ASSESSMENT

S I dont understand why I cant breathe good and what all this fuss is about, as verbalized by the pt. - fatigue

DIAGNOSIS Ineffective airway clearance r/t thick secretion of sputum a.m.b dyspnea.

PLANNING After 8 hours of nursing interventions, the patient will maintain a patent airway.

INTERVENTIONS 1. Regulating energy use.

RATIONALE 1. To treat or prevent fatigue and optimize function. 2. To maintain or advance to a higher level of fitness and health. 3. To prevent any complications.

EVALUATION

2. Facilitation of regular physical exercise.

0 Weight loss of 15 lbs. - Productive cough with thick, purulent sputum with a streaked of blood. - Exertional dyspnea - Cough - Crackles v/s: T = 99 F R = 26 cpm BP = 138/86 L&D - Matoux test = (-) @ 66 mm. - AFB = (+) tubercle bacilli - CXR = (+) for TB

3. Assisting with or providing a balanced dietary intake of foods and fluids. 4. Facilitating gain of ody weight. 5. Prevention and treatment of severe diet restrictions and over exercising or binging and purging of foods and fluids. 6. Collection and analysis of patient data. 7. Administration of oxygen and monitoring of its effectiveness. 8. Facilitating of patency of air passages.

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5. To prevent any possible complications.

6. To ensure airway patency and adequate gas exchange. 7. To promote good ventilation of the patient. 8. To ensure airway patency and adequate gas exchange.

9. Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles. 10. Providing information and support for a person who is making a decision regarding healthcare. 11. Purposeful and ongoing collection and analysis of information about the patient and the environment. 12. Analysis of potential risk factors, determination of health risks and prioritization of risk reduction strategies for an individual or group. 13. Manipulation of the patients surroundings.

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11. Use in promoting and maintain patient safety.

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13. For therapeutic benefit.