Question

Surgery Assignment

A 62-year old male client who has undergone a total laryngectomy for laryngeal
cancer is being cared for on the surgical unit. He has a tracheostomy tube in place. In
addition to providing tracheostomy care, the nurse is also trying to help the client
communicate his needs to the staff as he is unable to speak.

a.  By what means can the client with a tracheostomy communicate his needs to
the staff?
b. Develop a plan of care for this patient including two actual and two potential

Answer 1

a.Communication is particularly critical in health care environments where miscommunication may lead to misdiagnosis or delayed medical treatment.a patient with tracheostomy and mechanical ventilation with an inflated cuff are unable to produce voicing, and many do not speak for an extended period.

Numerous methods can be used to communicate including gestures, head nods, writing, use of communication boards, augmentative communication. These methods may be tailored to meet individualized patients’ needs. Leak speech, speaking valves and talking tracheostomy tubes are methods for the individual with tracheostomy to produce voicing.

B. Actual diagnosis

1.ineffective airway clearance relatedto artificial tracheotomy airway.

Goal:Client will maintain a clear, open airway as evidenced by normal breath sounds, normal rate, and depth of respiration, and the ability to effectively cough up secretions.

Nursing intervention

•Assess changes in BP, HR, and temperature.

Rationale:Tachycardia and hypertension may be related to an increased work of breathing. As the hypoxia and/or hypercapnia become severe, BP and HR drop.

•asess the respiratory status of the patient

Rationale :abnormalities in rate rhythm indicates respiratory compromise.

•Encourage the client to cough out secretions. If the cough is ineffective,suctioning as needed

Rationale :Coughing is the most helpful way to remove most secretions. The client may be able to perform independently. Suctioning removes secretions if the client is unable to effectively clear the airway.

2.impaired verbal communication related to presence of artificial tracheostomy airway

Goal:Client will use a form of communication to get needs met and to relate effectively with persons and environments.

Nursing intervention

•Assess the client’s communication ability. Rationale :Standard tracheostomy tubes allow the vocal cords to move, but no airflow passes over them if the cuff is inflated; therefore vocalization is not possible.

•Assess the effectiveness of nonverbal communication methods.

Rationale :The client may use hand signals, facial expressions, and changes in body posture to communicate with others.

•Provide emotional support to the client and significant others.

Rationale:Difficulties communicating are a source of frustration for all involved.

•Allow the client time to communicate his or her needs.

Rationale :The nurse should set aside enough time to attend to all of the details of client care. Care measures may take a longer time to complete in the presence of a communication deficit.

Potential diagnosis

1.risk for impaired gas exchange related to apiration/tracheostomy leakage/secretion

Goal:client will maintain optimal gas exchange.

Nursing intervention

•Assess the respiratory rate, rhythm, quality, depth, and effort.

Rationale Clients will alter breathing patterns over time to facilitate gas exchange. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties

•Monitor arterial blood gasses and oxygen saturation.

Rationale :Pulse oximetry is a useful tool to detect early changes in oxygen saturation. Oxygen saturation should be kept at 90% or greater.

•Place the client in a semi-Fowler’s to high Fowler’s position.

Rationale :This position promotes full lung expansion and improved air exchange.

•Administer humidified oxygen as needed. Rationale :The appropriate amount of oxygen must be delivered continuously so that the client maintains an oxygen saturation of 90% or greater. Humidification of oxygen prevents the drying of mucosal membranes.

2.risk for infection related to surgical incision of tracheostomy.

Goal:client will remains free from infection

Nursing intervention

•Assess client’s temperature.

Rationale :Fever may be a manifestation of an infection or inflammatory process.

•Assess skin integrity under tracheal ties. Rationale :This is a common site for infection and skin breakdown.

•Provide stoma care:using aseptic technique

rationale:Frequent stoma care is required for postoperative clients. Care for clients with long-term stoma placement is based on need.

•apply an antifungal or antibacterial medication, as prescribed, if any sign of infection.

Rationale : These agents are either toxic to the pathogen or retard its growth.