Name: Lina Posadas Age: 32 y/o ASSESSMENT SUBJECTIVE: Nahihirapan akong huminga at madali akong mapagod OBJECTIVE: DIAGNOSIS

S Ineffective breathing pattern related to acute infection and decreased lung capacity. INFERENCE
The risk of TB is a higher in older people who have close contact with a newly diagnosed TB patient, those who have TB before, gastrectomy patients, and those affected with diabetes mellitus. The aging process weakens the immune system, further increasing the likelihood of tubercular infection in older adults. Transmission occurs when droplet nuclei are produced form an infected persons coughs or sneezes. If inhaled, tubercle bacillus settles in the alveolus and infection occurs, with alveolocapillary dilation and endothelial swelling. The incubation time for TB is 4 to 8 weeks. TB is usually asymptomatic in primary infection.

Dx: PTB Cat 1, Pneumothorax

PLANNING After 8 hours of nursing intervention the patient will:

INTERVENTION Monitor respiratory status, including vital signs, breath sounds, and skin color.

RATIONALE Respiratory status assessment helps gauge the patients severity and whether its progressing. To provide relief from symptoms of hypoxemia and hypoxia. ABG levels and continuous pulse oximetry measures the bloods oxygen content and are good indicators of the lungs ability to oxygenate the blood.

EVALUATION After 8 hours of nursing intervention the patient was able to:

Cough that may be nonproductiv e at first but later produces sputum and progresses to hemoptysis. Crackles Pleuritc pain Dyspnea

Promote good respiratory function and treat infection Promote comfort

Administer oxygen therapy as ordered.

Breathing returned to normal rate and pattern Minimal or no signs of infection.

Monitor ABG levels and oxygen saturation as ordered.

Place the patient in semifowlers position and place the diaphragm in proper position to contract. Collect sputum samples as ordered.

To increase chest expansion and to alleviate dyspnea.

To monitor the progress of the disease and treatment.

Signed:
_______________________________ Kathleen Grace C. Taluban Nurse Trainee ___________________________________________________ Mrs. Julieta Meneses/ Mr. Eduardo Bandong Senior Nurse