivery.
• Tracheostomy Care Protocols: Ensuring consistent and best practices.
• Troubleshooting: Addressing any respiratory or tracheostomy-related issues.

6. Communication Assistance: Address communication challenges:

• Communication Aids: Provide pen and paper, alphabet boards, picture boards, electronic devices, sign language support.
• Speaking Valve Introduction: Consider a one-way speaking valve (like Passy-Muir valve) with appropriate assessment and physician order.

7. Patient and Family Support: Provide comprehensive support:

• Education: Teach tracheostomy care for long-term management at home.
• Demonstration: Show practical trach care techniques to patients and family.
• Emotional Support: Acknowledge and address emotional responses, anxiety, and fears related to tracheostomy.

Common Nursing Diagnoses Related to Tracheostomy

Nursing diagnoses are clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes. For patients with tracheostomies, several nursing diagnoses are commonly identified. These diagnoses guide the development of individualized nursing care plans.

1. Deficient Knowledge related to Tracheostomy Management

Nursing Diagnosis: Deficient Knowledge

Related to:

• Lack of exposure to information about tracheostomy and its care.
• Misinformation or misconceptions about tracheostomy procedures and management.
• Anxiety or fear affecting learning and information processing.
• Communication barriers hindering effective teaching.

As Evidenced By:

• Expressed concerns or questions about tracheostomy and care.
• Inaccurate statements about tracheostomy procedures or home care.
• Non-adherence to tracheostomy care regimens due to misunderstanding.
• Development of preventable complications (e.g., infection, obstruction).

Expected Outcomes:

• Patient and/or family will verbalize understanding of tracheostomy purpose, function, and required care.
• Patient and/or family will demonstrate competence in performing tracheostomy care procedures (e.g., suctioning, cleaning).
• Patient will experience no preventable complications related to knowledge deficit.

Nursing Interventions:

1. Assess Current Knowledge: Evaluate the patient’s and family’s existing understanding of tracheostomy.
2. Identify Learning Barriers: Assess for factors like language, cognitive limitations, or emotional distress that may impede learning.
3. Develop Individualized Teaching Plan: Tailor teaching to the patient’s and family’s needs and learning style.
4. Provide Clear and Simple Explanations: Use plain language to explain tracheostomy, care procedures, and potential complications.
5. Demonstrate Tracheostomy Care: Provide hands-on demonstrations of suctioning, stoma care, and equipment handling.
6. Provide Written Materials: Supplement verbal teaching with written instructions and visual aids.
7. Encourage Questions and Discussion: Create a supportive environment for asking questions and addressing concerns.
8. Evaluate Learning: Assess understanding through teach-back methods and observation of care skills.
9. Reinforce Positive Behaviors: Provide positive feedback for adherence to care plans and skill acquisition.

2. Impaired Spontaneous Ventilation related to Artificial Airway

Nursing Diagnosis: Impaired Spontaneous Ventilation

Related to:

• Presence of tracheostomy tube altering normal respiratory mechanics.
• Underlying conditions causing respiratory muscle weakness or dysfunction (e.g., neuromuscular disease).
• Airway obstruction or mechanical issues with the tracheostomy tube.

As Evidenced By:

• Dyspnea or increased work of breathing.
• Decreased respiratory rate or depth.
• Use of accessory muscles for breathing.
• Hypoxemia (low oxygen saturation).
• Hypercapnia (elevated carbon dioxide levels).

Expected Outcomes:

• Patient will maintain adequate spontaneous ventilation, as evidenced by stable respiratory rate and depth, and oxygen saturation within acceptable limits.
• Patient will be successfully weaned from mechanical ventilation (if applicable).
• Patient will demonstrate effective breathing patterns and airway management techniques.

Nursing Interventions:

1. Monitor Respiratory Status: Continuously assess respiratory rate, depth, pattern, and oxygen saturation.
2. Auscultate Breath Sounds: Assess for adventitious breath sounds or decreased air entry.
3. Assess Ventilator Dependence: Evaluate the patient’s ability to breathe spontaneously and progress towards ventilator weaning.
4. Optimize Tracheostomy Tube Management: Ensure proper tube placement, cuff inflation, and patency.
5. Suction as Needed: Clear airway secretions to maintain patency.
6. Provide Respiratory Support: Administer supplemental oxygen as ordered.
7. Position Patient for Optimal Breathing: Elevate head of bed to facilitate lung expansion.
8. Collaborate with Respiratory Therapy: Work with RTs to manage ventilation and weaning protocols.
9. Educate Patient on Breathing Exercises: Teach deep breathing and coughing techniques.

3. Impaired Verbal Communication related to Tracheostomy Tube

Nursing Diagnosis: Impaired Verbal Communication

Related to:

• Physical barrier of the tracheostomy tube diverting airflow away from the vocal cords.
• Mechanical ventilation altering normal speech production.
• Anxiety and emotional distress related to communication difficulties.

As Evidenced By:

• Inability to speak or produce voice sounds.
• Frustration or anxiety related to communication difficulties.
• Use of non-verbal communication methods (gestures, writing) or communication aids.
• Difficulty expressing needs or understanding communication from others.

Expected Outcomes:

• Patient will establish effective alternative communication methods.
• Patient will express needs and understand communication from others effectively.
• Patient will demonstrate reduced frustration and anxiety related to communication impairment.

Nursing Interventions:

1. Assess Communication Abilities: Determine the patient’s current communication methods and challenges.
2. Provide Communication Aids: Offer pen and paper, communication boards, picture boards, electronic devices, or translation apps.
3. Encourage Non-Verbal Communication: Support the use of gestures, facial expressions, and body language.
4. Facilitate Use of Speaking Valve: If appropriate and ordered, introduce and train the patient on using a speaking valve.
5. Simplify Communication: Ask yes/no questions, use simple language, and speak clearly and slowly.
6. Be Patient and Attentive: Allow ample time for communication and listen actively.
7. Consult Speech-Language Pathologist (SLP): Refer to SLP for comprehensive communication assessment and therapy.
8. Provide Emotional Support: Acknowledge and address the patient’s frustration and emotional impact of communication impairment.

4. Ineffective Airway Clearance related to Tracheostomy

Nursing Diagnosis: Ineffective Airway Clearance

Related to:

• Increased mucus production and thickened secretions associated with tracheostomy.
• Ineffective cough reflex due to artificial airway bypassing upper airway function.
• Potential for tracheostomy tube obstruction or displacement.

As Evidenced By:

• Adventitious breath sounds (e.g., rhonchi, crackles, wheezing).
• Cough, but ineffective in clearing secretions.
• Dyspnea or increased respiratory effort.
• Restlessness or anxiety.
• Changes in respiratory rate or rhythm.
• Cyanosis or decreased oxygen saturation.

Expected Outcomes:

• Patient will maintain a clear and patent airway, as evidenced by clear breath sounds and oxygen saturation within normal limits.
• Patient will effectively clear airway secretions with or without assistance.
• Patient will exhibit no signs of respiratory distress related to airway obstruction.

Nursing Interventions:

1. Assess Respiratory Status: Monitor breath sounds, respiratory rate, oxygen saturation, and effort.
2. Suction Tracheostomy Tube: Perform suctioning as needed to remove secretions and maintain airway patency.
3. Provide Humidification: Ensure humidified oxygen is administered to thin secretions.
4. Encourage Coughing and Deep Breathing: Promote effective coughing and deep breathing exercises.
5. Maintain Proper Positioning: Position patient to facilitate secretion drainage (e.g., semi-Fowler’s, side-lying).
6. Tracheostomy Care: Perform routine tracheostomy care to remove mucus and prevent crusting.
7. Monitor for Tube Obstruction: Regularly assess tracheostomy tube patency and for signs of obstruction.
8. Emergency Equipment at Bedside: Ensure suction and emergency tracheostomy equipment are readily available.
9. Educate Patient and Family on Secretion Management: Teach techniques for effective coughing, suctioning (if applicable at home), and recognizing signs of airway obstruction.

5. Ineffective Breathing Pattern related to Physiological Changes Secondary to Tracheostomy

Nursing Diagnosis: Ineffective Breathing Pattern

Related to:

• Altered respiratory physiology due to tracheostomy (e.g., bypassed upper airway, altered dead space).
• Pain or discomfort at the tracheostomy site affecting breathing pattern.
• Underlying respiratory conditions or complications (e.g., infection, atelectasis).

As Evidenced By:

• Changes in respiratory rate, rhythm, or depth (e.g., tachypnea, bradypnea, shallow breathing).
• Use of accessory muscles for breathing.
• Nasal flaring.
• Shortness of breath or dyspnea.
• Abnormal arterial blood gases.

Expected Outcomes:

• Patient will establish and maintain an effective breathing pattern, as evidenced by respiratory rate and rhythm within normal limits and adequate oxygenation.
• Patient will report reduced dyspnea or improved breathing comfort.
• Patient will demonstrate appropriate breathing techniques to optimize respiratory function.

Nursing Interventions:

1. Assess Breathing Pattern: Monitor respiratory rate, rhythm, depth, and effort.
2. Monitor Oxygen Saturation and ABGs: Evaluate oxygenation and ventilation status.
3. Optimize Tracheostomy Tube Management: Ensure proper cuff inflation and tube patency.
4. Pain Management: Address pain at the tracheostomy site to improve breathing comfort.
5. Position for Optimal Breathing: Elevate head of bed to promote lung expansion.
6. Provide Humidified Oxygen: Maintain airway moisture and ease breathing.
7. Suction as Needed: Clear secretions that may impede breathing.
8. Breathing Exercises: Teach and encourage diaphragmatic breathing and pursed-lip breathing.
9. Monitor for Complications: Assess for signs of infection, pneumothorax, or other respiratory complications.
10. Collaborate with Respiratory Therapy: Work with RTs for respiratory assessment and management strategies.

By addressing these common nursing diagnoses and implementing appropriate interventions, nurses play a critical role in ensuring the safety, comfort, and optimal outcomes for patients with tracheostomies. Continuous assessment, proactive care, and patient education are essential components of comprehensive tracheostomy management.

References

(References from the original article are implicitly used within this rewritten and expanded article. For a formal academic context, specific citations would be added to support factual claims and data. As the request was to improve upon the original content and focus on nursing diagnosis, the information is derived from established nursing practices and knowledge related to tracheostomy care.)