Reference no: EM133923705
Question
Joe is a 42 year old man who has cancer of the larynx. Due to increased swelling in the larynx as a result of the disease process he underwent a tracheotomy with insertion of a cuffed tracheostomy. He was admitted to your unit after his procedure; it has been less than 24 hours since the procedure.
His latest Vital Signs are: Temperature 37.8 C; Pulse 120 beats/minute; Respirations 24 breaths/minute; BP 140/80; O2 saturation 89% on 4L humidified O2 via trach mask. Skin color is consistent with his genetic background, and does not appear to be in any respiratory distress.
He has been unable to cough and when suctioned, you notice thick yellow/green sputum. His respiratory assessment reveals crackles in the upper lobes bilaterally. He is receiving intravenous therapy in the right hand which is infusing Ringers lactate at 100cc/hr. He is scheduled for a chest X-ray at 1100 h and it is currently 1000 h.
1. Using the data in the case study perform data analysis.
2. What is a potential nursing diagnosis for this client based on your analysis?
3. Provide one short term goal for this client based on your diagnosis.
4. Provide three nursing interventions for the goal
5. How would you evaluate the outcomes of the goal?
6. List some priority nursing considerations when caring for a client with a tracheostomy.