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    NCP - Ineffective Airway Clearance R/T Retained Secretions 2° BPN

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    Carl Elexer Cuyugan Ano
    This nursing care plan is for a 3-year-old patient with bronchopneumonia. The patient is experiencing ineffective airway clearance due to retained secretions from the bronchopneumonia. The short-term goals are to establish rapport, monitor vital signs, place the patient in an orthopneic position, and encourage deep breathing exercises and coughing to mobilize secretions. The long-term goals are for the patient to expectorate retained secretions and maintain a normal breathing pattern within 1-3 days.

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    NCP - Ineffective Airway Clearance R/T Retained Secretions 2° BPN

    Uploaded by

    Carl Elexer Cuyugan Ano
    20K views1 page
    This nursing care plan is for a 3-year-old patient with bronchopneumonia. The patient is experiencing ineffective airway clearance due to retained secretions from the bronchopneumonia. The short-term goals are to establish rapport, monitor vital signs, place the patient in an orthopneic position, and encourage deep breathing exercises and coughing to mobilize secretions. The long-term goals are for the patient to expectorate retained secretions and maintain a normal breathing pattern within 1-3 days.

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    NCP - Ineffective Airway clearance r/t retained secretions 2° BPN

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    This nursing care plan is for a 3-year-old patient with bronchopneumonia. The patient is experiencing ineffective airway clearance due to retained secretions from the bronchopneumonia. The short-term goals are to establish rapport, monitor vital signs, place the patient in an orthopneic position, and encourage deep breathing exercises and coughing to mobilize secretions. The long-term goals are for the patient to expectorate retained secretions and maintain a normal breathing pattern within 1-3 days.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF or read online from Scribd
    Download as doc or pdf
    20K views1 page

    NCP - Ineffective Airway Clearance R/T Retained Secretions 2° BPN

    Uploaded by

    Carl Elexer Cuyugan Ano
    This nursing care plan is for a 3-year-old patient with bronchopneumonia. The patient is experiencing ineffective airway clearance due to retained secretions from the bronchopneumonia. The short-term goals are to establish rapport, monitor vital signs, place the patient in an orthopneic position, and encourage deep breathing exercises and coughing to mobilize secretions. The long-term goals are for the patient to expectorate retained secretions and maintain a normal breathing pattern within 1-3 days.

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    Download as DOC, PDF or read online from Scribd
    Download as doc or pdf
    of 1

    Jerimae De Dios Carl

    Elexer C.Ano
    3 y/o July 8 2008
    SCIENTIFIC EXPECTED
    ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE
    EXPLANATION OUTCOME
    S>Ø Ineffective Airway Normally the lungs are Short term: >Establish rapport >To gain the client and The client shall have
    O> The pt manifested clearance r/t retained free from secretions. But SO’s trust. maintained airway
    the ff. secretions 2° BPN with Bronchopneumonia, After 2-4° of NI, the >Monitor VS. >To obtain data for patency AEB clear
    bacteria are invading the client will be able >Place on an orthopneic comparison. breath sounds.
     DOB lung parenchyma thus, maintain airway position >To maintain patent
     Orthopnea producing inflammatory patency AEB clear >Elevate HOB airway
     Wheezes on both process. And this breath sounds. >To take advantage of The client shall have
    lung fields response leads to filling >Encourage deep gravity ↓pressure on expectorated
     Chest indwelling of the alveolar sacs with Long term: breating exercise and the diaphragm. retained secretions
    exudates leading to coughing exercise >To mobilize secretion. and maintained
     Uses intercostal
    consolidation. Due to After 1- 3 days of NI the >Encourage to ↑ fluid normal breathing
    muscles upon
    consolidation the airway client will be able to intake >To moisten secretions pattern.
    respiration.
    is narrowed thus wheezes expectorate retained for easy expectoration
     Nasal flaring
    is being heard, DOB in secretions and maintain >Do CPT >To manage client’s
     Productive cough some cases orthopnea is normal breathing condition non-
     Tachypnea RR=(43 observed. pattern. >Give bronchodilators as pharmacologically
    cpm) ordered (e.g.BIONEB) >To pharmacologically
     Productive Cough >Refer for any abnormal manage client’s
    changes in the body condition
    > The pt manifested >To medically manage
    the ff. any complication.

    Restlessness
    Cyanosis

    BPN

     Impaired Gas Exchange r/t retained secretions 2° BPN


     Risk for Impaired Tissue Perfusion r/t Impaired Gas Exchange 2° BPN

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