Tracheostomy is a surgical procedure that involves creating an opening in the neck and inserting a tube, also known as a tracheostomy tube. The tube is inserted into a person’s trachea and allows them to breathe.
A nursing care plan for tracheostomy helps ensure safe, competent care of a patient who has undergone the procedure. It allows nurses to assess, plan, implement, and evaluate the care needs of the patient.
Physical assessment includes assessment of airway, breathing, and circulation, as well as any facial or neck injuries. The nurse should also assess the patient’s comfort level, as well as any risk factors for infection or bleeding, such as history of recurrent infection, poor oral hygiene, or exposure to chemical fumes.
Evaluation of mental status is an important part of the assessment. Nurses should look for signs of anxiety, depression, confusion, and potential difficulties with coping.
Nurses can use a variety of nursing diagnoses to develop a care plan for a patient who has undergone tracheostomy. These include risk for infection, altered airway management, impaired verbal communication, ineffective breathing pattern, and risk for unstable cardiovascular status.
Risk for infection may be related to open wound and/or compromised immune system. The nurse should assess for signs of local or systemic infection, such as fever, redness, and swelling.
Altered airway management is related to the tracheostomy tube. The nurse should assess the patient’s ability to cough, speak, and swallow, as well as their ability to manage and remove the tracheostomy tube.
The desired outcomes of nursing care plan for tracheostomy depend on the individual patient, but common goals include improved airway management and maintenance of a patent airway. Nurses also aim to promote comfort and reduce the risk of infection.
Examples of interventions for patients with tracheostomy include:
- Assess for signs and symptoms of infection
- Inspect wound site for signs of infection
- Provide patient and family education about the tracheostomy tube and the daily care needed
- Provide airway clearance techniques, as appropriate
- Instruct patient on proper care of tracheostomy tube and suctioning as needed
Rationales for interventions are based on evidence-based practice and data collected during the assessment stage. Rationales help nurses justify the interventions they choose to carry out. For example, providing airway clearance techniques can help prevent aspiration and other complications associated with tracheostomy.
Evaluating the outcomes of nursing care plans is essential to ensure the effectiveness of care. Some evaluation criteria for tracheostomy machines include:
- Patient’s airway is patent.
- Patient is comfortable and free from infection.
- Patient is able to effectively manage and remove tracheostomy tube.
- Patient and family have sufficient knowledge about tracheostomy care.
A nursing care plan is an important tool for providing safe, effective care to patients who have undergone a tracheostomy. By assessing patient’s physical and mental health, as well as the risk factors associated with tracheostomy, nurses can develop an individualized care plan that meets the patient’s needs.
- What is a tracheostomy? – A tracheostomy is a surgical procedure that involves creating an opening in the neck and inserting a tube, also known as a tracheostomy tube. The tube is inserted into a person’s trachea and allows them to breathe.
- What is a nursing care plan? – A nursing care plan is a systematic approach to providing individualized care for a patient. The plan includes assessment, diagnosis, outcomes, interventions, rationales, and evaluation components.
- How often should the tracheostomy tube be changed? – Tracheostomy tubes should be changed every three to four weeks or as recommended by the physician.
- What type of suctioning technique should be used with a tracheostomy? – Low-pressure, intermittent suctioning should be used with a tracheostomy.
- What are common outcomes of a nursing care plan for tracheostomy? – Common outcomes of a nursing care plan for tracheostomy include improved airway management and maintenance of a patent airway, promotion of comfort, and reduction of the risk of infection.