Tracheostomy
Tracheotomy is the
surgical incision into the
trachea for the purpose of
establishing an airway.
Tracheostomy is the
stoma, or opening, that
results from a
tracheotomy.
May be temporary or
permanent.
Nursing Assessment:
 Auscultation of the lungs
 Monitor o2 sats
 Assess for any increase in the amounts of blood in
the sputum
 SC emphysema in the neck
 Respiratory distress
 Patency of the tracheostomy tubing itself.
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Tracheostomy
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Accidental
Decannulation
Removal of the tub
Typically occurs with
downsizing the tube and/or
capping the trach tube to
block air from moving
through it and allowing the pt
to breathe through the normal
respiratory structures.
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Artificial airway requires humidification to the
airway because the normal upper airway passages
that humidify sections are bypassed.
Encourage pt. to do C&DB
Suction may be necessary to assist in clearing
secretions
IN ALL CASES OF BLEEDING, nurse must suction the
tracheostomy tube to maintain patency of the
patient’s airway and inflate the cuff if one is present.
Nurse must call for help, as this is an emergent
situation.
Ensuring that the inner cannula is changed
routinely to prevent occlusion is an important
component of the nursing care.
Cleaning trach site involves cleaning around the
tube with half-strength hydrogen peroxide on
cotton swabs and rinsing with normal saline.
Keep faceplate flush with the skin of the neck.
Check the ties frequently, and change them if
become soiled or wet.
Duo-Derm or a stoma wafer can be used to protect
the skin.
The nurse should teach the pt. to occlude the end of
the trach tube with a finger in order to speak on
exhalation.
Monitor patient’s oxygen and respiratory status.
Take not of any changes in patient’s behavior.
(Restlessness, agitation, or changes in LOC.)
If ^^ occur, remove inner cannula and start suction.
If cannula cannot be inserted, tube may have been
dislodged.
Remain with the patient and position pt. with Head
up and slightly extended.
Pt may need to be ventilated with a resuscitation
bag until the airway is replaced.
It is critical for the nurse to teach the patient how to
uncap or remove the cap of the tube.
Care issues for
patients with
tracheostomy
Prevention of tissue damage
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Cuff pressure can cause mucosal ischemia.
Minimal leak technique and occlusive technique.
Check cuff pressure often.
Prevent tube friction and movement.
Prevent and treat malnutrition, hemodynamic
instability, or hypoxia.
Discharge
priorities for
patients with a
tracheostomy
Safety with an artificial
airway is the priority for
teaching
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Teaching patient:
o Suctioning
o Saline instillation
o Wound care
o Inner cannula care
o Emergency measures
Assess the patients ability to read and write prior to
surgery and establish a suitable form of
communication.
Must demonstrate safe care
before discharge
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Head and Neck
Cancer
Cells change from the normal
division to altered cells that
grow along tissue planes and
into adjacent structures.
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Obstructive
Sleep Apnea
Patient stops breathing for
more than 10 seconds with
five or more episodes per
hour
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Caused by physical
obstruction from tissues in
the upper airway.
Air cannot flow in or out of
the person’s mouth despite
efforts to breathe.
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Gas exchange
(02, HR, pallor, cyanosis, cough, accessory muscles,
lung sounds, LOC, ABG)
Nasal drainage for presence of CSF
Skin integrity
(Color, blanching, odor, bleeding, wound
assessment)
Nutrition
(Bowels, lungs, residual volume pain management
Change of sleep position (side lying)
Weight loss
Positive-pressure ventilation
o Continuous PAP (CPAP)- continuous constant
o Bilevel pap (BPAP)- titration in inspiration and
expiration pressures separately
o Auto-titrating PAP (APAP)- pressures that are
more patient driven, depending on airflow,
circuit pressure, or snoring
Noctural dialysis (if kidney failure)
Avoid use of tobacco, alcohol, and sleeping pills.
Dental device that moves tongue forward
Evidenced by the paradoxical
motion of the abdomen and
rib cage with respiratory
effort
Laryngectomy
Removal of the larynx
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Necessitates a permanent
tracheal artificial airway
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Explain to the patient and family of all the risks and
benefits of each form of treatment.
Support patient in whatever decision is made, even
if it might not seem the best choice for complete for
complete removal of the disease.
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NG feeding tub placed intraoperatively because the
internal incision in the pharynx takes 5-7 days post
Laryngectomy.
 Before the patient resumes an oral diet, a barium
swallow is completed to evaluate the internal suture
lines in the pharynx, thereby ensuring that the
suture lines are intact and there is no leak of barium
through the incisions.
 Be patient with the patient with a tracheotomy or
someone on voice rest.
 Airway maintenance, pain management, nutrition,
and wound healing.
 Drain assessment and care
 Carotid artery exposure assessment and
management.
POWERPOINT
 Airway maintenance and ventilation
 Wound Care - Reconstructive Flaps, Graphs
 Bleeding
 Pain management
 Nutrition
 Speech and language rehabilitation
Myocutaneous
flap
Flap composed of muscle and
skin, used to reconstruct the
defect caused by the tumor
resection.
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Chyle Leak
Carotid artery
expose and
potential
rupture
A disruption in the lymph
system that causes lymphatic
fluid to leak from the thoracic
duct on the left side and the
lymphatic duct on the right
side.
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Can occur with a patient who
has problems with wound
healing, fistula formation,
poor nutrition, and/or history
of radiation therapy to the
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When the nurse assesses a reconstruction flap,
myocutaneous, or free, it should be pink and warm
with brisk cap refill (<2sec)
Tracheostomy and cupola ties (ties that secure the
oxygen to the trach mask in place) should be
positioned away from the graft to prevent pressure
on the area.
The head position should be maintained straight or
toward the operative side to prevent pressure or
tension on the flap.
HOB elevated at least 30degrees to facilitate
drainage of the fluid and to prevent edema of the
head and neck.
Nurse should report this condition to the healthcare
provider immediately because it can result in
serious fluid and electrolyte imblances.
Monitor pt. H/H and careful assess vital signs if
bleeding occurs.
Report decreased in H/H and/or any increase in the
pulse rate and decrease in BP to the surgeon.
Carotid tray at bedside
Four packages of fluffs at bedside
Dual-suction machines with large oral suction at
bedside
area.
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Cystic Fibrosis
(CF)
Atelectasis
An autosomal recessive
hereditary disease of the
exocrine glands that primarily
affects the respiratory and GI
systems.
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Collapsed alveoli
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Portable suction on unit for transport
One-liter LR solution at bedside with connecting
tubing
Two large bore IVs at all times
Type and antibody screen every 40 hours or per
hospital protocol.
Two units heparin at bedside
Post op wound care:
o Saline soaked dressings (wet-wet every 2 hours)
o When stable and healing, advance every 2 hours
while awake and every 4 hours at night, with
wetting of the dressing with normal saline every
2 hours
o Frequent observation of patient for “herald”
bleed (premature bleed), dry or dark area of
artery or aneurysm formation
o Call the house officer or surgeon immediately if
any of the above occurs
o Assess for a higher level of care if other
compounding problems are present such as
infection.
o Alert the OR and blood bank that patient is on
carotid precautions
Medication as ordered
Providing oxygen therapy
Instructing the patient and family on nutrition and
exercise.
Home care instructions
o Postural drainage techniques
o Aerosol-nebulization therapy
o Breathing retraining
o C&DB
C&DB
HOB up to 30-45 degrees
Administer oxygen as ordered or by hospital
protocol
Instruct patient to do “huff cough”
Encourage use of incentive spirometer