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  • NCP For LEC Act. 5

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    Keneth Dave Aglibut
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    The document contains an assessment, diagnosis, plan, rationale, and evaluation for a patient with ineffective airway clearance. The plan involves 1) educating the patient on breathing exercises and hydration, 2) assessing breath sounds, and 3) suctioning or administering medications as needed. The goals are to clear the airways after 1 day and identify factors inhibiting clearance after 2 weeks. After intervention, the patient's airways remained clear and goals were met.

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    NCP-for-LEC-Act.-5

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    The document contains an assessment, diagnosis, plan, rationale, and evaluation for a patient with ineffective airway clearance. The plan involves 1) educating the patient on breathing exercises and hydration, 2) assessing breath sounds, and 3) suctioning or administering medications as needed. The goals are to clear the airways after 1 day and identify factors inhibiting clearance after 2 weeks. After intervention, the patient's airways remained clear and goals were met.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    36 views1 page

    NCP For LEC Act. 5

    Uploaded by

    Keneth Dave Aglibut
    The document contains an assessment, diagnosis, plan, rationale, and evaluation for a patient with ineffective airway clearance. The plan involves 1) educating the patient on breathing exercises and hydration, 2) assessing breath sounds, and 3) suctioning or administering medications as needed. The goals are to clear the airways after 1 day and identify factors inhibiting clearance after 2 weeks. After intervention, the patient's airways remained clear and goals were met.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 1

    ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

    Subjective Data: Ineffective Short term: Independent: Independent: Short term:


    “Inuubo siya airway After 1 day of  Educate the patient to  To improve lung function After 1 day of
    tuwing gabi dahil clearance nursing intervention the practice deep breathing and help with mucus nursing intervention the
    sa lamig” as related to patient will be able to exercise. clearance. patient was able to
    verbalized by the cough as maintain clear, open maintain clear, open
    SO of patient evidenced by airways as evidenced by  Auscultate breath sounds  To ascertain current status airways as evidenced by
    dyspnea the absence of abnormal and assess air movement. and note effects of treatment the absence of abnormal
    Objective Data: breath sounds. in clearing airways. breath sounds.
    (+) presence of
    dyspnea Long term:  Encourage the patient to  Maintaining adequate “GOAL MET”
    (+) ineffective After 2 weeks of maintain adequate hydration helps in thinning
    cough nursing intervention the hydration. respiratory secretions, Long term Goal
    patient will be able to making them easier to After 2 weeks of
    Vital Signs: identify and avoid mobilize and clear from the nursing intervention the
    T: 36.5 ̊C specific factors that airways. patient was able to
    HR: 76 bpm inhibit effective airway identify and avoid
    RR: 24 bpm clearance. Dependent: specific factors that
    BP: 90/60 mmHg Dependent:  Suctioning is needed when inhibit effective airway
     Perform nasotracheal clients are unable to cough clearance.
    suctioning as necessary, out secretions properly due
    especially if the cough is to weakness, thick mucus
    ineffective. plugs, or excessive or “GOAL MET”
    tenacious mucus production.

     To help the patient improve


     Administer medications as airway patency and promote
    prescribed by the physician. effective secretion
    clearance.

    Collaborative: Collaborative:
     Collaborate with  To allow a
    pulmonologists. comprehensive
    assessment of the
    patient’s respiratory
    status.

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