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NCP 1

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION


EXPLANATION

Subjective: INEFFECTIVE AIRWAY viral-bacterial host Discharge Outcome: *Evaluate patients *To determine ability Discharge Outcome:
CLEARANCE RT interactions or cough / gag reflex and to protect own
“putang inang plema retained mucus secondary to turbulent After 2 days of Nursing swallowing. airways. After 2 days of Nursing
to! ayaw lumabas” as secretions AEB the (+) airflow Intervention the Intervention the
stated by the patient. crackles on both lower ↓ patient will be able to *Ascultate breath *Some degree of patient had been able
lung field. contact areas of the maintain airway sounds and note for bronchospasm is to maintain airway
middle meatus patency. abnormal breath present with patency.
↓ sounds (e.g wheeze obstruction in airway
narrow clefts in the and crackles). and may / may not be
anterior ethmoid manifested in
region that create adventitious breath
turbulent airflow, and sounds.
particularly when Short Term Outcome: Short Term Outcome:
Objective: narrowed by mucosal *Assist patient to *Elevation of head of
inflammation After 8 hours of assume comfortable bed facilitates After 8 hours of
*(+) crackles on both ↓ Nursing Intervention position (e.g elevate respiratory function by Nursing Intervention
lower lung field Ulceration or prolapse the patient will be able the head of the bed, use of gravity. the patient had been
*dyspnea of the submucosa can to verbalize have pt lean on Supporting arms/legs able to verbalize
*DOB occur, with understanding of overhead table/sit). without table, pillow understanding of
*RR: 17cpm reepithelialization and causes and therapeutic helps reduce muscle causes and therapeutic
*polyps in the right new gland formation management regimen. fatigue and can aid management regimen.
nostril ↓ chest expansion.
*oral ulcer heightened
inflammatory process *Encourage patient to *For better excretion
from epithelial cells, increase fluid intake of mucus secretion.
vascular endothelial up to 1200ml/day.
cells, and fibroblasts
affects the bioelectric *Encourage patient w/ *Provide pt w/ some
integrity of the sodium abdominal/pursed lip means to cope w/
channels at the breathing exercise. control dyspnea and
luminal surface of the decrease air trapping.
respiratory epithelial
cell in that section of
the nasal mucosa

increases sodium Collaborative:
absorption
↓ *Perform suctioning as *To clear airways.
water retention indicated.

polyp formation *Assist in Surgery to *To maintain patent
remove nasal polyp. airway.
-medscape

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