Question

A 65-year-old male was admitted for evaluation of pain on swallowing and a sore throat that has persisted for the past year. The discomfort has not changed with the use of various over the counter cold remedies. The client has lost weight due to a decrease in appetite and difficulty swallowing. He has smoked 3 packs of cigarettes a day for 40 years.

A laryngoscopy showed a subglottic mass. The client had a total laryngectomy with a tracheostomy to manage laryngeal cancer. He also has a nasogastric tube in place.

You will be providing care for this client during his first 72 hours after surgery.

Initial Discussion Post:

There are multiple nursing diagnoses that are applicable to this client during the time when you will be providing care.

Select one NANDA-I nursing diagnosis and describe why it is a priority for this client.

What is the cause or related factor for this NANDA-I nursing diagnosis?

Identify an outcome for this NANDA-I nursing diagnosis. The outcome must be patient-centered and measurable.

Identify two (2) nursing interventions that will help this client achieve the outcome.

Describe how each intervention will help the patient achieve the outcome.

Answer 1

Nursing Diagnosis:

Risk for ineffective airway clearance related to post operative edema

Cause or related factor:

Post surgery and the risk factor for getting infections

Outcome:

To maintain clear airway and lung sounds

Nursing intervention:

Assessment on respiratory rate, lung sounds, effectiveness of cough for every 4 hours- It helps to identify the patients problem before getting any complications

Monitor quantity, colour, odour of secretions- It helps to assess the patients infection status and effectiveness of cough