Hướng Dẫn What is the correct nursing intervention when a client with head injury begins to have a clear drainage from his nose?

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Hoàng Tiến Dũng đang tìm kiếm từ khóa What is the correct nursing intervention when a client with head injury begins to have a clear drainage from his nose? được Cập Nhật vào lúc : 2022-09-12 20:16:06 . Với phương châm chia sẻ Bí quyết Hướng dẫn trong nội dung bài viết một cách Chi Tiết Mới Nhất. Nếu sau khi Read Post vẫn ko hiểu thì hoàn toàn có thể lại phản hồi ở cuối bài để Ad lý giải và hướng dẫn lại nha.

Injuries to the head should always be treated seriously as there may be damage to the brain. Sometimes this damage may not be evident for hours after the injury occurs.

Nội dung chính

Signs and SymptomsGoals and OutcomesNursing Assessment for Ineffective Airway ClearanceNursing Interventions for Ineffective Airway ClearanceRecommended ResourcesReferences and SourcesWhat should you do if a head injury causes fluid to leak from a person's nose or ear?Which intervention would the nurse perform first for the client admitted with a closed head injury and increased intracranial pressure ICP )?Which intervention should the nurse implement to prevent an increase in intracranial pressure quizlet?Which of the following would be the first and most important signal of a serious head injury?

Head injuries such as concussion, brain compression, and skull fracture are difficult for a first aider to determine, and therefore all head injuries should be treated in the same way.

Fracture of the Skull

Back view of brain

Symptoms and signs – Not all may be present

altered conscious state, often deteriorating over timeblurred or double visiona thumping or pounding headachenausea or vomitingloss of balance and coordinationaltered sensation in the fingers or down one side of the bodyloss of short-term memory – e.g. recent eventsnoisy breathingleaking fluid from the nose or one earhistory of a blow to the head

How you can help

1. Assess the patient

Call 111 for an ambulance.

2. Give care until arrival of the ambulance

Cover any wound with a sterile dressing.If there is any discharge from the ears or nose, cover the area with a sterile dressing.

DO NOT pack the ears or nose with dressings.

3. Monitor the patient

4. Maintain body toàn thân heat

Always arrange for a doctor to check the patient in the case of a head injury even if it appears that a full recovery has occurred. In some cases the recognition of serious head injuries may be delayed for 24 to 48 hours due to a gradual increase in swelling or bruising around the brain.

Note: When a head injury is suspected in a player during contact sport, the first aider should recommend that the patient does not return to the trò chơi. The patient should be seen by a doctor for clearance to continue playing.

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Use this nursing diagnosis guide to formulate your ineffective airway clearance nursing care plan.

Breathing comes naturally and effortlessly to everyone. But there are some who are incapable of keeping their airways clear and their lungs healthy. Maintaining a patent airway has always been vital to life. When a problem concerning the airway happens, coughing takes place, which is the main mechanism for clearing it. However, coughing may not always be easy to everyone especially to those patients with incisions, trauma, respiratory muscle fatigue, or neuromuscular weakness. Mechanisms that exist in the lower bronchioles and alveoli to maintain the patency of the airway include the mucociliary system, macrophages, and the lymphatics. Also, anesthesia and dehydration can alter the function of the mucociliary system. Thus, increased production of secretions in conditions such as pneumonia and bronchitis can oppress these mechanisms.

Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., CVA or spinal cord injury) problem. High-risk for ineffective airway clearance are the aged individuals who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production.

There is a wide range of airway clearance interventions that nurses can choose from when they are teaching the patients and family members the strategies of secretion removal. In general, these interventions are done to maintain a patent airway, improve comfort and ease of breathing, improve pulmonary ventilation and oxygenation, and to prevent risks associated with oxygenation problems.

Signs and SymptomsGoals and OutcomesNursing Assessment for Ineffective Airway ClearanceNursing Interventions for Ineffective Airway ClearanceRecommended ResourcesSee alsoReferences and Sources

Signs and Symptoms

An ineffective airway clearance is characterized by the following signs and symptoms:

Abnormal breath sounds (crackles, rhonchi, wheezes)Abnormal respiratory rate, rhythm, and depthDyspneaExcessive secretionsHypoxemia/cyanosisInability to remove airway secretionsIneffective or absent coughOrthopnea

Goals and Outcomes

The following are the common goals and expected outcomes for Ineffective Airway Clearance.

Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths.Patient will demonstrate increased air exchange.Patient will classify methods to enhance secretion removal.Patient will recognize the significance of changes in sputum to include color, character, amount, and odor.Patient will identify and avoid specific factors that inhibit effective airway clearance.

Nursing Assessment for Ineffective Airway Clearance

Continuous assessment is necessary in order to know possible problems that may have lead to Ineffective Airway Clearance as well as name any concerns that may occur during nursing care.

AssessmentRationalesAssess airway for patency. Maintaining patent airway is always the first priority, especially in cases like trauma, acute neurological decompensation, or cardiac arrest. Auscultate lungs for presence of normal or adventitious breath sounds, as in the following: Abnormal breath sounds can be heard as fluid and mucus accumulate. This may indicate ineffective airway clearance.

Decreased or absent breath soundsThese may indicate presence of a mucous plug or other major obstruction.

WheezingThis may indicate partial airway obstruction or resistance.

Coarse cracklesThis may indicate presence of secretions along larger airways. Abnormal Breath Sounds:

BronchospasmConstant breath sounds of both rhonchi and wheezing; normally treated with bronchodilator.

Expiratory gruntFrequently occurs in combination with nasal flaring and intercostal or subcostal retractions, associated with increased work of breathing.

RalesClicking, rattling, or crackling sound heard during inspiration and expiration.

RhonchiContinuous low-pitched, rattling lung sounds that often resemble snoring.

StridorHigh-pitched, musical breathing sound caused by a blockage in the throat or voice box (larynx).

WheezeHigh-pitched, whistling sound when air moves through narrowed breathing tubes in the lungs. This is heard most commonly in asthmatics and CHF Assess respirations. Note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing. A change in the usual respiration may mean respiratory compromise. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction. Rates and Depths of Respiration:

ApneaTemporary cessation of breathing, especially during sleep

ApneusisDeep, gasping inspiration with a pause full inspiration followed by a brief, insufficient release

Ataxic patternsComplete irregularity of breathing with irregular pauses and increasing periods of apnea

Biot’s respirationGroups of quick, shallow inspirations followed by regular or irregular periods of apnea (10 to 60 seconds).

BradypneaRespirations fall below 12 breaths per minute depending on the age of patient

Cheyne-Stokes respirationProgressively deeper and sometimes faster breathing, followed by a gradual decrease that results in apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.

EupneaNormal, good, unlabored ventilation, sometimes known as quiet breathing or resting, respiratory rate

HyperventilationIncreased rate and depth of breathing

Kussmaul’s respirationsDeep respirations with fast, normal, or slow rate associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure

TachypneaRapid, shallow breathing, with more than 24 breaths per minute Note for changes in mental status. Increasing lethargy, confusion, restlessness, and/or irritability can be initial signs of cerebral hypoxia. Lethargy and somnolence are late signs. Note for changes in HR, BP, and temperature. Increased work of breathing can lead to tachycardia and hypertension. Retained secretions or atelectasis may be a sign of an existing infection or inflammatory process manifested by a fever or increased temperature. Note cough for efficacy and productivity. Coughing is a mechanism for clearing secretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled. Respiratory muscle fatigue, severe bronchospasm, or thick and tenacious secretions are possible causes of ineffective cough. Note presence of sputum; evaluate its quality, color, amount, odor, and consistency. Unusual appearance of secretions may be a result of infection, bronchitis, chronic smoking, or other condition. A discolored sputum is a sign of infection; an odor may be present. Dehydration may be present if patient has labored breathing with thick, tenacious secretions that increase airway resistance. Submit a sputum specimen for culture and sensitivity testing, as appropriate. Labored breathing may be a sign of respiratory infection that needs an appropriate treatment of antibiotics. Use pulse oximetry to monitor oxygen saturation; assess arterial blood gases (ABGs) Pulse oximetry is used to detect changes in oxygenation. Oxygen saturation should be maintained 90% or greater. Alteration in ABGS may result in increased pulmonary secretions and respiratory fatigue. Normal Blood Gas Values: pH 7.35 – 7.45 PaCO2 35 – 45 PaO2 Adults: 80 – 100
Infants: 60 – 80 HCO3 20 – 24 Assess hydration status: skin turgor, mucous membranes, tongue. Airway clearance is impaired with poor hydration and subsequent secretion thickening. Assess for abdominal or thoracic pain. Pain can result in shallow breathing and an ineffective cough. Check for peak airway pressures and airway resistance, if patient is on mechanical ventilation. Increases in these parameters signal collection of secretions or fluid and likely for ineffective ventilation. Review patient’s understanding of disease process. Patient teaching will vary depending on the acute or chronic disease condition as well as the patient’s cognitive level. Know if patient considers use of herbal treatment (e.g., echinacea for URTI, goldenseal for pneumonia, ma huang for bronchospasm). Drug interactions with prescribed medications and contraindications need to be evaluated (e.g., ma huang contains ephedrine, which should not be used by patients with increased BP, heart disease, prostate problems, and diabetes).

Nursing Interventions for Ineffective Airway Clearance

The following are the therapeutic nursing interventions for ineffective airway clearance:

Nursing InterventionsRationalesTeach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession). The most convenient way to remove most secretions is coughing. So it is necessary to assist the patient during this activity. Deep breathing, on the other hand, promotes oxygenation before controlled coughing. Educate the patient in the following:

Optimal positioning (sitting position)Use of pillow or hand splints when coughingUse of abdominal muscles for more forceful coughUse of quad and huff techniquesUse of incentive spirometryImportance of ambulation and frequent position changesThe proper sitting position and splinting of the abdomen promote effective coughing by increasing abdominal pressure and upward diaphragmatic movement. Controlled coughing methods help mobilize secretions from smaller airways to larger airways because the coughing is done varying times. Ambulation promotes lung expansion, mobilizes secretions, and lessens atelectasis. Position the patient upright if tolerated. Regularly check the patient’s position to prevent sliding down in bed. Upright position limits abdominal contents from pushing upward and inhibiting lung expansion. This position promotes better lung expansion and improved air exchange. Perform nasotracheal suctioning as necessary, especially if cough is ineffective. Suctioning is needed when patients are unable to cough out secretions properly due to weakness, thick mucus plugs, or excessive or tenacious mucus production.

Explain procedure to patientThis procedure can also stimulate a cough. Frequency of suctioning should be based on patient’s present condition, not on preset routine, such as every 2 hours. Over suctioning can cause hypoxia and injury to bronchial and lung tissue.

Use well-lubricated soft cathetersUsing well-lubricated catheters reduces irritation and prevents trauma to mucous membranes.

Use curved-tip catheters and head positioning (if not contraindicated).These facilitates secretion removal; from a specific side of the lung (left or right).

Instruct the patient to take several deep breaths before and after nasotracheal suctioning procedure and use supplemental oxygen, as appropriate.Hyperoxygenation before, during, and after suctioning prevents hypoxia.

Stop suctioning and provide supplemental oxygen if the patient experiences bradycardia, an increase in ventricular ectopy, and/or significant desaturation.Oxygen therapy is recommended to improve oxygen saturation and reduce possible complications.

Use universal precautions: gloves, goggles, and mask, as appropriate.As protection against the blood-related modes of transmission, health care workers should use universal precautions when coming in contact with the blood of all patients, or bodily fluids containing blood. Maintain humidified oxygen as prescribed. Increasing humidity of inspired air will reduce thickness of secretions and aid their removal. Encourage patient to increase fluid intake to 3 liters per day within the limits of cardiac reserve and renal function. Fluids help minimize mucosal drying and maximize ciliary action to move secretions. Give medications as prescribed, such as antibiotics, mucolytic agents, bronchodilators, expectorants, noting effectiveness and side effects. A variety of medications are prepared to manage specific problems. Most promote clearance of airway secretions and may reduce airway resistance. Coordinate with a respiratory therapist for chest physiotherapy and nebulizer management as indicated. Chest physiotherapy includes the techniques of postural drainage and chest percussion to mobilize secretions from smaller airways that cannot be eliminated by means of coughing or suctioning. Provide postural drainage, percussion, and vibration as ordered. Chest physical therapy helps mobilize bronchial secretions; it should be used only when prescribed because it can cause harm if patient has underlying conditions such as cardiac disease or increased intracranial pressure. Provide oral care every 4 hours. Oral care freshens the mouth after respiratory secretions have been expectorated. Pace activities especially for patients with reduced energy. Maintain planned rest periods. Promote energy-conservation methods. Fatigue is a contributing factor to ineffective coughing. Effective coughing requires enough energy and may consume an extra effort to the patient. For acute problems, resort in bronchoscopy. Bronchoscopy acquires lavage samples for culture and sensitivity, and eliminates mucous plugs. If secretions cannot be cleared, consider the need for an intubation. Once intubated: Readiness for an emergency helps prevent further complications. Intubation may be needed to facilitate removal of tenacious and copious amounts of secretions and provide source for augmenting oxygenation.

Start suctioning airway as determined by the existence of adventitious sounds.Suctioning clears mucus from the tube and is essential for proper breathing.

Use sterile saline solution for the period of suctioningThis promotes elimination of viscous secretions. Perform cardiopulmonary resuscitation (CPR) maneuvers for patients with complete airway obstruction. This is used to relieve airway obstructions and to sustain life until definitive treatment can be provided. Educate patient on coughing, deep breathing, and splinting techniques. Patient will understand the underlying principle and proper techniques to keep the airway clear of secretions. Provide patient understanding about the proper use of prescribed medications and inhalers. Understanding prescriptions promote safe and effective medication administration. Consider the need of humidifiers in home care setting. This facilitates liquefaction of secretions. Instruct patient about the need for adequate fluid intake even after hospital discharge. Hydration facilitates easy elimination of secretions. Educate caregivers in suctioning techniques. Provide opportunity for return demonstration. Modify techniques for home setting. This promotes safe and effective removal of secretions from the airway. Consider verbalization of feelings. Recognize reality of situation. Anxiety adds to oxygen demand, and hypoxemia potentiates respiratory distress or cardiac symptoms, which in turn increases anxiety. Explain further the effects of smoking, including secondhand smoke. Chemical irritants and allergens can increase mucus production and bronchospasm. Refer to the pulmonary clinical nurse specialist, home health nurse, or respiratory therapist as indicated. Consultants may be helpful in ensuring that proper treatments are met.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales

NANDA International Nursing Diagnoses: Definitions & Classification, 2022-2023 (12th Edition)

Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2022-2023 NANDA-I® Updates

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))

Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition

Maternal Newborn Nursing Care Plans (3rd Edition)

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)

All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)

References and Sources

Here are some recommended materials and sources for Ineffective Airway Clearance:

Hill, A. T., Barker, A. F., Bolser, D. C., Davenport, P., Ireland, B., Chang, A. B., … & McGarvey, L. (2022). Treating cough due to non-CF and CF bronchiectasis with nonpharmacological airway clearance: CHEST expert panel report. Chest, 153(4), 986-993.Shekleton, M. E., & Nield, M. (1987). Ineffective airway clearance related to artificial airway. The Nursing Clinics of North America, 22(1), 167-178.

Gil Wayne graduated in 2008 with a bachelor of science in nursing. He earned his license to practice as a registered nurse during the same year. His drive for educating people stemmed from working as a community health nurse. He conducted first aid training and health seminars and workshops for teachers, community members, and local groups. Wanting to reach a bigger audience in teaching, he is now a writer and contributor for Nurseslabs since 2012 while working part-time as a nurse instructor. His goal is to expand his horizon in nursing-related topics. He wants to guide the next generation of nurses to achieve their goals and empower the nursing profession.

What should you do if a head injury causes fluid to leak from a person's nose or ear?

Call triple zero (000) and ask for an ambulance if someone has a head injury and they fall unconscious, even if it's only for a second, or if they have a fit or seizure. They also need urgent medical attention if there is bleeding that won't stop, or if there is fluid coming from the nose or ears.

Which intervention would the nurse perform first for the client admitted with a closed head injury and increased intracranial pressure ICP )?

If a patient is suspected of having increased ICP, immediate interventions should include securing the airway, maintaining adequate oxygenation and ventilation, and providing circulatory support as needed.

Which intervention should the nurse implement to prevent an increase in intracranial pressure quizlet?

Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse will only take more time doing this without adding any useful information. a. high blood flow to the brain.

Which of the following would be the first and most important signal of a serious head injury?

The presence or absence of blood isn't a reliable indicator of the seriousness of the head injury. Symptoms of serious head injury can include clear fluid leaking from the nose or ears, altered consciousness or a period of unconsciousness, skull deformities, vision changes, bruised eyes and ears, nausea and vomiting. Tải thêm tài liệu liên quan đến nội dung bài viết What is the correct nursing intervention when a client with head injury begins to have a clear drainage from his nose?

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