Name of the college

Yenepoya Nursing College

Name
of
the MSc Nursing
postgraduate
Nursing
course/Department

Medical

Surgical

Date of admission to 16/09/2015

the course
Contact details

8867838204
lanleimalaiz@gmail.com

Name
Guide

of

the

Problem statement

PG Mr.Gireesh G.R.
A study to assess the knowledge
regarding tracheostomy care of staff
nurses in selected hospitals at
Mangaluru.

INTRODUCTION
Constant attention by a good nurse may be just as important as a
major operation by a surgeon.

Dag Hammarskjold

A tracheostomy is the formation of an opening into the trachea usually

between the second and third rings of cartilage. Tracheostomy is
indicated to facilitate weaning from mechanical ventilation by
decreasing anatomical dead space, prevention / treatment of retained
tracheo-bronchial secretions, chronic upper airway obstruction and
bypass acute upper airway obstruction .3
A tracheostomy is a surgically created opening in the trachea. A
tracheostomy tube is placed in the incision to secure an airway and to
prevent it from closing. Tracheostomy care is generally done every
eight hours and involves cleaning around the incision, as well as
replacing the inner cannula of the tracheostomy tube. After the site
heals, the entire tracheostomy tube is replaced once or twice per
week, depending on the physician's order.
The goals of tracheostomy care are to maintain the patency of the
airway, prevent breakdown of the skin surrounding the site, and
prevent infection. Sterile technique should be used during the
procedure.

The tracheostomy consists of two parts. Inner cannulaSmaller tube

that fits inside the tracheostomy tube, which can be removed quickly
if it becomes obstructed. This is often used for patients who have
copious secretions. Tracheostomy tubeAn indwelling tube used to
maintain patency of the tracheostomy. It can be made of metal (for
long term use) or disposable plastic. The tube can be cuffed (a balloon
is inflated to keep the tube in place) or uncuffed (air is allowed to
flow freely around the tube). It can also be fenestrated, which allows
the patient to speak.
Extra precautions should be taken when performing site care during
the first few days after the tracheostomy is surgically created. The site
is prone to bleeding and is sensitive to movement of the tracheostomy
tube. It is recommended that another health care professional securely
hold the tube while site care is performed. Tracheostomy care should
not be done while the patient is restless or agitated, since this
increases the chance that the tube may be pulled out and the airway
lost.
Tracheostomy care and management is more and more necessary in
both the intensive care setting and the general ward. It is, therefore,
ever more important that trained nurses are equipped with the
appropriate skills, knowledge and support to meet the unique needs of
each patient safely and competently.

NEED FOR THE STUDY

Tracheostomy is a common surgical procedure performed on critically

ill intensive care patients. Reports in India have documented
considerable associated morbidity, with complication rates varying
from 6 to 66%. The reports on mortality associated with tracheostomy
range from 0 to 5%.8
Tracheostomy is probably the most common surgical procedure
performed on critically ill patients. Approximately 10 percent of
mechanically ventilated critically ill patients undergo tracheostomy to
facilitate prolonged airway and ventilator support. Most critically ill
patients with respiratory failure tolerate tracheal intubation for short
duration with minimal complications, but longer duration (> 1week)
of mechanical ventilation will have adverse outcomes. With an
increasing demand for intensive care beds more nurses in

acute

and high dependency wards will be expected to care competently

for patients with

tracheostomy tubes.

Tracheal suctioning is an

essential aspect of effective

airway management. It is imperative that nurses are aware of the
risks and are able to practice according to current research
recommendations.
A descriptive study conducted in two hospitals of Davangere
(Karnataka) for the period of five years between April 2005 and
January 2010 reported the complications of bedside tracheostomy for
up to 60 days after the procedure. Complications were classified as
early complications, for events directly related to the surgical

procedure occurring during tracheostomy tube placement and up to 24

hours after the procedure. Late complications included those
occurring during the hospital stay or at home after discharge. Each
complication was classified as major or minor according to its clinical
relevance and whether or not it was life threatening. Patient's relatives
were educated by the intensivist and ICU nurse regarding routine
tracheostomy care, changing the tracheostomy tube and possible
complications that could be experienced and their management.9
In 1982, the experience with tracheostomy at The Children's Hospital
of Philadelphia was reported for 1971 through 1980. Patients received
a tracheostomy for airway obstruction (38%), chronic ventilation
(53%), or multiple indications (9%). The mean duration of
tracheotomy (adjusted for death and loss to follow-up) was 2.13
years. The tracheostomy-related mortality was 0.5%, and the
nontracheostomy-related mortality was 22%. Nineteen percent of
patients had complications in the first postoperative week, and 58%
had 1 or more late complications. In comparison with the previous
study from our institution, there was a great increase in long-term
tracheostomy and a continuing trend away from tracheostomy for
short-term airway management. Better monitoring and improvements
in parental teaching may have contributed to a decrease in
tracheostomy-related mortality.
The prevalence of tracheostomy was 10% in the long-term ventilated
patients (defined as > 24 h), or 1.3 % of all patients. Most
tracheotomies were performed during the 2nd week of ventilation.

The frequency of tracheostomy varied widely (0-60 %) and was only

slightly associated with the different language regions of our country
and with the policy of hospitals to accept or refuse intubated patients
on their normal wards. Most units offered either conventional surgical
tracheostomy (69 %) and/or percutaneous procedures (57 %). The
decision to perform a tracheostomy was made mostly by the
intensivist and the procedure was more often performed in the ICU
(65 %) than in the operating theatre (35 %). Units where the
intensivist had exclusive control used only percutaneous techniques.
An overall complication rate of 13 % was reported, bleeding and
infections being at the top of the scale. Only 27 % of the units
performed late follow-up protocols.11
Tracheostomy care is a relatively benign procedure. The greatest risk
is that the tube may be inadvertently removed and the airway lost. The
anticipated outcomes of tracheostomy care include continual patency
of the airway, prevention of skin breakdown around the stoma, and
prevention of infection.Many of the nursing skills employed are
aimed at the mobilization of pulmonary secretions. Frequent turning,
encouragement of deep breathing, and ambulation are important in the
prevention of pulmonary complications.5
A study was conducted to assess the frequency, timing and technique
of tracheostomy and its variation between different intensive care
units (ICUs) in Switzerland. A total of 48 ICUs (70 %) responded. In
1995 and 1996 the participating units had admitted 90,412 patients for
a total of 243,921 ICU days. Seventy percent of the contacted ICUs

answered the questionnaire. The prevalence of tracheostomy was 10%

in the long-term ventilated patients (defined as > 24 h), or 1.3 % of all
patients. Most tracheotomies were performed during the 2nd week of
ventilation. The frequency of tracheostomy varied widely (0-60 %)
and was only slightly associated with the different language regions of
our country and with the policy of hospitals to accept or refuse
intubated patients on their normal wards. Most units offered either
conventional surgical tracheostomy (69 %) and/or percutaneous
procedures (57 %). The decision to perform a tracheostomy was made
mostly by the intensivist and the procedure was more often performed
in the ICU (65 %) than in the operating theatre (35 %). Units where
the intensives had exclusive control used only percutaneous
techniques. An overall complication rate of 13 % was reported,
bleeding and infections being at the top of the scale. Only 27 % of the
units performed late follow-up protocols.11
The investigator while working as staff nurse had multiple
experiences that are related to lack of knowledge regarding
tracheostomy among staff nurses. It was also found nurses having
limited knowledge in various areas of tracheostomy care. The
investigator analyzed various body of research and clinical practice
changes and timely research projects on tracheostomy care and
decided to conduct a study on effectiveness of planned teaching
program regarding tracheostomy care in terms of knowledge of staff
nurses.
STATEMENT OF THE PROBLEM

A study to assess the knowledge of staff nurse regarding

tracheostomy in selected hospitals,manglore.
OBJECTIVES OF THE STUDY
To assess the knowledge regarding tracheostomy care among staff
nurses.
To find the association between level of knowledge with selected
socio demographic variables.
OPERATIONAL DEFFINITIONS
Assess-In this study assess refers to determining the knowledge score
of staff nurses regarding tracheostomy care using a self administered
knowledge questionnaire.
Effectiveness- It refers to significant gain in knowledge of staff nurses
regarding tracheostomy care determined by significant difference
between pre-test and post test knowledge scores.
Tracheostomy care - In this study it refers to caring of the
tracheostomy tube placed in the incision to secure an airway and to
prevent it from closing.
ASSUMPTION
The staff nurses have limited knowledge regarding tracheostomy care.

RESEARCH HYPOTHESIS
The hypothesis will be tested at 0.05 level of significance

H1:There is significant difference in pretest and post test knowledge

scores on tracheostomy care among staff nurses.
H2: There is significant association between knowledge level with
selected socio demographic variables.
RESEARCH VARIABLES
Dependent variable

Knowledge of staff nurses regarding

Tracheostomy care .
Independent variable : Tracheostomy care
Demographic variables:

Age, Gender, Religion, Family income,

Type of family and Source of information

DELIMITATIONS OF THE STUDY
The study is limited to staff nurses of selected hospital,Manglore.
The study is limited to a sample of 100 staff nurses only.

REVIEW OF LITERATURE
An article reported on the importance of providing guidance to
nurses on tracheostomy care and management. The aim of the article
was to discuss the indications for a tracheostomy and also the care
and management commonly carried out, with the purpose of
increasing knowledge and interest of the care of a patient with a
tracheostomy To care for a patient with a tracheostomy requires a

clear understanding of each patient's need for the tracheostomy and

the type of tube that is required. The impact of a tracheostomy on the
respiratory system includes thorough knowledge of respiration,
methods of humidification and also suctioning techniques. In addition
to this a tracheostomy may impact on swallowing, communication
and body image. Appreciation of these effects will guide the nurse and
the wider multidisciplinary team in future needs and care.
Tracheostomy care and management is more and more necessary in
both the intensive care setting and the general ward. It is, therefore,
ever more important that trained nurses are equipped with the
appropriate skills, knowledge and support to meet the unique needs of
each patient safely and competently.6
An internet-based study was conducted to evaluate registered
nurses' knowledge and recognition of assessment parameters for
displaced Tracheostomy tubes in patients with unobstructed upper
airways. There were 221 nurses who participated in the study that
queried their knowledge related to recognition and intervention for
patients with displaced Tracheostomy tubes in obstructed and
unobstructed upper airways. A questionnaire was used to assess
knowledge. The study results indicated that educational level is
independent of nurses' knowledge of tracheotomy management for a
displaced tracheotomy tube in tracheotomy patients with an
unobstructed (?2 (6, N =186) = 2.692, p > .05) or obstructed ( p > .05)
upper airway. Eighty-three percent of nurses did not recognize that, in
the patient with an unobstructed upper airway, improved voice signals

a need to assess for tracheotomy tube displacement. On the

parameters of practice setting for overall knowledge of obstructed and
unobstructed airways, nurses who practiced in an inpatient setting was
a significant predictor of overall knowledge scores when compared to
nurses who practiced in a nursing home setting (B = -0.161, p = .044).
Experience providing care to tracheotomy patients was the strongest
predictor of overall knowledge scores (B = 0.181, p = .017). The
results also concluded failure in the part of nurses to detect a
tracheotomy tube displacement into the subcutaneous tissues of a
patient and also to recognize that there is a difference in how to
provide respiratory support and patient management for an accidental
decannulation in a tracheotomy patient with an unobstructed versus an
obstructed airway.
A descriptive study was conducted to assess the graduate nurses'
comfort and knowledge level regarding tracheostomy care. This study
examined 104 new graduate nurses' (GNs) comfort level before and
after a tracheostomy in-service educational session. Results indicate
no correlation between reported comfort level and knowledge in
caring for patients with tracheotomies. Findings demonstrate that GNs
can benefit significantly from in-service education and skills
integration. This suggests that hands-on skills content should be a
priority for inclusion into nurse residency programs, particularly with
specialized, high-risk, low-incidence nursing skills, regardless of how
comfortable nurses report they are with a given patient population.12

A literature review was conducted to identify current

perspectives and areas for research regarding care and management of
tracheotomised adult patients discharged to general wards and the
community. The increased number of tracheotomies being performed
has led to more tracheotomised patients being discharged to nonspecialized areas. Staff within these diverse areas may care for this
patient group on an infrequent basis, and may lack the skills,
knowledge and confidence to provide safe tracheostomy care.
Although several guidelines and quality improvement initiatives have
been developed to guide and improve tracheostomy care, concerns
continue to be raised regarding this aspect of care. These factors
inadvertently create significant risks for example, tube displacement
in addition to the risks associated with procedures such as tracheal
suctioning. Database searches of MEDLINE, BRITISH NURSING
INDEX and CINAHL (1998-2009). Inclusion criteria were literature
regarding tracheotomised adult patients discharged to non-specialized
areas. Exclusion criteria was paediatric literature. Although best
practice is applied to the care of tracheotomised adult patients in some
areas, including support for ward staff from specialist nurses or teams,
this is not always formalized or consistent. Research is very limited in
relation to the care and management of tracheotomised adult patients
outside specialized areas, yet there is morbidity and mortality
associated with this patient group. Staff education is widely
recommended, but further development is needed to determine the
best methods of delivering education, especially for health care

professionals who care for tracheotomised patients on an infrequent

basis.13
A study was conducted to explore nurses' knowledge and
competence in performing tracheal suctioning in acute and high
dependency ward areas and to investigate discrepancies between
knowledge and practice using method triangulation. With an
increasing demand for intensive care beds more nurses in acute and
high dependency wards will be expected to care competently for
patients with tracheostomy tubes. Tracheal suctioning is an essential
aspect of effective airway management. However, this has many
associated risks and complications, ranging from trauma and
hypoxemia to, in extreme cases, cardiac arrest and death. It is
imperative that nurses are aware of these risks and are able to practice
according to current research recommendations. 28 nurses were
observed

using

nonparticipant

observation

and

structured

observation schedule. Each subject was interviewed and questioned

about their tracheal suctioning practices, and subsequently completed
a knowledge-based questionnaire. Scores were allocated for
knowledge and practice. The findings demonstrated a poor level of
knowledge for many subjects. This was also reflected in practice, as
suctioning

was

performed

against

many

of

the

research

recommendations. Many nurses were unaware of recommended

practice and a number demonstrated potentially unsafe practice. In
addition, there was no significant relationship between knowledge and
practice. The study raised concern about all aspects of tracheal

suctioning and has highlighted the need for changes in practice,

clinical guidelines and focused practice-based education.14.
A study was conducted on the effectiveness of tracheostomy
videos for staff education. Tracheostomy care is a basic nursing skill.
While it is a matter of routine procedure in the daily practice of
otolaryngology and critical care nurses, general nurses in other areas
may perform it infrequently. Therefore, many otolaryngology nurses
provide staff education when a tracheostomy patient is present in a no
specialty area. This educational effort can be time consuming and
repetitious for the specialty nurse. Audiovisual materials can be useful
as a basis for an educational session or as a substitute when the
specialty nurse is unavailable. The author conducted a thorough
search for available video recordings on nursing care of adults with
tracheotomies. Four videos were identified and acquired. Each one
was viewed twice, and then subjectively rated for completeness and
accuracy of content in a comparative, "Consumer Reports"-like
manner. Recommendations are made considering content, cost, and
availability. The review was written for experienced clinicians and
presumes a thorough knowledge of tracheostomy care.15
A descriptive study was conducted to determine intensive care
unit (ICU) staff knowledge of the use and care of endotracheal and
tracheostomy tube cuffs. There is an apparent high incidence of
tracheal stenosis in the Bloemfontein area. One hundred and twelve
qualified nurses, working in 11 different ICUs, were asked to

complete

an

anonymous

questionnaire

regarding

endotracheal/tracheostomy tube cuffs. The results highlight the

following three areas of concern: (i) there was an overall
misconception in 38% of the respondents that the function of the cuff
was to secure the tube in position in the trachea to prevent selfextubation; (ii) accurate regulation of cuff pressure was not routine
practice in any of the ICUs; and (iii) only half of the respondents felt
their training regarding cuff care management was sufficient. ICU
staff had misconceptions regarding the function and care of
endotracheal/tracheostomy tube cuffs. The concept of a higher cuff
pressure for better stabilisation of the tube is probably an important
factor that could have caused the increase in tracheal stenos is in the
Bloemfontein area. Critical care nursing needs to emphasise the use of
current techniques, discourage routine cuff deflation, and encourage
collaboration with ICU physicians on standards of care. A protocol
that could be used in the ICUs regarding the use and care of an
endotracheal/tracheostomy tube cuff was proposed.16
A nurse-driven investigation, using a convenience sample and
comparative descriptive design, was conducted within a large medical
centre to identify healthcare professionals' (N=885) knowledge of
emergency ventilation strategies for the Tracheostomy patient.
Registered nurses and physicians comprised the majority of survey
respondents (n=587) who answered a three-item questionnaire to
assess specific knowledge. Findings focused primarily on differences
in knowledge among subgroups of nurses, including those in critical

care and noncritical acute care settings. Although increasing

knowledge levels are documented since the mid 1980's, concern for
the knowledge available to manage the emergency ventilation of
Tracheostomy patients is voiced.The study results showed that only
less than half of nurses and physicians in this sample were able to
answer correctly all three questions asked regarding emergency
strategies. The study recommended to address on

this regard of

knowledge deficit among registered nurses and physicians in the care

of tracheostomy patients.18
A descriptive study was conducted to assess the frequency, timing
and technique of tracheostomy and its variation between different
intensive care units (ICUs) in Switzerland. A questionnaire was sent
to all intensive care units formally recognized by the Swiss Society of
Intensive Care Medicine. Excluded were paediatric ICUs. A total of
48 ICUs (70 %) responded. In 1995 and 1996 the participating units
had admitted 90,412 patients for a total of 243,921 ICU days. Seventy
percent of the contacted ICUs answered the questionnaire. The
prevalence of tracheostomy was 10% in the long-term ventilated
patients (defined as > 24 h), or 1.3 % of all patients. Most
tracheotomies were performed during the 2nd week of ventilation.
The frequency of tracheostomy varied widely (0-60 %) and was only
slightly associated with the different language regions of our country
and with the policy of hospitals to accept or refuse intubated patients
on their normal wards. Most units offered either conventional surgical
tracheostomy (69 %) and/or percutaneous procedures (57 %). The

decision to perform a Tracheostomy was made mostly by the

intensives and the procedure was more often performed in the ICU
(65 %) than in the operating theatre (35 %). Units where the
intensivist had exclusive control used only percutaneous techniques.
An overall complication rate of 13 % was reported, bleeding and
infections being at the top of the scale. Only 27 % of the units
performed late follow-up protocols.11
A study was conducted in areas of Tracheostomy care and
suctioning in the Walter Reed Army Medical Centre (WRAMC), as a
performance improvement where a concerted effort is put to make
current research into clinical practice. The focus of the project is
adapting the hospital's existing performance improvement model to
better

facilitate

evidence-based

practice.

Initial

surveys

on

Tracheostomy care conducted throughout the hospital showed an

inconsistent level of knowledge and a variation in clinical practice.
These inconsistencies represented a patient safety threat in the form of
nosocomial

infections,

prolonged

hospitalizations,

airway

complications, and even death. To address these issues, the Nursing

Performance Improvement and Nursing Research Departments
entered into a research collaboration. Representatives from these
departments worked with clinical experts to develop a plan and
timeline for conducting a Tracheostomy care project with the goal of
implementing evidence into practice and thereby improving patient
safety at the hospital. The group completed initial data collection in
April 2003 and then began work on the evidence-based procedure. A

literature review was completed using online search engines such as

MEDLINE, the Cumulative Index to Nursing and Allied Health
Literature (CINAHL), the Cochrane Collaboration, Medscape, the
American Association of Critical-Care Nurses (AACN) practice
guidelines, and the Joanna Briggs Institute. Pertinent articles were
identified and evaluated by two independent reviewers. The Agency
for Healthcare Research and Quality (AHRQ) levels of evidence were
used to grade more than 30 articles. The results of this search were
used to develop a WRAMC Department of Nursing Procedure for
Tracheostomy care, which was completed in September 2003.
3.METHODOLOGY-

Research approach
An evaluatory research approach will be adopted for the study.
Research design
Pre-test post- test design
Settings of the study
The study will be conducted in selected hospitals,Mangaluru
Population
Staff nurses working in selected Hospitals,Mangaluru
Sampling size
Total study sample consist of 100 staff nurses
Sample procedure
Non probability convenient sampling will be used to select the
sample.
Sampling criteria
Inclusive criteria
1. Staff nurses in selected hospital.

2. Staff nurses who are willing to participate.

3. Staff nurses who can read and understand English.
Exclusive criteria
1.Staff nurses who are on leave or absent at the time of data
collection.
2.Staff nurses who have already undergone training programmes on
Tracheostomy care.
VALIDIITY OF THE TOOLThe prepared instruction along with validity seeking letter,acceptance
fprm,problem

statement,objectives,hypothesis,operational

definition,blueprint,criteria check will be submitted to experts and ask

for their valuable suggestions and recommendations
RELIABILITY OF THE TOOLThe reliability will be established by using Cronbachs Alpha method.
PILOT STUDY
The pilot study will be conducted on 10 samples. The purpose of pilot
study is to find out the feasibility of conducting the main study and
design on plan of statistical analysis. The finding of the pilot study
sample will not be included in the main study.
PLAN FOR DATA COLLECTION:

Ethical clearance will be taken from the ethics committee.

Permission will be taken from the concerned authorities.
Voluntary informed consent will be obtained from the subjects.
The data will be collected from by using self administered
questionnaire to assess knowledge regarding Tracheostomy care
after getting signed concerns.

PLAN FOR DATA ANALYSIS: Demographic data will be analysed using frequency and
percentage.
The significant difference between the mean pre test and post
test score will be calculated using pairedt test.
The significant difference between the mean pre and post test
score between experimental and control group will be calculated
using unpairedt test.
Chi-square test to analyze the association of the demographic
variables with the post assessment level of knowledge of staff
nurse.