Details

Care Plan Detail

Client has tracheostomy. At risk for complications including respiratory distress, increased secretions, wt loss, infection.

Description
A tracheostomy patient faces ... Please Login or Join to access this information
Record Id
230
Code
00230
Downloads
137
References
Choate, K., Barbetti, J., Currey, J. (2018). Tracheostomy decannulation methods and procedures in adults: a systematic scoping review. International Journal of Evidence-Based Healthcare, 16(3), 130-149. https://doi.org/10.1097/XEB.0000000000000128
Mitchell, R. B., Hussey, H. M., Setzen, G., Jacobs, I. N., Nussenbaum, B., Dawson, C., ... & Brown, E. A. (2017). Clinical consensus statement: Tracheostomy care. Otolaryngology–Head and Neck Surgery, 156(1), 1-13. https://doi.org/10.1177/0194599816671827

Outcomes

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Will demonstrate clear and ... Please Login or Join to access this information
Description: Client will exhibit ... Please Login or Join to access this information
Rationale: Achieving clear, equal ... Please Login or Join to access this information
Record Id
234
Downloads
10,406
Evaluate in days
30
Evaluation Date
01/11/2026
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Will have WBC Count ... Please Login or Join to access this information
Description: Client will achieve ... Please Login or Join to access this information
Rationale: Maintaining the client's ... Please Login or Join to access this information
Record Id
236
Downloads
10,406
Evaluate in days
30
Evaluation Date
01/11/2026
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Will have no abnormal ... Please Login or Join to access this information
Description: Client will show ... Please Login or Join to access this information
Rationale: Ensuring no abnormal ... Please Login or Join to access this information
Record Id
237
Downloads
10,406
Evaluate in days
30
Evaluation Date
01/11/2026
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Will maintain or increase ... Please Login or Join to access this information
Description: The client will ... Please Login or Join to access this information
Rationale: Maintaining or increasing ... Please Login or Join to access this information
Record Id
238
Downloads
10,406
Evaluate in days
30
Evaluation Date
01/11/2026
Outcome References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2016). Nursing diagnosis handbook: An evidence-based guide to planning care. Elsevier Health Sciences.
Barnes, T. A., Gale, D. D., Kacmarek, R. M., & Kageler, W. V. (2016). Competencies needed by graduate respiratory therapists in 2015 and beyond. Respiratory care, 61(5), 612-637.
Marik, P. E., & Taeb, A. M. (2019). Sepsis guidelines and protocols: the evidence. Intensive Care Medicine Experimental, 7(S1), 30. https://doi.org/10.1186/s40635-019-0255-7
McLean, A., Huang, S. J., Hyams, C., Poh, L., Nalos, M., Pandit, R., Balik, M., Blyth, E., Kotecha, D., & Chambers, A. J. (2020). Neutrophil–lymphocyte ratio as a prognostic marker in COVID-19. Intensive care medicine, 46(12), 2393-2395. https://doi.org/10.1007/s00134-020-06279-8
Mitchell, R. B., Hussey, H. M., Setzen, G., Jacobs, I. N., Nussenbaum, B., Dawson, C., ... & de Alarcon, A. (2019). Clinical consensus statement: Tracheostomy care. Otolaryngology - Head and Neck Surgery, 160(1), 91-101. https://doi.org/10.1177/0194599818803840
Roberts, N., & Moule, P. (2017). A systematic review of nurses'' experiences of tracheostomy care. International Journal of Nursing Studies, 85, 11-21. https://doi.org/10.1016/j.ijnurstu.2017.07.002
Thomas, S. L., Hyde, J., Karunaratne, A., Kausman, R., & Komesaroff, P. A. (2008). They all work... when you stick to them: A qualitative investigation of dieting, weight loss, and physical exercise, in obese individuals. Nutrition Journal, 7(1), 34. https://doi.org/10.1186/1475-2891-7-34
Bartels, S.J., Pratt, S.I., Aschbrenner, K.A. et al. Clinically significant improved fitness and weight loss among overweight persons with serious mental illness. Psychiatric Services 64, 729–736 (2013). https://doi.org/10.1176/appi.ps.003622012

Actions

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Assess respiratory rate, depth, ... Please Login or Join to access this information
Description: Involves regular evaluation ... Please Login or Join to access this information
Rationale: Monitoring respiratory rate ... Please Login or Join to access this information
Record Id
1686
Downloads
14,567
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Monitor vital signs as ... Please Login or Join to access this information
Description: Involves regularly tracking ... Please Login or Join to access this information
Rationale: Monitoring vital signs ... Please Login or Join to access this information
Record Id
1687
Downloads
14,567
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Assess level of consciousness, ... Please Login or Join to access this information
Description: Involves regularly checking ... Please Login or Join to access this information
Rationale: Regular assessment of ... Please Login or Join to access this information
Record Id
1688
Downloads
14,567
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Encourage to cough and ... Please Login or Join to access this information
Description: Entails promoting regular ... Please Login or Join to access this information
Rationale: Coughing and deep ... Please Login or Join to access this information
Record Id
1689
Downloads
14,567
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Suction as necessary; when ... Please Login or Join to access this information
Description: Involves utilizing suction ... Please Login or Join to access this information
Rationale: Suctioning helps clear ... Please Login or Join to access this information
Record Id
1690
Downloads
14,567
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Follow universal precautions when ... Please Login or Join to access this information
Description: Implement standard safety ... Please Login or Join to access this information
Rationale: Following universal precautions ... Please Login or Join to access this information
Record Id
1691
Downloads
14,567
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Administer humidified O2 as ... Please Login or Join to access this information
Description: Involves the provision ... Please Login or Join to access this information
Rationale: Administering humidified O2 ... Please Login or Join to access this information
Record Id
1692
Downloads
14,567
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Maintain hydration (2-3 liters/day) ... Please Login or Join to access this information
Description: Involves ensuring the ... Please Login or Join to access this information
Rationale: Keeping hydrated aids ... Please Login or Join to access this information
Record Id
1693
Downloads
14,567
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Monitor intake & output ... Please Login or Join to access this information
Description: Involves tracking and ... Please Login or Join to access this information
Rationale: Monitoring intake and ... Please Login or Join to access this information
Record Id
1694
Downloads
14,567
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Ensure that tracheostomy ties ... Please Login or Join to access this information
Description: Involves maintaining tightness ... Please Login or Join to access this information
Rationale: Securing tracheostomy ties ... Please Login or Join to access this information
Record Id
1695
Downloads
14,567
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Assess tracheostomy incision for ... Please Login or Join to access this information
Description: Involves examining the ... Please Login or Join to access this information
Rationale: Checking the tracheostomy ... Please Login or Join to access this information
Record Id
1696
Downloads
14,567
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Weigh client ______________ (frequency). ... Please Login or Join to access this information
Description: Involves regularly measuring ... Please Login or Join to access this information
Rationale: Regularly weighing a ... Please Login or Join to access this information
Record Id
1697
Downloads
14,567
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Provide mouth care before ... Please Login or Join to access this information
Description: Involves administering oral ... Please Login or Join to access this information
Rationale: Proper mouth care ... Please Login or Join to access this information
Record Id
1698
Downloads
14,567
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Provide for adequate rest ... Please Login or Join to access this information
Description: Ensure the client ... Please Login or Join to access this information
Rationale: Rest periods between ... Please Login or Join to access this information
Record Id
1699
Downloads
14,567
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Speak to in a ... Please Login or Join to access this information
Description: Involves conversing with ... Please Login or Join to access this information
Rationale: Speaking normally and ... Please Login or Join to access this information
Record Id
1700
Downloads
14,567
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Provide alternative forms of ... Please Login or Join to access this information
Description: Involves offering different ... Please Login or Join to access this information
Rationale: Alternative communication forms ... Please Login or Join to access this information
Record Id
1701
Downloads
14,567
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Allow client time to ... Please Login or Join to access this information
Description: Ensures clients are ... Please Login or Join to access this information
Rationale: Allowing time for ... Please Login or Join to access this information
Record Id
1702
Downloads
14,567
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Keep call light within ... Please Login or Join to access this information
Description: Ensure the client's ... Please Login or Join to access this information
Rationale: Having the call ... Please Login or Join to access this information
Record Id
1703
Downloads
14,567
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Assist with ADLs as ... Please Login or Join to access this information
Description: Involves aiding clients ... Please Login or Join to access this information
Rationale: Assisting with Activities ... Please Login or Join to access this information
Record Id
1704
Downloads
14,567
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Monitor skin status. Use ... Please Login or Join to access this information
Description: Involves tracking the ... Please Login or Join to access this information
Rationale: Monitoring skin status ... Please Login or Join to access this information
Record Id
1705
Downloads
14,567
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Provide Range of Motion ... Please Login or Join to access this information
Description: Involves carrying out ... Please Login or Join to access this information
Rationale: Range of motion ... Please Login or Join to access this information
Record Id
1706
Downloads
14,567
Action References
Ramanan, M., & Street, A. (2019). Effective nursing communication during patient encounters. Australian Nursing & Midwifery Journal, 26(12), 36–39.
Litton, G., Sloane, D. M., & Aiken, L. H. (2020). The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 58(12), 1076–1082.
Voutilainen, A., Saaranen, T., & Sormunen, M. (2018). Conventional vs. e-learning in nursing education: A systematic review and meta-analysis. Nurse education today, 60, 136-149. https://doi.org/10.1016/j.nedt.2017.12.023
Stickley, T., & Freshwater, D. (2016). The art of loving and the therapeutic potential of non-verbal communication. Journal of Psychiatric and Mental Health Nursing, 23(2-3), 87-97. https://doi.org/10.1111/jpm.12282
Smith, D. B., & Yang, Q. (2019). The impact of verbal communication in the nursing care of patients with dementia: A systematic review. International Journal of Nursing Sciences, 6(2), 192–200. https://doi.org/10.1016/j.ijnss.2019.03.001
Nicolô, R., & Magnavita, N. (2018). Safety climate, psychosocial risk factors and needlestick injuries in a sample of Italian registered nurses in hospital settings. Journal of nursing management, 26(1), 2-10. https://doi.org/10.1111/jonm.12525
Arnold, E. C., & Boggs, K. U. (2017). Interpersonal Relationships: Professional Communication Skills for Nurses. Elsevier Health Sciences.
Kourkouta, L., & Papathanasiou, I. V. (2020). Communication in nursing practice. Mater Sociomed, 26(1), 64. https://doi.org/10.5455/msm.2014.26.64-67
Williams, K., Kemper, S., & Hummert, M. L. (2018). Enhancing communication with older adults: Overcoming elderspeak. The Gerontologist, 58(3), 435–446. https://doi.org/10.1093/geront/gnw197
Simmons, S. F., Schnelle, J. F., Sathe, N. A., Barker, A., Meldon, S. W., Durkin, D. W.,... & Vickrey, B. G. (2017). Managing delirium and agitation in the older emergency department patient: The ADEPT tool. Annals of Emergency Medicine, 69(2), 316-326. https://doi.org/10.1016/j.annemergmed.2016.06.039