FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

NURSING PROCESS

SUBMITTED BY:

TABALNO, ELIZABETH S.
TALAN, PRINCESS NEAH A.

BSN 134 – GROUP 134

SUBMITTED TO:

MR. LEONARDO DE GUZMAN III RN MAN

Clinical Instructor

QUEZON INSTITUTE

SEPTEMBER 18, 2010

 INTRODUCTION

This whole case study is about to discuss Pulmonary Tuberculosis (PTB). This
case will tackle about the disease, patient’s health, and nursing interventions.

Pulmonary tuberculosis is an infectious disease caused by slow- growing

bacteria that resembles a fungus, Myobacterium 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.

ANATOMY AND PHYSIOLOGY

Respiration is defined in two ways. In common usage, respiration refers to the

act of breathing, or inhaling and exhaling. Biologically speaking, respiration strictly
means the uptake of oxygen by an organism, its use in the tissues, and the release of
carbon dioxide. By either definition, respiration has two main functions: to supply the
cells of the body with the oxygen needed for metabolism and to remove carbon dioxide
formed as a waste product from metabolism. This lesson describes the components of
the upper respiratory tract.
 The upper respiratory tract conducts air from outside the body to the lower
respiratory tract and helps protect the body from irritating substances. The upper
respiratory tract consists of the following structures:

The nasal cavity, the mouth, the pharynx, the epiglottis, the larynx, and the upper
trachea. The esophagus leads to the digestive tract.

One of the features of both the upper and lower respiratory tracts is the
mucociliary apparatus that protects the airways from irritating substances, and is
composed of the ciliated cells and mucus-producing glands in the nasal epithelium. The
glands produce a layer of mucus that traps unwanted particles as they are inhaled.
These are swept toward the posterior pharynx, from where they are swallowed, spat
out, sneezed, or blown out.

Air passes through each of the structures of the upper respiratory tract on its way
to the lower respiratory tract. When a person at rest inhales, air enters via the nose and
mouth. The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a
tube like structure that connects the back of the nasal cavity and mouth to the larynx, a
passageway for air, and the esophagus, a passageway for food. The pharynx serves as
a common hallway for the respiratory and digestive tracts, allowing both air and food to
pass through before entering the appropriate passageways.

The pharynx contains a specialized flap-like structure called the epiglottis that
lowers over the larynx to prevent the inhalation of food and liquid into the lower
respiratory tract.

The larynx, or voice box, is a unique structure that contains the vocal cords,
which are essential for human speech. Small and triangular in shape, the larynx extends
from the epiglottis to the trachea. The larynx helps control movement of the epiglottis. In
addition, the larynx has specialized muscular folds that close it off and also prevent
food, foreign objects, and secretions such as saliva from entering the lower respiratory
tract.
I. Biographic Data

Name: J. O.
Gender: Male
Address: #120 Ilang – Ilang St., Upang, Antipolo City
Date of Birth: December 31, 1962
Place of Birth: Antique
Age: 47 years old
Marital Status: Married
Name of Spouse: Rowena Obac
Religion: Roman Catholic
Occupation: Construction Worker
Room and Bed #: 2BE – D12
Chief Complaint: Hemoptysis
Diagnosis: Pulmonary Tuberculosis
Attending Physician: Dr. Arnold Ortiz

II. Nursing History

A. Past Health History

During his childhood, the patient doesn’t remember having any illness
aside from fever and colds. The patient stated that he can’t remember anything
about his immunization because he is young that time but according to him, he
has an incomplete immunization. The patient has no known allergy. According to
the patient, he had an accident and got an operation on his left hand last March
2009 because he was hit by broken bottle of perfume. According to the patient,
he has not left the country during the past years.

B. Present Health History

The patient was admitted last September 10, 2010 with a chief complaint
of Hemoptysis. Prior to admission, the client had a massive hemoptysis with
chronic productive cough and yellowish phlegm. He was diagnosed to have
Pulmonary Tuberculosis. “Nagtatabas kasi ako ng tiles, yun ang trabaho ko sa
construction, hindi ko maiwasang malanghap yung dumi galing dito kaya ko daw
nakuha ang sakit kong ito,” as verbalized by the client. “Nung pagkauwi ko ng
bahay nung huwebes, uminom ako ng tubig tapos nasamid ako, bigla akong
sumuka ng madame, akala ko tubig lang tsaka yung kinain ko yun pala may
kasama ng dugo”, the patient added. “Tatlong hospital na ang pinagpa check-up-
an ko, pare-pareho ang resulta, TB nga raw. Sabi nung isang doktor pumunta
daw ako dito kaya dumiretso kami dito”, as verbalized by the patient.

C. Family History
 The patient’s father and mother are both dead. The client stated that his
family has no herodofamilial diseases. According to the patient he is the only
member of the family who has Pulmonary Tuberculosis due to his current
occupation which is a construction worker.

III. Patterns of Functioning

A. Psychological Health

The patient’s education attainment is elementary undergrad, he only

finished grade three. The patient verbalized that he is able to read and write. The
patient added that he has difficulty in reading because of his poor eye sight.
According to the client, he doesn’t have experience any change in smell, taste,
touch and memory but sometimes he has difficulty in remembering things.

The client rates his health before as 8/10 because according to him he
doesn’t easily get sick and can still perform daily activities but because of his
current condition, the client rates his health as 5/10. According to the client, a
healthy person eats three times a day, able to perform tasks of daily living
without difficulty, and has no vices. The patient eats three times a day. He eats
together with his co-worker during lunch and together with his family during
breakfast and dinner. According to the client, the usual foods that they are eating
are rice, vegetable, fish, and meat. According to the client he drinks a lot of
water, he can consume 1 gallon per day of water. But when the patient admitted
to the hospital, he said that he begins to lack his appetite and begins to loss
some weight. “Wala akong ganang kumain dito dahil naninibago ako”, as
verbalized by the patient. “Tsaka iba yung pagkain dito kumpara yung mga
kinakain ko sa bahay”, added by the patient. “Grabe, sobra na nga ang ipinayat
ko eh, hindi naman ako ganito kapayat dati para na nga akong buto’t balat”,
patient verbalized. The client does not have a routine of physical examination
because he and his family are not used to have a physical examination. The
client also stated that he only visit the doctor when he is sick and he also added
that sometimes instead of going to the doctor, he will consult to an “albularyo” or
a quack doctor. His hygienic practices include bathing, washing hands, trimming
nails, brushing teeth, and wearing slippers. “Pero ngayon yung mga dating
nagagawa ko sa bahay di ko dito magawa kahit magtootbrush, lalo na ang
pagligo dahil nanghihina ako”, as verbalized by the patient. “Buti na nga lang at
nandiyan yung anak ko para pag may kailangan ako eh matutulangan niya ko
kasi kung minsan kahit sa pag-ihi nahihirapan akong tumayo dahil hinang-hina
ako”, added by the patient. The patient said that he smokes and drinks alcohol
when he was not yet hospitalized. He consumes 5-7 sticks of cigarettes per day.
The patient also said that he is not aware of the consequences he can get from
smoking and drinking alcohol. “Masarap kasi pag umiinom at nagyoyosi, kahit
papano nawawala yung problema ko tsaka natural naman sa mga lalake ang
may bisyo”, as verbalized by the patient. According to the patient there is an
adequate lighting, space, water supply and ventilation in their home. The patient
said that their house is just enough for his family. The patient also added that
there are some vectors present in their home like mosquitoes and cockroaches.
The patient is a construction worker in Sta. Mesa. He works 6 times a week and
has a weekly salary of P2700 which is enough for his family.

The client defecates two to three times a day. The color of his stool is dark
brown and has an aromatic odor. No recent environmental changes the client
has undergone in his defecation pattern. The client voids at least three times a
day. The color of his urine is color light yellow and has no odor. The client does
not have any discomfort/ pain in his voiding activity and has no problem in
controlling it.

Before hospitalization, the client sleeps for about 5 to 7 hours and takes
naps. The usual time he’s going to sleep is about 9 to 10 in the evening, and he
wakes up 4 or 5 in the morning. The patient takes nap every afternoon after
lunchtime or during their break time in his work. According to the patient, he is
satisfied with his sleep and rest; he doesn’t have any problems in regards to it.
But when he was admitted to the hospital, the patient has only minimal time of
sleeping because according to him, he is not comfortable in sleeping in the
hospital together with other patients and he is easily disturbed by the noises of
other patients. “Hindi ako makatulog ng maayos dito kasi yung iba ang ingay,
ubo ng ubo”, verbalized by the patient. “Tsaka naninibago ako kasi ako yung tao
na hindi nakakatulog kapag wala ako sa sarili kong kwarto”, he added.

According to the client, the language that he is using when he is at home,

at work and with his friends is Tagalog. He communicates with his family and
friends by talking and listening to them. His language is understandable, clear
tone, exhibits thoughts, has logical sequence, makes sense and has sense of
reality. The client describes himself as someone who is humble, caring and
joyful. He stated that he does not have any physical defects. He is comfortable
with the gender that he belongs because he can express himself and can relate
with the same gender. The client has no problem or difficulty with his gender.

B. Socio-Cultural Patterns

The patient is already married. According to the patient, he is happy about

his family. He has four children, 2 boys and 2 girls. The eldest is Rosel (20 y/o),
the second is Jerwin (18 y/o), third is Jerome (15 y/o) and the youngest is Rolly
(12 y/o). The patient said that he has a good relationship to his family, both to his
wife and children. The patient is a construction worker in Sta. Mesa. He works 6
times a week and has a weekly salary of P2700 which is enough for his family.
He’s wife only stays at home; she is the one taking care of their youngest child.
 The client form of exercise is his work which is in a construction site. The
client’s usual hobby is to watch television when he has no work. “Sa trabaho
nauubos ang oras ko sa buong araw at kapag wala naman akong trabaho
tumutulong ako sa pagtitinda kasama ang asawa ko,” as verbalized by the client.
Before being diagnosed he has sufficient energy for completing a desired
required activity. Most of the time the patient feels easily tired but immediately
restores after resting. There is a sudden weight loss of the client after he was
diagnosed to have PTB. He had a productive cough and frequently experience
chest pain due to the dust that he inhales in the construction site. “Nahihirapan
ako huminga talaga dahil sa plema, sobrang makapit at kung minsan ang hirap
pa ilabas”, as verbalized by the patient.

According to the patient, their family is not having any major problems
because they are not taking life seriously, they are always happy. The patient
added that if they are having financial problem, they are getting money from 5-6.
In his current condition, the patient said that they do not consider it as a major
problem because according to him he will just be okay and will go out soon.

C. Spiritual Patterns

The patient’s religion is Roman Catholic. The patient goes to church every
Sunday for a mass together with his family but sometimes he is just alone. The
patient stated that it’s really important to maintain one’s health. According to the
patient, his family doesn’t have any health beliefs and practices. The patient also
stated that the most important person in his life is God, his family, and friends.
The client sees himself in society as an individual that has a societal role to be
done. According to the patient, an individual can be consider as a healthy person
when he has the ability to carry out daily tasks; ability to interact successfully with
people and within the environment; ability to manage stress and to express
emotion appropriately; ability to learn and use information effectively for personal,
family, and career development; ability to have owns moral, values, and ethics;
ability to achieve a balance between work and leisure time and lastly the ability to
promote health measures that improve the standard of living and quality of life in
the community.
IV. Activities of daily living

ADL Before During Interpretation and

Hospitalization Hospitalization Analysis
1. Nutrition The client eats The client’s diet The effects of
home prepared changed due to his drugs and
foods and has a hospitalization; he hospitalization on
healthy appetite has a disturb taste nutrition vary
when eating at perception that considerably. They
home. leads to lack of may alter appetite,
appetite and does disturb taste
not eat the usual perception or
amount of food that interfere with
he eats before nutrient absorption
because of the or excretion.
change in his
environment. Kozier & Erbs
Fundamentals of
Nursing, 8th
Edition, Volume
two (pg. 1238)

2. Elimination The client voids at There are few Hospitalized clients

least three times a changes on the may suppress the
day and defecates client’s defecation urge because of
two to three times a pattern and embarrassment
day. urination because about using a
of the presence of bedpan, because of
dirty CR on the lack of privacy or
hospital where he because defecation
is staying. is too
uncomfortable.

Kozier & Erbs

Fundamentals of
Nursing, 8th
Edition, Volume
two (pg. 1327)

3. Exercise The client’s form of The client no longer Many external

exercise is his work has any exercise factors affect a
which is in a because he is person’s mobility.
construction site. always on bed and
resting. He appears Kozier & Erbs
to be restless and Fundamentals of
 according to the Nursing, 8th
patient he can’t Edition, Volume
move because of two (pg. 1117)
body weakness.
4. Hygiene He takes a bath The client’s Hygiene is a highly
and does his hygienic practices personal matter
hygienic routines is also affected by determined by
every day. his hospitalization individual values
because he cannot and practices.
do all of his
hygienic routines Kozier & Erbs
every day. Fundamentals of
Nursing, 8th
Edition, Volume
one (pg. 742)

5. Substance He doesn’t use any The patient is Addiction or

Use substances like unable to smoke physical or
drugs, but smokes and drinks alcohol psychologic
and drinks alcohol. because of his dependence on a
hospitalization. substance, is
related to
properties of the
substance, the
individual user and
the social network
of the individual.

Kozier & Erbs

Fundamentals of
Nursing, 8th
Edition, Volume
one (pg. 396)

6. Sleep and He usually sleeps He is now having Hospital

Rest for 5 to 7 hours sleep disturbances environments can
every day without especially now that be quite noisy and
disturbances. there are changes special care needs
in his environment. to be taken to
reduce noise in the
hallways and
nursing care units.

Kozier & Erbs

Fundamentals of
Nursing, 8th

V. PHYSICAL ASSESSMENT:
NORMS
General Appearance
1. Posture/Gait Relaxed, erect posture;
coordinated movement;
bouncy purposeful walk
2. Skin color Varies from light to
deep brown; from
ruddy pink to light pink;
from yellow overtones
to olive
3. Personal Clean, neat
Hygiene/
Grooming
4. Age Age is appropriate
appropriateness
5. Verbal behavior Able to interpret their
feelings or emotions by
means of talking or
saying words with
simplicity, clarity, timing
and relevance
6. Non-verbal Able to interpret their
behavior feelings or emotions by
means of posture, gait,
facial expressions, and
gestures
Measurements
1. Temperature 36.5-37.5˚C
2. Pulse Rate 60-100 bpm
3. Respiratory 12-20 cpm
Rate
Edition, Volume
two (pg. 1170)
ACUTE FINDINGS INTERPRETATION
AND ANALYSIS
Slouchy; less Depressed or tired
purposeful posture people are more likely
to slouch. A less
purposeful, shuffling gait
often means the person
is sad or discouraged.
Certain gaits are
associated with illness.
Ref: Fundamentals of
Nursing, 5th edition by
Carol Taylor; et al.
(page 449)
Deep brown Skin color varies among
races and individuals.
Ref: Fundamentals of
Nursing, 5th edition by
Carol Taylor; et al.
(page 572)
The client, upon Within normal
inspection is clean and
neat.
Age is appropriate Within normal
answers to questions Within Normal
properly
Able to interpret their Within normal
feelings or emotions by
means of posture, gait,
facial expressions, and
gestures
36.9˚C Within normal
91 bpm Within normal
25 cpm Increased respirations
can be associated with
illness
Ref: Fundamentals of
Nursing, 5th edition by
Carol Taylor; et al.
(page 570)
4. Blood 120/60 mmHg 110/70 mmHg Within normal
Pressure
5. Weight 52-58 kilos 44 kilos Weight is lower
(medium frame) compared to the normal
weight of a 5’4” medium
frame adult (male)
which is 52-58 kilos
Ref: Fundamentals of
Nursing, 5th edition by
Carol Taylor; et al.
(page 573)
6. Height 5’4 ½ Within normal
7. BMI 18.5 – 24.9 16.4 Underweight
AREA TO BE ASSESSED
I. APPEARANCE AND MENTAL STATUS
A. Body built, height, and Proportionate, varies with
weight (in relation to lifestyle
client’s age, lifestyle, and
health)
B. posture and gait, Relaxed, erect posture;
standing, sitting, and coordinated movement
walking
C. Over all hygiene and
grooming
D. Body and breath odor
E. Signs of distress (in
posture or facial
expression)
F. Obvious signs of health
or illness
G. Attitude
H. Affect/mood
(appropriateness of
client’s response)
I. Quantity and quality of
speech
J. Relevance and
organization of thoughts
II. INTEGUMENTARY
A. SKIN
1. Skin color
2.) Uniformity of skin
NORMAL FINDINGS
Clean, neat
No body odor or minor odor
relative to work or exercise;
no breath odor
No distress noted
Healthy appearance
Cooperative
Appropriate to situation
Understandable, moderate
pace; exhibits thought
association
Logical sequence; makes
sense; has sense of reality
Varies from light to deep
brown; from ruddy pink to
light pink; from yellow
overtones to olive
Generally uniform except in
ACTUAL FINDINGS
Body build is proportionate
to age and lifestyle, stands
163 cm. and weighs 44
kilos
Slouchy, not coordinated
movements, less
purposeful posture
The client, upon inspection
is clean and neat.
Free from any foul body
and breath odor
No distress noted
Appears not healthy
Cooperative
Responds to questions
appropriately, correctly and
relevantly
Speech is soft but
understandable and at a
normal pace
Answers make sense and
in order
Skin color is dark brown
Evenly dark throughout the
INTERPRETATION AND
ANALYSIS
Within normal
(Kozier and Erbs.
Fundamentals of Nursing.
8th ed. p. 572)
Depressed or tired people
are more likely to slouch.
A less purposeful,
shuffling gait often
means the person is sad
or discouraged. Certain
gaits are associated with
illness.
Ref: Fundamentals of
Nursing, 5th edition by
Carol Taylor; et al. (page
449)
Within normal
Ref: Fundamentals of
Nursing, 8th edition by
Kozier and Erb’s (page
462)
Within normal
(Kozier and Erbs.
Fundamentals of Nursing.
8th ed. p. 572.)
Within normal
Illness can cause some
alteration in general
physical appearance.
Ref: Fundamentals of
Nursing, 5th edition by
Carol Taylor; et al. (page
449)
Within normal
Within normal
Within normal
Within normal
Within normal. Skin color
varies among races and
individuals.
Ref: Fundamentals of
Nursing, 5th edition by
Carol Taylor; et al. (page
572)
(Kozier and Erbs.
Fundamentals of Nursing.
8th ed. p. 579.)
Within normal
VI. Laboratory and Diagnostic Examination Results

Date Procedure Norms Result Interpretation

and Analysis
September URINALYSIS
13, 2010
Color Clear to Yellow Normal. The
Yellow patient’s urine
color is yellow
because he is
drinking
multivitamins.
Transparency Clear Slightly Turbid Deviation from
normal. Cloudy
urine or urine
with a high
level of
sediment may
be present in
cases of urinary
tract infection.
The patient
may be at risk
of having a
urinary tract
infection.

Microscopic
Exam
Red cells 0-3/HPF 3-4/HPF Deviation from
normal. When a
level of more
than 3 RBC's
are found, a
disease
condition is
often present.
One of the
most common
causes of
RBC's in the
urine is
infection or
inflammation of
the urinary tract
 itself (i.e.,
cystitis).
Trauma and
several other
conditions may
also cause
bleeding into
the urine. This
means that the
patient may be
at risk of having
a urinary tract
infection.
Pus cells Negative 1-2/HPF Deviation from
normal. When
the WBC count
in urine is high,
it means that
there is
inflammation in
the urinary tract
or kidneys. This
means that the
patient may be
at risk of having
a urinary tract
infection.
HEMATOLOGY
Hemoglobin Male: 140-180 126 g/L Less than
g/L normal. Low
hemoglobin
indicates
anemia, severe
hemorrhage
hemolysis,
cancer, kidney
disease, and
splenomegaly.
This is because
the patient is
suffering from
hemoptysis,
and it may
indicate that the
patient may be
at risk of having
 the said
diseases.
Hematocrit 0.42-0.54 0.33 Less than
normal. A low
hematocrit
indicates
anemia,
hemorrhage,
and leukemia.
This is because
the patient is
suffering from
hemoptysis,
and it may
indicate that the
patient may be
at risk of having
the said
diseases.
Neutrophils 0.40-0.60 0.70 Above normal.
High levels may
indicate an
active infection.
This means
that the patient
may be at risk
of having an
infection or he
has already an
infection.
SPUTUM EXAM
Appearance Absence of Bloodstained Deviation from
blood normal. The
sputum of the
patient is
stained with
blood because
the patient is
suffering from
hemoptysis so
he is coughing
up of blood.
Acid fast bacilli Negative 1+ Deviation from
stain: (direct normal. The
smear) sputum of the
client is positive
 with acid fast
bacilli.
FASTING
BLOOD SUGAR
EXAM
4.2-6.2 mmol/l 4.3 mmol/l Within normal.

VII. Medications

Generic/ Dosage/ Classifi- Indication Contra- Side Nursing

Trade Frequenc cation indication Effects Responsi-
Name y bilities
Trane- 500 mg 1 Cardio- Control of Severe GI • Store the
xamic ampule IV vascular hemorrhage renal disturbance, drug at
acid drugs in surgical insufficiency giddiness, room
(Hemos- and clinical . Patients hypotension, temperatu
tan) cases. with color vision re away
Hemostasis microscopic disturbance. from
in traumatic hematuria. sunlight
injuries, Hypersensit and
post- ivity to moisture.
extraction tranexamic • Instruct
and other acid. the
dental patient
procedures. not to
share the
medicatio
n with
others.
• Instruct
the
patient
that if he
miss a
dose, use
it as soon
as he
remem-
ber.
Cefuro- 750 mg Anti- Treatment of Hypersensit Nausea, • Give oral
xime every 8 infective/ lower ivity to vomiting, drug with
hours Antibiotic respiratory cephalos- headache, food to
infections porin. dizziness, decrease
caused by lethargy GI upset
 strepto- • Have Vit.
coccus K
pneumoniae available
in case
hypo
thrombi-
nemia
occurs
• Discontin
ue if
hyper-
sensitivity
reaction
occurs
• Instruct
the
patient to
swallow
the tablet
whole, do
not crust
it
• Instruct
the
patient
some of
it’s side
effects
Multi 1 capsule Multi Health Hypersensit • Assess
vitamins + OD vitamins maintenance ivity and patient for
Amino for fatigue, mal signs of
acid decline in absorption vitamin
(Moriamin energy. syndrome defi-
Forte) / Protein and ciency
Calcium vitamin before
Pantothen deficiencies, and
ic malnutrition, periodi-
adjuvant in cally
the therapy through-
of TB. out
therapy.
Assess
nutritional
status
through
24 h diet
 recall.
Determin
e
frequency
of
consumpt
ion of vit
rich foods

Butamirat 1 tablet Anti- Acute Hyper Rash, • Instruct

e citrate / TID cough cough due sensitivitv to nausea, the
Sinecod to variety of Butamirate diarrhea, patient
novartis causes, citrate or vertigo that if the
or forte especially any of it is cough
dry cough, ingredients lasts for
suppression more than
of 7 days,
preoperativ ask a
e and doctor for
postoperativ advice.
e cough in • Instruct
surgery and the
bronchosco patient
py. about the
whooping side
cough. effects
that he
may
experienc
e while
taking the
drug.
X. Prioritized List of Nursing Problems

CUES NURSING RANK JUSTIFICATION

DIAGNOSIS
Subjective: Ineffective 2 This is an actual,
• The patients Breathing Pattern health-threatening
chief complain is related to decrease problem. The client
massive lung capacity does not recognize this
as an urgent problem
hemoptysis with
that is requiring
chronic immediate intervention
productive but considered this
cough and next to his priorities
yellowish since it involves his
phlegm breathing.
Discussion of this
• Exposure to dust problem with the client
due to his requires a short period
occupation of time. Aside from
which is a educating the client
construction regarding measures on
worker. how to attain or to have
• “Nagtatabas kasi an effective breathing
ako ng tiles, yun pattern, it is also
ang trabaho ko required for the health
sa construction, care provider to
hindi ko evaluate whether the
maiwasang client has been
malanghap yung applying his acquired
dumi galing dito knowledge into action.
kaya ko daw Thus, monitoring
nakuha ang sakit follows. The client has
kong ito,” as no knowledge about
verbalized by the the measures or
client. techniques need to be
• “Nahihirapan done to relieve his
ako huminga difficulty of breathing
talaga dahil sa while the health care
 plema, sobrang provider has adequate
makapit at kung knowledge to address
minsan ang this problem. The
hirap pa ilabas”, health care provider is
as verbalized by patient enough to help
the patient. the patient know the
different
measures/interventions
Objective: needed to improve his
breathing pattern.
• + cough Financial resource of
• + DOB the client is not
• + Dyspnea required. Assistance of
• Weak looking the client’s partner to
• Restlessness monitor and assist the
patient may be
required. Resolution of
Measurement: this problem may
prevent or may help to
Vital signs: solve the other
identified problems.
BP- 110/70 mmHg

Temp- 36.9°C

RR- 25 cpm

PR- 91 bpm

Subjective: Knowledge Deficit 7 Whenever the

• The patient’s about his condition diagnostic label
education prognosis and Deficient Knowledge is
attainment is complications used, either the client
elementary related to lack of is seeking health
undergrad, he information information or the
only finished nurse has identified a
grade three. learning need.
• The patient said
that he smokes
and drinks
alcohol when he
was not yet
hospitalized. He
 consumes 5-7
sticks of
cigarettes per
day. The patient
also said that he
is not aware of
the
consequences
he can get from
smoking and
drinking alcohol.
• “Masarap kasi
pag umiinom at
nagyoyosi, kahit
papano
nawawala yung
problema ko
tsaka natural
naman sa mga
lalake ang may
bisyo”, as
verbalized by the
patient.

Objective:

• Lack of source
of information
• Frequent
questioning
about his
condition
• Coughing
without covering
his mouth

Subjective: Ineffective Airway 1 This is an actual

• The patient chief Clearance related problem which is
complain is to excessive according to Maslow’s
massive mucus secretion as Hierarchy Theory of
hemoptysis with manifested by Needs belonged to the
chronic cough and physiologic needs
productive presence of specifically airway.
cough and sputum This is health
yellowish threatening because it
 phlegm involves the airway of
• “Nahihirapan the patient which is
ako huminga vital for life survival.
talaga dahil sa The client wishes to
plema, sobrang prioritize this problem
makapit at kung first rather than
minsan ang anything else
hirap pa ilabas”, identified. Resolution of
as verbalized by this problem will
the patient. facilitate readiness for
learning to other health
problems. This may
Objective: also answer the client’s
• Weak looking problem regarding to
• Restlessness ineffective breathing
• Pale looking pattern and other
• + cough identified problems.
• + DOB The client has
• Use of insufficient knowledge
accessory of health maintenance
muscle while while the health care
coughing provider has adequate
knowledge that may
• + Yellowish
address this problem.
phlegm
The client exhibits a
• + wheezes and little of health-seeking
crackles upon behavior while the
auscultation health care provider is
patient enough to
teach and guide the
Measurements:
client towards
Vital signs: wellness.
There will be no
BP- 110/70 mmHg other human resources
that will be needed
Temp- 36.9°C except for the health
care provider and the
RR- 25 cpm client. For assistance
and support, any
PR- 91 bpm member of the family
may be included.
Financial resources to
sustain for medicines
and compliance to
some other health
practices are also
 required. Discussing
this problem to the
client does not require
too much of her time.
However, a
comfortable and well-
ventilated place / area
where the interventions
/ discussions will be
done should be
available. Usage of
other resources such
as visual aids and
recreational materials
are up to the health
care provider’s
preference. Visual
aids, and other
teaching equipments /
orientation should be
done in appropriate
with the client’s
development and
situation.
Subjective: Self care deficit 6 Muscle disused
• “Yung mga related to body associated with
dating nagagawa weakness prolonged bed rest can
ko sa bahay di contribute to
ko dito magawa complications of
kahit immobility like unable
magtootbrush, to manage one’s own
lalo na ang self. An important
pagligo dahil aspect of care is the
nanghihina ako”, prevention of these
as verbalized by complications.
the patient.
• “Buti na nga
lang at nandiyan
yung anak ko
para pag may
kailangan ako eh
matutulangan
niya ko kasi
kung minsan
kahit sa pag-ihi
nahihirapan
 akong tumayo
dahil hinang-
hina ako”, added
by the patient.

Objective:

• Weak looking
• Unable to stand
• Assisted by his
son
• Dirty nails on
fingers and toes
• Not well-
groomed
• Dirty physical
appearance

Subjective: Altered Nutrition: 3 This is an actual,

• The client rates less than body health-threatening
his health as requirement related problem. The client
5/10. to loss of appetite does not recognize this
• “Nung pagkauwi as manifested by as an urgent problem
ko ng bahay loss of weight that is requiring
nung huwebes, immediate intervention
uminom ako ng but considered this
tubig tapos third to his priorities
nasamid ako, since it involves the
bigla akong patient’s nutrition.
sumuka ng Discussion of this
madame, akala problem with the client
ko tubig lang requires a short period
tsaka yung of time. Aside from
kinain ko yun educating the client
pala may regarding measures on
kasama ng how to attain a
dugo”, the balanced nutrition, it is
patient added. also required for the
• “Wala akong health care provider to
ganang kumain evaluate whether the
dito dahil client has been
naninibago ako”, applying his knowledge
as verbalized by into action. Thus,
the patient monitoring follows. The
• “Tsaka iba yung client has no
pagkain dito knowledge about the
kumpara yung measures on how to
mga kinakain ko attain balanced
sa bahay”, nutrition while the
added by the health care provider
patient. has adequate
• “Grabe, sobra na knowledge to address
nga ang ipinayat this problem. The
ko eh, hindi health care provider is
naman ako patient enough to help
ganito kapayat the patient know the
dati para na nga different
akong buto’t measures/interventions
balat”, patient needed. Financial
verbalized. resource of the client is
maybe required
especially in meal
Objective: planning of nutritious
• Small body foods needed for his
frame condition. Assistance
• Weak looking of the client’s partner to
• Pale conjunctiva monitor and assist the
and mucous patient may be
membrane required.
• Dry skin
• Evidence of lack
of available food

Measurement:
Weight: 44 kg
Height: 5’4 1/2
BMI: 16.4

Subjective: Sleep disturbance 4 Multiple factors

• When he was related to change contribute to sleep
admitted to the in the environment deprivation, including
hospital, the noise level. Studies
patient has only have shown by the
minimal time of World Health
sleeping Organization that when
because men were deprived of
according to sleep, the experience
him, he is not major imbalances in
comfortable in carbohydrate
sleeping in the metabolism and
 hospital together hormone levels. The
with other researchers concluded
patients and he that lack of sleep has
is easily an effect similar to an
disturbed by the accelerated aging
noises of other process.
patients.
• “Hindi ako
makatulog ng
maayos dito kasi
yung iba ang
ingay, ubo ng
ubo”, verbalized
by the patient.
• “Tsaka
naninibago ako
kasi ako yung
tao na hindi
nakakatulog
kapag wala ako
sa sarili kong
kwarto”, he
added.

Objective:
• Presence of
dark circles
around the
eyes or eye
bags
• Weak looking
• Restlessness
• The patient is
yawning
• A little bit
irritable

Subjective: Activity intolerance 5 Muscle disused

• “Yung mga related to body associated with
dating nagagawa weakness prolonged bed rest can
ko sa bahay di contribute to
ko dito magawa complications of
kahit immobility. An
magtootbrush, important aspect of
lalo na ang care is the prevention
pagligo dahil of these complications
 nanghihina ako”,
as verbalized by
the patient.
• “Buti na nga
lang at nandiyan
yung anak ko
para pag may
kailangan ako eh
matutulangan
niya ko kasi
kung minsan
kahit sa pag-ihi
nahihirapan
akong tumayo
dahil hinang-
hina ako”, added
by the patient.

Objective:
• Weak looking
• Unable to stand
• Assisted by his
mother
• Anxious
behavior
• Pessimistic

XI. Nursing Care Plan

Cues Nursing Health Goal & Intervention Rationale Evaluation

Diagnosis Implication Objective

Subjective: Goal: After the

• The Ineffective Pulmonary By nursing
patient airway tuberculosis September intervention,
chief clearance is an 19, 2010 the client
complain related to infectious the client was able to
is excessive disease will be able have an
massive mucus caused by to have an effective
hemop- secretion as slow- effective airway
tysis with manifested growing airway clearance as
chronic by cough bacteria clearance. manifested
 productiv and by normal
e cough presence of that Objective RR, absence
and sputum resembles a s: of pallor and
yellowish fungus, After 1 cyanosis,
phlegm Myo- hour of and clear
• “Nahihira bacterium nursing lungs upon
pan ako tuberculosis interven- auscultation.
huminga , which is tion, the
talaga usually client will
dahil sa spread from be able to:
plema, person to
sobrang person by • have a • Adminis- Oxygen will
makapit droplet clear tered help to
at kung nuclei airway medication, relieve
minsan through the clearance oxygen and respiratory
ang hirap air. The and able suction if distress.
pa lung is the to exhibit needed as REF:Nursin
ilabas”, usual at least 3 prescribe g Diagnosis
as infection signs of by Doctor. reference
verbalize site but the effective manual
d by the disease can airway: Sixth
patient. occur 1. Normal Edition by
elsewhere RR Sparks and
in the body. 2. Lungs Taylor page
Objective: Typically, clear to 33.
• Weak the bacteria auscul-
looking from lesion tation Suctioning
• Restless (tubercle) in 3. Absence helps in the
ness the alveoli. of pallor removal of
• Pale The lesion and mucous
looking may heal, cyanosis secretions
• + cough leaving scar and sputum
• + DOB tissue; may in the lungs.
• Use of continue as REF:Nursin
accessor an active g Care
y muscle granuloma, Plans Third
while heal, then Edition by
coughing reactivate Gulanick
or may page 211.
•+
progress to
Yellowish
necrosis,
phlegm
liquefaction, Monitoring
•+ sloughing, • Monitor will identify
wheezes and respiratory progress
and cavitation of status q4: toward or
crackles lung tissue. rate, depth, deviations
upon effort, skin
 auscultati color, from goal.
on The initial mucous Ineffective
lesion may mem- Airway
disseminate branes. Clearance
Measurem bacteria Monitor leads to
ents: directly to also the poor
adjacent level of oxygenation
Vital signs: tissue, conscious- , as
through the ness. evidence by
BP- 110/70 blood pallor,
mmHg stream, the cyanosis,
lymphatic lethargy
Temp - system, or and
36.9°C the bronchi. drowsiness.
REF:Funda
RR- 25 Most mental of
bpm people who Nursing by
become Barbara
PR- 91 cpm infected do Kozier vol I
not develop page 227.
clinical • Maintain
illness proper Gravity
because the position allows for
body’s such fuller lung
immune Fowler’s or expansion
system semi- by
brings the fowler’s decreasing
infection position pressure of
under and abdomen
control. change and
However, position diaphragm
the every 2 and
incidence of hours. enhancing
tuberculosis drainage
(especially of/ventilatio
drug n to
resistant different
varieties) is lung
rising. segments.
Alcoholics, REF:Funda
the mental of
homeless Nursing by
and patients Barbara
infected Kozier vol I
with the page 227.
human
 • Encourage
immunodefi • Expecto- patient to It helps
ciency virus rate or increase liquefy
(HIV) are clear fluid intake secretions
especially secre- (1500 – and ensure
at risk. tions 2000 proper
Complicatio readily. mL/day). hydration
ns of and
tuberculosis improve
include secretion
pneumonia, clearance.
pleural REF:Nursin
effusion, g Diagnosis
and extra- reference
pulmonary manual
disease. Sixth
Edition by
Sparks and
Taylor page
35.
• Administer
analgesics. It improves
cough when
pain is
inhibiting
effort.
REF:Nursin
g Diagnosis
reference
manual
Sixth
Edition by
Sparks and
Taylor page
35.

• Monitor
• Client’s Its gauge
and
sputum the
document
will be effectivenes
the amount
normal. s of the
and
characterist therapy and
ics of detect
sputum. possible
Observe respiratory
for signs infection.
 and It’s also
symptoms ascertain
of infection. status and
note
progress,
promote
timely
intervention,
and to
examine
and report
changes in
color and
amount.
REF:Nursin
g Diagnosis
reference
manual
Sixth
Edition by
Sparks and
Taylor page
35.

Cues Nursing Health Goal & Intervention Rationale Evaluation

Diagnosis Implication Objective

Subjective: Ineffective Goal: After the

• The Breathing The risk of By nursing
patients Pattern TB is a September intervention,
chief related to higher in 19, 2010 the client
decrease older the client was able to
complain
lung people who will be able have an
is capacity have close to have an effective
massive contact with effective breathing
hemoptys a newly breathing pattern as
is with diagnosed pattern. manifested
chronic TB patient, by normal
productiv those who Objectives: RR.
have TB After 1
e cough
before, hour of
and gastrec- nursing
yellowish tomy interven-
 phlegm tion, the
patients, client will:
• Exposure and those
to dust affected
due to his with • Promote • Monitor Respiratory
occupatio diabetes good respiratory status
n which mellitus. respiratory status, assessment
is a The aging function including helps gauge
construct process vital signs, the patient’s
ion weakens breath severity and
worker. the immune sounds, whether it’s
• “Nagtata system, and skin progressing
bas kasi further color. .
ako ng increasing REF:Funda
tiles, yun the mental of
ang likelihood of Nursing by
trabaho tubercular Barbara
ko sa infection in Kozier vol I
construct older adults. page 227.
ion, hindi
ko
maiwasa • Administer To provide
ng oxygen relief from
malangha therapy as symptoms
p yung ordered. of
dumi hypoxemia
galing and
dito kaya hypoxia.
ko daw REF:Nursin
nakuha g Diagnosis
ang sakit reference
kong ito,” manual
as Sixth
verbalize Edition by
d by the Sparks and
client. Taylor page
• “Nahihira 33.
pan ako
huminga
talaga • Monitor ABG levels
dahil sa ABG levels and
plema, and oxygen continuous
sobrang saturation pulse
makapit as ordered. oximetry
at kung measures
minsan the blood’s
 ang hirap oxygen
pa content and
ilabas”, are good
as indicators of
verbalize the lung’s
d by the ability to
patient. oxygenate
the blood.
REF:Funda
Objective: mental of
Nursing by
• + cough Barbara
• + DOB Kozier vol I
• +Dyspne page 227.
a
• Weak • Promote
looking comfort To increase
• Restless- • Place the chest
ness patient in expansion
semi- and to
fowlers alleviate
Measurem position dyspnea.
ents: and place REF:Nursin
the g Diagnosis
Vital signs: diaphragm reference
in proper manual
BP- 110/70 position to Sixth
mmHg contract. Edition by
Sparks and
Temp- Taylor page
36.9°C 35.

RR- 25
bpm To monitor
• Collect the
PR- 91 cpm sputum progress of
samples as the disease
ordered. and
treatment.
REF:Nursin
g Diagnosis
reference
manual
Sixth
Edition by
Sparks and
 Taylor page
35.

Cues Nursing Health Goal & Intervention Rationale Evaluation

Diagnosis Implication Objective

Subjective: Altered Adequate GOAL: After the

• The client Nutrition: nutrition is After 5 nursing
rates his less than necessary hours of intervention,
health as body to meet the nursing the client
5/10. requirement body’s interven- was able to
• “Nung related to demands. tion, the have
pagkauwi loss of Nutritional client will sufficient
ko ng appetite as status can be able to knowledge
bahay manifested be affected have on proper
nung by loss of by disease sufficient nutrition
huwebes, weight or injury knowledge regarding on
uminom states (e.g., on proper his current
ako ng gastrointesti nutrition condition.
tubig nal [GI] regarding
tapos malabsorpti on his
nasamid on, cancer, current
ako, bigla burns); condition.
akong physical
sumuka factors Objectives:
ng (e.g., After 1
madame, muscle hour of
akala ko weakness, nursing
tubig poor interven-
lang dentition, tion, the
tsaka activity client will
yung intolerance, be able to:
kinain ko pain,
yun pala substance • state • discuss the Nutritional
may abuse); what is definition of counseling
kasama social proper proper includes
ng dugo”, factors nutrition nutrition providing
the (e.g., lack of in his information
patient financial own about
added. resources words proper
• “Wala to obtain nutrition.
akong nutritious (Fundament
ganang foods); or als of
 kumain psychologic Nursing by
dito dahil al factors taylor, 5th
naninibag (e.g., edition,
o ako”, depression, page 1260)
as boredom).
verbalize During
d by the times of • state the • discuss the Nutritional
patient illness (e.g., impor- importance counseling
• “Tsaka trauma, tance of of proper includes
iba yung surgery, proper nutrition providing
pagkain sepsis, nutrition information
dito burns), about
kumpara adequate proper
yung mga nutrition nutrition.
kinakain plays an (Fundament
ko sa important als of
bahay”, role in Nursing by
added by healing and taylor, 5th
the recovery. edition,
patient. Cultural and page 1260)
• “Grabe, religious
sobra na factors
nga ang strongly • explain • Discuss Food
ipinayat affect the briefly about the Pyramid
ko eh, food habits what food Food assists in
hindi of patients. pyramid Pyramid making sure
naman Women is all to offer
ako exhibit a about variety of
ganito higher and how the
kapayat incidence of it can recommend
dati para voluntary help him ed foods.
na nga restriction of in his (Maternal
akong food intake current and Child
buto’t secondary condition Health
balat”, to anorexia, Nursing, 5th
patient bulimia, and edition by
verbalize self- Adelle
d. constructed Pillitteri,
fad dieting. page 893)
Patients
Objective: who are
• Small elderly • state the • discuss the Meals
body likewise recom- recommen should be
frame experience mended ded food served on
• Weak problems in food pattern that right
looking nutrition pattern is amount
• Pale related to that is applicable regularly to
conjuncti lack of appli- in his meet the
va and financial cable in current nutritional
mucous resources, his condition requirement
membran cognitive current s. (ABC’s of
e impairments condition Nutrition by
• Dry skin causing Pataunia
• Evidence them to page 71)
of lack of forget to
available eat,
food physical • state the • Discuss the Carefully
limitations impor- importance planned
Measurem that tance of of meal meals
ent: interfere meal planning deliver
Weight: 44 with planning sufficient
kg preparing amount of
Height: 5’4 food, all the vital
½ (164 cm) deterioratio nutrients.
BMI: 16.4 n of their (ABC’s of
sense of Nutrition by
taste and Pataunia
smell, page 71)
reduction of
gastric
secretion • create a • Assist the Carefully
that meal plan client in planned
accompanie based on creating a meals
s aging and the meal plan deliver
interferes recomme sufficient
with nded amount of
digestion, food all the vital
and social pattern nutrients.
isolation suitable (ABC’s of
and for her Nutrition by
boredom condition Pataunia
that cause a page 71)
lack of
interest in
eating.
• create • Guide the Encourage
variety of client in a variety of
meals creating foods from
everyday variety of each food
to meet meals that groups in
the suits their amount
nutritional budget suited for
 require- the client's
ments appetite
needed and needs.
for his (ABC’s of
condition, Nutrition by
consider- Pataunia
ing also page 71)
the
budget of
the family

• have an
adequate
knowledg
e of the
proper
nutrition
about his
current
condition