Primary Nursing Diagnosis

Ineffective airway clearance related to respiratory muscle paralysis

OUTCOMES. Respiratory status: Gas exchange and ventilation; Safety status: Physical injury

INTERVENTIONS. Airway insertion; Airway management; Airway suctioning; Oral health promotion; Respiratory monitoring; Ventilation assistance

U PLANNING AND IMPLEMENTATION Collaborative

Report cases of botulism toxicity so that others can be protected from the illness. When botulism poisoning from ingestion is suspected, the patient's stomach is lavaged to remove any unab-sorbed toxin; a high colonic enema may also be administered for the same purpose. If impaired swallowing and chewing last longer than 72 hours, enteral feeding via a nasogastric (NG) or nasointestinal tube or total parenteral nutrition is instituted.

WOUND CARE. Infected wounds are explored and d├ębrided. Usually the physician prescribes antibiotics such as penicillin to kill bacteria in the wound, although the treatment with antibiotics is controversial.

SUPPORTIVE CARE. If respiratory paralysis occurs, intubation or tracheotomy and mechanical ventilation are essential to maintain airway and breathing. At least every hour, monitor the patient's breath sounds, placement, and position of the endotracheal tube; the respiratory rate and lung expansion; and the type and characteristics of secretions. A Foley catheter is inserted to monitor urinary output and prevent bladder distension.

Pharmacologic Highlights

Medication or

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