NAME OF PATIENT: Marichuchuchu Achu

AGE AND GENDER OF PATIENT: Female

ATTENDING PHYSICIAN: Dr. J. Sallo

NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS BACKGROUND OBJECTIVES INTERVENTION
Subjective: Risk for infection There is a high Date: October 8, Independent: Date: October 8,
The wife states related to susceptibility for 2022  Assess  Fever may be 2022
she thinks her excessive pooling infection in patient’s a
husband is getting of secretion and patients with Short term goals: temperature manifestation After 8 hours of
mad at her bypassing of tracheostomy due After 8 hours of of an nursing
because he can’t upper respiratory to the loss of nursing intervention infection or intervention the
communicate defenses as function of the the patient will: inflammatory goals are met:
with her evidenced by upper airway. process
patient having With an inflated  Report risk  Patient
Objective: tracheostomy and cuff, there is a factors that  Assess skin  This is a reported risk
 Multiple increased loss of airflow are integrity common site factors that
sutures through the upper associated under for infection are
around airway. Some of with tracheal ties and skin associated
the site the functions of infection breakdown with
 Produce the upper airway and perform infection and
more include condition proper  Observe the  The buildup perform
secretion of inspired air to precautions stoma for of mucus and proper
around body temperature when erythema, rubbing of precautions
stoma and 100% relative needed color, the when needed
 BP- humidity. exudates, tracheostomy  Patient
115/82 Tracheostomy can  Demonstrate and crusting. tube can demonstrated
 Temp- lead to correctly If present, irritate the correctly
99.6’ F pathological how to culture the skin and how to
changes of the properly stoma and serve as a properly
lower airways, clear airway notify site for apply clear
including damage by discharge physician infection. airway by
to the ciliated Culture and discharge
tracheal mucosa, sensitivity
thickening of reports guide
airway secretions, the antibiotic
and the loss of selection
mucociliary
transport.  Do not allow  These steps
Repeated cleaning secretions to keep the
and suctioning of pool around stoma clean
the lower the stoma. and dry. The
airway/the trachea Suction the back of the
is necessary, area, or wipe neck should
which results in with aseptic be checked
significant patient technique. carefully in
discomfort and Keep the bedridden
increases the risk skin under clients
of lower the because
respiratory tract tracheostomy secretions
infection and ties back of tend to flow
airway the neck to the back
obstruction. clean and dry of the neck.
Other Clean, dry
complications of skin helps
the tracheostomy prevent skin
that may increase irritation
the risk of
infection is that
the patient may
have poor
secretion
management and
an increased risk
of aspiration.
Diagnosis of an
infection is
sometimes
difficult because
patients with
tracheostomy are
often colonized
with potentially
pathogenic
bacteria. The
diagnosis is often
made on clinical
features such as
cough, purulent
secretion,
systemic signs of
infection,
impairments in
gas exchange and
the presence of an
infiltrate on chest
x-ray, should also
be checked.

(Hernandez,
2012) -
Tracheostomy
Education
ASSESSMENT NURSING SCIENTIFIC NURSING NURSING RATIONALE EVALUATION
DIAGNOSI BACKGROUN OBJECTIVES INTERVENTION
S D
Subjective: Risk of Alveolar- After 3 hours and 30 INDEPENDENT After 3 hours and 30
impaired gas capillary minutes of nursing minutes of nursing
The wife states exchange membrane intervention, the  Position  Upright or semi- intervention, the patient
she thinks her related to alterations, such patient will be able patient with Fowler’s was able to:
husband is copious as fluid shifts to: head of the position allows
getting mad at tracheal and fluid bed elevated, increased  Demonstrated
her because he secretions collection into  Demonstrate in a semi- thoracic improved
can’t secondary to interstitial space improved Fowler’s capacity, total ventilation and
communicate tracheostomy and alveoli, lead ventilation position (head descent of the adequate
with her due to as evidenced to impaired gas and adequate of the bed at diaphragm, and oxygenation of
the inability to by patient is exchange. As a oxygenation 45 degrees increased lung tissues by
produce speech having result, the of tissues by when supine) expansion ABGs within
from the increased alveolar ABGs within as tolerated. preventing the client’s normal
tracheostomy. secretions capillary client’s abdominal limits and
and difficulty membrane normal limits contents from absence of
Objective: removing experiences an and absence crowding. symptoms of
them. excess or of symptoms respiratory
deficiency of of  Help patient  This technique distress.
 The oxygen, which respiratory deep breath can help  Participated in
patient impairs the distress. and perform increase sputum treatment
starts to removal of  Participate in controlled clearance and regimen within
produce carbon dioxide. treatment coughing decrease cough level of ability
more Gas exchange regimen spasms. situation
secretio can be within level
ns hampered by the of ability  Suction as  Suction clears
around presence of lung situation necessary secretions if the
his congestion, patient is not
stoma pulmonary capable of
and at edema, and effectively
times secretion clearing the
 starts to accumulation. airway. Airway
cough obstruction
to Source: blocks
remove https:// ventilation that
the simplenursing.p impairs gas
secretio h/risk-for- exchange.
ns but is impaired-gas-
unable exchange-care-  Encourage or  Ambulation
to note/ assist with facilitates lung
complet #:~:text=Presen ambulation expansion,
ely ce%20of secretion
remove %20pulmonary clearance and
them %20congestion stimulates deep
 Irritable %2C breathing.
%20pulmonary,i
nto  Administer  Humidification
%20interstitial humidified of oxygen
%20space oxygen prevents the
%20and through drying of
%20alveoli. appropriate mucosal
device (e.g., membranes.
nasal cannula
or face mask
per
physician’s
order)

 Instruct patient  This is to reduce

to limit the potential
exposure to spread of
persons with droplets
respiratory between
infections patients.

 Regularly  Slumped
 check the positioning
patient’s causes the
position so abdomen to
that they do compress the
not slump diaphragm and
down in bed. limits full lung
expansion.

ASSESSMENT NURSING SCIENTIFIC NURSING NURSING RATIONALE EVALUATION

 DIAGNOSIS BACKGROUND OBJECTIVES INTERVENTION
Subjective: Impaired Verbal Verbal After 3-5 days of Independent: After 5 days of
Communication communication nursing care, the  Assess the  Standard nursing care, the
Objective: related to includes any mode patient will use a client’s tracheostomy patient was able
presence of of communication form of communication to use a form of
tubes allow the
 The patient artificial airway containing words, communication communication to
ability vocal cords to
manifested: as manifested by spoken, written, or to get needs met get needs met and
difficulty of signed. People and to relate move, but no was able to relate
- Little drowsy speaking communicate effectively with airflow passes effectively with
verbally through persons and over them if persons and
- Unable to
vocalization of a environments the cuff is environments
communicate system of sounds
- Unable to inflated;
that has been
produce therefore,
formalized into a
speech language. A vocalization is
- Producing variety of not possible
more challenges may
arise when using  Assess  The patient
secretions
verbal effectiveness may use hand
around stoma communication to of nonverbal signals, facial
- Presence of express oneself. communication expressions.
cough Misunderstandings
methods And changes
can arise because
of impaired in body
communication. posture to
communicate
with others.
However,
others may
have difficulty
in interpreting
these
nonverbal
techniques.
 Each new
method needs
to be assessed
for
effectiveness
and altered as
necessary.

 Assess for  The inability to

frustration and communicate
anxiety related enhances a
to not being client’s sense
able to of isolation
communicate and may
needs promote sense
of helplessness

 Provide a call  A prompt

light within response
easy reach at decreases
all times. anxiety and
Answer the prompt
light promptly provision of
patient’s
needs.
 Provide
alternative  Providing a
methods for variety of
communicating communicatio
n aids allows
the patient
 more channels
through which
information
can be
communicated.
Dependent:
 Administer
medications as  Administering
indicated and medications
ordered may enhance
patient’s
condition
Collaborative:
 In
collaboration
with the  The talking
physician and tracheostomy
speech provides a port
therapist on the for compressed
possible use of gas to flow in
a talking above the
tracheostomy tracheostomy
as indicated tube, allowing
and ordered are of
phonation
 If the patient
no longer
requires  These adaptive
mechanical devices can
ventilation, facilitate
consider the talking
use of a Passy-
Muir valve or
fenestrated
tracheostomy
tube
.