Concept Map: Interactions for pt w/trach, has rhonchi

[LiatrisAspera]

My instructor didn't care for a concept map I turned in, so I'm trying to spend more time on it just for my own education. I'm unsure of the interventions for the priority problem of a pt with a trach who has a nasty case of rhonchi, which seems present in bottom to top of both R & L lungs.

The top 3 interventions I am coming up with are: 1) Do trach suction 3x5-15 sec, Q4H or PRN. If order not standing, consult with Respiratory Therapist, they would need to obtain order if they agree it is appropriate intervention; 2) Raise pt to 30 degree incline. This will require education, encouragement and support because the patient does not want to move and is uncooperative; 3) Have patient lean forward and cough 3x, Q4H.

I am unsure of this interventions because of the trach. Your input would be greatly appreciated!

[Jenngirl34RN]

So, a good place to start would be identifying a nursing diagnosis. "has a trach and ronchi" is not a nursing diagnosis. What s/s is the patient exhibiting? You need to use a NANDA nursing diagnosis based on the problems your patient has that you need to address. These will be things you see during your assessment.

Next, what is your goal for this patient? This will help determine which interventions you need to do in order to reach that goal. Your interventions will be the things you will do as a nurse to help resolve his issues.

Your diagnosis and interventions need to be based on your assessment findings. If you are unsure about what you are seeing or about something like a trach, you need to look them up in your textbooks. You should be able to find trach care in your books, as well things that okay/not okay to do with a patient who has a trach. If you are absolutely unable to find the answers in your books and you have truly exhausted all other resources, you can ask your nurse if having a trach patient cough 3 times is a good intervention.