Vent and Trach care plan

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