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    NCP Croup

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    aurezea
    1. The client, a grandmother, reported that her grandson had just eaten chocolates and asked if he was allergic. 2. On examination, the grandson presented with signs of an obstructed airway including coughing, wheezing, rapid breathing and heart rate. 3. The nursing diagnosis was ineffective airway clearance related to tracheobronchial obstruction from possible chocolate allergy. The plan was to improve airway patency through interventions like positioning, suctioning, medications and monitoring over 8 hours.

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    NCP Croup

    Uploaded by

    aurezea
    5K views3 pages
    1. The client, a grandmother, reported that her grandson had just eaten chocolates and asked if he was allergic. 2. On examination, the grandson presented with signs of an obstructed airway including coughing, wheezing, rapid breathing and heart rate. 3. The nursing diagnosis was ineffective airway clearance related to tracheobronchial obstruction from possible chocolate allergy. The plan was to improve airway patency through interventions like positioning, suctioning, medications and monitoring over 8 hours.

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    NCP-croup

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    1. The client, a grandmother, reported that her grandson had just eaten chocolates and asked if he was allergic. 2. On examination, the grandson presented with signs of an obstructed airway including coughing, wheezing, rapid breathing and heart rate. 3. The nursing diagnosis was ineffective airway clearance related to tracheobronchial obstruction from possible chocolate allergy. The plan was to improve airway patency through interventions like positioning, suctioning, medications and monitoring over 8 hours.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    5K views3 pages

    NCP Croup

    Uploaded by

    aurezea
    1. The client, a grandmother, reported that her grandson had just eaten chocolates and asked if he was allergic. 2. On examination, the grandson presented with signs of an obstructed airway including coughing, wheezing, rapid breathing and heart rate. 3. The nursing diagnosis was ineffective airway clearance related to tracheobronchial obstruction from possible chocolate allergy. The plan was to improve airway patency through interventions like positioning, suctioning, medications and monitoring over 8 hours.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    CUES NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE FOR EVALUATION

    DIAGNOSIS EXPLANATION OR EACH PARAMETERS


    BACKGROUND INTERVENTION
    Subjective: Ineffective airway URT trauma or Goal: After 8 hrs The client’s airway
    “I just gave him clearance r/t irritant shift of nursing patency has
    some chocolates. tracheobronchial (chocolates) intervention improved.
    Is he allergic to obstruction. ↓ client’s airway
    that?” as stated tracheobronchial patency will
    by the client’s obstruction improve.
    grandmother. ↓
    Ventilation Objectives:
    perfusion (V/Q) The client will be
    Objective: mismatch able:
    -Cry ↓ 1.To be free from 1.Position with 1. Open airway 1. Client was free
    -Sharp barking Increase secretion secretions or airway open allows adequate from obstruction,
    cough production obstruction, (sniffing position if ventilation. breathes easily,
    -Audible stridor ↓ easier work of supine). respiratory and
    -Tachychardia Ineffective airway breathing, • Humidify oxygen • Help liquefy heart rate was
    -Tachypnea clearance respiratory and or room air and secretions for maintained within
    (+) nasal flaring heart rate within ensure adequate ease in clearance normal range).
    -Intercoastal parameters. fluid intake
    retractions (intravenous or
    -Productive oral).
    cough(sharp & • Suction with • Removal of
    frequent) bulb syringe or via secretions
    nasopharyngeal
    PR- 146 bmp catheter as
    (left radial pulse) needed.
    RR- 40 cpm • If tachypneic, • To avoid risk of
    ( irregular ) maintain NPO aspiration.
    T- 39C ( left axilla) status.
    • Encourage • To promote
    expectoration of airway clearance.
    sputum with
    coughing.
    • Perform chest • To mobilize
    physiotherapy if secretions
    ordered. with the
    assistance of
    percussion or
    vibration
    accompanied by
    postural drainage
    • Ensure •To avoid delay
    emergency should airway
    equipment is become
    readily available. unmaintainable.

    2. To take her due 2. Provide patient 2. Produces 2. Client was able


    medication optimal patent bronchodilation to take her due
    (as prescribed) airway with and exert a med.
    prescribed potent, locally
    bronchodilators acting anti-
    (racemic inflammatory
    epinephrine effect to decrease
    inhalant) and the frequency and
    corticosteroids severity of
    (betamethasone) attacks.
    as ordered.
    CANDO, Precious Gia G. May 28, 2010

    NCM104-AN01 Prof. Delia Tan

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