Low efficiency in cleaning respiratory tract
Refer to the relevant contents in the standard nursing plan for patients undergoing laryngeal tumor surgery.
Danger of gas exchange barriers.
correlative factor
1. Severe lung infection.
2. Excessive phlegm or thick phlegm cannot produce effective expectorant effect.
3. The inner sleeve is stuck and the outer sleeve is pulled out.
4. Severe subcutaneous emphysema and hematoma.
main performance
The patient has shortness of breath, tachycardia, sweating, pallor cyanosis or even suffocation.
Blood oxygen saturation decreased (less than 90%).
Nursing goal
The patient maintained normal gas exchange and showed normal oxygen saturation, sobriety and normal reaction.
There was no blockage and prolapse of tracheal catheter.
Nursing measures
Patients with tracheotomy should always check whether the cuff is tight and the lacing knot is firm.
Keep the respiratory tract unobstructed, and take the following measures in case of dyspnea:
If it is suspected that the outer tube is blocked, antibiotics will be dripped into the trachea to suck out the deep sputum and scab in the tube, and the tube will be changed if necessary.
If it is suspected that the inner sleeve is blocked, take out the inner sleeve, check whether it is blocked by sputum scab, and put it back after disinfection.
Check whether the tracheal sheath has come out. If there is prolapse, inform the doctor immediately and assist in re-intubation.
Check the skin for dyspnea caused by emphysema.
Patients can take a semi-recumbent posture to promote breathing.
If the patient has pneumothorax, assist the doctor to place a closed chest examination, collect a large number of arranged drainage tubes, and keep them unobstructed.
Restrict head and neck from overstretching and prevent sleeves from coming out.
Pat the patient's back twice a day to facilitate the dilution and discharge of sputum. Give ultrasonic atomization according to the doctor's advice.
Teach the patient to cough correctly, let the patient take a sitting position or a semi-sitting position, take a few deep breaths first, keep his mouth open after taking a deep breath, and cough hard twice to cough up phlegm from the depths.
Critical assessment
Monitor the changes of respiration, pulse and body temperature.
Whether the endotracheal tube is always unobstructed.
Monitor blood oxygen saturation and blood gas changes.
Anxious
Related factors: related to tracheotomy.
main performance
The patient was depressed, nervous and afraid to move.
Breathing, increased heart rate, decreased appetite, insomnia.
Nursing goal
Diet, sleep back to normal.
Patients and their families know about tracheotomy.
Nursing measures
Actively introduce competent doctors and nurses, introduce the environment, and eliminate their nervousness and strangeness.
Try to answer patients' questions, give preoperative guidance, explain the purpose of tracheotomy, and eliminate patients' worries about surgery and prognosis.
Strengthen patrol after operation, give patients more words of comfort and encouragement, so that patients have confidence.
Life nursing should be implemented to reflect the care of medical staff.
For patients who need to be discharged with tubes, an examination should be given to patients and their families two days before discharge to collect, explain and demonstrate nursing knowledge about cleaning and disinfection of casings.
Critical assessment
1. Family members and patients' awareness of tracheotomy.
2. Whether the patient's nervousness has been improved.
Fourth, language communication barriers.
Refer to the relevant contents in the standard nursing plan for patients undergoing laryngeal tumor surgery.
5. Risk of infection
Related factors: tracheotomy wound.
main performance
Have a fever
Cough, excessive phlegm.
There are inflammatory manifestations such as redness, swelling, heat, pain and exudation around the wound.
Nursing goal: no symptoms and signs of infection.
Nursing measures
Monitor the infection symptoms and temperature changes of the patient's wound.
Strict aseptic operation, tracheotomy and dressing change, disinfection of the inner sleeve 4 times a day, timely aspiration of catheter secretions, and good oral care.
Monitor the use of antibiotics.
Carry out health education for patients and explain the knowledge of preventing infection, such as keeping the wound clean and dry and avoiding taking a bath.
Critical assessment
Whether the wound skin is red, swollen and suppurative.
Quantity and nature of endotracheal secretions.