HomeChapter 8 Nursing Care Plan

Nursing Care PlanNursing DiagnosisIneffective Airway Clearance r/t tracheobronchial obstructionLong Term Goal:Patient will maintain a patent airway

Short Term Goals / Outcomes:Patients lungs sounds will be clear to auscultatePatient will be free of dyspneaPatient will demonstrate correct coughing and deep breathing techniques

InterventionRationaleEvaluation

Assess airway for patency by asking the patient to state his name.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.Patient is able to state their name without difficulty.

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

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

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

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

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

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

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

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

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

Prepare for placement of endotracheal or surgical airway (i.e. cricothyroidectomy, tracheostomy). If a patient is unable to maintain an adequate airway, an artificial airway will be required to promote oxygenation and ventilation; and prevent aspiration.Artificial airway is placed and maintained without complications.

Confirm placement of the artificial airway.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.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 clearance and constant assessment of airway patency2. note the degree of swelling to the face and amount of blood loss3. prepare the patient for definitive treatmentThe 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.

If neck trauma is present:1. assess for potential hemorrhage and disruption of the larynx or trachea2. prepare the patient for CT scanHemorrhage or disruption of the larynx and trachea can be seen as hoarseness in speech, palpable crepitus, pain with swallowing or coughing, or hemoptysis. The neck should be also assessed for ecchymosis, abrasions, or loss of thyroid prominence.Laryngeal injuries are most definitely diagnosed by CT scans as soft tissue neck films are not sensitive to these injuries.Patient is free of signs of hemorrhage or disruption. CT scan reveals no injury to the larynx.

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. Nursing DiagnosisImpaired Gas Exchange r/t altered oxygen supplyLong Term GoalPatient will maintain optimal gas exchange

Short Term Goals / Outcomes:Patient will maintain normal arterial blood gas (ABGs).Patient will be awake and alert.Patient will demonstrate a normal depth, rate and pattern of respirations.

InterventionsRationaleEvaluation

Assess respirations: quality, rate, pattern, depth and breathing effort.Rapid, shallow breathing and hypoventilation affect gas exchange by affecting CO2 levels. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention.Patient is free of signs of distress.ABGs show PaCO2 between 35-45Pts respirations are of a normal rate and depth.

Assess for life-threatening problems. (i.e. resp arrest, flail chest, sucking chest wound).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.Patient exhibits spontaneous breathing, no dyspnea, use of accessory muscles, resonance on percussion and no chest wall abnormalities.

Auscultate lung sounds. Also assess for the presence of jugular vein distention (JVD) or tracheal deviation.Absence of lung sounds, JVD and / or tracheal deviation could signify a Pneumothorax or Hemothorax.Patients lungs sounds are clear to auscultate throughout all lobes.

Assess for signs of hypoxemia.Tachycardia, restlessness, diaphoresis, headache, lethargy and confusion are all signs of hypoxemia.Patient is free of signs of hypoxia.

Monitor vital signs.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 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.Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure.ABGs show PaCO2 between 35-45 and PaO2 between 80 100.

Place the patient on continuous pulse oximetry.Pulse oximetry is useful in detecting changes in oxygenation. Oxygen saturation should be maintained at 90% or greater.SaO2 via pulse oximetry remains at 90 100%.

Assess skin color for development of cyanosis, especially circumoral cyanosis.Lack of oxygen delivery to the tissues will result in cyanosis. Cyanosis needs treated immediately as it is a late development in hypoxia.Patient is free of cyanosis.

Provide supplemental oxygen, via 100% O2 non-rebreather mask.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.Patient is receiving 100% oxygen. SaO2 via pulse oximetry is 90 100%.

Prepare the patient for intubation.Early intubation and mechanical ventilation are necessary to maintain adequate oxygenation and ventilation, prior to full decompensation of the patient.Artificial airway is placed and maintained without complications.

Treat the underlying injuries with appropriate interventions.Treatment needs to focus on the underlying problem that leads to the respiratory failure.Appropriate injury specific treatment has been started.

If rib fractures exist:1. Assess for paradoxical chest movements.2. Provide adequate pain 3. relief. Assess breath sounds.Paradoxical movements accompanied by dyspnea and pain in the chest wall indicate flail chest. Flail chest is a life-threatening 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.No paradoxical movements are noted.Patient reports pain as 90% during suctioning.

Pace activities and provide rest periods to prevent fatigue.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.

Nursing DiagnosisDeficient Fluid Volume r/t active fluid loss due to bleedingLong Term GoalPatient will maintain adequate fluid and electrolyte balance.

Short Term Goals / Outcomes:Patient will maintain urine output >30cc/hr.Patient will be normotensive with heart rate 60 -100bpm.Patient will demonstrate normal skin turgor.

InterventionsRationaleEvaluation

Palpate pulses: carotid, brachial, radial, femoral, popliteal and pedal. Note quality and rate.If carotid and femoral pulses are palpable, then the blood pressure is usually at least 60 80 mmHg systolic. If peripheral pulses are present, the blood pressure is usually higher than 80 mmHg systolic. Pulses may be weak and irregular.All pulses palpable, strong and regular.

Assess skin color and temperature.Cool, pale, diaphoretic skin suggests ineffective circulation due to hypovolemia.Skin pink, warm and dry.

Monitor patient for active blood loss from wounds, tubes, etc. Control any external bleeding.Active fluid and/or blood loss adds to Hypovolemic state and must be accounted for when replacing fluids.All external bleeding controlled.

Monitor vital signs. (T,P,R,B/P)Sinus tachycardia may occur with hypovolemia to maintain cardiac output. Hypotension is a hallmark of hypovolemia. Febrile states decrease body fluids through perspiration and increase respiratory rate.Vital signs within normal limits.

Monitor blood pressure for orthostatic changes.Greater than 10 mmHg drop signifies that circulating volume is reduced by 20%. Greater that 20 30 mmHg drop signifies blood volume is decreased by 40%.No orthostatic changes noted when patient placed from supine to Fowlers position.

Auscultate heart tones and inspect jugular veins.Abnormally flattened jugular veins and distant heart tones are signs of ineffective circulation.S1, S2 audible. No flattening or distention of jugular vein noted.

Assess mental status.Loss of consciousness accompanies ineffective circulating blood volume to the brain.Awake, alert and oriented X3.

Assess skin turgor over the sternum or inner thigh; and assess moisture and condition of mucous membranes.Dry mucous membranes and tenting of the skin are signs of hypovolemia. The sternum and inner thigh should be used for skin turgor due to loss of elasticity with aging.Normal skin turgor. Mucous membranes pink and moist.

Assess color and amount of urine.Concentrated urine and output