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NCP Copd

The patient has ineffective airway clearance due to increased secretions production. Short term goals include the patient demonstrating behaviors to improve airway clearance within the shift such as coughing effectively and expectorating secretions. Interventions include establishing rapport, monitoring vitals, assisting with pursed lip breathing exercises, providing health teaching on smoking cessation, nutrition, and proper techniques to expectorate secretions.

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Danica Salinas
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2K views2 pages

NCP Copd

The patient has ineffective airway clearance due to increased secretions production. Short term goals include the patient demonstrating behaviors to improve airway clearance within the shift such as coughing effectively and expectorating secretions. Interventions include establishing rapport, monitoring vitals, assisting with pursed lip breathing exercises, providing health teaching on smoking cessation, nutrition, and proper techniques to expectorate secretions.

Uploaded by

Danica Salinas
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 DOCX, PDF, TXT or read online on Scribd
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CUES

NURSING DIAGNOSI S A1: Ineffective airway clearance related to increased production of secretions.

LONG TERM

SHORT TERM

INTERVENTION

RATIONALE

EVALUATI ON

Subjective: y medyo nahihirap an pa din akong huminga

Objective: y Temp:36 C y RR:20 cpm y PR: 69bpm y BP: 140/80 mmHg y Difficulty of breathing y Productiv e cough with yellowish to whitish secretion s y Weak appearan

P1: Pt will demonstrate improvement in ventilation and adequate oxygenation within normal limits and having absence symptoms of respiratory distress

P1: Within the shift, the patient will be able to demonstrate behaviors to improve airway clearance. e.g. cough effectively and expectorate secretions.

 Established rapport

 Vital signs monitored and recorded.

 IVF regulated @ 5-10 gtts/min.  Assisted patient to assume position of comfort, e.g., elevate head of bed,

 To achieve E1: After expression 8hours of of feelings nursing intervention  Early s, the recognition patient was of adverse able to effects on pt. demonstrat e  To be able to behaviors to have proper improve hydration airway clearance.  Elevation of Such as the coughing head of the effectively bed facilitates and respiratory proper way function on how to by use of expectorate gravity. secretions

 Encouraged/ assisted with pursed lip breathing exercises.

 Provides patient with some means to cope or control dyspnea and reduce air trapping

ce, y Facial grimace

 Kept environmental pollution to a minimum, e.g., dust, smoke and feather pillows, according to Individual situation

 Precipitators of allergic type or respiratory reactions that can trigger or exacerbate onset of acute episode.

 Provided health Teaching on the ff:  Avoid y Smoking recurrence cessation of disease y achieve To eat  To optimum more fruits nutrition and vegetables to prevent infection and to have intake of essential vitamins and minerals.

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