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NCP Ineffective airway clearance related to presence of secretion in trachea-bronchial tree secondary to history of CAP

NCP Ineffective airway clearance related to presence of secretion in trachea-bronchial tree secondary to history of CAP

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Published by pa3kmedina

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Published by: pa3kmedina on May 28, 2010
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01/24/2013

 
V. NCP PROPER:Problem: CoughAssessment:
S:
”Inuubo ako. Medyo matagal na nga ito e. Tapos may lumalabas na puting plemakapag umuubo ako. Nakakatulog naman ako pero naaabala minsan nang dahil sakama kong matigas”O:
Coherent, alert and fully awake
(+) Pale conjunctiva
(+) Pale oral mucous membrane
Episode of non productive cough noted
(+) Use of sternocleidomastoid in breathing
Symmetrical lung expansion noted
Appears weak 
 Normal chest excursion (1 inch)
Capillary refills at 2 seconds
With wheezes on bilateral lower lobes noted upon auscultation
Good skin turgor 
In semi fowlers position
Pale skin noted
Vital Signs
o
BP=120/80 mmHg
o
PR: 70 beats/minutes
o
Temperature (Axilla) 36 degree Celsius
o
RR: 19 cycles/minute
X-ray and UTZ (February 22, 2010) reveals bibasal pneumoniaDiagnosis:Ineffective airway clearance related to presence of secretion in trachea-bronchialtree secondary to history of CAP
Explanation of the problem:
Entry of Streptococcus pneumonia, Haemophilus influenza and Staphylococcus speciesMycoplasma pneumonia, Legionella and Chlamydia Species through inspiration or aspirationActivation of defense mechanismLoss of effectiveness of defense mechanismPenetrate the sterile lower respiratory tract (lungs)
Nursing care plan
Submitted by:
MEDINA, PATRICK LUIS

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