Nursing 211

N211: Health Differences Across the Lifespan I

©2012 of 148 Nursing Interventions Provide pre-operative teaching, to allow client and family to observe and handle tracheostomy tubes and suction equipment, explain how suctioning will take place after surgery, plan for communication methods after surgery, referral to speech pathologist and discuss planned rehabilitation program. Always keep call bell within easy reach. Ask client yes and no questions whenever possible. Assess respiratory rate and characteristics everyone to two hours. Always keep bed in semi-Fowlers position. Always keep laryngeal airway humidified. Auscultate lung sounds every two to four hours. Provide tracheostomy care every two to four hours and as needed. Administer tube feedings as prescribed. Encourage ambulation as early as possible. Tracheostomy care involves cleaning the inner cannula, suctioning, and applying clean dressings. Air that enters the lungs is humidified along the nasobronchial tree. This natural humidifying pathway is gone for the client who has had a laryngectomy. If the air is not humidified before entering the lungs, secretions tend to thicken and become crusty. Fear of choking is very real for laryngectomy clients. They cannot cough as they could earlier because the glottis is gone. Teach the glottal stop technique to remove secretions by taking a deep breath, momentarily occlude the tracheostomy tube, cough and simultaneously remove the finger from the tube. Radiation therapy and or brachytherapy (placement of radioactive source next to the tumor) or chemotherapy may also be used for treatment. 2.10 Tuberculosis Tuberculosis is an airborne, infectious, communicable disease that is caused by Mycobacterium tuberculosis. The alveoli become infected from inhaled droplets containing tubercle bacilli. After the initial exposure, the bacteria encapsulate and form a Ghon lesion. The bacteria remain dormant until a later time, when clinical symptoms appear. Nursing Assessment Includes fever, night sweats, cough with yellow mucoid sputum, anorexia, weight loss, malaise, fatigue, hemoptysis, dyspnea, pleuritic chest pain with inspiration. Diagnostics Include a positive acid-fast bacillus sputum culture and cavitation or calcification or Ghon tubercle on chest x-ray. A positive TB skin test is exhibited by an induration of 10mm or greater in diameter 48 hours after the skin test indicates exposure. Anyone who has received bacillus Calmette-Guerin (BCG) vaccine will have a positive skin test and must be evaluated with a chest x-ray. Nursing D agnosis Achieve Page 63

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