RUNNING HEADER: Medical Surgical Module Care Plan #2
Medical Surgical Clinical Care Plan #2
Samantha A. Redmon
University of Arizona
Medical Surgical Module Care Plan #2
2
Patient Background
Date of Care: 10/16-10/17
Gender: Male 
Female 
Age Range (e.g. 60-65 yr): 50-55
Hospital Day #: 4 & 5
Advanced Directives (e.g. Living Will, Medical Durable Power of Attorney, Do Not Resuscitate or
Allow Natural Death): Full Code.
Allergies (Drug/Food/Environment): No known food, drug or environmental allergies.
Admission diagnosis: Acute respiratory failure; vocal cord paralysis.
Patient stated Chief Complaint: Worsening of SOB episodes; cough with white sputum; wheezing. Patient
stated in emergency department, “it feels like something is blocking my breathing.”
Briefly describe hospital course: Patient admitted to the ED on 10/12 presenting with stridor and expiratory
wheezes, as well as complaints of increasing shortness of breath and hoarseness within the last 24 hours.
While in the ED, patient entered acute respiratory failure and an awake tracheotomy was performed. Patient
was transferred to ICU for stabilization, and transferred to current unit. Patient scheduled for
arytenoidectomy on 10/17 to widen the laryngeal inlet.
Previous 24 hour I & O totals: Intake of 100 mL; output of 1,675 mL; net -1,575 mL.
Current Orders (exclude labs/medications/diagnostic tests):
Activity: Ambulation q2h
Diet: Regular
IV type/site: 18 g peripheral IV, right forearm; 18 g peripheral IV, left forearm.
IV fluids: N/A
Others: I/O q shift; SCDs on lower legs when non-ambulatory, HOB at least 30 degrees; ROM
exercises q8h; trach care q8h, humidified air (room air).
Interdisciplinary Services/Consults (e.g. PT, OT, ST, dietary, hospice): Respiratory therapy
Language spoken: English
Religious preference: Catholic
Insurance: State Medicaid program
Immunization status (flu and pneumonia): Not on file.
Domestic/Child/Elder abuse issues: None reported.
History of illicit drug/alcohol/tobacco use: Current marijuana user (2-3 times/week for 30+ years).
Medical Surgical Module Care Plan #2
3
Medical and Surgical History
Medical History
Brief Description of each Diagnosis
Acute respiratory failure
Acute respiratory failure is defined as a sudden change in the ability of the lungs
to effectively exchange oxygen and/or carbon dioxide between the environments
and the tissues. It is typically diagnosed with a PaO2 of less than 50 mmHg, a
PaCO2 of greater than 50 mmHg, and a pH of less than 7.35. (Phipps, Monahan,
Sands, Marek, & Neighbors, 2003, p. 592)
Vocal cord paralysis
Vocal cord paralysis occurs when infection or physical trauma causes damage to
the vagus nerve or the laryngeal nerves. Vocal cord paralysis typically presents
in stridor, weak or hoarse voice, and severe dyspnea. (Phipps et al., 2003, p. 494)
June, 2014:
Pneumonia
May, 2014:
Pedestrian struck
Marijuana use
Surgical History
Tracheotomy
Arytenoidectomy
Lower respiratory tract infection, caused by colonization of the lung tissue by
such pathogens as Pseudomonas aeruginosa, Staphylococcus aureus,
Streptococcus pneumoniae and others. (Phipps et al., 2003, pp. 525-526)
Patient was struck by a motor vehicle while crossing the street, sustaining the
following injuries: pneumothorax, right kidney laceration, right pelvic fracture,
closed TBI, right ulnar fracture, acute blood loss, and 8 or more right rib
fractures.
Patient may be educated about the risks of smoking and illicit drug use,
including psychosocial, behavioral, economic and physiological implications.
Potential interventions might include counseling, whereby the patient receives
accurate education about risks and cessation measures. Since the patient cites
pain relief as the main benefit of marijuana use, other, more healthful pain
management alternatives such as t’ai chi’, hypnosis, guided imagery or
acupuncture may be explored. (Phipps et al., 2003, pp. 13-15)
Brief Description of each Surgery
A tracheotomy is a surgical procedure whereby an incision is made on the
anterior aspect of the throat for the purpose of accommodating a tube which is
inserted directly into the trachea (Phipps et al., 2003, p. 515). In the case of this
patient, an alternative airway was created to bypass the laryngeal stenosis that
was obstructing his airway.
Arytenoidectomy is the surgical resectioning of the arytenoid cartilage for the
purpose of restoring the airway diameter of the larynx compromised by bilateral
vocal cord paralysis (Phipps et al., 2003, p. 494). In the case of this patient, the
procedure was intended to create a more permanent, reliable airway that will
provide for adequate ventilation following decannulation.
Medical Surgical Module Care Plan #2
4
Pathophysiology
Medical/Surgical
Primary Medical Diagnosis
Diagnosis
Acute respiratory Acute respiratory failure (ARF) occurs when the
failure, attributed to respiratory system incurs a sudden loss in the ability to
vocal cord paralysis effectively exchange oxygen and carbon dioxide with
the environment. The three criteria used to diagnose
ARF include a PaO2 of less than 50 mmHg, a PaCO2
of greater than 50 mmHg, and pH lower than 7.35.
Trauma, infection or obstruction at any point along the
respiratory tract can potentially result in ARF.
Common pathologies that lead to ARF include cystic
fibrosis, pulmonary embolism, severe infection, spinal
cord injury and prolonged mechanical ventilation.
Vocal cord paralysis can also result when the nerves
that innervate the muscles causing dilation and
constriction of the larynx fail to function. This loss of
function can be idiopathic, but typically results from
blunt trauma, cancer or severe infection. When the
vocal cords become paralyzed, the larynx is no longer
able to maintain patency, and the airway is thus
obstructed.
ARF related to vocal cord paralysis typically presents
in sudden symtpoms such as stridor, severe dyspnea,
and weak phonation. An emergent respiratory
situation may require the placement of a tracheostomy
to bypass the obstruction; if laryngeal paralyisis
persists, the cartilage to which the vocal cords attach
may be surgically resected to reopen the airway in a
procedure called arytenoidectomy.
(Phipps et al., 2003)
Patient’s Manifestations
(Signs and Symptoms)
Patient reports experiencing unrelenting hoarseness, periods of
dyspnea and expiratory wheezes since being extubated in June of
this year after being hit by a motor vehicle. Albuterol treatments,
prescribed by patient’s primary care provider, have not been
effective in relieving symptoms. Patient experienced a sudden
increase in the severity of these symptoms, bringing him to the
emergency department.
While in the ED, patient began exhibiting stridor and entered acute
respiratory failure, the cause of which was determined to be vocal
cord paralysis. An emergency awake tracheotomy was performed
in the ED to bypass the laryngeal stenosis created by the paralyzed
vocal cords, providing patient with an alternative airway. After
patient was sufficiently stabilized, an arytenoidectomy was
performed to surgically widen the laryngeal inlet for the purpose of
restoring the natural airway. Tracheostomy will remain in place
until it is determined that the natural airway will be sufficient for
ventilation.
Since patient was pedestrian-struck in May of this year, it is
plausible that trauma attributed to the impact itself, prolonged
intubation, extubation, traumatic brain injury, hospital-acquired
pneumonia, or a combination of any of these is a potential cause of
vocal cord paralysis and resulting respiratory failure.
Current treatment includes a combination bronchodilator to
promote dilation of the airway and pain management with opioid
analgesics. Post-surgical pain is currently insufficiently managed,
as patient consistently reports a pain level of 7/10, despite
adherence to a strict medication program. Furthermore, patient
identifies a tolerable pain level of 4/10.
Medication Worksheet
Drug Names
(Generic, Brand) Time Due
Classification &
Mech. of Action
Heparin
(Hep-Lock)
Anticoagulant,
antithrombolytic.
0600
1400
2200
Inhibits the
clotting factors
prothrombin or
thrombin (dosedependent).
Docusate
(Colace)
Stool softener.
Indications
Prevention of postoperative DVT/PE.
Dose,
Route,
Frequency
5,000 units
sub Q
0900
1700
Oxycodone
(Roxicodone)
Draws water into
colon resulting in
softening of stool
for ease of
passage.
Opioid analgesic.
Binds to opiate
receptors in the
CNS, altering the
perception of and
response to
painful stimuli.
Most common or
serious side effects
Bleeding, heparininduced
thrombocytopenia,
anemia.
q8h
Promote bowel
movement despite
reduced bowel
motility due to
narcotics and
analgesia.
100mg
Reduction of
moderate postoperative pain as
needed.
15 mg
PO
Mild abdominal
cramps, diarrhea,
skin rash.
b.i.d.
PO
q4h PRN
Respiratory
depression.
Confusion,
sedation,
constipation.
Contraindications &
Major Interactions
Contraindications:
Hypersensitivity,
uncontrolled bleeding,
severe thrombocytopenia,
open wounds.
Interactions: Aspirin,
NSAIDs, clopidogrel,
dipyridamole, some
penicillins, ticlopidine,
abciximab, eptifibitide,
tirofiban and dextran (may
increase risk of bleeding).
CI: Abdominal pain of
unknown origin,
nausea/vomiting, loose
stool/diarrhea.
I: No known significant
drug-drug or food
interactions.
CI: Hypersensitivity,
significant respiratory
depression, paralytic ileus,
acute/severe asthma.
I: MAO inhibitors
(unpredictable reactions;
begin with 25% of usual
oxycodone dose). Other
CNS depressants, such as
alcohol, antihistamines,
barbiturates. Potent
CYP3A4 inhibitors and
inducers.
Nursing Interventions and
Patient Teaching
Nursing Interventions: Assess for
bleeding gums, nosebleed,
unusual bruising, black, tarry
stools, hematuria; fall in
hematocrit or blood pressure
(may indicate unusual bleeding)
Patient Teaching: Report signs of
unusual bleeding to HCP; use soft
toothbrush and electric razor;
avoid potential injury; inform
HCP of medication use before
treatment or surgery.
Nurse should advise patient that
Colace is designed for short-term
therapy; long-term use may result
in electrolyte imbalance,
physiological dependence.
Encourage patient to use other
forms of bowel regulation and to
cease use with presence of loose
stool.
NI: Assess pain factors prior to
and one hour post administration.
Assess BP, pulse and respirations
prior to and throughout therapy.
Assess bowel function regularly.
PT: Warn patient of abuse
potential. Take caution when
changing position, ambulating, do
not use alcohol while taking this
medication. Refrain from driving
until effects are known. Educate
patient to turn, cough and deep
breathe q2h to decrease risk of
atelectasis.
Hydromorphone
(Dilaudid)
Opioid analgesic.
Binds to opiate
receptors in the
CNS, altering the
perception of and
response to
painful stimuli.
Ipratropium bromide and
albuterol sulfate
(DuoNeb)*
0500
1100
1700
2400
Bronchodilator.
Inhibition of B2cholinergic
receptors in
bronchial smooth
muscle, thereby
dilating airway.
*Administered by respiratory therapist
(Deglin & Vallerand, 2013)
Reduction of
moderate to severe
post-operative pain as
needed.
0.4 mg
IV
Hypotension,
confusion,
sedation,
constipation.
CI: Hypersensitivity.
Extended release only:
significant respiratory
depression, paralytic ileus,
acute/severe asthma.
I: MAO inhibitors
(unpredictable reactions;
begin with 25% of usual
oxycodone dose). Other
CNS depressants, such as
alcohol, antihistamines,
barbiturates. Nalbuphine,
pentazocine.
Bronchospasm
with excessive use.
Nervousness,
restlessness,
tremor, chest pain,
palpitations.
CI: Hypersensitivity to
adrenergic amines,
ipratropium, atropine,
belladonna alkaloids, or
bromide. Acute
bronchospasm.
I: Other adrenergic agents;
MAO inhibitors; beta
blockers; tricyclic
antidepressants; potassiumlosing diuretics; caffeinecontaining products.
q2h PRN
Reduce
bronchospasms that
impede breathing.
3 mL
nebulizer
q6h
NI: Assess pain factors prior to
and one hour post administration.
Assess BP, pulse and respirations
prior to and throughout therapy.
Assess bowel function regularly.
PT: Warn patient of abuse
potential. Take caution when
changing position, ambulating, do
not use alcohol while taking this
medication. Refrain from driving
until effects are known. Educate
patient to turn, cough and deep
breathe q2h to decrease risk of
atelectasis.
NI: Assess lung sounds, pulse,
and BP prior to and at peak of
administration. Note amount,
color, and character of sputum
produced. Monitor pulmonary
function tests before initiating
therapy and periodically during
therapy. Notify provider
immediately if wheezing is noted.
PT: An unpleasant taste may be
experienced. Report cough,
nervousness, headache, nausea,
GI distress, diaphoresis,
dizziness, palpitations, or chest
pain occurs, or if shortness of
breath is not relieved by
medication.
Laboratory Values Worksheet
Lab Data
Normal Value
Result #1
(10/13)
Result #2
Result #3
Description of Lab Test
WBC
Number of total leukocytes in the blood.
3.4-10.4
(thousand/mcl)
10.4
N/A
N/A
Normal
The primary phagocytic cells present in early
inflammation.
1.8-7.8
(thousand/mcl)
N/A
N/A
Neutrophils
9.4
N/A
Participate in cellular and humoral immune response.
1-4.8
(thousand/mcl)
N/A
Lymphocyte
0.8
Remove dead and injured cells, cellular debris,
microorganisms.
0.3-1
(thousand/mcl)
N/A
N/A
Monocytes
0.1
High; Indicates infection or inflammation. Likely high due
to the physiological stress this patient is experiencing due
to respiratory failure.
Low; could be caused by a variety of things, including
infection. Patient has had a recent history of infection and
ilness that may be contributing to lymphocytopenia.
Low; could be caused by a variety of things, including
infection. Patient has had a recent history of infection and
ilness that may be contributing to monocytopenia.
A protein contained within the erythrocyte, which is
responsible for binding to and transporting oxygen
throughout the body.
13.5-17.5
(thousand/mcl)
N/A
N/A
Hemoglobin
15.3
Hematocrit
Portion of a volume of blood occupied by erythrocytes.
40-51
(thousand/mcl)
44
Platelets
Cell fragments capable of aggregating and adhering to
form clots, thereby limiting blood loss.
150-450
(thousand/mcl)
221
Serum Na
Imperative to cell membrane transport, acid-base balance
and metabolism.
136-145
mmol/L
139
Serum K
Imperative to nerve and muscle function, acid-base
balance, renal function and intracellular osmotic pressure.
3.5-5.1
mmol/L
4.2
Serum Cl
Imperative to acid-base balance, extracellular osmotic
pressure and renal function.
101-111
mmol/L
105
Serum CO2
Measure of the serum bicarbonate level; indicative of acidbase balance.
20 to 29
mmol/L
24
BUN
A measure of urea nitrogen as a product of protein
breakdown in the blood.
9-26 mmol/L
14
Creatinine
Estimation of glomerular filtration rate.
0.7 to 1.3
mg/dL
0.8
Glucose
Measure of the body’s ability to manage blood glucose
levels.
70-105 mg/dL
133
Pathophysiology
Normal
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
High; Patient does not have a history of diabetes mellitus
nor is he being monitored or treated for DM, so high blood
glucose may be attributed to non-fasting state.
Ca
ABGs:
pH
pO2
pCO2
HCO3
BE
On room air
or what % O2
Indicative of renal function, endocrine function; calcium is
essential to proper nerve and muscle function.
8.6-10.6 mg/dl
9
Measure of components of the blood which contribute to
pH.
pH: 7.35-7.45
pO2: 70-95
mmHg
pCO2: 35-45
mmHg
HCO3: 22-26
mEq/L
BE: 0-2 meq/L
pH: 7.41
pO2: 79
pCO2: 46
HCO3:
28.5
BE: 3
Room air
(Phipps et al., 2003)
N/A
N/A
N/A
N/A
Normal
Bicarbonate and base excess both exceed normal range.
Elevated bicarbonate, slightly elevated CO2 and normal
pH is potentially indicative of metabolically-compensated
respiratory acidosis. Patient was likely not ventilating
optimally at this time, and thus retaining CO2; his kidneys
could have compensated by releasing more bicarbonate in
attempt to alkalize the blood.
Diagnostic Testing Worksheet
(e.g., x-ray, ECG, colonoscopy, etc.)
Tests
Purpose of Test
Biopsy: partial right
and left arytenoid
tissue
Microscopic examination of the surgically
excised arytenoid tissues to determine whether a
possible structural contribution to vocal cord
paralysis exists.
Date of Test
Test Results
10/17
Right and left tissue specimens both appear normal,
and are composed predominately of mature cartilage.
Chest X-ray (single
view)
Confirmation of tracheostomy tube placement.
10/14
Lungs clear. Small amount of air in the mediastinum
(pneumomediastinum). Tracheal tube in place.
Chest X-ray (single
view)
Rule out pneumothorax and pneumonia as a
potential cause of acute respiratory distress.
10/13
Lungs clear. No evidence of pneumothorax. Stable,
moderate pneumomediastinum noted.
Mind Map
Key Problem: Acute pain
Key Problem: Risk for infection
Supporting Data:

Chief Complaint/Medical Diagnosis
(Reason for needing health care): Hiatal hernia;
GERD
Surgical site (tracheostomy)
Anticipated assessments (prep): Neurological,

Invasive tracheal tube
cardiovascular, respiratory, pain, mobility,

Trach care infx potential
tracheostomy site, IV sites

Multiple IV sites
Actual assessments (care plan): Neurological,

Reduced activity
cardiovascular, respiratory, pain, ROM, mobility,

Multiple invasive surgeries
tracheostomy site, IV sites, GI, psychosocial

Compromised airway

Potential for aspiration
Supporting Data:

Pain rating 7/10

Requesting pain meds

Facial grimacing, flinching
esp. during trach care

Successive surgeries
Key Problem: Activity intolerance
Key Problem: Ineffective airway clearance
Supporting Data:
Key Problem: Verbal communication
Supporting Data:
Supporting Data:
Acute pain (7/10)

Successive surgeries

Respiratory secretions in TT

Opioid analgesic use

Ineffective airway due to

Tracheostomy placement

Excess respiratory secretions

Patient unable to vocalize

Expiratory wheezing

Non-verbal communication

Coarse overall lung sounds with
dim bases
(nodding, gesturing, writing on
white board, mouthing words)


Oxygen saturation lower than
optimal (91% versus 95-100%)
mucous production

Patient reports fatigue
Problem List and Nursing Diagnoses
Problem
1. Ineffective airway clearance
Nursing Diagnosis with R/T and AEB
Ineffective airway clearance R/T excess respiratory
secretions secondary to tracheostomy AEB
expiratory wheezing, diminished lung sounds in
bases, and patient complaints of periodic dyspnea.
2. Acute pain
3. Risk for infection
Risk for infection R/T tracheostomy bypassing
upper respiratory tract, respiratory secretion stasis,
invasive device and compromised skin integrity
secondary to tracheostomy and surgical procedures.
4. Activity intolerance
5. Impaired verbal communication
Impaired verbal communication R/T inability to
produce speech secondary to inflated tracheostomy
cuff, AEB patient unable to speak on assessment and
using nonverbal communication such as writing on
white board.
Medical Surgical Module Care Plan #1
12
Nursing Diagnosis Priority # 1: Ineffective airway clearance R/T excess respiratory secretions secondary to tracheostomy AEB
expiratory wheezing, diminished lung sounds in bases, and patient complaints of periodic dyspnea.
General Goal: Patient will maintain a patent airway.
Outcome: Patient will maintain 02 saturation of 90% or greater throughout my shift, and demonstrate techniques designed to improve
airway patency, such as directed coughing, by the end of my shift.
Interventions
Encourage
patient to
perform directed
coughing to clear
airway
Rationale
Directed deep breathing and coughing exercises are effective in mobilizing
and expelling secretions that block the airway, and may also be
instrumental in providing the high pressures needed to optimally expand
and ventilate the lungs. (Fink, 2007, p. 1212)
Patient Responses
Actual: Patient successfully performs directed
coughing technique to clear the airway.
Expected: Patient might engage in hourly
coughing exercises to maintain consistent airway
patency and prevent buildup of secretions.
Educate patient
about the
purpose of
maintaining
humidification of
inspired air
A tracheostomy intentionally bypasses the upper airway, which, under
normal conditions, filters and humidifies inspired air. Insufficiently
humidified air entering the lower respiratory tract leads to dehydration –
and thus increased viscosity – of respiratory secretions, which can result in
ciliary assault and increased risk of pulmonary infection, atelectasis, and
impaired gas exchange. (Dawson, 2014, p. 66)
Actual: Though I did not provide explicit
education regarding the importance of
humidification at this time, patient intentionally
maintains the position of humidification mask
near stoma. Expected: Patient will be able to
communicate the rationale behind humidification.
Maintain
continuous pulse
oximetry and
educate patient
about techniques
to employ if O2
drops below 90%
Optimal oxygen saturation ranges from 95 to 100% on room air, while a
reading of below 90% suggests hypoxemia. Prolonged hypoxemia can
eventually result in tissue hypoxia. Patient can be educated about the
purpose of pulse oximetry (Valdez-Lowe, Gharreb, & Artinian, 2009).
Additionally, the patient may be taught techniques designed to improve O2
saturation when the pulse oximeter reads lower than 90%. Such techniques
might include focused breathing efforts, repositioning to optimize airway
and maximize lung function, or directed cough to loosen and/or expel
secretions (Fink, 2007, p. 1212).
Expected: Patient will successfully demonstrate
techniques that optimize ventilation in the lungs
and oxygenation of the blood and tissues, and
communicate when and how these methods
should be used in conjunction with pulse oximeter
monitoring.
Evaluation of outcome: Outcome met, evidenced by the patient maintaining a pulse oxygen saturation of at least 90% observed in
hourly rounding. Patient was able to demonstrate of ability to perform directed coughing to clear the airway, and displayed
understanding of the purpose of humidification by maintaining position of the mask.
Medical Surgical Module Care Plan #1
13
Nursing Diagnosis Priority #2: Risk for infection R/T tracheostomy bypassing upper respiratory tract, respiratory secretion stasis,
invasive device and compromised skin integrity secondary to tracheostomy and surgical procedures.
General Goal: Patient will remain free of infection.
Outcome: Patient will remain free of signs and symptoms of infection (e.g., fever, malaise, redness, swelling, pain, purulent drainage,
adventitious breath sounds) of stoma site and respiratory tract for the duration of my shift.
Interventions
Encourage twice
daily oral hygiene
(tooth brushing and
0.12% chlorhexidine
rinse)
Rationale
Aspiration of bacteria contained in oral biofilms is a potential cause of
pulmonary infection, including hospital-acquired pneumonia. The risk is
particularly great among high-risk individuals such as the elderly, critically ill
and mechanically ventilated patients. One pilot study found that among various
protocols tested, twice daily oral care, including manual tooth brushing
followed by a 0.12% chlorhexidine rinse, was the most effective in reducing the
incidence of pneumonia (Quagliarello, Juthani-Mehta, Ginter, Towle, Allore, &
Tinetti, 2009).
Patient Responses
Actual: Though patient was not supplied
with a chlorhexidine mouth rinse, nor
was he educated regarding the increased
risk of aspiration pneumonia with
insufficient oral hygiene, he nonetheless
spontaneously performed oral care after
meals.
Head of bed at least
30 degrees when on
bed rest
Artificial airways such as tracheostomy increase the risk of aspiration and thus
the potential for developing lower respiratory infection. Maintaining the head of
bed elevation at a minimum of 30 degrees decreases the risk of aspiration (Guy
& Smith, 2009).
Actual: Patient’s head of bed was kept at
a minimum of 30 degrees, also as an
intervention to promote optimal
ventilation and comfort.
Perform stoma care
every 6 hours or
more often as needed
Due to invasive nature of the tracheostomy, the stoma site should be inspected
at least every 6 hours for signs of infection or inflammation such as heat,
erythema, edema and pain. The area should be thoroughly cleaned according to
facility protocol, with special attention to careful removal of dried secretions
that might harbor bacteria, especially around sutures. (Morris, Whitmer, &
McIntosh, 2013).
Actual: Tracheostomy care was
performed every 6 hours as directed.
Patient tolerated procedure well and
showed no signs or symptoms of
infection, including redness, swelling,
pain, malodor and purulent drainage.
Evaluation of outcome: Outcome met. Patient remained free of apparent signs and symptoms of infection, both at the stoma site and
in the respiratory tract. Although lung sounds were not clear throughout, and patient continued to display expiratory wheezes by the
end of shift, no changes in lung sounds occurred that might suggest development of infection or worsening of breathing ability.
Medical Surgical Module Care Plan #1
14
Nursing Diagnosis Priority #3: Impaired verbal communication R/T inability to produce speech secondary to inflated tracheostomy
cuff, AEB patient unable to speak on assessment and using nonverbal communication such as writing on white board.
General Goal: Patient will communicate non-verbally
Outcome: Patient will identify his preference for non-verbal communication tools/techniques, and apply them successfully by the end
of my shift.
Interventions
Repeat message back
to patient for
confirmation
Rationale
Provided the patient does not possess auditory barriers to communication, verbally
repeating the patient’s message back to the patient gives the patient the opportunity to
confirm or deny the accuracy and completeness of the message received. This
decreases the chance of miscommunication from patient to nurse, and furthermore
demonstrates the nurse’s interest in the patient’s needs. (Finke, Light, & Kitko, 2008)
Patient Responses
Actual: Patient was able and
willing to confirm or deny
messages by nodding or shaking
head.
Provide patient
ample time to
communicate using
non-verbal strategies
Despite the time-consuming nature of providing adequate time for patient
communication, doing so conveys patient respect, improves accuracy of delivery, and
increases overall patient satisfaction. Multiple studies indicate that patient anxiety and
frustration increase, and emotional and physical health suffers when patients lose the
ability to successfully communicate with their caregivers. (Finke et al., 2008)
Actual: Messages were confirmed
only after patient indicated closure
(setting pen down, making eye
contact). Patient’s behavior
conveyed no indication of
frustration or dissatisfaction.
Allow patient to
determine which
non-verbal
communication
methods work best
Patients communicate best with methods that are individualized to them (Ackley &
Ladwig, 2011, p. 233). Some patients will prefer the use of a white board, while
others will prefer the use of picture cards or pantomiming; some will prefer to use
several techniques in conjunction with one another (Finke et al., 2008).
Actual: Patient seemed satisfied in
communicating via white board,
but resorted to mouthing,
pantomiming or nodding head
when messages were more simple
in nature.
Evaluation of outcome: Outcome met. Patient was able to use a variety of non-verbal communication tools, such as writing on the
white board, gesturing, head nodding and mouthing to communicate non-verbally. Patient displayed no signs of frustration with
communication, no was there any apparent communication breakdown that could not be easily resolved with one or more alternative
communication techniques used by the patient.
Medical Surgical Module Care Plan #1
15
Evidence Based Practice
A systematic review published by Finke, Light and Kitko (2008) explores barriers to, and
potential improvements in, communication between the nurse and the patient with complex
communication needs (CCN); specifically of concern are those patients with physical or
developmental barriers, be they permanent or temporary, to producing speech. Such research is
paramount to the role of the nurse as an efficient, thorough and accurate communicator, because
patients suffer when communication fails. Anxiety, frustration and even compromised health
status are potential risks to the patient when complex communication needs are left unmet.
A total of twelve primary studies containing original data were ultimately included in this
review, among which four critical themes were explored: 1) importance of nurse-patient
communication; 2) barriers to such communication; 3) techniques for overcoming these barriers;
and 4) potential improvements for fulfilling complex communication needs. Of the studies, six
focused on subjective data from the patient’s perspective, five did so from the nurse’s
perspective, and two studies gathered subjective reports from other “carers” such as family
members present at bedside. A variety of augmentative and alternative communication (AAC)
means, such as mouthing words, use of a dry-erase board, electronic devices and gesturing were
explored in the studies.
Patients most consistently reported a seeming dearth of effort among nurses to
communicate, citing a perceived lack of desire, time and/or knowledge regarding the tailoring
and execution of individualized AAC practices. Conversely, nurses who displayed patience and
humor with the patient were rated positively. Among the suggestions for improvement were that
nurses take more time to talk to and try to understand the patient’s needs; emotions such as
anxiety, frustration and resentment were commonly cited consequences of ineffective
Medical Surgical Module Care Plan #1
16
communication. From the nurse’s perspective, a lack of time, training, resources and support
were largely to blame for communication mishandlings. In addition to feeling burdened in
having to engage in difficult and often time-consuming communication, unsuccessful attempts to
communicate with the CCN patient left nurses feeling frustrated and powerless, even
incompetent. In the two studies that explored the perspective unpaid carers at the bedside, these
individuals reported that they were forced to become responsible for communicating between the
nurse and the patient, some because they felt that the nurse was incapable of effectively
communicating, and others because they felt the nurse was essentially unwilling to do so.
Participants in four of the twelve studies offered recommendations for improving nursepatient communication in the complex needs scenario, and among these recommendations,
nurses, patients and carers alike agreed on one thing: nurses should receive AAC training and be
educated on the implications of ineffective communication with the CCN patient. Among other
recommendations, the theme of nurse education and awareness is common throughout, with
many patients simply requesting that the nurse exhibit patience and understanding that a lack of
effort and empathy can hinder recovery and emotional well being.
Though all of the themes, barriers and implications of this research are relevant to my
patient, I chose to implement specific interventions that I felt would be of particular importance
in providing best care. Since this patient demonstrated determination to successful non-verbal
communication, I felt it most necessary to ensure that the message was being received by me in
the way it was intended. Therefore, providing as much time as needed for the patient to
communicate a message, and repeating the message back to the patient, encourages not only
complete, but also accurate communication. Despite having the tools and ability to use those
tools, communication is not successful unless the intended message is conveyed its entirety.
Medical Surgical Module Care Plan #1
17
Physical Assessment Data
BP: 153/94
Pulse: 86
Height: 163 cm
Resp: 16
Pulse ox: 91 (ORA)
Weight: 77 kg
Temp: 37.2
BMI: 29
Pain (Indicate Scale used): 7/10 (Verbal Numerical Rating Scale)
Describe pain characteristics (PQRSTU): Soreness and throbbing in throat and chest,
particularly acute at tracheostomy insertion site. Pain is exacerbated by movement of head and
thorax, during coughing and deep breathing, and in producing speech. Pain is only somewhat
managed with opioid analgesics.
I&O
Restrictions: Regular diet, no restrictions.
Emesis: N/A
Tube feeding (type and rate): N/A
Residuals: N/A
Difficulties noted with feeding (e.g., assistance, problems swallowing/chewing): Patient
demonstrates no difficulty chewing or swallowing. Patient denies dysphagia, but does complain
of discomfort upon swallowing.
Hydration status (e.g., dehydrated including associated assessment data): Skin turgor,
mucous membranes, urinary output, sputum consistency and level of consciousness are all
indicative of good hydration status.
Tube/drains (e.g., Chest tube, JP, Hemovac, etc.): 6 Shiley, non-fenestrated tracheostomy
tube is midline and secured with sutures. Cuff is inflated to 5 mmHg. Inner cannula is clean and
free of secretions and other obstructions.
Shift I =
O=
1,600 ml
1,100 ml
24 hours intake:
24 hours urine output:
2,500 mL
2,100 mL
Activity
Ability to walk/gait/weakness: Patient is able to ambulate ad lib and can turn without any
demonstrable or reported weakness. Patient able to rise from bed in a maximum of two attempts.
Gait is smooth, coordinated and even.
Assistive Devices: N/A
Sleep habits (e.g., home vs. hospital, sleep aids, equipment, etc): Patient reports improvement
in sleep quality and duration since tracheotomy, and fewer episodes of sleep apnea.
Medical Surgical Module Care Plan #1
18
Fall risk assessment rating (state tool used): Hendrich II Fall Risk Score of 2 (not a fall risk).
Side rails (number): 2 (while in bed)
Bed position (Hi-Lo): Low
Restraints (e.g., type and why): N/A
Neurological/Mental
Mental Status:
Level of Consciousness (LOC): Awake, alert and calm.
Orientation: Oriented to person, place, time and reason for hospitalization.
Pupils (e.g. PERRLA/ size in mm): PERRLA, 4mm.
Motor (e.g. ROM X 4 extremities): Full range of motion displayed in all four extremities.
Sensation (e.g. X 4 extremities): No loss of sensation, numbness or tingling in extremities.
Sensory deficits (e.g. hearing, vision, taste, smell, sensation): No objective or subjective
indications of deficits.
Describe any sensory deficits (e.g., HOH) and any adaptive devices utilized (e.g. hearing
aids, eye glasses): Eyeglasses used for distance only.
Can this person express her/himself clearly and logically? Patient is able to successfully
communicate with healthcare personnel and spouse via whiteboard or mouthing when speaking
becomes too tiresome and painful. No indicators of receptive or expressive aphasia. Patient’s
communication, both spoken and written, is semantically clear and logical.
Musculoskeletal
Bones, joints, muscles assessment data (e.g., fractures, contractures, arthritis, spinal
curvatures): No fractures, contractures or abnormal spinal curvature noted. No objective or
subjective indicators of arthritis.
Devices (e.g., cast/splint/collar/brace) present. Include extremity circulation checks distal
to device which includes pulses, temperature, sensation, color, edema): N/A
Circulatory devices (e.g. TED hose, SCD’s, etc.): Lower-leg SCDs in use during periods of
bed rest.
Medical Surgical Module Care Plan #1
19
Cardiovascular
Heart Sounds (e.g., S1, S2, regular/irregular, murmur): S1/S2 clearly identifiable; no murmur
noted. Apical pulse is strong and regular.
Description of Peripheral Pulses: Radial, brachial, dorsalis pedis and posterior tibialis pulses
assessed. All are even, regular, non-thready, non-bounding and bilaterally symmetrical.
Capillary Refill (in seconds): 3 seconds; upper and lower nail beds assessed.
Neck Vein Distention: No evidence of jugular vein distention noted in semi-Fowler’s position.
Edema (e.g., degree, pitting, location): None observed aside from that reported at tracheostomy
site.
Chest pain (e.g., duration, strength, radiation): No complaints of current or previous chest
pain.
Other: N/A
Respiratory
Chest Shape: Gently rounded, chest expansion occurs evenly bilaterally.
Breathing Pattern (e.g., depth, rate, rhythm, use of accessory muscles): Breathing is
unlabored and regular in rate, rhythm and depth; no sign of accessory muscles employed in
breathing.
Breath Sounds (e.g., clear, coarse, wheezes, location, etc.): Lung sounds are coarse
throughout. Expiratory wheezes noted in RUL. Diminished breath sounds in RLL and LLL.
Cyanosis (e.g., location, severity): No evidence of cyanosis.
Cough (e.g., productive, nonproductive): Productive cough.
Sputum (e.g., color, amount, how obtained): Sputum is thin and blood-tinged; moderate
amount, produced by cough.
Use of O2 (e.g., nasal cannula, mask, trach collar, other): On room air.
Flow rate of O2: N/A
Humidification: Humidification via mask; placed near tracheostomy.
Smoking History (e.g., years smoking, quit date, never): No history of cigarette smoking, but
patient does report current, regular marijuana use approximately 2-3 days per week for an
estimated 30 years.
Medical Surgical Module Care Plan #1
20
Pack Years: N/A
Gastrointestinal
Appearance: Abdomen is gently rounded and symmetrical, and free of lesions or visible
protrusions. Slight ecchymosis noted at heparin injection sites.
Abdominal pain (e.g., tenderness, guarding, distention, soft, firm): Abdomen non-distended
and soft upon palpation. Patient denies tenderness, and no guarding demonstrated.
Bowel sounds (e.g., hypoactive, hyperactive, normoactive, quadrants): Normoactive in all
four quadrants.
Bowel pattern (including last bowel movement & elimination issues): Approximately 100
mL of loose stool in morning of 10/16.
NG tube (describe residual and output): N/A
Ostomy (type, stoma site, output): N/A
Other: N/A
Urinary
Urinary pattern (e.g., incontinence, Foley, frequency issues): Voiding without Foley. Patient
denies dysuria, frequency or urgency. No hematuria or other signs of GU infection.
Catheter: N/A
Ostomy: N/A
Type: N/A
Type: N/A
Skin and Wounds
Describe skin (e.g., color, turgor, rash, bruises): Slight bruising at heparin injection sites;
skin is appropriately warm and uniform in color; turgor is satisfactory. All other parameters
unremarkable.
Wounds: Skin at tracheostomy site is erythematous and slightly edematous. Thin, blood-tinged
mucous drainage cleared from site and dried exudate removed from sutures during tracheostomy
care.
Dressings (e.g., clean, dry, intact, sutures, staples, steri-strips): IV dressings (2) clean, dry
and intact and secured with occlusive dressing and steri-strips.
Drains (e.g., type, location): N/A
Risk for pressure ulcer assessment (Identify tool used): 20/23 (Braden Scale for Predicting
Pressure Ulcer Risk); not a pressure ulcer risk.
Medical Surgical Module Care Plan #1
21
Eyes, Ears, Nose, Throat (EENT)
Eyes (e.g. redness, drainage, edema, ptosis): Sclera are white, conjunctiva moist and pink,
palpebrae are non-edematous. No discharge or lesions noted. Globes are round, normal fundus
noted. Eyes appear equal bilaterally.
Ears (e.g. drainage): Intact, bilaterally symmetrical and free of lesions or drainage, no
complaints of tenderness or pain.
Nose (e.g. redness, drainage, edema): Nostrils are patent; nose is non-edematous and nonerythematous; no drainage noted.
Mouth (e.g., gums, teeth, mucous membranes): All teeth intact and apparently free of decay,
gingivae are pink, non-edematous and free of lesions.
Throat (e.g. pain, edema): Trachea and tracheostomy are midline. Patient exhibits strong
swallow. Pain, swelling and drainage at tracheostomy site as previously expounded.
Psychosocial, Cultural and Spiritual
Marital status: Married
Occupation: Employed as a scrap metal worker until he was pedestrian struck in May 2014.
Spiritual considerations: Patient is Catholic, denies the need for spiritual support at this time.
Emotional state: Calm, cooperative and accepting.
Cultural needs or habits during hospitalization: None identified by myself, and patient denies
the need for additional support.
What support systems does this person currently have available? Wife has been bedside for
most of patient’s hospital stay and is instrumental in helping patient in performing ADLs,
including toileting, bathing, dressing and repositioning. Patient and spouse appear to share a
close, positive relationship. Patient’s father and sister have also visited; the overall family
dynamic appears to be one of mutual respect and support. Patient cites religious faith and family
support for his strength.
Medical Surgical Module Care Plan #1
22
References
Ackley, B.J., & Ladwig, G.B. (2011). Nursing diagnosis handbook: An evidence-based guide to
planning care (9th ed.). St. Louis, MO: Mosby.
Dawson, D. (2014). Essential principles: tracheostomy care in the adult patient. British
Association of Critical Care Nurses,19(2), 63-72. doi: 10.1111/nicc.12076
Deglin, J., & Vallerand, A. (2013). Davis’s drug guide for nurses (13th ed.). Philadelphia, PA:
F.A. Davis.
Fink, J. B. (2007). Forced expiratory technique, directed cough, and autogenic drainage.
American Journal of Respiratory and Critical Care, 52(9), 1210–1221. Retrieved from
http://rc.rcjournal.com/content/52/9/1210.full.pdf+html
Finke, E. H., Light, J., & Kitko, L. (2008). A systematic review of the effectiveness of nurse
communication with patients with complex communication needs with a focus on the use
of augmentative and alternative communication. Journal of Clinical Nursing 17, 2102–
2115. doi: 10.1111/j.1365-2702.2008.02373.x
Guy, J. L., & Smith, L. H. (2009). Preventing aspiration: A common and dangerous problem for
patients with cancer. Clinical Journal of Oncology Nursing, 13(1), 105-108. doi:
10.1188/09.CJON.105-108.
Morris, L. L., Whitmer, A., & McIntosh, E. (2013). Tracheostomy care and complications in the
intensive care unit. American Association of Critical-Care Nurses, 33(5), 18-30. doi:
http://dx.doi.org/10.4037/ccn2013518
Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F. & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis, MO: Mosby.
Medical Surgical Module Care Plan #1
23
Quagliarello, V., Juthani-Mehta, M., Ginter, Towle, V., Allore, H., & Tinetti, M. (2009). Pilot
testing of intervention protocols to prevent pneumonia in nursing home residents. Journal
of the American Geriatrics Society, 57(7), 1226-1231. doi: 10.1111/j.15325415.2009.02311.x
Valdez-Lowe, C., Gharreb, S. A., & Artinian, N. T. (2009). Pulse oximetry for adults. American
Journal of Nursing, 109(6), 52-59. doi: 10.1097/01.NAJ.0000352474.55746.81
Statement of academic integrity: “I have reviewed the Code of Academic Integrity and can
attest that this document is consistent with the provisions of the code and represents my own
original work. Signed, Samantha A. Redmon.”
Medical Surgical Module Care Plan #1
24