NCP-croup
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CUES NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OR BACKGROUND PLANNING INTERVENTION S RATIONALE FOR EACH INTERVENTION EVALUATION PARAMETERS Subjective: “I just gave him some chocolates. Is he allergic to that?” as stated by the client’s grandmother. Objective: -Cry -Sharp barking cough -Audible stridor - Tachychardia -Tachypnea (+) nasal flaring - Intercoastal retractions Ineffective airway clearance r/t tracheobronc hial obstruction. URT trauma or irritant (chocolates) ↓ tracheobronc hial obstruction ↓ Ventilation perfusion (V/Q) mismatch ↓ Increase secretion production ↓ Ineffective airway clearance Goal: After 8 hrs shift of nursing intervention client’s airway patency will improve. Objectives: The client will be able: 1.To be free from secretions or obstruction, easier work of breathing, respiratory and heart rate within parameters. 1.Position with airway open (sniffing position if supine). • Humidify oxygen or room air and ensure adequate fluid intake (intravenous or oral). • Suction with bulb syringe or via 1. Open airway allows adequate ventilation. • Help liquefy secretions for ease in clearance • Removal of secretions • To avoid The client’s airway patency has improved. 1. Client was free from obstruction, breathes easily, respiratory and heart rate was maintained within normal range).
Transcript of NCP-croup
CUES NURSING DIAGNOSIS
SCIENTIFIC EXPLANATION OR
BACKGROUND
PLANNING INTERVENTIONS RATIONALE FOR EACH
INTERVENTION
EVALUATION PARAMETERS
Subjective:“I just gave him some chocolates. Is he allergic to that?” as stated by the client’s grandmother.
Objective:-Cry-Sharp barking cough-Audible stridor-Tachychardia-Tachypnea (+) nasal flaring-Intercoastal retractions-Productive cough(sharp & frequent)
PR- 146 bmp (left radial pulse)RR- 40 cpm ( irregular )T- 39C ( left axilla)
Ineffective airway clearance r/t tracheobronchial obstruction.
URT trauma or irritant
(chocolates)↓
tracheobronchial obstruction
↓Ventilation
perfusion (V/Q) mismatch
↓Increase secretion
production↓
Ineffective airway clearance
Goal: After 8 hrs shift of nursing intervention client’s airway patency will improve.
Objectives:The client will be able:1.To be free from secretions or obstruction, easier work of breathing, respiratory and heart rate within parameters.
1.Position with airway open (sniffing position if supine).• Humidify oxygen or room air and ensure adequate fluid intake (intravenous or oral).• Suction with bulb syringe or via nasopharyngeal catheter as needed.• If tachypneic, maintain NPO status. • Encourage expectoration of sputum with
1. Open airway allows adequate ventilation.
• Help liquefy secretions for ease in clearance
• Removal of secretions
• To avoid risk of aspiration.
• To promote airway clearance.
The client’s airway patency has improved.
1. Client was free from obstruction, breathes easily, respiratory and heart rate was maintained within normal range).
2. To take her due medication(as prescribed)
coughing.• Perform chest physiotherapy if ordered.
• Ensure emergency equipment is readily available.
2. Provide patient optimal patent airway with prescribed bronchodilators (racemic epinephrine inhalant) and corticosteroids(betamethasone) as ordered.
• To mobilize secretionswith the assistance ofpercussion or vibrationaccompanied bypostural drainage•To avoid delay should airway becomeunmaintainable.
2. Produces bronchodilation and exert a potent, locally acting anti-inflammatory effect to decrease the frequency and severity of attacks.
2. Client was able to take her due med.
CANDO, Precious Gia G. May 28, 2010
NCM104-AN01 Prof. Delia Tan
