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3350 Care Map

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Amy Brule

on 4 April 2013

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Transcript of 3350 Care Map

Assessment History: Review of Systems General: Pt. is currently going through radiation and chemotherapy for laryngeal and bladder CA.
Skin: Pt. has sutures in RT side of neck from laryngectomy, and redness around surgical site.
HEENT: Pt. had total laryngectomy and has tracheostomy, causing dysphagia and inability to speak.
Cardiovascular: Pt. has had heart cath, coronary stent, LT popliteal stent, four stents in RT leg for DVT.
Hematology: N/A.
Respiratory: Pt. has laryngeal CA.
Gastrointestinal: Pt. has dysphagia due to laryngeal CA/laryngectomy/
tracheostomy, G-tube inserted, cholecystectomy 2002 due to gall bladder disease.
Hepatic/Accessory GI: N/A.
Renal: N/A.
Endocrine: N/A.
Musculoskeletal: Pt. has arthritis in both knees, has had left knee surgery x3.
Neurological: Pt. had CVA 2007.
Psychiatric: Pt. has depression.
Infectious Disease: N/A..
Reproductive: N/A Patient Data Initials: B.E., Gender: Male, DOB: 12/21/51, Age: 60, Ht: 74", Wt. 167.5 lb, Code Status: Full Code Current Visit Date & Time of Care: 10/04/12 at 12:00
Reason: Pt. is receiving post-op care after having a total laryngectomy on 10/03/12 r/t laryngeal cancer. Pt. has tracheostomy and has had a G-tube inserted. Allergies NKA. Past Medical Visits Larygeal Cancer (2012)
Right Neck Cancer (2012)
Gross Hematuria (2012)
Urinary Tract Infection (2012)
Bladder Cancer (2012) Psychosocial Marital Status: Married
Occupation: Unemployed
Primary Language: English
Sociocultural: American, no religious preference
Home Situation: Lives at home with wife
Substance use: Tobacco, 20 pack years (1 pack q 1.5-2 days x 40 yrs, quit 9/12)
ADLS/IADLS: needs assistance with eating and wound care. Family Hx Father: Diabetes, stomach CA, kidney CA
Mother: CAD, HTN Labs CBC/Blood Types MCHC: 31.0
Hgb: 11.3(low)
Hct: 36.4 (low) BMP/CMP Na: 137
K: 4.4
Glucose: 116
Ca: 8.6
Cl: 102 Renal Function BUN: 15.0
Cr: 0.7 Other Tests Negative for gastric occult blood. Medications Pain Morphine Sulfate (morphine PCA) as directed PRN IV
Morphine Sulfate (morphine sulFATE) 2mg q5m PRN IVP Infection Cefazolin Sodium 1gm/Dextrose 500ml @ 100ml/hr q8h IV
Bacitracin (Bacitracin) 1pkt q8h top GI Lansoprazole (Prevacid Solutab) 15mg qday NG
Ondansetron HCl (Zofran) 4mg q6h PRN IVP Anxiety Lorazapam (Ativan) 2mg q2h PRN IVP Amy Brulé NURS 3350 CareMap Vital Signs BP 110/62; R 10 on 4L T-piece; Sa02 100%; HR 52; Temp 99.4°F; Pain Level 4 out of 10. Diagnoses #1. Risk for Ineffective Airway
Clearance r/t increased secretions,
bleeding from surgical site,
and mucous plugs aeb post-op laryngectomy and tracheotomy. Short-Term Goal:
Pt. will maintain a patent airway at all times aeb Sa02 >92%, respirations between 12-20 breaths/min, and proper suctioning throughout clinical shift. Auscultate breath
sounds and assess
q1-2h. Administer 02 and medications as
prescribed by
physician. Teach pt. to
perform deep
breathing and
controlled coughing. Place call light
within pt's reach. Suction airways
PRN, such as when crackles are heard in the throat or if pt. is coughing up
fluids. Elevate HOB
to between 30° and 45° at all times. Teach pt. to call
for assistance if he experiences any trouble breathing or feels like he needs secretions to be cleared. Monitor Sa02 on exertion, such as when ambulating and during ADL's. Pt. just had surgery the previous day, so it is expected that he will have a lot of increased secretions in his airways and could have some bleeding from the surgical site. All of these things can interfere with the patient's breathing and proper oxygenation. Pt. may have increased 02 demand because of
secretions, and he is not used to breathing through
the tracheostomy on his own yet. Antibiotics will prevent infection, which can cause swelling and more obstruction of the airways. Coughing and deep breathing can help to loosen secretions, which can then be suctioned out to increase airway clearance. Call light should be in reach so that pt. can get to it
quickly and get assistance if he is experiencing any difficulty breathing. Pt. should call for help when he first starts having difficulty because the longer he waits the more difficult his breathing will become. Suctioning is necessary because the pt. has increased secretions in his airways and he is unable to clear them on his own. Upright positioning (Semi-Fowler's position)
allows for maximal lung expansion. Ambulation, ADL's, and other activities increase oxygen demand, making it more difficult to breathe. These activities also loosen secretions, causing airway obstruction. Following ABCs (Airways, Breathing, and Circulation) the pt's breathing is the first priority because if it is obstructed it is the most life threatening. Because of this, it should be addressed first. #2. Risk for infection r/t invasive procedure, inadequate primary defenses (broken skin), pooling of secretions, and increased environmental exposure to pathogens aeb post-op laryngectomy and tracheotomy, and hospitalization. Infection is the second priority in this pt. because he just had surgery and is in the hospital, and both of those circumstances increase risk for infection, which can lead to obstructed airways and sepsis. Long-Term Goal:
Pt. will know how to
maintain a patent airway aeb demonstrating effective
coughing/deep breathing,
clear breath sounds, and proper
suctioning technique
by discharge. This will prevent the pt. from developing hypoxemia, promote healing, and help to prevent infection which can obstruct the airways. Teach pt. how to
suction airways and when it is needed, and
have him demonstrate. Pt. needs to be able to do this on his own so that he can remove secretions that obstruct his airway that he is not able to clear by coughing. He also needs to be able to recognize when it is needed. Have pt. demonstrate
deep breathing and
controlled coughing
and explain the
importance of it. It is important that the pt. understands the reason for deep breathing and controlled coughing and that it will help him to loosen secretions to make breathing easier and increase oxygenation. Have pt. explain
why ambulation is
important. Ambulation will help loosen secretions and will decrease his chances of getting pneumonia. Have pt. explain
ways that he can get
help and who he can
contact if he needs
assistance and in case of emergency. It may take pt. some time before he gets used to living with a tracheostomy, so he may need help caring for himself at first (such as a home health nurse or family member). He also needs to have someone who he can reach quickly if breathing becomes a problem. Teach pt's wife
and have her demonstrate
how to perform trach. care
and suctioning for pt., and have her explain when
it is needed. There may be times when pt. needs help performing suctioning and trach. care, and his wife should understand that it is needed when coarse crackles are heard because this means that secretions are obstructing pt's. breathing. Short-Term Goal:
Pt. will remain free of
symptoms of infection aeb
temp. <100.5°F, clear lung sounds
and having no increased redness,
warmth, swelling, or discharge
from incision site by
discharge. Long-Term Goal
Pt. will be able to explain
infection prevention techniques,
demonstrate how to properly care
for incision site/tracheostomy, and
state signs and symptoms of infection
to be aware of by discharge. Auscultate lung
sounds q 4 h. Assess temperature
q 4 h and report if
>100.5°F. Fever is usually one of the first sign that the pt. has an infection. Use sterile
technique to clean
incision sites from
tracheotomy, and
G-tube. Sterile technique is especially important to use in hospital settings whenever there is a loss of skin integrity because there is an increased chance of infection in hospitals. Diminished lung sounds, crackles, and other adventitious lung sounds can indicate infections such as pneumonia. Elevate HOB at at
least 30°, ambulate as
tolerated, and encourage
deep breathing and
controlled coughing. All of these interventions help to expand the lungs and loosen secretions, which decrease the chances of developing pneumonia. Assess areas with
impaired skin integrity for increased redness, swelling, warmth and discharge. These are all signs that the pt. may have an infection. Assess sputum color and characteristics q6-8h. Administer
antibiotics as
prescribed. Thick, discolored, and foul smelling sputum can indicate that the pt. has an infection. Antibiotics will help the pt. fight off infections Teach pt.
proper techniques
to clean incision
sites and have him demonstrate. Have pt.
of infection Have pt's wife
demonstrate how to properly clean incision
sites. Have pt. explain
when he should
seek medical
attention. Teach pt.
to keep taking
antibiotics until
they are completely
finished. Many people do not realize that they should continue taking the entire course of antibiotics even if they are not having any signs and symptoms of infection. Have pt.'s
wife explain ways to recognize infection Pt. should be able to recognize signs of infection such as fever, pain, redness, swelling, warmth, and discharge at incision sites so that it can be treated early on. Have pt. explain
why it is important
to assess for infection and report it. It is important for pt. to understand that he is at greater risk for infection than he was before surgery because of impaired skin integrity, so he needs to watch more closely for it than he did before. Pt. needs to know to seek medical attention at first signs of infection because the longer he waits, the greater the infection is going to be, so it needs to be treated early on. There may be times where pt. will need assistance performing trach. care, so it is important that his wife is able to perform it using clean techniques to prevent infection. Pt. may be reluctant at times to seek medical attention, so it is important that his wife also knows signs of infection so that she knows when he needs medical attention. She also may be able to catch things that he may have missed. Pt. needs to know how to properly clean his incision sites and tracheostomy site to prevent infection. Pt. has increased risk of infection while incision sites are healing and while in the hospital, so it is important to monitor for infection during his time there so that it can be treated right away. Pt. needs to be able to continue to prevent and recognize infection himself when he is discharged so that he will not develop infection later on, and so that if he does develop infection it will be treated sooner rather than later. Pt.'s incision sites are not healed yet, so he may have some bleeding in airway as well as increased secretions and swelling which can obstruct his airways. After discharge and even after incision sites are healed, it is very important that pt. understands how to keep airway clear on his own. Evaluation of Diagnosis #1 Short-Term Goal:
Pt.'s airways remained clear throughout clinical shift. He did not need any suctioning or trach. care during the shift, some wheezing was heard during auscultation, but pt. was not coughing up any secretions and throat sounded clear. Long-Term Goal:
Unable to evaluate long-term goal because I did not get a chance to talk to pt. about these techniques during my clinical shift. Evaluation of
Diagnosis #2. Short-Term Goal:
I was unable to assess pt. after my clinical shift was over, but during shift
his temperature remained <100.5°F, and incision site remained free of discharge and did not have more redness or swelling than expected after surgery. Lung sounds also remained mostly clear. Long-Term Goal:
Unable to evaluate long-term goal because I did not get the chance to teach pt. these techniques or signs of infection during my clinical shift. Key Diagnoses Goals Rationales Interventions
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