Tracheostomy Care of adults For BNS student

1. 7/24/2022
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2. UNIT-1(1.1)
RESPIRATORY SYSTEM
TracheoStomy care
PREPARED BY:
Arpana Bhusal
BNS
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3. Content layout
 Definition
 Purpose
 Indication
 Contraindication
 Equipments for tracheostomy insertion.
 Goals of tracheostomy care.
 Equipments for tracheostomy care.
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4. Content Layout
 Components and Types of tracheostomy tube
 Care of patient with tracheostomy
 Daily care of patient with tracheostomy.
 Nursing management
 Complication.
 Preventing complication associated with tracheostomy
tube
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5. DEFINITION
 Trachea = windpipe
 Ostomy = surgical opening in the body
 Tracheostomy is a surgical procedure which consist of
making an artificial opening on the anterior aspect of neck
and opening a direct airway through an incision in the
trachea(2-3/3-4 tracheal rings).
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6. DEFINITION (1/4)
 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 ventilatory support and/ or the removal of
tracheobronchial secretions.
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9. PURPOSE
a) To maintain the airways to facilitate the therapeutic
exchanges of gases.
b) To remove trachea bronchial secretion.
c) To maintain optimum physical comfort.
d) To decrease airway resistance.
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10. PURPOSE
e) To provide a method of mechanical ventilation.
f) To improve respiratory insufficiency.
g) To prevent from aspiration and transmission of
pathogenic micro-organisms.
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11. INDICATION
1. Airway obstruction
 Hemorrhage after thyroid surgery or upper airway
bleeding.
 Foreign bodies impacted in larynx.
 Trauma to larynx or pharynx.
 Acute edema of epiglottis e.g. diphtheria,
Facial burns
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13. indication
2. Congenital cause
 Laryngeal weakness stenosis
 Inflammatory disease conditions
 Tracheal laryngeal fracture
 Need for continuous mechanical ventilation
 Tumor in the respiratory airway
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14. indication
3. Retained secretions in tracheo-bronchial tree
 Unconscious patient following head injury and poisoning.
 Chest injury patient who is unable to cough.
 Paralysis of the muscles of respiration.
 Tetanus
 For radical surgery in the neck e.g. laryngectomy.
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15. INDICATION
4. Others
 To protect / minimize risk of aspiration in the patients
with poor or absent cough reflex
 Neurologic conditions (Amyotrophic lateral sclerosis)
 Severe sleep apnea
 Laryngeal hypoplasia
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16. CONTRAINDICATION
 No absolute contraindications exist to tracheostomy.
 Relative contraindication is Laryngeal CA.
 Tracheo-esophageal fistula.
 Cancer in upper GI or respiratory tract
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17. EQUIPMENTS FOR TRACHEOSTOMY
INSERTION
 Tracheostomy tube (size 6-9 mm for most adults)
 Sterile instruments: blade, forceps, suture material,
scissors
 Sterile gown and gloves
 Cap and face shield
 Antiseptic preparation solution
 Gauze pads
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18. EQUIPMENTS FOR TRACHEOSTOMY
INSERTION
 Shave preparation kit
 Sedation
 Local anesthetic and syringe
 Resuscitation bag and mask with oxygen source
 Suction source and catheters
 Syringe for cuff inflation
 Respiratory support available for post
tracheostomy(mechanical ventilation, tracheal oxygen mask,
CPAP)
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19. TRACHEOSTOMY CARE
GOALS
 To maintain airway patency by removing mucous and
encrusted secretions.
 To maintain cleanliness and prevent infections to the
tracheostomy site.
 To facilitate healing and maintain skin intergrity.
 To promote comfort and prevent displacement.
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20. EQUIPMENTS FOR TRACHEOSTOMY CARE
 Sterile disposable tracheostomy cleaning kit or supplies
( sterile containers, sterile nylon brush or pipe cleaner)
 Sterile applicators ( gauze squares)
 Sterile suction kit and Sterile normal saline
 Sterile gloves and clean gloves
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21. EQUIPMENTS
 Towel to drape to protect bed linens
 Sterile gauze dressing, cotton twill ties and clean scissors
 Moisture proof bag
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22. Disposable tracheostomy cleaning kit

23. BED SIDE EQUIPMENTS
 Spare tracheostomy tubes same size and type as the patient is
wearing
 Tracheal dilator
 Suctioning equipment
 Oxygen equipment with humidification
 Gloves (non sterile)
 Gloves (sterile) for suctioning
 Infectious waste bag
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24. Tracheal dilator

25. Tracheostomy tube
 Tracheostomy tube is a curved tube that is inserted into
the tracheostomy stoma made of plastic rubber or metal.
 Tracheostomy tubes have an outer cannula that is
inserted into the trachea and a flange that rests against the
neck and allows the tube to be secured in place with tape
or ties.
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26. TRACHEOSTOMY TUBE
 Tracheostomy tubes also have an obturator which is used
to insert the outer cannula which is then removed
afterwards. The obturator is kept at the client's bedside in
case the tube becomes dislodge and needs to be
reinserted.
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27. COMPONENTS OF TRACHEOSTOMY TUBE
 Outer cannula
 Inner cannula: fits snugly into outer tube, can be easily
removed for cleaning
 Flange: Flat plastic plate attached to outer tube –lies flush
against the patient’s neck
 15mm outer diameter termination: Fits all ventilator and
respiratory equipment.
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29. PARTS OF TRACHEOSTOMY TUBE
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30. TYPES OF Tracheostomy TUBE
1. Metal Tube 2.Plastic tube
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31. TYPES OF TRACHEOSTOMY TUBE
3. Cuffed and uncuffed 4. Fenestration
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32. TYPES OF TRACHEOSTOMY TUBE
5. Single and double lumen
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33. CARE OF PATIENT WITHTRACHEOSTOMY
1. PREPARATIVE PHASE
 Assess the condition of the patient .
 Bathing or scrubbing the local skin area with antiseptic
procedures.
 Keep the patient in NPO.
 Promote rest and sleep
 Collect informed consent, report of diagnostic test .
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34. CARE OF PATIENT WITHTRACHEOSTOMY
 Provide the preoperative medications.
 Instruct patient to remove jewellery, dentures, contact
lenses
 Perform mouth care
 Place the identification band.
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35. CARE OF PATIENT WITHTRACHEOSTOMY
2. PERFORMANCE PHASE
 Explain the procedure to the patient. Discuss a
communication system with the patient
 Obtain consent for operative procedure
 Shave a neck region
 Assemble equipments. Using aseptic technique.
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36. CARE OF PATIENT WITHTRACHEOSTOMY
 Position the patient (in a supine position with head
extended and a support under the shoulders)
 Obtain an order for and apply soft wrist restraints if the
patient is confused.
 Give medication if ordered
 Position the light source
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37. CARE OF PATIENT WITHTRACHEOSTOMY
 Assist with antiseptic preparation
 Assist with gowning and gloving
 Assist with sterile draping
 Put on face shield
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38.  During procedure, monitor the patient’s vital signs,
suction as necessary , give medication as prescribed, and
be prepared to administer emergency care.
 Immediately after the tube is inserted , inflate the cuff.
The chest should be ausculted for the presence of bilateral
breath sounds.
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CARE OF PATIENT WITHTRACHEOSTOMY

39. CARE OF PATIENT WITHTRACHEOSTOMY
 Secure the tracheostomy tube with tapes or other securing
device and apply dressing
 Apply appropriate respiratory assistive device(mechanical
ventilation. Tracheostomy, oxygen mask, CPAP)
 Check the tracheostomy tube cuff pressure
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40. 3. Follow up phase/ Post-operative phase
 Check the symmetry of chest expansion.
 Auscultate the breathe sound of anterior and the lateral chest
bilaterally .
 Obtain order for chest x-ray to verify proper tube
placement.
 Check cuff pressure every 8-12 hrs
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CARE OF PATIENT WITHTRACHEOSTOMY

41. CARE OF PATIENT WITHTRACHEOSTOMY
 Monitor the sign and symptoms of aspiration
 Assess vitals signs and breath sounds; note tube size
used, physician performing procedure, type, dose, and
route of medications given.
 Assess and chart condition of stoma: bleeding, swelling,
subcutaneous air
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42. CARE OF PATIENT WITHTRACHEOSTOMY
 Administer oxygen concentration as prescribed by
physician
 Secure the tube to the patient face with the tape, and
mark the proximal end for position maintenance.
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43. Use the sterile suction technique and airway care to
prevent iatrogenic contamination and infection.
Continue to reposition patient every 2 hours and as needed
to prevent atelectasis and to optimize lung expansion.
Provide oral hygiene and suction the oropharynx whenever
required.
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CARE OF PATIENT WITHTRACHEOSTOMY

44. CARE OF PATIENT WITHTRACHEOSTOMY
Maintain patency of tracheostomy tube and airway
 Frequent atraumatic suction.
 Humidification of inspired air and oxygen
 Fowler’s position to aid in breathing
 Maintain adequate fluid intake
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45. CARE OF PATIENT WITHTRACHEOSTOMY
 Provide frequent mouth wash
 Mucolytic agents
 Coughing and physiotherapy
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46. CARE OF PATIENT WITHTRACHEOSTOMY
 Prevent infection and complication:
 Aseptic tube suction, handling and tube changing
 Prophylactic antibiotics
 An extra tube, obturator, and tracheostomy kit should be
kept at the bedside. In the event of tube dislodgement,
reinsertion of a new tube mat be necessary .
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47. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
1.Assessment
 An increased monitoring of the patient’s blood pressure,
respiratory rate, pulse and color is necessary
 An increased in the respiratory rate, wheezes ,an
increased pulse rate may indicate the need for suction
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48. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
 Cyanosis and distress not relieved by suctioning should
be reported promptly
 Increasing restlessness with a rapid pulse rate may
indicate hypoxia or bleeding
 Observe the wound for bleeding and then check daily for
signs of infection
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49. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
2.Maintain an open airway:
 Assess the patient regularly for excess secretions and
suction and clean the tube as indicated.
 The trachea is suctioned using a sterile glove and a sterile
suction catheter moisture in sterile water or normal saline
with aseptic technique.
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50. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
 Frequent repositioning of the patient
3. Suctioning
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51. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
 Suctioning raises the risk of hypoxemia, bronchospasm,
and other adverse reactions, so suction only when needed,
not on a set schedule, and suction for the shortest time
necessary to clear secretions.
 Suctioning can be an uncomfortable and scary experience
for the patient, so thoroughly explain the procedure to
him before start.
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52.  Indications for suctioning include coughing, secretions in
the airway, respiratory distress, presence of rhonchi on
auscultation, increased peak airway pressures on the
ventilator, and decreasing SaO2 or PaO2.
 Comfortable position of the patient.
 Maintain aseptic technique .
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DAILY CARE OF PATIENT WITH
TRACHEOSTOMY

53. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
4.Cleaning of the tracheostomy tube and wound care:
 Tracheostomy care includes cleaning or changing the
inner cannula, changing the dressing and tracheostomy
tube holder, and suctioning if needed.
 Never clean and reuse a disposable cannula.
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54. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
 Unlock and remove the inner cannula and place it in a solution
of equal parts hydrogen peroxide and 0.9% sodium chloride
unless the manufacturer directs otherwise.
 The inner cannula of the tracheostomy tube is carefully
removed, cleansed every 3-5 hours or as often as
necessary(perhaps even hourly)
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55.  Remove encrusted secretions from the lumen with sterile
pipe cleaners.
 After cleaning, rinse the cannula thoroughly with sterile
0.9% sodium chloride solution.
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DAILY CARE OF PATIENT WITH
TRACHEOSTOMY

56. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
 Reinsert the inner cannula and securely lock it into place.
 Stoma should be cleaned everyday carefully without
dislodging tube.
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57. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
5.Humidification:
 Maintaining humidification is another key nursing
responsibility.
 Provide constant airway humidification to avoid
thickening and crusting of bronchial secretion .
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58. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
 Ensure humidification of inspired air placing a piece of moist
gauze over the tracheostomy tube so that the air takes up the
moisture.
 Humidifier is useful.
 In addition, patient must be properly hydrated; for example,
with I.V. fluids.
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59. DAILYCARE OF PATIENT WITHTRACHEOSTOMY
6.Mouth care:
 Provide frequent mouth care in every 2 hours for the
patient’s comfort and to reduces the possibility of
infection.
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60. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
7.Nutrition:
 If the patient eats by mouth, it is recommended that the
tracheostomy tube be suctioned prior to eating. This often
prevents the need for suctioning during or after meals,
which may stimulate excessive coughing and could result
in vomiting
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61. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
 Encouraging fluid intake is helpful for a patient with a
tracheostomy. Increased fluid intake will thin and loosen
secretions making coughing and suctioning easier.
 Always observe the patient while eating to be sure food
does not get into the trachea.
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62. DAILY CARE OF PATIENT WITH
TRACHEOSTOMY
8. Communication
9. Documentation
 Document the patient's response each time you suction,
including his vital signs, cardiac rhythm, oxygen
saturation, amount and consistency of secretions, breath
sounds, and the frequency of needed suctioning
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63. NURSING MANAGEMENT
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64. NURSINGASSESSMENT
 Frequent monitoring of the patients blood pressure ,
respiratory rate, pulse and color is necessary.
 An increased in the respiratory rate , wheezes, an
increased pulse rate may indicate the need for suction.
 Cyanosis and distress not relieved by suction should be
reported promptly.
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65. NURSING ASSESSMENT
 Increasing restlessness with a rapid pulse rate may
indicate hypoxia or bleeding.
 Observe the wound for bleeding in the immediate post-
operative period and then check daily for signs of
infection and sloughing.
 Assess patient ability to understand the spoken word.
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66. NURSING ASSESSMENT
 Assess patients ability to expression.
 Assess and observe swallowing reflexes , gag reflexes.
 Assess mental status confusion , lethargy , restlessness.
 Assess amount, color, consistency of secretion.
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67. NURSING DIAGNOSIS
1. Ineffective airway clearance related to presence of
artificial airway (tracheostomy) as evidenced by
tachypnea and changes in breathing pattern.
2. Impaired verbal communication related to presence of
artificial airway as evidenced by difficulty in maintaining
the usual communication pattern.
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68. Nursing diagnosis
3) Anxiety related to threat to self concept as evidenced by
expressed feeling of distress over the presence of
tracheostomy.
4) Knowledge deficit related to new procedure or
intervention in hospital as evidenced by increased
questioning.
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69. Nursing diagnosis
5) Risk for infection related to surgical incision of
tracheostomy.
6) Risk of aspiration related to presence of tracheostomy.
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70. GOALS AND OUTCOME
1) Patient will maintain a clear ,open airways and ability to
effectively cough up secretion.
2) Patient will use a form of communication to get needs
met and to relate effectively with persons and
environment.
3) Patient will verbalize their own feeling.
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71. GOALS AND OUTCOME
4) Patient or caregiver will demonstrate the knowledge and
skills appropriate for tracheostomy care.
5) Patient will remain free of infection.
6) Patient will swallow meals without coughing, choking or
changing color.
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72. NURSING INTERVENTION
1. Maintaining airway clearance
 Assess changes in BP, Heart rate and temperature.
 Auscultate the lungs , presence of breathe sounds.
 Observe the color , consistency , and quantity of secretion
 Provide warm humidified air
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73. Nursing intervention
 Administer O2 as needed.
 Encourage patient to cough out secretion.
 Keep suction equipment and AMBU bag at bed side.
 Keep the patient in semi fowlers position.
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74. Nursing intervention
2. Promoting verbal communication
 Assess the clients communication ability.
 Assess the effectiveness of non verbal communication
methods.
 Place the patient in a room close to the nurses station.
 Provide a call light within easy reach at all times.
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75. Nursing intervention
 Provide alternative methods for communicating.
 Hand gestures
 Word and phrase cards
 Picture board
 Writing pad
 Pencil or pen
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76. Nursing intervention
3. Reducing anxiety
 Assess the level and manifestation of anxiety in patients.
 Allow patient to express fears and concerns to ask,
inquiries about disease and procedure.
 Inform of all procedure and care to the patient as well as
visitors.
 Provide psychological support.
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77. Nursing intervention
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4. Enhancing knowledge
 Assess the patients knowledge regarding the purpose and
care of tracheostomy.
 Provide instruction in sterile tracheostomy care and
suctioning.
 Instruct in the need to call health care provider if the
amount of secretion increases or change in color and
characteristics occurs.

78. NURSING INTERVENTION
5. Preventing infection
 Assess patients vital sign.
 Assess skin integrity under tracheal ties.
 Monitor white blood cell count.
 Observe the stoma for color, crusting lesions
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79. NURSING INTERVENTION
 Provide stoma care.
 Do not allow secretions to pool around the stoma , suction
the area , wipe with aseptic technique.
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80. NURSING INTERVENTION
6. Preventing aspiration
 Assess the ability to swallow and type of food
consistency.
 Encourage liquid initially in small amounts and gradually
increase as tolerated.
 Maintain in an upright sitting position during feeding.
 Suction fluids from mouth and airway.
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81. COMPLICATIONS
1. Immediate (at the time of operation):
 hemorrhage, air embolism, cardiac arrest apnea,
aspiration, pneumothorax, injury to laryngeal nerves and
esophagus, local damage (thyroid cartilage, cricoid
cartilage, recurrent laryngeal nerve).
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82. complications
2. Intermediate(during first few hours or days)
 bleeding, displacement of tube, blocking of tube,
subcutaneous emphysema, pneumothorax, scabs, tracheal
necrosis, tracheitis, local wound infection and dysphagia
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83. COMPLICATIONS
3. Late (with prolonged use of tube for weeks and months):
 laryngeal stenosis, tracheal stenosis, tracheo - esophageal
fistula.
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84. Preventing complications WITH TUBE
 Administer adequate warmed humidity: steam inhalation,
nebulization, keeping wet gauze piece over the
tracheostomy site and changing it as per need.
 Maintain cuff around tube
 Suction as needed per assessment findings
 Maintain skin integrity. Change tape and dressing as
needed or per protocol
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85. Preventing complication WITH TUBE
 Ascultate lungs sounds
 Monitor for signs and symptoms of infection, including
temperature and white blood cell count
 Protein rich diet should be provided for early healing of
incision site.
 Administer prescribed oxygen and monitor oxygen
saturation
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86. PREVENTINGCOMPLICATION WITH TUBE
 Monitor for cyanosis
 Maintain adequate hydration of the patient
 Use sterile technique when suctioning and performing
tracheostomy care
 Emergency drugs should be ready
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88. REFRENCES
 Smeltzer.S.G. Bare.B.G. Hinkle.J.G. Cheezer K.H.(2010)
“Brunner & Suddarth’s textbook of Medical- Surgical
Nursing", Volume 1. (12th edition). New Delhi, Kluwer
India. Pvt. Ltd. 2078/04/10 at 1 pm
 Mandal G.N (2016) “A Textbook Of Medical Surgical
Nursing”. 5th edition. Kathmandu. Makalu Publication
House.2078/04/11at 3 pm.
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89. REFRENCES
 2019. Mayo Foundation Of Medical Foundation And
Research. Tracheostomy care
https://www.mayoclinic.org@2021/08/02at 3pm.
 Nov4,2019,tracheostomy care
https://www.slideshare.net/gamandeep@2021/08/03 at
5pm
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