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Diagnosa Ineffective airway clearence related to tracheobronchial obstruction as manifested by tissue oedema and stridor sound Definitions : Inability to secretion or obstruction from the respiratory tract to maintain airway patency
NOC
1. Respiratory
NIC
1. Cough
Status : Airway Patency Common expected Outcome : Patient secretion are mobilized and airway is free of execessive secretion, as evidenced by clear lung sounds, eupnea and inability to effectively cough up secretion after treatment and deep breath
enhancement: airway
2. Management :
patency
o Auscultate lungs
note quality, rate, rhytm, depth, flaring of nostril, dyspneu, use of accesory muscles and position for breathing
o Asses cough for
suctioning of the airway as determined by the present of adventitious sounds, increased peak airway pressure and visible secretion in the tubing Education / Continuity of Care
o Teach coughing,
on the warning sign as of impending or recurring pulmonary problem and their appropriate management
strategies 2. Ineffective Breathing Pattern related to tracheobronchial obstruction as manifested by stridor sounds Definitions Inspiration or expiration that does not provide adequate ventilation
1. Respiratory 1. Airway
Status : Ventilation ; vital signs status Common expected outcome : Patients breathing pattern is effectively maintained as evidenced by eupnea, normal skin color and minimal or no complains of dyspnea
breathing pattern
o Observ for
training as appropriate
o Use pain
oxygen therapy, including the type and use of equipment and why its maintainance is important 3. Impaired Gas Exchange related to altered blood flow as manifested by restlessness Definition :
1. Respiratory 1. Respiratory
Monitoring; Oxygen
Common expected Outcome : Patient maintanance optimal gas exchange as manifested by arterial blood gases (ABGs) witihn the patient usual range, alert responsive mentation or no further reduction and mental status, and no sign of respiratory distress
pulse oximetry) Therapeutic Intervention o 4. Ineffective peripheral tissue perfusion related to blockage of microcirculation as manifested by brain injury in chest, face, and hands area Definitions : Decrease in oxygen resulting in failure to nourish the tissues at capilarry refill
1. Circulation 1. Circulatory
Status : tissue perfussion ; peripheral Common expected Outcome : Patient maintain normal tissue perfussion to extremities, as evidenced by palpable pulses in all extremities, and normal sensation in extremity
temperature extremities
o Check for pain ,
alignment of extremity
o Apply sequential
range of motion Prepare for and assist with fasciotomy and escharotomy