Humber ITAL PN Nursing Care Plan Step 2 Analysis

Student Name: Christina Jakji____Date: _______ Week: __2____

All Medical Diagnosis: (Admission, Surgical, Other)
Anoxia, Scrotal Debris

Report Day 1:
Priority(s) Day 1: Maintaining open airway for proper ventilation.
Report Day 2:

Pertinent Data:
Low oxygen when
not on humidifier, or
when bed is laid flat.
Too much secretion
blocks airways.
Pertinent Data:

Priority(s) Day 2:
Nursing (Client) Problem (1):
Poor oxygen levels
Immediate Stimuli:
Trach tube
Contributory Stimuli:
Anoxia due to suicide attempt.
Nursing Diagnosis (1):
Pt has poor oxygen levels due to trach cause by suicide attempt.
Expected Outcome(s)

Target
Date(s)

1. Keep upright to prevent low 02 levels

2. Low 02 level if build up of secretions, be aware of amount.
3. ineffective ventilation if trach tube is not positioned correctly.
4. keep a humidifier to heat air.
5. body function is affected from insufficient amount of O2 in body
Nursing Interventions (Minimum 5)
1. Keep bed at appropriate position which is pt upright in high to semi fowlers.

QD
QD
QD
QD
QD

2.Keep pts trach in tact and all parts secure.

3.keep patient suctioned as many times as needed per day to promote clear airway.
4. Monitor pt frequently to ensure trach is clear so oxygen can flow through
5.Change trach equipment as per needed.
Community Resource: (related to clients needs)
Respiratory therapy.