Primary Nursing Diagnosis

Risk for ineffective airway clearance related to unresponsiveness and inability to clear secretions

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level

INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suction-ing; Airway insertion and stabilization; Cough enhancement; Positioning; Respiratory monitoring

U PLANNING AND IMPLEMENTATION Collaborative

To maintain a patent airway, many patients require endotracheal intubation, oxygen therapy, and mechanical ventilation if gas exchange is impaired. One of the most important roles of the nurse and physician is ongoing neurological assessment. Using serial assessments, the healthcare team documents changes in the patient's condition and initiates proper care immediately. Pupil size and reaction, level of consciousness, strength and motion of the extremities, and the patient's response to noxious stimuli are all essential for patient assessment and management.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Antiviral agents

Adults: Acyclovir 10 mg/kg q 8 hr; Infuse IV over at least 1 hr for 7-10 days; Children: 250 mg/m2 q 8 hr; Infuse IV over at least 1 hr for 7-10 days; vidarabine (ARA-A) 15 mg/kg per day infused IV over 12 hr

Interferes with DNA synthesis and viral

Combat herpes simplex encephalitis

Independent

The maintenance of airway, breathing, and circulation is the foremost concern for the patient with encephalitis. If the patient is unable to clear secretions or maintain a patent airway as the disease progresses, notify the physician immediately, and prepare for endotracheal intubation. The family is likely to be anxious and need a great deal of support should intubation and mechanical ventilation be necessary. Once the airway is in place, maintaining an open airway with suctioning as needed is a primary nursing responsibility.

Always take into account patient safety, and weigh it against the possibility of the patient's further increase in intracranial pressure. Implement measures to limit the effects of immobility, such as skin care, range-of-motion exercises, and a turning and positioning schedule. Note the effect of position changes on intracranial pressure, and space activities as necessary.

The patient and significant others need assistance in learning about the disease process and treatments. The patient's behavioral and communication changes are often the most difficult to face and understand. Alterations can occur in thought processes when intracranial pressure begins to increase and the level of consciousness begins to decrease. Reorient the patient to time, place, and person as needed. Keep familiar objects or pictures around the patient. Allow visitation of significant others. Establish alternate means of communication if the patient is unable to maintain verbal contact (e.g., the patient who needs intubation).

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