Answer:
When assisting with the care of a client who is 2 days postoperative following the creation of a tracheostomy, the nurse should plan to take the following actions:
Assess the tracheostomy site: Check the tracheostomy site for signs of infection, such as redness, swelling, or discharge. Monitor for any signs of bleeding or excessive secretions.
Monitor respiratory status: Observe the client's respiratory rate, oxygen saturation levels, and ease of breathing. Auscultate lung sounds to assess for any abnormalities or signs of respiratory distress.
Suctioning: If necessary, perform tracheostomy suctioning to remove secretions and maintain a clear airway. Follow appropriate sterile technique and assess the client's response to suctioning.
Tracheostomy tube care: Cleanse the tracheostomy site and inner cannula (if applicable) according to facility protocols. Ensure proper alignment and securement of the tracheostomy tube to prevent accidental dislodgement.
Monitor vital signs: Assess the client's vital signs, including temperature, heart rate, and blood pressure. Changes in vital signs may indicate complications or infection.
Provide humidification: Ensure humidification of inspired air to prevent drying of the airway and promote comfort. This can be achieved by using a humidification system or providing warm, moistened air.
Encourage coughing and deep breathing: Teach and encourage the client to perform coughing and deep breathing exercises to promote lung expansion and prevent respiratory complications.
Positioning: Help the client find a comfortable position that promotes optimal breathing and facilitates drainage of secretions. Elevating the head of the bed may be beneficial.
Education and support: Provide education to the client and family members about tracheostomy care, signs of complications, and emergency management. Offer emotional support and address any concerns or questions they may have.
Collaboration with the healthcare team: Collaborate with the healthcare team, including respiratory therapists, to ensure coordinated care and address any specific needs or concerns of the client.
It is essential for the nurse to closely monitor the client's respiratory status, provide appropriate care, and promptly report any changes or concerns to the healthcare provider. By implementing these actions, the nurse can help ensure the client's safety, comfort, and recovery following the tracheostomy procedure.
Step-by-step explanation: