Vous êtes sur la page 1sur 4

Nursing Diagnosis Ineffective Airway Clearance r/t tracheobronchial obstruction 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 Assess airway for patency by asking the patient to state his name. Inspect the mouth, neck and position of trachea for potential obstruction. Auscultate lungs for presence of normal or adventitious lung sounds. Assess respiratory quality, rate, depth, effort and pattern. Assess for mental status changes. Assess changes in vital signs. Monitor arterial blood gases (ABGs). Administer supplemental oxygen. Decreased or absent sounds may indicate the presence of a mucous plug or airway obstruction. Wheezing indicates airway resistance. Stridor indicates emergent airway obstruction. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention. Increasing lethargy, confusion, restlessness and / or irritability can be early signs of cerebral hypoxia. Tachycardia and hypertension occur with increased work of breathing. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. Early supplemental oxygen is essential in all trauma patients since early mortality is associated with inadequate delivery of oxygenated blood to the brain and vital organs. Position Patient with head of bed 45 degrees (if tolerated). Assist Patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes). Prepare for placement of endotracheal or surgical airway (i.e. cricothyroidectomy, tracheostomy). Confirm placement of the artificial airway. If a patient is unable to maintain an adequate airway, an artificial airway will be required to promote oxygenation and ventilation; and prevent aspiration. Complications such as esophageal and right main stem intubations can occur during insertion. Artificial airway placement should be confirmed by CO2 detector, equal bilateral breath sounds and a chest x-ray. Assist patient to improve lung expansion, the productivity of the cough and mobilize secretions. Promotes better lung expansion and improved gas exchange. Rationale Maintaining an airway is always top priority especially in patients who may have experienced trauma to the airway. If a patient can articulate an answer, their airway is patent. Foreign materials or blood in the mouth, hematoma of the neck or tracheal deviation can all mean airway obstruction.

Long Term Goal: Patient will maintain a patent airway

Evaluation Patient is able to state their name without difficulty.

No foreign objects, blood in mouth noted. Neck is free of hematoma. Trachea is midline.

Patients lungs sounds are clear to auscultation throughout all lobes.

Patient is free of signs of distress.

Patient is awake, alert and oriented X3. Patient is normotensive with heart rate 60 100 bpm. ABGs show PaCO2 between 35-45 and PaO2 between 80 100. Patient is receiving oxygen. SaO2 via pulse oximetry is 90 100%.

Patients rate and pattern are of normal depth and rate at 45 degree angle.

Patient is able to cough and deep breathe effectively.

Artificial airway is placed and maintained without complications.

CO2 detector changes color, bilateral breath sounds are audible equally and artificial airway is at the tip of the carina on x-ray.

If maxillofacial trauma is present: 1. position the patient for optimal airway Nursing Diagnosis clearance and constant assessment of airway Impaired Gas Exchange r/t altered oxygen supply patency Short2. note the/ degree of swelling to the face and Term Goals Outcomes: amount of blood arterial blood gas (ABGs). Patient will maintain normalloss 3. prepare the patient for Patient will be awake and alert. definitive treatment

The patient with maxillofacial trauma is usually more comfortable sitting up. Any time there is trauma to the maxillofacial area there is the possibility of a compromised airway. Noting swelling is important as a baseline for comparison later.

Patient exhibits normal respiratory rate and depth in sitting position. Patient is free of wheezing, stridor and facial edema. Long Term Goal Patient will maintain optimal gas exchange

Patient will demonstrate a normal depth, rate and pattern of respirations. If neck trauma is present: Interventions Assess respirations: quality, rate, pattern, depth and 1. assess for potential hemorrhage and breathing effort. disruption of the larynx or trachea 2. prepare the patient for CT scan Hemorrhage or disruption of the larynx and trachea can be seen as hoarseness in speech, palpable crepitus, pain with Patient is free of signs of hemorrhage or disruption. CT scan reveals no injury to the Rationale Evaluation swallowing or coughing, or hemoptysis. The neck should be also assessed for ecchymosis, abrasions, or loss of thyroid larynx. Rapid, shallow breathing and hypoventilation affect gas exchange by affecting CO 2 levels. Flaring of the nostrils, dyspnea, Patient is free of signs of distress. prominence. use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention. ABGs show PaCO2 between 35-45 Laryngeal injuries are most definitely diagnosed by CT scans as soft tissue neck films are not sensitive to these injuries. Pts respirations are of a normal rate and depth. Absence of ventilation, asymmetric breath sounds, dyspnea with accessory muscle use, dullness on chest percussion and gross chest wall instability (i.e. flail chest or sucking chest wound) all require immediate attention. Absence of lung sounds, JVD and / or tracheal deviation could signify a Pneumothorax or Hemothorax. Patient exhibits spontaneous breathing, no dyspnea, use of accessory muscles, resonance on percussion and no chest wall abnormalities. Patients lungs sounds are clear to auscultate throughout all lobes.

Assess for life-threatening problems. (i.e. resp arrest, flail chest, sucking chest wound). Auscultate lung sounds. Also assess for the presence of jugular vein distention (JVD) or tracheal deviation. Assess for signs of hypoxemia. Monitor vital signs.

Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all signs of hypoxemia. Initially with hypoxia and hypercapnia blood pressure (BP), heart rate and respiratory rate all increase. As the condition becomes more severe BP may drop, heart rate continues to be rapid with arrhythmias and respiratory failure may ensue.

Patient is free of signs of hypoxia. Patient is normotensive with heart rate 60 100 bpm and respiratory rate 10-20.

Assess for changes in orientation and behavior.

Restlessness is an early sign of hypoxia. Mentation gets worse as hypoxia increases due to lack of blood supply to the brain.

Patient is awake, alert and oriented X3.

Monitor ABGs. Place the patient on continuous pulse oximetry. Assess skin color for development of cyanosis, especially circumoral cyanosis. Provide supplemental oxygen, via 100% O2 nonrebreather mask. Prepare the patient for intubation.

Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. Pulse oximetry is useful in detecting changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia. Early supplemental oxygen is essential in all trauma patients since early mortality is associated with inadequate delivery of oxygenated blood to the brain and vital organs. Early intubation and mechanical ventilation are necessary to maintain adequate oxygenation and ventilation, prior to full decompensation of the patient.

ABGs show PaCO2 between 35-45 and PaO2 between 80 100. SaO2 via pulse oximetry remains at 90 100%. Patient is free of cyanosis.

Patient is receiving 100% oxygen. SaO2 via pulse oximetry is 90 100%.

Artificial airway is placed and maintained without complications.

Treat the underlying injuries with appropriate

Treatment needs to focus on the underlying problem that leads to the respiratory failure.

Appropriate injury specific treatment has been started.

interventions. If rib fractures exist: 1. 2. 3. Assess for paradoxical chest movements. Provide adequate pain relief. Paradoxical movements accompanied by dyspnea and pain in the chest wall indicate flail chest. Flail chest is a lifethreatening complication of rib fractures that requires mechanical ventilation and aggressive pulmonary care. Pain relief is essential to enhance coughing and deep breathing. Absence of bilateral breath sounds in the presence of a flail chest, indicates a pneumo/hemo thorax. Assess breath sounds. If Pneumothorax or Hemothorax exist: 1. 2. obtain chest x-ray prepare for insertion of a chest tube A chest x-ray confirms the presence of a Pneumothorax and / or Hemothorax. A chest tube decreases the thoracic pressure and re-inflates the lung tissue. Chest tube is placed and connected to 20cm wall suction with good tidaling and no air If open Pneumothorax exists place a dressing that is taped on three sides for temporary management. A three sided dressing gives the accumulated air a way to escape, thereby decreasing thoracic pressure and preventing a tension Pneumothorax. A chest tube must then be inserted. Three-sided dressing maintained. No further cardiopulmonary decompensation noted in patient. Position patient with head of bed 45 degrees (if tolerated). Assist patient with coughing and deep breathing techniques (positioning, incentive spirometry, frequent position changes, splinting of the chest). Suction patient as needed. Suctioning aides to remove secretions from the airway and optimizes gas exchange. Patient suctioned for moderate amount of thin yellow secretion. Lung sounds clear after suctioning. Hyperoxygenate patient with 100% before and after suctioning. Keep suctioning to 10-15 seconds. Pace activities and provide rest periods to prevent fatigue. 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. Even simple activities, such as bathing, can increase oxygen consumption and cause fatigue. No changes to cardiopulmonary status noted during activity. Patients SaO2 remains >90% during activities. Prevents alteration in oxygenation during suctioning. Patients SaO2 remained >90% during suctioning. Promotes alveolar expansion and prevents alveolar collapse. Splinting helps reduce pain and optimizes deep breathing and coughing efforts. Patient is able to cough and deep breathe effectively. Promotes better lung expansion and improved gas exchange. Patients rate and pattern are of normal depth and rate at 45 degree angle. leak or SQ emphysema noted. No paradoxical movements are noted. Patient reports pain as <3 on 0-10 scale. Bilateral breath sounds present in all lobes.