NCP I

Nursing
Cues Nursing Diagnosis Inference Objective Rationale Evaluation
Intervention

Subjective Short Term Goal Independent

◈ Ineffective Irritant ◈After 4 hours of
◈ “Nahihirapan Airway Clearance (inhalation) ◈ After 4 hours of ◈ Vital signs ◈ This is for nursing
akong huminga r/t secretions in nursing monitored and baseline intervention, the
dahil sa kakaubo the bronchi intervention, airway recorded. comparison. goal is met through
ko,” as verbalized. patency will be maintenance of
inflammatory maintained, airway patency and
response ◈ Assisted in semi- ◈ Proper positioning
Objective secretions will be fowler’s position. helps in draining reduction in
readily secretions. congestion.
◈ pale in expectorated and
increase production there will be signs
appearance of secretions ◈ Encouraged deep ◈ This will promote
of reduction in
congestion. breathing exercise. proper lung
◈ dyspnea expansion.
airway constriction
◈ (+) use of Dependent
accessory muscles
when breathing dyspnea ◈ Administered ◈ Prescribed meds
prescribed such as
◈ (+) productive medications. bronchodilators
cough helps in aiding
effective airway
clearance.
◈ RR=24cpm
◈ Provided ◈ Nebulization
Reference: supplemental helps in liquefying
Understanding humidification via secretions for better
Pathophysiology, use of nebulizer. and faster
Huether expectorating the
secretions.
NCP II

Cues Nursing Diagnosis Inference Objective Nursing Intervention Rationale Evaluation

Subjective Short Term Goal Independent

◈ Hyperthermia r/t Irritant ◈After 1 hour of
◈ “Nilalamig ako at inflammatory (microbial) ◈ After 1 hour of ◈ Vital signs ◈ This is for baseline nursing intervention,
medyo masakit ang response nursing intervention, monitored and comparison. the goal is met
ulo ko,” as body temperature will recorded. through the
verbalized. be maintained within ◈ TSB will help in maintenance of body
inflammatory response the normal range. temperature within
◈ Provided tepid lowering the patient’s
Objective sponge bath. temperature. the normal range.
tissue injury
◈ weak looking ◈ Advised to increase ◈ Increase in oral
fluid intake. fluids will prevent
◈ skin warm to dehydration.
touch vascular response
◈ Instructed to ◈ This will help in
◈ T = 38.5°C maintain bedrest. reducing metabolic
RR = 24cpm hyperemia demands and oxygen
(heat, redness, pain) consumption.

◈ Encouraged deep ◈ This will promote

Reference: breathing exercise. proper lung expansion.
Mastering
Fundamentals of
Nursing, Udan Dependent

◈ Administered ◈ Prescribed meds

prescribed such as paracetamol
medications. help in reducing fever
by direct action on
hypothalamus heat-
regulating center with
consequent peripheral
vasodilation,
sweating, and
dissipation of heat..