Monitor and record patient's respiratory status. Changes in parameters (such as respiratory rate, cough, sputum production, and skin color) may indicate airway obstruction.- Monitor and record patient's neurologic status. Headache, depression, apathy, memory loss, poor muscle coordination, fatigue, stupor, and loss of consciousness may indicate hypoxia.
- Monitor patient's vital signs and report changes. Tachycardia and a slight rise in blood pressure may indicate hypoxia. Reduced heart rate and loss of consciousness indicate advanced hypoxia.
- Position patient on the side or adjust position of head and neck to prevent relaxed neck muscles from obstructing airway to allow maximal chest expansion and prevent aspiration and airway obstruction.
- Check all ventilator connections every 30 minutes if patient is on mechanical ventilation to ensure patient receives proper amount of oxygen at appropriate volume and rate.
- Check ventilator alarms every 30 minutes and after suctioning to ensure proper alarm function.
- Obtain suction equipment, assemble, and keep at bedside to assure equipment readiness in case of need.
- Suction airway, as needed, to prevent secretion accumulation. Do this only as needed to prevent tracheal irritation.
- Make sure patient lies on a firm surface and doesn't sink into the mattress, mattress cover, or blanket to decrease the risk of suffocation.
Teach parents to maintain child's bed with sheets that fit snugly on the mattress to keep it from coming off and getting wrapped around child's head.- Teach parents of infants and small children to avoid having loose blankets, toys, or other articles in the crib and bed to decrease the risk of accidental suffocation.
- Teach parents of infants and small children to promptly dispose of plastic shopping bags and plastic dry-cleaning bags and to keep all plastic bags, including garbage bags and sandwich-style plastic bags, out of the reach of young children to avoid playing with plastic bags and to decrease the risk of accidental suffocation.
- Provide patient and family members with information about safety practices including appliance (refrigerator/freezer) disposal, home environment, swimming pool safety, and use of space heating equipment to enable them to take an active role in patient's care and ensure performance of safety measures.
Suggested NIC Interventions