NCP 1

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Ineffective Short Term Goal: Independent: Short Term Goal:
“Gikapoy nako sigeg Airway After 2 hours of nursing Assess respiratory Diminished breath sounds may After 2 hours of nursing
ubo-ubo, hapit na ni Clearance interventions, the function noting breath sounds, rate, reflect atelectasis. Rhonchi, wheezes interventions, the client will feel
mag isa ka bulan ug related to client will: rhythm, and depth, and use of indicate accumulation of secretions a little bit comfortable to the
galisod nasad kog thick, bloody accessory muscles. and inability to clear airways that breathing exercises and position,
ginhawa.” bronchial Verbalize feeling of may lead to use of accessory muscles report decreased malaise and
secretions as comfort while and increased work of breathing fatigue, increase his fluid intake,
Objective: evidenced by performing breathing and understand the nature of the
dyspnea exercises Note ability to expectorate mucus Expectoration may be difficult when disease.
Yellow Phlegm and cough effectively; document secretions are very thick as a result
Achieve a comfortable character, amount of sputum, of infection and/or inadequate
Dyspnea position presence of hemoptysis. hydration. Blood-tinged or frankly
bloody sputum results from tissue Long Term Goal:
Productive cough Report decreased breakdown (cavitation) in the lungs After 8 hours of nursing care, the
malaise and fatigue or from bronchial ulceration and goal is partially met as evidenced
Chest pain may require further evaluation or by client’s participation to
Increase fluid intake intervention. breathing and coughing exercises
Crackles upon and ability to expectorate sputum
auscultation Understand the nature Suction secretions as necessary. To help clear thick phlegm that the upon evaluation; still there are
of the disease patient is unable to expectorate. episodes of dyspnea as claimed
Manifests malaise Prevents obstruction and aspiration. by the client.
and fatigue Long Term Goal:
After 8 hours of nursing Maintain fluid intake of at least 2500 High fluid intake helps thin
VS taken as follows: interventions, the mL/day unless contraindicated. secretions, making them easier to
PR: 82 bpm client will: expectorate.
RR: 27
T: 37.1 Expectorate secretions Humidify inspired air and oxygen Prevents drying of mucous
BP: 120/90 membranes and helps thin
SpO2: 85% Have absence or secretions
decrease in episodes of Maintain room or environment free
dyspnea. from any sorts of allergen.
Instruct to take warm liquids instead
of cold ones.
Teach and encourage deep
breathing and coughing exercises.
Place patient in semi or high-
Fowler’s position. Assist patient with
coughing and deep-breathing
exercises.
Educate client and family about
disease condition and the need for
compliance with the therapeutic
regimen.
Dependent:
Administer supplemental oxygen, as
prescribed. Discontinue if SpO2 level
is above the target range, or as
ordered by the physician.
Administer prescribed TB
medications:
Mucolytic agents: acetylcysteine
(Mucomyst);
Bronchodilators: oxtriphylline
Allergen may trigger more
accumulation of secretion due to
respiratory response.
Warm fluids help in loosening the
secretions while cold liquids triggers
cough more often
These exercises hasten the expulsion
of sputum and aids in maintaining
Positioning help the expansion of the
lungs, enabling patient to breathe
more effectively.
PTB can be transmitted through
droplet inhalation and 6 months
compliance to medication is needed
in order to be treated with it
To increase oxygen level and achieve
an SpO2 value of at least 94%
Reduces the thickness and stickiness
of pulmonary secretions to facilitate
clearance.
(Choledyl), theophylline (Theo-Dur);
Corticosteroids (prednisone);
Steroids
Be prepared for/assist with
emergency intubation.
Increases lumen size of the
tracheobronchial tree, thus
decreasing resistance to airflow and
improving oxygen delivery.
May be useful in presence of
extensive involvement with
profound hypoxemia and when
inflammatory response is life-
threatening.
To reduce the inflammation in the
lungs.
Intubation may be necessary in rare
cases of bronchogenic TB
accompanied by laryngeal edema or
acute pulmonary bleeding.
 NCP 2
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective Short term goal: Independent: Short term goal:
“Gusto na kayko breastfeeding After 3 hours of 1. Identify factors that 1. Some conditions After 3 hours of
mupatotoy sa bata related to nursing contribute to may preclude nursing
pero dili mugawas knowledge intervention, the ineffective breastfeeding. intervention, the
ang gatas.” deficit as mother will be able breastfeeding. mother is able to
2. Early detection
evidenced by to 2. Assess the structure of verbalize and
Objective: and treatment of
infant’s  verbalize and nipples and breasts. demonstrate her
 VS: abnormalities.
inadequate demonstrate understanding in
 BP: 3. Provide emotional 3. Helps verbalize
milk intake her proper
140/90 support and allow needs and makes
understanding breastfeeding, have
mmHg clients to voice their her feel better.
in proper positive self-
 PR: 85 breastfeeding, expectations and esteem, hold her
bpm  Manifest worries. 4. Discomfort and baby properly, and
 RR: 20 positive self- 4. Promote comfort and increased tension explain alternative
cpm esteem relaxation are linked to methods if the baby
 Temp:  Hold her baby decreased "let- is unable to
36.9 properly down reflex and breastfeed.
 Does not  Explain premature Additionally, the
know how to alternative discontinuance of infant manifested
breastfeed method if breastfeeding. signs or adequate
infant is Anxiety and fear milk intake.
unable to can reduce milk
breastfeed 5. Provide necessary production.
Infant will: health teaching about 5. For effective
 Manifest signs breastfeeding such as breastfeeding.
of adequate proper positioning,
milk intake when to breastfeed,
and how to get a good
attachment.
6. Observe infant’s ability 6. To determine if
to suck. the infant is
competent in
sucking.
7. Support baby’s head, 7. For the safety of
neck, and back while the baby and to
the mother is breastfeed
breastfeeding. properly.
8. Encourage mother to 8. Provides
continue trying. emotional support
to the mother.
9. Alternate
9. For adequate milk
breastfeeding from
intake.
either breast.
10.Teach mother to 10.Teaching mother
observe infant will build her
behavioral cues and confidence and
breastfeeding knowledge base.
responses.

11.Increase fluid intake. 11.To stay hydrated

 12.Eat healthy foods and 12. Prevents
increase caloric intake. inadequate
nutrient intake for
the infant.
13.Encourage maternal
13.Boosts the
support from husband
mother's
and other family
confidence in
members.
achieving effective
14.Encourage mother to breastfeeding.
use the bathroom and 14. To avoid
change baby’s diaper interruption.
before breastfeeding.
15.Evaluate adequacy of 15.To monitor the
infant intake. improvement.
16. Evaluate and record 16.The let-down
signs of oxytocin reflex is an
release. indication of
oxytocin release
and is necessary
for transfer of milk
to infant.
Dependent:
1. Administer
multivitamins/ 1. To provide
medicine to infant as nutrition and
attending physician’s health
order. maintenance
 necessary for
breastfeeding.

NCP 3
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Low self- Short Term Goal: Independent: Short Term Goal:
“Pamati nako nag esteem After 3 hours of 1. Determine client’s 1. Unplanned After 3 hours
fail ko as a mother related to nursing level of anxiety and cesarean births nursing
and wife kay wala perceived interventions, the source of concern. can damage a interventions, go
nako nakaya ang failure at a client will: Encourage the client's self- were met.
vaginal delivery.” life event as  Discuss client/couple to share esteem, making The client:
evidenced concerns any unmet needs. her feel  Shared
“Gibuhat man gyud by related to inadequate and a concerns
nako ang tanan verbalization her/his role in failure as a perception
pero wala gyud of negative and woman. her b
2. Determine the client/
nako nakaya.”, as feelings perception of 2. To identify other experience
couple’s response to
verbalized by the the birth concerns.  Shared
cesarean birth.
patient 2 days after experience. understand
3. Explain the normalcy 3. Helps the
the birth of her first  Verbalize of
of such feelings. woman realize
baby. understanding circumstan
that it is not her
of the that led
Objective: 4. Review client/couple fault.
circumstance current
 Anxious role in birth 4. Help them see
that led to situation.
 VS: experience. Identify the big picture of
current  Expressed
 PR: 58 positive prenatal and pregnancy and
situation. positive s
bpm antenatal behaviors. how their
 Express appraisal.
 RR: 17 activities have
positive self-
cpm helped the
appraisal.
 T: 37.1 5. Encourage partner's result.
 BP: presence/participation. 5. Encourages
140/90 verbalization of
concern and
 provides
6. Differentiate vaginal emotional
and cesarean births. support.
Maintain a positive 6. Emphasis is
attitude and provide placed on the
postpartum care outcome rather
similar to the care than the birth
given to clients after process, implying
vaginal birth. that cesarean
7. Help the client/couple birth was needed
find coping methods 7. Reduces
and build new ones as emotions of
needed. inadequacy and
promotes
8. Provide correct positive role
client/infant status. adaption.
8. Misinformation
can enhance
feelings of
helplessness/loss
Collaborative: of control.
1. If the client's
reactions are
maladaptive, refer to
professional 1. They may need
counseling. further
professional
help.