Nursing diagnosis: risk for ineffective Airway Clearance
Risk factors may include
Tracheobronchial obstruction—mucosal edema and loss of ciliary action (smoke inhalation); circumferential full-thickness burns of the neck, thorax, and chest, with compression of the airway or limited chest excursion
Trauma—direct upper-airway injury by flame, steam, hot air, and chemicals or gases
Fluid shifts, pulmonary edema, decreased lung compliance
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Airway Patency
Demonstrate clear breath sounds, respiratory rate will be within normal range and be free of dyspnea and cyanosis.
Nursing intervention with rationale:
1. Obtain history of injury. Note presence of preexisting respiratory conditions and any history of smoking.
Rationale: Causative burning agent, duration of exposure, and occurrence in closed or open space predict probability of inhalation injury. Type of material burned, such as wood, plastic, or wool, suggests type of toxic gas exposure. Preexisting conditions increase the risk of respiratory complications.
2. Assess gag and swallow reflexes; note upper airway burns, drooling, inability to swallow, hoarseness, and wheezy cough.
Rationale: Suggestive of inhalation injury, which may develop over several days.
3. Monitor respiratory rate, rhythm, and depth; note presence of pallor or cyanosis and carbonaceous or pink-tinged sputum.
Rationale: Tachypnea, use of accessory muscles, presence of cyanosis, and changes in sputum suggest developing respiratory distress or pulmonary edema and need for medical intervention.
4. Auscultate lungs, noting stridor, wheezing, crackles, diminished breath sounds, and brassy cough.
Rationale: Airway obstruction and respiratory distress can occur very quickly or may be delayed, for example, up to 3 days after burn.
5. Note presence of pallor or cherry-red color of unburned skin.
Rationale: Suggests presence of hypoxemia or carbon monoxide.
6. Investigate changes in behavior and mentation, such as restlessness, agitation, and confusion.
Rationale: Although often related to pain, changes in consciousness may reflect developing, worsening hypoxia or effects of inhaled toxins, especially carbon monoxide.
7. Monitor 24-hour fluid balance, noting variations or changes.
Rationale: Fluid shifts or excess fluid replacement increases risk of pulmonary edema. Note: Inhalation injury increases fluid demands as much as 35% or more because of edema and fluid shifts.
8. Elevate head of bed. Avoid use of pillow under head, as indicated.
Rationale: Promotes optimal lung expansion and respiratory function. When head and neck burns are present, a pillow can inhibit respiration, cause necrosis of burned ear cartilage, and promote neck contractures.
9. Encourage coughing, deep-breathing exercises, and frequent position changes.
Rationale: Promotes lung expansion, mobilization, and drainage of secretions.
10. Suction, if necessary, with extreme care, maintaining sterile technique.
Rationale: Helps maintain clear airway, but should be done cautiously because of mucosal edema and inflammation. Sterile technique reduces risk of infection.