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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 escharotomy