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NCP PROPER

Problem # 1: COUGH

NURSING DIAGNOSIS: Ineffective Airway clearance related to accumulation of secretions

GOAL/LTO
After 4 days of nursing interventions, the patient will be able to maintain its airway patency as manifested by:
a. Absence of adventitious breath sounds upon auscultation
b. Decrease oxygen inhalation from 2-3 lpm to 1-2 lpm
STO
a. After 8 hours of nursing interventions, the patient will demonstrate an increase in its fluid intake from 3-5 glasses per day to 5-7 glasses per day as
tolerated
b. After 8 hours of nursing interventions, the patient will verbalize a readily expectoration of secretions of at least 1 teaspoon per coughing episode
c. After 8 hours of nursing interventions, the patient will demonstrate a decrease in coughing episodes from 6-8 coughing episodes pre shift to 4-6
coughing episodes per shift

Assessment Explanation of the problem


S- “I have cough but I can’t expectorate the phlegm” The patient has unproductive cough therefore secretions are retained in
O- with vital signs of CR- 55 bpm, RR- 24 cpm and T°- 36.1°C the bronchi. The inability to expectorate out secretions causes it to
- frequent unproductive coughing episodes noted accumulate at the bronchi that now leads to an obstruction into the
- appears weak respiratory tract which causes the patient to experience ineffective airway
- with O2 inhalation of 2-3 lpm clearance.
- crackles heard over lung fields
- noted fluid intake of 3-5 glasses per day
INTERVENTIONS RATIONALE CRITERIA FOR EVALUATION EVALUATION

Dx:
-Assessed and recorded Vital Signs - V/S serve as baseline data and GOAL/LTO fully met if the patient
validates the autonomic responses will be able to:
of the patient a. Demonstrate an absence of
adventitious breath sounds
- Noted for physiological and - Knowing the factors, we can know b. Decrease oxygen inhalation from
psychological factors that is related the underlying cause of the problem 2-3 lpm to 1-2 lpm
to ineffective airway clearance and in order for us to give
appropriate interventions GOAL/LTO partially met if the
patient will only demonstrate one of
- Noted for coughing episodes and - To determine the patient’s ability the 2 given criteria
characteristic to expectorate secretions to
maintain a patent airway GOAL/LTO not met if the patient is
not able to demonstrate any of the
-Assessed hydration status by - A person’s hydration status can 2 given criteria
noting fluid intake be determined by noting fluid
intake. An increase in fluid intake STO fully met if the patient will be
may help liquefy secretions for able to:
Tx: expectoration. a. Increase its fluid intake from 1L
- Auscultated lung fields to note to 1.5L per day as tolerated
presence of adventitious breath - Presence of adventitious breath b. Verbalize a readily expectoration
sounds sounds indicates respiratory of secretions to at least 1 teaspoon
distress and or accumulation of per coughing episode
secretions c. Decrease in coughing episodes
- Assisted during nebulizatio and from 6-8 coughing episodes to 4-6
back tapping done - Nebulization and Back tapping coughing episodes per shift
helps liquefy viscous secretions
- Elevated head of bed STO partially met if the patient is
- This is to open or maintain an able to demonstrate only 2 out of 3
open airway of the above stated criteria
- Maintained oxygen inhalation of 2-
3 lpm - Various modalities may be STO not met if the patient is not
required to maintain adequate able to demonstrate or demonstrate
airway, improve respiratory function only 1 out of the 3 stated criteria
- Administered medications such as and gas exchange
expectorants and bronchodilators
as ordered - These medications helps in
maintaining a patent airway where
it aids in expectoration of
Edx: accumulated secretions
- Encouraged patient to increase
fluid intake as tolerated
- Hydration can help liquefy viscous
secretions and improve secretion
- Instructed to maintain position clearance
where head of bed is elevated
- This is to maintain an open airway
- Encouraged to do coughing and
deep breathing exercises
- These exercises help in
expectoration of secretions
- Reiterated importance of therefore maintaining patent airway
compliance to therapeutic and drug
regimen - Compliance to therapeutic and
drug regimen aides in treatment of
the condition