Group 4 NCP
Group 4 NCP
Group 4 NCP
GROUP 4
General Objective:
To facilitate the maintenance of oxygen
supply to all body cells
Subjective Cues
*As verbalized by the folks:
Di sya mayo ka ginhawa kag ga sakit iya nga ulo.
Di sya mayo katulog kung gab.i kay nabudlayan sya
maginhawa.
Gindala sya namon sa ospital kay nabudlayan gid sya
maginhawa.
Objective Cues
Temp: 36.8 C
HR: 85 bpm
RR: 26 cpm
BP: 110/70 mmHg
Abnormal breath sound: wheezing
Restlessness and Irritability noted
Coughing without sputum production
Dyspnea noted
Capillary refill: 3 seconds
Others
Chest x-ray revealed progression of bilateral lung pneumonia.
Pulmonary congestion noted. NGT and ET tubes still in place.
No signs of pleural effusion.
Gram staining in sputum via endotracheal aspirate result:
Gram stained smear shows many pus cells and few epithelial
cells.
Culture and sensitivity result: No growth after 5 days of
intubation.
ABG: metabolic acidosis uncompensated
NURSING
DIAGNOSIS
Ineffective airway
clearance r/t
increased
tracheobronchial
secretions 2
Community
Acquired
Pneumonia High
Risk
RATIONALE
SPECIFIC
OBJECTIVE
Within 3
days of
rendering
nursing care,
the client will
be able to
maintain a
patent
airway.
INTERVENTION
RATIONALE
INDEPENDENT
Assess airway for patency
INTERVENTION
RATIONALE
INDEPENDENT
Assess changes in mental status.
INTERVENTION
RATIONALE
INDEPENDENT
Assist patient in performing
coughing and breathing maneuvers:
INTERVENTION
RATIONALE
INDEPENDENT
Encourage oral intake of fluids
within the limits
To prevent fatigue
INTERVENTION
COLLABORATIVE
Monitor arterial blood gases (ABGs).
If cough is ineffective, use
nasotracheal suctioning as needed
Institute appropriate isolation
precautions for positive cultures
RATIONALE
To verify maintenance or
improvement in O2 saturation.
For management of underlying
pulmonary condition, respiratory
distress, cyanosis.
To help facilitate removal of
tenacious sputum.
INTERVENTION
RATIONALE
COLLABORATIVE
Administer diuretic (furosemide)
IV/stock 40mg/2mL/0.3cc every 12
hours, as ordered.
To verify maintenance/
improvement in O2 saturation
EVALUATION
After 3 days of rendering effective
nursing care, the client with ineffective
airway clearance was able to restore a
patent airway as evidenced by stable
and normal vital signs (BP: 110/70
mmHg, RR: 20 cpm, PR: 80 bpm, Temp:
36.7 C), clear breath sounds as
manifested by absence of wheezes,
cough effectively through capability to
expectorate all accumulated secretions.