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Discussion

Help with care plan please!

I have a patient that I'm having some trouble with. He has a trach so I wanted to do my careplan on that because we just had a lecture on it this past week (plus its the only thing the guy has going on thats significant). I picked ineffective airway clearance for my nursing dx but i can't think of a good long term goal. My two short term goals were to suction the trach and assess vitals for hypoxia and hypercapnia. If anyone can think of a long-term goal for me to add i'd really appreciate it!

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I have a patient that I'm having some trouble with. He has a trach so I wanted to do my careplan on that because we just had a lecture on it this past week (plus its the only thing the guy has going on thats significant). I picked ineffective airway clearance for my nursing dx but i can't think of a good long term goal. My two short term goals were to suction the trach and assess vitals for hypoxia and hypercapnia. If anyone can think of a long-term goal for me to add i'd really appreciate it!

I don't believe that "to suction the trach and assess vitals for hypoxia and hypercapnia" are goals for the care plan - these would be interventions. The goal on a nursing care plan is something that is an outcome that is patient-centered, measurable and can be long- or short-term...an example for a trach patient could be (ref. http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=02)

  • Patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths.

Long term goal? Maintain care of the stoma site and trachy to prevent superficial wound infection & subsequent consequences (e.g. spread/sepsis)

Short term goal? Replace lost natural function of upperairway and reduce the risk of the tubebecoming blocked with dried secretions. Therefore your interventions would include suctioning and pedantic mouth care.

THIS paper might be helpful.

  • Experts

For goals to be customized to the patient they need to reflect what your nursing interventions are. Goals should be the predicted results of your nursing interventions. So, what kind of nursing interventions are you doing for the Ineffective Airway Clearance for this patient? They are really the direction you need to go with your long term goal. Since one of your related factors for this diagnosis is the fact that the patient has a trach (presence of a foreign body), one long term goal might be to prevent an infection or maintain aseptic conditions when suctioning or working around this trach since an infection would increase secretions, one of the causes of obstructed airway for this diagnosis.

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