V.

NCP PROPER:

Problem: Cough

Assessment:

S:
 ”Inuubo ako. Medyo matagal na nga ito e. Tapos may lumalabas na puting plema
kapag umuubo ako. Nakakatulog naman ako pero naaabala minsan nang dahil sa
kama kong matigas”

O:
 Coherent, alert and fully awake
 (+) Pale conjunctiva
 (+) Pale oral mucous membrane
 Episode of non productive cough noted
 (+) Use of sternocleidomastoid in breathing
 Symmetrical lung expansion noted
 Appears weak
 Normal chest excursion (1 inch)
 Capillary refills at 2 seconds
 With wheezes on bilateral lower lobes noted upon auscultation
 Good skin turgor
 In semi fowlers position
 Pale skin noted
 Vital Signs
o BP=120/80 mmHg
o PR: 70 beats/minutes
o Temperature (Axilla) 36 degree Celsius
o RR: 19 cycles/minute
 X-ray and UTZ (February 22, 2010) reveals bibasal pneumonia

Diagnosis:
Ineffective airway clearance related to presence of secretion in trachea-bronchial
tree secondary to history of CAP

Explanation of the problem:

Entry of Streptococcus pneumonia, Haemophilus influenza and Staphylococcus species

Mycoplasma pneumonia, Legionella and Chlamydia Species through inspiration or
aspiration

Activation of defense mechanism

Loss of effectiveness of defense mechanism

Penetrate the sterile lower respiratory tract (lungs)

Nursing care plan Submitted by: MEDINA, PATRICK LUIS

 alveoli

multiplication

Irritation of the airways

Increase goblet cells

Increase mucus production

Cough

Objectives:

GOAL: After the entire hospitalization, the patient will manifest clear airway and
effective breathing

LTO
>After After 3 days of nursing interventions, the patient will maintain patent airway as
manifested by clear breath sounds, normal rate of respiration, and effective cough

STO
>After almost 8 hours of Nursing Interventions, the patient:

1. Will manifest stable and normal vital signs (BP, RR, PR, Temp)

2. Will manifest clear breath sounds as manifested by absence of wheezes

3. Will cough effectively through capability to expectorate all accumulated

secretions

4. will enumerate at least 2 management of cough

5. will adhere and comply to all therapeutic regimens like medications

Nursing care plan Submitted by: MEDINA, PATRICK LUIS