in need some to make Case study assignment

See agine the picture and will see how I need .. I want arrange the steps and I want the nursing intervention about the tracstomy and the rational and Compare with evidence .. so I need evey thing sample

first : introduction

2- brif history then vital sings

3- impact family

4- introduction about the tracstomy

5- the nursing intervention and rational about tracstomy

with compare with evidence

6- how to care and about the goal .. as soon as posiple will remove the tracstomy .

7- when you write about the conclusion you should not summarized , you should tell what you learn form patient and make a suggestion that’s it + add 1 refrencess more + no plagiarism please

8- make a title for every paragraph

This is the case study about patients within the critical care placement environment and under this case study I will talk about the care intervention of a patient with tracheostomy. I will explain how I took care of a patient with this condition in detail and what I learnt or discovered about patients of this nature.

The patient is Mr. Jone an 83-year-old male patient who was diagnosed with chronic illness. The patient was admitted on14-12-2018 due to acute pulmonary edema. The patient was diagnosed with stroke, HTN, Asthma and Tracheostomy. Later he was admitted to Gama hospital on 4/3/2018 for long-term unit.

When a serious illness attacks one member of a family, the entire family is affected by the disease process and the whole care practice. Since each person in a family plays an important role that is part of family’s normal operative. Due to this the illness of Mr. Jone illness was a blow to his family since the other family members had to adjust their lifestyle and take some of his roles. His illness caused extra stress economically since they had to carter for most of his hospital expenses and bills. His illness posed a psychological stress to his wife since by the look of things he was the only company she had. The children had to leave their respective residential areas to come to hospital frequently to be with their dad and comfort their mother which was not easy on their careers and families that required them too. Though there was a lot of stress for his family his illness brought them together and since they had been so busy with their careers and making both ends meet on their side all this other time, know they had to come together and figure out together on how to help their father. This wasn’t easy on any of the family member as all of them were uncertain of the fate of their loved one.

Patients with acute illness and more so of old age require intensive care which involves persistent attention by a team of trained specialists. Patients falling under this category need members in the ICU to work close to improve the patients care. Communication will help in error detection and good decision making. So, collaboration was the best care aspect that I found was best for me to help Mr. Jone.

Mr. Jone requires a critical review of his critical problems and a comprehensive assessment, reassessment, and evaluation of interdisciplinary care. He requires the provision of significant value by reduction of disintegration and improvement of care transition for him. His family also requires significant education which is a critical component. He needs to be made comfortable and to be taught his own personal hygiene. He also needs to forget his cravings and be guarded so that he cannot overeat and be prevented from eating before meals.

Mr. Jone requires a risk nursing diagnosis because of the hospital risks are likely to develop unless nurses intervene. For him being old he has high chances of acquiring other infections, therefore the label for risk infection is supposed to be used to describe the risk for infection so as to describe the patient's health status.

The nursing diagnosis that I identified and concentrated on is tracheostomy, this is a medical procedure that is either temporary or permanent, that pertains creating an opening in the neck in order to place a tube into a person's neck. This tube is implanted through a cut in the neck below the vocal cords. This allows air to pass through the tube, avoiding the mouth, nose, and throat. A tracheostomy is done for many reasons. It is commonly used in patients who require long mechanical ventilation, mainly to provide a more relaxed long-term airway and to enable weaning from ventilatory support (Brook, G, et al 2000).

The conditions that may require tracheostomy include anaphylaxis which is a severe allergic reaction to venom, food, or medication, birth defects of the way, diaphragm disfunction, chronic lung disease, coma, facial burns or surgery, infection, injury to the larynx, injury to the chest wall, need for prolonged respiratory or ventilator support, obstruction of the airway by a foreign body, obstructive sleep apnea paralysis of muscles used in swallowing, tumors, vocal cord paralysis and cancer in the neck (Huang, T. et al, 1963).

The patient to undergo tracheostomy will be told to prepare for the procedure. This may include fasting up to 12 hours before the procedure. Most scheduled tracheostomies are given a general anesthesia, which makes them fall asleep so as not to feel pain. In case, the patient case was an emergency he/she will be vaccinated with a local anesthesia. This anesthetizes the area of the neck where the whole is made. The procedure will start only after the anesthesia has begun working. The surgeon then makes a hole in the neck of the patient just below Adam's apple. The cut will go through the cartilage rings of the outer wall of the trachea. Then a wide enough hole is opened to fit a tracheostomy tube. The doctor may connect the tube to a ventilator in case the patient is needed to breathe through a machine. The tube needs to be secured with a tube encircling a patient's neck, this aids in keeping the tube in place while the skin around the wound heals (Ceriana, A, et al 2003).

The nurse and patient outcomes of tracheostomy are for the patient to stop suffering aspirations during his hospitalization, the patient to prove how to properly clear airway by discharge. The patient is supposed to report risk factors that are related to infection and perform proper safeguards when needed. On the side of Mr. Jone I had to be more careful in studying any risks since this was not the only illness he had so it needed more attention to know what exactly is disturbing him.

The main principles when looking after tracheostomy patients are based on maintaining a patient safety, easing communication and avoiding complications resulting from the procedure. Here airway is the sternest problem rising from a tracheostomy. It is a medical emergency and can lead to cardiac arrest (Woodrow, 2002). Patients with this condition should be taken care of with devotion in an area with operational oxygen and suction apparatus. Pulse oximetry should be used to monitor primary vital signs, mostly respiratory rate. Taking care of a tracheostomy patient one should be able to realize partial and total airway barrier and should contain the necessary skills to secure an airway in case it occurs.

In Mr.Jone, the tracheostomy was of an internal tube design, where there is large tube outside covering a small one on the inside. In this condition, if the partial or complete blocking is suspected the inner part is detached and a momentary spare inner tube will substitute the blocked one, thus creating a space. These spare tubes are supposed to be kept near the patient's space. Due to asthma, I examined him closely with proper consultancy to ensure that he didn’t suffer from tube blocking.

While I was doing this I also made sure that I washed my hands and applied alcohol gel before and after all actions. Also, I used a non-septic non-touch technique for all manipulations of the stoma. This was to avoid contaminating the tracheostomy tube and also protecting myself. The patient was required to be safe from all infections and the best way was for me to maintain cleanness since I handled the tube more often.

A tracheostomy avoids the ordinary upper airway mechanisms for humidification, purification, and warming of inhaled gases. Ander usual circumstances the point where air reaches 100% qualified humidity is just below the carina, but in a patient with tracheostomy this occurs in inferior breathing tract and can be further be occupied by the use of hazardous gases (Dawson, 2014). This gives rise to the high viscosity of mucous excretions, which depresses ciliary function; this may result in chest infections, reduced gas exchange, and atelectasis. Patients are characterized by dry coughs which was common on Mr. jone and it may be related to tracheitis, an inflammation of the tracheal lining that can become diseased resulting in ulceration of tracheal mucosa. So, if adequate humidification is not provided to take care of this issue it can lead to tracheostomy tube blockage. I used to check and mostly I administered Atrovent to him so as to relax the muscles in the respiratory system to increase airflow to the lungs.

Cuff monitoring is required at the start of each turn if a cuff seepage is overheard after any process where the tube might have moved position (Hess, 2005). Ischaemia can be caused by an over-inflated cuff which can result in the damage of the trachea whereas an under-inflated cuff may cause exhalations of gastric contents into the lungs and inhibit suitability of mechanical ventilation. Common causes of excessive cuff pressure include; small tracheostomy tube, poor tube placing and over-inflated cuff and lessened lung-compliance (St George's healthcare, 2012). Four methods have been proposed for specialist care of the cuff; subjective estimation of cuff pressure by palpation of the pilot balloon, minimal occlusion volume (MOV), cuff pressure measurement and minimum leak technique (Rose and Redl 2010).Mostly an old person like Mr. Jone seems to mostly suffer from this condition hence he requires close attention with frequent visits and monitoring to observe his condition all the time. With him struggling to move when he has tried it becomes a difficult task due to his old age and this could lead him to alter or twist the tube due to this he requires someone to always stay by his side. I was very careful about this having just learned how serious it can turn out to be if in any case the tracheostomy tube is adjusted.

Because Mr. Jone was not able to secrete his own emission i always assessed him for sputum in the airways (Mullet et al, 2013). The process called suctioning is supposed to be reserved for patients who are not able to secrete their own secretions. As the suction tube and suction pressure may have caused tracheal injury and may have found the process stressful (Sherlock et al 2009). Pre-oxygenate for 30–60 s particularly in those patients getting additional oxygen (AARC, 2010); in COPD patients this must be no more than 20% above zero (Day et al., 2002). I made sure that a non-fenestrated inner cannula was existing through suctioning. The suctioning tube was not more than half the ID of the tube.

The tracheostomy tube is supposed to be checked at least once daily for trauma, infection or inflammation and results documented in the wound chart (St Georges healthcare, 2012). inflamed stomas should be changed. The stoma should be cleaned using 0.9% saline and a small cut dressing applied to dress the tube. Where the skin of the stoma has upbraided a film-making acrylate block such as Cavilon can be applied locally to prevent further corrosion. This task requires two people and thus called a two-person technique since the tracheostomy must be detached to sufficiently clean and asses the tube. I ensured that the tracheostomy tube was effectively secured with a commercial tracheostomy holder. This prevented Mr. Jone from the pressure on the back of his neck and simply attuned. This helped Mr. Jone by maintaining his health and hygiene. It helped him to regain quicker and it made him comfortable.

Mr. Jone underwent a daily assessment of the mouth with the condition of the teeth, gums. Lips and mucous membranes (Berry et al. 2014). I did the oral inspection for Mr. Jone twice a day because he was not able to complete it for himself. I used a soft brush to brush both the surfaces of his teeth. And I gave him sterile water to rinse his mouth. This kept him free from bacteria that can cause infections by getting in touch with the tube. I taught him how to correctly cough and deep breathe throughout the hospitalization.

The patients of tracheostomy are subjected to loss of the ability to converse verbally which is a great frustration for these patients (Foster, 2010; Sherlock et al., 2009; Donnelly and Wiechula, 2006). The patient or the relatives should be made to understand that the patient might not be able to speak with the tracheostomy tube in place this is because the air is not passing through the vocal cords. This was applicable to Mr. Jone since members of his family because of worry wanted to listen and hear him talk, I had to explain to them as to why he was not able to speak and I reassured them of recovery. A one-way speaking valve or alternating finger blocking can be used to create a voice. In the conscious patients, different means of communication should be found using lip reading or electronic communication tools. One way speaking valve, if the patient tolerates tube occlusion then this method is applied so as to allow the patient breathing through the vocal cords, nose, and mouth. This may aid the patient to speak audibly. The duration of time the patient is able to bear a speaking valve will vary from one patient to the other and that can be the best known by observing the patient's work of breathing. For other patients’ tolerance will not pose a problem, others may have to create the time they use the valves starting with a few minutes. The intention is to create tolerance to enable the patient to use the valve continuously.

For patients who have suffered upper airway obstruction, decannulation cap might provide the clinician and the patient with better assurance prior to decannulation. This cap occludes the tube completely requiring the patients to breathe through their nose and mouth. It is not normal to use the cap for more than 4 hours as it increases the work of breathing. And may make the patient get tired frequently. For my patient, all this methods dint apply since he was old even in a normal situation he would not have spoken correctly in a hurry so we just used the lips to communicate which proved to be effective with him since he didn't have to speak.

Decannulation is supposed to be undertaken as soon as it is possible to minimize the risks accompanied by a long-term tube. However, it also avoids dangers such as airway blockage, exhalation, ventilatory failure, spectrum rendition and problem in oral retention.

The other main problem for patients with the tracheostomy is the incapability to swallow efficiently (Foster, 2010; Sherlock et al., 2009). Some manage oral intake without aspiring with the cuff overblown. In the normal situation, the cuff should be fully deflated, and a test of swallowing is introduced before oral intake is started. The risk of aspiration is highest in those patients with related or pre-existing neurological or mechanical sources of dysphagia, following head and neck surgery or in those ongoing significant breathing problems. Sips of sterile water should be given to the patient and if stood without coughing, desaturation or symptoms of aspiration on tracheal suctioning then the patient may eat and drink. Patients under the critical care unit are likely to have loosed appetite. A mixture of oral and enteral feeding may help inspire swallowing and appetite while preserving nutritional needs. If the patient does not swallow effectively he or she should be referred to speech and language professional for further evaluation (St. George Healthcare, 2012). Mr. Jone was one who had no appetite for any food, swallowing was difficult for him, so I offered to try the oral and internal feeding, which is still under progress I could say he has not improved that much but there are mild signs of improvement.

There are many stages of weaning procedure that can be attained over time. This stage may be achieved using the tube in situ. However, when there in situ sufficient oxygen then downsizing a tube may be of importance. There is no any indication that if airflow the nose or mouth be enough, then regularly reducing or changing to a fenestrated tube helps with weaning. I used Cuff deflation, I emptied the cuff using synchronous suction and depression to prevent the transfer of secretions at the top of the overblown cuff into the lungs.Gloved finger occlusion: Once Mr. Jone was able to endure insistent periods of cuff deflation, I applied a gloved towards the end of the tracheostomy tube to check the flow of air, flow within the tube and through the vocal cords to the nose and mouth. The finger being in the mouth I asked him to count to three. During obstruction, I monitored Mr. Jone for symptoms of distress if this occurs, but I had to abort the process since it caused obstruction. He experienced complications as a result old age, so I did not do many of the procedures. But he needed a close attention since he could not have done many of the tasks for himself. Breathing for him was hard due to asthma. So, the method of gloved finger occlusion would not do well in him.

As I stayed with Mr. Jone I realized he showed signs of trouble in breathing by breathing fast, pulling of skin between ribs when breathing, extreme fussiness, and restlessness and when this happened it is when I used to suction the tube. I taught his family on how to take care of him and since he was old he needed love and people being there for him. He required people to encourage him and to always speak words of hope. Reminding him of his happy moments.

This condition is distressful for an old person like Jone. All the time he was in the hospital wasn't easy for him due to his chronic illness and combination of illness. But with the care and close supervision, there was hope. Since I followed the rules and procedure of caring for patients with tracheostomy it really showed results. I used to train the family different methods to take good care of him and it gave me hope of prolonging his life.

References

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