Page 297 - Critical Care Nursing Demystified

282 CRITICAL CARE NURSING DeMYSTIFIED

Hemoptysis
Subcutaneous emphysema

Hoarseness
Anxiety and air hunger
Stridor

Treatment
Keeping the airway patent may require emergency tracheostomy, especially if
swelling is severe and airway is compromised. Mechanical ventilation (MV)
may be needed if gas exchange is comprised. Monitor and treat for shock if the
patient is symptomatic.

Nursing Diagnosis for TBI Expected Outcomes
Airway clearance ineffective The patient will maintain a patent airway
Ineffective breathing pattern The patient will have regular breathing
patterns with normal breath sounds

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Observe for change in level of consciousness, increased respiratory rate, dys-
pnea, cough, and stridor, which can indicate airway compromise.
Ask patient if he or she has air hunger, which can be the first symptom of a
tracheobronchial issue.
Palpate for the presence, location, and extent of subcutaneous emphysema,
which can indicate swelling and subsequent airway closure.
Administer oxygen to help load up hemoglobin molecule, getting oxygen satura-
tion at optimum point.
Prepare for intubation and MV if the patient’s status deteriorates to get oxy-
gen more directly to the alveolus.
Teach the patient to report post-nasal drip, which could indicate bleeding or
cerebral spinal fluid (CSF) leak.

Breathing

Head Injury

See Chapter 5 (Care of the Patient with Neurological Needs).