- Deficient Knowledge related to lack of knowledge about tracheostomies and misconceptions about tracheostomy care as evidenced by anxiety about the procedure or lifestyle changes and frustration with trach care
- Impaired Spontaneous Ventilation related to presence of artificial airway as evidenced by Low oxygen saturation and dyspnoea
- Impaired Verbal Communication related to no air flowing in the vocal cords (larynx) and mechanical ventilation as evidenced by difficulty speaking and no voice sound
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbalizes poor understanding Seeks additional information Denial of a need to learn Objective data: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment or worsening medical condition -Avoiding eye contact or remaining silent during teaching | Deficient Knowledge related to lack of knowledge about tracheostomies and misconceptions about tracheostomy care as evidenced by anxiety about the procedure or lifestyle changes and frustration with trach care | Patient will be able to express an understanding of the tracheostomy procedure and care management Patient will cooperate in the care of their tracheostomy Patient will not develop a complication from their tracheostomy | 1. Create a care plan with the patient. Having a tracheostomy and being unable to communicate is frustrating. Patient engagement in decision-making before the tracheostomy will help the patient feel empowered and in control. 2. Involve the family. Family members can be instructed on caring for the trach and recognizing complications. If the patient will have the trach long-term or permanently, the family must know how to care for it. 3. Welcome inquiries. A welcoming and approachable manner invites questions to clarify misconceptions and misunderstandings. Patients with a tracheostomy experience anxiety, fear, and powerlessness; clarification can reduce these feelings. 4. Reinforce positive feedback. When patients achieve their goals and prevent complications, reinforce positive feedback and show appreciation for their efforts and adherence to their care plan. 5. Clarify that tracheostomy can be temporary or permanent. A tracheostomy is typically a temporary breathing alternative while addressing other medical problems. The tracheostomy is commonly the best long-term and permanent option if patients need a ventilator for life | Patient expressed an understanding of the tracheostomy procedure and care management Patient cooperated in the care of their tracheostomy Patient will not develop a complication from their tracheostomy |
| Subjective data: Expresses inability to breathe normally Objective data: Low oxygen saturation Decreased cooperation Dyspnoea Tachycardia Restlessness | Impaired Spontaneous Ventilation related to presence of artificial airway as evidenced by Low oxygen saturation and dyspnoea | Patient will demonstrate the ability to wean off the ventilator. Patient will maintain an effective airway. | 1. Hyperoxygenate the patient. Prior to suctioning, hyperoxygenate the patient to prevent hypoxia. 2. Communicate effectively with the patient. The patient with a tracheostomy will not be able to speak immediately. Find other ways to communicate, such as using nonverbal gestures, electronic devices, or writing. In time, the patient will be taught how to speak by occluding the trach or using a Passy-Muir valve. 3. Have family members demonstrate care. Instruct on proper trach care, including hygiene care, suctioning, oxygenation, and when to seek emergency services. 4. Collaborate with the respiratory therapist. Review ventilator settings, oxygen titration, and tracheostomy care with the RT. | Patient demonstrated the ability to wean off the ventilator. Patient maintained an effective airway. |
| Subjective data: Expresses unable to speak properly Objective data: -Difficulty speaking -Inability to communicate -No voice sound -Hoarseness -Anxious appearance -Fear of being misunderstood -Frustration | Impaired Verbal Communication Related to no air flowing in the vocal cords (larynx) and mechanical ventilation as evidenced by difficulty speaking and no voice sound | Patient will be able to use a method and device to communicate. Patient will be able to express their needs clearly and effectively. Patient will be able to manifest satisfaction after communication | 1. Offer communication methods and devices. Communication alternatives available to patients with tracheostomy: Writing Gestures Mouthing words Speaking valves Use of AAC (Augmentative and Alternative Communication) devices such as communication boards, tablets, and picture boards 2. Provide emotional support. Being unable to communicate and feeling misunderstood can cause anxiety, helplessness, and isolation and can be frustrating for the patient. 3. Closely monitor the patient. Due to difficulty in communication, the patient may not be able to communicate symptoms or concerns. It is crucial to closely monitor and observe patients for nonverbal behaviors that signal changes in their health status. 4. Advise the patient to use the call bell when necessary. Patients can notify any healthcare personnel of their need for assistance in a healthcare setting by using a nurse call bell system to ensure patient safety. 5. Use a communication board or gestures for simple questions. A communication board is a device that shows images, symbols, or illustrations to assist people who struggle to communicate verbally. The patient, nurse, and family can use gestures or sign language as applicable for simple communication. 6. Ask questions answerable by yes or no reactions. Try to construct questions that can be answered by “yes” or “no” responses. The patient can nod or blink their response. 7. Teach to use a Passy-Muir Valve. This one-way valve attaches to the tracheostomy to allow air into the trach but not out. The patient is first suctioned to remove secretions, and then the cuff is deflated. The valve is twisted onto the trach tube and easily twisted off to remove. 8. Consult with the speech-language pathologist. The SLP can assess the patient’s swallowing and language functions and their ability to produce voice and tolerate a speaking valve. | Patient used method and device to communicate. Patient expressed their needs clearly and effectively. Patient manifested satisfaction after communication |