NURSING CARE PLAN

Pre-operative

Nursing Diagnosis No. 1: Impaired Verbal Communication related to presence of

endotracheal tube

Objective Cues:

 Presence of endotracheal tube

 Unable to speak

General Objective: Establish method of communication in which needs could be understood

Specific Objective:After 30 minutes of nursing intervention patient will able to;

 Use alternative methods of communication.

 Have a satisfactory method of communication with the staff nurses as evidence by being

able to summon help and have needs met.

Nursing Intervention and Rationale:

1. Assess the client’s ability to communicate by alternative means

Rationale: to be able to assess patient needs

2. Pay attention to nonverbal cues and gestures.

Rationale: Patients may have specific gestures or cues they use to communicate.
3. Display proper speech etiquette.

Rationale: to avoid misunderstanding

4. Provide a writing pad, and pencil and use finger movements for “yes” or “no” responses.

Rationale: to help the patient express feeling and communicate needs.

5. Use short sentences, and ask only one question at a time.

Rationale: allows the patient to stay focused on one thought

6. Maintain a calm, unhurried manner. Provide sufficient time for the patient to respond

Rationale: to decrease patients frustration

7. Clarify your understanding of the patient’s communication with the patient

Rationale: Feedback promotes effective communication.

8. Place important objects within reach.

Rationale: To maximize the patient’s sense of independence.

Evaluation: Goals met. the patient used alternative method of communication and needs

were met.
Nursing Diagnosis No. 1: Ineffective airway clearance related to excessive accumulation of

secretion

Objective Cues:

 Crackles were heard upon auscultation.

Vital signs:

 Temperature:

 Respiratory rate

 Pulse rate

 Blood pressure:

 O2 Saturation

General Objective: To facilitate and maintain of oxygen supply to all body cells

Specific Objective: After 8 hours of nursing intervention patient will able to;

 The client will maintain clear, open airways, as evidenced by normal breath sounds after

suctioning.

 The client will be free of aspiration.

 The caregiver will identify potential complications and initiate appropriate actions.
Nursing Intervention and Rationale:

1. Assess vital signs especially respiratory status

Rationale: to serve as baseline data and determine further management

2. Auscultate the lungs 

Rationale: to determine the presence of normal or adventitious breath sounds.

3. Position patient in semi fowler

 Evaluation: Goals met. The client will maintain clear, open airways, as evidenced by

normal breath sounds after suctioning and free of aspiration and the caregiver identified

the potential complications and initiated appropriate actions.