CUES AND CLUES

Objective: -audible grunt -SpO2= 87%

NURSING DIAGNOSIS
Ineffective airway clearance related to stasis of respiratory secretions secondary to general anaesthetic use

RATIONALE
General anaesthesia results in the loss of airway patency due to the relaxation of the pharyngeal muscles and posterior displacement of the tongue. The ability to manage secretions is lost, and saliva and mucous can obstruct the oropharynx. The loss of the cough reflex allows secretions (or refluxed gastric contents) onto the vocal cords, causing laryngospasm, or to enter the trachea and lungs causing bronchospasm and ultimately infection.

OBJECTIVES
After immediate intervention: oxygen saturation will continuously range at normal values. no abnormal breath sounds and breathing patterns observed. Within the time stayed in the PACU, there will be:

INTERVENTIONS
Loosen clothing from neck/chest and abdominal areas Suction the patient as ordered, being sure to hyper oxygenate the patient prior to, during, and after procedure. Limit active suctioning to less than 15 seconds

RATIONALE
Facilitates breathing and maximizes lung expansion. Patients who are just undergone surgery under GA have ineffective cough reflexes thus suctioning is required to remove the secretions. Suctioning time should be minimized and hyper oxygenation to reduce the potential for hypoxia High Fowlers or semi-fowlers position promotes maximal lung expansion Promotes drainage of secretions; prevents tongue on obstructing the airway May reduce cerebral hypoxia resulting from decreased circulation and oxygenation

EVALUATION
After implementation of nursing interventions: oxygen saturation are normal Normal breath sounds and breathing patterns are noted. Alert level of consciousness is achieved Baseline vital signs are in acceptable values.

Position the client in high Fowlers or semi-fowlers position if not contraindicated

considerable improvement in patients breathing patterns, breath sounds. gradual improvement These effects result of the patients in airway obstruction level of and prevent the consciousness. passage of gases into and out of the lungs resulting in hypoxia and hypercapnia.

Administer supplemental oxygen or bag ventilation, as ordered