SKILLS LABORATORY 3B (ETT SUCTIONING)
End of rotation Evaluation
Instruction:
From the scenario, make an NCP considering 3 nursing diagnosis. This is to be
submitted on or before September 25,2020 in my messenger account.
A patient is admitted post-opt on your unit after having a procedure for a
tracheostomy. The patient is a little drowsy but slowing becoming more alert but
is unable to communicate with you due to the inability to produce speech from
the tracheostomy. The surgical site is moisten with petroleum jelly and has multiple
sutures around the site. You have orders to administer saline drops every 2-4 hours
to keep secretions from building up around the site and to apply petroleum jelly
around the stoma every 3 hours to keep the stoma clean. In addition, the patient
has a trach collar on with humidified oxygen at 30%. At the bedside you have
endotracheal suction to suction the patient as needed. Patient’s vital signs are BP
115/82, HR 85 (sinus rhythm), oxygen saturation 99%, respiratory rate 16, and
temperature 99.6 ‘F. The patient’s wife is with him. The wife states she thinks her
husband is getting mad at her because he can’t communicate with her. During
your assessment while asking the patient questions he became agitated because
of his inability to communicate with you and his wife. You note he throws his hands
up in the air and shakes his head in frustration. As the day progresses you note
that he is starting to produce more secretions around his stoma and at times starts
to cough to remove the secretions but is unable to completely remove them. You
have suctioned him 3 times and the mucous is thin and clear in nature.
Good luck everyone!
Wilfreda Monette B. Moran
Instructor
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SKILLS LABORATORY 3B (ETT SUCTIONING)
End of rotation Evaluation
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
Subjective: Ineffective Airway After 4hrs of nursing Independent: Goal met
Clearance r/t intervention patient will Establish rapport to pt. and SO.
“Gasa ģayd sakёn a sёgёd tracheostomy and copious remain a clear, open airway Assess changes in BP, HR, and After the 4hrs of nursing
ko ta di kami nagkakausip” secretions evidenced by as evidenced by normal Temperature. intervention patient had
as verbalized by the Wife. ineffective cough breath sounds, normal rate, Assess respirations: note the quality, remain a clear, open
and dept. of respiration, and rate, rhythm, nasal flaring, and any airway as evidenced by
“Tinapon pataas ng the ability to effectively increased use of accessory muscles of normal breath sounds,
paseynte ang kanyang cough up secretions. respiration. normal rate, and dept.
kamay at umiling dahil sa Auscultate the lungs, noting areas of of respiration, and the
pagkabigo” as verbalized by decreased ventilation and for the ability to effectively
nurse on duty presence of adventitious breath sounds. cough up secretions.
Assist the effectiveness of cough.
Objective: Observe the color, consistency, and
A bit drowsy yet quantity of secretions.
becoming alert Encourage the pt. to cough out
Unable to communicate secretions. If the cough is ineffective,
With trach collar and Institute suctioning of the airway as
humidified oxygen at needed.
30% Provide warm, humidified air.
Agitated Transport the patient with portable
More secretion around oxygen, Ambu bag, suction equipment,
stoma and extra tracheostomy tube.
Ineffective coughing to Dependent:
secret secretions. Administer prescribed humidified oxygen
Suctioned 3x at 30%
Vitals: Administer saline drops every 2-4 hours
BP: 115/82mmhg to keep secretions from building up.
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SKILLS LABORATORY 3B (ETT SUCTIONING)
End of rotation Evaluation
HR: 85 bpm (sinus Impaired Verbal After 4hrs of nursing Independent: Goal met
rhythm) Communication r/t intervention patient will use Establish rapport to Pt and SO.
RR: 16 bpm tracheostomy evidenced a form of communication to Assess the patient’s communication After 4hrs of nursing
BT: 99.6°F by frustration and get his needs met and to ability. intervention patient
O2Sat: 99% agitation relate effectively with Assess the effectiveness of nonverbal used forms of
persons and his communication methods. communication to get
environments. Assess for frustration and anxiety related needs his met and to
to not being able to communicate needs. relate effectively with
Provide emotional support to the pt. and persons and his
SO. environments.
Place the pt’s in a room close to the
nurses’ station.
Provide a call light within easy reach at
all times. Answer the light promptly.
If the pt. is able to nod or speak “yes” or
“no” answers, try to phrase questions so
that the patient can use these responses.
Provide alternative methods for
communicating:
Hand gestures
Word-and-phrase cards
Picture board for patients who
are unable to write
Writing pad
Allow the patient time to communicate
his needs.
Collaborative:
Collaborate with physician and speech
therapist on the possible use of “talking”
tracheostomy tube as indicated.
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SKILLS LABORATORY 3B (ETT SUCTIONING)
End of rotation Evaluation
Risk for infection r/t After 4hrs of nursing Independent: Goal met
tracheostomy, increased interventions patient will Establish rapport to pt. and SO
secretions, and suctioning remain free of infection, as Assess client’s temperature. After 4hrs of nursing
of airway evidenced by normal Assess skin integrity under tracheal ties. interventions patient
temperature, normal sputum Observe the stoma for erythema, color, remained free of
culture, normal WBC count, exudates, and crusting lesions. If infection, as evidenced
absence of purulent drainage present, culture the stoma and notify the by normal temperature,
around stoma, and have clear physician. normal sputum culture,
breath sounds. Monitor white blood cell (WBC) count. normal WBC count,
Maintain an inflated tracheostomy cuff at absence of purulent
the lowest pressure possible to maintain drainage around stoma,
an adequate seal for ventilation. and have clear breath
Keep a tracheal obturator taped at the sounds.
head of the bed for emergency use. Keep
a spare tracheostomy tube of same size
and brand at the bedside.
Do not allow secretions to pool around
the stoma. Suction the area, or wipe
with aseptic technique. Keep the skin
under the tracheostomy ties and back of
the neck clean and dry.
Collaborative:
Provide stoma care:
Administer petroleum jelly every
3hrs around stoma.
Keep the stoma clean and dry.
Secure the tracheostomy tube
with twill tape, using a square
knot on the side of the neck or
specially designed foam
tracheostomy ties.
REA CRISELLE M. BRONDIAL
CSPC – BSN 3B Page | 4
CLINICAL GROUP 2
