Ineffective Airway Clearance | Nursing Care Plan for Radical Neck Surgery

Nursing diagnosisi: ineffective airway clearance related to partial or total removal of the glottis, altering ability to breathe, cough, and swallow; temporary or permanent change to neck breathing—dependent on patent stoma; edema formation—surgical manipulation and lymphatic accumulation; copious and thick secretions

Possibly evidenced by

Dyspnea and difficulty breathing

Changes in rate and depth of respiration; use of accessory respiratory muscles

Abnormal breath sounds

Cyanosis

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Airway Patency

Maintain patent airway with breath sounds clear or clearing.

Clear secretions and be free of aspiration.

Nursing intervention with rationale:

1. Monitor respiratory rate and depth; note ease of breathing. Auscultate breath sounds. Investigate restlessness, dyspnea, and development of cyanosis.

Rationale: Changes in respirations, use of accessory muscles, and presence of crackles or wheezes suggest retention of secretions. Airway obstruction (even partial) can lead to ineffective breathing patterns and impaired gas exchange, resulting in complications, such as pneumonia and respiratory arrest.

2. Elevate head of bed 30 to 45 degrees.

Rationale: Facilitates drainage of secretions, work of breathing, and lung expansion. Note: Increase elevation when oral intake is provided.

3. Encourage swallowing, if client is able.

Rationale: Prevents pooling of oral secretions, reducing risk of aspiration. Note: Swallowing is impaired when the epiglottis is removed and/or significant postoperative edema and pain are present.

4. Encourage effective coughing and deep breathing.

Rationale: Mobilizes secretions to clear airway and helps prevent respiratory complications.

5. Suction laryngectomy and tracheostomy tube and oral and nasal cavities. Note amount, color, and consistency of secretions.

Rationale: Prevents secretions from obstructing airway, especially when swallowing ability is impaired and client cannot blow nose. Changes in character of secretions may indicate developing

problems, such as dehydration and infection, and need for further evaluation and treatment.

6. Demonstrate and encourage client to begin self-suction procedures as soon as possible. Educate client in “clean” techniques.

Rationale: Assists client to exercise some control in postoperative care and prevention of complications. Reduces anxiety associated with difficulty in breathing or inability to handle secretions when alone.

7. Maintain proper position of laryngectomy or tracheostomy tube. Check and adjust ties as indicated.

Rationale: As edema develops or subsides, tube can be displaced, compromising airway. Ties should be snug but not constrictive to surrounding tissue or major blood vessels.

8. Observe tissues surrounding tube for bleeding. Change client’s position to check for pooling of blood behind neck or on posterior dressings.

Rationale: Small amount of oozing may be present; however, continued bleeding or sudden eruption of uncontrolled hemorrhage presents a sudden and real possibility of airway obstruction

and suffocation.

9. Change tube and inner cannula, as indicated. Instruct client in cleaning procedures.

Rationale: Prevents accumulation of secretions and thick mucous plugs from obstructing airway. Note: This is a common cause of respiratory distress and arrest in later postoperative period.

10. Provide supplemental humidification, such as compressed air or oxygen mist collar and increased fluid intake.

Rationale: Normal physiological (nasal passages) means of filtering and humidifying air are bypassed. Supplemental humidity decreases mucous crusting and facilitates coughing or suctioning of secretions through stoma.