Ineffective breathing pattern related to paralysis of the diaphragm muscle.
Intervention:
1 Maintain airway; head position without movement.
Rationale: Patients with cervical injury will require help to prevent aspiration / maintain the airway.
2 Perform suction mucus, if necessary, record the number, type and characteristics of the secretions.
Rationale: If the cough is not effective, the suction needed to remove secretions, and reduce the risk of respiratory infections.
3 Assess respiratory function.
Rational: Trauma C5-6 cause partial loss of respiratory function, due to respiratory muscle paralysis.
4. Auscultation of breath sounds.
Rational: Hypoventilation usually occur or lead to the accumulation of secretions that result in pneumonia.
Observation 5. skin color.
Rationale: Describes the presence of respiratory failure that requires immediate action.
6 Assess abdominal distension and muscle spasm.
Rational: Full abnormalities in the stomach caused by paralysis of the diaphragm.
7 Instruct the patient to drink a minimum of 2000 cc / day.
Rational: help thin secretions, increasing the mobilization of secretions as an expectorant.
8 Perform measurement of vital capacity, tidal volume and respiratory strength.
Rationale: Determining the function of the respiratory muscles. Continuous assessment to detect the presence of respiratory failure.
9 Monitor blood gas analysis.
Rationale: To determine the function of gas exchange abnormalities as an example: hyperventilation low PaO2, and PaCO2 increased.
10 Give oxygen in the proper way: the method chosen in accordance with the state isufisiensi breathing.
· Perform physiotherapy breath.
Rational: to prevent retained secretions
Intervention:
1 Maintain airway; head position without movement.
Rationale: Patients with cervical injury will require help to prevent aspiration / maintain the airway.
2 Perform suction mucus, if necessary, record the number, type and characteristics of the secretions.
Rationale: If the cough is not effective, the suction needed to remove secretions, and reduce the risk of respiratory infections.
3 Assess respiratory function.
Rational: Trauma C5-6 cause partial loss of respiratory function, due to respiratory muscle paralysis.
4. Auscultation of breath sounds.
Rational: Hypoventilation usually occur or lead to the accumulation of secretions that result in pneumonia.
Observation 5. skin color.
Rationale: Describes the presence of respiratory failure that requires immediate action.
6 Assess abdominal distension and muscle spasm.
Rational: Full abnormalities in the stomach caused by paralysis of the diaphragm.
7 Instruct the patient to drink a minimum of 2000 cc / day.
Rational: help thin secretions, increasing the mobilization of secretions as an expectorant.
8 Perform measurement of vital capacity, tidal volume and respiratory strength.
Rationale: Determining the function of the respiratory muscles. Continuous assessment to detect the presence of respiratory failure.
9 Monitor blood gas analysis.
Rationale: To determine the function of gas exchange abnormalities as an example: hyperventilation low PaO2, and PaCO2 increased.
10 Give oxygen in the proper way: the method chosen in accordance with the state isufisiensi breathing.
· Perform physiotherapy breath.
Rational: to prevent retained secretions
