BRIOLA, KAREN ROSE L.

BSN 104 group 15

NURSING CARE PLAN

Assessment Diagnosis Analysis Planning Intervention Rationale Evaluation

S: After 8 hours
After 8 hours
“ nahihirapan Ineffective Immediate of nursing
of nursing
huminga si tatay, Airway cause: intervention
Clearance interventions, the patient
may plema din Ineffective
related to the patient was able to
kapag umuubo airway
retained will be able to manifest a
siya” verbalized by clearance
secretions manifest a patent
the relative
patent airway airway.
Intermediate
“nagigising nalang as evidenced
cause:
siya bigla pag-gabi by:
Cough and Assess Bronchial
kakaubo”
Secretions ventilation lung sounds
verbalized by the - Respiratory
relative and presence are
Root cause: rate within of commonly
PTB normal range adventitious heard over -
O:
of 16-20cpm sounds areas of lung
 Restlessness
Tuberculosis density or
 Adventitious
is an - Absence of consolidation.
breath
infectious adventitious
sounds
(crackles and disease sound like Monitor chest These
wheezes) caused by TB wheezing and
x-ray results. determine
 Difficulty bacteria crackles;
vocalizing (Mycobacteriu progression
 Presence of m - of disease
cough tuberculosis) Demonstratio
process (e.g
 Difficulty in that primarily n of deep
breathing breathing and Assist client clearing of
affects the
 Irritable lungs. This coughing with coughing infiltrates.
 Sleepy condition is exercises; and deep
 RR- 27 known as and breathing. This improves
 PR- 100 pulmonary productivity
tuberculosis - Place the of cough
 BP-140/100
client in high
 Temp- 36 (PTB). You Expectoration
or semi- Maximize
may also have of secretions
fowler’s chest
tuberculosis in readily. position. excursion and
the bones, subsequent
meninges, movement of
joints, genito- Encouraged air.
urinary tract, expectoration
liver, kidneys, of secretions. Thickened
intestines and secretions are
heart and this more likely to
is called Maintain occlude
extra- adequate airway
pulmonary hydration.
Increase oral To aid in the
tuberculosis.
fluid intake at mobilization
least 2oo ml of secretions.
per day in
level of
cardiac
tolerance.

Assist client in
performing Helps client
specific to promote
airway effective
clearance airway
techniques or clearance.
respiratory
muscle
training as
indicative
Administer To treat non-
medications productive
such as cough cough, loosen
suppressant and mobilize
and secretions.
mucolytics as
prescribed
A nebulizer
Consult the may be used
respiratory to humidify
therapist for the airway to
nebulizer thin
treatments, secretions to
as appropriate facilitate their
and ordered removal.