Question

write a care plan for the following scenario

Care Plan Scenario John is a 24-year-old white male with diagnosis of head injury due to a motorcycle accident. He also has diabetes, anemia, and HTN. He is a resident on your nursing home. He has I sister and both parents are living. He has a trach with copious amounts of thick white sputum. He has a G-tube and receives Glucerma full strength at 70 cc/hr. He has a foley catheter which is draining clear yellow urine. His lungs are clear in all lobes. He has active bowel sounds in all quadrants. He has a 2c. sacral decubitus without any drainage. He has contractures of both lower extremities. He is disoriented to place and time. He will look at you when his name is called. PPPPE. Unable to turn, stand, or erform any ADL's. Up in wic daily per hoyer lift. MMMP. Muscle mass equal. Grimaces when legs are moved. PERRLA. Unable to swallow. Has leg spasms when moved. Skin turgor is 4 seconds. No JVD, hemorrhoids, VV. Skin is dry and scaly. PROM of upper extremities only. Patient weighs 130 pounds and is 6 feet tall. VS-98.6 degrees F, 86 and regular, 20 and unlabored. Apical pulse 86 and regular. BP- 160/90. sis2 Medications: Lasix 40 mg per tube BID ASA tab 1 per tube QD Glyburide tab I per tube QD Ferrous sulfate 325 mg per tube BID Calan 20 mg per tube QD Colace tab 1 per tube QD Lab Values: K-2.4 Hgb-9 Na 124 Gliucose 146.

Answer 1

Nursing Care plan

1. Ineffective airway clearance related to increased production of sputum secondary to tracheostomy as evidenced by increased secretions.

Goal : The patient will not experience aspiration during his hospitalization (STG)

The patient will demonstrate correctly how to properly clear airway by discharge( LTG)

Nursing interventions

1. Do the suction/ deep suction , according to the patient' s conditions.

Rationale: to remove the excess sputum from the airway

2. Keep the stoma free from any debris or mucous build up as needed.

Rationale: to prrevent the infection

3. maintain adequate humidity of inspired air every 2 hrs.

Rationale: to prevent dryness of the mucous membranes of the airway.

4. Assess the changes in BP, Heart rate and temperature

Rationale: hypertension may be related to the increased work of breathing.

Evaluation

At the end of the shift, the client was able to display patency of airway as there s no report about aspirations.