My first care plan

Hi Everyone,

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...

Data:

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

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!