Situation: You are assigned to care for Mrs. Penny Lane, a 25-year-old woman with a tracheostomy.

Background: The night shift nurse gives you a report on Mrs. Lane that the patient was transferred from the PCU yesterday afternoon. She has had the tracheostomy for 2 weeks and is stable enough to be on humidified room air. Mrs. Lane has a nasogastric tube in because she refused to have the Percutaneous Endoscopic Gastrostomy (PEG) tube placed as the tracheostomy tube was her husband's decision, not hers. At the time the tracheostomy was placed, she was having an anaphylactic reaction with severe angioedema and could not speak for herself. She is receiving Jevity 1.5 tube feedings via the NG tube at 55 mL/hour as ordered by the dietician to meet her caloric needs.

Assessment: She is awake, alert, and oriented to person and place; however, she is unsure what the date is. Her lungs are clear but diminished throughout. She has a course cough with thick, yellowish sputum from her tracheostomy. You also note that her tongue has furrows and appears dry. Her abdomen is soft, round, with slightly hyperactive bowel sounds. She has no peripheral edema and has strong pulses throughout. When you check her skin turgor you note that she has tenting of her skin on the back of her hand. She is continent of urine and voids without difficulty. You roll her over to check her backside and notice that she has been incontinent for a small amount of liquid brown stool. Her vital signs are as follows: HR - 96, BP 114/70 (85), RR - 20, T - 97.5 F (36.4 C), Oxygen saturation of 90% on room air. You finish your assessment and are about to leave the room to get fresh linen when she starts coughing uncontrollably and starts to turn blue. Her oxygen saturation drops to 85%.

Points to assess: Is this Acute or Chronic? Is the patient Unstable or Stable? Is this Urgent or Nonurgent?

Recommendations:

What do you think are the primary alterations in health with this patient (diagnosis)?

What is the pathophysiology related to the patient's problems?

What are the risk factors for this patient, and do they contribute to the current primary problem?

What assessment(s) (expected finding) should be your focus? (Hint: Identify the relevant information first to determine what is most important.) What signs and symptoms are commonly seen with this diagnosis?

What data should you analyze (laboratory and diagnostic procedures) and report to the health care provider? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.)

What would your plan (nursing care) and recommendation(s) be to the health care provider? (Hint: Consider all possibilities and determine their urgency and risk for this client.)

What intervention(s) (therapeutic procedures and/or medications) would be your priority with this patient? (Hint: Determine the desired outcome first to decide which interventions are appropriate and those that should be avoided.) Which intervention would be best for this patient?

What data/clinical information would you evaluate to support the plan to improve the patient's outcome? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.) What changes to the patient's condition would I expect to see happen or have happened?

What can be done to thin out her secretions?

What is a furrowed tongue and skin tenting an indication of?

How often should someone with a tracheostomy be suctioned?

How often should tracheostomy care be performed?

What do you inspect when doing tracheostomy care?

What should you document after suctioning and tracheostomy care?

What should be at the patient's bedside at all times?

What medications may be added to thin her secretions?

What is the mechanism of action of the medication(s) used to thin secretions?

What can be added to her tube feedings to increase her fluid intake?

How often should oral care be done?

What is the worst possible/most likely complication(s) to anticipate based on the primary problem (to prevent death)?

What nursing assessments/interventions will assist you in identifying this complication EARLY if it develops?