NCP I

Nursing Intervention
Cues
Nursing Diagnosis
Inference
Objective
Rationale
Evaluation
Subjective ◈ “Nahihirapan akong huminga dahil sa kakaubo ko,” as verbalized. Obj
ective ◈ pale in appearance ◈ dyspnea airway constriction ◈ (+) use of accessory
muscles when breathing ◈ (+) productive cough ◈ RR=24cpm
Reference: Understanding Pathophysiology, Huether
Short Term Goal ◈ Ineffective Airway Clearance r/t secretions in the bronchi Irr
itant (inhalation) ◈ After 4 hours of nursing intervention, airway patency will
be maintained, secretions will be readily expectorated and there will be signs o
f reduction in congestion.
Independent ◈ Vital signs monitored and recorded. ◈ Assisted in semifowler’s pos
ition. ◈ This is for baseline comparison. ◈ Proper positioning helps in draining
secretions. ◈ This will promote proper lung expansion. ◈After 4 hours of nursin
g intervention, the goal is met through maintenance of airway patency and reduct
ion in congestion.
inflammatory response
increase production of secretions
◈ Encouraged deep breathing exercise.
Dependent dyspnea ◈ Administered prescribed medications. ◈ Prescribed meds such
as bronchodilators helps in aiding effective airway clearance. ◈ Nebulization he
lps in liquefying secretions for better and faster expectorating the secretions.
◈ Provided supplemental humidification via use of nebulizer.
NCP II
Cues
Nursing Diagnosis
Inference
Objective
Nursing Intervention
Rationale
Evaluation
Subjective ◈ “Nilalamig ako at medyo masakit ang ulo ko,” as verbalized. Objecti
ve ◈ weak looking ◈ skin warm to touch ◈ T = 38.5°C RR = 24cpm tissue injury ◈ H
yperthermia r/t inflammatory response Irritant (microbial)
Short Term Goal ◈ After 1 hour of nursing intervention, body temperature will be
maintained within the normal range.
Independent ◈ Vital signs monitored and recorded. ◈ Provided tepid sponge bath.
◈ Advised to increase fluid intake. ◈ This is for baseline comparison. ◈ TSB wil
l help in lowering the patient’s temperature. ◈ Increase in oral fluids will pre
vent dehydration. ◈ This will help in reducing metabolic demands and oxygen cons
umption. ◈ This will promote proper lung expansion. ◈After 1 hour of nursing int
ervention, the goal is met through the maintenance of body temperature within th
e normal range.
inflammatory response
vascular response ◈ Instructed to maintain bedrest.
hyperemia (heat, redness, pain)
Reference: Mastering Fundamentals of Nursing, Udan
◈ Encouraged deep breathing exercise.
Dependent ◈ Administered prescribed medications. ◈ Prescribed meds such as parac
etamol help in reducing fever by direct action on hypothalamus heatregulating ce
nter with consequent peripheral vasodilation, sweating, and dissipation of heat.
.