PLEASE HELP!!! Careplan assistance with pediatric patient

[teresa2557]

Hello I am writing a care plan for a patient that is an adolescent and has Arthrogryposis multiplex congenita, a tracheostomy , MIC-KEY G-Tube, respiratory abnormality (non-teratogenic), ventilator & o2 concentrator, Contractures of demineralized bones and significant scoliosis resulting in requiring 2 person mechanical transfer (Hoyer), no longer uses wheel chair and is primarily in bed in-home care.

My Nursing intervention looks like this:

Ineffective airway clearance r/t increased secretions and mucus secondary to respiratory abnormality AEB excessive sputum, diminished and adventitious breath sounds auscultation, inability to tolerate disconnection of CPAP for long periods of time, and restlessness when having difficulties with secretions.

I"m hoping I got the hang of it but could use some assistance.

I've also written my interventions and goals but again I am unsure, perhaps some reassurance or redirection could be helpful, and very much appreciated as well. :)

Short term goal:

Patient will exhibit lungs sounds clear to auscultation, no signs of cyanosis or decreased oxygenation, and oxygen saturation levels higher than 90% at all times until the end of shift, at 16:00 today.

Long term goal:

Patient will maintain a patent airway at all times and exhibit no signs of respiratory distress over the next week, as evidenced by oxygen saturation levels higher than 90% at all times.

I am worried it is too redundant, although my ST interventions and LT Interventions for these goals include

Intervention #1:

The nurse will auscultate the lung sounds every two hours, listening for coorifice crackles on late inspiration or wheezing, or any other adventitious breath sounds.

The nurse will also be consciously aware of breath sounds throughout the shift, listening for noisy breathing or body language signaling respiratory distress.

The nurse will administer Albuterol as medication order states in the event wheezing occurs:

Albuterol MDI via trach. 1-2 puffs q4H-PRN for wheezing

Intervention #2:

The nurse will use the client's closed, in-line suction device attached to tracheostomy to clear mucus secretions from airway, with no more than three insertions per incidence, as needed for respiratory assistance, increased secretions or difficulty breathing.

The nurse will first inform the patient of the need for suctioning. Suctioning should be completed in 10 seconds and the entire process should take no more than 15 seconds.

Intervention #3:

The nurse will reposition the patient every two hours, altering sides and elevation of HOB (head of bed) varying. The nurse will also position the patient's HOB allowing to be positioned from 30-45 degrees at least once every two hours.

Long Term Goal

Intervention:

The nurse will administer oxygen if oxygen saturation levels drop below 90%.

The nurse will administer oxygen through tracheostomy/ventilator, CPAP.

The nurse will ensure the settings be adjusted to 2-5 liters per minute (Per doctors orders).

The nurse will apply continuous pulse oximetry on patient when patient is sleeping and every two (2) hours while awake/alert.

[Esme12, ASN, BSN, RN]

I think it looks good to me......nicely done!

[FineAgain]

I think so too! I might have switched the long term and short term goals but this is really well thought out, concise, and SMART!

[nurseprnRN, BSN, RN]

Very good job, gold star! :flwrhrts:

My only little cavil is that I am on a quest to remove the words "doctor's orders" from the nursing lexicon for good and all.

We do not take orders; this is not a hierarchy. We are legally responsible to implement some parts of the medical plan of care,but not all of them-- not, for example, PT, or lab studies, or nutrition assessment, or radiology... We are also legally responsible NOT to implement a part of the medical plan of care if we have good reason to know that it would be harmful. Because we are not privates taking orders from the captain. Because we are responsible in a way the private can never be. We have our own science, discipline, and diagnostic taxonomy to support our autonomous practice; our nurse practice act requires this of us. It's not optional, not nice to do...it's required.

Doesn't it give you a whole different feeling to say, "Oxygen as per medical plan of care" or "Give Albuterol per prescription as needed for XYZ finding"? I recommend it.