NURSING CARE PLAN:

Assessment Subjective: nahihirapan akong huminga...) as verbalized by the client . Objective: RR= 23 breaths/ min PR= 95 beats/min T= 37.5 degree Celsius Easy fatigability Productive cough Chills at night Loss of appetite as claimed Chest X- ray and sputum examination revealed positive for pulmonary tuberculosis

Nursing Diagnosis Ineffective Airway Clearance related to presence of bronchial infection and secretion

Inference

Outcome

Nursing Interventions

Rationale

Cough is the most common symptom of pulmonary tuberculosis. It may produce yellowish or greenish colored sputum especially during the day. Eventually, the sputum may be streaked with blood. Furthermore, a person with PTB may experience fatigue and loss of energy. It may affect his or her ability to expectorate secretions, too. Aside from that, difficulty of breathing signifies that there may be an accumulation of secretion in the bronchial cavity of the lungs.

After 8 hours of nursing care, client will be able to readily expectorate secretions and will have absence or decrease in episodes of dyspnea.

-Maintain infection control through the use of mask and performance of hand washing before and after contact with client.

-PTB is transmitted via droplet inhalation so proper precaution should be performed to avoid transmission to other clients. - Elevating the head of the bed and turning client every two hours help in decreasing the -Place client in high pressure placed on the fowlers position and diaphragm. encourage reposition every two hours. - Allergen may trigger more accumulation of secretion due to respiratory response. - These exercises hasten the - Maintain room or expulsion of sputum and aids in environment free from any maintaining airway patency. sorts of allergen. - Fluids help loosen secretion in - Teach and encourage deep the lungs. breathing and coughing exercises. -Warm fluids help in loosening the secretions while cold liquids -Emphasize to increase triggers cough more often. fluid intake depending on individual tolerability or as - Through the aid of gravity and indicated. percussion secretions are readily expelled. - Instruct to take warm liquids instead of cold ones. - It provides baseline data for

future comparison in the evaluation of disease condition. -Provide postural drainage and percussion. - PTB can be transmitted through droplet inhalation and 6 months compliance to -Monitor breathing patterns medication is needed in order to and breath sounds. be treated with it. -Educate client and family about disease condition and the need for compliance with the therapeutic regimen.

DRUG STUDY GENERI C NAME: Ketorolac BRAND NAME: Toradol DOSAG E: 30mg/am p1 amp IM CLASSIFICATI ON: Nonsteroidal antiinflammatory agents, nonopioid analagesics MECHANISM OF ACTION: - Inhibits prostaglandin synthesis, producing peripherally mediated analgesia - Also has antipyretic and antiinflammatory properties. - Therapeutic effect:Decreased pain INDICATION: Short term managemen t of pain (not to exceed 5 days total for all routes combined) CONTRAINDICATI ONS - Hypersensitivity - Cross-sensitivity with other NSAIDs may existPre- or perioperative use - Known alcohol intoleranceUse cautiously in: 1) History of GI bleeding 2) Renal impair-ment (dosage reduction may be required) 3) Cardiovascular disease SIDE EFFECTS/ ADVERSE EFFECTS: - CNS: 1) drowsiness 2) abnormal thinking 3) dizziness 4) euphoria 5) headache- RESP: 1) asthma 2) dyspnea - CV: 1) edema 2) pallor 3) vasodilation - GI: 1) GI Bleeding 2) abnormal taste 3) diarrhea 4) dry mouth 5) dyspepsia 6) GI pain 7) nausea - GU: 1) oliguria 2) renal toxicity 3) urinary frequency - DERM: 1) pruritis 2) purpura 3) sweating 4) urticaria - HEMAT: NURSING IMPLICATIONS/RE SPONSIBILITIES: - Patients who have asthma, aspirininduced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria. - Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. - Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy. - Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional.

1) prolonged bleeding time - LOCAL: 1) injection site pain - NEURO: 1) paresthesia - MISC: 1) allergic reaction, anaphylaxis

- Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur. - Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another.