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NURSING DIAGNOSIS: Breathing Pattern/Airway Clearance, risk for ineffective
Risk factors may include
- Tracheal/bronchial obstruction/edema
- Decreased lung expansion, pain
Possibly evidenced by
- [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Desired Outcomes
Respiratory Status: Ventilation (NOC)
- Maintain a normal/effective respiratory pattern free of cyanosis and other signs of hypoxia, with ABGs within acceptable range.
8 Laminectomy Nursing Care Plan (NCP)
- Impaired Physical Mobility — Laminectomy Nursing Care Plan (NCP)
- Ineffective Tissue Perfusion — Laminectomy Nursing Care Plan (NCP)
- Risk for Trauma — Laminectomy Nursing Care Plan (NCP)
- Ineffective Breathing Pattern — Laminectomy Nursing Care Plan (NCP)
- Acute Pain — Laminectomy Nursing Care Plan (NCP)
- Constipation — Laminectomy Nursing Care Plan (NCP)
- Urinary Retention — Laminectomy Nursing Care Plan (NCP)
- Knowledge Deficit — Laminectomy Nursing Care Plan (NCP)
Ineffective Breathing Pattern — Laminectomy Nursing Care Plan (NCP): Nursing Interventions & Rationale
| Nursing Interventions | Rationale |
| Inspect for edema of face/neck (cervical laminectomy), especially first 24–48 hr after surgery. | Tracheal edema/compression or nerve injury can compromise respiratory function. |
| Listen for hoarseness. Encourage voice rest. | May indicate laryngeal nerve injury, which can negatively affect cough (ability to clear airway). |
| Auscultate breath sounds, note presence of wheezes/rhonchi. | Suggests accumulation of secretions/need to engage in more aggressive therapeutic actions to clear airway. |
| Assist with coughing, turning, and deep breathing. | Facilitates movement of secretions and clearing of lungs; reduces risk of respiratory complications (pneumonia). |
| Administer supplemental oxygen, if indicated. | May be necessary for periods of respiratory distress or evidence of hypoxia. |
| Monitor/graph ABGs or pulse oximetry. | Monitors effectiveness of breathing pattern/therapy. |
Found through:
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