nursing assessment report for patient with tracheostomy

When evaluating the patient after suctioning, assess and document physiologic and psychological responses to the procedure. Convey your findings verbally during nurse-to-nurse shift report and to the interdisciplinary team during daily rounds. Trach site care and dressing changes

Full Answer

What care is needed for a tracheostomy?

1. Adjust the wall suction to the appropriate level.
2. Explain the procedure to the client.
3. Open sterile packages and set up sterile field.
4. Auscultate the client's lung sounds for evaluation of the intervention
5. Don sterile gloves.
6. Adjust the bed and position the client.

What are the 4 types of nursing diagnosis with examples?

Four types of nursing diagnoses were identified: problem-focused, health promotion, risk, and syndrome.

When can a patient begin to swallow following tracheostomy?

While it has been suggested that oral intake should be considered and offered only when the tracheostomy cuff is deflated, new evidence has shown that cuff deflation does not result in swallowing success or increased swallowing safety. 13,14 It is, therefore recommended that patients be assessed on an individual basis.

What you should know about tracheostomy care?

WHAT YOU NEED TO KNOW: What is tracheostomy care? Tracheostomy (trach) care is done to keep your trach tube clean. This helps prevent a clogged tube and decreases your risk for infection. Trach care includes suctioning and cleaning parts of the tube and your skin.

What nursing assessment should be done on a patient with a tracheostomy?

AssessmentRespiratory status (ease of breathing, rate, rhythm, depth, lung sounds, and oxygen saturation level)Pulse rate.Secretions from the tracheostomy site (character and amount)Presence of drainage on tracheostomy dressing or ties.Appearance of incision (redness, swelling, purulent discharge, or odor)

What are 5 nursing considerations when caring for a patient with a tracheostomy?

ProcedureClearly explain the procedure to the patient and their family/carer.Perform hand hygiene.Use a standard aseptic technique using non-touch technique.Position the patient. ... Perform hand hygiene and apply non-sterile gloves.Remove fenestrated dressing from around stoma.More items...

How do you document a tracheostomy care?

Checklist for Tracheostomy Care With a Reusable Inner CannulaPerform hand hygiene.Check the room for transmission-based precautions.Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.Confirm patient ID using two patient identifiers (e.g., name and date of birth).More items...

How do you assess a trachea in nursing?

3:115:54Examination of the Trachea - YouTubeYouTubeStart of suggested clipEnd of suggested clipOne should place two fingers on either side of these muscles. And simply then run your middle fingerMoreOne should place two fingers on either side of these muscles. And simply then run your middle finger gently down the trachea. Using your other two fingers of points of reference.

Which assessment findings provide the best indication that the nurse needs to suction the client?

Findings that suggest the need for suctioning include increased work of breathing, changes in respiratory rate, decreased oxygen saturation, copious secretions, wheezing, and the patient's unsuccessful attempts to clear secretions.

Which action should the nurse take first when performing tracheostomy care?

The first nursing action for a patient following an airway procedure is to assess the patient's respiratory status; this requires auscultation of the lungs. Suction is not needed if the lungs are clear to auscultation.

What do you document after completing tracheostomy suctioning?

22.5: Checklist for Tracheostomy Suctioning and Sample DocumentationThe need to maintain the patency and integrity of the artificial airway.Deterioration of oxygen saturation and/or arterial blood gas values.Visible secretions in the airway.The patient's inability to generate an effective spontaneous cough.More items...•

How do you describe a tracheostomy secretion?

Secretions are a natural reaction to tracheostomy, not a sign of a problem. A trach tube bypasses the upper airway, which normally cleans and moistens the air. This causes the body to produce more secretions. When tracheostomy cuffs are kept inflated for a prolonged period, these secretions can pool in the airway.

What are the complications of tracheostomy?

Complications and Risks of TracheostomyBleeding.Air trapped around the lungs (pneumothorax)Air trapped in the deeper layers of the chest(pneumomediastinum)Air trapped underneath the skin around the tracheostomy (subcutaneous emphysema)Damage to the swallowing tube (esophagus)More items...

How do I document a normal neck assessment?

Documentation of a normal neck and back exam should look something along the lines of the following: Neck and back have no deformities, external skin changes, or signs of trauma. Curvature of the cervical, thoracic, and lumbar spine are within normal limits.

How do you complete a respiratory assessment?

Observe the patient for important respiratory clues:Check the rate of respiration.Look for abnormalities in the shape of the patient's chest.Ask about shortness of breath and watch for signs of labored breathing.Check the patient's pulse and blood pressure.Assess oxygen saturation.

What are the physical assessment skills required in respiratory assessment?

"A thorough respiratory assessment involves checking the respiratory rate, the symmetry, depth and sound (auscultation) of breathing, observes for accessory muscle use and tracheal deviation," says Ms Stokes-Parish.

The Resuscitation Flowchart

(currently under review, new chart coming soon)For a tracheostomy patient follows APLS principles.It is recommended that a copy of this flow chart...

Post Operative Management of A New Tracheostomy

After a tracheostomy is inserted, the patient is managed in either the Paediatric Intensive Care (PICU - Rosella) or Neonatal Unit (NNU - Butterfly...

Routine Tracheostomy Management

Routine tracheostomy management consists of: 1. Equipment & environment 2. Supervision and monitoring 3. Humidification 4. Suctioning 5. Management...

Equipment and Environment

Each shift ensure 1. All equipment for tracheostomy care is at the bedside and within easy access/reach 2. Tracheostomy kit to be available with th...

Tracheostomy Tube Changes

The frequency of a tracheostomy tube changes is determined by the Respiratory and ENT teams except in an emergency situation. This can vary dependi...

Tracheostomy Decannulation

Decannulation is a planned intervention for the permanent removal of the tracheostomy tube once the underlying indication for the tracheostomy has...

What is the goal of a nursing care plan for a client who had undergone a tracheost

Nursing care plan goals and objectives for a client who had undergone tracheostomy include maintaining a patent airway through proper suctioning of secretions, providing an alternative means of communication, providing information on tracheostomy care, and preventing the occurrence of infection.

How does a tracheostomy help with weaning?

A tracheostomy can facilitate weaning from mechanical ventilation by reducing dead space and lowering airway resistance. It also improves client comfort by removing the endotracheal (ET) tube from the mouth or nose. The tracheostomy is preferred over an ET when an artificial airway is needed for more than a few days.

How does a tracheostomy work?

Provide warm, humidified air. A tracheostomy bypasses the nose, which is the body area that humidifies and warms inspired air. A decrease in the humidity of the inspired air will cause secretions to thicken. Also, cool air may decrease the ciliary function.

Why should a tracheostomy cuff be kept at the lowest pressure?

An inflated cuff protects the airway and is required for mechanical ventilation. Cuffs should be kept at the lowest pressure to prevent tracheal erosion.

What is a tracheostomy collar?

Tracheostomy is a surgical procedure in which an opening is done into the trachea to prevent or relieve airway obstruction and/or to serve as access for suctioning and for mechanical ventilation and other modes of oxygen delivery (tracheostomy collar, T-piece).

What skills are needed to manage a tracheostomy tube?

Assess the ability to manage care at home. Both cognitive and technical skills are required for managing tracheostomy tubes. Assess the ability to respond to emergency situations. This information is especially important because the lack of airway patency is a life-threatening problem.

What is a tracheostomy reinsertion?

Tracheostomy reinsertion. Obtaining an audiotape for home use that can be played when emergency service is called. Preparing ahead of time can reduce distress and complications. The client will feel more secure in the home environment with a means for rapid communication in an emergency.

What is a tracheostomy diagnosis?

This is a nursing care plan and diagnosis for Tracheostomy or Tracheotomy. It includes nursing diagnosis for: Risk for in effective airway clearance, risk for infection, and impaired verbal communication. As a nurse you may encounter a patient who has a tracheostomy. In the medical setting you may hear it called a “trach”. A patient with a tracheostomy “breathes” through an opening that a surgeon through a procedure called a tracheotomy created through the trachea compared to how the average person who breathes through their nose. The nose in an average person acts as a filter (which filters out bacteria, virus, and debris from entering the lungs). However, this is not the case for a person who has a “trach”. A person with a tracheostomy is at risk for many different medical issues due to the in ability to clear secretions and the amount of care it takes to care for a tracheostomy etc.

What is the risk of ineffective airway clearance related to increased secretions secondary to tracheostomy?

Risk for ineffective airway clearance related to increased secretions secondary to tracheostomy as evidence by patient is post-opt from tracheostomy placement and is having increased secretions and difficulty removing them.

How often should you apply petroleum jelly to a stoma?

You have orders to administer saline drops every 2-4 hours to keep secretions from building up around the site and to apply petroleum jelly around the stoma every 3 hours to keep the stoma clean. In addition, the patient has a trach collar on with humidified oxygen at 30%.

What is the name of the procedure that a patient breathes through?

A patient with a tracheostomy “breathes” through an opening that a surgeon through a procedure called a tracheotomy created through the trachea compared to how the average person who breathes through their nose. The nose in an average person acts as a filter (which filters out bacteria, ...

How often should a nurse assess for humidity?

The nurse will maintain and assess for adequate humidity of inspired air every 2 hours. The nurse will keep stoma free from any debris or mucous buildup as needed. The nurse will deep suction the patient as needed. The nurse will educate the patient how to properly cough and deep breathe throughout the hospitalization.

Why is a patient admitted post-opt?

The patient is a little drowsy but slowing becoming more alert but is unable to communicate with you due to the inability to produce speech from the tracheostomy.

Is a tracheostomy a risk?

However, this is not the case for a person who has a “trach”. A person with a tracheostomy is at risk for many different medical issues due to the in ability to clear secretions and the amount of care it takes to care for a tracheostomy etc. Why is a tracheostomy used?

What is the purpose of a tracheostomy?

A tracheostomy is a surgical opening into the trachea below the larynx through which an indwelling tube is placed to overcome upper airway obstruction, facilitate mechanical ventilator support and/or the removal of tracheo-bronchial secretions.

What is a tracheostomy kit?

A tracheostomy kit is to accompany the patient at all times and this must be checked each shift by the nurse caring for the patient to ensure all equipment is available.

How does a tracheostomy affect a child's voice?

Children communicate in many different ways, such as using gestures, facial expressions and body postures, as well as vocalising. The tracheostomy may impact on the child's ability to produce a normal voice. For all patients with a new tracheostomy a referral to a speech pathologist for assessment and provision of communication aids is recommended.

How long does it take for a stoma to mature?

Trache stoma maturation takes approximately 5 – 7 days after insertion of the tracheostomy tube or 2 – 3 days if stoma maturation sutures are placed. The ENT team, in consultation with the parent medical team, will perform the first tube change, including the removal of the stay sutures.

Why do you suction a tracheostomy tube?

Suctioning of the tracheostomy tube is necessary to remove mucus, maintain a patent airway, and avoid tracheostomy tube blockages. The frequency of suctioning varies and is based on individual patient assessment.

What causes cardiac arrest in children with a tracheostomy?

Cardiorespiratory arrest most commonly results from tracheostomy obstructions or accidental dislodgement of the tracheostomy tube from the airway.

How is the frequency of a tracheostomy tube change determined?

The frequency of a tracheostomy tube changes is determined by the Respiratory and ENT teams except in an emergency situation. This can vary depending on the patient's individual needs and tracheostomy tube type.

What is the role of a nurse in tracheostomy?

Nurses play a vital role in providing effective tracheostomy care. Learning to care for a patient with tracheostomy requires the support and individual attention of the whole health care team.

What is the purpose of a tracheostomy tube?

A tracheostomy tube is inserted at the time of surgery to maintain a patent airway. The aim of tracheostomy is to bypass obstruction in the upper airway; to aid prolonged and assisted ventilation; and to facilitate the removal of respiratory secretions. Tracheostomy can be a temporary solution or a long-term measure.

What is tube dislodgement?

‘Tube dislodgement is displacement of tracheostomy tube by unintentional and unplanned tube removal. The displacement or dislodgement can be a partial or complete tube come out of the stoma or out of the trachea into the soft tissue of the neck’ (The Royal Free Hampstead NHS Trust, 2002).

What should healthcare administrators consider in their in-house quality assurance programmes?

Healthcare administrators should consider these guidelines in their in-house quality assurance programmes. Nurses should critically review the implications of these guidelines for their routine care delivery, trainee teaching and patient education needs.

Can a tracheostomy cause pneumonia?

The presence of a tracheostomy can adversely affect swallowing function in patients. A speech therapist will be able to perform in-depth investigations such as dysphagia screening. This is to reduce the risk of aspiration, which may lead to aspiration pneumonia. (St George’s Healthcare NHS Trust, 2000)

What is the role of tracheostomy in nursing?

When caring for a patient with a tracheostomy, nursing care includes suctioning the patient, cleaning the skin around the stoma, providing oral hygiene, and assessing for complications. Normal functions of the upper airway include warming, filtering, and humidifying inspired air.

What is the most common indication for tracheostomy?

The most common indication for tracheostomy is the need for long-term mechanical ventilation secondary to chronic respiratory failure. Other indications for tracheostomy include severe facial or or neck trauma or extensive surgery, congenital anomalies or upper airway obstruction.

How to clean a stoma?

Stoma care. Moisten cotton-tipped swabs or a gauze pad with sterile physiologic saline to clean the stoma, the outer cannula, and the faceplate. The peristomal area should be cleaned using a semicircular motion in an inward to outward direction. Pat the skin dry with gauze pads to prevent breakdown.

What is required for a tracheostomy tube?

Sterile technique and appropriate personal protection gear, including gown and eye protection , are required for providing tracheostomy tube care. Your facility may provide tracheostomy cleaning kits for nondisposable tracheostomy tubes that contain a brush and pipe cleaners for inner cannula cleaning. You must clean off all the secretions using a sterile solution, generally saline.

Why should tracheostomy tube cuffs be deflated?

Tracheostomy tube cuff pressure should be monitored using a manometer to reduce the risk of complications. 3 If no aspiration risk, tracheostomy tube cuffs should be deflated when a patient no longer requires mechanical ventilation.

What are the advantages of a tracheostomy?

Advantages of a tracheostomy compared with an endotracheal tube include facilitating oral hygiene, promoting patient comfort, providing a more secure airway, and decreasing the risk of tracheal necrosis.

How long after a tracheostomy should you contact a speech pathologist?

2 If a speech pathologist wasn't contacted prior to the procedure, consider contacting them within 24-48 hours after the tracheostomy.

What is a tracheostomy tube?

A tracheostomy is a temporary or permanent artificial opening (stoma) made into the trachea; a tracheostomy tube is inserted to maintain the patency of the stoma and the procedure can be performed either surgically or percutaneously. Box 1 lists the most common indications for tracheostomy insertion.

What is an emergency tracheostomy box?

An emergency tracheostomy box should be available for all patients with tracheostomies on critical care units, wards or at home. Key points. A tracheostomy is a temporary or permanent artificial opening in the trachea. Patients with a tracheostomy follow a complex pathway through critical care to general wards.

How to hold a tracheostomy tube in place?

A tracheostomy tube can be held in place by several different methods. At initial insertion, the tracheostomy will be held in place by suture and, in addition, a collar or twill ties may also be used. Once the sutures are removed, the tracheostomy must be secured in place by a Velcro collar or twill ties.

How often should a stoma site be cleaned?

The stoma site should be checked at least once a day, or more frequently if required, and this requires two nurses: one to hold the tube and one to clean the stoma site. The site should be cleaned using a tracheostomy wipe or with 0.9% sodium chloride solution, and dried thoroughly.

What is the purpose of humidification in a tracheostomy?

Humidification. As air passes through the mouth and the nose, it is warmed, filtered and moistened. Breathing via a tracheostomy bypasses the nose and mouth, so artificial humidification is crucial to keep the tracheostomy tube patent; humidification methods are outlined in Box 2. Box 2.

How far above the carina should a tube be?

An adult female can accommodate a tube up to 10mm and an adult male up to 11mm. Ideally the tube tip should be a few centimetres above the carina (a ridge at the base of the trachea separating the openings of the right and left main bronchi), and placement should be checked with an endoscope.

Is it safe to use a double cannula for tracheostomy?

The ICS (2014) notes that tracheostomy tubes with an inner cannula are inherently safer and are normally preferred. The double cannula allows routine inspection and clearance of secretions to prevent blockage of the tube, making it safer and easier to care for in a ward environment.

How does a tracheostomy affect the respiratory system?

The impact of a tracheostomy on the respiratory system includes thorough knowledge of respiration, methods of humidification and also suctioning techniques. In addition to this a tracheostomy may impact on swallowing, communication and body image.

Is tracheostomy care necessary in intensive care?

Tracheostomy care and management is more and more necessary in both the intensive care setting and the general ward. It is, therefore, ever more important that trained nurses are equipped with the appropriate skills, knowledge and support to meet the unique needs of each patient safely and competently.

What is tracheostomy care?

Tracheostomy care is provided on a routine basis to keep the tracheostomy tube’s flange, inner cannula, and surrounding area clean to reduce the amount of bacteria entering the artificial airway and lungs. See Figure 22.9 [1] for an image of a sterile tracheostomy care kit.

How often should you clean a tracheostomy tube?

Some inner cannulas are designed to be disposable, while others are reusable for a number of days. Follow agency policy for inner cannula replacement or cleaning, but as a rule of thumb, inner cannula cleaning should be performed every 12-24 hours at a minimum. Cleaning may be needed more frequently depending on the type of equipment, the amount and thickness of secretions, and the patient’s ability to cough up the secretions.

How to clean a stoma?

Clean the stoma with cotton applicators using one on the superior aspect and one on the inferior aspect. With your dominant, noncontaminated hand, moisten sterile gauze with sterile saline and wring out excess. Assess the stoma for infection and skin breakdown caused by flange pressure.

What dressing is used for a tracheostomy?

tracheostomy split sponge dressing. , sterile basin, normal saline, and a disposable inner cannula or a small, sterile brush to clean the reusable inner cannula). Perform safety steps: Perform hand hygiene. Check the room for transmission-based precautions.

How to check stoma site?

Inspect stoma site for redness, drainage, and signs and symptoms of infection. Remove the gloves and perform proper hand hygiene. Open the sterile package and loosen the bottle cap of sterile saline. Don one sterile glove on the dominant hand. Open the sterile drape and place it on the patient’s chest.

How to clean a cannula?

With your dominant hand, use a brush to clean the inner cannula. Place the brush back into the saline basin. After cleaning, place the inner cannula in the second saline basin with your nondominant hand and agitate for approximately 10 seconds to rinse off debris. Repeat cleansing with brush as needed.

How often should a stoma site be cleaned?

Stoma site should be assessed and a clean dressing applied at least once per shift. Wet or soiled dressings should be changed immediately. [3] . Follow agency policy regarding clearing the inner cannula; it should be inspected at least twice daily and cleaned as needed.