Scribd
Upload
9 views2 pages

NCP Problem - 1

A 5-year-old male child presents with a productive cough, shortness of breath, and crackles upon auscultation. The nursing diagnosis is ineffective airway clearance due to increased mucous production, with a plan that includes oxygen inhalation, nebulization, and chest physiotherapy. The goal is to decrease mucous secretion and improve airway clearance within 2-3 days through specific nursing interventions.

Uploaded by

TW 999
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
9 views2 pages

NCP Problem - 1

A 5-year-old male child presents with a productive cough, shortness of breath, and crackles upon auscultation. The nursing diagnosis is ineffective airway clearance due to increased mucous production, with a plan that includes oxygen inhalation, nebulization, and chest physiotherapy. The goal is to decrease mucous secretion and improve airway clearance within 2-3 days through specific nursing interventions.

Uploaded by

TW 999
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Problem: A case of 5 year male child with a chief complaint of productive cough, yellowish in color for 4 days, SOB

, (+) crackles RR- 40cpm,temp


38C, HR 110bpm, mother verbalizes that “naa lagi ubo akong anak nga dunay plemas” with an order to administer oxygen inhalation @ 3L/min via
nasal cannula, salbutamol nebulization 1 neb + 2cc NSS every 6 hours, Co-amoxiclav sysrup 5ml BID P.O, place on a high back rest, may turn to side
q2, do chest physiotherapy every after nebulization.

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION


(cite source)
Subjective cues: Ineffective Airway Short Term: Independent [Link] position Short Term:
“naa lagi ubo akong Clearance RT increased At the end of 8 hours [Link] patient in high back promotes better lung After 8 hours of
Anak nga dunay mucous production AEB in rendering nursing rest expansion and rendering nursing
Plemas” as verbalized presence of productive intervention patient improved air exchange. intervention patient will
By the mother cough mucous secretion will [Link] turn to side q2 2. Helps to mobilizes be able to expectorate
be loosen/liquify secretions, and lessens secretion
secretion [Link] chest physiotherapy atelectasis.
every after nebulization 3. Chest physiotherapy
Objective Cues: includes the techniques
• Productive [Link] to increase oral of postural drainage and
cough Long Term: fluid intake within cardiac chest percussion to
• (+) crackles At the end of 2-3 days tolerance mobilize secretions Long Term:
upon in rendering nursing from smaller airways After 2-3 days rendering
auscultation intervention patient that cannot be nursing intervention
• Shortness of mucous secretion will Dependent eliminated by means of patient will be able to
breath be decreased as [Link] O2 inhalation coughing or suctioning. have a decreased
• Shallow chest evidence by minimal 3L/min via nasal cannula as 4. Fluids help minimize production of secretion
expansion amount of mucous ordered mucosal drying and as evidence by minimal
noted secretion maximize ciliary action amount of mucous
• RR 40cpm [Link] nebulization to move secretions. secretion
• Temp 38C Salbutamol 1 nebule + 2cc
NSS q6H as ordered

[Link] Coamoxiclav
sysrup 5ml P.O. BID as
prescribed
Dependent
1. Oxygen has been
shown to correct
hypoxemia, which can
be caused by retained
respiratory secretions.
2. Bronchodilator
medication it relaxes
airway of smooth
muscles thereby causing
to open air passages.
3. Helps to eradicate
bacterial infection,
which decreases
lingering, chronic
infection.

You might also like