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NCP PROPER Cough Coro

NCP PROPER Cough Coro

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Published by: konoha2214839 on Jul 01, 2010
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07/05/2013

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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 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 Explanation of the problem 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

RATIONALE

CRITERIA FOR EVALUATION

EVALUATION

- V/S serve as baseline data and validates the autonomic responses of the patient

- 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

GOAL/LTO fully met if the patient will be able to: 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 23 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 required to maintain adequate airway, improve respiratory function 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

STO not met if the patient is not able to demonstrate or demonstrate only 1 out of the 3 stated criteria

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