{
  "name": "Tracheostomy Care",
  "slug": "tracheostomy-care",
  "url": "https://nursingplex.com/care-plans/tracheostomy-care",
  "category": "Respiratory",
  "summary": "Stoma and tube management, suctioning, humidification and emergency preparedness.",
  "nursing_diagnoses": [
    "Ineffective airway clearance",
    "Impaired verbal communication",
    "Risk for infection"
  ],
  "overview": [
    "A tracheostomy is a surgical opening into the trachea with a tube that provides a stable airway. It is placed for prolonged ventilation, upper airway obstruction, secretion clearance or airway protection. Compared with an endotracheal tube it is more comfortable, reduces dead space and laryngeal injury, and permits eating and sometimes speaking — but it bypasses the nose and mouth entirely, so inspired air is no longer warmed, humidified or filtered, and the cough loses much of its force.",
    "That loss of natural conditioning is the source of most complications: thick, tenacious secretions that plug the tube. Continuous humidification, adequate systemic hydration and appropriate suctioning prevent the emergency of a mucus plug. The other defining nursing responsibility is preparedness — an obturator, a same-size tube, a smaller-size tube and suction must be at the bedside every moment, because accidental decannulation in the first week before the tract matures is a true airway emergency requiring reinsertion or oral ventilation while covering the stoma."
  ],
  "key_facts": [
    {
      "label": "Bedside always",
      "text": "Obturator, a spare tube of the same size, a tube one size smaller, suction, and a bag-valve device."
    },
    {
      "label": "Suction technique",
      "text": "Preoxygenate, insert without suction, apply intermittent suction while withdrawing, limit to about 10 seconds and no more than three passes."
    },
    {
      "label": "Humidification",
      "text": "Mandatory — the upper airway no longer conditions air; dryness causes plugging and mucosal damage."
    },
    {
      "label": "Cuff pressure",
      "text": "Keep at 20–30 cm H2O; a deflated or cuffless tube is needed for speaking valve use."
    },
    {
      "label": "Speaking valve",
      "text": "One-way valve requires cuff fully deflated — using it with an inflated cuff prevents exhalation and is life-threatening."
    }
  ],
  "nursing_priorities": [
    "Maintain airway patency and be prepared for tube obstruction or dislodgement.",
    "Keep secretions thin through humidification, hydration and appropriate suctioning.",
    "Prevent stoma infection and skin breakdown.",
    "Establish reliable communication for a patient who cannot phonate.",
    "Assess swallowing safety and prevent aspiration.",
    "Prepare the patient and family for competent home care."
  ],
  "assessment": {
    "subjective": [
      "Nonverbal signals of dyspnea, need to be suctioned, pain or anxiety",
      "Frustration and isolation from inability to speak",
      "Reports of difficulty swallowing or coughing during meals",
      "Family fears about managing the tube at home and about emergencies",
      "Body-image distress about the visible tube and stoma"
    ],
    "objective": [
      "Respiratory rate, effort, breath sounds, oxygen saturation and audible gurgling or whistling",
      "Secretion volume, color, consistency and odor; resistance during suction passes",
      "Stoma appearance: redness, purulent drainage, granulation tissue, maceration, bleeding",
      "Skin under the ties and flange, including the posterior neck",
      "Tube position, security of ties, presence and integrity of the inner cannula",
      "Cuff pressure readings and audible cuff leak",
      "Subcutaneous emphysema around the neck and chest",
      "Signs of aspiration: coughing with meals, wet voice, food or tinted secretions in suction returns, fever"
    ],
    "related_factors": [
      "Bypass of the upper airway with loss of humidification, filtration and effective cough",
      "Thick tenacious secretions and impaired mucociliary clearance",
      "Surgical stoma providing a direct portal for infection",
      "Loss of airflow through the vocal cords preventing speech",
      "Altered swallowing mechanics and tethering of the larynx"
    ]
  },
  "goals": [
    "The client will maintain a patent airway with clear breath sounds and saturation above the ordered target.",
    "The client will have thin, easily cleared secretions and no episode of tube obstruction.",
    "The client's stoma will remain clean, intact and free of infection.",
    "The client will communicate needs consistently using an established method.",
    "The client will remain free of aspiration and maintain adequate nutrition.",
    "The client and caregiver will independently perform suctioning, inner cannula and stoma care before discharge."
  ],
  "interventions": [
    {
      "title": "1. Maintaining airway patency and emergency readiness",
      "points": [
        "Keep the obturator, a same-size spare tube, a smaller spare tube, suction equipment and a bag-valve device at the bedside at all times and check them each shift.",
        "Assess respiratory status, breath sounds and secretions at least every 2–4 hours and whenever distress or noisy breathing appears.",
        "For accidental decannulation, immediately attempt reinsertion using the obturator with the neck extended; if the tract is immature or reinsertion fails, cover the stoma and ventilate by bag-valve-mask over the mouth and nose while calling for emergency help.",
        "For a suspected mucus plug, attempt suction, then remove and replace or clean the inner cannula; if obstruction persists, call for emergency airway assistance.",
        "Secure ties snugly enough to admit one finger and change them with a second person holding the tube; never leave the tube unsecured.",
        "Report bright red bleeding from the stoma or pulsatile bleeding immediately, as it may signal a tracheoinnominate fistula."
      ]
    },
    {
      "title": "2. Suctioning and secretion management",
      "points": [
        "Suction only when clinically indicated — visible or audible secretions, rising pressures, desaturation, ineffective cough — not on a fixed schedule.",
        "Preoxygenate, use sterile technique, insert the catheter without suction applied, then apply intermittent suction while withdrawing and rotating.",
        "Limit each pass to about 10 seconds and to no more than three passes, allowing recovery and reoxygenation between them.",
        "Choose a catheter no larger than half the internal diameter of the tube and monitor heart rate, rhythm and saturation throughout.",
        "Provide continuous humidification with a heated humidifier, tracheostomy collar or heat-moisture exchanger and maintain generous systemic hydration.",
        "Clean or replace the inner cannula per protocol at least once per shift and more often with heavy secretions.",
        "Encourage deep breathing, position changes and assisted coughing to move secretions proximally."
      ]
    },
    {
      "title": "3. Stoma and skin care",
      "points": [
        "Cleanse the stoma with normal saline or prescribed solution using sterile technique, working from the tube outward, at least once per shift.",
        "Use a pre-cut manufactured tracheostomy dressing — never cut gauze, because loose fibers can be aspirated.",
        "Change the dressing whenever it is damp; moisture under the flange macerates skin rapidly.",
        "Inspect the neck under the ties, including posteriorly, and pad pressure points to prevent device-related pressure injury.",
        "Watch for granulation tissue, foul odor, purulent drainage, increasing redness or fever and report them."
      ]
    },
    {
      "title": "4. Communication and psychosocial support",
      "points": [
        "Establish a communication method before it is needed — writing board, picture chart, letter board, phone app or agreed gestures — and document it.",
        "Assess candidacy for a one-way speaking valve with speech therapy and verify the cuff is fully deflated before placement; never place it with an inflated cuff.",
        "Keep the call light in reach at all times and answer promptly; the inability to call out is deeply frightening.",
        "Allow time for responses, face the patient, and never speak about them as if they were absent.",
        "Acknowledge grief and body-image concerns and connect the patient with peer support and scarves or covers if desired."
      ]
    },
    {
      "title": "5. Nutrition, swallowing and home preparation",
      "points": [
        "Arrange a swallow evaluation before oral intake; deflate the cuff as directed for meals per team protocol.",
        "Position upright at 90 degrees for meals and for 30–60 minutes afterward, and use small bites with chin tuck as instructed.",
        "Watch for coughing, wet voice or tinted secretions in the suction return as evidence of aspiration and stop feeding.",
        "Teach the patient and caregiver full care with return demonstration: suctioning, inner cannula cleaning, stoma care, tie changes and emergency response.",
        "Teach shower and hygiene precautions — cover the stoma, no swimming, avoid aerosols, powders and loose fibers.",
        "Arrange home suction equipment, supplies, emergency contacts and home health follow-up before discharge, and advise medical alert identification."
      ]
    }
  ],
  "patient_teaching": [
    "Always keep the spare tubes, obturator and suction machine within reach — at home too.",
    "Suction when you hear or feel secretions, not on a clock; use clean technique and short passes.",
    "Keep humidity going and drink plenty of fluid so mucus stays thin and does not plug the tube.",
    "Never cut gauze for a dressing; use the manufactured split dressings only.",
    "Cover the stoma in the shower, never swim, and keep powders, sprays and pet hair away.",
    "Call for help immediately for bright red bleeding, a tube that comes out and will not go back, or breathing difficulty that suctioning does not fix.",
    "Wear medical alert identification stating you breathe through your neck."
  ]
}