N o. 1.

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 :

Airway Suctioning 0ngoing Assesment :

o Asses airway for

patency
o Auscultate lungs

for present of adventitious breath sound

o Asses respiration :

note quality, rate, rhytm, depth, flaring of nostril, dyspneu, use of accesory muscles and position for breathing
o Asses cough for

effectiveness and productivity Therapeutic Interventions

o Assist the patient

in performing coughing and breathing manuevers

o Institute

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,

breathing and splinting technique

o Instruct the patient

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

Management ; Respiratory Monitoring 0ngoing Assesment :

o Asses respiratory

rate, rhytm, depth

o Asses for the

quality, duration, intensity, and distress assosiated with dispnea

o Asses nutritional

status (e.g weight, albumin and electrolyte level)

o Monitoring

breathing pattern
o Observ for

excessive use acessory muscles.

o Monitor for

diagframatic muscle fatigue or weakness Therapeutic Intervention :

o Position the

patient with proper body alignment for optimal breathing pattern

o Encourage the

patient to clear his / her own secretion with effective cough

o Provide relaxation

training as appropriate
o Use pain

management as appropriate Education / Continuity of Care

o Explain use of

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

Status : Gas Exchange

Monitoring; Oxygen

Excess or deficient in oxygention and or carbondioxide elimination alveolar capilary membran

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

Therapy ; Airway Management Ongoing Assesment

o Asses respiration :

note quality, rate, rhytm, depth and breathing effort

o Asses lung sound,

noting area of decrease ventilation and the present of adventitious sounds

o Asses for

tachycardia, restlessness, diaphoresis, headache, visual disturbance and confusion

o Asses skin color

for development cyanosis

o Monitor effects of

position change on oxygenation (ABGs, SVO2 and

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

Care ; Vital Sign monitoring Ongoing assesment :

o Asses for signs of

decrease peripheral tissue perfusion like cold extremity.

o Monitor vital

signs: BP,HR, and RR for abrupt change

o Asses color and

temperature extremities
o Check for pain ,

numbness, swelling of extremities Therapeutic Intervention

o Maintain good

alignment of

extremity
o Apply sequential

compression device on non burned extremities

o Perform passive

range of motion Prepare for and assist with fasciotomy and 5 Impaired skin integrity related to mechanical force (friction, shear, pressure) 1. Tissue Integrity : Skin and Mucous membrane 2. Wound healing : Primary intentions 3. Wound healing : secondary intentions escharotomy 1. Wound Care; Infection Protection; Teaching: Prescribed Medication

Ongoing Assesment a.Determine the etiology of tissue damage. b. Assess the patients level of discomfort c.Identify signs of itching and scratching d. Assess the patients nutritional status, including weight, weight loss, and serum albumin level if ordered e. assess for environmental moisture (wound

Common Expected Outcome: Condition in impaired tissue improves as evidenced by decreased redness, swelling and pain

drainage, excessive perspiration, high humidity) f. assess skin on admission and daily for increasing number of risk factors g. assess the condition of surrounding tissue. Therapeutic Intervention a.Cleanse with normal saline or a non toxic cleanser, as appropriate b. Maintain sterile dressing technique during wound care. c.Initiate pressurerelieving devices as needed and improve circulation to painful area d. Administered antibiotic as ordered Education/ Continuity of Care a.Teach patient or caregiver about cause of tissue integrity impairment b. Instruct the patient or caregiver in proper care of wound c.Teach patient or

6.

Risk for infection related to inadequate primary defences: broken skin as manifested by open punctum scissum Definitions : at increased for being invaded by pathogenic organism

Imune status; knowledge: infection control 1. Patient remains free of local or system infection, as evidenced by absence of copious, foulsmelling wound exudates. 2. patient maintains normal body temperature 3. infection is recognize early to allow for prompt treatment

caregiver about sign and symptoms of infection and when to notify the physician or nurse d. Teach the patient or caregiver pain control measures Infection control; infection protection Ongoing assesment 1. assess punctun scissum for drainage, color of tissue and odor 2. assess nutritional status 3. monitorsign of infection: temperature, redness, increase pain, swelling, purullen drainage Therapeutic intervention 1. maintain or teach a sepsis for dressing changes and wound care 2. provide wound care as prescribed 3. obtain wound culture if available 4. monitor WBC

count Education or continuity of care 1. teach the patient and caregiver the sign and symptoms infection and when to report this to the physician and nurse 2. administer antibiotic as prescribed

N o

Nursing Diagnosa

NOC

NIC

7. Acute pain related to pain resulting from trauma as manifest by patient report pain

Comfort level; Analgesic medication response; administration; pain control conscious sedation; pain management; Common expected pain controlled outcome: patient analgesia assistance verbalize adequate relief of pain or Ongoing assessment ability to cope with incompletely relieved a. asses pain characteristics : pain quality, severity, locatition, onset, duration, precipitating or

relieving factors b. observe or monitor signs and symptoms associated with pain, blood pressure, HR, temperature, colour and moisture of skin, restlessness and ability to focus. c. Asses to what degree cultural, environtmental, interpersonal and intraphysics factors may contribute to pain or pain relief d. Monitor the patient for changes in general condition that may herald need for change in pain relief methods. e. Numbness, tingling in extremities. Therapeutic intervention a. anticipate need for pain relief b. eliminate additional stressor

or resources of discomfort whenever possible c. Give analgesic as ordered d. Determine the appropriate pain relief method: pharmacological and non pharmacological. Education/continuity of care a.instruct the patient to report pain b. instruct the patient to evaluate effectiveness of measure used c. teach the patient effective timing of medication dose in relation to potentially uncomfortable activities and prevention of peak pain period