No.

Diagnosa NOC NIC

1. Ineffective airway clearence related to 1. Respiratory 1. Cough
tracheobronchial obstruction as manifested Status : Airway enhancement:
by tissue oedema and stridor sound Patency airway
Definitions :
Common expected 2. Management :
Inability to secretion or obstruction from
Outcome : Airway Suctioning
the respiratory tract to maintain airway
patency Patient secretion are 0ngoing Assesment :
mobilized and o Asses airway for
airway is free of patency
execessive secretion,
o Auscultate lungs for
as evidenced by
present of
clear lung sounds,
adventitious breath
eupnea and inability
sound
to effectively cough
up secretion after o Asses respiration :
treatment and deep note quality, rate,
breath rhytm, depth, flaring
of nostril, dyspneu,
use of accesory
muscles and position
for breathing

o Asses cough for

effectiveness and
productivity

Therapeutic
Interventions
o Assist the patient in
performing
coughing and
 breathing
manuevers

o Institute suctioning
of the airway as
determined by the
present of
adventitious
sounds, increased
peak airway
pressure and
visible secretion in
the tubing

Education / Continuity
of Care
o Teach coughing,
breathing and
splinting technique

o Instruct the patient

on the warning sign
as of impending or
recurring pulmonary
problem and their
appropriate
management
strategies

2. Ineffective Breathing Pattern related to 1. Respiratory 1. Airway

tracheobronchial obstruction as manifested Status : Management ;
by stridor sounds Ventilation ; Respiratory
Definitions vital signs status Monitoring
Inspiration or expiration that does not Common expected 0ngoing Assesment :
provide adequate ventilation outcome : o Asses respiratory
Patients breathing rate, rhytm, depth
pattern is effectively
o Asses for the quality,
maintained as
duration, intensity,
evidenced by
and distress
eupnea, normal skin
assosiated with
color and minimal
dispnea
or no complains of
dyspnea o Asses nutritional
status (e.g weight,
albumin and
electrolyte level)

o Monitoring
breathing pattern

o Observ for excessive

use acessory
muscles.

o Monitor for
diagframatic muscle
fatigue or weakness

Therapeutic
Intervention :
o Position the patient
with proper body
alignment for
optimal breathing
pattern
 o Encourage the
patient to clear his /
her own secretion
with effective cough

o Provide relaxation
training as
appropriate

o Use pain
management as
appropriate

Education /
Continuity of Care
o Explain use of
oxygen therapy,
including the type
and use of
equipment and why
its maintainance is
important

3. Impaired Gas Exchange related to altered 1. Respiratory Status 1. Respiratory

blood flow as manifested by restlessness : Gas Exchange Monitoring;
Definition : Oxygen Therapy ;
Common expected
Excess or deficient in oxygention and or Airway
Outcome :
carbondioxide elimination alveolar capilary Management
Patient maintanance
membran
optimal gas exchange Ongoing Assesment
as manifested by o Asses respiration :
arterial blood gases note quality, rate,
(ABGs) witihn the rhytm, depth and
patient usual range,
 alert responsive breathing effort
mentation or no further
o Asses lung sound,
reduction and mental
noting area of
status, and no sign of
decrease ventilation
respiratory distress
and the present of
adventitious sounds

o Asses for
tachycardia,
restlessness,
diaphoresis,
headache, visual
disturbance and
confusion

o Asses skin color for

development
cyanosis

o Monitor effects of
position change on
oxygenation
(ABGs, SVO2 and
pulse oximetry)

Therapeutic
Intervention
o

4. Ineffective peripheral tissue perfusion 1. Circulation Status : 1. Circulatory Care ;

related to blockage of microcirculation as tissue perfussion ; Vital Sign
manifested by brain injury in chest, face, peripheral monitoring
and hands area
Ongoing assesment :
Definitions : Common expected o Asses for signs of
Decrease in oxygen resulting in failure to decrease peripheral
Outcome :
nourish the tissues at capilarry refill tissue perfusion like
Patient maintain normal cold extremity.
tissue perfussion to
o Monitor vital signs:
extremities, as
BP,HR, and RR for
evidenced by palpable
abrupt change
pulses in all extremities,
and normal sensation in o Asses color and
extremity temperature
extremities

o Check for pain ,

numbness, swelling
of extremities

Therapeutic
Intervention
o Maintain good
alignment of
extremity

o Apply sequential
compression device
on non burned
extremities

o Perform passive
range of motion

Prepare for and assist

with fasciotomy and
escharotomy