UNIVERSITY OF SAN JOSE – RECOLETOS

School of Allied Medical Science

Nursing

NURSING CARE PLAN

Patient’s Name: T.B Age: 40 years old Gender: Male Status: Married
Medical Diagnosis: Infiltrative TB of left lung with cavitation without MTB Physician: N/A
Date of Admission: 1/18/ 21 Hospital: PSH- 3B
SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLAN OF CARE
IMPLEMENTATION RATIONALE EVALUATION
CUES CUES DIAGNOSIS REFERENCE /OBJECTIVES
 The patient  Abnormal  Ineffective  Tuberculosis is Short Term: Independent: 1. This information is After 2 hours of
verbalized that breath sounds, airway a common and After 2 hours of 1. Assess level of essential for identifying holistic nursing
he had difficulty Unilateral (left clearance potentially a holistic nursing consciousness / cognition potential for airway interventions goals
in breathing due side) related to deadly interventions, the and ability to protect own problems, providing are met as evidenced
to his severe crepitation, fatigue and infectious patient will be able to airway. (Doenges, M., et. Al, baseline level of care by patients’ ability to
cough rales poor cough disease usually demonstrate behaviors 2018) needed, and influencing demonstrate
effort secondary affecting the to improve maintain 2. Monitor respiration and choice of interventions. behaviors to
to Tuberculosis respiratory airway clearance. breath sounds. Noting rales 2. Indicative of respiratory improve/ maintain
as manifested system and  Participate in and sounds. (Doenges, M., distress/ accumulation of airway clearance and
by abnormal causing the treatment et. Al, 2018) secretions. participate in
breath sounds, sound regimen. 3. Evaluate patients cough/ 3. To determine ability to treatment regimen.
unilateral properties of gag reflex, amount and type protect own airway.
crepitation and symptomatic After 8 hours of of secretions and swallowing 4. To open or maintain After 8 hours of
rales. infected lungs holistic nursing ability. (Doenges, M., et. Al, open airway in at rest or holistic nursing
to differ from interventions, the 2018) compromised individual. interventions goal is
non-infected patient will be able to 4. Position head appropriate met as evidenced by
lungs. Patients expectorate without for age and condition. Dependent: patients’ ability to
with pulmonary assistance. (Doenges, M., et. Al, 2018) 1. To clear airway when expectorate sections
TB will have excessive or viscous by himself.
abnormal Long Term: Dependent: secretions are blocking
breath sounds 1. Suction nose, mouth and airway. After 3 days of
especially over After 3 days of holistic trachea PRN. (Doenges, M., holistic nursing
the involved nursing interventions et. Al, 2018) Collaborative: interventions goal is
areas. Rales the patient will: 1. To clear/ maintain met as evidenced by
and bronchial Collaborative: open airway. patients ability to
breath signs,  Be able to 1. Assist with procedures maintain patent
indicating lung maintain patent (bronchoscopy or airway.
consolidation. airway. tracheostomy) (Doenges, M.,
(Becker , K, et. et. Al, 2018)
Al, 2018).
 UNIVERSITY OF SAN JOSE – RECOLETOS
School of Allied Medical Science
Nursing

NURSING CARE PLAN

Patient’s Name: T.B Age: 40 years old Gender: Male Status: Married
Medical Diagnosis: Infiltrative TB of left lung with cavitation without MTB Physician: N/A
Date of Admission: 1/18/ 21 Hospital: PSH- 3B

SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLAN OF CARE

IMPLEMENTATION RATIONALE EVALUATION
CUES CUES DIAGNOSIS REFERENCE /OBJECTIVES
 Temperature of  Elevated body  Fever has been Short Term: Independent: 1. To frequently assess After 30 minutes of
39 C temperature reported to After 30 minutes of 1. Monitor core temperature. the status of the patient. holistic nursing
 HR- 110 Bpm related to illness occur in 60- holistic nursing (Doenges, M., et. Al, 2018) 2. Central hypertension or interventions goal is
 RR-30 Cpm secondary to 85% of patient interventions the 2. Monitor blood pressure postural hypotension can met as evidenced by
 Flushed skin , Tuberculosis as afflicted with patient’s temperature and invasive hemodynamic occur. the patients
skin is warm to manifested by a pulmonary TB. will go down from 39 parameters if available. 3. Dysrhythmias and temperature of 37.3
touch temperature of As a rule every C to 37.4 (Doenges, M., et. Al, 2018) electrocardiogram (ECG)
39 C case of active 3. Monitor heart rate and changes are common due
pulmonary TB After 8 hours of rhythm. (Doenges, M., et. Al, to electrolyte imbalance
exhibits some holistic nursing 2018) direct effects of After 3 days of
degree of interventions the 4. Monitor respirations. hyperthermia. holistic nursing
pyrexia which is patients temperature (Doenges, M., et. Al, 2018) 4. Hyperventilation may interventions goal is
one of the will remain within 5. Administer antipyretics initially be present. met as evidenced by
important signs normal range ( 36.0 C orally. (Doenges, M., et. Al, patient’s temperature
of TB activity. to 37.5 C) 2018) of 37. 5 C
( Rosha, 2018) 6. Promote surface cooling
Long Term: by means of undressing
After 3 days of holistic (heat loss by radiation and
nursing interventions conduction) (Doenges, M.,
the patient will: et. Al, 2018)

 Demonstrate
behaviors to Dependent:
monitor and 1. Administer medications as
promote indicated to treat underlying
normothermia. cause such as antibiotics for
infection.
(Doenges, M., et. Al, 2018)
UNIVERSITY OF SAN JOSE – RECOLETOS
 School of Allied Medical Science
Nursing

NURSING CARE PLAN

Patient’s Name: T.B Age: 40 years old Gender: Male Status: Married
Medical Diagnosis: Infiltrative TB of left lung with cavitation without MTB Physician: N/A
Date of Admission: 1/18/ 21 Hospital: PSH- 3B

SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC PLAN OF CARE

IMPLEMENTATION RATIONALE EVALUATION
CUES CUES DIAGNOSIS REFERENCE /OBJECTIVES
 The patient  The patient’s  Imbalanced  Malnutrition and Long Term: Independent: 1. This will help in After 5 days of
verbalized that appearance is nutrition less tuberculosis are 1. Ascertain patient’s usual improving the dietary holistic nursing
he is skinny an than body both problems After 5 days of holistic dietary pattern. Include in pattern of the patient. interventions goals is
experiencing indication of requirements of considerable nursing interventions selection of food. (Doenges, 2. To keep track of the met as evidenced by
loss of appetite. weight loss probably related magnitude in the patient will be able M., et. Al, 2018) progress of the patient. patients ability to
to frequent most of the to demonstrate 2. Monitor I & O and weight 3. It helps patient to demonstrate
severe cough underdeveloped progressive weight periodically. (Doenges, M., conserve energy. progressive weight
and fever as regions of the gain toward goal with et. Al, 2018) 4. This will help the gain towards goal
evidenced by world. It is normalization of 3. Encourage and provide for patient to slowly adjust with normalization of
reported loss of important to laboratory values and frequent rest period. and meet his personal laboratory vales and
appetite. consider, how be able to maintain (Doenges, M., et. Al, 2018) and cultural preference. able to maintain
these two good nutrition. 4. Encourage SO to bring good nutrition.
problems tend healthy food for the patient. Collaborative:
to interact with 1. It will help the patient
each other. The Collaborative: to improve his diet.
term 1. Refer patient to dietitian
consumption for proper recommendation
has been of diet.
virtually
synonymous
with
tuberculosis
throughout the
history1 and the
link between
tuberculosis and
malnutrition has
long been
recognized;
malnutrition
may predispose
people to the
development of
clinical disease
and tuberculosis
can contribute
to malnutrition.
(Gupta, K., et.
Al, 2018)