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NCP 3

Robert Laureño was admitted with ineffective airway clearance related to excessive secretions. The nursing assessment found difficulty breathing and a productive cough. Objectively, mucus accumulation was observed in the airway passage and gurgling sounds upon coughing. The short-term nursing plan was to maintain airway patency and normal breath sounds after 8 hours of interventions. The long-term goal was for the patient to expectorate mucus secretions and maintain normal breathing after 1 day.
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0% found this document useful (0 votes)
59 views3 pages

NCP 3

Robert Laureño was admitted with ineffective airway clearance related to excessive secretions. The nursing assessment found difficulty breathing and a productive cough. Objectively, mucus accumulation was observed in the airway passage and gurgling sounds upon coughing. The short-term nursing plan was to maintain airway patency and normal breath sounds after 8 hours of interventions. The long-term goal was for the patient to expectorate mucus secretions and maintain normal breathing after 1 day.
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PATIENT’S NAME: LAUREÑO, ROBERT

DATE INITIATED: 09-05-2023

STUDENT’S NAME: JAMES F. GARCESA BSN 3C

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONS


SUBJECTIVE: Ineffective Airway OBJECTIVE: • Establish rapport. To gain patient’s and SHORT TERM (goal
“Nahihirapan po siya Clearance related to Achieve airway relative’s trust. partially met)
minsan huminga dahil sa excessive secretions. clearance
mga plema na bumabara • Monitor VS To obtain baseline data. After the 8hrs of effective
sa kanyang lalamunan at SHORT TERM: nursing interventions, the
ang hirap minsan ilabas” After 8hrs of nursing clint have maintained
as verbalized by the intervention, the patient • Suction To decrease secretion airway patency, clear
patient’s sister. will be able to maintain secretions PRN. retained. breath sounds.
airway patency and
OBJECTIVE: normal breath sound. • Place in the To maintain patent LONG TERM (goal met)
• Difficulty of semi/high fowler airway.
breathing LONG TERM: position. After the 1 day of
• Productive Cough After 1 day of nursing effective nursing
intervention, the patient • Elevate the head To take advantage of the interventions, the patient
will be able to: of bed (HOB) gravity decrease shall have expectorated
• Mucus • Perform effective pressure on the retained secretion and
accumulation on coughing to diaphragm. maintain normal
airway passage expectorate breathing pattern.
• Gurgling sound mucus secretions. • Encourage to To moisten secretions for
upon coughing • Eliminate mucus increase fluid easy expectoration.
accumulation intake.
through
expectoration and • Monitor Frequent respiratory
Respiratory assessments are
proper use of
Status
suctioning essential to evaluate the
devices. patient's progress.
• Relieve breathing Monitor vital signs,
difficulties. oxygen saturation,

• Maintain normal breath sounds, and signs

breath sound. of respiratory distress.


Any deterioration in the
patient's respiratory
status should be
addressed promptly.

• Collaborate with
the Healthcare Collaboration with other
Team healthcare team
members, such as
respiratory therapists
and physicians, is
essential to develop and
implement an effective
plan of care. Ensure that
interventions are
coordinated and adjusted
as needed based on the
patient's response and
any changes in their
condition.

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