Ncp Cough

NURSING CARE PLAN- COUGH ASSESSMENT | DIAGNOSIS | PLANNING | INTERVENTION | RATIONALE | EVALUATION | Subjective Data:“Ubo siya ng ubo pero nahihirapan siyang ilabas yung kanyang plema” asverbalized bythe father.Objective Data: * Dyspnea * Wheezes upon auscultation * Facial grimace noted * Productive cough (yellow to green sputum) * V/S takenas follows:T: 37.7P: 90R: 27BP: 110/80 | Ineffective airway clearance related to retained bronchial secretions as manifested by dyspnea, wheezes upon auscultation, facial grimace and productive cough (yellow to green sputum). | After 4 hours of proper nursing interventions , the patient will: * Maintain RR of at least 16-20 from the initial 27. * Learn and perform breathing and coughing exercise. * Clear secretions readily with father’s assistance. * The mother will demonstrate behaviors to improve or maintain clear airway. | Independent: 1. Monitor vital signs esp. the respiratory rate. 2. Monitor respirations and breath sounds, noting rate and sounds. 3. Evaluate the coughing reflex. 4. Position head appropriate for age or condition. 5. Encourage the father to give or increase fluid intake. 6. Encourage the patient to expectorate the secretion. 7. Teach the patient how to do proper breathing and coughing exercise. 8. Avoid exposure to irritants such as cigarette smoke. 9. Place the patient in moderate high back rest. 10. Observe skin and mucous membranes for signs of cyanosis.Dependent: 1. Administer antibiotics as ordered. 2. Administer bronchodilators with use of nebulizer.Collaborative: 1. Perform Chest X-ray as ordered. | 1. To note the improvement to his breathing pattern. 2. To monitor the indications of respiratory distress and accumulation of secretions. 3. To determine ability to protect own airway. 4. To open or maintain airway. 5. Hydration can help liquefy viscous secretions and improve secretion clearance. 6. To clear secretions from the airway. 7.