NURSING CARE PLAN

Assessment Diagnosis Objective/ Intervention Rationale Evaluation

Planning

Subjective: Imbalanced nutrition: Short term: Document Useful in Goals met,

“Ginahilanat ako, less than body After 8 hours of patient’s defining after 2-3
kung gabi ga requirements related nursing nutritional degree or days of
balhas ko kag to fatigue and interventions, the status on extent of effective
wala ko gana frequent cough as patient will be admission, problem and nursing
magkaon.” as evidenced by weight able to verbalize noting skin appropriate interventio
verbalized by the loss and lack of in understanding turgor, current choice of n, the
patient appetite of causative weight and interventions. patient
factors and degree of was able
Objective: Rationale: necessary weight loss, to
VS: Nutritional imbalance interventions to integrity of demonstra
RR: 25 cpm PR: can be brought on by promote optimum oral mucosa, te
90 bpm the inability of an nutrition. ability, or behavior,
T: 38 °C individual's body to inability to lifestyle
take in and absorb swallow, changes to
O2: 90% specific nutrients or it presence of regain
may even result from Long term: bowel tones, appropriat
-Looks pale, with a poor diet plan. After 2-3 days of history of e weight.
dry and flushed nursing nausea and
skin Reference: intervention, the vomiting or
-Looks older than https://thebanyans.com.au  patient will be diarrhea.
her age › SEO articles able to initiate
-Crackles breath behavior/lifestyle Ascertain Helpful in
sound changes to regain patient’s usual identifying
-Enlarged lymph and or to maintain dietary specific needs
nodes and appropriate pattern. and strengths.
distended weight with Include in Consideration
abdomen normalization of selection of of individual
laboratory values.. food. preferences
may improve
dietary intake.

Monitor I&O
and weight
periodically. Useful in
measuring
effectiveness
of nutritional
Encourage and fluid
 and provide support.
for frequent
rest periods. Helps
conserve
energy,
especially
when
Encourage metabolic
small, requirements
frequent are increased
meals with by fever.
foods high in
protein and Maximizes
carbohydrates. nutrient
intake without
undue
fatigue/energy
expenditure
from eating
large meals,
and reduces
gastric
irritation.

Assessment Diagnosis Objective/ Intervention Rationale Evaluation

Planning

Subjective: Risk for Short term: Review pathology of Helps patient Goal is met as
“Gasakit infection After 8 hours of disease realize or accept evidenced by:
(active and inactive
akon ulo, related to nursing phases; dissemination
necessity of a. Patient was
kung gabi ga inadequate interventions, the of infection adhering to able to identify
balhas ko primary patient will be through bronchi to medication interventions to
kag wala ko defenses, able to identify adjacent tissues or via regimen to prevent prevent the risk
gana decreased interventions to bloodstream reactivation or of infection.
magkaon.” ciliary prevent/reduce and/or lymphatic complication.
as action/stasis risk of spread of system) and potential Understanding of b. Patient was
verbalized of infection. spread of infection via how the disease is able to
airborne droplet during
by the secretions coughing, sneezing,
passed and demonstrate
patient spitting, talking, awareness of techniques to
laughing, singing. transmission promote safe
Objective: Long term: possibilities help environment by
VS: After 2-3 days of Identify others at patient and SO take isolating herself
RR: 25 cpm nursing risk like household steps to prevent after discharge.
PR: 90 bpm intervention, the members, close infection of others.
T: 38 °C patient will be associates and
able to friends. Those exposed
O2: 90% demonstrate may require a
techniques/initiat Instruct patient course of drug
-Looks pale, e lifestyle to cough or sneeze and therapy to prevent
with dry and changes to expectorate into tissue spread or
and to refrain from
flushed skin promote safe spitting. Review proper
development of
-Looks older environment. disposal of tissue and infection.
than her age good hand
-Crackles washing techniques. Behaviors
breath sound Encourage return necessary to
-Enlarged demonstration. prevent spread of
lymph nodes infection.
and Monitor
distended temperature as
abdomen indicated.

\
Review importance Febrile reactions
of follow-up and are indicators of
periodic reculturing continuing
of sputum for the presence of
duration of therapy. infection.

These second-line
drugs may be required
when infection is
resistant to or
intolerant of primary
drugs or may be used
concurrently with
primary anti tubercular
drugs. MDR-TB
requires minimum of
18–24 mo therapy with
at least three drugs in
the regimen known to
be effective against the
specific infective
organism and which
patient has not
previously taken.
Treatment is often
Administer anti- extended to 24 mo in
infective agents as patients with severe
symptoms
indicated
 or HIV infection.

Initial therapy of
uncomplicated
pulmonary disease
usually includes
four drugs, e.g.,
four primary drugs
or combination of
primary and
secondary drugs.

Assessment Diagnosis Objective/ Intervention Rationale Evaluation

Planning
Subjective: Ineffective Short term: Assess respiratory Diminished Goal is met
“Ginahilanat airway After 8 hours of function noting breat breath sounds as evidenced
ako, kung clearance nursing h sounds, rate, may reflect by:
gabi ga related to interventions, the rhythm, and depth, atelectasis. a. Patient
balhas ko kag bloody patient will be and use of accessory Rhonchi, wheezes was able to
wala ko gana secretions as able to maintain muscles. indicate maintain
magkaon.” as abnormal patent airway. accumulation of patent
verbalized by breath sounds secretions and airway
the patient inability to clear
airways that may b. Able to
Objective: Long term: lead to use of demonstrate
VS: After 8 hours of Note ability to accessory behaviours
RR: 25 cpm nursing expectorate mucus muscles and to improve
PR: 90 bpm interventions, the and cough increased work of airway
T: 38 °C patient will be effectively, document breathing clearance
able to character, amount of
O2: 90% demonstrate sputum, presence of Expectoration may be
behaviors to hemoptysis. difficult when
secretions are very
-Looks pale, improve/maintai thick as a result of
with dry and n airway infection and/or
flushed skin clearance. inadequate
-Looks older hydration. Blood-
than her age tinged or frankly
-Crackles bloody sputum
results from tissue
breath sound Place patient in semi breakdown
-Enlarged or high-Fowler’s (cavitation) in the
lymph nodes position. Assist lungs or from
and distended patient with coughing bronchial ulceration
abdomen and deep-breathing and may require
further evaluation or
exercises. intervention.

Positioning helps
maximize lung
expansion and
decreases respiratory
Clear secretions effort. Maximal
from mouth and trachea; ventilation may open
suction as necessary. atelectatic areas and
pro mote
movement of
secretions into larger
airways for
Humidify inspired air expectoration.
and oxygen

Prevents obstruction
and aspiration.
Suctioning may be
necessary if patient is
unable to expectorate
secretions.

Prevents drying
of mucous
membranes and
helps thin
secretions.