NANDA-NursingPlan Area 11 Safety/Defense

NANDA-nursing plan 00036 Risk for suffocation

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

This pose is a universal “choking” finding called the “choke sign”.
(# ゚Д゚) When I saw this pose, I thought, “Oh my God!!” Σ(゚д゚lll)
If you are conscious, try the “Heimlich method” or the “back blow method”!
If you are unconscious, gather people and start “cardiopulmonary resuscitation CPR”!


Area 11 Safety/Defense
Category 2 Bodily injury Bodily harm or injury

Risk for suffocation

Nursing Diagnosis: Risk for suffocation

Definition: A condition in which sufficient air for inhalation is likely to become inadequate and may be detrimental to health.

1. Indications for Nursing Diagnosis “Risk for suffocation”

・ Risk of lack of oxygen (lack of oxygen due to carbon monoxide poisoning):
· Driving a vehicle in a closed garage, using a fuel system heater without an exhaust pipe
・Inadequate supervision of infants
(Risk of becoming unable to breathe, such as being trapped or drowning):
· Empty refrigerators and washing machines
・Bathtub filled with hot water
・A pacifier around the baby’s neck
・Kakemono, soft cushions, etc. placed around infants
・Let them play with a plastic bag
・Infants cannot manage crisis,
・Crisis management is not possible due to dementia

2. aim setting

Goal setting by linkage (listed in the second half of the NOC)

* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

・Respiratory status: airway patency (0410)
(Definition: Cleared trachea/bronchi open for gas exchange)

・Respiratory condition: Ventilation (0403)
(Definition: movement of air in and out of the lungs)

・Aspiration prevention (1918)
(Definition: Individual actions to prevent water and solid particles from entering the lungs)

Knowledge: Children’s physical safety (1801)
(Definition: Level of understanding of safety in caring for children ages 1-17)

・Parenting Achieved: Infant Physical Safety (2900)
(Definition: Parental Actions to Prevent Physical Injury in Infants from Birth to Age 2)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”

・Carers can take measures to prevent suffocation, such as improving the living environment for infants and not letting them play with small toys.

• Caregivers can arrange the living conditions of people with dementia and take measures to prevent suffocation.

• Caregivers and caregivers can state strategies for suffocation prevention.

・If you have difficulty breathing or cannot breathe, you can immediately press the nurse call button.

・Caregivers and caregivers can take measures when they discover suffocation. Can perform the Heimlich method and the back blow method by giving a nurse call.

*Nurse goals include:

・Prepare the living environment for infants and prevent suffocation.

・Provide a living environment for patients with dementia to prevent suffocation.

• Assist caregivers and caregivers in acquiring knowledge of choking prevention.

・Maintain airway patency by cleaning the airway, such as by suctioning.

・Check the SPO2 value on the monitor and try to detect suffocation early.

3. nursing plan

1) Observation plan (OP)

・Choke sign
Abnormalities in breathing rate, breathing rhythm, and depth of breathing
・tidal volume
・SPO2, PaO2, cyanosis
・Breath sounds (air entering and left/right difference) ・Adjunct noise ・Airway constriction sound
・Chest X-ray image
・Pulmonary function test
Ability to remove secretions
・Alar respiration ・Gaping respiration ・Pursed lip respiration ・Recessed respiration
・Use of accessory muscles of respiration
・Cough, retention of sputum
・Death Respiration
・asthma
・Conscious state ・Consciousness turbidity
・Comprehension/cognitive impairment

・Recognition of risk factors
・Actions to avoid risk factors
・Position when eating and drinking
・ Is the food form suitable for swallowing ability?
・Position after meals (whether you are sitting or not)

〈Knowledge: Child Physical Safety〉
・Activities appropriate to the child’s developmental level
・Cause of drowning
・Presence or absence of acquisition of the Heimlich method (★1) and the back blow method (to ★2)

・Handling of infants ・Cribs (whether they meet safety standards)
・The patient is sleeping in the prone position.
・The patient is lying in the lateral recumbent position
・Items on the crib (Are there any stuffed animals or towels that may cause suffocation?)
・Appropriate play equipment (size)
・Is baby food suitable for age and chewing/swallowing?

★ 1 Heimlich method

See MSD Manual: Heimlich Maneuver for Conscious Adults – 21. Critical Care Medicine – MSD Manual Professional Edition (msdmanuals.com)

(1) Overview:
The Heimlich maneuver is a quick first aid for choking patients whose upper airway is obstructed by a foreign object, such as food or a toy.

(2) Adaptation
・Suffocation due to severe upper airway obstruction by a foreign object
(Signs of choking are inability to speak, cough, or breathe adequately).
The Heimlich maneuver should only be used when airway obstruction is severe and life threatening.
Do not intervene if the choking patient can speak, forcefully cough, or breathe adequately.

(3) Contraindications
① Absolute contraindications
・Less than 1 year old

(2) Relative contraindications
 • Abdominal thrusts should be used sparingly in children <20 kg (usually <5 years).

 • Chest thrusts rather than abdominal thrusts should be done in obese patients or women in late pregnancy.

(4) Complications – Rib injury or fracture

 ・Internal injury

(5) Other considerations

 • Use this method of immediate first aid immediately wherever someone is choking.

 • Do not perform the Heimlich maneuver if the choking patient can speak, forcefully cough, or breathe adequately.

 • Use chest thrusts rather than abdominal thrusts in obese patients or women in late pregnancy.

(6) Heimlich method in practice

(1) Check whether the Heimlich method is applicable: Both the Heimlich maneuver and the back blows are performed on a conscious person. If unconscious, perform CPR immediately. Look for signs of severe airway obstruction, such as inability to speak, cough, or breathe adequately.

Is there a chalk sign (★3)?

“Can’t you breathe?” he asks. If patients nod and cannot speak, cough, or breathe adequately, it means they have severe airway obstruction and need help.

(2) The rescuer stands behind the patient. For children < 20 kg (usually < 5 yr), rescuers kneel at the child’s feet rather than straddle them.

(3) Follow the procedure shown in the figure below.

 ① Make a fist with one hand and place it between the navel and the xiphoid process.

 ②Cover your fist with your other hand

 ③ Raise both hands vigorously backwards and upwards (towards the back and lungs at the same time)

 ④Repeat this action up to 8-10 times

 ⑤Transport by ambulance even if the blockage is removed

 ⑥ Perform CPR if the patient loses consciousness  

★ 2 Back hitting method

Japan Medical Association Emergency Resuscitation Method “Removal of Airway Foreign Body” See: Procedure for removing airway foreign body | Japan Medical Association Emergency Resuscitation Method (med.or.jp)

Both the Heimlich maneuver and the back blows are performed on a conscious person. If unconscious, perform CPR immediately.  

★ 3 choke sign

It refers to the gesture of covering the neck with both hands, as shown in the figure below.  

2) Action plan (TP)

・When phlegm build-up or productive cough is observed, perform aspiration to keep the airway open.

• If signs of choking are seen, aspirate immediately after the back blows to remove the obstruction. If you still can’t remove it, don’t leave the place, call the staff, and follow the doctor’s instructions (remove with a bronchoscope, etc.)

・Do not place unnecessary items such as stuffed toys and towels around the infant’s bed.

・Do not place small objects that can be put in the mouth where infants touch.

*It is said that the size of an infant’s open mouth is 4 cm. It’s about the same size as the hole in the roll of toilet paper, so be careful not to put anything that goes through this hole out of reach of a toddler, as they might put it in their mouths (・∀・) of

・Arrange things on the bed according to the infant’s ability to roll over.

・For infants, provide baby food according to their age and chewing and swallowing function.

• Provide meals in a food format suitable for swallowing ability. (Bite-sized, chopped thick, porridge, soft rice)

・Adopt a suitable position for eating. Also, keep the sitting position for 30 minutes after eating.

・Confirm swallowing of each mouthful and provide feeding assistance.

・If you have dementia and have pica eating habits, do not put unnecessary things within reach.   

3) Education plan (EP)

・In diseases with chronic airway inflammation such as asthma, there is a high risk of airway obstruction.

・In the living environment of infants, think with caregivers about possible suffocation risks and deepen their understanding of a safe environment.

・When eating quickly, there is a risk of suffocation.

・Instruct the patient to eat in a sitting position and to remain seated for 30 minutes after eating.

・Using a pamphlet, explain what kind of baby food is specifically according to the age and mastication of infants.

・Explain that infants should not be put to sleep in a prone position out of sight.  

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.

Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.

Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.

Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan

K.K. Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.

Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

Thank you for watching until the end. We are waiting for your opinions and impressions from the comment section below.

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