ASSESSMENT

Nahihirapan ako huminga as verbalized by the client. Objective: Use of accessory muscle RR of 28 cycles per minute Excessive Sputum Restlessness

NURSING DIAGNOSIS
Ineffective breathing Pattern related to Decrease lung Capacity

RATIONALE
Inhalation of mycobacterium tuberculosis

PLANNING
After 4 hours of nursing intervention, clients breathing pattern will able to maintain as evidenced by:

NURSING INTERVENTION
. Independent:: Push fluids and promote hydration Induce sputum with heated aerosol if needed

RATIONALE

EVALUATION
After 4 hours of nursing intervention, clients breathing pattern was able to maintain as evidenced by:

To liquify secretions

Bacilli eludes upper airway defense system

Decreased use of accessory muscle Decreased RR Decreased amount of sputum Verbalization of adequate rest

Enter the Lungs

To expedite diagnosis and start early treatment To facilitate easy breathing

Bacilli implants in alveolus in the upper lobe

Maintain semi-fowlers position

Bacterial multiplication Causes an inflammatory response in the lung area The inflammatory response brings the phagocytic cells in the sight of invasion

Collaborative: Administer O2 as ordered Decreases work of Breathing

Decreased use of accessory muscle Decreased RR of 23 cycles per minute Decreased amount of sputum Verbalization of adequate rest

Phagocytic cells engulf and destroy the bacilli Accumulation of exudates

Production of Sputum

Remaining bacilli causes formation of granulomatous lesion

Lesion becomes surrounded by macrophages

Increases workload of lungs

Tightness of the chess occurs

Difficulty of Breathing

ASSESSMENT Subjective: Hindi ako makatulog dahil sa ubo ko as verbalized by the patient.

NURSING DIAGNOSIS Sleep disturbances related to retained mucus secretion secondary to pulmonary tuberculosis

INFERENCE Pathogen invades the body

PLANNING Short Term Objective: -After 4 hours of nursing interventions, the patient will demonstrate a measurable increase in tolerance in activity with absence of dyspnea and excessive fatigue. Long Term Objective:

INTERVENTION Independent: -Provide a quiet environment and limit visitors during acute phase. - Elevate head and encourage frequent position changes, deep breathing and effective coughing. - Encourage adequate rest balanced with moderate activity. promote adequate nutritional intake. -Force fluids to at least 3000 ml per day and offer warm, rather than cold fluids.

RATIONALE

EVALUATION Short Term Objective: After 4 hours of nursing interventions, the patient was able to demonstrate a measurable increase in tolerance inactivity with absence of dyspnea and excessive fatigue. Long term Objective: After 7 days of nursing interventions, the patient will demonstrate free from intolerance in activity with absence of dyspnea and

Defense mechanism fails, the pathogen invades the lungs

- Reduces stress and excess stimulation, promoting rest.

Objective: RR: 28 Fatigue Restlessness Irratability Dyspnea Yellowish Cough noted

It will irritate the lining of the lungs and increase the production of mucus

- These Measures promotes maximal inspiration, enhance expectoration of secretions to improve ventilation.

Decrease oxygen is delivered in the body

Increased in RR, metabolism and disturbs the sleeping cycle

- Facilitates healing process and enhances natural resistance.

Restlessness

-After 7 days of nursing interventions, the patient will demonstrate free from intolerance in activity with absence of dyspnea and excessive

-Fluids especially warm liquids aid in mobilization and expectoration of secretions.

fatigue.

Collaborative: - Administer medications as prescribe: mucolytics or expectorants.

-Aids in reduction of bronchospasm and mobilization of secretions.

excessive fatigue.

ASSESSMENT Subjective: Mabilis ako hingalin at mapagod as verbalized by the client Objective: Verbal report of fatigue or weakness Inability to begin activity

NURSING DIAGNOSIS Activity Intolerance related to imbalance between O2 Supply and demand

INFERENCE Increased workload of the lungs

PLANNING After 8 hours of nursing interventions, client will able to maintain activity level within capabilities as evidenced by: Verbal report of adequate rest

INTERVENTION Independent:

RATIONALE

EVALUATION After 8 hours of nursing interventions, client was able to maintain activity level within capabilities as evidenced by: Verbal report of adequate rest Ability to begin activity Normal BP Absence of shortness of breath and fatigue

Imbalance between O2 supply and demand

Encourage adequate To reduce cardiac rest periods, workload especially before meal ambulation and meals Refrain of To promote rest performing non essential procedures Encourage active ROM exercises three times a day To maintain muscle strength and joint range of motion

Tightness of the chest Ability to begin activity Shortness of Breath Normal BP Absence of shortness of breath and fatigue

Abnormal BP of 90/70 Exertional discomfort or dyspnea

Easily get fatigue