risk for ineffective Breathing Pattern/Airway Clearance | Nursing Care Plan for Disc Surgery

Nursing diagnosis: risk for ineffective Breathing Pattern/Airway Clearance

Risk factors may include
Tracheal and bronchial obstruction or edema
Decreased lung expansion or pain

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Maintain a normal, effective respiratory pattern free of cyanosis and other signs of hypoxia, with arterial blood gases (ABGs) within acceptable range.

Nursing intervention with rationale
1. Inspect for edema of face and neck (cervical laminectomy), especially first 24 to 48 hours after surgery.
Rationale: Tracheal edema and compression or nerve injury can compromise respiratory function.

2. Listen for hoarseness. Encourage voice rest.
Rationale: Hoarseness may indicate laryngeal nerve injury or edema of surgical area, which can negatively affect cough and ability to clear airway.

3. Auscultate breath sounds. Note presence of wheezes or rhonchi.
Rationale: Abnormal breath sounds suggest accumulation of secretions or need to engage in more aggressive therapeutic actions to clear airway.

4. Assist with coughing, turning, and deep breathing. Encourage client’s use of incentive spirometry or other devices used to aid deep breathing.
Rationale: These maneuvers facilitate movement of secretions and clearing of lungs. They also reduce the risk of such respiratory complications as pneumonia, pulmonary embolus, and others.

5. Administer supplemental oxygen, if indicated.
Rationale: Supplemental oxygen may be necessary for periods of respiratory distress or evidence of hypoxia.

6. Monitor and graph ABGs or pulse oximetry.
Rationale: Monitors adequacy of breathing and oxygen therapy.