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Student Nurses’ Community

NURSING CARE PLAN


ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Ineffective The risk of TB is After 8 hours • Monitor respiratory • Respiratory status After 8 hours of
breathing a higher in older of nursing status, including vital assessment helps nursing
The patient may pattern people who have intervention signs, breath sounds, gauge the intervention the
report: related to close contact the patient will: patient was able
and skin color. patient’s severity
acute with a newly and whether it’s to:
• Past infection and
diagnosed TB • Promote progressing.
exposure to decreased
TB. lung patient, those good • Administer oxygen • To provide relief • Breathing
who have TB respiratory therapy as ordered. from symptoms of returned to
• Progressive capacity.
before, function and normal rate
fatigue hypoxemia and
gastrectomy treat
• Loss of hypoxia. and pattern
infection
appetite patients, and • Monitor ABG levels • ABG levels and • Minimal or
• Promote
• Unexplained those affected and oxygen continuous pulse no signs of
comfort
weight loss. with diabetes saturation as ordered. oximetry infection.
mellitus. The measures the
OBJECTIVE: aging process blood’s oxygen
weakens the content and are
• Cough that immune system, good indicators of
may be further increasing the lung’s ability
nonproductiv the likelihood of to oxygenate the
e at first but tubercular
later
blood.
infection in older • Place the patient in • To increase chest
produces
adults. semi-fowlers position expansion and to
sputum and
progresses and place the alleviate dyspnea.
to Transmission diaphragm in proper
hemoptysis. occurs when position to contract.
• Crackles droplet nuclei are • Collect sputum • To monitor the
• Pleuritc pain produced form samples as ordered. progress of the
• Dyspnea an infected disease and
person’s coughs treatment.
or sneezes. If
inhaled, tubercle
bacillus settles in
the alveolus and
infection occurs,
Student Nurses’ Community

with
alveolocapillary
dilation and
endothelial
swelling. The
incubation time
for TB is 4 to 8
weeks. TB is
usually
asymptomatic in
primary infection.