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CHAPTER 20 Caring for Clients With Upper Respiratory Disorders

NURSING CARE PLAN 20-1

The Client With a Tracheostomy ( continued )

Evaluation of Expected Outcome Client does not have any signs or symptoms of infection. Nursing Diagnosis. Altered Health Maintenance and Knowledge Deficiency related to the lack of knowledge about tracheostomy care and home support Expected Outcome. Client or caregiver will demonstrate skills appropriate for tracheostomy care. Interventions Rationales Assess client’s and caregiver’s ability to provide adequate home care. This assessment provides a baseline for teaching needs and referrals. Begin teaching skills one at a time. Step-by-step teaching provides time to absorb information.

Demonstration of skills ensures that client or caregiver has adequate knowledge for home care.

Teach client how to suction airway, clean tube, change dressing and ties, provide stoma care, and reinsert tracheostomy tube. Have client demonstrate skills. Teach client or caregiver to check for signs and symptoms of infection. Refer client and caregiver to support groups and home care services.

Such measures prevent or enable early treatment of infection.

Home care needs are planned for before discharge.

Evaluation of Expected Outcome Client or caregiver demonstrates adequate skill in tracheostomy care and is sufficiently independent for discharge home.

the removal of an endotracheal tube may be done by the nurse, the respiratory therapist, or the doctor. Before remov ing the tube, emergency equipment for respiratory support must be available. The pharynx must be suctioned before the cuff is deflated to prevent the aspiration of secretions dur ing removal of the tube. The tube is usually removed with the client in semi-Fowler position. If laryngospasm occurs, air is administered by positive pressure. Reinsertion of the endotracheal tube by the healthcare provider or other trained personnel may be necessary if laryngospasm continues. Pos sible complications with the use of endotracheal intubation include ulceration and stricture of the trachea or larynx, atel ectasis, and pneumonia. Nursing Management Major goals for the intubated client are to improve respira tions, maintain a patent airway, and communicate needs to others. The nurse monitors vital signs periodically, depend ing on the client’s condition and the reason for endotracheal tube insertion. Blood gas studies and pulse oximetry provide methods of ongoing evaluation of the client’s respiratory sta tus. The nurse reviews the results of these studies and reports changes to the primary provider. The nurse observes the client at frequent intervals for response to respiratory support and complications associated with endotracheal intubation. They evaluate any change in mental status. Confusion may result from abnormal blood gas levels or electrolyte imbalances. Sudden restlessness or agitation may indicate obstruction of the endotracheal tube, which can be life-threatening. The nurse auscultates the lungs and observes the symmetric rise and fall of the

chest every 30 to 60 minutes. If bilateral breath sounds cannot be detected, the nurse notifies the primary provider immediately. Humidification is necessary to keep the inspired air moist. Clients with endotracheal intubation cannot cough, secretions are often thick and tenacious, and swallowing reflexes are depressed. An increase in PaCO 2 caused by blockage of the endotracheal tube or malfunctioning of the ventilator may oc cur secondary to secretions or because the client is biting on the tube. Keeping the airway patent at all times is absolutely necessary, using the same suctioning technique as for a tra cheostomy. If the client is biting on the tube, a bite block or oral airway may be used to keep the tube patent. The nurse changes the client’s position every 2 hours to prevent atelectasis and gives oral care as needed to keep the mouth and lips free of crusts and mucus. The nurse suc tions the oropharynx and mouth as needed and cleans the teeth with applicators. The nurse inspects the oral cavity fre quently and reports any signs of oral bleeding to the primary provider. The client may display anxiety or fear because of the tube, inability to speak, suctioning, and dependence on a ma chine for breathing. Each time suctioning is needed, the nurse reassures the client that the procedure takes only a short time. The client may attempt to remove or pull on the tube if they are awake or partially awake, and restraining the client may be necessary. The nurse should contact the primary provider if the client is extremely restless. Providing a “Magic Slate,” wipe board, electronic device, or pencil and paper to the cli ent enables communication, as does asking questions that the client can answer by shaking the head yes or no.

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