A tracheostomy or tracheotomy is a surgical incision of the front of the neck into the trachea to open the airway. A tracheostomy tube is placed into the opening and connected to a mechanical ventilator or another oxygen delivery device. The term “trach” is used as an abbreviation.
If the normal breathing pathway is compromised or restricted or medical conditions necessitate prolonged use of a ventilator, a tracheostomy can assist patients in breathing. An emergency tracheotomy is often done after a traumatic injury in the upper airway.
A tracheostomy can be temporary or permanent. When a tracheostomy is no longer necessary, it is surgically sealed or left to heal on its own. Some patients may require lifelong tracheostomies.
Early tracheostomy should be done 5–7 days following the intubation of patients. It is indicated for patients with severe closed-head injuries or those requiring prolonged ventilatory support. It aims to reduce the risk of complications from long-term intubation, particularly subglottic stenosis (airway constriction between the vocal cords and trachea). Likewise, tracheostomy is also advised 5-7 days post-intubation in non-trauma patients with unsuccessful ventilator weaning.
The most common setting for tracheostomies is an operating room when patients are completely unconscious during the surgery. If general anesthesia will compromise the airway or if the procedure is performed outside the operating room, a local anesthetic to numb the neck and throat is employed.
Types of Tracheostomies:
- Surgical tracheostomy
- Performed in an operating room
- Surgical dissection to create an opening in the trachea to insert a tracheostomy tube for ventilation.
- Percutaneous tracheostomy
- Also known as a minimally invasive tracheotomy or beside tracheostomy
- Performed in a hospital room
- A small incision to insert a tracheostomy tube without a direct view of the trachea
Note: The type of tracheostomy depends on the indication and urgency to perform the procedure.
Both tracheostomies create an incision to insert a tracheostomy tube. Then, the faceplate of the tube is strapped to the neck to prevent it from slipping out of the opening, and temporary sutures affix the faceplate to the neck’s skin.
The correct placement is confirmed by a direct view (bronchoscopy) of the carina, end-tidal carbon dioxide, effective breathing, and sufficient oxygen saturation.
Nursing Process
Tracheostomy is a safe and effective procedure that can maintain a patent airway. Post-operative and ongoing hygiene care is crucial to a complication-free tracheostomy.
A tracheostomy makes speaking and eating difficult or impossible for the patient. Over time, the patient can be taught how to speak and eat effectively with a tracheostomy. Nutrients and hydration are given enterally or peripherally to prevent aspiration and malnutrition if the patient is on a ventilator.
Nursing Care Plans Related to Tracheostomy
Ineffective Airway Clearance
Ineffective airway clearance associated with tracheostomy can be caused by an obstruction in the stoma or opening of the trachea.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Excessive secretions
- Thick secretions
- Misaligned tracheostomy
- Decannulation
As evidenced by:
- Abnormal breath sounds upon auscultation
- Dyspnea
- Irregular breathing pattern
- Coughing difficulty
- Use of accessory muscles
- Cyanosis
Expected outcomes:
- Patient will maintain an oxygen saturation of 95-100%.
- Patient will be able to manifest clear breath sounds upon auscultation.
- Patient will remain absent of signs of respiratory distress such as cyanosis and dyspnea.
Assessment:
1. Assess the respiratory status.
Continuously monitor the patient’s oxygen saturation and observe any changes in the breathing pattern. Intervention should occur when oxygen saturation levels go below 95%.
2. Determine the placement of the tracheostomy.
A displaced tracheostomy tube needs urgent manual ventilation attempts and suction with a sodium chloride solution to remove the mucus plug. A displaced tracheostomy can be fatal for the patient if management is delayed.
3. Review the confirmatory tracheostomy placement results.
Tracheostomy position is essential to airway patency. Direct visualization (bronchoscopy), end-tidal carbon dioxide, ventilation efficiency, and adequate oxygen saturation confirm proper placement.
4. Check for tracheal secretions.
With a tracheostomy tube, the upper airway that purifies and moisturizes the inhaled air is bypassed. Secretions are a normal response to the presence of a tracheostomy. However, these secretions may accumulate in the airway if tracheostomy cuffs are left inflated for an extended period.
5. Inspect for any signs of bleeding or edema in the tracheostomy site.
The most frequent tracheostomy complication is bleeding. Bleeding can be fatal if it obstructs the airway. Bleeding and edema can happen during or after surgery due to the development of a fistula. The tracheostomy tube typically erodes through the trachea’s wall or a major vessel to cause late hemorrhage.
7. Auscultate for breath sounds.
Wheezing suggests partial airway obstruction. Crackles and rhonchi may indicate the presence of secretions. Diminished or absent breath sounds indicate a mucus plug or other airway obstruction.
8. Obtain arterial blood gas (ABG).
Perform an ABG test to determine whether the oxygen delivered via tracheostomy and ventilator (if a mechanical ventilator is attached) is adequate.
Interventions:
1. Maintain an upright position.
For conscious patients, maintain a semi-Fowler’s position to prevent aspiration of secretions. On the other hand, a side-lying position is best for unconscious patients to facilitate the drainage of secretions by gravity and decrease the risk of aspiration.
2. Suction the secretions.
Suction excess and thick secretions to maintain a patent airway. Suction can also be used to obtain sputum samples for diagnostic testing if an infection is suspected.
3. Remember to hyperoxygenate before suctioning.
Preoxygenate the patient with 100% oxygen prior to suctioning. Preoxygenation aids in preventing hypoxia, while hyperinflation lessens suction-induced atelectasis.
4. Maintain sterility in tracheostomy care.
Tracheostomy care removes mucus and cleans encrusted secretions to facilitate airway patency. It also prevents infection and skin breakdown at the stoma site. Sterility of equipment will maintain a pathogen and microorganism-free environment in the trachea.
5. Perform tracheostomy care as prescribed.
Follow the healthcare provider’s orders or the institution’s policy regarding the frequency of care and prescribed solutions. It is usually recommended to use saline or half-strength hydrogen peroxide to clean the stoma area and cannula.
6. Provide humidified oxygen as ordered.
In a client with a tracheostomy, the typical humidification process, warming and filtering of air by the nose and mouth, is bypassed. Humification can keep secretions thin.
7. Change tracheostomy ties regularly or as needed.
Get help changing the ties holding the tracheostomy in place, then cut and remove the old ties after placing the new ones. A trach tube may also be held in place by velcro, which can also be changed.
8. Keep an emergency tracheotomy kit at the bedside.
An emergency tracheotomy kit should include:
- Spare tracheostomy tubes (one identical size and one size smaller than the patient’s current tracheostomy tube)
- Obturator
- Clamps
- Manual resuscitation (Ambu) bag
9. Encourage deep breathing and coughing exercises.
Deep breathing and coughing exercises can help move secretions, preventing atelectasis and pneumonia.
10. Collaborate with a respiratory therapist.
Managing mechanical ventilation and tracheostomies is a function of respiratory therapists. They set up the equipment, provide input regarding the right size and kind of tracheostomy tube, and assist in ventilating the patient throughout the process.
Impaired Verbal Communication
Impaired verbal communication associated with tracheostomy can be caused by airflow diverting through the tracheostomy tube instead of passing through the vocal cords and the upper airway.
Nursing Diagnosis: Impaired Verbal Communication
Related to:
- No air flowing in the vocal cords (larynx)
- Damaged larynx
- Obstructed airway
- Mechanical ventilation
As evidenced by:
- Difficulty speaking
- Inability to communicate
- No voice sound
- Hoarseness
- Anxious appearance
- Fear of being misunderstood
- Frustration
Expected outcomes:
- Patient will be able to use a method and device to communicate.
- Patient will be able to express their needs clearly and effectively.
- Patient will be able to manifest satisfaction after communication.
Assessment:
1. Assess the patient’s ability to communicate.
Air must pass through the larynx to create voice sound—patients with a cuffed tracheostomy tube experience aphonia or speech loss.
2. Determine the best way for the patient to communicate.
Patients with a tracheostomy on a ventilator may need to write or type requests.
3. Note any signs of anxiety and frustration.
The inability to communicate can increase a patient’s sense of helplessness and isolation.
Interventions:
1. Offer communication methods and devices.
Communication alternatives available to patients with tracheostomy:
- Writing
- Gestures
- Mouthing words
- Speaking valves
- Use of AAC (Augmentative and Alternative Communication) devices such as communication boards, tablets, and picture boards
2. Provide emotional support.
Being unable to communicate and feeling misunderstood can cause anxiety, helplessness, and isolation and can be frustrating for the patient.
3. Closely monitor the patient.
Due to difficulty in communication, the patient may not be able to communicate symptoms or concerns. It is crucial to closely monitor and observe patients for nonverbal behaviors that signal changes in their health status.
4. Advise the patient to use the call bell when necessary.
Patients can notify any healthcare personnel of their need for assistance in a healthcare setting by using a nurse call bell system to ensure patient safety.
5. Use a communication board or gestures for simple questions.
A communication board is a device that shows images, symbols, or illustrations to assist people who struggle to communicate verbally. The patient, nurse, and family can use gestures or sign language as applicable for simple communication.
6. Ask questions answerable by yes or no reactions.
Try to construct questions that can be answered by “yes” or “no” responses. The patient can nod or blink their response.
7. Teach to use a Passy-Muir Valve.
This one-way valve attaches to the tracheostomy to allow air into the trach but not out. The patient is first suctioned to remove secretions, and then the cuff is deflated. The valve is twisted onto the trach tube and easily twisted off to remove.
8. Consult with the speech-language pathologist.
The SLP can assess the patient’s swallowing and language functions and their ability to produce voice and tolerate a speaking valve.
Deficient Knowledge
Deficient knowledge associated with tracheostomy can result in misunderstanding the tracheostomy procedure and care management.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Lack of knowledge about tracheostomies
- Fear of tracheostomy procedure, outcomes, and complications
- Misconceptions about tracheostomy care
- Communication barriers
- Barriers with eating and speaking with a trach
As evidenced by:
- Expressed concerns about a tracheostomy
- Anxiety about the procedure or lifestyle changes
- Frustration with trach care
- Development of complications
- Uncooperative behavior
Expected outcomes:
- Patient will be able to express an understanding of the tracheostomy procedure and care management
- Patient will cooperate in the care of their tracheostomy
- Patient will not develop a complication from their tracheostomy
Assessment:
1. Assess the patient’s knowledge of tracheostomy surgery.
Assess the patient’s knowledge about the tracheostomy procedure, how the trach works, and what hygiene care is expected.
2. Identify factors affecting learning.
Since a tracheostomy can already interfere with communication with the patient, it can negatively impact the delivery of quality and safe care. Assess for other barriers, such as developmental or cognitive delays.
3. Determine misconceptions and beliefs about tracheostomy.
Determine the patient’s beliefs about tracheostomies to assess for knowledge gaps. Most patients believe that a tracheostomy is a long-term and permanent treatment.
Interventions:
1. Create a care plan with the patient.
Having a tracheostomy and being unable to communicate is frustrating. Patient engagement in decision-making before the tracheostomy will help the patient feel empowered and in control.
2. Involve the family.
Family members can be instructed on caring for the trach and recognizing complications. If the patient will have the trach long-term or permanently, the family must know how to care for it.
3. Welcome inquiries.
A welcoming and approachable manner invites questions to clarify misconceptions and misunderstandings. Patients with a tracheostomy experience anxiety, fear, and powerlessness; clarification can reduce these feelings.
4. Reinforce positive feedback.
When patients achieve their goals and prevent complications, reinforce positive feedback and show appreciation for their efforts and adherence to their care plan.
5. Clarify that tracheostomy can be temporary or permanent.
A tracheostomy is typically a temporary breathing alternative while addressing other medical problems. The tracheostomy is commonly the best long-term and permanent option if patients need a ventilator for life.
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Mayo Clinic. (2019, October 22). Tracheostomy. Retrieved January 2023, from https://www.mayoclinic.org/tests-procedures/tracheostomy/about/pac-20384673
- National Center for Biotechnology Information. (2022, July 1). Tracheostomy – StatPearls – NCBI bookshelf. Retrieved January 2023, from https://www.ncbi.nlm.nih.gov/books/NBK559124/
- Silvestri, L. A., & Silvestri, A. E. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
- Tracheostomy Education. (2022, July 17). Complications of tracheostomy | Tracheostomy education. Retrieved January 2023, from https://tracheostomyeducation.com/blog/complications-of-tracheostomy/
- UK National Health Service. (2017, October 20). Tracheostomy. NHS UK. Retrieved January from https://www.nhs.uk/conditions/tracheostomy/
