Question

A 65-year-old male was admitted for evaluation of pain on swallowing and a sore throat that has persisted for the past year. The discomfort has not changed with the use of various over-the-counter cold remedies. The client has lost weight due to a decrease in appetite and difficulty swallowing. He has smoked 3 packs of cigarettes a day for 40 years.

A laryngoscopy showed a subglottic mass. The client had a total laryngectomy with tracheostomy to manage laryngeal cancer. He also has a nasogastric tube in place.

You will be providing care for this client during his first 72 hours after surgery.

Initial Discussion Post:

There are multiple nursing diagnoses that are applicable to this client during the time when you will be providing care.

• Select one NANDA-I nursing diagnosis and describe why it is a priority for this client.
• What is the cause or related factor for this NANDA-I nursing diagnosis?
• Identify an outcome for this NANDA-I nursing diagnosis. The outcome must be patient-centered and measurable.
• Identify two (2) nursing interventions that will help this client achieve the outcome.
• Describe how each intervention will help the patient achieve the outcome..

Answer 1

# Nursing diagnosis according to the priority is - Risk for ineffective airway clearance related to retained secretions and tracheal edema post surgery . It is in the upmost priority because getting oxygen is the basic physical need of a human being to be alive .

# The cause for this diagnosis is the presence of excessive secretions and tracheal edema due to damage caused during the surgery .

# Outcome - after the implementation of nursing interventions ,the client will be able to expectorate secretions and maintain normal breathing. It can be measured by assessing the SPO2 , respiratory rate , auscultation etc .

# Nursing Interventions to achieve the outcome are :-

- Provide the patient a semi -fowlers position , it helps the lungs to be fully expanded by drainage of secretions.

- Suction when ever needed , helps to decrease the secretions

- encourage deep breathing , it helps to keep the lungs expanded and for proper perfusion.

- use of expectorants to secret out the secretions

- monitor vital signs for assessing any changes in the viatls so that immediate action can be taken to prevent complications.