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TEJERO, ROSHIN MAE E.

BSN 3B
Nursing Care Plan

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Subjective Cues: Ineffective airway After 12 hours of 1. Assess respiratory 1. Diminished 1. Respiratory function, After 12 hours of
clearance related to nursing intervention: function noting breath breath sounds noting breath sounds, nursing intervention,
 Patient complaint of retained secretions  Patient will be sounds, rate, rhythm, may reflect rate rhythm, and the goal was met.
persistent cough for the as evidenced by able to verbalize and depth, and use of atelectasis. depth and use of The patient was able
past 3 months abnormal understanding of accessory muscles. Rhonchi, accessory muscles to:
 Patient described respiratory rate and cause and 2. Note ability to wheezes indicate was assessed.
that she was coughing up blood therapeutic expectorate mucus and accumulation of 2. Ability to expectorate  Patient was able
experiencing chills management cough effectively; secretions and mucus and cough to verbalized
and night sweats regimen document character, inability to clear effectively was noted. understanding
Imbalanced nutrition and cause and
 Patient admits that  Patient will be amount of sputum, airways that may 3. Patient was placed in
less than body therapeutic
she was also able to maintain presence of lead to use of semi fowler’s position
requirements related management
coughing up blood airway patency hemoptysis. accessory and patient was
to frequent cough as regimen
 Patient and able to 3. Place patient in semi muscles and assisted with
evidenced by loss of  Patient was able
acknowledges she expectorate or high-Fowler’s increased work coughing and deep
20lbs weight to maintain
has been more secretions position. Assist patient of breathing. breathing exercises.
fatigued lately and  Patient will with coughing and 2. Expectoration 4. Secretions were clear airway patency
reports a recent identify deep-breathing may be difficult from mouth and and able to
unintentional weight potential exercises. when secretions trachea. And suction expectorate
loss of 20 lbs in the complications 4. Clear secretions from are very thick as was done. secretions
last 2 months. and initiate mouth and trachea; a result of 5. Fluid intake was  Patient was able
appropriate suction as necessary. infection and/or maintained. to identify
Objective Cues: 5. Maintain fluid intake inadequate 6. Inspired air and potential
actions
of at least 2500 hydration. oxygen were complications
 Ronchi in the upper mL/day unless Blood-tinged or humidified. and initiate
right lobe contraindicated. frankly bloody appropriate
 Weight loss (20lbs) 6. Humidify inspired air sputum results actions
 Skin clammy and and oxygen from tissue
pale breakdown
 Elevated blood (cavitation) in
pressure of 146/78 the lungs or from
mmhg
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 High temperature of bronchial
38.30 C ulceration and
may require
further
Vital Signs: evaluation or
 Heart rate: 92 bpm intervention.
 Respiratory rate: 24 3. Positioning helps
bpm maximize lung
 Spo2: 90% in room expansion and
air decreases
respiratory effort.
Diagnostic Procedures:
Maximal
 Chest x-ray ventilation may
 Sputum culture with open atelectatic
AFB smear areas and
 Blood cultures x2 promote
 Tuberculin skin test movement of
secretions into
larger airways
for
expectoration.
4. Prevents
obstruction and
aspiration.
Suctioning may
be necessary if
patient is unable
to expectorate
secretions.
5. High fluid intake
helps thin
secretions,
making them
easier to
expectorate.
6. Prevents drying
of mucous
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 membranes and
helps thin
secretions.

Reference/s:

Verra M. (2019, April 10). 5 pulmonary tuberculosis nursing care plans, Retrieved on November 19, 2021 from https://nurseslabs.com/5-pulmonary-tuberculosis-nursing-care-
plans/2/

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