Alternative Learning System

Related Learning Experience

Nursing Care of Children with Alterations in Health Status (Acute and Chronic)
ALTERATIONS IN PERCEPTION AND COORDINATION

NURSING CARE PLAN (NCP)

DARUNDAY, EZRA M. BSN 2B

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE

Subjective Cues: Ineffective airway SHORT TERM: INDEPENDENT After the

 Worried clearance related After 4 hours, the Assess airway for Maintaining patent airway is Assessed the airway of implementation of
because the to yellow sputum client will; patency. always the first priority, the patient for patency. care:
son has retention as  Demonstrate especially in cases like trauma,  The client
evidenced by behaviors to acute neurological demonstrated
having
cough increased air decompensation, or cardiac behaviors of
fever for
exchange arrest. increased air
two days exchanged as
 Classify
with cough Methods to evidenced by
and enhance Abnormal breath sounds can be clear and
yellowish Auscultate lungs for Auscultated the lungs for
secretion heard as fluid and mucus patent airway
presence of normal presence of normal or
phlegm for removal. accumulate. This may indicate with good
or adventitious adventitious breath
five days  Maintain breath sounds. ineffective airway clearance. respiratory
sounds. rate and
and clear, open Wheezing may indicate asthma
irritable airways as depth.
behavior. evidence by  Identified
Objective Cues: normal Respirations may be methods to
respiratory Assess and monitor Assessed and monitored enhance
 Wheezes respiratory rate. shallow and rapid, with
rate and respiratory rate. secretion
audible at prolonged expiration in
RUQ with depth or comparison removal,
substernal respiration, to inspiration. such as the
 retractions and ability use of
to cough up Elevation of the head of the bed prescribed
Vital Signs: secretion. Assist client to facilitates respiratory function Assisted the client to medication
 PR – 130 maintain a using gravity; however, client in maintain a comfortable
bpm LONG TERM comfortable position severe distress will seek the position to facilitate
 RR – 42 After 24 hours, the to facilitate position that most eases breathing by elevating
client will: breathing by breathing. Supporting the head of bed, leaning
b/m
 Recognize elevating the head of arms and legs with table, on over- bed table, or
the bed, leaning on pillows, and so on helps sitting on edge of bed.
significant over- bed table, or reduce muscle fatigue and can
changes in sitting on edge of aid chest expansion.
sputum bed.
color, Cough can be per sis tent but in
character, Observe for effective, especially if client Observed for persistent
amount, and persistent, hacking, is elderly, acutely ill, or hacking, or moist cough.
odor. or moist cough. debilitated. Coughing is most Assisted with measures
 Identified Assist with effective in an upright or in a to improve the
the factors measures to improve head- down position after effectiveness of cough
that inhibit effectiveness of chest percussion. effort.
effective cough effort.
airway Precipitators of allergic type of
clearance Limit exposure to respiratory reactions that can
Limited the exposure to
 Maintain environmental trigger or exacerbate onset of
environmental pollutants
patent pollutants such as acute episode.
such as dust, smoke, and
airway with dust, smoke, and feather pillows.
clear breath feather pillows.
sounds.

COLLABORATIV Humidity helps reduce viscosity

E of secretions, facilitating
Administer Administered medication
expectoration, and may reduce
as indicated by the
medication as or prevent formation of
indicated, such as physician
thick mucus plugs in
nebulizer for bronchioles.
humidification
Persistent, exhausting cough
may need to be suppressed to
Administer conserve energy and permit Administered analgesics,
 Analgesics, cough client to rest. cough suppressants, or
suppressants, or antitussives as necessary.
antitussives.

Cite Reference/s:
In Herdman, T. H., In Kamitsuru, S., & North American Nursing Diagnosis Association,. (2018). NANDA International, Inc. nursing diagnoses: Definitions & classification 2018-
2020.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. 10th Edition. Philadelphia: F.A. Davis
Co.