Vent and Trach care plan

[AlissaYoung]

I am doing clinicals in the PCU and am trying to formulate a care plan for a patient with a trach on a vent. I have this so far; am I missing anything or is any information incorrect? Also, here's the list of care plans that I formulated; are there any other conditions that I might see in this unit? Thanks for your help!

Care plan: Trach and Vent

Interventions:

- Take vital signs, check oxygen saturation, listen to breath sounds, note changes to previous findings, and assess pain and anxiety levels. Check the tube insertion site and consult respiratory therapy for consult.

- Suction appropriately - hyperoxygenate before suctioning; don't instill normal saline solution into the endotracheal tube in an attempt to promote secretion removal.

- Prevent ventilator-assisted pneumonia (VAP)

o HOB 30-45 degrees

o Sedation vacations and assess vitals and ABGs

o Provide peptic ulcer disease prophylaxis as with a histamine-2 blocker such as famotidine

o Provide dvt prophylaxis, as with an intermittent compression device

o Perform oral care with chlorhexadine daily

- Monitor blood pressure q2-4h. Mechanical ventilation causes thoracic-cavity pressure to rise on inspiration, which puts pressure on blood vessels and may reduce blood flow to the heart; as a result, blood pressure may drop.

- Maintain hemodynamic stability through IV fluids and drugs like dopamine or norepinephrine as ordered.

- High levels of inspiratory pressure with PEEP increase the risk of barotrauma and pneumothorax. To detect these complications, assess breath sounds and oxygenation status often.

o Symptoms include sudden SOB, painful breathing, sharp chest pain, often on one side, chest tightness, low blood pressure, tachycardia, low O2 levels, loss of normal breath sounds

o Focus on general appearance, temperature, pulse, respirations and blood pressure

- When performing mouth care, suction oral secretions and brush the patients teeth, gums, and tongue at least twice a day with a soft tooth brush.

- Patients with tracheostomy tubes may be able to swallow food but also may have feeding tubes with liquid nutrition provided through the gut like a percutaneous endoscopic gastrostomy (PEG) tubes:

o Before feedings are given, bowel sounds should be examined to ensure that the GI tract can digest and absorb nutrients.

o Patient should be at least at 30 degrees and remain there for one to two hours after to decrease the risk for aspiration pneumonia.

o The PEG tube should be flushed before and after with 60 mL of water

o When administering meds, pills should be crushed and then dissolved in water.

***Make sure medications can be crushed***

o Clean and check the tube twice a day and check for redness, swelling, discharge and soreness

o Check policy on residuals, usually anything under 250 is fine to continue with the tube feeding

Ex: If the patient is getting 60 mL/hr and the residual is 150 mL, this means that in 2.5 hours nothing has left the stomach; this could be a sign of slow motility. Return the residual, stop the tube feeding and assess the patient. Are bowel sounds present? Does the abdomen feel soft/hard? Tender? Distended? Notify the physician of the residual and assessment findings.

Complications:

- Bag-valve-mask ventilation is an essential emergency skill. The basic airway management technique allows for oxygenation and ventilation of patients until a more definitive airway can be established. Give breaths like in CPR (30:2), and make sure you see the chest rise.

Patient and family education

- Teach them why mechanical ventilation is needed and emphasize the positive outcomes it can provide.

- Explain every procedure every time in the room.

And here is the list of the care plans that I have made up, are there any other conditions you have seen in this unit? Thanks!

- Sepsis

- Unstable angina

- Non-stemi

- STEMI

- Acute coronary syndrome

- Dysrhythmias (AF, AVT)

- CHF exacerbation

- COPD exacerbation

- Pneumonia

- Acute respiratory distress syndrome

- Acute renal failure

- Chronic renal failure

- GI bleed

o Upper

o Lower

[Esme12, ASN, BSN, RN]

Stroke, DKA....the list is endless.

What is exactly your assignment. You ahve done complete care plans in all of these diagnosis?

[AlissaYoung]

It's not an assignment, I just want to be prepared for clinical in the PCU; I've only had stable patients for all of my other semesters so I just wanted to be prepared; the clinical instructor has worked in the PCU before teaching so she knows everything, and she's very challenging so I just want to be able to answer the questions she throws at me bc the last two clinicals I wasn't prepared...I had no idea what I was getting myself into! Yes, I've made the care plans for the ones listed, I'm just hoping all this hard work pays off. I'll definitely brush back up on DKA though, thank you! And any other suggestions would be greatly appreciated!

[meanmaryjean, DNP, RN]

Sounds like you've prepared well AND (more importantly) learned something from your other clinical experiences. Good job!

[leonard_huh, BSN, MSN, RN, APN]

i always use the nanda book it has everything you need for those so called care plans

[Esme12, ASN, BSN, RN]

It's not an assignment, I just want to be prepared for clinical in the PCU; I've only had stable patients for all of my other semesters so I just wanted to be prepared; the clinical instructor has worked in the PCU before teaching so she knows everything, and she's very challenging so I just want to be able to answer the questions she throws at me bc the last two clinicals I wasn't prepared...I had no idea what I was getting myself into! Yes, I've made the care plans for the ones listed, I'm just hoping all this hard work pays off. I'll definitely brush back up on DKA though, thank you! And any other suggestions would be greatly appreciated!

I am impressed! Good job!

Really any patient that needs close monitoring for ANY reason will be on a PCU type unit. Brush up on different arrhythmia like A fib and SVT. Internal pacemakers and defibrillators...and V tach. Cardiomyopathy would be another. Cor Pulmonale.

[AlissaYoung]

Thank you so much for the positive feedback! I've spent my whole spring break brushing up on info and making sure I can keep my patients safe; I really only posted this to get ideas of how I could be better, but thank you for the boost of confidence!! This is my 6th semester, only because I'm retaking the 5th semester course because I didn't score high enough on the tests (which I'm doing much much better this second time around), but I've made it through 5 semesters of clinical without an unsatisfactory mark so I know that I know what I'm doing, but this instructor finds me incapable of maintaining patient safety and the inability to critically think, and being that this is "dress rehearsal" I should know better by now, but like I've said, I've never had the opportunity to work with any patient other than the stable patients so this is all new to me and the expectations/intimidation are far more than what I've ever fathomed... so thank you for giving me the confidence, and now I just need to show her I know what I'm doing and not let the intimidation factor get to me...easier said than done so wish me luck, but thank you very much for your responses!!

[AlissaYoung]

And thank you for the cardiovascular complications, the second time through this semester I'm much better at the ekgs and s/s so I'm one step ahead of the game right? Let's hope :)

[Esme12, ASN, BSN, RN]

I know this is not easy but try not to be nervous. It can overwhelm you into simple errors. BREATHE! Remember ABC's, NEVER forget the rights of med administration. In an emergency take your won pulse first...thinking about how ridiculous that sounds it helps to calm you. Head to toe assessment. Get a rhythm to your assessment.

Good Morning I am xyz your nurse today.....and You are Mr. SoandSO? What is your Date of birth? look at the arm band. I am going to take your vitals now and listen to your lungs and heart. Look at IV sites, drainage tubes and bandages if any. How Do your legs look? look for breakdown and edema. How do you feel today? Is there something I can do for you? I will be back with xyz at 9 am. Call me (check for call bell, is it in reach, does it work? I will usually test it and cancel it my self) if you need any thing in the meantime. I will be here until 2 PM what time would you like to wash up?

What tripped you up last time?

[Esme12, ASN, BSN, RN]

Remember rhythms are slow fast and absent. They either have a pulse or not. No pulse? Call for help start CPR. Fast and they look crummy they are unstable...ABC's .....O2 IV EKG treat rhythm.

BREATHE! ((HUGS))

[nurseprnRN, BSN, RN]

I am impressed by the amount of thought and study you have put into this. You sound thoughtful and as well-prepared as you can be at this point.

A few cavils, which I hope you and others who are planning nursing care for patients will take to heart.

1) Consider the difference between an intervention and an assessment. "Something I'm gonna do" does not always equal "intervention." Hint: Taking a BP is not an intervention. When you find yourself writing, "VS as prescribed by physician," scratch that out. You are correct in assuming that nursing can decide to check VS (as an example) and other assessments more often depending on nursing judgment; when you plan care for the person, say why you would do X,Y, and Z and what you would do if ... .

2) Giving medications is not a nursing decision or intervention either, even though that, too, is something nurses do. Meds and prescribed medical treatments are part of nursing's legal obligation to implement some parts of the medical plan of care, but that does not make them nursing interventions. A nurse cannot prescribe them; that's how you know the difference. When you find yourself writing your nursing plan of care for someone and including things like, "Meds and IVs as prescribed by physician," take out your eraser or highlight and delete. :) Not nursing decisions.

3) Nursing interventions are things we do for the patient because we, nurses, have assessed and decided that s/he needs them done/watched/taught/fixed. They are things we do within our own scope of practice, on our own judgment and volition, without having to be told to do them as part of somebody else's specialty plan of care. We are responsible for them.

Have fun!

[nurseprnRN, BSN, RN]

Oh, and A..Y..? Change your posting name stat. (The mods can help you prn.) There are many, many good reasons you should guard your identity carefully on line. For one thing, many instructors read these posts. Yours may be among them. You really want him/her to see what you think of him/her?