BSN3A – Group 3

NCM71 Assignment

1. Mary Par, 44 years of age, is a female patient who presents to the emergency
department with epistaxis. She has a bath towel saturated with bright red blood and
small clots. She is breathing through her mouth as she has her head tilted forward and
has direct pressure applied to the soft outer portion of the nose against the midline
septum using her thumb and index finger. She applied direct pressure for over 15
minutes and her nose will not stop bleeding. (Learning Objective 4)

a. What nursing management is needed for the patient?

 Have an ongoing assessment regarding airway patency and vital signs until the
condition is stabilized.
 Provide an emesis basin so the patient may expectorate excess blood into it.
 Blood loss on the bath towel can be frightening to the patient. Provide ongoing
emotional support to the patient.
 Assess the patient's history. Take note whether she had a traumatic event
leading to the epistaxis or a history of bleeding or clotting problems in the past,
and if the patient is taking anticoagulants, such as aspirin or warfarin, or any
herbal treatments, or if she has high blood pressure.
 Assist the emergency department physician in controlling the bleeding.
 Provide ordered medications and laboratories. The laboratories may include
hemoglobin and hematocrit and platelet count, PT, and PTT. The ordered
medications and interventions may include an IV infusion of normal saline,
replacement of platelets if the patient has thrombocytopenia, replacement of
clotting factors if low, and replacement of blood if low.
 On rare occasions, a patient may have a significant hemorrhage. If indicated,
assess the patient’s cardiac status via cardiac monitoring and oxygenation using
pulse oximetry.

b. What measures may be used to treat the epistaxis?

Management depends on its cause and the location of the bleeding site.
 The use of nasal speculum, penlight, or headlight may be used to identify the site
of bleeding in the nasal cavity.
 If the bleeding is from the anterior portion of the nose, apply direct pressure as
an initial treatment.
 Assist the patient to tilt her head forward and pinch the soft outer portion of the
nose against the septum for 5 to 10 minutes to prevent aspiration and swallowing
of blood.
 Application of nasal decongestant to act as a vasoconstrictor may be necessary.
 If visible bleeding sites are found but do not respond to the above treatment, they
may be cauterized with silver nitrate or electrocautery.
 Surgicel or Gelfoam patch to stop bleeding may be used.
 Alternatively, a cotton tampon may be used to stop the bleeding by direct
occlusion of localized vessels. Also, pack the nose with gauze with petroleum or
antibiotic ointment to decrease bleeding if unable to identify the bleeding vessel.
A topical anesthetic spray and decongestant agent may be used before the
gauze packing is inserted, or a balloon-inflated catheter may be used. The
packing may remain in place for 3 to 4 days if needed.

c. Once the bleeding is controlled and the underlying cause is identified, if

able and treated, what instructions should the nurse provide the patient?

Once the bleeding is controlled, the nurse instructs the patient to:
 Avoid vigorous exercise or bending over with her head down for the next several
days.
 Avoid hot or spicy foods or tobacco products because these products will lead to
an increased risk for bleeding.
 Avoid forceful nose blowing, straining or high altitudes, or nasal trauma.
 If a nose bleed occurs in the future, apply direct pressure to the nose as
previously done as presented to the emergency department, and if the bleeding
does not stop after 15 minutes, seek medical attention.
BSN3A – Group 3
NCM71 Assignment

Nursing Care Plan

Patient’s Code: Mary Par Age: 44 y/o Sex: F Civil Status: N/A Religion: N/A Date & Time of Admission: N/A Room: _ N/A
Attending Physician: None Chief Complaints: Nosebleed

Nursing Diagnosis (PES): Risk for bleeding related to deficient clotting as evidenced by bath towel saturated with heavy bright red blood and small clots.

Definition: Susceptible to a decrease in blood volume, which may compromise health.

Assessment/ Cues Planning Interventions Rationale Evaluation

(Subjective/ Objective) (Goals and Objectives)
Subjective Data At the end of my 8 hours of Independent The planned care was…
nursing care, the patient will be  MET
able to:
1. Dependent
As evidenced by:

Objective Data
> BBath towel saturated
with bright red blood and
small clots.
> Applied direct pressure
for over 15 minutes but will
not stop bleeding.
BSN3A – Group 3
NCM71 Assignment
BSN3A – Group 3
NCM71 Assignment

2. Donald Bark, a 55-year-old patient, is diagnosed with laryngeal cancer and is

scheduled for a total laryngectomy. He is in the outpatient department to receive patient
education and preadmission testing for the surgery scheduled next week. The patient is
a high school math teacher. He plans on retiring from the teaching career in 5 years. He
has already undergone radiation therapy. His voice is deep, raspy, and weak. He has a
long history of alcoholism and drinks two six-packs of beer every weekend. He recently
quit smoking cigarettes and has a two pack per day history for 35 years. The patient’s
life partner recently died. He lives by himself in a one-story home.

a. Using the nursing process as a framework, discuss the care the patient will
need?

Assessment – Vital signs (with a

strong focus on pulse oximetry
levels). Assess education level on
total laryngectomy. Asses how Mr.
Bark feels about the surgery.
Assess level of support system
client has
for after the surgery. Assess for
edema.
Diagnosis - Risk for ineffective
airway clearance. Risk for
infection.
Deficient Knowledge. Risk for
aspiration. Risk for impaired gas
exchange. Risk for impaired verbal
communication. Altered health
BSN3A – Group 3
NCM71 Assignment

maintenance due to alcohol

consumption and Hx of alcoholism
and
smoking.
Planning – Plan for pre surgery
routines (not eating after midnight,
lab
draws). Scheduling time to discuss
concerns and feelings throughout
the week leading up to surgery.
Arrange dietary consult to
determine
caloric requirements. Do not drink
or smoke in time leading up to
surgery and after.
Intervention- Assess respiratory
status (rate, pattern, lung sounds,
and cough effectiveness q2-4hrs).
Monitor quantity, color, and odor
of
BSN3A – Group 3
NCM71 Assignment

secretions. Assess VS (including

pain) q 2-4hrs. Administer
analgesics
as ordered. Monitor I&O and daily
weight. Educate on smoking and
alcohol cessation.
Evaluation- Mr. Bark reports pain
is controlled. Respiratory status is
stable. Clear breath sounds
throughout. Oxygen saturation of
94% or
higher. Client is afebrile and
expresses a desire to begin eating.
I&O’s
are stable. Weight is appropriate
and no drastic loss or gained noted.
Client is receptive to receiving
information about follow-up care.
Smoking and alcohol intake have
ceased.
Assessment – Vital signs (with a
strong focus on pulse oximetry
BSN3A – Group 3
NCM71 Assignment

levels). Assess education level on

total laryngectomy. Asses how Mr.
Bark feels about the surgery.
Assess level of support system
client has
for after the surgery. Assess for
edema.
Diagnosis - Risk for ineffective
airway clearance. Risk for
infection.
Deficient Knowledge. Risk for
aspiration. Risk for impaired gas
exchange. Risk for impaired verbal
communication. Altered health
maintenance due to alcohol
consumption and Hx of alcoholism
and
smoking.
Planning – Plan for pre surgery
routines (not eating after midnight,
lab
BSN3A – Group 3
NCM71 Assignment

draws). Scheduling time to discuss

concerns and feelings throughout
the week leading up to surgery.
Arrange dietary consult to
determine
caloric requirements. Do not drink
or smoke in time leading up to
surgery and after.
Intervention- Assess respiratory
status (rate, pattern, lung sounds,
and cough effectiveness q2-4hrs).
Monitor quantity, color, and odor
of
secretions. Assess VS (including
pain) q 2-4hrs. Administer
analgesics
as ordered. Monitor I&O and daily
weight. Educate on smoking and
alcohol cessation.
Evaluation- Mr. Bark reports pain
is controlled. Respiratory status is
BSN3A – Group 3
NCM71 Assignment

stable. Clear breath sounds

throughout. Oxygen saturation of
94% or
higher. Client is afebrile and
expresses a desire to begin eating.
I&O’s
are stable. Weight is appropriate
and no drastic loss or gained noted.
Client is receptive to receiving
information about follow-up care.
Smoking and alcohol intake have
ceased.
Assessment – Vital signs (with a
strong focus on pulse oximetry
levels). Assess education level on
total laryngectomy. Asses how Mr.
Bark feels about the surgery.
Assess level of support system
client has
for after the surgery. Assess for
edema.
BSN3A – Group 3
NCM71 Assignment

Diagnosis - Risk for ineffective

airway clearance. Risk for
infection.
Deficient Knowledge. Risk for
aspiration. Risk for impaired gas
exchange. Risk for impaired verbal
communication. Altered health
maintenance due to alcohol
consumption and Hx of alcoholism
and
smoking.
Planning – Plan for pre surgery
routines (not eating after midnight,
lab
draws). Scheduling time to discuss
concerns and feelings throughout
the week leading up to surgery.
Arrange dietary consult to
determine
caloric requirements. Do not drink
or smoke in time leading up to
surgery and after.
BSN3A – Group 3
NCM71 Assignment

Intervention- Assess respiratory

status (rate, pattern, lung sounds,
and cough effectiveness q2-4hrs).
Monitor quantity, color, and odor
of
secretions. Assess VS (including
pain) q 2-4hrs. Administer
analgesics
as ordered. Monitor I&O and daily
weight. Educate on smoking and
alcohol cessation.
Evaluation- Mr. Bark reports pain
is controlled. Respiratory status is
stable. Clear breath sounds
throughout. Oxygen saturation of
94% or
higher. Client is afebrile and
expresses a desire to begin eating.
I&O’s
are stable. Weight is appropriate
and no drastic loss or gained noted.
BSN3A – Group 3
NCM71 Assignment

Client is receptive to receiving

information about follow-up care.
Smoking and alcohol intake have
ceased.
Assessment – Vital signs (with a
strong focus on pulse oximetry
levels). Assess education level on
total laryngectomy. Asses how Mr.
Bark feels about the surgery.
Assess level of support system
client has
for after the surgery. Assess for
edema.
Diagnosis - Risk for ineffective
airway clearance. Risk for
infection.
Deficient Knowledge. Risk for
aspiration. Risk for impaired gas
exchange. Risk for impaired verbal
communication. Altered health
BSN3A – Group 3
NCM71 Assignment

maintenance due to alcohol

consumption and Hx of alcoholism
and
smoking.
Planning – Plan for pre surgery
routines (not eating after midnight,
lab
draws). Scheduling time to discuss
concerns and feelings throughout
the week leading up to surgery.
Arrange dietary consult to
determine
caloric requirements. Do not drink
or smoke in time leading up to
surgery and after.
Intervention- Assess respiratory
status (rate, pattern, lung sounds,
and cough effectiveness q2-4hrs).
Monitor quantity, color, and odor
of
BSN3A – Group 3
NCM71 Assignment

secretions. Assess VS (including

pain) q 2-4hrs. Administer
analgesics
as ordered. Monitor I&O and daily
weight. Educate on smoking and
alcohol cessation.
Evaluation- Mr. Bark reports pain
is controlled. Respiratory status is
stable. Clear breath sounds
throughout. Oxygen saturation of
94% or
higher. Client is afebrile and
expresses a desire to begin eating.
I&O’s
are stable. Weight is appropriate
and no drastic loss or gained noted.
Client is receptive to receiving
information about follow-up care.
Smoking and alcohol intake have
ceased.
The diagnosis of the patient is laryngeal cancer and the patient has
come for preoperative education for total laryngectomy. The care
needed for the patient on the basis of a nursing process are:

ASSESSMENT: Obtain a health history that focuses on his symptoms such as

hoarseness, sore throat, dyspnea, dysphagia, and pain or burning in the throat.
BSN3A – Group 3
NCM71 Assignment

Assess the patient’s physical domain which includes a thorough head and neck
examination. Palpate the neck and thyroid for swelling, nodularity, or adenopathy.
Assesses the patient’s general state of nutrition such as his height, weight and body
mass index. Review laboratory values that assist in determining the patient’s
nutritional status (albumin, protein, glucose, and electrolyte levels).

Since the treatment includes surgery, the nurse must know the nature of the surgery
to plan appropriate care. If the patient is expected to have no voice as a result of the
surgical procedure, a preoperative evaluation by the speech therapist is essential.
The patient’s ability to hear, see, read, and write is assessed. Visual impairment and
functional illiteracy may create additional problems with communication and may
require creative approaches to ensure that the patient is able to communicate any
needs. Because alcohol abuse is a risk factor for cancer of the larynx, the patient’s
pattern of alcohol intake must be assessed. Patients who are accustomed to daily
consumption of alcohol are at the risk for alcohol withdrawal syndrome (delirium
tremens) when alcohol intake is stopped suddenly. It is also not uncommon that
patients are active smokers at the time of diagnosis; assessment of readiness for
smoking cessation should be done, and nicotine replacements prescribed to avoid
nicotine withdrawal, as indicated.

In addition, the nurse assesses the psychological readiness of the patient and
family. The fear of a diagnosis of cancer is compounded by the possibility of
permanent voice loss and, in some cases, some degree of disfigurement. The nurse
evaluates the patient’s and family’s knowledge of the planned surgical procedure
and expected postoperative course and assesses their coping methods and support
systems. The nurse assesses the patient’s spirituality needs based on the patient’s
individual preferences, beliefs, and culture.

DIAGNOSIS:
- Deficient knowledge about the surgical procedure and postoperative course
- Anxiety related to the diagnosis of cancer and impending surgery
- Ineffective airway clearance related to excess mucus production secondary to
surgical alterations in the airway
- Impaired verbal communication related to anatomic deficit secondary to removal
of the larynx and to edema
- Imbalanced nutrition: less than body requirements, related to inability to ingest
food secondary to swallowing difficulties
- Disturbed body image and low self-esteem secondary to major neck surgery,
change in appearance, and altered structure and function
- Self-care deficit related to pain, weakness, fatigue, musculoskeletal impairment
related to surgical procedure and postoperative course

PLANNING:
The following are the major goals for the patient:
1. Attain adequate level of knowledge
2. Reduce anxiety
3. Maintain patent airway
4. Use of alternative means of communication effectively
5. Attain optimal levels of nutrition and hydration
6. Improve body image and self-esteem
7. Improved self-care management
8. Absence of complications

INTERVENTION:

Preoperative
1. Clarify any misconceptions by identifying the location of the larynx, its function,
the nature of the planned surgical procedure, and its effect on speech. Further,
the patient’s ability to sing, laugh, and whistle will be lost. Informational materials
(written and audiovisual) about the surgery should be given to the patient and
family for review and reinforcement.
BSN3A – Group 3
NCM71 Assignment

2. Since a total laryngectomy is planned, have the patient understand that the
natural voice will be lost, but that special training can provide a means for
communicating. Let the patient know that until training is started, communication
will be possible by using the call light, by writing, or by using a communication
device.
3. Provide the patient and family with opportunities to ask questions, verbalize
feelings, and discuss perceptions. Questions and misconceptions of the patient
and family should be addressed. Active listening provides an environment that
promotes open communication and allows the patient to verbalize feelings. Clear
instructions and explanations are given to the patient and family in a calm,
reassuring manner.
4. Review equipment and treatments for postoperative care with the patient and
family.
5. Teach important coughing and deepbreathing exercises and have the patient
perform return demonstrations.

Postoperative
1. Clarify the patient’s role in the postoperative and rehabilitation periods. The
family’s needs must also be addressed because family members are often
responsible for complex care of the patient in the home.
2. Position the patient in the semi-Fowler or Fowler position after recovery from
anesthesia. This position decreases surgical edema and promotes lung
expansion.
3. Assess the patient’s lung sounds and report changes that may indicate
impending complications. Medications that depress respiration, particularly
opioids, should be used cautiously. However, adequate use of analgesic
medications is essential for pain relief because postoperative pain can result in
shallow breathing and an ineffective cough.
4. Encourage the patient to turn, cough, and take deep breaths. If necessary,
suctioning may be performed to remove secretions, but disruption of suture lines
must be avoided.
5. Encourage and assist the patient with early ambulation to prevent atelectasis,
pneumonia, and venous thromboemboli formation (e.g., pulmonary embolism
and deep vein thrombosis).
6. Monitor the patient’s oxygen saturation level through the use of pulse oximetry.
7. Since a total laryngectomy was performed, a laryngectomy tube will most likely
be in place. In some instances a laryngectomy tube is not used; in others it is
used temporarily; and in many it is used permanently. The care of this tube is
similar to that for a tracheostomy tube.
8. Change the inner cannula (if present) every 8 hours if it is disposable. Although
nondisposable tubes are used infrequently, if one is used, clean the inner
cannula every 8 hours or more often as needed.
9. If a tracheostomy tube without an inner cannula is used, humidification and
suctioning of this tube are essential to prevent formation of mucus plugs.
10. If a T-shaped laryngectomy tube is used, both sides of the T-tube should be
suctioned to prevent obstruction due to copious secretions. Also, secure
tracheostomy ties to prevent tube dislodgement. Clean the stoma daily with soap
and water or another prescribed solution and a soft cloth or gauze, taking care to
prevent water and soap or solution from entering the stoma. If a non–oil-based
antibiotic ointment is prescribed, it is applied around the stoma and suture line. If
crusting appears around the stoma, the crusts are removed with sterile tweezers
and additional ointment is applied.
11. Observe, measure, and record drainage. When drainage is less than 30 mL/day
for 2 consecutive days, have the surgeon remove the drains. Wound drains,
inserted during surgery, may be in place to assist in removal of fluid and air from
the surgical site. Suction also may be used, but cautiously, to avoid trauma to the
surgical site and incision.
12. Reassure the patient that brassy-sounding, mucus-producing coughing will
diminish in time as the tracheobronchial mucosa adapts to the altered
physiology. Frequently, the patient coughs up large amounts of mucus through
this opening. Because air passes directly into the trachea without being warmed
and moistened by the upper respiratory mucosa, the tracheobronchial tree
BSN3A – Group 3
NCM71 Assignment

compensates by secreting excessive amounts of mucus. Therefore, the patient

has frequent coughing episodes and may develop a brassy-sounding, mucus-
producing cough.
13. After the patient coughs, wipe the tracheostomy opening and clear mucus. A
simple gauze dressing, washcloth, or even paper towel (because of its size and
absorbency) worn below the tracheostomy may serve as a barrier to protect the
clothing from the copious mucus that the patient may initially expel.
14. To understand and anticipate the patient’s postoperative needs, work with the
patient, speech therapist, and family to encourage the use of alternative
communication methods. These means of communication are established
preoperatively and must be used consistently by all personnel who come in
contact with the patient postoperatively. Thus, the patient must be given
adequate time to communicate their needs. The patient may become impatient
and angry when not understood.
15. Postoperatively, the patient may not be permitted to eat or drink for at least 7
days. Alternative sources of nutrition and hydration include IV fluids, enteral
feedings through a nasogastric or gastrostomy tube, and parenteral nutrition.
When the patient is ready to start oral feedings, a speech therapist or radiologist
may conduct a swallow study (a video fluoroscopy radiology procedure) to
evaluate the patient’s risk of aspiration.
16. Once the patient is cleared for oral feedings, Explain that thick liquids will be
used first because they are easy to swallow.
17. Encourage the patient to express feelings about the changes brought about by
surgery, particularly feelings related to fear, anger, depression, and isolation.
Encouraging the use of previous effective coping strategies may be helpful.
Referral to a support group may help the patient and family deal with the
changes in their lives. Information about these support groups can be found in
the Resource section at the end of the chapter.
18. Assess the patient’s readiness for decision making and encourage the patient to
participate actively in performing care.
19. Provide positive reinforcement when the patient makes an effort in self-care. The
nurse needs to be a good listener and a support to the family, especially when
explaining the tubes, dressings, and drains that are in place postoperatively.
20. Monitors the patient for signs and symptoms of respiratory distress and hypoxia,
particularly restlessness, irritation, agitation, confusion, tachypnea, the use of
accessory muscles, and decreased oxygen saturation on pulse oximetry (SpO2).
Any change in respiratory status requires immediate intervention.
21. Notify the surgeon of any active bleeding, which can occur at a variety of sites,
including the surgical site, drains, and trachea.
22. Monitor the patient for signs of postoperative infection. These include an increase
in temperature and pulse, a change in the type of wound drainage, and increased
areas of redness or tenderness at the surgical site. Other signs include purulent
drainage, odor, and increased wound drainage.
23. Monitor the patient’s white blood cell (WBC) count; a rise in WBCs may indicate
the body’s effort to combat infection.
24. Observe the stoma area for wound breakdown, hematoma, and bleeding and
report their occurrence to the surgeon.
25. Assesses for the presence of nausea and administers antiemetic medications, as
prescribed. Keep a suction setup available in the hospital and instructs the family
to do so at home for use if needed.

Recovery and Rehabilitation

1. Assess the patient’s readiness to learn and the level of knowledge about self-
care management.
2. Reassure the patient and family that most self-care management strategies can
be mastered. The patient needs to learn a variety of self-care behaviors,
including tracheostomy and stoma care, wound care, and oral hygiene.
3. Instruct the patient about the need for adequate dietary intake, safe hygiene, and
recreational activities.
4. Provide specific instructions to the patient and family about what to expect with a
tracheostomy and its management. Instruct the patient and caregiver how to
perform suctioning and emergency measures and tracheostomy and stoma care.
BSN3A – Group 3
NCM71 Assignment

Stress the importance of humidification at home and instruct the family to obtain
and set up a humidification system before the patient returns home.
5. Instruct the patient and family about safety precautions that are needed because
of the changes in structure and function resulting from the surgery. Special
precautions are needed in the shower to prevent water from entering the stoma.
Wearing a loose-fitting plastic bib over the tracheostomy or simply holding a hand
over the opening is effective. Swimming is not recommended because a person
with a laryngectomy can drown without submerging their face. Barbers and
beauticians need to be alerted so that hair sprays, loose hair, and powder do not
get near the stoma, because they can block or irritate the trachea and possibly
cause infection.
6. Refer for home, communitybased, or transitional care.

EVALUATION

At the end of the plan of care, the patient:

1. Demonstrates an adequate level of knowledge, verbalizing an understanding of

the surgical procedure and performing self-care adequately

2. Demonstrates less anxiety

a. Expresses a sense of hope
b. Is aware of available community organizations and agencies that provide
patient education and support groups
c. Participates in support group for people with a laryngectomy

3. Maintains a clear airway and handles own secretions; also demonstrates

practical, safe, and correct technique for cleaning and changing the tracheostomy or
laryngectomy tube

4. Acquires effective communication techniques

a. Uses assistive devices and strategies for communication (Magic Slate, call
bell, picture board, sign language, speech reading, handheld electronic devices)
b. Follows the recommendations of the speech therapist
c. Demonstrates ability to communicate with new communication strategy
d. Reports availability of prerecorded messages to summon emergency
assistance by telephone

5. Maintains adequate nutrition and adequate fluid intake

6. Exhibits improved body image, self-esteem, and self-concept

a. Expresses feelings and concerns
b. Participates in self-care and decision making
c. Accepts information about support group

7. Adheres to rehabilitation and home care program

a. Practices recommended speech therapy
b. Demonstrates proper methods for caring for stoma and laryngectomy or
tracheostomy tube (if present)
c. Verbalizes understanding of symptoms that require medical attention
d. States safety measures to take in emergencies
e. Performs oral hygiene as prescribed

8. Absence of complications
a. Demonstrates a patent airway
b. No bleeding from surgical site and minimal bleeding from drains; vital signs
(blood pressure, temperature, pulse, respiratory rate) are normal
c. No redness, tenderness, or purulent drainage at surgical site
d. No wound breakdown e. Clear breath sounds; oxygen saturation level within
acceptable range; chest x-ray clear
f. No indications of infection, stenosis, or obstruction of tracheal stoma
BSN3A – Group 3
NCM71 Assignment
BSN3A – Group 3
NCM71 Assignment

Nursing Care Plan

Patient’s Code: Donald Bark Age: 55 y/o Sex: M Civil Status: Married Religion: N/A Date & Time of Admission: N/A Room: _ N/A
Attending Physician: None Chief Complaints: Patient education and preadmission testing for total laryngectomy scheduled next week

Nursing Diagnosis (PES): Deficient knowledge related to surgical procedure and postoperative course of treatment.

Definition: Absence of cognitive information related to a specific topic, or its acquisition.

Assessment/ Cues Planning Interventions Rationale Evaluation

(Subjective/ Objective) (Goals and Objectives)
Subjective Data At the end of my 8 hours Independent The planned care was…
of nursing care, the  MET
patient will be able to:
1. Attain adequate level Dependent
of knowledge As evidenced by:
regarding the surgical
procedure and
postoperative course
of treatment.
2. Verbalize
Objective Data
BSN3A – Group 3
NCM71 Assignment