Trach care plan

  1. I have a CAT tool due tomorrow and I ALWAYS have problems with care plans. My pt is on vent dept and is in a vegitative state. Can anyone help me with a good care plan for trach? I need 5 interventions and rationales for each?
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    About mjspn27

    Joined: Nov '08; Posts: 1


  3. by   suzanne4
    It works the other way here. You give us your ideas and then we can help you from that; but we do not do homework here for anyone. You need to be the active participant in the learning end of what you are to be doing.

    And if you are having issues with care plans then this is more of a reason for you to come up with the initial part of it.

    Having a trach is far from the only part of your carre plan, it is actually only a small little detail of it. Start with that and lets see what you can come up with.
  4. by   Daytonite
    a tracheostomy and ventilator are medical treatments. a vegetative state is a medical condition. a nursing care plan contains your strategies to treat the patient's nursing problems. nursing problems are determined by applying the nursing process to what is happening to the patient. the medical condition (vegetative state) will need to be converted into nursing problems. you have not provided the information for me to show you how to do that. you can see examples on this sticky thread: - assistance - help with care plans. here is how you can use the steps of the nursing process to help you with that:
    1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
      • a physical assessment of the patient
      • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
      • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
      • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
      • your instructors might have given it to you.
      • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95
      • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
      • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
      • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
    3. planning (write measurable goals/outcomes and nursing interventions)
      • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
        • improve the problem or remedy/cure it
        • stabilize it
        • support its deterioration
      • how to write goal statements:
      • interventions are of four types
        • assess/monitor/evaluate/observe (to evaluate the patient's condition)
          • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
        • care/perform/provide/assist (performing actual patient care)
        • teach/educate/instruct/supervise (educating patient or caregiver)
        • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)