Primary Nursing Diagnosis

Ineffective airway clearance related to airway obstruction secondary to trauma and tissue damage

OUTCOMES. Respiratory status: Ventilation; Respiratory status: Gas exchange; Symptom control behavior; Comfort level; Infection status; Cognitive ability

INTERVENTIONS. Airway management; Airway insertion and stabilization; Airway suctioning; Artificial airway management; Oxygen therapy; Respiratory monitoring; Ventilatory assistance; Vital signs monitoring

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Antibiotics Analgesics

Varies with drug Varies with drug

Physicians may follow cultures of wounds, urine, blood, and sputum rather than use prophylactic antibiotics

IV morphine sulfate provides pain control and can be reversed with naloxone if complications occur

Protect from or combat bacterial infections

Reduce pain so that they increase mobility

Other Drugs: Patients with significant chest trauma causing a hemothorax may benefit by the placement of an epidural catheter for pain management. A tetanus booster is administered to patients with chest trauma whose immunization history indicates a need or whose history is unavailable.

Independent

The most critical nursing intervention is maintaining airway, breathing, and circulation. Have an intubation tray available in case endotracheal intubation and mechanical ventilation are necessary. Maintain a working endotracheal suction at the bedside as well. If the patient is hemody-namically stable, position the patient for full lung expansion, using the semi-Fowler position with the arms elevated on pillows. Because the cervical spine is at risk after injury, maintain body alignment and prevent flexion and extension by a cervical collar or by other strategies dictated by trauma service protocols.

If the patient is hemodynamically unstable, consider alternate positions but never place the adequacy of airway and breathing at risk. When the patient has inadequate circulation, consider

410 Hepatitis placing the patient flat with the legs raised if airway and breathing are adequate (usually when the patient is intubated and on mechanical ventilation). Trendelenburg's position is not recommended because it may increase the systemic vascular resistance and decrease the cardiac output in some patients, interfere with chest excursion by pushing the abdominal contents upward, and increase the risk of aspiration.

Establish adequate communication. The patient is likely to be very anxious, even fearful, for several reasons. If the hemothorax is the result of a chest trauma, the injury itself is unexpected and possibly quite frightening. The patient is experiencing pain and may not be receiving sedatives or analgesics until the pulmonary status stabilizes. The patient may have low oxygen levels, which lead to restlessness and anxiety. Remain with the patient at all times and reassure him or her until airway, breathing, and circulation have been stabilized.

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