What are nursing interventions for a patient with a tracheostomy?
(See Tracheostomy tubes.) 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 are the priority nursing diagnosis for patients requiring a tracheostomy?
Here are nine nursing care plans and nursing diagnoses for tracheostomy:
- Ineffective Airway Clearance.
- Impaired Verbal Communication.
- Deficient Knowledge.
- Risk for Impaired Gas Exchange.
- Risk for Infection.
- Anxiety.
- Deficient Knowledge.
- Risk for Aspiration.
Which interventions should be included in the care plan for a patient with a nursing diagnosis of ineffective airway clearance related to pulmonary secretions?
Nursing Interventions for Ineffective Airway Clearance
- Optimal positioning (sitting position)
- Use of pillow or hand splints when coughing.
- Use of abdominal muscles for more forceful cough.
- Use of quad and huff techniques.
- Use of incentive spirometry.
- Importance of ambulation and frequent position changes.
What to do if tracheostomy comes out?
If the tracheostomy tube falls out
- If the patient normally required oxygen and/or is on a ventilator, place oxygen over the tracheal stoma site.
- Gather the equipment needed for the tracheostomy tube change.
- Always have a clean tracheostomy tube and ties available at all times.
- Wash your hands if you have time.
What is the first priority when caring for a client with tracheostomy?
Hydration is an important part of tracheostomy care, as dehydration can result in secretions becoming thick and dry, increasing the risk of a blocked tube. The majority of patients with a tracheostomy will be nil by mouth, and regular mouth care is essential in preventing problems, such as mouth ulcers and oral thrush.
What are nursing interventions for ineffective airway clearance?
Nursing Care Plan for Ineffective Airway Clearance 3
| Nursing Interventions for Ineffective Airway Clearance | Rationale |
|---|---|
| Prepare suction machine in the patient’s bedside. | The patient may not be able to cough out the foreign body and build up of secretions. Suctioning will prevent the worsening of obstruction. |
What is the nursing diagnosis of ineffective airway clearance?
Ineffective Airway Clearance is a common NANDA-I nursing diagnosis for pneumonia nursing care plans. This diagnosis is related to excessive secretions and ineffective cough or nonproductive coughing. Inflammation and increased secretions in pneumonia make it difficult to maintain a patent airway.
What safety precautions are necessary when caring for someone with a tracheostomy?
Wear clothing that is loose around your neck, and avoid clothing with loose fibres. In a bath or shower, avoid getting water into the tracheostomy. Cover the stoma so that no water gets in but you can still breathe. You can also shower with your back to the water.
Which of the following is the most important priority when caring for a patient for a newly placed tracheostomy?
Adherence to sterile technique is the most important factor in minimizing the patient’s risk for infection during tracheostomy care.
Which intervention should be included on the care plan for the patient at risk for aspiration pneumonia?
A patient with aspiration needs immediate suctioning and will need further lifesaving interventions such as intubation. Inform the physician or other health care provider instantly of noted decrease in cough/gag reflexes or difficulty in swallowing.
Which interventions should be included in the care plan for a patient with a nursing diagnosis of ineffective airway clearance?
Nursing Care Plan for Ineffective Airway Clearance 5 Encourage coughing up of phlegm. Suction secretions as needed. Perform steam inhalation or nebulization as required/ prescribed. To help clear thick phlegm that the patient is unable to expectorate.
What nursing intervention could be implemented to decrease risk for aspiration?
Mixing pills with food helps reduce risk for aspiration. Stop continual feeding temporarily when turning or moving patient. When turning or moving a patient, it is difficult to keep the head elevated to prevent regurgitation and possible aspiration. Provide oral care before and after meals.
What is the nursing care plan for a tracheostomy?
This is a nursing care plan and diagnosis for Tracheostomy or Tracheotomy. It includes nursing diagnosis for: Risk for ineffective airway clearance, risk for infection, and impaired verbal communication. As a nurse you may encounter a patient who has a tracheostomy.
How can I encourage parents to participate in the tracheostomy procedure?
Encourage parents to participate with the procedure in an effort to comfort the child and promote client teaching. Care for the skin at the tracheostomy site is important especially for the elders whose skin is more fragile and prone to breakdown.
Can a nurse suction a tracheostomy?
Note the client’s ability or inability to remove the secretions through coughing. Suctioning a tracheostomy or endotracheal tube is a sterile, invasive technique requiring application of scientific knowledge and problem solving. This skill is performed by a nurse or respiratory therapist and is not delegated to UAP.
How do you treat cardiopulmonary arrest with a tracheostomy?
In the event of cardiopulmonary arrest, treat tracheostomy patients as other patients: Step 1: Expose the patient’s neck. Remove any clothing covering the tracheostomy tube and the neck area. Do not remove tracheostomy. Step 2: Check the patency of the inner cannula.