LESSON PLAN

Subject : Fundamental of Nursing

Topic : Tracheostomy
Guide : Mrs. G. Hemavati
Participant : 3rd Year [Link]. Nursing Students
Date : 6/10/2009
Time :
Venue : P. G. College of Nursing
A. V. Aids Used : Chart, Black Board &Demonstration
Method of Teaching : Explanination, Lecture,
Demonstration
Previous Knowledge :
CENTRAL OBJECTIVE:

At the end of the class the students will be able to know all about the care of
tracheostomy.
SPECIFIC OBJECTIVE:

1. To review the anatomy and physiology of trachea.

2. To explain definition of tracheotomy.
3. To describe indication of tracheostomy.
4. To illustrate surgical procedure of tracheostomy.
5. To explain about tracheostomy tube.
6. To list down dwtrche of tracheostomy.
7. To Describe the procedure of tracheostomy.
 Incision of tracheostomy is made through the fibrous tissue above the third cartilage.

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1. 1 mt. TRACHEOSTOMY
Anatomy of Trachea: The trachea is a
10-11 cm. tube composed of ring of
cartilage anteriorly and membrane
posteriorly. This membrane also forms
the anterior wall of the esophagus (the
musculomembranous canal between
the pharynx and the stomach.)
Introduction: Tracheostomy is a
2. 1 mt. surgical popening into trachea. That is
usual to prevent or relieve obstruction
and or to serve as a access for
suctioning and for mechanical
ventilation. A Tracheostomy can
facilitate weaning from mechanical
ventilation by reducing dead space and
lowering airway resistance at also
improve patient comfort by remaining

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the endotrachial (ET) tube from the

mouth and nose.

Definition: “Tracheostomy is an
incision into the trachea below the
larynx”. Tracheostomy is the formation
of an opening into the trachea into
which a tube is inserted through which
patient breaths.
Indications:
- Need for long term artificial
airway.
- Impossible upper airway
obstruction (emergency
tracheostomy (Cricothuyrotomy
is done)
- Altered level of consciousness
such as increasing lethargy,
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Producing inability to protect lower
airway.
- remove tracheobronchial
secretion.
- Promot long term use of
mechanical ventilation.
- Prevent aspiration of oral or
gastric secretion in unconscious
or paralyzed patient.
- Replace endotracheal tube when
long term mechanical ventilation
is required.

Condition Required (Disease

condition) Tracheostomy:
1. Obstructed Breathing.
2. Vocal card paralysis.

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3. Lavingo Spasm
4. Acute inflammation of upper
airway tract.
5. Severe trauma to the
hypopharynx or larynx.
6. Acute laringio tracheal bronclititis
or epiglottis in infant.
7. Faringeal edema, prolonged
intubation.

Surgical Procedure of the Trachea:

1. Tracheostomy is often done with
patient under local anesthesia,.
2. The patient is supine with
support under the shoulders to
hyperextended the neck.
3. A transverse incision is made,

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Producing a better cosmotic result, or a
midline vertical incision is made
between the cricoid cartilage and the
suprasternal notch. The overlying
isthmus of the thyroid gland is retracted
or divided and exposed third and forth
tracheal rings are incised through a
midline vertical incision.
4. After removal of blood and
secretion, a tracheostomy tube
is is inserted with the abturator in
place immedicately after
insertion of tube the abturator is
removal to open the airway.
5. Wound is closed with a few
sutures.
6. Tape tied to the ends of the
outer cannula and sease around
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The neck. It should allow one fingure
incision, too tight will compress juglar
vein, and too loose will abtained with
coughing.
Tube should not removed before 24-48
hours.
7. Suctioning through a
tracheostomy tube is done as a
sterile procedure with a sterile
catheter.
8. Careful suctioning prevent
trauma.
9. These patient require humidify
air, to keep secretions liquefied
and to prevent drying of tissue.
Special Communication
Tracheostomy tube: The
tracheostomy opening is fitted with a
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Tube to maintain airway patency.
Tracheostomy tube vary in their
composition, number of separate parts.
Shape and size. Tracheostomy tube
are choosen specially for each client.
Incorrectly fitted tube can precipitate
permanent or life threatening damage.
The diameter of a tracheostome tube
should be smaller than the trachea so
that it lies comfortably within the
tracheal lumen. Air should be able to
pass between mucosa.
The length and curve of a tracheostomy
tube are important. They may be
angeyled with the anylewith the angle
varying from 50 to 90 degree. Short
tubes with an angle of about 60 degree

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Are often used. A tube must be long
enough to avoid dislodgment into
paratracheal tissue when client turn or
cough out.
Tracheostomy tube may be cuffed or
uncuffed. An inflated cuff permits
mechanical ventilation and protect the
lower airway by creating a seal
between the upper and lower airways.
Tracheostomy cuffs do not hold the
tube in place.
The Tracheostomy tubes are made of
various substances such as non
reactive plastic, stainless steel, sterling
silver or silicone.
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Universal Tracheostomy:
The most common tube is a universal
or standard tracheostomy tube, having
three parts.
1. Outer cannula with cuff, flange
and pilot tube.
2. Inner cannula
3. Obturater
1. The outer cannula fits in the
tracheostomy stoma to keep it open.
2. The outer cannula has flange or neck
plate with holes to ties for tieng cloth
tape may be used.
I. The abturator is placed into the outer
tube before insertion. Its rounded tip
smooth the end of the cannula and
faclilitates nontraumatic insertion of the
tube into the stoma. The obturator is
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Removed immediately after incision to
open the tube. Once the obturator is
removed, the new cannula is placed
into the outer cannula.
Single Cannula Tracheostomy tube:
A single cannula tracheostomy tube is
slightly longer than a standard double
cannula tube. Single cannula tube
should not be used in client with
excessive secretion or difficulty clearing
secretions. It is used on the client with a
thick neck or with an altered airway in
whom a standard tracheostomy tube
would be too short.
Fenestrated Tracheostomy:
A fenestrated tracheostomy tube has
one large opening or several small
ones. On the curvature of the posterior
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wal of the outer cannula. Fenestrated
tube have an inner cannula may be
cuffed or cuffless. This tube may be
used while a client is being weaned
from a tracheostomy is expected to be
prolonged.

Tracheostomy speaking valves:

For a talking tracheostomy” a one way
valve in a plastic T piece is attached to
the 15 mm end of the inner cannula of a
universal trachestomy tube. This
modification permits talking without the
need to plug the tracheostomy tube.

Tracheostomy button:
Use of a tracheostomy button is
sometimes indicated during weaning as
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an intermediate measure between
using a standard tracheostomy tube
extubation. A button is a short straight
plastic cylinder secured by a flange to
the anterior tracheal wall but is not
deep enough to enter the tracheal
lumen.
A button can not be used with a
ventilator.
Permanent Tracheostomy:
Most client with a permanent
tracheostomy use a universal cuffless
tracheostomy tube or a client has had a
total laryngectomy, the cut end of the
trachea is sutured to the skin creating a
permanent stoma is healed most
laryngectomy clients do not need a
tube.
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Metal Tracheostomy tube:
Metal tracheostomy tubes are made of
sterling silver or stainless steel. The
most papulor type is the Jackson
tracheostomy tube. Metal tubes are
cuffless and most often used in client
who have a permanent tracheostomy or
laryngectomy. (Hollinger tube is also
similar to Jackson tube.)

PROBLEMS OF TUBE & CUFFS

1. Tracheal Damage: This is because
the normal pressure within tracheal
arteries is 42 cm. H2O. in the veins and
lymphatic vessels, the normal
pressures are 24 cm. H2O and 7 cm.
H2O respectively. Tracheal damage
from cuff pressure is a frequent
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Complication of intubation. Cuffed
tubes can cause tracheal damage in as
few as 3 to 5 days.
2. Tracheal Wall necrosis: Necrosis
of the tracheal wal can lead to the
formation of an abnormal opening
between the posterior trachea and the
esophagus. (Tracheoesophageal
fistula)
3. Tracheal dilation: Prolonged
intubation can lead to dilation of the
trachea from the cuff.
4. Tracheal stenosis: Narrowing of
trachea at noted from 1 week or 2 yrs of
intubation (before of inflammation or
fibrosis)
5. Airway obstruction
6. Infection
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Pre Operative Care:
1. Patient who is going for elective
tracheostomy.
2. Health education should be provided
previously Eg. all about mechanical
respiratory management.
Post operative management in change
of ability to speak and eat, should be
explained.
If tracheostomy is expected to be
permanent information about
modification of clothing and productive
life with tracheostomy should explained.
If patient is unable to retain the
aducation , his family should provide
this information.
- Consent has to be taken.
- Anesthetised should be informed
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- The ornaments has to be
removed.
- Premedication has to be given.
- Instruction for indication should
be taught to patient.
Accidental decannolation.
Subcutaneous emphysema.
POSTOPERATIVE CARE:
Assessment: Vital Sign (secretions:
colour amount and consistency, shock,
hemorrhage.
Suctioning.
Adequate hydration.
Prevent tube movement, infection,
aspiration.
Impaired verbal communication.
Constipation
Reduced anxiety and fear.
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Assessing with Tracheostomy:
Def.: Assiss in creating a surgical
opening into anterior wall of trachea
and inserting a tube to maintain patient
airway.

Articles (Trachestomy set):

1. Toothed dissecting forceps 1
2. Curbed mosquito forceps 2
3. Straight mosquito forceps 2
4. Artery forceps 2
5. Allis forceps 2
6. Needle holder
7. Double hook retractor 2
8. Blunt hook
9. Cricoid hook
10. Sharp scissors
11. Tracheal dilator
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12. Gall – Pots 2
13. Cutting edge suture needle with
cotton thread.
14. Dressing forceps
15. Vaseline Iquze
A Clean tray containing:
1. Suction catheter with connection
2. Hand towel
3. Kidney tray
4. Scalped blade
5. Gloves
6. Apren
7. Antiseptic solution.
8. Local anesthetic (Xylocaine 2%)
9. Syringes and needle
10. Sandbag.
11. Spot light
12. Tracheostomy tube
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Procedure:

Nursing Action Rational

Explain procedure Reduce anxiety

and get consent. and facilitate
Place patient in patient
supine position cooperation.
with full extension Promote
of neck and head. visualization of site
of insertion for
procedure.
Keep suction and Facilitate timely
oxygen need for use of articles.
use.
Assist in preparing Reduce risk of
skin and infection, reduce
administering local sensation of pain.
anesthesia.

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Assist in oral
support patient as
incision is made
and provide
suitable
tracheostomy tube
for insertion.

Assist in securing Reduce chance for

tracheostomy tube tube displacement.
to neck while tying
with tape.
Assist patient to a
comfortable
position.
Place baseline
gauze around
neck.
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Assist patient to a
comfortable
position.
Replace
equipment.
Document time,
tube size, purpose
of tracheostomy
and patient’s
condition.
POST PROCEDURE CARE:
1. Connect to ventilator ( if needed)
2. Place patient in semi fowler’s
position.
3. Check vital sign.
4. Administer analgesics and sedative
as per order.

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5. Watch for complications like
bleeding, respiratory failure and
blockage of tracheostomy tube with
secretions.
6. If metal tube is inserted, leave the
stillete in a sterile tray at the bedside.
7. Keep suction apparatus and suction
tube nearly at bedside.

Providing Tracheostomy Care:

Definition: Tracheostomy care includes
chaging a tracheostomy inner tube,
cleaning tracheostomy and site and
changing dressing around the site.
PURPOSE:
1. To maintain airway patency.
2. To prevent infection at the
tracheostomy site.
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3. To facilitate healing and prevent skin
excoriation around the tracheostomy
site.
4. To promote comfort.
5. To assess condition of ostomy.
Equipment:
Tracheostomy care kit containing.
1. Gallipot 3
2. Sterile towel
3. Sterile nylon brush tube
4. Sterile gauze squares
5. Cotton twill ties or tracheostomy tie
tapes.
6. Sterile bowl for solution.
II. A clean tray containing
1. Sterile suction catheter
2. Hydrogen peroxide.
3. Normal Saline.
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4. Sterile gloves 2 pairs.
5. Clean scissors
6. Face mask, eye shield.
7. K. Basin
8. Water proof pad.
III. Suction apparatus.

Procedure:
NURSING ACTION RATIONAL

1. Assess condition Presence of any

of stoma (redness, of these
swelling, character indicates
of secretions, infection. And
presence of culture
purulence or examination may
bleeding) be warranted.

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NURSING ACTION RATIONAL

2. Examine neck for Indicates air leak

subcutaneous into
emphysema subcutaneous
evidenced by tissue.
crepitus around the
ostomy site.
3. Explain procedure Obtain
to the patient and cooperation from
teach means of the patient.
communication such
as eye blinking or
raising a finger to
indicate pain or
distress.
4. Assist patient to a Promote lung
Fowler’s position expension,
and place water prevent soiling
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NURSING ACTION RATIONAL

Proof pad on chest Of linen

5. Wash hand Prevent cross
Thoroughly infection.
6. Assemble
equipments.
a. Open the sterile Hydrogen
tracheostomy kit, peroxide and
pour hydrogen saline removes
peroxide and sterile mucus and crust
normal saline in which promote
separate gallipots. bacterial growth.
7. Wear sterile glove Remove
and do the suction. secretion.
8. Remove inner Hydrogen
tube and put into remove dried
saline and hydrogen secretion.
peroxide.
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NURSING ACTION RATIONAL

- Remove soiled
tracheostomy
dressing discard the
dressing and gloves.
- Take a second pair
of sterile gloves.
- Clean the flange of Using the
the tube using sterile applicator gauze
application or gauze. once only avoid
Moistened with contaminating a
hydrogen peroxide clean with soiled
and then with gauze.
normal saline. Use
each applicator
once.
- Clean the stoma
area with gauze
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NURSING ACTION RATIONAL

Make only a single

single sweep with
each gauze sponge
before discarding.
- Half strength
hydrogen peroxide
mixed with normal
saline may be used.
- Dry the stoma tube
with dry sterile
gauze. Antibiotic
ointment may be
used according to
physician order.
- Clean the inner
cannula thoroughly
and tap the cannula
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NURSING ACTION RATIONAL

To remove the
solution inside.
- Replace the inner This secures the
cannula and seal it flange of the
by locking. inner cannula to
the outer
cannula.
- Apply sterile
dressing 4x4 gauze Do not put
cut into V shape cotton.
ensure that the
tracheostomy tube is
securely supported.
- Change the
tracheostomy ties
- Document all
relevant information
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NURSING ACTION RATIONAL

In the chart
- Suctioning done.
- Tracheostomy care
carried.
- Dressing changed
- Observation.

Special Consideration:
1. Trachyostomy dressing should be
done every 8 hrs, or whenever dressing
are soiled.
2. Tracheostomy tube may come with
disposable inner cannula or without the
inner cannula. If disposable inner
cannula is present then replace the one
that is inside with a new one.
3. If only single lumen is present, then
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suction the tracheostomy tube and
clean the neck plate aml tracheostomy
site.

BIBLIOGRAPHY:
1. Gulani’s “Nursing care plan”. Fifth edition pp. 459.
2. Nancy Maria Phillips (Berri Khan’s) “Operation room techniques”. 7th edition P. 852.
3. Black and Hauks “Medical surgical nursing” 7th edition, PP 745.
4. Luckman Sourensen “Medical surgical nursing” 3rd edition, PP 745.
5. Annamma Jacab. “Clinical Nursing Procedure The art of Nursing practice” PP 396, 1 st edition.
6. Kozier & Erb’s “Fundamental of Nursing” 8th edition.