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    Bronchitis NCP

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    Nikael Patun-og
    Assist with activities of daily living as needed Rationale: to conserve patient's energy for breathing and coughing Provide comfort measures as needed Rationale: to promote patient comfort Encourage fluid intake as tolerated Rationale: to thin secretions Monitor intake and output Rationale: to assess fluid balance Monitor vital signs and oxygen saturation Rationale: to detect early signs of deterioration Monitor cough effectiveness and depth of respirations Rationale: to assess

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    Bronchitis NCP

    Uploaded by

    Nikael Patun-og
    65 views8 pages
    Assist with activities of daily living as needed Rationale: to conserve patient's energy for breathing and coughing Provide comfort measures as needed Rationale: to promote patient comfort Encourage fluid intake as tolerated Rationale: to thin secretions Monitor intake and output Rationale: to assess fluid balance Monitor vital signs and oxygen saturation Rationale: to detect early signs of deterioration Monitor cough effectiveness and depth of respirations Rationale: to assess

    Original Title

    BRONCHITIS NCP

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    Assist with activities of daily living as needed Rationale: to conserve patient's energy for breathing and coughing Provide comfort measures as needed Rationale: to promote patient comfort Encourage fluid intake as tolerated Rationale: to thin secretions Monitor intake and output Rationale: to assess fluid balance Monitor vital signs and oxygen saturation Rationale: to detect early signs of deterioration Monitor cough effectiveness and depth of respirations Rationale: to assess

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    65 views8 pages

    Bronchitis NCP

    Uploaded by

    Nikael Patun-og
    Assist with activities of daily living as needed Rationale: to conserve patient's energy for breathing and coughing Provide comfort measures as needed Rationale: to promote patient comfort Encourage fluid intake as tolerated Rationale: to thin secretions Monitor intake and output Rationale: to assess fluid balance Monitor vital signs and oxygen saturation Rationale: to detect early signs of deterioration Monitor cough effectiveness and depth of respirations Rationale: to assess

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 8

    ASSESSMENT DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

    IDENTIFICATION

    SUBJECTIVE: Ineffective Patient will Short term: Independent: After 8 hours of


    airway clearance maintain clear, open nursing
    related to airways as interventions, the
    "Nahihirapan After 8 hours of Position the
    increased evidenced by normal patient was able
    akong huminga at nursing patient upright if
    production of breath sounds, to:
    ilabas ang plema interventions, the tolerated
    mucus and normal rate and
    kahit grabe na patient will:
    retained thick, depth of Demonstrate
    ang pag-ubo ko (I Rationale: to limit
    viscous secretions respirations, and improved
    am having Demonstrate abdominal contents
    as evidenced by ability to ventilation and
    difficulty Improved from pushing
    abnormal effectively cough up adequate oxygen
    breathing and ventilation and upward and
    depth/rate of secretions after 1
    expelling phlegm adequate oxygen inhibiting lung
    respirations, week of nursing Verbalize
    even if my expansion
    abnormal breath intervention. decreased signs of
    coughing is already Verbalize
    sounds, and respiratory
    severe) as decreased signs Regularly check the
    ineffective or distress
    verbalized by the of respiratory patient’s upright
    nonproductive
    patient” distress position to prevent
    coughing. Establish a
    sliding down in bed
    breathing pattern
    OBJECTIVE: Establish a
    from 27
    breathing Rationale: to
    breaths/min to 20
    pattern from promote better
    Presence of breaths/min
    27bpm to 20bpm. lung expansion and
    rhonchi
    GOALS MET
    Presence of Long Term: improved air
    wheezing sounds exchange Long Term:
    Educate the
    After 1-3 days of
    Ineffective or patient about After 1-3 days of
    nursing
    absent cough optimal positioning nursing
    interventions, the
    (sitting position) intervention, the
    patient will:
    Abnormal and use of pillow or patient was able
    respiratory rate, hand splints when to:
    Demonstrate
    rhythm, and depth coughing
    improved ability
    Demonstrate
    to expectorate
    Inability to Rationale: to improved ability to
    retained
    remove airway promote effective expectorate
    secretions.
    secretions coughing by retained
    increasing secretions
    Maintain
    abdominal pressure
    effective
    V/S taken as and upward Maintain effective
    breathing
    follows diaphragmatic breathing pattern
    pattern.
    movement
    T: 37.2 GOALS MET
    PR: 79 Teach the patient
    RR: 27 the proper ways of
    BP: 110/80 coughing and
    breathing

    Rationale: to help
    the patient in
    doing this activity
    as it is the most
    convenient way to
    remove most
    secretions.

    Encourage patient
    to increase fluid
    intake to 3 liters
    per day unless
    contraindicated
    (e.g., heart
    failure).

    Rationale: to help
    minimize mucosal
    drying and
    maximize ciliary
    action to move
    secretions

    Dependent:
    Give medications
    as prescribed:
    1. Antibiotics
    2. Antitussives
    3. Mucolytics
    4. Bronchodilators
    5. Expectorants
    Rationale:

    1. to eliminate the
    bacterial
    infection causing
    the disease
    2. to promote
    patient comfort
    by suppressing
    and relieving
    coughs
    3. to increase
    expectoration of
    sputum by
    reducing its
    viscosity
    4. to alleviate
    bronchial
    obstruction and
    airflow
    limitation by
    relaxing the
    muscles in the
    lungs and
    widening the
    airways
    (bronchi)
    5. to help cough up
    mucus by
    thinning and
    loosening mucus
    in the airways

    Maintain humidified
    oxygen as
    prescribed

    Rationale: to
    reduce thickness of
    secretions and aid
    their removal

    Perform
    nasotracheal
    suctioning as
    necessary,
    especially if cough
    is ineffective

    Rationale: to expel
    secretions when
    patients are unable
    to do it
    themselves

    Collaborative:

    Coordinate with a
    respiratory
    therapist for chest
    physiotherapy as
    indicated

    Rationale: to
    mobilize secretions
    from smaller
    airways that
    cannot be
    eliminated by
    means of coughing
    or suctioning

    Provide postural
    drainage,
    percussion, and
    vibration as
    ordered
    Rationale: to help
    mobilize bronchial
    secretions

    Monitor serial
    chest x-rays,
    ABGs, and pulse
    oximetry readings

    Rationale: to
    identify imbalances
    in PaCO2 and
    PaO2 which
    indicates
    respiratory fatigue

    Refer to the
    pulmonary clinical
    nurse specialist as
    indicated

    Rationale: to
    ensure that proper
    treatments are
    met
    Perform intubation
    as ordered if
    secretions cannot
    be cleared

    Rationale: to help
    prevent further
    complications by
    facilitating removal
    of tenacious and
    copious amounts of
    secretions

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