Nursing Care Plan (2).

HOLY‌‌‌NAME‌‌‌UNIVERSITY‌‌‌‌
COLLEGE‌‌‌OF‌‌‌HEALTH‌‌‌SCIENCES‌‌‌‌
NURSING‌‌‌DEPARTMENT‌‌‌‌
City‌‌‌of‌‌‌Tagbilaran‌‌‌‌
‌‌
‌‌
NURSING‌‌‌CARE‌‌‌PLAN‌‌‌



Name of Mr. L.J
Patient:___________________ Poblacion, Baclayon, Bohol
Address:______________________________________ Impression: Pulmonary Tuberculosis, Relapse
________________________________________________
November 12, 2020
Date of Visit / Admission: _____________________________ Ward: Room: _________________________
Medical Widow
Status: __________________________ 70 years old
Age: ________________ Sex:

ASSESSMENT PLANNING INTERVENTIONS
PROBLEM CUES/
RATIONALE OF DESIRED BEHAVIORAL NURSING
NURSING RATIONALE
THE PROBLEM OUTCOME(S) OUTCOME(S) INTERVENTIONS
DIAGNOSIS
Ineffective airwayIneffective airway After 48 hours of After 8 hours of nursing Independent Af
clearance related to thick,
clearance can be acute nursing interventions, intervention, the patient nu
- Assess respiratory -Diminished breath
viscous, and bloody or chronic. High-risk the patient will be will be able to: th
function noting breath sounds may reflect
secretions for ineffective airway able to maintain pa
sounds, rate, rhythm, and atelectasis. Rhonchi,
clearance are the aged clear, open airways as m
depth, and use of wheezes indicate
individuals who have evidenced by normal  Demonstrate air
accessory muscles. accumulation of
Subjective an increased incidence breath sounds, coughing and by
secretions and inability
of emphysema and a normal rate and depth breathing exercises br
-“Bation ko ug hangak higher prevalence of to clear airways that may
of respiration, and  Classify methods to no
kon mosulti ko unya chronic cough or lead to use of accessory
ability to effectively enhance secretion br
mosakit ako dughan ug sputum production. muscles and increased
cough up secretions removal no
kapoy akong lawas” as work of breathing
after treatments and  Recognize the re
verbalized by the patient deep breaths. pe
significance of
-“He seemed lack in changes in secretions co
-Expectoration may be af
interest in usual activities to include color,
difficult when secretions de
and that he seemed has character, amount and
are very thick as a result
no appetite in eating his odor -Note ability to
dc

, ASSESSMENT PLANNING INTERVENTIONS
PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL
NURSING INTERVENTIONS RATIONALE
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S)


meals which resulted to  Identify and avoid expectorate mucus and of infection and/or
losing his weight from 70 factors that inhibit cough effectively; inadequate hydration.
kilograms to 50 ineffective airway document character, Blood-tinged or frankly
kilograms” as stated by clearance amount of sputum, bloody sputum results
his daughter. presence of hemoptysis. from tissue breakdown
(cavitation) in the lungs
-“He is experiencing on
or from bronchial
and off fever with chills
ulceration and may
especially during
require further evaluation
afternoon and developed
or intervention.
productive cough for
more than three weeks
with presence of blood”
as reported by his
daughter.
-“He was diagnosed with -Positioning helps
pulmonary tuberculosis maximize lung expansion
for the past 3 months” as and decreases respiratory
verbalized by her effort. Maximal
daughter. -Place patient in semi or ventilation may open
high-Fowler’s position. atelectatic areas and
Assist patient with promote movement of
Objective coughing and deep- secretions into larger
breathing exercises. airways for expectoration
-Pale
-Weak
-Unilateral crepitation
-Tachypnea, stridor,