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Cap NCP

The client reported difficulty breathing due to phlegm. After 2 hours of monitoring and interventions like adjusting positioning and providing breathing exercises and expectorants, the goal of relieving breathing difficulty was not met as the client's respiration rate and depth increased, likely due to increased phlegm obstruction. Continued monitoring and interventions were needed to help clear airways and reduce bronchospasm.

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kyshb
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7K views2 pages

Cap NCP

The client reported difficulty breathing due to phlegm. After 2 hours of monitoring and interventions like adjusting positioning and providing breathing exercises and expectorants, the goal of relieving breathing difficulty was not met as the client's respiration rate and depth increased, likely due to increased phlegm obstruction. Continued monitoring and interventions were needed to help clear airways and reduce bronchospasm.

Uploaded by

kyshb
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC or read online on Scribd
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ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS S
Subjective: Ineffective After 2 hours • Monitor RR, • To After 2 hours of
“Nahihirapan Airway of nursing taking note of the establish nursing
akong Clearance related interventions, the depth and rate, baseline data intervention, goal
huminga dahil sa to client’s BP, PR and monitor was not met as
plema”, as presence of respiration will •Auscultate lung changes evidenced by an
verbalized by the Secretions improve and fields, noting • To increase in the
client. secondary to difficulty of presence of determine depth and rate of
Community – breathing will be adventitious possible respirations due
Objective: acquired relieved. breath sounds bronchospas to an increase in
• productive pneumonia • Elevate head of m or difficulty of
cough – bed to high obstruction breathing.
sputum is fowler’s
thick and • To
brownish in facilitate
color • Provide health breathing and
• crackles teachings lung
• DOB regarding expansion
• Deep coughing and
breathing deep breathing • To
exercise. facilitate in
• irritability
the expulsion
• Encourage of mucus
client to increase
fluid intake to
about 2000 mL • To liquefy
secretions
• Administer
medications such
as expectorants
• To reduce
as ordered
bronchospas
m and
mobilize
secretions

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