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The patient is a male who underwent a total laryngectomy and has a tracheostomy tube. He is complaining of blood-tinged sputum and difficulty breathing. On assessment, he has dyspnea, cough, use of accessory muscles, and a history of smoking. The nursing care plan is to establish rapport, assess respiratory status every 4 hours, keep the head of the bed elevated, encourage deep breathing exercises, suction the tracheostomy tube and provide humidification to decrease mucus and facilitate coughing. Serial lab work and monitoring will be done to evaluate the patient's condition.
The patient is a male who underwent a total laryngectomy and has a tracheostomy tube. He is complaining of blood-tinged sputum and difficulty breathing. On assessment, he has dyspnea, cough, use of accessory muscles, and a history of smoking. The nursing care plan is to establish rapport, assess respiratory status every 4 hours, keep the head of the bed elevated, encourage deep breathing exercises, suction the tracheostomy tube and provide humidification to decrease mucus and facilitate coughing. Serial lab work and monitoring will be done to evaluate the patient's condition.
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The patient is a male who underwent a total laryngectomy and has a tracheostomy tube. He is complaining of blood-tinged sputum and difficulty breathing. On assessment, he has dyspnea, cough, use of accessory muscles, and a history of smoking. The nursing care plan is to establish rapport, assess respiratory status every 4 hours, keep the head of the bed elevated, encourage deep breathing exercises, suction the tracheostomy tube and provide humidification to decrease mucus and facilitate coughing. Serial lab work and monitoring will be done to evaluate the patient's condition.
Copyright:
Attribution Non-Commercial (BY-NC)
Formati disponibili
Scarica in formato DOC, PDF, TXT o leggi online su Scribd
Subjective Cues Ineffective After 8 hours Established rapport to patient To gain trust and cooperation of After 8 hours of “may dugo ang airway of Nursing and patients relative the patient Nursing plema ko at mejo clearance intervention intervention the nahihirapan ako related to the patient will Assessed respiratory status Change in respiration, use of patient was able to huminga” total be able to including rate, pattern, lung accessory muscle or presence of maintain patent removal of maintain sounds, crackles/ wheezes- suggest airway and lung and cough effectiveness at least retention of secretions Objective Cues glottis patent airway every 4 hour Airway obstruction can lead to sounds (+) blood tinged altering to and lung ineffective breathing patter and sputum, breathe, sounds impaired gas exchange, leading hemoptysis cough and in complication. swallow Elevated head of the bed 30- 45 degree Facilitate drainage of secretions (+) Dyspnea and lung expansion
(+) cough Encouraged Deep breathing Mobilizes secretion to clear
exercise airway and helps prevent respiratory complications Use of accessory muscle when Suctioned tracheostomy tube, Prevent secretion from breathing oral, nasal cavities, note amount obstructing airway esp when of color and consistency of swallowing ability is impaired and With history of secretions client cannot blow nose Change in character of secretions smoking may indicate developing problems (DHN, INFECTION) and With need further evaluation tracheostomy Maintained Proper position of laryngectomy/ tracheostomy As edema develops tubes can be tube tube, checked or adjust ties displaced, compromising airway when indicated ties should be snug out not w/ nasogastric constricted to surrounding tissue tube or major Blood vessels Provided supplemental humidification eg. Compressed/ Normal physiologic (nose, nasal ambulatory oxygen mist collar, increase passages) means of filtering/ fluid intake humidifying air are bypassed Vital signs taken supplemental humidity decrease as follows mucous and facilitated coughing. T- 36.7 Monitored serial ABG’s Pulse Pooling of secretions/ presence of PR- 92 and Oximeter chest X-ray atelectasis may lead to regular pneumonia, requiring aggressive RR- 18 therapeutic measures BP- 120/80