Santos, Jielliane Mae V.

BSN 4R
A Client TOTAL LARYNGECTOMY

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Cues Ineffective After 8 hours Established rapport to patient To gain trust and cooperation of After 8 hours of
“may dugo ang airway of Nursing and patients relative the patient Nursing
plema ko at mejo clearance intervention intervention the
nahihirapan ako related to the patient will Assessed respiratory status Change in respiration, use of patient was able to
huminga” total be able to including rate, pattern, lung accessory muscle or presence of maintain patent
removal of maintain sounds, crackles/ wheezes- suggest airway and lung
and cough effectiveness at least retention of secretions
Objective Cues glottis patent airway every 4 hour Airway obstruction can lead to
sounds
(+) blood tinged altering to and lung ineffective breathing patter and
sputum, breathe, sounds impaired gas exchange, leading
hemoptysis cough and in complication.
swallow Elevated head of the bed 30- 45
degree Facilitate drainage of secretions
(+) Dyspnea and lung expansion

(+) cough Encouraged Deep breathing Mobilizes secretion to clear

exercise airway and helps prevent
respiratory complications
Use of accessory
muscle when Suctioned tracheostomy tube, Prevent secretion from
breathing oral, nasal cavities, note amount obstructing airway esp when
of color and consistency of swallowing ability is impaired and
With history of secretions client cannot blow nose
Change in character of secretions
smoking may indicate developing
problems (DHN, INFECTION) and
With need further evaluation
tracheostomy Maintained Proper position of
laryngectomy/ tracheostomy As edema develops tubes can be
tube
tube, checked or adjust ties displaced, compromising airway
when indicated ties should be snug out not
w/ nasogastric constricted to surrounding tissue
tube or major Blood vessels
Provided supplemental
humidification eg. Compressed/ Normal physiologic (nose, nasal
ambulatory oxygen mist collar, increase passages) means of filtering/
fluid intake humidifying air are bypassed
Vital signs taken supplemental humidity decrease
as follows mucous and facilitated coughing.
T- 36.7
Monitored serial ABG’s Pulse Pooling of secretions/ presence of
PR- 92 and Oximeter chest X-ray atelectasis may lead to
regular pneumonia, requiring aggressive
RR- 18 therapeutic measures
BP- 120/80