NCP 1

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Ineffective Short Term Goal: Independent: Short Term Goal:
“Gikapoy nako sigeg Airway After 2 hours of nursing Take note of breath sounds, rhythm, Reduced breath sounds After 2 hours of nursing
ubo-ubo, hapit na ni Clearance interventions, the and depth and accessory muscle use. indicate atelectasis. Rhonchi, interventions, the client will feel
mag isa ka bulan ug related to client will: wheezes reflect buildup of a little bit comfortable to the
galisod nasad kog thick, bloody secretions and a difficulty to clear breathing exercises and position,
ginhawa.” bronchial Verbalize feeling of airways, that results in the use of report decreased malaise and
secretions as comfort while accessory muscles and an increased fatigue, increase his fluid intake,
Objective: evidenced by performing breathing work of breathing and understand the nature of the
dyspnea exercises disease.
Yellow Phlegm Note effective expectoration and Expectoration might be difficult
Achieve a comfortable coughing, sputum nature and when secretions are very thick.
Dyspnea position volume, and hemoptysis. Hemoptysis may require
further evaluation or intervention. Long Term Goal:
Productive cough Report decreased After 8 hours of nursing care, the
malaise and fatigue Suction secretions as necessary. To help the patient expectorate thick goal is partially met as evidenced
Chest pain phlegm. Prevents obstruction and by client’s participation to
Increase fluid intake aspiration breathing and coughing exercises
Crackles upon and ability to expectorate sputum
auscultation Understand the nature Maintain fluid intake of at least 2500 High fluid intake helps thin upon evaluation; still there are
of the disease mL/day unless contraindicated. secretions, making them easier to episodes of dyspnea as claimed
Manifests malaise expectorate. by the client.
and fatigue Long Term Goal:
After 8 hours of nursing Humidify inspired air and oxygen Prevents drying of mucous
Chest X- ray and interventions, the membranes and helps thin
sputum examination client will: secretions
revealed positive for
pulmonary Expectorate secretions Maintain a clean and allergen-free Allergen may cause increased
tuberculosis environment/room secretion due to respiratory
Have absence or reaction.
VS taken as follows: decrease in episodes of Instruct to take warm liquids instead Warm liquids assist release
PR: 82 bpm dyspnea. of cold ones. secretions whereas cold liquids
RR: 27 cpm cause coughing.
BP: 120/90
SpO2: 85% Assist patient in coughing and deep- These exercises help spit out
breathing exercises. sputum.

Place patient in semi or high- Positioning helps the expansion of

Fowler’s position. the lungs, enabling patient to
breathe more effectively.

Educate client and family about PTB can be transmitted through

disease condition and the need for droplet inhalation and 6 months
compliance with the therapeutic compliance to medication is needed
regimen. in order to be treated with it

Dependent:
Administer supplemental oxygen, as To increase oxygen level and achieve
prescribed. Discontinue if SpO2 level an SpO2 value of at least 94%
is above the target range, or as
ordered by the physician.

Administer prescribed TB
medications:

Mucolytic agents: acetylcysteine Reduces the thickness and stickiness

(Mucomyst); of pulmonary secretions to facilitate
clearance.

Bronchodilators: oxtriphylline Increases lumen size of the

(Choledyl), theophylline (Theo-Dur); tracheobronchial tree, thus
decreasing resistance to airflow and
improving oxygen delivery.

Corticosteroids (prednisone); May be useful in presence of

 extensive involvement with
profound hypoxemia and when
inflammatory response is life-
threatening.

Steroids To reduce the inflammation in the

lungs.

Be prepared for/assist with Intubation may be necessary in rare

emergency intubation. cases of bronchogenic TB
accompanied by laryngeal edema or
acute pulmonary bleeding.
 NCP 2
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Imbalanced Short term goal: Independent: Long term goal:
“Di nako ganahan mag Nutrition: Less After 1 hour of nursing Useful in measuring Patient
Document patient’s
kaon kaon gud ma’am Than Body interventions, the patient verbalizedunderstanding
kay kapoy kayo sige’g Requirements will be able to nutritional status on effectiveness of
andcompliance on his
ubo unya sakit na pod Related to admission, noting skin nutritional and fluid nutrient intake.
akong tutunlan” Frequent cough Understand the turgor, current weight and support.
and sputum importance of Patient showcased a
production as maintaining a proper degree of weight loss,
Objective: better appetite forsmall,
evidenced by nutrient intake integrity of oral mucosa, frequentmeals and
 VS: poor muscle tone ability or inability to swallow, verbalized that he will
 BP: Long term goal: continue to try it for the
presence of bowel tones,
140/90 After 8 hours of nursing upcoming days.
interventions, the patient history of nausea and
mmHg
will be able to vomiting or diarrhea.
 PR: 85 Helps define problem
bpm initiate behavior/lifestyle Monitor I&O and weight severity and select
 RR: 20 changes to regain and/or
relevant treatments.
to maintain appropriate periodically.
cpm
weight.
 Temp: Helps identify needs and
36.9 Ascertain patient’s usual strengths. Individual
 Tired looking dietary pattern. Include in preferences may help
 restless selection of food. enhance dietary intake.

Helps in energy
Encourage and provide for
conservation when
frequent rest periods.
metabolic demands are
elevated by fever.

Provide oral care before and
after respiratory treatments.
Encourage small, frequent
meals with foods high in
protein and carbohydrates.
Encourage SO to bring foods
from home and to share
meals with patient unless
contraindicated.
Investigate anorexia, nausea,
and vomiting and note
possible correlation to
medications. Constantly
monitor bowel movements.
Plan respiratory therapy
sessions 1–2 hours before or
after meals.
Reduces bad taste from
sputum or respiratory
medications that can
stimulate the vomiting
center.
Reduces gastrointestinal
discomfort and
maximizes nutrient
intake without excessive
fatigue or energy
expenditure.
Conveniently
accommodates personal
and cultural preferences.
May impact dietary
choices and
identify areas to improve
nutrient intake and
usage.
May help prevent nausea
and vomiting after drugs
or respiratory treatments
 on a full stomach.

Dependent:
Monitor laboratory
studies: BUN, serum protein,
and prealbumin, albumin.
Administer antipyretics as
appropriate.
Low values suggest
malnutrition and require
care and a change in
therapy.
Fever raises metabolic
demands and calorie
intake.

NCP 3
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Deficient knowledge Evaluate the patient's learning Emotional and physical
related to Lack of capacity. Note level of fear, preparation are required for
“dugay najud ko exposure concern, fatigue, participation learning.
sige ug ubo-ubo to/misinterpretation level; How much content, what
pero abi nakog of information as media and language should be
normal lang ni kay evidenced by used? Who should be involved?
Expressed
abog mansad gud misconceptions Encourage patient and SO to Corrects assumptions and
sa lugar nga about health status express concerns. Answer reduces anxiety. Insufficient
akoang truthfully. Note the repeated funds or protracted denial may
gitrabahoan” denial. hinder coping and managing
the tasks necessary to regain
health.
“Kadugayan
nakabantay na Provide precise written Written information relieves
akong mga kauban information for patient to refer to the patient of needing to
medication schedule and follow- remember large volumes of
sa construction site
up sputum testing for data. Repetition improves
nga dugay naulian documenting response to therapy. memory.
akong ubo maong
niadto ko diri Identify symptoms that should be
reported to healthcare provider: May indicate illness
ma’am” hemoptysis, chest pain, fever, progression or pharmaceutical
difficulty breathing, hearing loss, adverse effects that
vertigo. necessitate additional
evaluation.
Emphasize the importance of
maintaining high-protein and Minimizes fatigue and
carbohydrate diet and adequate promotes recovery. Liquids
fluid intake. help liquefy or expectorate
Objective: secretions
 Anxious Explain the medication dosage,
frequency, predicted action, and Enhances patient participation
 VS:
extended treatment period. with therapy regimen and may
 PR: 58 Review possible medication
interactions.
bpm
 RR: 17
cpm
 T: 37.1
Review potential side effects of
 BP: treatment (dryness of mouth,
140/90 constipation, visual disturbances,
headache, orthostatic
hypertension) and problem-solve
solutions.
Stress need to abstain from
alcohol while on INH.
Collaborative
Refer for eye examination after
starting and then monthly while
taking ethambutol.
Evaluate job-related risk factors,
working in foundry or rock quarry,
sandblasting.
Encourage abstaining from
smoking.
avoid early medication
discontinuation. Directly
observed therapy (DOT) is
used when a patient is unable
or unwilling to take prescribed
drugs.
May prevent or reduce
discomfort associated with
therapy and enhance
cooperation with regimen.
Combination of INH and
alcohol has been linked with
increased incidence
of hepatitis.
Impaired capacity to
distinguish green may be the
first indicator of decreased
visual acuity.
Exposure to silicone dust
increases the risk of silicosis,
which can lead to bronchitis.
Although smoking does not
stimulate recurrence of TB, it
does increase the likelihood of
respiratory dysfunction or
bronchitis.
Review how TB is transmitted and
hazards of reactivation. Knowledge may reduce risk of
transmission/reactivation.