Skills ON Nancy Gilbert SIM PDF

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Summary

Case Study on Tracheostomy (Sim lab)...

Description

ADETOLA AKINSETE PROF. NANCY OKERE SIM LAB WORK NR 324

SKILLS ON NANCY GILBERT

Assessment

Care plan 1

Care plan 2

Care plan 3

Auscultate lungs, decreased breath sounds, rhonchi and crackles heard, RR is 22

Assess mouth and communication ability, no vocalization possible due to tracheostomy, cuff is inflated.

Assess the respiratory rate, rhythm, quality, depth, and effort. Client is breathing using accessory muscles, she has shortness of breath, no signs of cyanosis

Impaired Verbal Communication r/t to tracheostomy as evidenced by nonverbal status

Risk for impaired gas exchange r/t to Copious tracheal secretions as evidenced by oxygen sat of 92%

Nurse will explore ways to communicate with patient, patient will use a different form of communication to get needs met

Client will maintain optimal gas exchange. Nurse will ensure trach suctioning to clear client airway

Suction the trach to clear out airway

Place the client in a room close to the nurse ‘s station

encourage the client to cough out secretions

Provide a board or notepad for patient to write on.

provide warm humidified air

Asked closed ended question that requires a simple nod for yes and a head shake for no.

-Place client in semi-fowlers or high-fowlers position -Ensure the effectiveness and proper placement of the tracheostomy cuff -A mucus plug can become lodged in the tube and obstruct the client’s airway, remove the inner cannula and replace with a new one.

Patient feels better, airway is clear of fluids

Patient and nurse can communicate without difficulties, patients’ needs are met

Diagnosis

Ineffective Airway clearance r/t increased secretions as evidenced by abnormal breath sounds (crackles, rhonchi) Outcome/planning Client will maintain a clear, open airway as evidenced by normal breath sounds

3 Interventions /implementation (Question 2)

Evaluation

O2 sat is now 99% on 2l oxygen, client can breathe better.

3---When should a nurse suction a tracheostomy patient   

When a patient has difficulty breathing, O2 sat is low When patient has excess fluid in airway, auscultation of lung sounds will indicate so. Acute care patients need to be assessed every two hours for the need for suctioning.

4---How often do the nurse perform trach. Care/suctioning Trach care should be performed routinely twice daily, more often if needed, or if infection occurs. Acute care patients need to be suctioned every two hours. 5---What three important equipment should the nurse have at the patient’s bedside. Suction equipment Oxygen equipment with humidification An emergency bag containing (tracheostomy care kit, replacement tube, obturator, spare inner cannula, water-soluble lubricant)

SKILLS ON KEOLA AKANA 1---What are PVCS They are premature heartbeats originating from the ventricles 2---What are some of the causes of PVCS Alcohol consumption, caffeine consumption, use of tobacco or drugs, stress, some medications. 3---What is the nurse’s responsibility in caring for a patient on telemetry    

Monitor and interpret the recorded data Educating patient about their health conditions Monitor the electrical activity of the patient’s heart, and other vital signs Administering prescribed medications where appropriate

4---What is digoxin? This is an antiarrhythmic, it increases the force of myocardia contraction and prolongs the refractory period of the AV node 5---What are some of the conditions that can be treated with digoxin Heart failure, atrial fibrillation, atrial flutter 6---What is the nurse’s responsibilities in administering digoxin? o Monitor apical pulse for a full minute and administer meds only if pulse is between 60-100 for adults and 70-90 in infants, otherwise, withhold dose and notify provider o Monitor BP while patient is receiving digoxin o Monitor ECG throughout IV administration of digoxin, and 6 hours after each dose o Notify provider if digoxin levels rise above 2.0 between doses, hold medication for further directions by the provider

o Teach patient to take pulse and alert the provider before taking medication if pulse is 100...