Problem Subjective Cues: Nahihirapan ako huminga ng maayos, as verbalized by the patient.

Scientific Basis

Objective Cues: Pale in appearance (+) thick mucus secretion RR of 24 cpm (+) use of accessory muscles

Analysis: Impaired gas exchange r/t thick

As lung tissue is destroyed, the Respiratory surface area for gas status exchange decreases. assessment In addition, the helps gauge widespread fibrous the patients tissue increases the severity and thickness of the whether its respiratory progressing. membrane, further Doenges, M.E. et.al. restricting gas Maintain a normal (2008). Nurses exchange in persons respiratory Pocket Guide who has pulmonary rate from 24 tuberculosis and cpm to 16-20 Diagnoses, Prioritized other respiratory cpm. Interventions and diseases. Long term goal: Rationales.(11th Edition). F.A. Davis Demonstrate Company, improved Philadelphia, ventilation Pennsylvania. P. and 337-341. adequate oxygenation of tissues by ABGs within Place the patient acceptable To increase in semi-fowlers ranges. chest position.

Goals Objective Intervention Criteria At the end of my Independent: 8 hours span of care the patient Monitor respiratory will be able to: status, including Short term goal: vital signs, breath sounds, Report and skin color . decreased dyspnea. Source:

Rationale

Evaluation Goal partially met as evidence by the patient has evidenced by the patient was able to report that dyspnea was lessen with respiratory rate of 21 cpm

mucus secretions secondary to ptb.

Source: Vander, E.(2001). Human Physiology: The Mechanisms of Body Function. Retrieved August 24, 2012 from http://www .mhhe.com /biosci/ap/vander/resp /reading3.mhtml

Be free of symptoms of respiratory distress.

Source: Doenges, M.E. et.al. (2008). Nurses Pocket Guide Diagnoses, Prioritized Interventions and Rationales.(11th Edition). F.A. Davis Company, Philadelphia, Pennsylvania. P. 337-341. Encourage to rest.

expansion and to alleviate dyspnea.

For relaxation purposes and helps prevent Source: further dyspnea. Doenges, M.E. et.al. (2008). Nurses Pocket Guide Diagnoses, Prioritized Interventions and Rationales.(11th Edition). F.A. Davis Company, Philadelphia, Pennsylvania. P. 337-341.

 Monitor patients ABGs.

Increasing PaCO2 and decreasing Source: PaO2 are signs of Doenges, M.E. et.al. respiratory (2008). Nurses failure Pocket Guide Diagnoses, Prioritized Interventions and Rationales.(11th Edition). F.A. Davis Company, Philadelphia, Pennsylvania. P. 337-341.

Collaborative: Administer oxygen inhalation via nasal cannula @ 2 Lpm as ordered. Source: Doenges, M.E. et.al. (2008). Nurses To aid in proper oxygenation.

Pocket Guide Diagnoses, Prioritized Interventions and Rationales.(11th Edition). F.A. Davis Company, Philadelphia, Pennsylvania. P. 337-341. Administer Fluimicil 100mg as ordered. Treatment of respiratory affections characterized by thick and viscous hypersecretions