Far Eastern University

Institute of Nursing

Case Study of TUBERCULOSIS

Group 133
TAMARGO, Janina Marie
VALENZUELA, Cherilyn

Submitted to:
Sir Israel
(Clinical Instructor)
SEPTEMBER 19, 2010

I. INTRODUCTION
 Pulmonary tuberculosis is an infectious disease caused by slow-
growing bacteria that resembles a fungus, Mycobacterium
tuberculosis, which is usually spread from person to person by droplet
nuclei through the air. The lung is the usual infection site but the
disease can occur elsewhere in the body. Typically, the bacteria from
lesion (tubercle) in the alveoli. The lesion may heal, leaving scar tissue;
may continue as an active granuloma, heal, then reactivate or may
progress to necrosis, liquefaction, sloughing, and cavitation of lung
tissue. The initial lesion may disseminate bacteria directly to adjacent
tissue, through the blood stream, the lymphatic system, or the bronchi.
Most people who become infected do not develop clinical illness
because the body’s immune system brings the infection under control.
However, the incidence of tuberculosis (especially drug resistant
varieties) is rising. Alcoholics, the homeless and patients infected with
the human immunodeficiency virus (HIV) are especially at risk.
Complications of tuberculosis include pneumonia, pleural effusion, and
extrapulmonary disease.

II. BIOGRAPHIC DATA

Name: Mr. SJ

Address: C-84 NIA Roab, Quezon City

Age: 28 years old

Gender: Male

Religion: Roman Catholic

Marital Status: Single

Occupation: None

Room and bed#: D16

Chief Complaint: Difficulty of breathing

Admitting Diagnosis: Pulmonary tuberculosis

Attending Physician: Dr. Ortiz

 III. NURSING HISTORY

A. Past Health History

According to the patient’s father, the patient was diagnosed with

pulmonary tuberculosis. His childhood illness was chicken pox and
tigdas and he only experienced cough and cold last 1996-1997. The
patient was never been hospitalized before and he was fully
immunized. He also added that the patient has no allergy on any food
or medication.

B. Family History

The patient’s family was a history of tuberculosis, hypertension and

cardiac diseases. The family is exposed to PTB.
C. Present History of Illness

The client was admitted at the Quezon Institute with the chief
complaint of Difficulty of breathing. The patient experienced fatigue
and body weakness upon admission. The client was admitted by Dr.
Ortiz due to pulmonary tuberculosis cor pulmonale T/C MDR T/C CAP3.
After the client was admitted, the client had vital signs of BP: 110/80,
CR: 91 and RR of 32; Chest results: symmetrical lung expansion and
presence of rhythm tachypneic; upon auscultation there was presence
of crackles and upon percussion hyper resonant sounds were noted.

IV. PATTERNS OF FUNCTIONING

A. Psychological Health

The father verbalized that the patient is able to read and write.
According to the father, he doesn’t notice any change in smell, taste,
touch and memory of his son. The patient’s father stated that his son is
fond of staying with his friends rather than staying at home. Also
according to him his son was used to drink alcohol most of the time
and smokes every day. According to the father, he does not notice any
problem from his son with regards to his family. The patient seldom
talks with his family about his problems. If the patient and his family
have problems, they can easily solve it because they do not let the
problem pass. They talk about it and settle the problem. In my own
observation the patient was sad and weak maybe because of the
disease he is suffering and he is worried about his condition.
 INTERPRETATION: The Client’s Psychological Health is considered in
a healthy state. As his communication style of verbalizing his appropriate
emotions (gestures, interactions with support persons and verbal expression)
can be expressed. And thus the major stressors such as problems that the
client encounters are still manageable.

ANALYSIS: He is physically and psychologically mature and ready to

assume responsibilities and be self sufficient.

REFERNCE: Kozier, Erbs. Fundamentals of nursing (5th ed.), pg.408

B. Socio -Cultural Patterns

The patient is living with his father, mother and his nephew. His
father is the one who makes decision regarding family events such
as birthdays and fiesta and his son agrees with it but sometimes his
son is “pasaway”. The patient recreational activities are watching tv
and socializing with his friends. The patient personal expenses are
all paid and given by his elder sister, his elder sister is the one who
supports on his financial expenses because he doesn’t have
occupation. The patient used to be a smoker and consumes 1 pack
per day and alcohol drinker, he drinks 3 to 4 bottles a day.
According to his father there is an adequate lighting, water supply
and ventilation in their home but outside their house is crowded.

INTERPRETATION: The client is dependent financially.

ANALYSIS: A person’s perception of and reactions are

influenced by individual factors including family health beliefs and practices,
economic factors and cultural background.

REFERNCE: Kozier, Erbs. Fundamentals of nursing (5th ed.), pg.791

C. Spiritual Patterns

The patient is a Roman Catholic. According to his father his son

doesn’t attend mass every Sunday but his son prays before he goes
to sleep.

The patient according to his father is “pasaway: and lazy. His

father told that his son became active with many kinds of vices that
are influenced by his friends and that’s the reason why he got
tuberculosis.

INTERPRETATION: The patient has its own way of interacting with

others and way of his living of his own life.
 ANALYSIS: Some young adults abandoned traditional religious
practices.

REFERNCE: Kozier, Erbs. Fundamentals of nursing (5th ed.), pg.411

V. ACIVITITES OF DAILY LIVING

BEFORE DURING INTERPRETAT

ADL HOSPITALIZAT HOSPITALIZAT ION AND
ION ION ANALYSIS

There was
moderate
decrease on
The patient eats appetite
The patient 2-3 meals a because of the
consumes 4 to day.DAT or diet side effects of
5 meals a day as tolerated his medication
1. Nutrition and because of
and he eats advised by his
whatever food doctor. his condition.
he wants. He was
advised to take
DAT diet to
sustain his
nutritional
needs.

The patient There is a

voids large The patient decrease
amount of urine usually voids 2 bowel
2. Eliminatio
4 to 6 times a to 3 times a day movement due
n
day and and defecates to decreased
defecates once once a day. appetite.
a day.
3. Exercise Hanging out Patient’s daily
with his friends, exercise is
take a walked The patient has limited
limited
 movement he because of
only sits at his body
bed and walks a weakness.
little during his
confinement. Patient
with them was performs deep
his form of Patient breathing and
exercise. performs deep coughing
breathing and exercise to
coughing facilitate
exercise. airway and
proper
circulation.
The patient
can’t perform
The patient hygienic
Bed bath done
takes a bath 3 practices
by his father
4. Hygiene times a day and because of his
and he doesn’t
brushes teeth condition and
brush his teeth.
twice a day. he is
experiencing
boy weakness.

The patient
drinks 7 to 8 The patient has
5. Fluids and glasses per day. The patient decreased
Electrolyte drinks 5 to 6 intake of fluid
s He consumes 3 glasses per day. because of his
to 4 bottles of condition.
alcohol a day.

6. Sleep The patient The patient The patient is

Pattern sleep pattern is sleeps is still experiencing
disturbed, most disturbed and difficulty in
of the time he he sleeps only 2 sleeping
doesn’t sleep to 3 hours. because he is
well and he worried about
usually sleeps his condition
only 2 to 3 and he is not
hours because comfortable in
according to his his situation.
father his son
always
 complains that
it is hot in their
place.

VI. PHYSICAL ASSESSMENT

A. VITAL SIGNS

TEMPARATURE: 35.9 o C

BLOOD PRESSURE: 100/70 mmHg

RR: 45 cpm

PR: 98 bpm

B. GENERAL APPEARANCE

NORMAL ACTUAL
ANALYSIS
FINDINGS FINDINGS

1. Posture and
gait, standing, Relaxed, erect The patient is Deviation
sitting and posture; not relaxed from normal
walking coordinated during the because of his
movements interview condition.

Deviation
2. Overall hygiene from normal.
and grooming Clean and neat Clean, but
He can’t do
there's a
his hygienic
presence of
practices
body odor.
because of his
condition.
 3. Signs of Healthy The client Deviation
distress in appearance shows signs of from normal.
posture of distress. The patient’s
facial
shows sign of
expression
distress
because of
the disease he
have.

4. Client’s Cooperative Cooperative Normal

attitude

5. Client’s Appropriate to Appropriate to Normal

mood/affect situations the situation
and
appropriatenes
s of client’s
responses

C. HEAD TO TOE ASSESSMENT

BODY PARTS NORMAL ACTUAL ANALYSIS/

FINDINGS FINDINGS INTERPRETATI
ON
A. HEAD
a. Skull Rounded Normoceph Normal findings
(normocephali alic
c, with frontal,
parietal and
occipital
prominences)

b. Hair Evenly Typical hair type

distributed; Evenly of men
thick hair; distributed
silky resilient
 hair; no
infestation or
infection;
variable
amount of
c. Face body hair Normal findings
Symmetric
Symmetric facial
facial features, features
palpebral
fissures equal
d. Eye/vision in size,
4.1 Eyeball symmetric Normal findings
nasolabial
folds Round,
4.2 Lid margins uniform in Normal findings
Shape is size
round; size
equal Close
symmetrical
Protects eyes,
4.3 Conjunctiva anteriorly Undernourished,
meet at the lack of vitamins
medial and
lateral corners Smooth and
of eye. pale

4.4 Sclera Delicate Normal findings

membrane;
covers part of
the outer Appears
4.5 Pupils surface of the white Normal findings
eyeball

Outermost
tunic, thick Normal
white pupil
connective constriction
tissue.
4.6 Eyebrow, lashes, Normal findings
color, symmetry, quality Pupils
of hair, placement constrict when
looking at
4.7 Eye movement in all near objects, Normal findings
directions pupils Hair evenly
converge distributed,
 when object is intact skin
moved
towards the Equal
nose movement

Hair evenly
distributed,
intact skin

Equal
movement
C. EARS
a. Pinna Same color as Same color Normal ear
facial skin, as facial features
pinna recoils skin, pinna
after it is recoils after
folded it is folded

b. External canal Wet and

Dry ear wax sticking Normal findings
grayish-tan cerumen
color or sticky with
wet cerumen transparent
in various color
shades of
brown/ pearly
gray color;
c. Hearing acuity semitranspare
nt Responds to Normal findings
moderately
Responds to loud voice
moderately tone
loud voice
tone
D. NOSE Symmetric, No (+) dyspnea,
normal deformity, patient have
breathing, (+) cough which
able to difficulty of reflex is not the
identify breathing. only way to
familiar smell With runny protect our
nose airways which
causes patient
to have runny
nose.
E. MOUTH/LIPS
a. Gums Pink gums; Dark gums Gums darkened
 moist firm due to smoking
texture history
b. Teeth Yellowish
32 adult teeth with few Needs dental
smooth, white cavities. work
yellowish
shiny tooth
c. Tongue enamel
Central
Central position, No remarkable
position, pale pale in color findings
d. Palate-hard/soft in color
Pale in color
No remarkable
e. Oropharynx/ Tonsil Pink and findings
smooth; freely Pale
movable posterior No remarkable
wall findings
Pink and
smooth
posterior wall
F. CHEECKS Hollow in Indicates
appearance malnutrition,
due to weight
loss
A. NECK Lymph nodes Lymph Normal findings
freely movable nodes freely
movable
B. CHEST Quiet rhythmic (+) Presence of
a. Anterior and effortless difficulty of crackles caused
b. Posterior respirations; breathing, by fluid often
full symmetric with associated with
excursions abnormal inflammation or
sound in infection of the
the right alveoli.
lower lobe Indicates
respiratory
problems such
Full and us TB.
C. HEART symmetric
Full and Normal findings
symmetric

D. ABDOMEN Flat, rounded Flat, Client is not well

(convex) or scaphoidal nourished.
scaphoids in shape It is also due to
 weight loss.
E. UPPER EXTREMETIES Equal in size Equal in Client is not well
on both sides size but nourished
of the body; muscular
no muscle atrophy
atrophy; evident.
normally firm;
smooth
coordinated
movements
F. LOWER EXTREMETIES Equal in size With Client is not well
on both sides muscular nourished
of the body; atrophy
no muscle evident.
atrophy;
normally firm;
smooth
coordinated
movements

VII. LABORATORY DIAGNOSTIC EXAMINATION RESULTS

LAB/DIAGNO
DAT INTERPRETATION AND
STIC NORMS RESULT
E ANALYSIS
PROCEDURE
Neutrophils Male 0.80 High/ Rule out stress, pain,
and very high or very low body
Female: temperatures (which cause
0.40- cortisol to be released from
0.60 the system), drugs such as
cortisone, strenuous exercise,
bacterial infections (cat bite
abscesses are a fabulous
representation of this!),
increased heart rate and
increased blood pressure.
When neutrophils increase
with stress (called a stress
leukogram), the neutrophil
count goes up and the
leukocyte count decreases at
 the same time.

Reference:
http://www.naturalhealthtech
niques.com/BasicsofHealth/la
b_result_meaning1.htm#Neut
rophils
Lymphocytes Male 0.18 Low/ Rule out corticosteroids,
and stress, pain, acute systemic
Female: infections (viral and
0.20- bacterial), acquired T
0.40 lymphocyte deficiency
(neonatal infections),
immunosuppressive drugs,
irradiation, loss of lymph,
chylous thoracic effusion
(ruptured thoracic duct),
lymphosarcoma, enteric
neoplasms, granulomatous
enteritis, Johne's disease
(cattle), protein-losing
enteropathies, ulcerative
enteritis, lymphatic cancer
destroying lymph nodes, and
hereditary T-cell deficiency.

Reference:
http://www.naturalhealthtech
niques.com/BasicsofHealth/la
b_result_meaning1.htm#Lym
phocytes
Creatinine Male 101.11 High/The increase in your
and mmol/L creatinine levels signifies a
Female: high possibility of kidney
52 – 97 problems. If you have
mmol/L diabetes, you are at a very
high risk of experiencing this
type of elevation. It is
important o understand that
this rise in creatinine levels is
not a health condition in itself
but rather a symptom of a
deeper underlying cause that
must be treated in order to
reduce the levels.
 Reference:
http://www.home-remedies-
for-
you.com/askquestion/45333/h
igh-creatinine-levels-my-
creatine-level-has-incre.html
Sodium Male 130.9 Low/ Low sodium or
and mmol/L Hyponatremia. Rule out
Female Addison's disease (adrenal
135-148 cortical insufficiency),
mmol/L diarrhea, overhydration with
fluids not containing salt,
malabsorption, diabetic
acidosis, severe renal disease,
ruptured or obstructed urinary
system, overdose of certain
drugs such as diuretics and
blood pressure medications
(like hydrochlorothiazide),
excess antidiuretic hormone,
nephrosis, hypoadrenalism,
myxedema, congestive heart
failure, vomiting, diabetic
acidosis, and excessive water
intake in patients with heart
or liver disease.

Reference:
http://www.naturalhealthtech
niques.com/BasicsofHealth/la
b_result_meaning1.htm#Sodi
um
Chloride Male 78.8 Low/ mineralocorticoid
and mmol/L excess, vomiting, diabetes
Female mellitus with ketoacidosis
98-107
mmol/L Reference:
http://www.globalrph.com/labint
er.htm
 VIII. DRUGS STUDY

DRUG DOSA CLASSIFICATI INDICATION ADVERS CONTRAINDIC NURSING

NAME GE/RO ON E ATION RESPONSIBIL
UTE REACTIO ITY
N

Levodrop 2tsp/BI
rizine D
Syrup
Aldacton 25 Anti- Short term Gynecom Acute renal Obtain patient
e mg/tab Hypertensive preoperative astia,agra insufficiency, history,
BID Drugs. treatment of nulysytosi anuria, including drug
primary s, hyperkalemia. history and
hyperaldosteronism, headache any known
long term , hypersensitivit
maintenance drowsines y.
therapy for s,lethargy Monitor for
idiophatic , GI manifestations
hyperaldosteronism, disturban of
management of ces. hyperkalemia.
essential Monitor for
hypertension. manifestations
of
hyponatremia.
Combive 150mg Respiratory Prophykaxis for Sedation, Hypersensitivity
nt Neb /tab drugs asthma, allergic dry
bronchitis and other mouth,
symptoms dizziness,
associated with weight
fever. Prevention of gain.
multi system Occasion
allergic disorders. ally CNS
 stimulatio
n, visual
acuity
changes,
dry eyes,
headache
and
fatigue.
Kalium 1 Electrolytes To prevent CNS:Pare Contraindicated Monitor ECG
Durule tab/BID and hypokalemia, sthesia of in patients with and
replacement severe hypokalemia limbs, severe renal electrolyte
solutions and acute MI. impairment with levels during
listllessne
oliguria, anuria, therapy
ss, or azotemia; Monitor renal
confusion with untreated function
, addison’s Teach patient
weakness disease or with signs and
or acute symptoms of
heaviness dehydration, hyperkalemia
heat cramps,
of limbs,
hyperkalemia,
flaccid hyperkalemic for
paralysis of familial
periodic
CV:arrhyt paralysis, or
hmias,he other conditions
artblock, linked to
cardiac extensive tissue
arrest, breakdown
ecg
changes,
hypotensi
 on,
postinfusi
on
phlebitis

GI:
nausea,
vomiting,
abdomina
l pain,
diarrhea

Doxopyli ½
ne tab/BID
IX. PATHOPHYSIOLOGY

X. ECOLOGIC MODEL
 A. Hypothesis

Based on the gathered data and information, we presume that there

are many predisposing that may have cause the disease. These factors led
us to hypothesize in using agent host environmental model.

Tuberculosis is a chronic, recurrent, infection caused by

Mycobacterium Tuberculosis, M. Bovis or M. Africanum. The common TB
popular in the Philippines and other Asian countries is Pulmonary (lung)
Tuberculosis due to M. tuberculosis. TB can occur in persons of any age,
although it is more common in children and in older persons whose immune
systems are weak. TB can be seen in any age group that is
immunocompromised. It may develop after inhaling droplets sprayed into the
air from a cough or sneeze by someone infected with M. tuberculosis. The TB
bacteria to become pathogenic and make a person sick will need a poor diet
or a much stressed lifestyle.

In the case of Mr. SJ, he has a PTB. He consumes 1 pack of cigarette a

day. He also has a familial history of tuberculosis. The occurrence of
Tuberculosis is attributed to client’s exposure to PTB carriers and pathogen
and immunosuppression due to substance abuse and past history of PTB.

B. Pre-Disposing factors

Host

Age: 28 years old

Sex: Male

Nationality: Filipino

Customs: Substance abuse (consumes 1 pack of cigarette a

day)

Heredity: Familial history of tuberculosis

Agent

Physical: Mycobacterium Tuberculosis is a rod-shaped, aerobic

bacterium that is resistant to destruction and can persist necrotic and
calcified lesions for prolonged periods and remain capable of
reinstating growth.
 Mechanical: Mycobacterium is passed and acquired through
respiratory secretions /droplets which transmit when sneezing,
coughing, and talking.

Chemical: Substance abuse smoking and drinking alcohol

Environment

Physical

Physical contact to person with PTB and has PTB before.

Socio-economic
He is exposed to persons with PTB in community or home.

ECOLOGIC MODEL

We have chosen the agent-host-environmental model due to may factor inter

relating to the disease causation. Predisposing factor in which the client are
exposed to can be easily seen using the agent-host-environmental model.

HOST

- 28 years old

- Male

- Filipino AGENT

- Substance - Mycobacterium
abuse tuberculosis
(consumes 1
pack of
ENVIRON
cigarette a
MENT
day)

- Physical contact to person with

PTB and has PTB before.

- He is exposed to persons with

PTB in community or home.
D. Analysis

The agent-host-environment model is primarily used in predicting

illness rather than promoting wellness, although identification of risk
factors that result from the interaction of agent, host, and environment
are helpful in promoting and maintaining health. Because each of the
agent-host-environment factors constantly interacts with others, health is
an ever changing state. Health is seen when all three elements are in
balance while illness is seen when one, two, or all three elements are not
in balance.
(Fundamentals of Nursing by Kozier 2004)

Occurrence of Pulmonary Tuberculosis in the patient is caused by

contact with carriers of pathogen, confined living condition, substance
abuse, nature of work. Past history of PTB may affect the development of
the condition.

E. Conclusion and Recommendations

We therefore conclude Tuberculosis is a chronic granulomatous

infection that usually affects the pulmonary system but may also invade
other organs and tissues. The incidence is highest in crowded, poverty-
stricken settings. It spreads from one person to another by airborne
transmission. An infected person releases droplet nuclei through talking,
coughing, sneezing, laughing or singing. Larger droplet nuclei; smaller
droplets remain suspended in the air and are inhaled by susceptible
persons. Risk factors for TB are close contact with someone who has
 active TB, immunocompromised status, substance abuse, inadequate
health care, pre-existing medical condition, institutionalization, living in
crowded, substandard housing and caring for TB patients. In the case
of the patient, the substandard / crowded housing, contact with active TB
and immunocompromised status are the factors that have
contributed to the development of the disease.

As a Student Nurse we recommend a vital role in caring for patients

with TB and family, which includes assessing the patient’s ability to
continue therapy at home. The nurse instructs the patient and family
about infection control procedures, such as proper disposal of
tissues, covering the mouth during coughing and hand hygiene.
Assessment of the patient’s adherence to the medication regimen is
imperative because of the risk of developing resistant strains of TB if
treatment is not followed faithfully.

XI. PRIORITIZED LIST OF NURSING PROBLEMS

CUES NURSING RANK JUSTIFICATION

DIAGNOSIS
Subjective Cues: Ineffective 1 - It is ranked first
airway because
- “medyo naahihirapan clearance according to
ako huminga” as related to Maslow’s
verbalized by the hierarchy of
increased
client. needs,
mucus secretion physiological
secondary to needs are to be
“naninigarilyo ako nun bacterial
hindi pa ko naoospital” prioritized first
infection as and also airway
as verbalized by the
client
evidenced by must be given
crackles upon the first
“nakaka 1 pack ako ng auscultation attention as
sigarilyo sa isang based on
araw” as verbalized by the rule of
 ABC. And
the client since the
client is
Objective Cues: experiencing
this, a loss of
- Presence of respiratory
adventitious breath functioning is a
sound (Crackles) life -
upon auscultation. threatening
- Oriented problem.
- Immediate
- BP- 100/70 mmHg,
CR: 98 bpm, RR: 45 attention must
cpm be done first
36 cpm, T- 35.9 o C since the
client manifest
-signs of distress. difficulty of
- Difficulty of breathing
breathing which can lead
to anxiety
- Productive cough, use then another
of accessory muscle. problem may
occur.
- The student
nurse's primary
concern is to
promote the
client's
oxygenation
because
oxygenation is
a vital need
for every cell,
if there are
any problems
that may
occur then it
might affect
the
functioning of
the
individual.

Subjective: Impaired gas 2 - Immediate attention

exchange related must also be done
- pale conjunctiva to altered oxygen since it might impair
ventilation and
 supply oxygenation of tissues
-Client verbalized of client.
“medyo masakit ang
ulo ko pag gising ko - It is ranked second
kanina” because gas exchange
won't happen if the
- “naninigarilyo ako airway clearance of
nun hindi pa ko patient is not
naoospital” as restricted.
verbalized by the client

- “nakaka 1 pack ako

ng sigarilyo sa isang
araw” as verbalized by
the client.

Objective:

- client is restless
- irritable
- signs of distress
- pale conjunctiva
- difficulty of
breathing

- BP- 100/70
mmHg, CR: 98
bpm, RR: 45
cpm
36 cpm, T- 35.9
oC
Subjective: Sleep 3 - It is ranked 3rd
Deprivation since the problem is
- The patient sleeps related not life threatening
only 2 to 3 hours. to prolonged but it needs an
- The client is physical immediate attention
experiencing discomfort since sleep pattern
(dyspnea) as falls under
intermittent
evidenced by physiologic needs
sleep disturbance inability to according to
because according concentrate Maslow’s hierarchy of
to him he feels needs.
difficulty of breathing
- Prolonged time
and upon coughing. without sleep or
insufficient sleep can
-since the patient
keep on sitting cause anxiety and can
lead to another illness.
because according to
him he can breathe
more easily that’s
why he can sleep
continuously.

Subjective:

- Restlessness

- Irritability

- Inability to
concentrate

- Sings of
distress

Subjective: Activity 4 -It is ranked

intolerance 4rth since the
- The father related to problem is not
verbalizes that his inadequate life
son is easily getting oxygen supply threatening
tired. Only in a few as and doesn’t
minutes the patient evidenced by need
gets tired and keeps easy immediate
on resting. fatigability attention,
however, it
- dyspnea can affect the
body’s normal
functioning.
Objective:
- Patient
- Restlessness experiencing
- Irritable insufficient
- Signs of physiological
distress and
- BP- 100/70 psychological
mmHg, CR: 98 energy mat
bpm, RR: 45 affect his
cpm sense of
36 cpm, T- 35.9
oC wellness.
- Individuals
who cannot
complete
required or
desired daily
activities
are at risk for
many
problems that
can affect
body systems.
- Clients
experience a
significant
decrease in
the muscular
strength
whenever they
do not
maintain a
moderate
amount of
physical
activity.
 XII. NURSING CARE PLAN

NURSING GOAL AND INTERVENTI EVALUATIO

CUES ANALYSIS RATIONALE
DIAGNOSIS OBJECTIVES ON N
Subjective Ineffective Scientific Goal: Effectiveness
Cues: airway implication:
clearance Hypoxia may Within 4 - Was the
- “medyo related to occur if not hours patient
naahihirapan treated
increased of nursing able to
ako huminga” immediately due
mucus to impaired gas intervention, maintain
as verbalized secretion the patent
exchange.
by the client. secondary to patient will airway?
http://copd.about
bacterial .com/ be -Was the
“naninigarilyo
infection as od/glossaryofcop able to patient
ako nun hindi dterms/g
pa ko
evidenced by maintain able to
crackles /hypoxia.htm patent airway mobilize her
naoospital” as
verbalized by upon through the secretions?
the client auscultation - This mobilization -Was the
condition of patient
“nakaka 1 can cause secretions as able to have
pack ako ng Acute evidenced by patent
sigarilyo sa Respiratory productive Objective 1: airway?
isang araw” as Distress cough. Objective 1:
verbalized by Syndrome 1. Tapping Adequacy
the client (ARDS) which Objectives: Independent- the chest can
results from After 30 mins. of Facilitative: loosen the -Was all the
Objective the nursing secretions. planned
Cues: combination intervention: Objective 1: (Taylor et.al, nursing
of FON 5th interventions
- Presence of infection and 1.The client Independent- ed. Page are
adventitious inflammatory will be able enough in
breath sound response. to mobilize
 (Crackles) The her Facilitative: 1251) achieving
upon lungs secretions. and
auscultation. become 1. Perform 2. Suction maintaining
- Oriented quickly filled Chest removes patent
- BP- 100/70 with physiotherap secretions airway?
mmHg, CR: fluid and y. through the -Was all the
98 bpm, RR: become use of a resources of
45 cpm very stiff. Dependent- strong the
36 cpm, T- This Facilitative: pressure. nurse like
35.9 C stiffness, 3. They act on time and
combined 2. Suction the effort are
-signs of with secretion as respiratory enough?
distress. difficulties needed. tract, it
- Difficulty of extracting opens Appropriaten
breathing oxygen due Dependent- narrowed ess
to Supplemental airways.
- Productive the alveolar : (Black, MSN -Was the
cough, use of fluid creates 3. Administer 7th ed. interventions
accessory a need bronchodilato Page 1652) mentioned
muscle.
for rs as are
ventilation. ordered. applicable
Septic shock 2. The and
is student Objective 2: Objective 2: beneficial to
one potential nurse will the
complication. maintain Independent- 1. To take patient?
patent Facilitative: advantage of
airway of the 1. Elevate gravity Acceptability
Immediate patient. the head of decreasing
cause: the bed / pressure on the - Was the
-excessive diaphragm and
change position family
production of every 2 hours enhancing
drainage of / willfully
mucus
secretions ventilation to accepted
 different lung
Root Cause: and as needed. segments the
(Nursing Care interventions
- Bacterial 2. Encourage Plans by Meg done to the
Gulanick et. al)
infection of deep breathing patient.
the and coughing
exercises 2. This will help
respiratory promote proper
system. lung expansion.
3. Position (Nursing Care
Health the head in Plans by Meg
the midline of Gulanick et. al)
Implication: the body.
3. Position
changes
allow free
movement
of the
diaphragm
and
expansion of
the chest
wall. (Taylor
et.al, FON5th
Objective 3: ed. Page
1396).
1.Increase fluid
intake at least Objective 3:
2000ml per day
3. The client will
with warm or
be able to 1.Hydration
tepid liquid
expectorate helps decrease
secretions the viscosity of
secretions,
facilitating
expectoration.
Using warm
liquids may
decrease
bronchospasm.
(Nursing Care
Plans by Meg
Gulanick et. al)