Question

A 65-year-old male was admitted for evaluation of pain on swallowing and a sore throat that has persisted for the past year. The discomfort has not changed with the use of various over the counter cold remedies. The client has lost weight due to a decrease in appetite and difficulty swallowing. He has smoked 3 packs of cigarettes a day for 40 years.

A laryngoscopy showed a subglottic mass. The client had a total laryngectomy with tracheostomy to manage laryngeal cancer. He also has a nasogastric tube in place.

You will be providing care for this client during his first 72 hours after surgery.

 

Initial Discussion Post:

There are multiple nursing diagnoses that are applicable to this client during the time when you will be providing care.

Select one NANDA-I nursing diagnosis and describe why it is a priority for this client.
What is the cause or related factor for this NANDA-I nursing diagnosis?
Identify an outcome for this NANDA-I nursing diagnosis. The outcome must be patient centered and measurable.
Identify two (2) nursing interventions that will help this client achieve the outcome.
Describe how each intervention will help the patient achieve the outcome..

Answer 1

Select one NANDA-I nursing diagnosis and describe why it is a priority for this client.

Impaired Swallowing: Irregular operational of the swallowing instrument connected with shortages in oral, pharyngeal, or esophageal construction or function.

Impaired swallowing contains extra time and exertion to transmission food or fluid from the mouth to the stomach. It happens when the muscles and nerves that aid transfer food through the throat and esophagus are not occupied right. It can be a provisional or permanent difficulty that can be deadly.

What is the cause or related factor for this NANDA-I nursing diagnosis?

Aspiration of food or liquid can also happen perhaps brought about by a physical problem, break or dysfunction of neural trails, reduced asset or trip of muscles complicated in mastication, facial paralysis, or perceptual damage. The swallowing muscles can develop feeble with age or idleness.

Identify an outcome for this NANDA-I nursing diagnosis. The outcome must be patient centered and measurable.

-Measure capability to swallow an insignificant quantity of water. If aspirated, little or no damage to the patient happens.

-Check for remaining food in mouth after consumption. Pocketed nourishment may be naturally pronounced at a later time.

-Checkered for nourishment or watery vomiting through the nares. Vomiting designated reduced aptitude to gulp food or liquids and an augmented danger for ambition.

Identify two (2) nursing interventions that will help this client achieve the outcome.

-For impaired swallowing, use a dysphagia side calm of a reintegration nurse, talking pathologist, dietitian, doctor, and radiologist who effort composed.

-Location patient standing at a 90-degree viewpoint with the head activated onward at a 45-degree angle.

Describe how each intervention will help the patient achieve the outcome.

-The dysphagia squad can aid the patient study to gulp securely and uphold a decent nutritious rank.

-This location permits the trachea to near and gullet to open, which makes swallowing calmer and decreases the danger of aspiration.