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Nursing Care Plan

Nursing Diagnosis Long Term Goal:


Ineffective Airway Clearance r/t tracheobronchial Patient will maintain a patent
obstruction airway

Short Term Goals / Outcomes:


Patients lungs sounds will be clear to auscultate
Patient will be free of dyspnea
Patient will demonstrate correct coughing and deep breathing techniques

Intervention Rationale Evaluation

Assess airway for Maintaining an airway is always top priority Patient is able to state their
patency by asking especially in patients who may have name without difficulty.
the patient to state experienced trauma to the airway. If a
his name. patient can articulate an answer, their
airway is patent.

Inspect the mouth, Foreign materials or blood in the mouth, No foreign objects, blood in
neck and position hematoma of the neck or tracheal mouth noted. Neck is free of
of trachea for deviation can all mean airway obstruction. hematoma. Trachea is midline.
potential
obstruction.

Auscultate lungs Decreased or absent sounds may indicate Patient’s lungs sounds are clear
for presence of the presence of a mucous plug or airway to auscultation throughout all
normal or obstruction. Wheezing indicates airway lobes.
adventitious lung resistance. Stridor indicates emergent
sounds. airway obstruction.

Assess respiratory Flaring of the nostrils, dyspnea, use of Patient is free of signs of
quality, rate, depth, accessory muscles, tachypnea and /or distress.
effort and pattern. apnea are all signs of severe distress that
require immediate intervention.

Assess for mental Increasing lethargy, confusion, restlessness Patient is awake, alert and
status changes. and / or irritability can be early signs of oriented X3.
cerebral hypoxia.

Assess changes in Tachycardia and hypertension occur with Patient is normotensive with
vital signs. increased work of breathing. heart rate 60 – 100 bpm.

Monitor arterial Increasing PaCO2 and decreasing PaO2 are ABGs show PaCO2 between 35-45
blood gases signs of respiratory failure. and PaO2between 80 – 100.
(ABGs).

Administer Early supplemental oxygen is essential in Patient is receiving oxygen.


supplemental all trauma patients since early mortality is SaO2 via pulse oximetry is 90 –
oxygen. associated with inadequate delivery of 100%.
oxygenated blood to the brain and vital
organs.

Position Patient Promotes better lung expansion and Patient’s rate and pattern are of
with head of bed improved gas exchange. normal depth and rate at 45
45 degrees (if degree angle.
tolerated).

Assist Patient with Assist patient to improve lung expansion, Patient is able to cough and deep
coughing and deep the productivity of the cough and mobilize breathe effectively.
breathing secretions.
techniques
(positioning,
incentive
spirometry,
frequent position
changes).

Prepare for If a patient is unable to maintain an Artificial airway is placed and


placement of adequate airway, an artificial airway will be maintained without
endotracheal or required to promote oxygenation and complications.
surgical airway (i.e. ventilation; and prevent aspiration.
cricothyroidectomy
, tracheostomy).

Confirm placement Complications such as esophageal and CO2 detector changes color,
of the artificial right main stem intubations can occur bilateral breath sounds are
airway. during insertion. Artificial airway audible equally and artificial
placement should be confirmed by CO2 airway is at the tip of the carina
detector, equal bilateral breath sounds and on x-ray.
a chest x-ray.

If maxillofacial The patient with maxillofacial trauma is Patient exhibits normal


trauma is present: usually more comfortable sitting up. Any respiratory rate and depth in
time there is trauma to the maxillofacial sitting position. Patient is free of
1. position the area there is the possibility of a wheezing, stridor and facial
patient for compromised airway. edema.
optimal
airway Noting swelling is important as a baseline
clearance for comparison later.
and
constant
assessment
of airway
patency
2. note the
degree of
swelling to
the face and
amount of
blood loss

3. prepare the
patient for
definitive
treatment

If neck trauma is Hemorrhage or disruption of the larynx and Patient is free of signs of
present: trachea can be seen as hoarseness in hemorrhage or disruption. CT
speech, palpable crepitus, pain with scan reveals no injury to the
swallowing or coughing, or hemoptysis. larynx.
1. assess for The neck should be also assessed for
potential ecchymosis, abrasions, or loss of thyroid
hemorrhage prominence.
and Laryngeal injuries are most definitely
disruption of diagnosed by CT scans as soft tissue neck
the larynx films are not sensitive to these injuries.
or trachea

2. prepare the
patient for
CT scan

Teach patient correct coughing and Deep breathing techniques.


Weak, shallow breathing and coughing is ineffective in removing secretions.
Patient is able to demonstrate correct coughing and breathing techniques.