NCP PROPER

Problem # 1: COUGH

NURSING DIAGNOSIS: Ineffective Airway clearance related to accumulation of secretions

GOAL/LTO
After 4 days of nursing interventions, the patient will be able to maintain its airway patency as manifested by:
a. Absence of adventitious breath sounds upon auscultation
b. Decrease oxygen inhalation from 2-3 lpm to 1-2 lpm
STO
a. After 8 hours of nursing interventions, the patient will demonstrate an increase in its fluid intake from 3-5 glasses per day to 5-7 glasses per day as
tolerated
b. After 8 hours of nursing interventions, the patient will verbalize a readily expectoration of secretions of at least 1 teaspoon per coughing episode
c. After 8 hours of nursing interventions, the patient will demonstrate a decrease in coughing episodes from 6-8 coughing episodes pre shift to 4-6
coughing episodes per shift

Assessment Explanation of the problem

S- “I have cough but I can’t expectorate the phlegm”
O- with vital signs of CR- 55 bpm, RR- 24 cpm and T°- 36.1°C
- frequent unproductive coughing episodes noted
- appears weak
- with O2 inhalation of 2-3 lpm
- crackles heard over lung fields
- noted fluid intake of 3-5 glasses per day
The patient has unproductive cough therefore secretions are retained in
the bronchi. The inability to expectorate out secretions causes it to
accumulate at the bronchi that now leads to an obstruction into the
respiratory tract which causes the patient to experience ineffective airway
clearance.
 INTERVENTIONS
Dx:
-Assessed and recorded Vital Signs
- Noted for physiological and
psychological factors that is related
to ineffective airway clearance
- Noted for coughing episodes and
characteristic
-Assessed hydration status by
noting fluid intake
Tx:
- Auscultated lung fields to note
presence of adventitious breath
sounds
- Assisted during nebulizatio and
back tapping done
- Elevated head of bed
RATIONALE CRITERIA FOR EVALUATION EVALUATION
- V/S serve as baseline data and GOAL/LTO fully met if the patient
validates the autonomic responses will be able to:
of the patient a. Demonstrate an absence of
adventitious breath sounds
- Knowing the factors, we can know b. Decrease oxygen inhalation from
the underlying cause of the problem 2-3 lpm to 1-2 lpm
and in order for us to give
appropriate interventions GOAL/LTO partially met if the
patient will only demonstrate one of
- To determine the patient’s ability the 2 given criteria
to expectorate secretions to
maintain a patent airway GOAL/LTO not met if the patient is
not able to demonstrate any of the
- A person’s hydration status can 2 given criteria
be determined by noting fluid
intake. An increase in fluid intake STO fully met if the patient will be
may help liquefy secretions for able to:
expectoration. a. Increase its fluid intake from 1L
to 1.5L per day as tolerated
- Presence of adventitious breath b. Verbalize a readily expectoration
sounds indicates respiratory of secretions to at least 1 teaspoon
distress and or accumulation of per coughing episode
secretions c. Decrease in coughing episodes
from 6-8 coughing episodes to 4-6
- Nebulization and Back tapping coughing episodes per shift
helps liquefy viscous secretions
STO partially met if the patient is
- This is to open or maintain an able to demonstrate only 2 out of 3
open airway of the above stated criteria
- Maintained oxygen inhalation of 2-
3 lpm
- Administered medications such as
expectorants and bronchodilators
as ordered
Edx:
- Encouraged patient to increase
fluid intake as tolerated
- Instructed to maintain position
where head of bed is elevated
- Encouraged to do coughing and
deep breathing exercises
- Reiterated importance of
compliance to therapeutic and drug
regimen
- Various modalities may be STO not met if the patient is not
required to maintain adequate able to demonstrate or demonstrate
airway, improve respiratory function only 1 out of the 3 stated criteria
and gas exchange
- These medications helps in
maintaining a patent airway where
it aids in expectoration of
accumulated secretions
- Hydration can help liquefy viscous
secretions and improve secretion
clearance
- This is to maintain an open airway
- These exercises help in
expectoration of secretions
therefore maintaining patent airway
- Compliance to therapeutic and
drug regimen aides in treatment of
the condition