Risk for Ineffective Airway Clearance | NCP Thyroidectomy

Nursing diagnosis: risk for ineffective Airway Clearance

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/Evaluation Criteria—Client Will
Respiratory Status: Airway Patency
Maintain patent airway, with aspiration prevented.

Nursing intervention with rationale:
1. Monitor respiratory rate, depth, and work of breathing.
Rationale: Respirations may remain somewhat rapid because of hyperthyroid state, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.

2. Auscultate breath sounds, noting presence of rhonchi.
Rationale: Rhonchi may indicate airway obstruction and accumulation of copious thick secretions.

3. Assess for dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice.
Rationale: Indicators of tracheal obstruction or laryngeal spasm, requiring prompt evaluation and intervention.

4. Keep head of bed elevated 30 to 45 degrees. Caution client to avoid bending neck; support head with pillows in the immediate postoperative period.
Rationale: Enhances breathing and reduces likelihood of tension on surgical wound.

5. Assist with repositioning, deep breathing exercises, and coughing, as indicated.
Rationale: Maintains clear airway and ventilation. Although “routine” coughing is not encouraged and may be painful, it may be necessary to clear secretions.

7. Ascertain that suction equipment is functioning and available. Suction mouth and trachea, as indicated, noting color and characteristics of sputum.
Rationale: Edema and pain may impair client’s ability to clear own airway.

8. Check dressing frequently, especially posterior portion.
Rationale: If bleeding occurs, anterior dressing may appear dry because blood pools dependently. Note: Highest risk of bleeding is first postoperative 2 hours, but risk continues up to 24 hours.

9. Investigate reports of difficulty swallowing and drooling of oral secretions.
Rationale: May indicate edema and sequestered bleeding in tissues surrounding operative site.

10. Keep tracheostomy tray at bedside.
Rationale: Compromised airway may create a life-threatening situation requiring emergency procedure.