NCP PROPERProblem # 1: COUGHNURSING DIAGNOSIS
: Ineffective Airway clearance related to accumulation of secretions
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 auscultationb. Decrease oxygen inhalation from 2-3 lpm to 1-2 lpm
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 astoleratedb. After 8 hours of nursing interventions, the patient will verbalize a readily expectoration of secretions of at least 1 teaspoon per coughing episodec. After 8 hours of nursing interventions, the patient will demonstrate a decrease in coughing episodes from 6-8 coughing episodes pre shift to 4-6coughing episodes per shift
“I have cough but I can’t expectorate the phlegm”
- 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
Explanation of the problem
The patient has unproductive cough therefore secretions are retained inthe bronchi. The inability to expectorate out secretions causes it toaccumulate at the bronchi that now leads to an obstruction into therespiratory tract which causes the patient to experience ineffective airwayclearance.