MANILA DOCTORS COLLEGE

Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City

NCM 105 LEADERSHIP AND MANAGEMENT: HEAD NURSING

Patient’s initials: DPJ

DIAGNOSIS: PTB

CUES / DATAS NURSING RATIONALE GOALS AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIBVES INTERVENTIONS

• Presence of
Objective Data: Ineffective Clinical signs Short term: • Observe respiratory these symptoms
After 30 minutes of
• Presence airway of pulmonary status, patient’s ability may indicate nursing intervention,
of sputum clearance edema begin After 30 minutes of to maintain airway, impending the client
with and related to with the nursing intervention, work of breathing, respiratory failure.
blood blood accumulation the client will nasal flaring, pursed- • Positioning Demonstrated
helps maximize
• Difficulty of secretions of interstitial lip breathing, and lung expansion and
behaviors to
breathing fluid and fluid *Demonstrate prolonged expiratory decreases improve/maintain
• Body accumulating behaviors to phase. respiratory effort. airway clearance
in the improve/maintain Maximal ventilation
weakness may open
cough perivascular airway clearance • Place client in semi or atelectatic areas
*Identify potential
and high fowlers and promote complications and
peribronchial *Identify potential position.assist client movement of initiate appropriate
spaces. As complications and secretions into actions
with coughing and larger airways for
alveolar flood initiate appropriate deep breathing expectoration.
begins, there actions exercises. • Expiratory
are further wheezing or ronchi
decreases in Long term: may be heard as
secretions and air
lung volume • Auscultate lung fields move through the
and *Maintain patent hours and prn. Notify narrowed airways.
pulmonary airway physician for Decreased breath
compliance. sounds throughout
significant changes. the lung fields is a
With some *Participate in critical sign
alveolar field treatment because it means
with fluids, regimen,within the the patient cannot
there is an level of ability move enough air to
be heard by the
increased in clinician and
the fraction of oxygenation and
the lung that is perfusion are
severely
perfused but compromised.
poorly • Epinephrine
ventilated. is usually given SQ
every 20-30
Source: minutes for 3 doses
as needed to
Pathophysiolo relieve broncho-
gy of Disease: constriction.
An Terbatuline is
introduction of usually not the first
drug of choice in
Clinical acute situations
medicine, 5th because of the
Edition. (page delayed onset of
249) action, but
frequently used
after the patient
shows
improvement.
• -Helps to
maintain hydration
to allow for thinning
of secretions.
• Humidificati
on of oxygen helps
to keep
• Secretions
thinned to allow for
easy expectoration.
Oxygen saturation
levels less than
90% correspond to
arterial blood gas
readings of PaO2
60 mmHg or less,
which
compromises
perfusion and
oxygenation of
tissues.
• High fluid
intake helps thin
secretions, making
them easier to
expectorate