Timby's MedSurg 14e

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UNIT 5 Caring for Clients With Respiratory Disorders

Clinical Scenario A 70-year-old client has a tracheostomy placed because they are on long-term mechanical ventilation. What are the major considerations for the nurse when planning and providing nursing care to this client? See Nursing Care Plan 20-1.

NURSING CARE PLAN 20-1

The Client With a Tracheostomy

Assessment • Monitor for vital signs and auscultate breath sounds. • Assess skin color, level of consciousness, and mental status. • Monitor for potential complications.

• Assess frequently for a patent airway. • Inspect tracheostomy frequently for placement and security of ties.

Nursing Diagnosis. Safety, postsurgical procedure Expected Outcome. The nurse will prevent or manage complications of the tracheostomy. Interventions Rationales

Early recognition of signs and symptoms of respiratory distress prevents further complications.

Monitor for signs and symptoms of respiratory distress: difficulty breathing, diminished or absent breath sounds, use of accessory muscles, and asymmetric chest wall movements. Assess for subcutaneous emphysema (air trapped in tissues) around the stoma, neck, and chest.

Injury or trauma to the airway can cause air to leak into surrounding tissues. Severe subcutaneous emphysema indicates significant leaking and potential airway obstruction. A tracheostomy bypasses the nose; thus, inspired air is not warmed or humidified. Increased warmth and humidity thin and help remove secretions. Ties maintain tube placement without damaging underlying skin or causing discomfort.

Provide humidification.

Keep tracheostomy ties secure but not too tight (one finger should slip easily under ties). Monitor pulse oximetry or arterial blood gas (ABG) results. Administer oxygen as needed. Evaluation of Expected Outcome The nurse manages the client’s care and prevents complications.

Such monitoring ensures adequate oxygenation.

Nursing Diagnosis. Ineffective Airway Clearance related to increased secretions and possible occlusion of the inner cannula Expected Outcome. Airway and tracheostomy tube will remain clear. Interventions Rationales Provide warm, humidified air. Such air prevents drying and crusting of secretions. Suction as needed. Suctioning clears secretions.

These measures remove thick secretions and possible mucus plugs and promote lung expansion.

Maintain a patent airway. In cases of suspected obstruction, (1) suction the tracheostomy, (2) induce coughing, (3) change the inner cannula, and (4) position client to maximize respiratory effort.

Evaluation of Expected Outcome Client’s airway and tracheostomy are patent. Nursing Diagnosis. Infection Risk related to loss of upper airway protection Expected Outcome. Risk for infection will be reduced. Interventions Rationales Monitor stoma for erythema, exudate, or odor.

Such findings may indicate infection.

Assess skin around stoma and under tracheostomy ties for signs of breakdown.

Intact skin prevents infection.

Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. Monitor white blood cell (WBC) count. Elevated WBCs may indicate infection.

Provide routine tracheostomy care every 8 hours and as necessary. Maintain sterile technique. Position client so that secretions do not pool around the stoma.

These measures prevent infection.

Maintaining a clean and dry stoma prevents infection.