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    Nursing Care Plan Ineffective Airway Clearance (Bronchi)

    Uploaded by

    deric
    A free sample nursing care plan (ncp) for Ineffective Airway Clearance r/t secretions in the bronchi.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Nursing Care Plan Ineffective Airway Clearance (Bronchi)

    Uploaded by

    deric
    114K views2 pages
    A free sample nursing care plan (ncp) for Ineffective Airway Clearance r/t secretions in the bronchi.

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    NursingCrib.com Nursing Care Plan Ineffective Airway Clearance (Bronchi)

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    A free sample nursing care plan (ncp) for Ineffective Airway Clearance r/t secretions in the bronchi.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    114K views2 pages

    Nursing Care Plan Ineffective Airway Clearance (Bronchi)

    Uploaded by

    deric
    A free sample nursing care plan (ncp) for Ineffective Airway Clearance r/t secretions in the bronchi.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    NCP I

    Nursing
    Cues Nursing Diagnosis Inference Objective Rationale Evaluation
    Intervention

    Subjective Short Term Goal Independent


    ◈ Ineffective Irritant ◈After 4 hours of
    ◈ “Nahihirapan Airway Clearance (inhalation) ◈ After 4 hours of ◈ Vital signs ◈ This is for nursing
    akong huminga r/t secretions in nursing monitored and baseline intervention, the
    dahil sa kakaubo the bronchi intervention, airway recorded. comparison. goal is met through
    ko,” as verbalized. patency will be maintenance of
    inflammatory maintained, airway patency and
    response ◈ Assisted in semi- ◈ Proper positioning
    Objective secretions will be fowler’s position. helps in draining reduction in
    readily secretions. congestion.
    ◈ pale in expectorated and
    increase production there will be signs
    appearance of secretions ◈ Encouraged deep ◈ This will promote
    of reduction in
    congestion. breathing exercise. proper lung
    ◈ dyspnea expansion.
    airway constriction
    ◈ (+) use of Dependent
    accessory muscles
    when breathing dyspnea ◈ Administered ◈ Prescribed meds
    prescribed such as
    ◈ (+) productive medications. bronchodilators
    cough helps in aiding
    effective airway
    clearance.
    ◈ RR=24cpm
    ◈ Provided ◈ Nebulization
    Reference: supplemental helps in liquefying
    Understanding humidification via secretions for better
    Pathophysiology, use of nebulizer. and faster
    Huether expectorating the
    secretions.
    NCP II

    Cues Nursing Diagnosis Inference Objective Nursing Intervention Rationale Evaluation

    Subjective Short Term Goal Independent


    ◈ Hyperthermia r/t Irritant ◈After 1 hour of
    ◈ “Nilalamig ako at inflammatory (microbial) ◈ After 1 hour of ◈ Vital signs ◈ This is for baseline nursing intervention,
    medyo masakit ang response nursing intervention, monitored and comparison. the goal is met
    ulo ko,” as body temperature will recorded. through the
    verbalized. be maintained within ◈ TSB will help in maintenance of body
    inflammatory response the normal range. temperature within
    ◈ Provided tepid lowering the patient’s
    Objective sponge bath. temperature. the normal range.
    tissue injury
    ◈ weak looking ◈ Advised to increase ◈ Increase in oral
    fluid intake. fluids will prevent
    ◈ skin warm to dehydration.
    touch vascular response
    ◈ Instructed to ◈ This will help in
    ◈ T = 38.5°C maintain bedrest. reducing metabolic
    RR = 24cpm hyperemia demands and oxygen
    (heat, redness, pain) consumption.

    ◈ Encouraged deep ◈ This will promote


    Reference: breathing exercise. proper lung expansion.
    Mastering
    Fundamentals of
    Nursing, Udan Dependent

    ◈ Administered ◈ Prescribed meds


    prescribed such as paracetamol
    medications. help in reducing fever
    by direct action on
    hypothalamus heat-
    regulating center with
    consequent peripheral
    vasodilation,
    sweating, and
    dissipation of heat..

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