B.

NCP with Evaluation

CUES NURSING ANALYSIS NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVE INTERVENTION

S: P> Ineffective 01-22-08 7am Independent: Date: 01-22-08

“ narigat suna nga airway clearance viruses that attack the With in the 1 day Auscultate lungs as needed To note significant changes in Time: 5:30pm
lining of the bronchial stay patient will
maka anges ta adu tree be free of
breathe sounds Level of Attainment:
ti plemas na” as E>r/t hypertrophy ↓ secretions and Asses characteristics of To properly document or note -goal partially met
verbalized by the of muscus- infection of the bronchial clear breath secretions the consistency, quality, color,  AEB: pt. is not totally
mother. secreting glands tree sounds and able and odor free of secretions.
↓ to breathe  Still with whistling
normally
“Uyek nga uyek S> AEB “ narigat Swelling and mucus
Allow patient to perform Increases pt self esteem. breath sound.
isuna supay ngata suna nga maka secretion task @ his own rate.  Pt. is able o breathe
pakirigrigatan na ah anges ta adu ti ↓ normally.
umangesen” added plemas na” as Harder to breathe Keep side rails of bed. Promotes safe environment.
by the mother . verbalized by the ↓
Use of accessory muscle
mother. to breathe. Whistling
Monitor I & O, nutritional Pressure sores develop more
“haan unay isuna sound when auscultated status. quickly in pt. w/ a nutritional
makakaan to nasyat  Productive ↓ deficit
ta deta nga cough Ineffective airway
sitwasyon na” as clearance. Encourage coughing and Prevent build up of secretion,
 Use of
verbalized by his accessory DBE. development of hypostatic
mother. muscles when pneumonia.
breathing
O: Encourage liquid intake To optimize hydration &
 Conscious and unless contraindicated. prevent hardening of stool
coherent.
 Restless at times
 Weak in
appearance
 Use of accessory Collaborative:
muscle to breath.
 Irritable. Assist in mobilizing To facilitate airway clearance
 Productive cough secretions.
 V/S as follows:
BT 37C Anticipate administration To relieve bonchoconstriction
HR: 180bpm of bronchodilators.
RR: 30cpm
No DOB Consult rehabilitation
Hgb 14.6g/dl personnel or therapist as
Hct 44% appropriate.
WBC 11.2
Neutrophils 0.92
Lymphocytes 0.08
Platelet count: 295 Independent: Level of Attainment:
Swelling of the Patients Asses for altered breathing Proper and accurate -goal partially met
P>impaired gas bronchiole walls maintain pattern documentations is needed to  AEB:
exchange ↓ optimal gas asses pt. to look for danger
E>r/t increased exchange Assess for signs and sx of signs The patient still using
residual volume, Increased the AEB normal hypoxia, cyanosis, her accessory muscle for
upper and lower production of sputum vital signs and tachypnea, restlessness breathing,
airway resistance ↓ normal
cause by breathing Monitor vital signs For proper documentation “Marigatan pay lang
overproduction of Decreased Oxygen suna makaanges adding
secretions along exchange Keep side rails of bed. Promotes safe environment. “ as verbalized by her
↓
bronchial tubes. mother
S>AEB: “ narigat Monitor I & O, nutritional Pressure sores develop more
Impaired gas
suna nga maka status. quickly in pt. w/ a nutritional
exchange
anges ta adu ti deficit
plemas na” as
verbalized by the
mother.
Use of accessory
muscles of Collaborative:
breathing
Promote more effective For better gas exchange
Restlessness breathing pattern

Increase rate and Teach patient pursed lip For more complete exhalation
depth of breathing
respiration
Anticipate administration To relieve bonchoconstriction
of bronchodilators.

Consult rehabilitation
personnel or therapist as
appropriate.

Independent: Level of Attainment:

Disease condition Patient -goal met
P> Altered ↓ optimal Asses caloric requirements
nutriotion: less nutritional and caloric intake AEB: The patient eats 1
than body Dyspnea and fatigue status is So that you can eliminate those cup of rice drinks plenty
requirements ↓ maintained Assess for possible cause factors that’s affecting the of water
AEB of poor appetite appetite of the pt.
E>r/t increased Decreased appetite maintenance “ mangmangen metten
↓
metabolic need of body adding nasayaat met
caused by weight and Offer small feedings of They are easier to digest and pagkaan nan
Poor nutrition nutritious food
increased work of ↓
increased requires less chewing nabisbisiann ngatan ah “
breathing appetite as verbalized by her
Assist pt. with meals mother
Altered nutrition less
Poor appetite than body
resulting from Instruct pt to avoid very To prevent abdominal
requirements
dyspnea hot/cold foods, gas forming distension
foods.
S> AEB Plan activities
Top promote rest period for the
S>:“haan unay patient
isuna makakaan Collaborative:
to nasyat ta deta Consult and work with the
nga sitwasyon na” dietician to estimate caloric
as verbalized by needs.
his mother.

Weak in
appearance

Independent:
Swelling Risk for Brochial breath sounds and Level of Attainment:
P> high risk for Of the bronchiole infection is Auscultate lungs rales may indicate pneumonia -goal met
infection walls reduced
↓ through early My indicate presence of
E> r/t retained assessment Assess significant change infection AEB: the patient did not
secretions( good Increased production and in sputum show any signs of
for bacterial of sputum intervention. To prevent infection infection like fever her
growth) ↓ Assess for other signs and temperature was normal
sx of infection
Poor nutrition Retain secretions V/S
↓
Impaired Encourage increased fluid T> 37 C
pulmonary intake To maintain good hydration
good for bacterial
defence because increased fluid loss is
growth
mechanism ↓
present when there is nfection
secondary to Minimize retained
COPD. high risk for infection secretions by encouraging Retained secretions promote
pt to cough. bacterial growth
 Independent:
Inadequate Level of Attainment:
P> Knowlegde knowledge about the Assess knowledge base of -goal met
deficit of patient disease condtion of Patient COPD
and significant the patient verbalizes AEB: Significant others
others ↓ understanding Establish common goals was able to understand
of the disease the disease condition and
E>r/t recent Lack of information process and Discuss relation of disease the ways on how to take
diagnosis about care of treatment. process to signs and sx care about the condition
ineffective past significant others of their daughter
teaching, ↓ Discuss about the
ignorance of the Knowledge deficit medication “Maawatam min adding
disease condition noh kasano mo alagaan
Discuss sign and symptoms ken preventaran ton ti
S> AEB of infection panagsakit nan” as
Display of verbalized by her mother
anxiety Discuss importance of
Inability to specific therapeutic
verbalize health measures
maintenance
regime Health teaching:
Misconception
about health 1. Drink of plenty of water
status 6-8 glasses a day
Multiple question 2. instruct significant
or none others about proper
coughing technique
3. instruct significant
others about proper deep
breathing exercises
4. explain significant
others about importance of
strict compliance of
medication regimen
5. discuss significant others
about signs and symptoms
of infection like fever
6. Instruct significant
others on proper hygiene
7. Instruct significant
others for regular follow up
care
8. Discuss the significant
others about the disease
condition for future
prevention
9. Instruct significant
others about eating healthy
and nutritious food like
green leafy vegetables
10. Instruct significant
others about proper
exercises