DEPARTMENT OF NURSING

Nursing Care Plan

 

 

Student Name:Stephanie Regas

Course number:281

Health care agency: Barnert Hospital

Date of Care:2/22/05-2/23/05

Patient’s initials:E.B.

Patient’s room: 364

Age:91

Developmental state:Old Age: Integrity

Instructor:Prof. Polnyj


 

 

 

Instructor’s comments:

 

 

 

ASSESSMENT

Universal Self

Care Requisites Normalcy

NURSING DIAGNOSIS

Problem, Etiology, Symptoms

 

GOALS

 

PLANNING

INTERVENTIONS

 

SCIENTIFIC RATIONALES

 

EVALUATION

Self Care Agency (SCA):

Willingness of family to provide care to the pt by displaying verbal concern and interest in pts well being when discharged home with tracheostomy.

 

 

 

 

 

 

 

Self Care Deficit (SCD)

SCD’s:

Language barrier, frustration with pts deteriorating health, doesn’t understand purpose of suctioning, and why it has to be done.

 

 

 

 

 

 

 

 

Nursing agency:

Wholly compensatory

Partially compensatory

Supportive-educative

 

 

P: Knowledge deficit (cognitive) concerning suctioning tracheostomy

 

 

 

 

E: Related to pt discharged home with family with tracheostomy

 

 

 

 

S: Manifested by cognitive limitation. Pt unable to verbalize, unable physically perform task on her own. Language barrier, lack of exposure in regards to family. 

GREAT DIAGNOSIS

 

 

Pt family will verbalize understanding of reason for suctioning.

Pt family will demonstrate suctioning.

Pt’s family will recognize need for suctioning.  Explain how to incorporate new health regimen into lifestyle.

Pt’s family will demonstrate how to perform procedure satisfactorily.

GOOD

 

 

 

 

 

 

NICE INTERVENTIONS AND RATIONALES.

1. Asses barriers to learning.

 

 

 

 

 

 

 

 

2.  Observe the ability of the client’s family and their readiness to learn.

 

 

 

 

 

 

 

 

 

 

3. Present material that is most significant to the client first, and provided information about each piece and what it is used for.  Have family verbalized back understanding of each piece of equipment and its use.

 

 

  1. Gather equipment that is needed to suction the tracheostomy.  Explain to family what each piece of equipment is for, and how it is used during the procedure.

 

 

  1. Use visual aids such as diagrams, pictures, videotapes, audiotapes, and interactive Internet websites for them to refer back to when in the home setting with the pt. And gave them this web site to refer to for help http://www.neurosy.

       org/care giving/patient      care/suctioning. Need to make sure they have access/know how to use a computer/internet      

 

 

 

  1. Explain the procedure step by step to the family:

*Wash hands thoroughly.

 

*Turn on the suction machine, and adjust the regulator dial to the proper setting.

*Position client in semi-fowlers or sitting upright with head hyper extended, unless contraindicated.

*Remove the suction cath. From its wrapper.

 

*Dip the loose tip of the catheter into the sterile water.

 

 

*Remove oxygen from pt and gently insert the catheter into the trachea until you feel resistance.  When resistance is felt the catheter has probably hit carina. Pull catheter back 1cm before applying suction.

 

 

*Apply intermittent suction by placing and releasing nondominant thumb over vent of catheter; slowly withdraw catheter while rotating it back and forth between dominant thumb and forefinger. Watch for respiratory distress.

* Asses for need to repeat suctioning procedure.  Allow adequate time between suction passes for ventilation and oxygenation. You may nee to apply oxygen to pt at this time.

 

*When you are done rinse the catheter with water in cup until connecting tubing is cleared of secretions. Turn off suction machine.

 

 

*When suctioning is completed roll catheter around fingers of dominant hand. Pull glove off inside out so that catheter remains coiled in glove. Pull off other glove over first glove in same way to seal in contaminants. Discard in appropriate receptacle.

*Compare pts respiratory assessments before and after suctioning

*Observe airway secretions and check for color and consistency.

 

 

 

 

  1. Repeat and reinforce information during several brief sessions during teaching.

 

 

 

 

  1. Evaluate the family’s ability to verbalize and physically demonstrate there understanding of tracheostomy suctioning procedure with confidence.

 

FYI: suctioning at home is often not a sterile procedure, simply a clean procedure.  No sterile water, just clean water, Sometimes they even just clean the suction tubing and reuse. Also, if pt’s are being discharged with any type of self care procedure it’s a good idea to give them supplies to get them started (clean gloves, suction catheter, trach gauzes). In this type of situation you would also make sure visiting nurse arrangements had been make to make sure the family is managing the procedure as instructed. 

  1. The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences.

 

 

  1. Education in self-care must take into account physical, sensory, mobility, sexual, and psychosocial changes related to age.

 

 

 

 

 

 

  1. Information building begins with explaining simple concepts and moves on to explanations of complex application situations.

     

 

 

  1. The equipment used is the suction machine, connecting tubing, basin, sterile water, and suction catheter.

 

 

 

  1. Verbal reinforcement of personalized, written instructions appears to be the best-tested intervention. Computer- generated, personalized instructions improved adherence when compared with handwritten instructions.

 

 

 

6. 

 

* Reduces transmission of microorganisms.

*Usually the setting should be between 80-120mm Hg but no higher than 120 mm Hg

*Hyperextension facilitates insertion of catheter into trachea.

 

 

 

 

*This will help the catheter glide more easily and allow a small amount of water to flow back through the tubing.

*  Application of suction pressure while introducing catheter into trachea increases risk for damage to mucosa and increases risk of hypoxia. You do not want to initiate suctioning before pulling the catheter out because you can damage the tissue.

*Intermittent suction and rotation of catheter prevent injury to tracheal mucosal lining. If catheter grabs mucosa, remove thumb to release suction.

 

*Observe for alterations in cardiopulmonary status. Suctioning can induce hypoxemia. Repeated passes clear the airway of excessive secretions but can also remove oxygen and may induce laryngospasm.

*Rinsing the catheter reduces probability of transmission of microorganisms. Clean suction tubing enhances delivery of set suction pressure, prevents skin breakdown.

*Reduces transmission of microorganisms.

 

 

 

 

 

*Identifies physiological effects of suction procedure to restore airway patency.

*Provides data to document presence or absence of respiratory tract infection.

 

 

 

7.Understanding past information is essential to acquiring new knowledge.  Brief sessions focus attention on essential information.

 

 

 

  1. Presenting information along with examples of how to apply the information has been found more successful than providing information alone in a home care setting.

 

 

 

(Ackley Nursing Diagnosis Handbook pgs 607-611)

(Mosby Fundamentals pgs1167-1171)
  1. Pt’s family speaks and understands Spanish, so a translator was used in order for the family to be able to understand the trach. suctioning purpose and procedure.

 

 

  1. Pt’s family verbalized, “They want their mother to come home.”  I explained to them that their mother would go home with this trach. and the importance of them being able to suction her as needed. Pt’s family agreed.

 

 

  1. Not implemented.

 

 

 

 

 

 

 

4.                   Not implemented.

 

 

 

 

 

 

 

  1. Not implemented.

 

 

 

 

 

 

 

 

 

 

 

 

6.  Not implemented.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.  Not implemented.

 

 

 

 

 

 

8.  Not implemented.