NURSING CARE PLAN

Problem: Hypoxia
Nursing Diagnosis: Impaired gas exchange related to altered oxygen carrying capacity of blood
Cause Analysis: Impaired gas exchange results from the destruction of the walls of overdistended alveoli. As the walls of alveoli are destroyed, the alveolar surface
area in direct contact with pulmonary capillary continually decreases, causing an increase in dead space and impaired oxygen diffusion, which leads to hypoxemia
( Medical-surgical Nursing by Smeltzer page 570).

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:
““Nahihirapan akong huminga kung The patient will be able to
walang oxygen,” as verbalized by the Experience increased pulmo-
patient.
Objectives:
 Irritable
 Tachypneic
 Difficulty of vocalizing
 BP-100/60 mmhg
 PR – 114 bpm
 RR – 48 bpm
 O2 saturation – 80%
STO:
Within 3 days of nursing care,
nary ventilation and adequate
Gas exchange as evidenced by
Increased oxygen saturation
and normal respiratory rate.
INDEPENDENT
Auscultated lung sounds, monitor v/s.
Positioned client inhigh Fowler’s
position.
Instructed and encourage the client in
deep breathing and effective coughing
exercises.
Provided calm, quiet environment.
Limit pt’s activity or encourage
Bed rest.
COLLABORATIVE
Monitored pulse Oximetry.
STO:
This allows evaluation of effects of After 3 days of nursing
Therapy. Care, the goal was
partially met with an O2
This maximizes pulmonary ventilation saturation of 92% and an
RR of 25bpm.
These techniques improve ventilation
By opening airways to facilitate
Clearing the airways of sputum. Gas Exchange improved
and fatigue is Reduced.
This minimizes shortness of breath
And Fatigue.
Useful tool to detect changes in
oxygenation early on

Administered O2 inhalation @ 9LPM Appropriate amount of oxygen is

Via face mask continuously delivered so that the patient does not
desaturate

Administered Berodual 1 neb q 8H, A bronchodilator is a substance that

Salbutamol 1 neb q 4H & Flixotide 1 dilates the bronchi and
neb q 12H bronchioles, decreasing
resistance in the respiratory airway
and increasing airflow to the lungs
 NURSING CARE PLAN

Problem: Risk for Injury

Nursing diagnosis: Risk for injury related to generalized muscle weakness and edema on lower extremities
Cause Analysis: Weak leg muscles, weak knees, poor balance and loss for flexibility may contribute to falls and may have increase risk for injury.
(Reference: Fundamentals of Nursing by Kozier pp. 118 – 119)
CUES OBJECTIVES NURSING INTERVENTIONS RATIONALES EVALUATION
SUBJECTIVE: STO: INDEPENDENT: STO:

“Hindi ko na After 3 days of nursing 1. Promoted bed rest/chair (recliner) 1 Available energy use for healing. After 3 days of nursing
naalagaan ang sarili interventions the pt will be rest during toxic state. Activity & an upright position are interventions, the goal wasn’t
ko dahil nanghihina na able: believed to decrease hepatic blood met. the pt will wasn’t able to
ang katawan ko,” as - to achieve measurable flow, w/c prevents optimal circulation achieve measurable increase in
verbalized by the increase in activity to the liver cells. activity tolerance & wasn’t to
patient. tolerance. reduce fatigue & weakness.
- to reduced fatigue & 2. Provided quiet environment; limit 2. Allows for extended periods of
weakness. visitors. uninterrupted rest.

3. Do necessary task quietly & at one 3. Promotes optimal respiratory fxn &
time as tolerated. minimizes pressure areas to reduce
risk of tissue breakdown.

4. Recommend changing position 4. Prolonged bed rest can be

OBJECTIVE: frequently. Provider/instant caregiver deliberating. This can be offset by
in good skin care. limited activity
• (+) wheezes
• appears weak 5. Increased activity as tolerated,
& drowsy demonstrated passive ROM 5. Promotes rest and relaxation..
• Tachypnea exercise.
• RR- 48 bpm
• Irritability
• Sputum color
COLLABORATIVE:.
of yellowish &
slightly sticky
Monitored pulse Oximetry. Useful tool to detect changes in
• Bilateral pitting oxygenation early on
edema grade 3
• Distended Administered O2 inhalation @ 9LPM Appropriate amount of oxygen is
abdomen with Via face mask continuously delivered so that the patient does not
abdominal desaturate
girth of 88cm
 NURSING CARE PLANS

Problem: Loss of appetite

Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements r/t malnutrition 2t Miliary TB
Cause Analysis: Malnutrition is a symptom that presents as a complex disorder with many possible differential diagnoses. A decreased appetite and
an unwillingness to eat are characteristics of the symptom. The symptoms of malnutrition and weight loss, in addition to hemoptysis, chills, fever and
night sweats are important pathologic clues to a diagnosis of TB. (individualbraids.gq.nu/anorexia)
CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE: STO: INDEPENDENT: STO:
 Documented client’s • Useful in defining degree
“Parang wala siyang After 3 days of nursing nutritional status on or extent of problem and After 3 days of nursing
gana kumain, kasi intervention, the client wil admission, noting skin appropriate choice of intervention, the was not
konteng konte lang ang verbalize & demonstrate turgor, current weight and interventions. met, the client wasn’t able to
na uubos niya,” as selection of foods or meals degree of weight loss, demonstrate selection of
verbalized by the SO. that will achieve a cessation integrity of oral mucosa, foods or meals that will
of wt. loss. ability or inability to swallow achieve a cessation of wt.
presence of bowel tones, loss.
OBJECTIVE: and history of nausea and
vomiting or diarrhea.
• Observable wt.  Monitored I&O • Useful in measuring
loss effectiveness of nutritional
• Dry, pale lips and fluid support.
• Appears weak &  Investigated anorexia and • May affect dietary choices
drowsy nausea/ vomiting, and note and identify areas for
• Dry & cracked possible correlation to problem solving to
lips, slightly pale medications. Monitored enhance intake/ utilization
mucosa frequency, volume, and of nutrients.
• occasional consistency of stools.
productive cough,  Encouraged and provided • Helps conserve energy,
yellowish and for frequent rest periods. especially when metabolic
slightly sticky requirements are
sputum increased by fever.
• minimal food  Encouraged small, frequent • Maximizes nutrient intake
intake meals with foods high in without undue fatigue or
• tachypneic protein and carbohydrates energy expenditure from
• (+) Miliary TB eating large meals, and
reduces gastric irritation.
. • Creates a more normal
  Encouraged SO to bring social environment during
foods from home and to mealtime, and helps meet
share meals with client personal and cultural
unless contraindicated. preferences.

COLLABORATIVE: • Provides assistance in

• Refered to the dietitian for planning a diet with
adjustments in dietary nutrients adequate to meet
composition. client’s metabolic
requirements, dietary
preferences, and financial
resources post/ discharge.