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    NCP For Scenario Breathing

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    my mozn
    The patient reported difficulty breathing and productive cough. Assessment found wheezing on auscultation, productive greenish cough, tachycardia, and hypoxia. The nursing diagnosis was ineffective airway clearance related to productive cough. The plan was for the patient to maintain a patent airway during their hospital stay through respiratory assessments, cough effectiveness monitoring, suctioning, and observation of sputum characteristics. The expected outcome was for the patient to display patency of the airway by the end of the shift through normal respiratory rate and absence of wheezing.

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    NCP For Scenario Breathing

    Uploaded by

    my mozn
    106 views4 pages
    The patient reported difficulty breathing and productive cough. Assessment found wheezing on auscultation, productive greenish cough, tachycardia, and hypoxia. The nursing diagnosis was ineffective airway clearance related to productive cough. The plan was for the patient to maintain a patent airway during their hospital stay through respiratory assessments, cough effectiveness monitoring, suctioning, and observation of sputum characteristics. The expected outcome was for the patient to display patency of the airway by the end of the shift through normal respiratory rate and absence of wheezing.

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    NCP for Scenario Breathing

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    The patient reported difficulty breathing and productive cough. Assessment found wheezing on auscultation, productive greenish cough, tachycardia, and hypoxia. The nursing diagnosis was ineffective airway clearance related to productive cough. The plan was for the patient to maintain a patent airway during their hospital stay through respiratory assessments, cough effectiveness monitoring, suctioning, and observation of sputum characteristics. The expected outcome was for the patient to display patency of the airway by the end of the shift through normal respiratory rate and absence of wheezing.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    106 views4 pages

    NCP For Scenario Breathing

    Uploaded by

    my mozn
    The patient reported difficulty breathing and productive cough. Assessment found wheezing on auscultation, productive greenish cough, tachycardia, and hypoxia. The nursing diagnosis was ineffective airway clearance related to productive cough. The plan was for the patient to maintain a patent airway during their hospital stay through respiratory assessments, cough effectiveness monitoring, suctioning, and observation of sputum characteristics. The expected outcome was for the patient to display patency of the airway by the end of the shift through normal respiratory rate and absence of wheezing.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The document discusses nursing assessments and interventions for patients with respiratory issues like ineffective breathing patterns and airway clearance.

    Nursing interventions for an ineffective breathing pattern include assessing respiratory rate and depth, auscultating breath sounds, using pulse oximetry, and teaching breathing exercises.

    Signs of ineffective airway clearance include changes in respiration rate/rhythm, tachycardia, productive cough, sputum, and hypoxia.

    Scenario 1

    Assessment data Nursing diagnosis Plan / Expected Implementation / Nursing Rational Evaluation
    outcome intervention
    Subjective: Ineffective After 30 minutes of  Assess rate and to detect early signs Establish a
    pt. said " I have Breathing Pattern nursing of respiratory normal/effective
    depth of respirations, compromise.
    difficulty in related to hypoxia intervention, the respiratory patter
    breathing manifested by patient will be able type of n
    changes in depth to do coping
    breathing pattern
    Objective: and rhythm mechanisms to
    O2 saturation of improve his
    85%, and abnormal breathing pattern
    ABGS

     Auscultate breath to detect decreased or


    sounds at least every adventitious breath
    sounds, report
    4 hours changes.

     Utilize pulse Pulse oximetry is a


    oximetry to check helpful tool to detect
    alterations in
    oxygen saturation oxygenation
    and pulse rate. initially. 
    helps reduce
     Administer O2 to the hypoxemia and
    patient. relieve respiratory
    distress.

     Elevated head of For chest expansion


    bed.

     assist client to These techniques


    promote deep
    learn breathing inspiration, which
    exercises. increases
    oxygenation and
    prevents atelectasis.
    Controlled breathing
    methods may also aid
    slow respirations in
    patients who are
    tachypneic.
    Prolonged expiration
    prevents air trapping.

    to conserve energy
     Help patient with and avoid
    ADLs, as needed overexertion and
    fatigue.
    Subjective: Ineffective airway During the client’s  Assess the rate, Tachypnea, shallow At the end of the
    pt. said " I have clearance related to stay at the hospital, rhythm, and depth of respirations and
    shift, the patient
    difficulty in productive cough he will be able to respiration, chest asymmetric chest
    breathing and cough manifested by maintain patent movement, and use movement are was able to
    changes in depth airway of accessory frequently present
    display patency of
    Objective: and rhythm of muscles. because of
     On respiration, discomfort of moving airway as
    auscultation, tachycardia, sputum chest wall and/or
    manifested by:
    noted a and hypoxia fluid in lung due to a
    wheeze compensatory .
    sounds in response to airway
    Client’s
    both side of obstruction.
    chest. respiratory rate is
     Productive
    within normal
    cough with  Assess cough Coughing is the most
    greenish effectiveness and effective way to
    secretion. productivity remove secretions. 
     Pt. is
    tachycardia
    with irregular  Auscultate lung
    respiration fields, noting areas Decreased airflow
    of decreased or occurs in areas with
    absent airflow and consolidated fluid. 
    adventitious breath
    sounds: crackles,
    wheezes.
     Observe the sputum Changes in sputum
    color, viscosity, and characteristics may
    odor. Report indicate infection
    changes.

     Suction as indicated Stimulates cough or


    mechanically clears
    airway in patient who
    is unable to do so
    because of ineffective
    cough or decreased
    level of
    consciousness. 

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