V. NCP PROPER: Problem: Cough Assessment: S:  ”Inuubo ako. Medyo matagal na nga ito e.

Tapos may lumalabas na puting plema kapag umuubo ako. Nakakatulog naman ako pero naaabala minsan nang dahil sa kama 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 pneumonia               Diagnosis: Ineffective airway clearance related to presence of secretion in trachea-bronchial tree secondary to history of CAP Explanation of the problem: Entry of Streptococcus pneumonia, Haemophilus influenza and Staphylococcus species Mycoplasma pneumonia, Legionella and Chlamydia Species through inspiration or aspiration

Activation of defense mechanism Loss of effectiveness of defense mechanism

Penetrate the sterile lower respiratory tract (lungs)

Nursing care plan

Submitted by: MEDINA, PATRICK LUIS

alveoli multiplication Irritation of the airways Increase goblet cells Increase mucus production Cough

Objectives: GOAL: After the entire hospitalization, the patient will manifest clear airway and effective breathing LTO >After After 3 days of nursing interventions, the patient will maintain patent airway as manifested by clear breath sounds, normal rate of respiration, and effective cough STO >After almost 8 hours of Nursing Interventions, the patient: 1. Will manifest stable and normal vital signs (BP, RR, PR, Temp) 2. Will manifest clear breath sounds as manifested by absence of wheezes 3. Will cough effectively through capability to expectorate all accumulated secretions 4. will enumerate at least 2 management of cough 5. will adhere and comply to all therapeutic regimens like medications

Nursing care plan

Submitted by: MEDINA, PATRICK LUIS

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