Standardized Care Plan for patients with tracheostomy PDF

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Summary

tracheostomy, is a surgical technique that corresponds to the opening of the anterior wall of the trachea, whose objective is to put the tracheal lumen in contact with the outside to establish a safe airway, the tracheostoma is the hole created in the trachea that continues in the skin ...

Description

Standardized Care Plan for patients with tracheostomy tracheostomy, is a surgical technique that corresponds to the opening of the anterior wall of the trachea, whose objective is to put the tracheal lumen in contact with the outside to establish a safe airway, the tracheostoma is the hole created in the trachea that continues in the skin (1,2). The terms tracheostomy and tracheostomy are frequently used interchangeably but they should not be confused as they present differences between them. According to Caravaca García “the TRACHEOTOMY is the surgical technique while the TRACHEOSTOMY is the clinical situation” (3). Therefore, in a tracheostomy, the patient must carry a cannula in all cases, while 80% of the tracheostomy will end up not requiring any type of cannula, leaving the entrance to the trachea open continuously (3,4).

The incidence of performing this procedure is high, mainly in intensive care unit areas, due to the large number of patients who require prolonged mechanical ventilation (MV) supports. Documentation is scarce but it is observed that the need for tracheostomies for patients hospitalized in ICU with MV ranges from 1.3 to 10% (2.5). The current COVID-19

pandemic

has

increased

the

number

of

patients

requiring

endotracheal intubation and subsequent tracheostomy (6). (Annex I) Tracheostomy carries a morbidity of 10 to 33%, and its mortality ranges between 1-3%, which has been reduced due to advances in postoperative care (7). In its history, the tracheostomy has gone through 3 periods: the first (1500 BC to 1500 AD) in which the first incisions are made in the neck and throat. Later (1546 to 1833), Baussorolo's writings are observed in which he describes the technique as an inappropriate procedure. It is in 1833, when Trousseau turns the tracheostomy into a successful surgery to mainly treat acute respiratory obstruction and asphyxia. Finally, C. Jackson standardized the technique and indications for the operation, reducing the complications associated with the intervention (1).

1

Currently,

we

can

distinguish

three

types of tracheostomy:

emergency

tracheostomy, emergency tracheostomy and regulated tracheostomy. (1,3,8). (Annex II) It should be mentioned that after this intervention there are modifications in the functioning of the upper aerodigestive tract, which can affect the patient's quality of life (5,6,9,10). (Annex III) The indications and contraindications in its performance may be due to different situations (1,2,3,11,12). (Annex IV) and (Annex V) The incidence of tracheostomy complications varies, speaking between 0.3% and 3% when performed electively and between 20% and 40% when performed in high-risk patients (13). Complications are usually divided into perioperative ( 24 h) and late (> 6 months) (1,3,5,7,13). (Annex VI)

Nursing occupies a key place in the evolution of tracheostomy patients. Some of its functions are the surveillance of symptoms and comorbidity factors; knowledge of the types of cannulas, parts, uses and care (4,14,15,16) (Annex VII); managing the physical and psychological impact; and continued care.

Due to the need to provide comprehensive care supported by the work of a multidisciplinary team, in order to help the patient manage their new health situation and preserve their biopsychosocial integrity, a standardized care plan has been developed for tracheostomy patients , since they consist of a specific care protocol, aimed at a group of patients who present a series of real or potential problems associated with a health problem, creating a pre-established action plan based on scientific evidence, in the observation of the behavior of patients and professional experience, reflecting the diagnoses, objectives and activities that most frequently occur in a specific profile (17).

1. OBJECTIVES

Principal

-

Prepare an updated standardized care plan focused on systematically applying comprehensive nursing care adapted to the tracheostomy patient.

Secondary

-

Identify the main problems that patients with a tracheostomy tube can develop.

-

Identify the nursing care that should be applied to tracheostomy patients.

-

Have

a tool

that

unifies

professional

practice

and

guides

future

professionals, so as to avoid / reduce possible complications caused by improper handling and increase the level of care for patients. -

Create an informative brochure as a physical support to help patients and families.

2. METHODOLOGYTO

To carry out this work, the competencies established in the Study Plan of the University Nursing Degree have been applied A bibliographic search was carried out on different aspects of the tracheostomy patient, the technique and their care. For this, the Science, Pubmed, sciElo and Elsevier databases were used. The Health Science Descriptors used were tracheostomy, tracheotomy, nursing care

care), health education, nursing functions and therapeutic contraindications. The Boolean operators used were AND and OR. As inclusion criteria to delimit the search for scientific articles, those that met the following requirements were chosen: -

Documents published in Spanish and English and available in full text.

-

Documents published less than 10 years old.

-

Free access.

Also, information obtained through the protocols observed in the POLIVALENTE ICU of the Miguel Servet University Hospital (HUMS) and the otorhinolaryngology surgery plant located on the 4th floor of HUMS has also been compiled. In addition, a search for information has been carried out in different associations and specific societies on the subject: -

Otolaryngology Nursing Association (AEEORL).

-

Society of Otolaryngology (SEORL).

-

Society of Otolaryngology and Head and Neck Surgery (SEORL-CCC).

-

American Academy of Otolaryngology.

The standardized care plan has finally been carried out by means of an assessment according to the basic needs nursing model of Virginia Henderson, and by identifying the main problems that these patients most frequently present, following the international NANDA (North American Nursing Diagnosis Association)

nursing

taxonomies

(18

,

21),

NOC

(Nursing

Outcomes

Classification) (19,21) and NIC (Nursing Interventions Classification) (20,21); following the interpretation of the Virginia Henderson model made by Maria Teresa Luis Rodrigo. Finally, it is worth mentioning that the care plan must be piloted and evaluated prior to implementation, and that after its implementation it must undergo a reevaluation.

3. DEVELOPMENT

The standardized care plan is considered globally for an adult target population with a tracheostomy tube. Taking as a reference the model of Virginia Henderson (22) (Annex VI) and based on the bibliography consulted, the following altered needs are evident: -

Need # 1: Need to breathe normally.

-

Need # 2: Need to eat and drink properly.

-

Need # 9: Need to avoid environmental hazards and avoid injuring other people.

-

Need # 10: Need to communicate with others expressing emotions, needs, fears or opinions.

-

Need # 12: Need to engage in something in such a way that your work has a sense of personal fulfillment.

-

Need # 14: Need to learn, discover, or satisfy the curiosity that leads to normal development and use available resources.

The main nursing diagnoses and potential complications associated with tracheostomies during the hospital period and at discharge are the following: Nursing diagnoses - [00031] Ineffective cleaning of the airways (r / c) retention of secretions

(physical strength, knowledge) (m / p) excessive amount of sputum, ineffective cough, dyspnea. -

[00146] Anxiety r / c changes in health status (knowledge) m / p distress, nervousness, worry, restlessness.

-

[00118] Disorder of the body image r / c body alteration produced by the tracheostomy (psychic strength, knowledge) m / p change in social involvement, fear of rejection, negative feelings about the body

-

[00126] Poor knowledge: tracheostomies, therapeutic regimen

r / c insufficient information and knowledge (knowledge) m / p inappropriate behavior, inaccurate following of instructions, reports the problem. -

[00161] Willingness to improve knowledge m / p the patient expresses a desire to improve learning (knowledge).

Collaboration issues -

HYPOXEMIA secondary to accidental decannulation.

-

ACUTE PAIN secondary to surgical intervention.

-

HEMOPTISIS secondary to trauma to the cannula itself or traumatic erosion after aspiration.

-

DYSPHAGIA secondary to surgical intervention.

-

AFONIA secondary to surgical intervention.

In these diagnoses, the most common circumstances in these situations have been taken into account. In this way, depending on each patient and situation, this standardized plan must be individualized.

NURSING DIAGNOSTICS

[00031] Ineffective cleaning of the airways (r / c) retention of secretions (physical strength, knowledge) (m / p) excessive amount of sputum, ineffective cough, dyspnea. Definition: Inability to clear secretions or obstructions from the respiratory tract to keep the airways clear. Domain:Security / Protection. Class: 2 Physical injury. Need:1 Breathe normally. Pattern: 4 Activity-exercise. General purpose: The patient will achieve an adequate cleaning of the airways, eliminating secretions effectively within three months after discharge. Specific objectives:

10

-

The patient will explain what are the disadvantages of ineffective cleaning of the airways before discharge.

-

The patient will state what are the strategies to avoid the appearance of dyspnea before discharge.

INEFFECTIVE CLEANING OF AIRWAYS NOC / INDICATORS

ACTIVITIES

N I C -

Provide care to the trachea, according to

0410 Status

3180 Handling

respiratory:

tracks aerial

dry the area around the stoma, and change the

Permeability of

artificial

tracheostomy clamp (3,7,9,15,16,23) (Annex

appropriate: clean the inner cannula, clean and

IX)

respiratory tract Ways

tracheobronchial

-

Tube maintenance

open, clear and clean

endotracheal

for air exchange.

tracheostomy tubes

INDICATORS SCALE: Substantial

Serious

(1);

(2); Moderate (3); Mild (4); None (5).

[41003] Asphyxia [41007]

prevention of associated complications with its use.

or of

Inspect the skin around the tracheal stoma for drainage, redness, irritation, and bleeding.

-

Elevate the head of the bed to 30 ° or more, or help the patient sit in a chair during feeding, if

and

possible. -

Check the color, quantity and consistency of secretions.

-

Perform endotracheal aspiration, as appropriate (4,23). (Annex X)

Noises respiratory

pathological [41013] Nasal flutter [41018]

Use of muscles

accessories

INDICATORS SCALE: Serious deviation from range normal (1); Substantial deviation from rank

normal (2); Deviation

moderate of normal range (3); Slight deviation from the normal range (4); No deviation from normal range (5)

[41004] Respiratory rate [41005] Respiratory rate [41012] Ability to remove secretions

[00146] Anxiety r / c changes in health status (knowledge) m / p distress, nervousness, worry, restlessness. Definition: Vague and unsettling feeling of discomfort or threat accompanied by an autonomic response (the origin of which is often unspecific or unknown to the person); feeling of apprehension caused by anticipation of danger. It is a red flag

that warns of imminent danger and allows the person to take action to deal with the threat.

Domain:9 Coping / Stress Tolerance. Class: 2 Coping Responses. Need:1 Breathe normally. Pattern: Selfperception-self-concept. General purpose: The patient will explain how to maintain a stable emotional state, trying to avoid the appearance of anxiety in a period of one month after discharge. Specific objectives: -

The patient will identify the signs and symptoms of anxiety three months after discharge.

-

The patient will explain how to perform relaxation exercises when they detect the appearance of anxiety after three months after discharge. ANXIETY

NOC / INDICATORS

NIC

[1402] Self-control of

5820

the anxiety Personal

ACTIVITIES Decreased

-

anxiety

actions

to

eliminate or reduce feelings

during the procedure.

Minimize apprehension, fear, omens, or concern related to

of apprehension, tension, or

an

unease from an unidentified

anticipated danger.

unidentified

source

-

of

-

SCALE: Shown: Never (1); Rarely TO

-

Frequently (4); Always (5).

[140214] Refers to sleep

-

adequately

the

patient's

Provide objective information regarding

Absence of

Encourage the family to stay with the

Create an environment that facilitates trust. Encourage the expression of feelings, perceptions and fears.

of

-

anxiety

behavior

Identify changes in the level of anxiety.

[140217] Controls the anxiety

-

response [140207]

understand

patient, if applicable.

times

(3);

manifestations

to

diagnosis, treatment and prognosis.

INDICATORS

[140216]

Try

perspective on a stressful situation.

source.

(2);

Explain all the procedures, including the possible sensations to be experienced

Staying with the patient to promote safety and reduce fear.

Use

relaxation

-

techniques to reduce anxiety

Administer medications that reduce anxiety, according to medical guidelines.

5580

-

Present the sensations and procedure / treatment in the sequence most likely to

information

be presented.

preparatory: sensory Description

-

inconcrete

and events

with a

procedure / treatment of

the

expected

duration

of

sensations and procedures or when a

terms and objectives of the associated normal sensations

Describe

change can be expected. -

Give the patient the opportunity to ask questions misunderstandings.

and

clarify

stressful health care provided.

5230 Improve coping

-

Facilitation of cognitive and behavioral efforts to manage

-

stressors,

changes,

-

perceived

threats

interfere

with

or that

meeting the

demands and roles of life.

Assess the patient's understanding of the therapeutic process. Use a calm, reassuring approach. Help the patient develop an objective assessment of the event.

-

Help the patient to identify the information that he is most interested in obtaining.

-

Encourage the verbalization of feelings, perceptions, and fears.

-

Assess the patient's need for support Social.

[00118] Body image disorder r / c body alteration produced by the tracheostomy (psychic strength, knowledge m / p change in social involvement, fear of rejection, negative feelings about the body. Definition: Confusion in the mental image of the physical self. Domain: 6 Self-perception. Class:3 Body image. Need: 12 Work / perform. Pattern: Self-perception-self-concept. General purpose: The patient will verbalize a realistic perception of their body image within 4 weeks of discharge. Specific objectives -

The patient will manifest the meaning of the change in their daily life within 3 months of discharge.

-

The patient will explain the real or perceived changes in their body image before discharge.

BODY IMAGE DISORDER NOC / INDICATORS

NIC

[1200] Body image

5220 Improved

Perception

of

the own

ACTIVITIES

Improvement of the

bodily.

perceptions and attitudes conscious

Use anticipatory guidance in the preparing the patient for changes in

body image

appearance and functions

INDICATORS

-

body image that are predictable.

-

See if the patient can look at the part

and SCALE:

Never positive

body that has undergone the change.

unconscious of the patient

(1); Rarely positive (2); Sometimes positive (3); Often positive

towards your body.

-

Facilitate contact with people who have

suffered similar body image changes

(4); Always positive (5).

[120014] Adaptation to changes

5440 Increase

bodily surgery

-

support systems

[120007] Adaptation to changes

Calculate the psychological response to the situation and

Facilitate patient support

in the physical aspect

the availability of the support system.

from family, friends, and

[120016] Attitude towards playing the

-

the community.

affected body part

Decide the degree of family support and

economic, as well as other resources.

[120003] Part Description

-

Determine the barriers to the use of the systems of

affected body

unused or underused support. -

Refer to a self-help group, or a resource

Internet based if deemed appropriate. -

Identify the resources available for support caregiver (24,25). (Annex XI)

[00126] Deficient knowledge: tracheostomy, therapeutic regimen r / c insufficient

information