Pxs Name: Wilfredo Rodriguez Tuberculosis Age: 59y/o Gender: Male

ASSESSMENT DIAGNOSIS

Nursing Care Plan

Diagnosis: Pulmonary Room#: (male ward) RGH

PALNNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Difficulty of breathing c/c. Objective: Abnormal breath sounds: wet crackles. Dyspnea; use of accessory muscles for respiration: elevated shoulders. Restless Vital signs: BP - 80/60 hhmg T - 36.5c RR - 26 cpm PR - 75 bpm

` Ineffective airway clearance related to poor cough effort possibly evidence by abnormal breath sounds and dyspnea.

Short term goal: During my 6hrs nursing intervention, the client will be able to: Sustain respiratory rate within normal range: RR = 1220 cpm. Display decreasing amount of secretion. Allay restlessness. Long term goal: During the clients stay at the hospital he

Assessed respiratory rate.

Provides a basis for evaluating adequacy of ventilation. Use of accessory muscles of respiration may occur in response to ineffective ventilation. Crackles indicate accumulation of secretions and inability to clear airways. Expectorations may be different when secretions are very thick. Positioning

Noted chest movement; use of accessory muscles during respiration.

` At the end of the shift, the client was able to display patency of airway as manifested by: Clients respiratory rate is within normal range: RR-19 bpm. Secretions decreased. Clients restlessness was alleviated and remained calm.

Auscultated breath sounds; noted areas with presence of adventitious sounds. Documented respiratory secretions: character and amount of sputum.

will be able to maintain patent airway as evidenced by: Normal respiration as evidenced by absence of dyspnea and adventitious breath sounds (wet crackles). Normal breathing pattern: RR = 1220 cpm. Absence of bronchial secretions. Allay restlessness

Maintained patient on moderate high back rest. Checked for obstructions: accumulation of secretions. Take medications as ordered by the physician.

helps maximize lung expansion. To maintain adequate airway patency.