NCP 1

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTIONS RATIONALE EVALUATION

KNOWLEDGE

Subjective: Ineffective Airway Ineffective airway NOC- Respiratory NIC Airway Management GOAL MET
- Mrs. SC stated that Ivana Clearance related to clearance: Status: Airway
had colds for a week and bronchospasm / Inability to clear Patency
denied fever, trauma and airway spasm secretions or
ingestion of object secondary to asthma obstructions from the Short term: Short term:
respiratory tract to After 8 hours of nursing After 8 hours of nursing
-Verbalized that her child maintain a clear interventions: interventions:
vomited once to previously airway (NANDA,
ingested milk formula 2018)
The patient will be able Assessed respiratory rate, Provides a basis for The patient was able to
Asthma is a to demonstrate signs of depth, and rhythm. Noted evaluating adequacy of demonstrate signs of airway
respiratory problem patent airway and inspiratory- to expiratory ventilation. Respirations patency and improved air
Objective: where muscles can increased air exchange. ratio. may be shallow and rapid, exchange as evidenced by
-12 months old contract and narrow with prolonged expiration relaxed breathing, normal
your airway. When in comparison to respiratory rate or pattern,
-Severe difficulty of that happens, it's inspiration. and absence of cyanosis and
breathing called a bronchial arterial blood gas/ pulse
spasm, or a oximetry results within client
-Cyanotic bronchospasm. Assisted with appropriate To identify causative/ norms
During a bronchial testing (e.g., pulmonary precipitating factors.
-Severe retractions of the spasm, breathing function/ sleep studies) The patient’s mother was
sternum becomes more able to identify and avoid
difficult. specific factors that inhibit
-Wheezing effective airway clearance
Auscultated lungs for Abnormal breath sounds such as dust, pollen, and
-Has decreased intake adventitious breath sounds can be heard as fluid and smoke.
(wheezes and rhonchi). mucus accumulate. This
-ROD ordered Ivana for may indicate ineffective
Intubation stat. airway clearance. The patient’s mother was
able to verbalize
-Lethargic understanding of the
Assessed the effectiveness of Coughing is a natural way therapeutic management
-UTZ result: cough. to clear the throat and regimen.
Normal breathing passage of
foreign particles, irritants,
-T: 37.2 C and mucus. Severe
bronchospasm, thick Long term
-PR: 120 bpm secretions, and respiratory After 3 days of nursing
muscle fatigue are some of interventions:
-RR: 54 bpm the causes of an ineffective
cough. The patient was able to
maintain clear, open airways
as shown by normal
Suctioned naso/ tracheal/ oral To clear the airway when respiratory rate, depth, and
when necessary excessive or viscous rhythm, as well as the
secretions are blocking the absence of signs and
airway or client is unable to symptoms that could indicate
swallow or cough insufficient airway
effectively. clearance.

Assessed the amount, color, Normal secretion is clear or

odor and viscosity of the gray and minimal;
secretions. abnormal sputum is green,
yellow, or bloody;
malodorous; often copious.
Thick tenacious secretions
increase airway resistance.
Monitored and recorded Provides information on
intake and output (I&O) the fluid balance of the
adequately. patient. Dehydration can
contribute to viscous
secretions and may result in
decreased airway
clearance.

Monitored oxygen saturation Oxygen saturation less than

using pulse oximetry. 90% indicates problems
with oxygenation

Monitored chest x-ray A chest x-ray provides

results. information regarding the
presence of infiltrates, lung
inflation, or the presence of
barotrauma.

Monitored laboratory results Establishes a baseline for

as indicated: WBC, monitoring progression or
Potassium, ABG regression of disease
process and complications.

Obtained peak expiratory Peak expiratory flow rate

flow rate (PEFR) or forced
expiratory volume in 1
second (FEV1) before and
after respiratory treatment.
(PEFR) is the maximum
flow rate generated during
forceful exhalation. It
should be improved with
effective therapy. FEV1 is
 the volume exhaled during
the first second of a forced
expiratory maneuver
started from the level of
total lung capacity.

Encouraged increased fluid Hydration can help prevent

intake of up to 3000 ml/day
within cardiac or renal
reserve.
the accumulation of
viscous secretions and
improve secretion
clearance. Fluids help
minimize mucosal drying
and increase ciliary action
to remove secretions.

Administered IV fluids and IV fluid therapy can be

medication as ordered. beneficial for clients with
dehydration. Medications
such as bronchodilators and
inhaled corticosteroids may
be prescribed.

Administered oxygen as Oxygen therapy corrects

ordered. hypoxemia, which can be
caused by retained
respiratory secretions.

Assisted and prepared the Acute exacerbations of

patient for intubation as asthma can lead to
ordered by the physician. respiratory failure
 requiring intubation.

Informed the mother about To avoid situations that

the risk and triggering factors may predispose the child to
of asthma, such as dust, ineffective airway
pollen, smoke, etc. clearance. Precipitators of
allergic types of respiratory
The patient’s mother reactions can trigger or
will be able to identify exacerbate onset of acute
and avoid specific episodes.
factors that inhibit
effective airway
clearance. Performed or assist the Various therapies/
mother of the client in modalities may be required
learning airway clearance to acquire and maintain
techniques, such as postural adequate airways and
drainage and percussion improve respiratory
The patient’s mother (chest function and gas exchange
will be able to verbalize physical therapy [CPT]),
understanding of the flutter devices, high-
therapeutic frequency chest
management regimen. compression with an
inflatable vest,
intrapulmonary percussive
ventilation (IPV), and active
cycle breathing technique
(ACBT).
Long term:
After 3 days of nursing
intervention the patient
will be able to:

Maintain clear, open Positioned head midline with Reinforcing proper

airways as evidenced flexion appropriate for positioning enhances
by normal breath age/condition comfort and reduces stress-
sounds, normal rate and promotes stability of
depth of respirations, behavioural state through
and ability to containment and security.
effectively cough up
secretions after
treatments and deep Elevated head of the To open or maintain open
breaths. bed/change position every 2 airway in at-rest or
hours prn to take advantage compromised individual.
of gravity decreasing
pressure on the diaphragm
and enhancing drainage
of/ventilation to different
lung segments (pulmonary
toilet).

Monitored for feeding To clear the airway when

intolerance, abdominal secretions are blocking the
distention, and emotional airway.
stressors that may
compromise airway.
Inserted oral airway as To maintain anatomic
appropriate position of tongue and
natural airway.

Assisted with procedures To clear/maintain open

(e.g., bronchoscopy, airways.
tracheostomy)

Kept the environment To avoid situations that

allergen free (e.g., dust, may lead to inadequate
feather pillows, smoke) airway clearing in the child.
according to the individual's
situation.

Documented response to To determine the efficacy

treatment or therapy of the treatment and to
identify any adverse
reactions.
 NCP 2

ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

KNOWLEDGE
Objective: Impaired Gas According to NANDA NOC: Respiratory Status: NIC: Oxygen Therapy and GOAL MET
- Colds that Exchange Related (2018-2020), Impaired Gas Exchange Respiratory Monitoring
lasted for To Ineffective Gas Exchange is excess or
almost a week Airway Clearance deficit in oxygenation Short Term: Short Term:
Secondary To and/or carbon dioxide After 24 hours of nursing After 24 hours of nursing
- The patient is Asthma elimination at the interventions, the patient will interventions, the patient;
experiencing alveolar-capillary be able to:
severe membrane. On the other - Maintained
difficulty of hand, Ineffective Airway - maintain vital signs Assessed patient’s vital Rapid and shallow normal vital signs
breathing Clearance is defined as within the normal signs, especially respiratory breathing patterns and as evidenced by
inability by an individual range and rate, depth, and effort, hypoventilation affect (HR- 120 beats
- Patient was to clear secretions or demonstrate adequate including the use of gas exchange (Gosselink per minute (bpm),
cyanotic obstructions from the oxygenation with accessory muscles, nasal & Stam, 2005). RR- 25 (bpm),
respiratory tract to ABGs within normal flaring, and abnormal Increased respiratory BP- 90/75 mm
- On the day of maintain a clear airway. limits breathing patterns. rate, use of accessory Hg, T- 97.4
admission the Asthma is a condition muscles, nasal flaring, F).Demonstrated
patient wherein the airway’s abdominal breathing, adequate
deteriorated diameter is highly and a look of panic in the oxygenation with
further with reduced. This is due to patient’s eyes may be normal ABGs.
severe severe bronchospasm, seen with hypoxia. (o2- 92%, pH-
retractions of mucosal edema and 7.35, PaCO2- 30
 the sternum, mucus plug formation. Assessed the lungs for areas Any irregularity of mm Hg, PaO2- 65
wheezing, and There is a rise in airway of decreased ventilation and breath sounds may mm, Base
decreased resistance which leads to auscultated presence of disclose the cause of Excess- +2
intake and decreased amount of air adventitious sounds. impaired gas exchange. mEq/liter)
lethargic. that enters upon The presence of crackles
inspiration as well as and wheezes may alert
- The ROD expiration. Thus, the nurse to airway
ordered Ivana ventilation is impaired. obstruction, leading to or Long Term:
for Intubation exacerbating existing After 7 days of nursing
stat. hypoxia. Diminished interventions, the patient;
breath sounds are linked
Chart Data with poor ventilation. - Remained in a
- RR: 54 cpm stable condition
Monitored oxygen saturation Pulse oximetry is a useful and achieved
continuously, using a pulse tool to detect changes in optimal gas
oximeter. oxygenation. An oxygen exchange as
saturation of <90% evidenced by the
(normal: 95% to 100%) client having no
or a partial pressure of difficulty of
oxygen of <80 (normal: breathing
80 to 100) indicates
significant oxygenation
problems - Maintained clear
lung fields and
Auscultate lung sounds at Patients with respiratory remained free of
least every 2 to 4 hours. problems may have signs of
Listen for adventitious wheezes, crackles, or respiratory
breath sounds. sound diminished. distress.

Put the patient on an oxygen Helps the patient get

ventilator. adequate oxygen and
clears carbon dioxide.
Checked for the fraction of The fraction of inspired
inspired oxygen (FiO2) and oxygen, FiO2, is an
Positive end-expiratory estimation of the oxygen
pressure (PEEP) content a person inhales
and is thus involved in
gas exchange at the
alveolar level.
Understanding oxygen
delivery and interpreting
FiO2 values are
imperative for the proper
treatment of patients
having problems with
breathing. The benefit of
PEEP has been
demonstrated in terms of
preventing cyclic
opening and collapsing
alveoli in acute
respiratory distress
syndrome patients
(ARDS). Moreover,
protective ventilation,
even in noninjury lungs,
should be considered
such as during
perioperative period
aiming to prevent
collapsing of alveoli.

Checked vitals every 30 This will monitor the

minutes progress of the patient
and will help the
 healthcare providers in
charge to assess the
condition of the patient
and plan further
interventions.

Upright or semi-
Position patient with head of Fowler’s position allows
the bed elevated, in a semi- increased thoracic
Fowler’s position (head of capacity, total descent of
the bed at 45 degrees when the diaphragm, and
supine) as tolerated. increased lung
expansion preventing the
abdominal contents from
crowding.

Slumped positioning
Regularly check the patient’s causes the abdomen to
position so that they do not compress the diaphragm
slump down in bed. and limits full lung
expansion.

Infants and children. The

Connected IV Line to avoid most likely group to
severe dehydration experience severe
diarrhea and vomiting,
infants and children are
especially vulnerable to
 dehydration. Having a
higher surface area to
volume area, they also
lose a higher proportion
of their fluids from a high
fever or burns. Young
children often can't tell
you that they're thirsty,
nor can they get a drink
for themselves.

Long Term:
After 7 days of nursing
interventions, the patient will
be able to: Changes in behavior and
- remain in a stable Monitored patient’s behavior mental status can be
condition and achieve and mental status for the early signs of impaired
optimal gas exchange onset of restlessness, gas exchange.
agitation, confusion, and (in Restlessness, which may
the late stages) extreme be triggered by
lethargy. conditions that change
the respiratory state,
presented high
specificity in a
determination study
conducted by Pascoal
(2015). Cognitive
changes may occur with
chronic hypoxia.

Central cyanosis of
Observed nail beds, cyanosis tongue and oral mucosa
in the skin; especially noted indicates severe hypoxia
 the color of the tongue and and is a medical
oral mucous membranes. emergency (Pahal et al.,
2021). Peripheral
cyanosis in extremities
may or may not be
serious.

Irritants in the
Assessed the home environment decrease
environment for irritants that the patient’s
impair gas exchange. Helped effectiveness in
the patient adjust the home accessing oxygen during
environment as necessary breathing.
(e.g., installing an air filter to
decrease dust).

This technique can help

Help patient deep breathe increase sputum
and perform controlled clearance and decrease
coughing. Have the patient cough spasms.
inhale deeply, hold breath Controlled coughing
for several seconds, and uses the diaphragmatic
cough two to three times muscles, making the
with mouth open while cough more forceful and
tightening the upper effective.
abdominal muscles as
tolerated. This technique promotes
deep inspiration, which
Encourage slow deep increases oxygenation
breathing using an incentive
- maintain clear lung spirometer as indicated.
fields and remain free and prevents atelectasis.
of signs of respiratory
distress. Anticipate the need for Early intubation and
intubation if noninvasive mechanical ventilation
oxygen delivery methods fail are recommended to
to maintain adequate prevent full
ventilation. decompensation of the
patient. Mechanical
ventilation is often
needed to achieve
adequate gas exchange

Turn and reposition the Frequent positioning

patient every 2 hours. helps prevent the pooling
of secretions in the lungs
and prevents alveoli
from collapsing.

Keep the head of the bed Intubated patients have a

elevated at least 30 degrees decreased ability to
at all times. manage their secretions.
Keeping the head
elevated helps move
secretions and prevents
compromising the
airway.

Suction the airway as

needed. Clearing the airway from
secretions helps improve
ventilation and,
therefore, gas exchange.