Copy Of Ncp(2)

B. NCP with Evaluation CUES

NURSING DIAGNOSIS

S: “ narigat suna nga maka anges ta adu ti plemas na” as verbalized by the mother.

P> Ineffective airway clearance

“Uyek nga uyek isuna supay ngata pakirigrigatan na ah umangesen” added by the mother .

S> AEB “ narigat suna nga maka anges ta adu ti plemas na” as verbalized by the mother.

E>r/t hypertrophy of muscussecreting glands

“haan unay isuna makakaan to nasyat  Productive ta deta nga cough sitwasyon na” as  Use of verbalized by his accessory mother. muscles when breathing O:  Conscious and coherent.  Restless at times  Weak in appearance

ANALYSIS

viruses that attack the lining of the bronchial tree ↓ infection of the bronchial tree ↓ Swelling and mucus secretion ↓ Harder to breathe ↓ Use of accessory muscle to breathe. Whistling sound when auscultated ↓ Ineffective airway clearance.

NURSING OBJECTIVE

NURSING INTERVENTION

01-22-08 7am With in the 1 day stay patient will be free of secretions and clear breath sounds and able to breathe normally

Independent: Auscultate lungs as needed Asses characteristics of secretions Allow patient to perform task @ his own rate. Keep side rails of bed.

RATIONALE

EVALUATION

Date: 01-22-08 To note significant changes in Time: 5:30pm breathe sounds Level of Attainment: To properly document or note -goal partially met the consistency, quality, color,  AEB: pt. is not totally and odor free of secretions.  Still with whistling Increases pt self esteem. breath sound.  Pt. is able o breathe normally. Promotes safe environment.

Monitor I & O, nutritional status.

Pressure sores develop more quickly in pt. w/ a nutritional deficit

Encourage coughing and DBE.

Prevent build up of secretion, development of hypostatic pneumonia.

Encourage liquid intake unless contraindicated.

To optimize hydration & prevent hardening of stool

Use of accessory muscle to breath.  Irritable.  Productive cough  V/S as follows: BT 37C HR: 180bpm RR: 30cpm No DOB Hgb 14.6g/dl Hct 44% WBC 11.2 Neutrophils 0.92 Lymphocytes 0.08

Collaborative:



Assist in mobilizing secretions.

To facilitate airway clearance

Anticipate administration of bronchodilators.

To relieve bonchoconstriction

Consult rehabilitation personnel or therapist as appropriate.

Platelet count: 295

P>impaired gas exchange E>r/t increased residual volume, upper and lower airway resistance cause by overproduction of secretions along bronchial tubes. S>AEB: “ narigat suna nga maka anges ta adu ti plemas na” as verbalized by the mother. Use of accessory

Swelling of the bronchiole walls ↓

Increased the production of sputum ↓

Decreased Oxygen exchange ↓

Impaired gas exchange

Patients maintain optimal gas exchange AEB normal vital signs and normal breathing

Independent: Asses for altered breathing pattern Assess for signs and sx of hypoxia, cyanosis, tachypnea, restlessness

Proper and accurate documentations is needed to asses pt. to look for danger signs

Monitor vital signs

For proper documentation

Keep side rails of bed.

Promotes safe environment.

Monitor I & O, nutritional status.

Pressure sores develop more quickly in pt. w/ a nutritional deficit

Level of Attainment: -goal partially met  AEB: The patient still using her accessory muscle for breathing, “Marigatan pay lang suna makaanges adding “ as verbalized by her mother

muscles of breathing

Collaborative:

Restlessness Increase rate and depth of respiration

Promote more effective breathing pattern

For better gas exchange

Teach patient pursed lip breathing

For more complete exhalation

Anticipate administration of bronchodilators.

To relieve bonchoconstriction

Consult rehabilitation personnel or therapist as appropriate. Independent: Disease condition P> Altered nutriotion: less than body requirements E>r/t increased metabolic need caused by increased work of breathing Poor appetite resulting from dyspnea

↓

Dyspnea and fatigue ↓

Decreased appetite ↓

Poor nutrition ↓

Altered nutrition less than body requirements

Patient optimal nutritional status is maintained AEB maintenance of body weight and increased appetite

Asses caloric requirements and caloric intake Assess for possible cause of poor appetite Offer small feedings of nutritious food Assist pt. with meals

Level of Attainment: -goal met AEB: The patient eats 1 So that you can eliminate those cup of rice drinks plenty factors that’s affecting the of water appetite of the pt. “ mangmangen metten adding nasayaat met They are easier to digest and pagkaan nan requires less chewing nabisbisiann ngatan ah “ as verbalized by her mother

Instruct pt to avoid very To prevent abdominal hot/cold foods, gas forming distension foods.

S> AEB

Plan activities Top promote rest period for the patient

S>:“haan unay isuna makakaan to nasyat ta deta nga sitwasyon na” as verbalized by his mother.

Collaborative: Consult and work with the dietician to estimate caloric needs.

Weak in appearance Independent: P> high risk for infection

Swelling Of the bronchiole walls ↓

E> r/t retained secretions( good for bacterial growth) Poor nutrition Impaired pulmonary defence mechanism secondary to COPD.

Increased production of sputum ↓

Retain secretions ↓

good for bacterial growth ↓

high risk for infection

Risk for infection is reduced through early assessment and intervention.

Auscultate lungs Assess significant change in sputum

Brochial breath sounds and rales may indicate pneumonia My indicate presence of infection To prevent infection

Assess for other signs and sx of infection Encourage increased fluid intake Minimize retained secretions by encouraging pt to cough.

Level of Attainment: -goal met AEB: the patient did not show any signs of infection like fever her temperature was normal V/S T> 37 C

To maintain good hydration because increased fluid loss is present when there is nfection Retained secretions promote bacterial growth

Independent: P> Knowlegde deficit of patient and significant others E>r/t recent diagnosis ineffective past teaching, ignorance of the disease condition S> AEB Display of anxiety Inability to verbalize health maintenance regime Misconception about health status Multiple question or none

Inadequate knowledge about the disease condtion of the patient ↓

Lack of information about care of significant others ↓

Knowledge deficit

Patient verbalizes understanding of the disease process and treatment.

Assess knowledge base of COPD Establish common goals Discuss relation of disease process to signs and sx Discuss about the medication Discuss sign and symptoms of infection Discuss importance of specific therapeutic measures Health teaching: 1. Drink of plenty of water 6-8 glasses a day 2. instruct significant others about proper coughing technique 3. instruct significant others about proper deep breathing exercises 4. explain significant others about importance of strict compliance of

Level of Attainment: -goal met AEB: Significant others was able to understand the disease condition and the ways on how to take care about the condition of their daughter “Maawatam min adding noh kasano mo alagaan ken preventaran ton ti panagsakit nan” as verbalized by her mother

medication regimen 5. discuss significant others about signs and symptoms of infection like fever 6. Instruct significant others on proper hygiene 7. Instruct significant others for regular follow up care 8. Discuss the significant others about the disease condition for future prevention 9. Instruct significant others about eating healthy and nutritious food like green leafy vegetables 10. Instruct significant others about proper exercises