tracheostomynursingprocedure

Nurses who are caring for patients with tracheostomies are required to have a thorough knowledge of the natural anatomy of the airway and how artificial appliances affect the breathing patterns and respiration of the patient. There is also a need to recognize the signs and symptoms of hypoxia and the skills necessary to provide effective nursing care should the tracheostomy tube accidentally gets dislodged. However, there is also a need to know what exactly tracheostomy is all about and what are the conditions that require a patient to have it.

 A tracheostomy is an opening in the cervical portion of the trachea that is created surgically. The procedure is quite commonly done for patients who needed an artificial airway, but normally not done as an emergency procedure. This is because other procedures such as oral intubation or cricothyrotomy are much faster and less complicated than performing a tracheostomy, especially in cases of respiratory arrest. Normally, the following reasons require an order for performing tracheostomy:

  • To bypass an airway obstruction
  • To help ensure airway patency in some patients
  • As an aid to removing secretions more efficiently
  • To provide better oxygenation to a patient (through mechanical ventilation or others) on a long-term basis
tracheostomy tube placement
Figure 1. Tracheostomy tube and its placement.

Because a tracheostomy (and other procedures related to it such as suctioning or mechanical ventilation) is a high-risk procedure that patients undergo, the nurse must adhere to the accepted standards of practice or follow care protocols according to the health facility where he is working. Moreover, the nurse must also be familiar with the equipment used on patients to help ensure the quality of care.

trachoestomy tube diagram
Figure 2. Diagram of a Tracheostomy Tube.

As mentioned previously, a tracheostomy is created to help provide an artificial airway for patients who have varied health conditions which alter airway patency and affect gas exchange. These include:

  • Stroke, or comatose patients
  • Patients who are suffering from laryngeal cancer
  • Patients who have suffered laryngeal edema and damage because of burns 
  • A patient with COPD and in need of mechanical ventilation
  • Pediatric patients who are suffering from congenital airway congestions

There are also anatomical abnormalities or problems that may necessitate the creation of a tracheostomy in the absence of a pathologic problem such as:

  • An inherent abnormality in the anatomy of the trachea or the larynx
  • Presence of a tumor or foreign object in the throat
  • Severe injuries in the airway, specifically involving the neck, throat, or mouth
  • Inability to cough, swallow or expectorate sputum due to a variety of causes

Different Types of Tracheostomy Tube Insertion Procedures

           The usual process of inserting a tracheostomy tube is performed in the operating room with the patient normally placed under general anesthesia although the activity can also be performed under general anesthesia. The placement of the tube is normally done between the second and the third or fourth tracheal cartilages (see Figure 1), with sutures placed in the cartilage. These sutures also have their ends taped onto the skin of the patient and serve to stabilize the tracheostomy. 

There is also another procedure done that creates tracheostomies at the bedside of the patient, especially when the patient is admitted to the ICU. This is known as percutaneous dilatational tracheostomy or PDT. Done in less time than most tracheostomies, the PDT is performed using a local anesthetic or a narcotic sedative and a guide wire is used to create a stoma where the tube is inserted. This process takes roughly 15 minutes and is found to cause less scarring and complications. However, this type of procedure cannot be performed on patients who have anatomical problems or those with issues in coagulation.

tracheostomy tube placement anatomy
Figure 3. Side view of tracheostomy placement.

           Another procedure that is performed to create a tracheostomy is known as the mini tracheostomy. This procedure is also done at the bedside and treated as a compromise step to help decongest operating rooms because patients no longer need to be inside the ORs for the tracheostomies. This also helps in ensuring that patients are monitored continuously while keeping costs of care lower.

different types tracheostomy
Figure 4. Different Types of Tracheostomy Tubes (standard adult, cuflless, pediatric, fenestrated tubes)

Benefits and Risks of a Tracheostomy

Because tracheostomies can be performed either on a temporary or a permanent basis, it poses several benefits to the patients as compared to other artificial airway created. Firstly, creating a tracheostomy will help keep the airway patent in case the tube gets dislodged. This is because the upper airway of the patient remains connected with each other. Secondly, there is no need to remove any part of the larynx or trachea unlike in a laryngectomy where the larynx is removed to create an artificial airway.

There are also risks associated with the creation of a tracheostomy, ranging from those seen during the creation or after the patient has been placed on ventilation support on a long-term basis. These risks include:

  • Reaction to the medications and/or anesthetics used
  • Infection of the insertion site
  • Bleeding tendencies
  • Problems and issues with clotting
  • Severe respiratory problems
  • Potential of suffering from respiratory or cardiac arrest

 

Moreover, there are also patients who are seen to experience other less serious complications such as inflammation of the wound site. Some patients are also seen to suffer from an inability to expectorate sputum and difficulty adjusting to having the tracheostomy.

Care of the Patient After Tracheostomy Procedure

Patients who have undergone creation of a tracheostomy may complain of pain and other discomforts in the immediate post-operative period. For the first 48 hours post-procedure, the patient is expected to be in a stage of both trying to recover from the trauma of the procedure and adjusting to the presence of the tube while trying to find ways to communicate better. The following can help the nurse care better for the patient post-procedure:

  • Assess breathing and ability of the patient to communicate. Note for rate, rhythm and respiratory sounds and sputum characteristics to determine potentials for complications.
  • Provide patient with other means to communicate such as writing pads.
  • Monitor vital signs and document them, especially when determining when patients can be transferred to their rooms. Note for any irregularities and inform the physician.
  • Avoid excessive manipulation of the tube to prevent dislodgement, especially since the stoma has the potential to close shut in the immediate post-op period.
  • Assis the physician on the first tube change, which usually happens a week after the creation of the stoma.
  • Brush up on the symptoms and findings that are anticipated to see among patients who have undergone tracheostomy such as:
    • A slight increase in the respiratory secretions after the procedure
    • Signs indicating imbalances in gas exchange (this can be corrected once patients are hooked to ventilation support, or taught deep breathing techniques)
    • Small amounts of bleeding in the tracheostomy site
    • Inflammation in the incision site in the immediate post-operative phase
    • Escape of small amounts of air in the incision site (this is no cause of alarm)

Nursing Care with Rationale

Intervention Rationale
Examine the trach tube, any tubing and equipment connected to it, as well as the stoma site. Observe for redness, purulent drainage, and abnormal bleeding around the stoma. Note the amount, color, consistency, and odor of secretions. This step allows the nurse to determine the potential source of any problem or issues with the patient and the tubing set-up and help in planning for effective care.
Assess breath sounds, noting for the depth, rate and rhythm of the respirations. Also note for sputum production and characteristics of the expectorate. To determine the potential or presence of a complication of the procedure or improvement of the patient’s condition.
If a patient needs humidification, ensure the type of humidification the patient needs and administer it according to facility protocols. Patients may need different forms of humidification and these may differ in administration from one another. Ensuring the type of humidification needed by the patient allows the nurse to plan for more effective care.
Perform measures to mobilize secretions:
  • Increase fluid intake (if not contraindicated)
  • Repositioning regularly
  • Deep breathing and coughing
  • Chest physiotherapy
  • Postural drainage
These measures help ensure that secretions are mobilized and easier to expectorate.
If patient needs suctioning, ensure that the steps for proper suctioning is followed:
  • Position patient in semi-Fowler’s. Time the suctioning procedure to occur prior to eating.
  • Select the appropriate size suction catheter, based on the size on the tracheostomy tube used.
  • Hyperoxygenate before each pass with the catheter, although some initial suctioning should be done if using bag ventilation, so as not to drive secretions deeper toward the lungs. (Exceptions to hyperoxygenation are children and those with long-term tracheostomies.)
  • Insert the catheter to a pre-measured depth matching the length of the tube and only to a point of resistance, if deeper suctioning is necessary.
  • Supply suction intermittently while rotating unless the catheter has side holes.
  • Limit suctioning to 5 seconds for pre-measured depth and 10-15 seconds for deep suctioning
  • Use suction pressure between 80 and 120 mmHg.
  • Limit suctioning to 3 passes and discontinue if heart rate drops by 20, increases by 40, produces arrhythmias, or decreases oxygen saturation to less than 90%.
  • Suction mouth after trach suctioning to remove secretions above a cuffed tube. Do not contaminate the trach by going from mouth back to trach.
  • Reassess the patient’s condition after suctioning and recommence oxygen therapy as soon as possible, ideally within 10 seconds of completing suctioning
Following these steps ensure that the nurse performs suctioning appropriately and that the patient does not not suffer from hypoxia as a complication from applying too much pressure or taking too long to suction secretions.
Ensure that the ties are properly secured and are changed at least once every 24 hours. This prevents dislodgement of the tubes and maintains the integrity of the tracheostomy. Follow the facility protocols in changing the tracheostomy ties.
Use sterile technique to clean the reusable cannula with half-strength hydrogen peroxide and normal saline solution, or normal saline. This prevents buildup of mucus and other sediments in the cannula and prevent infections.
Cuff pressure should be maintained in a range from 20 mmHg to 25 mmHg. Complications can arise quickly from excessive pressure that can inhibit capillary perfusion.
Clean the stoma with a Q-tip or gauze square moistened with normal saline solution (NSS). Avoid using hydrogen peroxide unless the site is infected. Using hydrogen peroxide can impair healing of the stoma site.

Nursing Diagnoses

Potential and actual nursing problems can be seen among patients who have tracheostomy. These nursing problems can be identified using a thorough assessment of the patient which involves both considering the verbalization of the patient and his symptoms and correlating these with the physical assessment and laboratory data. Below is a list of possible nursing diagnoses that can be made for patients: (Note: related factors will depend on the assessment data)

  • 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
  • Fear
  • Anxiety
  • Situational low self-esteem
  • Knowledge deficit
  • Health seeking behavior

Patient Education

The goal of tracheostomy for patients is to help improve oxygenation, ventilation and gas exchange. While some of these are created temporarily, some patients require to have the tracheostomy on a long-term basis. Therefore, patient education is an important aspect of care and should include both the patient and his significant others. Below are some patient education reminders to help ensure that the goal of creating a tracheostomy is met:

  • Prior to health education, allow the patient to verbalize his thoughts and feelings related to the tracheostomy as this would help facilitate better patient education.
  • Include in the teaching plan alternative ways for communication such as the use of pens and paper, writing slabs and flashcards to allow the patient to convey his thoughts.
  • Demonstrate to the patient and significant others the process in cleaning the stoma, changing the ties and tube replacement and ask them to demonstrate it back to ensure that they can do it with the correct technique.
  • Stress the importance of ensuring that the appliance/tube in the stoma is properly secured and is not pressing on other structures to prevent impeding circulation and prevent ulceration along with the insertion site.
  • Remind the patient to cover the hole with a cloth when outdoors to prevent dust, powder and pollen from entering the site.
  • Teach proper ways of humidifying the air.
  • Remind the patient that there are activities he cannot do such as swimming or anything that places a risk of aspiration.
  • Include in the teaching signs of a healthy stoma and what symptoms should be reported to the physician.

References

  1. Basavanthappa, B., (2015). Medical Surgical Nursing. New Delhi: Jaypee Brothers Medical Publishers.
  2. Billings, D. and Hensel, D., 2019. Lippincott Q & A Review For NCLEX-RN. 13th ed. St. Louis, MO., USA.: Wolters Kluwer Medical.
  3. Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia: Wolters Kluwer.
  4. Morton, P., & Fontaine, D. (2018). Critical Care Nursing. Wolters Kluwer.
  5. Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2019). Essentials for Nursing Practice (9th ed.). St. Louis: Elsevier.

2 COMMENTS

  1. @ Barbara Bansale: Your additional informations could really help. Thanks a lot! The cuff should really be inflated just to really make sure that the tube is in place while doing the changing. and yes, the manual rescucitation bag, just in case the patient becomes distress. Thanks a lot! =)

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