I am in my first semester of nursing school and we have our first nursing care plan due this week. We have not covered this very much in class, so I feel like I'm walking in the dark a little bit. I feel that I have done the best that I can with the knowledge that I have so far about care plans and I have definitely learned alot from the other threads about care plans. I just need to know where to start. So here it goes...
Pt. was diagnosed with laryngeal carcinoma after he came to the hospital complaining of shortness of breath and dysphagia. CT revealed that he had a minimum T3N2 laryngeal carcinoma and a chest CT showed bilateral masses on the upper apical lobes of the lungs. He has refused to have the masses in the lungs treated. He had a direct tracheostomy and oncothyroidectomy. Currently has a trach and a Gtube. Has history of Bipolar disorder and schizophrenia, COPD, and HTN. Also has a history of smoking - 64 pack years.
His physical exam revealed clear and equal breath sounds, equal expansion. No signs of peripheral edema. Capillary refill was about 4 sec. on the first day I had him, but his hands were cold. The second day it was < 3. Blood pressure and psychologic disorders are being managed by meds. On chemo and radiation to treat cancer. GTube wound site showed no signs of infection. Trach tube begining to show some redness and signs of break down underneath but MD ordered an antibacterial ointment and increased dressing changes to Q4 hours. Pt. is also on contact precausions - MRSA, which he had before he had before being admitted. Subjective data: "Its going to be a great day" "My sister came to visit me today, shes so nice" "my whole family is messed up" "I am not going to touch one more cigarette for the rest of my life" Pt. easily frustrated. Occationally complains of aching pain at trach site when he becomes frustrated. Seems to happen when being misunderstood. When being offered assistance with a bath, initially cooperative and pleasant, then when he began to bathe, became frustrated "I can't bath because I can not get these tubes wet, Im just going to have to smell, now you have ****** me off... get my pain medicine."
So, I think I start with my nursing diagnosis first. We only have to do one. At first I was thinking risk for infection, but he already has MRSA and then risk for ineffective airway clearance. However, he has a productive cough and get get most secretions out of his airway that way. He refuses suctioning, and his O2 sats are at 98%. My instructor suggested risk for impaired verbal communication, because he gets so frustrated and is sometimes hard to understand. What nursing diagnosis should I go with and when I come up with one, where do I find the interventions that go with that? I have not bought a nursing care plan book. Does anyone know of some other online source where I can find nursing interventions?
Please let me know if I am thinking the right way and where to go next... thanks!