NURSING CARE PLAN

Assessment Nursing Inference Planning Intervention Rationale Evaluation

Diagnosis
Subjective Cues: Impaired Verbal Presence of Short Term Objective Independent: Short Term Objective
N/A Communication tracheostomy After 4 hours of 1. Establish rapport assess patient’s 1. To gain and trust, promotes a After 4 hours of
related to presence rendering nursing ability to use or comprehend language. collaborative working relationship, rendering nursing
Objective Cues: of artificial airway: intervention, nurse will 2. Assess environmental factors (e.g., understand limits and capabilities, devise intervention, nurse was
 Presence of tracheostomy Decrease or absence be able to build rapport room noise level). appropriate strategy for effective able to build rapport
tracheostomy evidenced by of the ability to use or with the patient and will 3. Assess the patient’s preferred communication with and the patient
inability to speak. understand language. identify patient’s language for verbal and written 2. The surrounding may affect the ability to and identifies the
primary and preferred communication communicate. patient’s primary and
means of 4. Assess the patient’s primary and 3. Patients may speak a language properly preferred means of
communication. preferred means of communication without being able to read it effectively. communication.
Impaired Verbal (e.g., verbal, written, gestures) Discharge self-care and follow-up
Communication After 8 hours of 5. Ability to get spoken word information must be communicated and After 8 hours of
rendering nursing 6. Ability to understand written words, strengthened with written information that rendering nursing
intervention, the pictures, and gestures the patient can use. In recognition of the intervention, the
patient will 7. Learn patient needs and pay attention wide array of cultures and physical patient demonstrates
demonstrate to nonverbal cues. challenges that patients face, it is the acceptance of self as
acceptance of self as 8. Place important objects within reach. nurse’s responsibility to communicate is rather than idealized
is rather than idealized 9. Give the patient ample time to effectively. image
image respond. 4. Patients may have skills with many forms
10. Maintain a calm, unhurried manner. of communication, yet they will favor one
Provide sufficient time for patient to method for important communication. Long Term Objective
Long Term Objective respond. 5. It is necessary for the health care team After 5-7 days of
After 5-7 days of 11. Try to phrase questions requiring a to learn that the construct of gestured nursing intervention,
Reference: Reference: nursing intervention, “yes” and “no” answers. language has a completely different the patient was able to
Doenges, M. E., Doenges, M. E., the patient will be able 12. Speak slowly. structure from verbal and written English. communication with
Moorhouse M. F., & Moorhouse M. F., & to communication with 13. Provide concrete directions that the 6. A way to be certain if communication has primary and preferred
Murr, A. C. (2008). Murr, A. C. (2008). primary and preferred patient is physically capable of doing been productive is to provide for a certified means of
Nurse’s Pocket Nurse’s Pocket Guide means of (e.g., “point to the pain,” “open your interpreter to confirm information from both communication.
Guide Diagnoses, Diagnoses, communication. mouth,” “turn your head”). sides of the discussion.
Prioritized Prioritized 14. Provide word-and-phrase cards, 7. The nurse should set aside enough time
Interventions and Interventions and writing pad and pencil, or picture to attend to all of the details of patient care. After 3 months of
Rationales. 11th ed. Rationales. 11th ed. After 3 months of board. Use eye blinks or finger Care measures may take longer to collaborative
collaborative movements for “yes” or “no” complete in the presence of a intervention, patient’s
intervention, patients responses. communication deficit. demonstrates active
will demonstrate active Dependent: 8. To maximize patient’s sense of participation to speech
participation to speech 15. Coordinate with the physician for a independence. therapy
therapy more comprehensive approach for the 9. It may be difficult for patients to respond
patient’s speech therapy under pressure; they may need extra time
to organize responses, find the correct
Collaboration: word, or make necessary language
11. Coordinate with the speech therapist for a translations.
more comprehensive approach for the patient’s 10. Individuals may talk more easily when
speech therapy they are rested and relaxed and when they
are talking to one person at a time.
11. Patients can be frustrated when they
cannot communicate in a simple manner.
12. This approach provides the patient with
more channels through which information
can be communicated.
13. Simple, one-action directions enhance
comprehension for the patient with
language impairment.
14. Supplemental communication devices
are especially helpful for tracheal patients.
10. Speech therapy is important. A consult
with the physician won’t hurt to have a
more comprehensive intervention for the
patient, making sure that the speech
therapy plan will be perfectly customized to
the patient needs parallel to her health
condition.
11. Speech therapist are h health
professional who diagnoses and treats
communication and swallowing problems.
Collaborating with them can contribute a lot
for the best interest of the patient.