NCP

Nursing
Goal/ Nursing
problem/ Analysis Rationale Evaluation
objectives interventions
cues

Ineffective The feature Goal:

Airway common to all Client will have
Clearance types of improved
related to pneumonia is breathing
retained an patterns, as
secretions in inflammatory evidenced by a
the bronchi. pulmonary respiratory rate
response to within normal
the offending limits, adequate
Subjective: organism or chest expansion
• “hindi po agent. The and clear breath
ako defense sounds and
masyadong mechanisms decreased
makahinga” of the lungs dyspnea. • asses the • to evaluate the The client was
• “parang my lose client’s knowledge of the able to verbalize
plema pero effectiveness understanding client the cause of
hindi ko po and allow Objectives: about his breathing pattern
mailabas” organisms to 1. after 30 condition disturbances in
penetrate the minutes, client • promotes relation to his
Objective: sterile lower and significant • discuss with the understanding of condition.
• RR: 22 respiratory others will significant current situation
• Temp: 37.4 tract, where verbalize the others about the and importance
inflammation cause of pneumonia of cooperation
• PR: 120
develops. breathing with treatment
Disruption of pattern • Discuss the regimen
the disturbances in etiologies of
mechanical relation to his pneumonia
defenses of condition. • promotes
cough and • Discuss the understanding of
ciliary motility causes of current situation
leads to ineffective and importance
colonization of
the lungs and breathing of cooperation
subsequent pattern in with treatment
infection. relation to regimen
Inflamed and pneumonia The client was
fluid-filled able to
alveolar sacs understand and
cannot state ways to
exchange • promotes improved
oxygen and 2. after 15 comfort in breathing
carbon dioxide minutes, client • position client breathing pattern.
effectively. and significant for comfort and
Alveolar others will to facilitate
exudate tends understand and breathing.
to consolidate, state ways to Client should be
so it is improved positioned with • promotes comfort
increasingly breathing head raise 45°. during coughing
difficult to pattern. • Teach client or
expectorate. significant
others how to
Sources: splint the chest
Medical- wall with a
surgical pillow for The client was
nursing vol2 comfort during able to state and
by Black page coughing and • promotes easy perform a return
1841 about the use of expulsion of demo of ways to
incentive mucus that can improve airway
3. after 15 spirometry. provide comfort clearance
Immediate minutes, client for the patient
cause: and significant • teach client
Infection others will and significant
state and others about
Intermediate perform a coughing
cause: return demo of exercises and
Disfunction of ways to its benefits.
the defense improve airway
mechanisms clearance • Teach client
of the lungs and significant
 others about
Root cause: steam
Inflammation inhalation or • monitoring lab
of the alveolar have a results and vital
sacs nebulizer to signs can help in
loosen a the promotion of
congested nose health and
4. client will to promote prevents further
receive expulsion of damage due to
interventions to mucus further damage
monitor client’s
status. • routinely
monitor •promotes
respiratory rate improved
breathing pattern
and comfort
5. client will
receive • Auscultate
prescribed the chest
medications. Sources:
Fundamentals of
• administer Nursing
prescribed
cough
suppressants
and analgesics.

Sources:
Medical-surgical
nursing vol2 by
Black page 1843

Health Guide by
DOH
Page 392