Assessment

Subjective:
(+) Chest pain
(+) Nasal
congestion
(+) Difficulty of
breathing
Objective:
RR: 27 cpm
(+) Ronchi
(+)Crackles

Diagnosis
Ineffective
airway
clearance
related to tihck
nasal secretions

Planning
After several
nursing
interventions,
the patient will
be able to:
Maintain
patent
airway.
Expectorate
secretions
without
assistance.
Demonstrate
behaviors to
improve/main
tain airway
clearance.
Participate in
treatment
regimen,
within the
level of
ability/situati
on.
Identify
potential
complications
and initiate
appropriate
actions.

Intervention
Assess
respiratory
function, e.g.,
breath sounds,
rate, rhythm,
and depth, and
use of accessory
muscles.

Rationale
Diminished breath
sounds may
reflect atelectasis.
Rhonchi, wheezes
indicate
accumulation of
secretions/inabilit
y to clear airways
that may lead to
use of accessory
muscles and
increased work of
breathing

Evaluation
After 8 hours of
nursing care, the
goal is met, as
evidenced by
clients
participation to
breathing and
coughing
exercises and
ability to
expectorate
sputum upon
evaluation.

Note ability to
expectorate
mucus/cough
effectively;
document
character,
amount of
sputum,
presence of
hemoptysis.

Place patient in
semi- or highFowlers
position. Assist
patient with
coughing and
deep-breathing
exercises.

Expectoration
may be difficult
when secretions
are very thick as a
result of infection
and/or inadequate
hydration. Bloodtinged or frankly
bloody sputum
results from tissue
breakdown
(cavitation) in the
lungs or from
bronchial
ulceration and
may require
further evaluation/
intervention.
Positioning helps
maximize lung
expansion and
decreases
respiratory effort.
Maximal
ventilation may
open atelectatic
areas and
promote
movement of
secretions into
larger airways for

Clear secretions
from nose,
mouth and
trachea; suction
as necessary.

Humidify
inspired
air/oxygen.

expectoration.
Prevents
obstruction/aspira
tion. Suctioning
may be necessary
if patient is unable
to expectorate
secretions.
Prevents drying of
mucous
membranes; helps
thin secretions.

Administer
Salbutamol
nebulizer every
4 hours as
prescribed by
the doctor.

Salbutamol is a
bronchodilator,
which increases
lumen size of the
tracheobronchial
tree, thus
decreasing
resistance to
airflow and
improving oxygen
delivery.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Temperature: 38
degree Celsius
RR: 27 cpm

Hyperthermia
related to the
infection process

Short Term
After 1 hour of
appropriate
nursing
intervention the
patients
temperature will
decrease to
37.5oC.

Monitor vital
signs.

Vital signs
provide more
accurate
indication of core
temperature.

After 4 hours of
nursing
intervention,
the clients
temperature
and respiratory
rate are within
normal range
(T: 37.5C; RR:
20cpm)

Provide tepid
sponge bath. Do
not use alcohol.

TSB helps in
lowering the body
temperature and
alcohol cools the
skin too rapidly,

Long Term
After 4 hours of
appropriate
nursing
intervention the
patients vital
signs will return
to normal range;
with a
temperature of
36.5-37.5oC,
respiratory rate
of 12-20 cycles
per min.

Remove excess
clothing and
covers.

Advise patient to
increase oral fluid
intake.

Maintain bed rest.

Administer
Paracetamol as
needed as
prescribed by the
doctor.

causing
shivering.
Shivering
increases
metabolic rate
and body
temperature
These decrease
warmth and
increase
evaporative
cooling.
Additional fluids
help prevent
elevated
temperature
associated with
dehydration.

Reduce metabolic
demands/ oxygen
consumption
Paracetamol is an
antipyretic.

Assessment
Patient coughs
without covering
mouth and nose.

Diagnosis
Risk for spread
of infection
related to
insufficient
knowledge to
avoid spread of
pathogens

Planning
After several
nursing
interventions,
the patient
will be able
to:

Identify
interventions
to
prevent/redu
ce risk of
spread of
infection.
Demonstrate
techniques/in
itiate lifestyle
changes to
promote safe
environment.

Intervention
Identified others
at risk, e.g.,
household
members, close
associates/friend
s.

Instructed
patient to
cough/sneeze
and expectorate
into tissue and to
refrain from
spitting.
Reviewed proper
disposal of tissue
and good hand
washing
techniques.
Encouraged
return
demonstration.
Reviewed
necessity of
infection control
measures, e.g.,
temporary

Rationale
Those exposed
may require a
course of drug
therapy to
prevent spread/
development of
infection.
Behaviors
necessary to
prevent spread
of infection.

May help patient

understand need
for protecting
others while
acknowledging
patients sense
of isolation and
social stigma
associated with
communicable

Evaluation
After 8 hours of
nursing
intervention,
patient and
family members
demonstrate
understanding of
techniques to
prevent/reduce
risk of spread of
infection by
performing the
instructions of
the nurse.

respiratory
isolation.

Stressed
importance of
uninterrupted
drug therapy.
Evaluated
patients
potential for
cooperation.

Reviewed

diseases.

Contagious
period may last
only 23 days
after initiation of
therapy, but in
presence of
cavitation or
moderately
advanced
disease, risk of
spread of
infection may
continue up to 3
months.
Compliance with
multidrug
regimens for
prolonged
periods is
difficult, so
directly observed
therapy (DOT)
should be
considered.
These secondline drugs may
be required

importance of
follow-up and
periodic
reculturing of
sputum for the
duration of
therapy.

when infection is
resistant to or
intolerant of
primary drugs or
may be used
concurrently with
primary anti
tubercular drugs.