NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIIC PLANNING NURSING INTERVENTION RATIONALE EVALUATION

EXLANATION
S: “Eto, Ineffective ®PTB is a 1. Auscultated breath to ascertain
nahihirapan airway chronic, Within 8 hours sounds & assessed air status & note
huminga” clearance recurrent, span of nursing movement progress.
related to infection
O: secondary caused care will be 2. Elevated head of the At the end of
 Abnormal secretions by some bed or change position To take
able the shift, the
breath related to bacteria. The every 2hrs. advantage of
sounds; PTB common TB to: gravity client was able
(+) popular in decresing
crackles the Philippines 2 pressure on to display
at the left & other a.)expectorate the
Asian diaphragm patency of
and right
lower lobe countries is secretions and airway as
 Dyspnea; Pulmonary enhancing
use of (lung), due to drainage of manifested by:
b.)demonstrate
accessory M. veb\ntilation
intervention
muscles Tuberculosis. to diff. lung
such as deep
for A person segment  Client’s
breathing
respiratio
3. Encouraged deep respirator
n;
breathing & coughing
elevated who acquired ®promotes rate is
exercise
shoulders.
 Restless this kind of optimal chest within
 bacteria from a expansion &
normal
person by drainage of
range.
sneezing, secretions.
RR- 19
coughing, 4. Encouraged bpm.
talking, will increase
®to help  Secretions
fluid intake
enter to the liquefy
®to help liquefy
secretions decreased
secretions
lungs and may
.
grow to 5.Encouraged/provide
d  Client’s
produce warm versus cold
liquids restlessne
secretions.
as appropriate. ss was
These
alleviated
secretions may Positioning
6.Maintained
helps and
patient on
lodge to maximize
moderate high
lung remained
airways if not back rest.
expansion.
calm.
coughed up.
There will be 7.Checked for
To maintain
obstructions:
adequate
an accumulation
airway
of secretions.
ineffective patency

airway
8.take medications
clearance. as ordered by
the physician.