Marco, Carmela Dawn M.

BSN III- 3/A ASSESSMENT Subjective Data: medyo nahihirapan akong lumunok verbalized by the patient Objective Data: Seen patient with tracheostomy Facial grimace connotes difficulty Minimal voice produces Seen patient difficulty in swallowing NURSING DIAGNOSIS Risk for ineffective airway clearance. Related to tracheal obstruction SCIENTIFIC EXPLANATION Thyroidectomy is the removal of all or a portion of the thyroid gland. The procedure is usually performed to treat various disease of the thyroid gland that may not be treated effectively by chemotherapy or medication. A total thyroidectomy is indicated for certain carcinomas and to relieve tracheal or esophageal compression. PLANNING After 4 hours of nursing interventions, the patient will maintain patent airway, with aspirations prevented. INTERVENTION Independent Monitor respiratory rate, depth, and work of breathing. RATIONALE Respirations may remain rapid because of hyperthyroid state, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage. Indicators of tracheal obstruction or laryngeal spasm. Enhances breathing and reduces likelihood of tension on surgical wound. Maintain clear airway and ventilation. EVALUATION After 4 hours of nursing interventions, the patient was able to maintain patent airway, with aspirations prevented.

Assess for dyspnea, stridor, crowning and cyanosis. Keep head of the bed elevated 30 to 45 degrees. Assist in repositioning, deep breathing exercises, and coughing, as indicated. Check dressing frequently. Keep tracheostomy tray at bedside.

Anterior dressing may appear dry because blood pools dependently. Compromised airway may create a life-threatening situation requiring emergency procedure. Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions.

Collaborative Provide stream inhalation; humidify room air.