School of Nursing and Allied Medical Sciences

Holy Angel University

Angeles City

Integrative Activity
Module 2: Structural, Functional, Infectious and Inflammatory
Problems affecting Oxygenation (Upper and Lower Airway
Disorders) – Problem-based Learning and Nursing Care
Mapping
Dela Torre, Bianca Mariz M.
Galang, Adryan
Lacson, Maria Isaiah M.
Limus, Nericah Gayle M.
Munsayac, Ericka Eunice T.
Nunez, Jana Mikaella O.
Sta.Rosa, Ralph Vincent H.
Togonon, Gabriel M.

NCM 112 – Care of Clients with Problems in Oxygenation, Fluid and Electrolyte, Infectious,
inflammatory and Immunologic Response, Cellular Aberration, Acute and Chronic

Medical Diagnosis: Pulmonary Tuberculosis

Tuberculosis remains a worldwide problem despite well documented, well publicized methods
of prevention and cure. This disease is common in the Philippine setting and is susceptible to people
with an HIV infection, infants or children, and in our case people who have underlying conditions that
can progress to tuberculosis. Mrs. A, who is 61 and is overweight, has shown signs of dyspnea and
hypertension (160/100 mmHg) and has no past history of smoking and alcoholism. Upon admission she
has complained of a productive cough with blood and signs of cyanosis, however no complaint of chest
pain. The body reacts to inflammation in the airway by coughing to eliminate it (Müller, 2016). Coughing
up bright red blood, a symptom that occurs when the blood vessels inside the lungs become eroded and
begin to bleed (Winney, 2014). The possible causes for the development of hypertension in these
patients are the destruction of the vascular bed due to parenchymal abnormalities, vasculitis, and
endarteritis, leading to reduced cross-sectional area of the pulmonary vasculature (Verma, 2020).
Campbell and Bah-Sow stated, tuberculosis is most commonly found among people living in poor
conditions and especially in elderly people.
Nursing Care Map
Ineffective Airway Clearance

Ineffective airway clearance is the inability of the body to clear secretions or obstructions from
the respiratory tract. Due to the inability to clear airway obstruction, the patient reported shortness of
breath and cyanosis which is related to ineffective tissue perfusion. Ineffective airway clearance affects a
patient’s ability to meet adequacy in nutritional needs as she reported shortness of breath upon eating.
A patient with generalized fatigue and weakness contributes to the inability of her to clear airway
secretions. Moreover, activity intolerance related to ineffective airway clearance is evident because the
patient also complains of shortness of breath upon eating and doing ADL’s.

Ineffective Tissue Perfusion

Ineffective tissue perfusion is decreased in blood circulation to the periphery that may
compromise health. It is characterized by cyanosis and shortness of breath since the tissues inside the
body can’t get enough supply of blood which is related to ineffective airway clearance and cardiac
output. In relation to fatigue and activity intolerance, they are both manifested with generalized
weakness and inability to do activities in daily living which is related to ineffective tissue perfusion since
shortness of breath is also present

Decreased cardiac output

Decreased cardiac output is the inadequate blood pumped by the heart to meet the metabolic
demands of the body. Cardiac output and tissue perfusion is interrelated because when cardiac output
decreases tissue perfusion problem will develop which will result to Ineffective tissue perfusion. Since
the client is experiencing ineffective cough and reported shortness of breath, Ineffective airway
clearance is present. Decreased cardiac output causes fatigue to patients as she experiences generalized
weakness.

Excess Fluid Volume

Excess fluid volume refers to an isotonic expansion of the extracellular fluid due to an increase
in total body sodium content and an increase in total body water. Presence of moderate pitting edema
grade 2+ on the patient’s leg were noted. Due to this, the patient’s independent actions such as moving
were limited. It then resulted to the inability of the patient to eat well due to the generalized weakness
felt and tired feeling during meal times, which resulted in fatigue.

Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less than body requirements is considered as a nursing diagnosis when
the intake of nutrients is insufficient to meet daily requirements because of inadequate food intake or
improper digestion and absorption of food. Ineffective airway clearance prevents the client to acquire
proper nutrition because of frequent coughing and sputum production existence. Our body needs the
proper amount of nutrients in order to function best. If our body out-performs its caloric intake, this can
cause increased tiredness which can lead to fatigue, which can lead to activity intolerance beacause the
energy required cannot be given by the body. Imbalanced nutrition but excess in fluid volume is possible
when one's potassium levels are low.

Fatigue
 Fatigue is a term used to describe an overall feeling of tiredness or lack of energy, and it is a
common symptom of many medical conditions that range in severity from mild to serious. It’s also a
natural result of some lifestyle choices such as lack of exercise or poor diet causing the patient to not
meet their body’s nutritional needs. Making them weak and is unable to perform ADL’s. Fatigue is
related to decrease cardiac output & ineffective tissue perfusion since the heart does not pump enough
blood to meet the needs of the body and is also causing disruption of gas exchange to the blood and
cells causing patients to experience fatigue. Fatigue is also related to ineffective airway clearance since
weakness contributes to the inability of her to clear airway secretions.

Activity Intolerance

Activity intolerance is the insufficient physiological energy to complete or endure daily activities.
It is characterized by general weakness, fatigue, alteration in blood pressure, edema and shortness of
breath. Which results in ineffective airway clearance. Due to the weakness and fatigue the client
experiences loss of appetite and that leads to imbalance in nutrition. In relation to the client's excessive
fluid volume, it resulted to edema. These manifestations are affecting the client in doing her ADL's.
Problem No. 1: Ineffective Airway Clearance
Goal: Maintain a clear and open airway
Outcome: patient will be able to expectorate secretions effectively, will be able to tolerate ADLs
without SOB, will have clear lung sounds, SpO2 above 85%, AFB test (-) , and patient exhibits normal chest x-ray
findings on the upper lobe of the lungs.
Nursing Interventions: Evaluation:

1. Assess for respiratory function 1. Normal breath sounds, RR of 16cpm, Sp02 of

through noting breath sounds, Sp02 96%
rate, rhythm, and depth, and use of
accessory muscles to monitor and
prevent possible complications.

2. Pt. in semi-fowler’s, verbalized “I can

2. Position the patient in a semi-
breathe much better”
fowler’s position to maximize lung
expansion and decrease respiratory
effort.

3. Pt. ambulated early and was able to cough

up secretions in minimal amounts.
3. Promote early ambulation to allow
mobilization of secretions, prevent retention
of secretions, and exercise the lung muscles. 
4. Pt. performed deep breathing exercise; RR
4. Provide health education about of 16 cpm ; Sp02 of 96% 
deep breathing exercises to promote
maximal ventilation and improve shortness of 5. Pt. verbalized understanding and performed
breath.  hand washing techniques 

5. Provide health education about 6. Pt. verbalized “ I have to follow my

proper cough etiquettes and hand washing to medications for me to not develop TB
prevent the risk of infection. 
complications and recover effectively” 
6. Provide health education about the
importance of adherence to treatment 7. Pt. took meals effectively w/o episodes of
regimen to promote fast recovery.  SOB and fatigue; RR of 16 cpm; Sp02 of 96%

7. Advise patient about the need to eat 8. Pt. verbalized understanding and was able to
small, frequent meals to lessen fatigue, enumerate possible drug side effects.
shortness of breath, and loss of appetite. 

8. Provide health education about the side 9. Received chest physiotherapy, expectorated
effects of Anti tuberculosis drugs and proper
thick greenish sputum; RR of 16 cpm
interventions with these side effects to
prepare and equip the patient with adequate
knowledge when side effects are
experienced. 10. Pt. verbalized relief after the procedure

9. Collaborate with respiratory

 therapist for chest physiotherapy as indicated
to promote elimination of secretions and
improve airway clearance  11. Chest x-ray done; communicated with the
physician
10. Collaborate with respiratory
therapist for nebulation therapy as indicated
to improve airway clearance and shortness of
breath.  12. Lab results updated; relayed to physician,
AFB(-)
11. Collaborate with the radiologic
13. Pt. received proper diet and nutrition from
technology department about the patient’s
chest x-ray to be reported and the department; no signs of loss of appetite
communicated to the physician.  and fatigue 

12. Collaborate with medical technology

department for monitoring patient’s sputum
test and relaying to physician
14. Pt. verbalized relief and expectorated thick
13. Collaborate with the dietary and greenish sputum 
nutrition department on the adequate and
proper diet of the patient to promote
recovery and improve airway clearance. 

15. Pt. adhered to treatment regimen

14. Provide postural drainage,

percussion, and vibration as ordered to
16. Administered oxygen therapy; Sp02 of 96% 
dislodge secretions 

17. Cleared and suctioned secretions; pt. has

lessened secretion retention 
15. Administer Anti- Tuberculosis drugs
as ordered to treat the existing disease.
18. Pt. expectorated thick greenish sputum;
16. Provide oxygen therapy as ordered verbalizes relief on breathing; RR of 16 cpm
to promote clearing of airway 

17. Clear secretions from mouth and

trachea through suctioning as ordered to
prevent obstruction and aspiration

18. Provide steam inhalation as ordered

to promote humidity and liquefaction of
secretions

Impression: Patient expectorated secretions effectively, no episodes of SOB upon doing ADLs, has clear lung
sounds on the upper lobe, Sp02 of 96%, AFB test (-), and patient exhibits normal chest x-ray findings. 
Problem No. 2:Ineffective Tissue Perfusion
Goal: To improve the exchange of oxygen and carbon dioxide
Outcome: Patient hemoglobin is at the normal level
Nursing Interventions: Evaluation:
1. Monitor and record vital signs to 1.BP: 140/90 mmHg
have a baseline. RR: 18cpm
PR:  82 bpm

2.140mg/dl

2. Monitor blood glucose level to

identify if the blood sugar level is 3.Absence of edema
high or low.
Back to normal skin color and temperature
3. Assess for signs of decreased tissue
perfusion to know that particular
4.SpO2: 95%
cluster of signs and symptoms occur
PR: 82 bpm
differing causes
5.12g/dL
4. Use pulse oximetry to monitor
oxygen saturation and pulse rate to
detect changes in oxygenation 6. Client will no longer pale and have a normal
skin temperature
5. Check Hgb levels because low level
reduces the uptake of oxygen at the
alveolar capillary membrane and
oxygen delivery to the tissues. 7. Client received 2 packed of BT

6. Check for pallor, cyanosis, cool or

clammy skin because systemic 8. Administered IV fluid
vasoconstriction resulting from
reduced cardiac output
9. Administered medication

7. Blood component therapy (BT) as

ordered to increases the patient’s
blood volume 10. Administered O2 therapy

8. Administer IV fluids as ordered to

maintains circulating volume to
maximize tissue perfusion
9. Administer medications as 11. Client’s wears support hose
prescribed to treat underlying
problem to facilitate perfusion for
 most causes of impairment. 12. Medical technologist sent results

10. Provide oxygen therapy as ordered

(if necessary), to saturates
circulating hemoglobin and
augments the efficiency of blood
13. Requested a diagnostic test
that is reaching the ischemic tissues

11. Apply support hose as ordered 14. Dietary dept. will be able to serve the
because wearing support hose helps appropriate diet to the client
decrease edema.

12. Coordinate with the medical

technologist dept. to monitor 15. Client will be able to comply the regular
laboratory studies such as check up
hemoglobin, hematocrit and RBC
since normal values indicate
adequate tissue perfusion 16. Treatment relayed

13. Submit patient to diagnostic testing

as indicated to have further
diagnostic examination.

14. Coordinate with the dietary dept. to

apply the appropriate diet to the
client.

15. Encourage to follow the regular

medical check up to monitor client’s
condition.

16. Refer to podiatrist if needed, to treat

the numbness or swelling in one
foot.

Impression: Patient hemoglobin level elevated to normal range after latest laboratory result.

 
Problem No. 3: Decreased cardiac output
Goal: Maintain cardiac output within normal level
Outcome: Decreased episodes of shortness of breath
Nursing Interventions: Evaluation:

1. Monitor Vital Signs to provide a baseline 1. BP: 140/90

for comparison to follow trends and RR: 18
evaluate response to interventions PR: 82
Maintain vital signs in normal range

2. UO: 27cc/hr
2. Assess urine output hourly or periodically to Patient should void at least 30cc/hr
allow for timely alterations in therapeutic
regimen 3. Adequate rest
Patient will have enough rest
3. Provide a quiet environment to promote
4. Less than 3 seconds
adequate rest
5. Patient participated in limiting activities
4. Assess capillary refill. Prolonged indicates
6. Patient had skin rashes
poor cardiac output
Patient will have alternative meds
5. Instruct client to limit activities which can
7. Sodium reduction
cause changes in cardiac pressure
Patient will comply

6. Relay significant sign/symptoms to 8. All within normal value

physician which may be sign of drug
toxicity
9. EKG and Chest X-ray are clear
7. Arrange time with dietitian to adjust
individually appropriate diet
10. Verbalized understanding of the importance
of regular medical follow up care
8. Relay to the physician the laboratory results
to know that interventions are going well 11. Received fluids
Minimized dehydration
9. Relay results of Chest X-ray to the
physician to know that interventions are 12. Labs: waiting for result
going well Display hemodynamic stability

10. Emphasize the importance of regular 13. Meds taken

medical follow up care to monitor patient’s
condition
 11. Administer fluids and electrolytes as 14. EKG and Chest X-ray: waiting for results
ordered to support systemic and cardiac 15. Administered oxygen as indicated
circulation No presence of cyanosis

12. Send the request for laboratory data to

identify client at risk and promote early
intervention

13. Administer medications as ordered to

manage cardiac function

14. Send the request for diagnostic studies to

identify client at risk and promote early
intervention

15. Administer oxygen as ordered to increase

oxygen available for cardiac function

Impression: Patient maintained cardiac output within normal level

Problem No. 4: Fluid Volume Excess

Goal: To stabilize the fluid volume of the patient.
Outcome: Patient will demonstrate behavior on how to monitor fluid status and prevent the reoccurrence of
excess fluid volume.
NURSING INTERVENTIONS EVALUATIONS

INDEPENDENT:

1. Educate the patient and significant others 1. The patient and the significant others
about the importance of fluid restrictions. complied with the health education provided.
Information and knowledge about
condition are vital to patients who will be
co-managing fluids.
2. Patient’s intake of sodium rich foods was
2. Limit sodium intake as prescribed, minimized.
restriction of sodium aids in decreasing
fluid retention.
3. Patient’s fluid intake was monitored.
3. Monitor patient’s fluid intake as this
enhances the compliance of the patient
with the regimens.
 4. There’s certain changes with the patient’s leg,
4. Elevate edematous extremities and handle minimized presence of swelling were noted.
with care.
5. Early ambulation was observed with the
patient and risk for tissue perfusion and skin
5. Promote early ambulation to decrease the breakdown were prevented.
risk for tissue perfusion and skin
breakdown.

DEPENDENT: 6. Patient was able to urinate on a normal output.

6. Administer diuretics as per doctor’s
order, this will help reduce the congestion
and occurrence of having edema. 7. Patient complied with the said dietary
restriction.

7. Encourage patient to have a low sodium

diet as recommended by the physician
restriction of sodium rich foods helps
with decreasing fluid retention.
8. Physician was informed.

8. Inform physician with the intervention

made and the progress of the patient’s
condition.
9. Results relayed.

9. Relay any abnormal values or progress

regarding the patient’s lab result.
10. Signs and symptoms were relayed.

10. Notify physician immediately for any

signs/symptoms of excess fluid volume.
11. Lab values were monitored.

INTERDEPENT:

11. Coordinate with the laboratory

department about the patient’s lab results
12. Nutritional goals for the given meal plan were
such as: createnine, potassium and urea
achieved by the patient.
levels.

12. Consult with the dietary department to 13. Patient’s ability to move was improved
develop a meal plan. minimized swelling around her leg area was
noted.

13. Collaborate with a physical therapist to 14. Dietician was able to provide a dietary
help in improving the patient's discharge plan for the patient.
movement.  
 14. Refer patient to a dietician to provide a 15. Occupational therapist set a scheduled activity
dietary plan upon discharge which will for the patient.
help the patient go back to her healthy
state.

15. Refer patient to see an occupational

therapist for a scheduled 30 minutes to 1
hour of activity which would help to
improve patient’s movement and other
activities of daily living.

Impression: Patient demonstrated a changed in her behavior, minimized presence of swelling on her legs was
achieved, normal urine output per hour was noted as well as nutritional goals were reached.

Problem No. 5: Imbalanced Nutrition: Less than body requirements

Goal: Improve nutrition
Outcome: Client’s glucose level will fall on normal range and intake of fluids and electrolytes will
balance outputs
Nursing Interventions: Evaluation:

1. Assess the capability of the patient to ingest
nutrients or any other barriers because
knowing the factors that may affect digestion
or ingestion can help in solving the root
problem.
1. Frequent cough/sputum production, dyspnea,
and fatigue affects the client’s ingestion of food.
2. Weight: 65kgs
I&O: 27cc/hr

2. Monitor I&O and weight periodically to 3. Liked the taste, said it improved a lot.
measure the effectiveness of nutritional and
fluid support.

4. Helped in increasing glucose levels.

3. Provide oral care before and after respiratory
treatments to reduce bad taste left from
sputum or medications used for respiratory
treatments that can stimulate the vomiting
center. 5. Glucose level: 140 mg/dl
4. Administer fast-acting sugar-containing food/
drink like orange juice or candy for 6. Started to add leafy greens to meals.
hypoglycaemia because they are easily
digested and absorbed compared to complex
sugars. 7. Verbalized tiredness was lessened during meal
times.
5. Monitor blood glucose level to know the
need for more or just enough intake of
carbohydrate/sugar to prevent overeating.
8. Signs and symptoms relayed.

6. Teach patient and SO about foods that are

sources of folic acid to enable the patient
reach the resources properly. 9. Results relayed.

7. Encourage and provide for frequent rest

periods to conserve energy, especially when 10. Physician suggested best time to take meds,
metabolic requirements are increased by should take a good multivitamin and mineral
fever. supplement.

11. Medications administered.

8. Communicate with the physician about
sign/symptoms to which may be sign of
undernutrition.
12. Recommendations noted.

9. Communicate with the physician about the

laboratory results to know that interventions
are going well. 13. Fluids and electrolytes administered.

10. Relay to the physician the drug interactions

to know if some of the drugs are affecting the
14. Dietitian planned a diet for the client.
appetite, food intake or absorption.

11. Administer medications that improve

nutrient intake as ordered by the physician.
15. Dietary dept. able to deliver planned diet.

12. Give the recommended multivitamin and

mineral supplements as ordered the
physician. 16. Respiratory therapist planned treatment 1
hour before meals.

13. Administer fluids and electrolytes as ordered

because they play a vital role in homeostasis
 within the body by regulating various bodily
functions. 17. Medical technologist sent results.

14. Refer to dietitian for adjustments in dietary

composition to provide assistance in planning
18. Concern relayed.
a diet with nutrients adequate to meet
patient’s metabolic requirements, dietary
preferences, and financial resources post
discharge.

15. Coordinate with the dietary dept. to apply

the planned diet and hand to the client.

16. Consult with respiratory therapy dept. to

schedule treatments 1–2 hr before or after
meals to help reduce the incidence of nausea
and vomiting associated with medications or
the effects of respiratory treatments on a full
stomach.

17. Coordinate with medical technology dept. to

monitor laboratory studies: BUN, serum
protein, and prealbumin, albumin to indicate
need for intervention and change in
therapeutic regimen.

18. Refer to an occupational therapist for

adaptive devices because special devices
provided by an expert may help patients feed
themselves.

Impression: Nutritional status in balance with intake equal to output; glucose level improved within normal
range.

Problem No. 6 : Fatigue

Goal: Improve sense of energy
Outcome: Patient verbalized increased energy and improved well-being.
Nursing Interventions: Evaluation:
1. Assess vital signs to evaluate fluid status & 1. Vital signs are within normal parameters.
cardiopulmonary response to activity.

2. Monitor nutritional intake for adequate

energy sources and metabolic requirements. 2. Patient was able to meet nutritional and
metabolic needs.
3. Assess ability to perform ADL to influence
choice of intervention or needed assistance.

4. Educate energy-conservation 3. Patient was able to perform their ADL

techniques.Organization and time management without assistance.
can help the client conserve energy and reduce
fatigue.

5. Assess the specific cause of fatigue to 4. Patient was able to manage her time well.
determine other related medical problems.

6. Educate patient to eat small, frequent

meals. Eater smaller, more frequent meals may
be more appealing and take less energy-but still 5. Findings: Anemia
get the nutrition their body needs to heal.
6. Patient verbalized understanding on health
7.  Monitor Laboratory test to identify changes
teaching.
before they become potentially life-threatening.

8. Provide supplemental oxygen therapy, as

needed. Oxygen saturation should be kept at 7. Lab results within normal values.
90% or greater.

9.  Relay to the physician the laboratory results 8. Oxygen saturation did not go below 90%
to know that interventions are going well.

10..  Work with the physician to determine if 9. Results relayed

the client has chronic fatigue syndrome.

11.  Review medications for side effects. Certain 10. No signs of CFS
medications (e.g., beta-blockers,
antihistamines, pain medications) may cause
fatigue in the elderly. 11. Medications reviewed

12.   Refer to dietitian for adjustments in

dietary composition to provide assistance in
planning a diet with nutrients adequate to meet 12. Dietitian planned a diet for the client.
patient’s metabolic requirements, dietary
preferences, and financial resources post
discharge.

13.  Refer client to occupational therapy to

13. Patient was referred
learn new energy-conserving ways to perform
tasks.
 14.   Coordinate with medical technology dept. 14. Medical Technologist sent results
to monitor laboratory results to indicate need
for intervention and change in therapeutic
regimen.
15. Dietary department able to deliver planned
15.  Coordinate with the dietary dept. to apply diet
the planned diet and hand to the client.

16.  Emphasize the importance of regular

16. Verbalized understanding of the importance
medical follow up care to monitor patient’s
of regular medical follow up care
condition.

Impression:Patient has improved energy, not experiencing any headaches and no longer feeling weak, dizzy,
and irritable.

Problem No. 7 : Activity Intolerance

Goal:exhibit tolerance during physical activity
Outcome: Pt. would be able to tolerate ADL’s
Nursing Interventions: Evaluation:
1. BP: 140/90
1. Monitor vital and cognitive signs for RR: 18
baseline information and to note changes. PR: 82

2.   Note patient’s report of weakness, fatigue, 2. Noted patient’s response.

pain and difficulty accomplishing tasks. Symptoms
of these may be a result of intolerance of activity.

3.   Determine the patient’s current activity 3. Slight fatigue and dyspnea at rest.
level and physical conduction. This provides a
baseline for comparison and an opportunity to
track changes.
4. Patient uses bed pan in voiding.
4.       Encourage the use of bed pan for urinating to
conserve strength.
5.       Advice given.
5.   Advice to avoid abrupt standing and moving  
to prevent orthostatic hypotension  
6.       Provided assistance
6.       Involve patient and SO in planning activities  
as much as possible to assist and provide comfort  
for the patient. 7.       Referred to a physical therapist.
 
7.       Provide referral to other disciplines, such as  
physical therapist as indicated to develop 8.       Exercise implemented.
  
individually appropriate therapeutic regimens.
9.       Encouraged to do a conditioning program.
8.       Implement a physical exercise program in  
conjunction with the patient and other team  
members for enhancement of health. 10.   Discussed symptoms with physician.

9.       Promote and implement a conditioning  

program. Support inclusion in activity groups to 11.   Patient was referred for assistance resources.
prevent deterioration.
 
10.   Identify and discuss symptoms for which the 12.   Supplemental oxygen given.
patient needs to seek medical assistance for  
providing timely interventions.  
13.   Laboratory results relayed on physician.
11.   Refer to appropriate resources for assistance  
to sustain activity level. 14.   IVF given and regulated.
 
12.   Provide response to supplemental oxygen,  
medication and changes in treatment to help 15.   Care plan given.
compensate for oxygen to aid dyspnea.

13.   Refer laboratory results to determine extent

of severity of condition.

14.   Regulate IVF at ordered rate to help regain

strength since it contains electrolytes and also
where medications are usually given. 

15.   Plan care to carefully balance rest periods

with activities to reduce fatigue.
 

Impression: Patient was responsive to the treatment regimen and was able to tolerate ADL’s
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Campbell, I., Bah-Sow, O. (2020). Pulmonary tuberculosis: diagnosis and treatment. National Center for
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http://www.tbonline.info/posts/2016/3/31/pulmonary-tb/.

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