X - Problem Prioritization and NCP

X. Problem Prioritization A. Short Short Term Term Obje Objectiv ctivee After 2 days of nursing interventions the patient will not experience ineffective airway clearance. The complications  brought about by pneumonia will be prevented through proper participation to the different medical and nursing interventions. B. Prob Proble lem m List List CUES Subjective cues: •

“Hirap ako huminga dahil ubo ako ng ubo na my kasamang  plema at minsan my dugo pa.” as verbalized by the patient.

NURSING PROBLEM Ineffective airway clearance related to retained secretions in the respiratory tract secondary to bacterial infection.

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Objective cues:

Cough with phlegm Hemoptysis Restless Diminished breath sounds (crackles) Subjective cues:

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“Hirap ako huminga dahil ubo ako ng ubo na my kasamang  plema at minsan my dugo pa.” as verbalized by the patient.

Ineffective breathing  pattern related to hypoventilation secondary to pneumonia

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Objective cues: •

Dyspnea

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JUSTIFICATION Airway must be given the first attention as based on the rule of ABC which is Airway, Breathing and Circulation. Circulation. In addition, difficulty of breathing can cause anxiety to the client that is why, immediate attention must be done. Addressing the problem to  proper health care provider will give patent airway to the client. Oxygenation is a vital need for every cell, if there are any problems related to it can easily affect the functioning of the individual. Retained secretions can cause blockage of airway which will further cause difficulty of breathing (Fundamentals of Nursing 8 th ed by Kozier and erb’s  p. 1299)

This demands immediate treatment/care and subsequent subsequent medical attention, as they can result in ineffective breathing pattern. pattern. This also needs attention as based on the rule of ABC which is Airway, Breathing and Circulation. This is an actual  problem that needs to address. Lack of action in this health care problem may cause dyspnea which may later cause a bigger threat to the health of the patient. Difficult and labored in breathing during which the

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individual has a persistent, unsatisfied need for air  and feel distressed. (Fundamentals of Nursing 8 th ed  by Kozier and erb’s p. 549)

Alterations of depth of breathing Use accessory muscles to breath

Risk for impaired gas exchange related to alveolar-capillary membrane changes

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This condition needs to be addressed immediately for the patient to be able to give patient awareness about his condition in his body and to be able to maintain a good gas exchange. Lack of attention in this health care problem may lead to impaired gas exchange which may later  cause bigger threat to the health of the patient.

NURSING CARE PLAN

Cues

Subjective Cues

Nursing Diagnosis

Ineffective airway clearance related to • “Hirap ako huminga retained dahil ubo ako secretions in ng ubo na my the respiratory tract kasamang secondary to  plema at  bacterial minsan my infection. dugo pa.” as verbalized by the patient.

Objective cues:

Cough with phlegm hemoptys is Restless Diminish ed breath sounds (crackles) •

Inference

Nursing

Rationale

Evaluation

Intervention

Irritant

Short Term Goal

(inhalation) 

inflammatory Response

After 4 hours of  nursing intervention, airway patency will be maintained, secretions will be

Independent Assess rate/depth of  Frequently present respirations and chest  because of discomfort movement. of moving chest wall and/or fluid in lung.

Auscultate lung Decreased airflow fields, noting areas of  occurs in areas decreased/absent consolidated with fluid. airflow and adventitious breath sounds. Elevate head of bed, change position frequently.

readily increase  production

expectorated and

of secretions

there will be signs

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of reduction in

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Objective

congestion.

Assist patient with frequent deep  breathing exercises.

airway constriction Suction as indicated

Dyspnea Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer  warm, rather than

Lowers diaphragm,  promoting chest expansion, aeration of  lung segments, mobilization and expectoration of  secretions.

Deep breathing facilitates maximum expansion of the lungs/smaller airways. Stimulates cough or  mechanically clears airway in patient who is unable to do so  because of ineffective cough or decreased level of consciousness. Fluids (especially warm liquids) aid in mobilization and expectoration of 

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After 4 hours of nursing intervention, the goal is met through maintenance of  airway patency and reduction in congestion.