NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION

(Subjective & DIAGNOSIS ANALYSIS (Dependent,
Objective) Independent &
Collaborative)
Subjective: Ineffective PTB occurs when After 6 hours of Independent: >Maintaining the After 6 hours of
“kapoy akong breathing M. tuberculosis nursing >assessed airway airway is always nursing
lawas nya mag pattern related primarily attacks interventions, the for patency the first priority, interventions, the
ubo2 ko usahay” to fatigue the lungs. patient will be especially in cases patient was able
as verbalized by secondary to A person with able to: of trauma, acute to display
the patient. pulmonary PTB may >Sustain neurological patency of airway
Objective: tuberculosis experience respiratory rate >auscultate lungs decompensation. as manifested by:
>Decreased fatigue and loss within normal for presence of >These may >Patients’ RR is
breath sound of energy. It may range: RR= 12-20 normal or indicate presence within normal
>Crackle sound affect her ability cpm adventitious breath of mucus plug range: RR=20
noted to expectorate >Tolerate sounds cpm
>Elevated secretions. Aside performance of -decreased breath >secretions
shoulders from that, simple, day to sound >these may decreased
>Decreased difficulty in day activities. indicate increase >Patients’ fatigue
fremitus breathing >Demonstrate -coarse sounds airway resistance was alleviated.
>Vital Signs: signifies that proper breathing Collaborative: >These may
T= 36.1 there may be an exercises. Administer indicate fluid along
P= 90 bpm accumulation of >Decrease medications as larger airways.
R= 22 cpm secretions in the fatigue prescribed by the
BP= 110/80 bronchial cavity physician.
mmHg of the lungs.
Source: Medical
Surgical Nursing
13th edition by
Brunner and
Siddhart