Tracheostomy, a surgical procedure done to provide artificial airway, is an important avenue for both clients needing temporary and permanent ventilation assistance. It is performed by making an opening through the neck to the trachea and by inserting an indwelling tube, which should be maintained in place to ensure that airway is patent (Anderson, 1990).
It alleviates emergency conditions like anaphylactic shock accompanied with laryngeal edema and in some cases, foreign body obstruction ( Critical Care Nursing Made Incredibly Easy 3rd Edition, 2012). However, it is often utilized to be the last resort in respiratory treatment if medications cannot totally ease up the condition. For instance, a stroke client with prolonged COPD may be advised to undergo tracheostomy in order to have “sputum outlet” and be prevented from the nursing diagnosis of ineffective airway clearance. This time, it is more likely permanent because the client has difficulty coughing out his sputum; unless the client recovers his health and wean off from it.
Like suctioning, tracheostomy care is another essential nursing duty in taking care of client with tracheostomy. The nurse should put in mind that part from the basic operation procedure A-B-C which is important in an individual is airway. So, the airway which is actually artificial (tracheostomy) should be sterile and free from moist dressing (secretions) in order for the client to be away from skin irritation and further infection.
Furthermore, it should be done at least once a day or as necessary since there are times when clients are on medications and they would have copious secretions; which in some cases mimics a projectile motion upon coughing. Educating the client to have a cloth or tissue to catch his secretion might be helpful in this case.
Routine care of this artificial airway should be accompanied with keen observation of client’s reaction/s. A complete set of emergency tracheostomy equipment should be always visible and available in bedside, in case the indwelling tube is accidentally dislodged.
The emergency tracheostomy equipment is composed of:
a.) Sterile hemostat or dilator
b.) Extra sterile tracheostomy tube and obturator
c.) Suctioning machine and sterile suction catheters (oral and tracheal)
Utilizing the nursing process, tracheostomy care follows the steps below:
The nurse identifies the presence of infection through the following signs:
- Bleeding or purulent discharges
- Character of secretions
Aside from that, the nurse should also make sure that the client is stable. She or he must as well check the client’s:
- Respiratory status through oxygen saturation level, breath sounds, recent ABG and diagnostic results
- Vital signs
- Cardiac rhythm
COMMON NURSING DIAGNOSES
- Ineffective airway clearance
- High risk for aspiration
- Ineffective breathing pattern
- Impaired gas exchange
- Inability to maintain spontaneous ventilation
- High risk for infection
- Impaired swallowing
- High risk for impaired skin integrity
- Altered oral mucous membrane
- Situational low self- esteem
- Knowledge deficit
- Health seeking behavior
PLANNING/IMPLEMENTATION (Adopted from Brunner & Suddarth, 1986)
1. Explain and inform the client about the procedure.
2. Obtain a packaged tracheostomy care kit or if there is none, gather sterile materials, like:
- Sterile gloves
- Sterile towel
- Sterile gauze
- Sterile cotton applicators
- Normal saline solution
- Tracheostomy tie tapes, cotton ones or Velcro holder
- Hydrogen peroxide or mild soap and water
- Antiseptic solution or ointment
3. Suction the oropharyngeal and tracheal areas thoroughly. Allow the client to rest afterward prior to care.
4. Make sure to do the hand washing prior to and after the procedure.
5. Ensure a sterile field by placing the sterile towel under the tracheostomy site.
6. Assemble the sterile materials in the sterile field and don the sterile gloves.
7. Clean the external portion of the indwelling tube with sterile gauze with hydrogen peroxide (depending on hospital policy) and discard thereafter.
8. Clean the stoma area with sterile gauzes soaked in normal saline solution and discard thereafter. Start wiping from 12o’clock to 3o’clock then 12o’clock to 9o’clock, then 30’clock to 6o’clock and lastly, 9o’clock to 6o’clock. Make sure to use one sterile gauze per one direction and discard properly. (Nance-Floyd, July 2011)
9. Remove any crust or thick mucus plugs around the site with sterile cotton applicators.
10. Apply antiseptic solution or ointment using a sterile cotton applicator to the stoma (OPTIONAL).
12. Change the tracheostomy tie: (It should be changed every 24 hours or as needed if soiled frequently)
Two person technique is actually practiced today as it prevents dislodgement of the tube. One person holds the tracheostomy tube while the other does the changing. (Nance-Floyd, July 2011)
a. Secure the tube by holding it in place but do not put pressure downward since it could stimulate cough reflex; while stabilizing the tube, cut or untie the soiled tape and remove carefully. (Change the tape one by one…)
b. Remove any secretions underneath with sterile gauze and make sure its dry.
c. Grasp slit end of clean tape and pull it through the small opening on the side. Do this on the other side.
d. Tie the tapes at the side of the neck in square knot and alternate the tie every time tapes are changed. It should be tight enough to secure the indwelling tube but loose enough to be able to allow two fingers to fit between the tape and the neck. One may use a cotton tie or a Velcro holder, as advised.
13. And lastly, insert dry sterile gauze between stoma and the tracheostomy tube to absorb the secretions and to provide a barrier beneath. (Optional: depending on physician’s order or hospital protocol).
At the end of the procedure always check for the client’s comfort level or reaction/s. Make sure to document the date and time of the performance of the procedure, the assessment made prior to tracheostomy care and if the cuff is maintained deflated or inflated depending on physician’s order.
The nurse should as well document for presence of complications, like hemorrhage, edema, aspiration of secretions, hypoxemia, and subcutaneous emphysema (Critical Care Nursing Made Incredibly Easy 3rd Edition, 2012).
Tracheostomy care may be done by a respiratory technician or a nurse. It is often noticed in intensive care units where clients are on ventilator assistance or sometimes in private rooms or wards. Thereby, educating our clients about it may be necessary as part of our discharge planning.
- Talk to your client and allow him to communicate his thoughts about tracheostomy and doing the self care. You may provide a paper and a pen if client prefers to.
- Teach your client how to clean the external hole of his tracheostomy, even how to suction and replace his tube; how to change the dressing and tie appropriately. You may provide a visual sample by doing this.
- Inform him or her how important to maintain good hygiene and that ties should be alternated once it is changed to avoid pressure ulcers.
- To be unable to speak is one thing that is being feared by these clients, so you may tell him that he could still speak if only he could cover the hole once in a while or by using a speaking valve. You may refer him to a speech therapist, too.
- Inform client to cover the hole with a cloth when going outside and be sure not to inhale dust, food, powder, or water. He is not allowed to go on swimming.
- Make sure to keep an extra tube with him.
- Educate him that by breathing through it the air is not humidified like breathing through the nose, so you may advise him to put a wet gauze or cloth on the external portion of the hole; that is for air to be moist when breathed in.
- Educate him that the stoma site should be pinkish and painless, and if he notices any unusuality like fever, bleeding or purulent discharge from the site, swelling and redness, he should seek consult to his physician, right away.
Anderson, K. &. (1990). Mosby’s Pocket Dictionary of Medicine, Nursing, and Allied Health Philippine Edition. Merriam & Webster, Inc. Brunner, L. &. (1986). The Lippincott Manual of Nursing Practice. J.B. Lippincott Company. Critical Care Nursing Made Incredibly Easy 3rd Edition. (2012). Lippincott Williams & Wilkins. Mannheim, J. (January 2012). Tracheostomy Care. MedlinePlus .Retrieved from http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000076.htm Nance-Floyd, B. (July 2011). Tracheostomy care: An evidenced based guide to suctioning and dressing changes. American Nurse Today .Retrieved from http://www.americannursetoday.com/article.aspx?id=8022&fid=7986