Tracheostomy Case Studies

Mrs. Sylvia Moore is 71-year-old woman admitted to ICU with pneumonia. She has a

history of COPD and CHF. A tracheostomy was inserted to facilitate long-term

mechanical ventilation. After 7 weeks in ICU, Mrs. Moore was transferred to a medical

unit. She has a cuffed, fenestrated tracheostomy tube with an inner cannula. A trach

cradle is providing humidification with a FiO2 of 30% and the client requires minimal

suctioning. Mrs. Moore has expressed a great deal of anxiety at the prospect of having

the tracheostomy plugged.

1. Describe your nursing assessment of the client with a tracheostomy.

•Level of consciousness

•Assess patient’s ability to protect their own airway

•Observation of work of breathing

•Auscultate breath sounds and to evaluate presence of secretions

•Vital signs and SpO2

•Oxygen equipment and humidity

•Tracheostomy type and size

•Tracheostomy tube cuffed or non-cuffed, inner cannula or no inner cannula

2. Discuss nursing care of the client with a tracheostomy. Include strategies to help

Mrs. Moore deal with her anxiety.

Routine tracheostomy care and dressing changes are done every 12 hours, palpate the

tracheostomy site for any signs of pain, inspect dressing for drainage or odour and inspect

tracheostomy skin ties to make sure the are secure. Ensuring all safety equipment is at the

bedside. Have Mrs. Moore discuss with you her concerns and anxiety and give her the

teaching necessary on ways to reduce the likelihood of having the tracheostomy plugged.

3. Explain the causes and prevention of the following complications:

a. Hypoxia

Cause: Ineffective oxygenation before, during and after suctioning, use of a suction

catheter that is too large for the tracheostomy tub, prolonged suctioning time, excessive

suction pressure, frequent suctioning

Prevention: Allow the patient to spontaneously breathe 100% O2 for one minute prior to

suctioning. After suctioning, assist the patient’s breathing efforts as necessary to alleviate

dyspnea and hypoxemia, do not suction for longer than 10-15 seconds, set suction

pressure to 120-150 mmHg (for adults), allow a patient a minimum of 5 breaths before

repeating suctioning, ensure suction catheter is completely withdrawn and control valve

is turned to the “lock” position after suctioning

b. Tissue trauma

Cause: Frequent suctioning, prolonged suctioning time, excessive pressure

Prevention: Assess the patient to determine the need for suctioning, do not suction for

longer than 10-15 seconds and allow a minimum of 5 breaths before repeating procedure,

when inserting a suction catheter, pull back on the catheter slightly when a slight

obstruction is felt before applying suction

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Mrs. Sylvia Moore is 71-year-old woman admitted to ICU with pneumonia. She has a history of COPD and CHF. A tracheostomy was inserted to facilitate long-term mechanical ventilation. After 7 weeks in ICU, Mrs. Moore was transferred to a medical unit. She has a cuffed, fenestrated tracheostomy tube with an inner cannula. A trach cradle is providing humidification with a FiO2 of 30% and the client requires minimal suctioning. Mrs. Moore has expressed a great deal of anxiety at the prospect of having the tracheostomy plugged.

Describe your nursing assessment of the client with a tracheostomy.
- Level of consciousness
- Assess patient’s ability to protect their own airway
- Observation of work of breathing
- Auscultate breath sounds and to evaluate presence of secretions
- Vital signs and SpO
- Oxygen equipment and humidity
- Tracheostomy type and size
- Tracheostomy tube cuffed or non-cuffed, inner cannula or no inner cannula
Discuss nursing care of the client with a tracheostomy. Include strategies to help Mrs. Moore deal with her anxiety. Routine tracheostomy care and dressing changes are done every 12 hours, palpate the tracheostomy site for any signs of pain, inspect dressing for drainage or odour and inspect tracheostomy skin ties to make sure the are secure. Ensuring all safety equipment is at the bedside. Have Mrs. Moore discuss with you her concerns and anxiety and give her the teaching necessary on ways to reduce the likelihood of having the tracheostomy plugged.
Explain the causes and prevention of the following complications: a. Hypoxia Cause: Ineffective oxygenation before, during and after suctioning, use of a suction catheter that is too large for the tracheostomy tub, prolonged suctioning time, excessive suction pressure, frequent suctioning Prevention: Allow the patient to spontaneously breathe 100% O2 for one minute prior to suctioning. After suctioning, assist the patient’s breathing efforts as necessary to alleviate dyspnea and hypoxemia, do not suction for longer than 10-15 seconds, set suction pressure to 120-150 mmHg (for adults), allow a patient a minimum of 5 breaths before repeating suctioning, ensure suction catheter is completely withdrawn and control valve is turned to the “lock” position after suctioning b. Tissue trauma Cause: Frequent suctioning, prolonged suctioning time, excessive pressure Prevention: Assess the patient to determine the need for suctioning, do not suction for longer than 10-15 seconds and allow a minimum of 5 breaths before repeating procedure, when inserting a suction catheter, pull back on the catheter slightly when a slight obstruction is felt before applying suction

c. Infection Cause: Bacteria entering the trachea during suctioning procedure Prevention: Suction and instill saline only when indicated, use the in-line system for suctioning tracheostomies, the in-line system is changed by the RT when it becomes contaminated and according to protocol. d. Bronchospasm Cause: Irritation of the airway causes bronchospastic response Prevention: If it is difficult to bag due to bronchospasm, the patient may require a bronchodilator to relieve distress

Demonstrate suctioning of a tracheostomy tube using a sterile glove and catheter set to collect a specimen.
- Check physician order if applicable.
- Select catheter no larger than one-half diameter of patient’s airway and appropriate length:
- Assess lung sounds prior.
- Dons clean gloves.
- Open catheter package, leave protective covering over catheter.
- Set regulator to control vacuum level of suctioning 120-150 mm Hg.
- Place client semi-Fowler’s position, or dorsal recumbent with head tilted backward to open airway.
- Perform any procedures that loosen secretions (i.e. postural drainage, percussion, nebulization).
- Administer 100% oxygen 1-2 mins to hyper oxygenate prior if patient unable to breathe deeply, 3-5 deep ventilations with BVM.
- Open sterile irrigation solution, pour into sterile cup, open suction catheter package.
- Dons sterile glove on dominant hand.
- Pick up suction catheter with sterile hand and attach suction-control port of tubing if suction source (held with non-sterile, non-dominant hand). Attach sputum trap if specimen is needed.
- Slide sterile hand from control-port to suction to facilitate control of tubing, or wrap tubing around hand.
- Lubricate 3-4 cm of catheter tip with irrigating solution.
- Perform suction:
- Insert catheter into Tracheostomy tube using slanted downward motion (making sure finger is not covering opening of suction port) until resistance is met or coughing is initiated. Pull back catheter 1cm before applying suction.
- Place thumb over suction port.
- Encourage patient to cough.
- Withdraw catheter in a circular motion, rotating between thumb and finger.
- Do not suction for more than 10-15 sec.
- Place tip suction catheter in sterile NS solution, apply suction 1-2 sec. to clear clogged suction catheter and tubing.

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Tracheostomy Case Studies