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NCP 29-2
NCP 29-2
Ineffective breathing pattern related to alveolar hypoventilation, anxiety, chest wall alterations, and hyperventilation as
evidenced by assumption of three-point position, dyspnea, increased anterior-posterior diameter, nasal aring, orthopnea,
prolonged expiration, pursed-lip breathing, use of accessory muscles to breathe
1. Returns to baseline respiratory function
2. Demonstrates an effective rate, rhythm, and depth of respirations
OUTCOMES (NOC)
Respiratory Status: Ventilation
Measurement Scale
1
2
3
4
5
= Severely compromised
= Substantially compromised
= Moderately compromised
= Mildly compromised
= Not compromised
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
NURSING DIAGNOSIS
PATIENT GOALS
Ineffective airway clearance related to expiratory airow obstruction, ineffective cough, decreased airway humidity,
and tenacious secretions as evidenced by ineffective or absent cough, presence of abnormal breath sounds, or absence
of breath sounds
1. Maintains clear airway by effectively coughing
2. Experiences clear breath sounds
OUTCOMES (NOC)
Respiratory Status: Airway Patency
Assist patient to sitting position with head slightly exed, shoulders relaxed, and knees exed to allow
for adequate chest expansion.
Instruct patient to inhale deeply, bend forward slightly, and perform three or four huffs (against an open
glottis) to prevent airway collapse during exhalation.*
Instruct patient to inhale deeply several times, exhale slowly, and cough at the end of exhalation
to loosen secretions before coughing.
Instruct the patient to follow coughing with several maximal inhalation breaths to reoxygenate the lungs.
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Airway Management
Encourage slow, deep breathing; turning; and coughing to mobilize pulmonary secretions.
Position patient to maximize ventilation potential.
Regulate uid intake to optimize uid balance to liquefy secretions for easier expectoration.
Perform endotracheal or nasotracheal suctioning as appropriate to clear the airway.
Administer bronchodilators and use airway clearance devices to facilitate clearance of retained secretions
and increase ease of breathing.
Continued
Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
NCP 29-2
NCP 29-2
NURSING DIAGNOSIS
PATIENT GOALS
OUTCOMES (NOC)
Respiratory Status: Gas Exchange
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
NURSING DIAGNOSIS
PATIENT GOALS
Imbalanced nutrition: less than body requirements related to poor appetite, lowered energy level, shortness of breath,
gastric distention, sputum production, and depression as evidenced by weight loss >10% of ideal body weight, serum
albumin level below normal values, lack of interest in food
1. Maintains body weight within normal range for height and age
2. Consumes adequate nutrients for metabolic needs
OUTCOMES (NOC)
Appetite
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Monitor food/uid ingested and calculate daily caloric intake to determine adequacy of intake.
Monitor laboratory values for evidence of malnutrition.
Provide oral care before meals to moisten and clean the mouth of sputum taste.
Provide patient with high-protein, high-calorie, nutritious nger foods and drinks that can be readily consumed to provide adequate calories and protein that do not require much energy to consume.
Select nutritional supplements to provide nutritional between-meal snacks.
Weigh patient at appropriate intervals to assess nutritional status. Provide food selection to stimulate
the appetite.
Adjust diet to patients lifestyle to reduce bloating.
Provide appropriate information about nutritional needs and how to meet them to ensure nutritional
adequacy after discharge.
Measurement Scale
1 = Not adequate
2 = Slightly adequate
3 = Moderately adequate
4 = Substantially adequate
5 = Totally adequate
*Guidelines for effective huff coughing are presented in Table 29-23.
Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.