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NURSING DIAGNOSIS: Airway Clearance, risk for ineffective
Risk factors may include
- Tracheal obstruction; swelling, bleeding, laryngeal spasms
Possibly evidenced by
- [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Desired Outcomes
- Respiratory Status: Airway Patency (NOC)
- Maintain patent airway, with aspiration prevented.
5 Thyroidectomy Nursing Care Plan (NCP)
- Acute Pain — Thyroidectomy Nursing Care Plan (NCP)
- Ineffective Airway Clearance — Thyroidectomy Nursing Care Plan (NCP)
- Impaired Verbal Communication — Thyroidectomy Nursing Care Plan (NCP)
- Risk for Injury — Thyroidectomy Nursing Care Plan (NCP)
- Knowledge Deficit — Thyroidectomy Nursing Care Plan (NCP)
Ineffective Airway Clearance — Thyroidectomy Nursing Care Plan (NCP): Nursing Interventions & Rationale
| Nursing Interventions | Rationale |
| Monitor respiratory rate, depth, and work of breathing. | Respirations may remain somewhat rapid, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage |
| Auscultate breath sounds, noting presence of rhonchi. | Rhonchi may indicate airway obstruction/accumulation of copious thick secretions. |
| Assess for dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice. | Indicators of tracheal obstruction/laryngeal spasm, requiring prompt evaluation and intervention. |
| Caution patient to avoid bending neck; support head with pillows. | Reduces likelihood of tension on surgical wound. |
| Assist with repositioning, deep breathing exercises, and/or coughing as indicated. | Maintains clear airway and ventilation. Although “routine” coughing is not encouraged and may be painful, it may be needed to clear secretions. |
| Suction mouth and trachea as indicated, noting color and characteristics of sputum. | Edema/pain may impair patient’s ability to clear own airway. |
| Check dressing frequently, especially posterior portion. | If bleeding occurs, anterior dressing may appear dry because blood pools dependently. |
| Investigate reports of difficulty swallowing, drooling of oral secretions. | May indicate edema/sequestered bleeding in tissues surrounding operative site. |
| Keep tracheostomy tray at bedside. | Compromised airway may create a life-threatening situation requiring emergency procedure. |
| Provide steam inhalation; humidify room air. | Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions. |
| Assist with/prepare for procedures, e.g.: Tracheostomy;Return to surgery. |
May be necessary to maintain airway if obstructed by edema of glottis or hemorrhage.May require ligation of bleeding vessels. |
