Nursing Care Plan

Px’s Name: Wilfredo Rodriguez Diagnosis: Pulmonary

Tuberculosis
Age: 59y/o Gender: Male Room#: ½ (male ward) RGH

ASSESSMENT DIAGNOSIS PALNNING INTERVENTION RATIONALE EVALUATION

Subjective: ` Ineffective Short term goal: • Assessed • Provides a ` At the end of

airway clearance respiratory basis for the shift, the
“Difficulty of related to poor During my 6hrs rate. evaluating client was able to
breathing” c/c. cough effort nursing adequacy of display patency
possibly intervention, the ventilation. of airway as
evidence by client will be able manifested by:
Objective: abnormal breath to: • Noted chest
sounds and movement; • Use of • Client’s
• Abnormal dyspnea. • Sustain use of accessory respiratory rate
breath sounds: respiratory accessory muscles of is within
wet crackles. rate within muscles respiration normal range:
normal range: during may occur in RR-19 bpm.
• Dyspnea; use RR = 12-20 respiration. response to
of accessory cpm. ineffective • Secretions
muscles for ventilation. decreased.
respiration: • Display
elevated decreasing • Auscultated • Crackles • Client’s
shoulders. amount of breath sounds; indicate restlessness
secretion. noted areas accumulation was alleviated
• Restless with presence of secretions and remained
• Allay restless- of adventitious and inability to calm.
• Vital signs: ness. sounds. clear airways.

BP - 80/60 • Expectorations
hhmg Long term goal: • Documented may be
Tº - 36.5ºc respiratory different when
RR - 26 cpm During the secretions: secretions are
PR - 75 bpm client’s stay at character and very thick.
the hospital he amount of
will be able to sputum.
maintain patent • Positioning
airway as • Maintained helps
evidenced by: patient on maximize lung
moderate high expansion.
• Normal back rest.
respiration as • To maintain
evidenced by • Checked for adequate
absence of obstructions: airway
dyspnea and accumulation patency.
adventitious of secretions.
breath sounds
(wet crackles). • Take
medications
• Normal as ordered by
breathing the physician.
pattern: RR =
12-20 cpm.

• Absence of
bronchial
secretions.

• Allay restless-
ness