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Agbannawag Jan Derick D.

Nov 27, 2010

BSN-103 FEU-IN Grp.9 C.I. Liezel Salcedo


Patient: F.D.
Bed: D13
Primary Diagnosis: PTB V, CAP T/C COPD Acute infectious Exacerbation
Analysis Goal and Objectives Nursing Interventions Rationales Evaluation
Activity Pulmonary tuberculosis Goal: After 8 hours of • Note client reports of • Symptoms may be After 8 hours
Intolerance is an infectious disease Nursing Intervention, the weakness and difficulty in result of/or contribute of Nursing
related to caused by slow- growing client will Report measurable doing a task. to intolerance of Intervention,
imbalance bacteria that resembles a increase in activity activity. the client
between intolerance and will able to • Ascertain ability to stand • To determine current Reports
fungus, Myobacterium
oxygen supply identify techniques to and move about and degree status and needs measurable
tuberculosis, which is
and demand as enhance activity tolerance as of assistance necessary/use associated with increase in
evidenced by usually spread from manifested by a decrease in activity
of equipment. participation in needed/
shortness of person to person by physiological signs of desired activities. intolerance and
breath. droplet nuclei through intolerance. • Assess • Stress/depression might was able to
the air. The lung is the emotional/psychological be the result of being identify
Subjective: usual infection site but Objectives: factors affecting the current forced into inactivity. techniques to
“hindi ko the disease can occur situation. enhance
magawa gusto elsewhere in the body. • Provide positive • Helps to minimize activity
kong gawin Typically, the bacteria atmosphere, while frustration and tolerance as
kasi from lesion (tubercle) in • Client identifies factors acknowledging difficulty of rechannel energy. manifested by
nahihirapan affecting activity intolerance the situation for the client. a decrease in
the alveoli. The lesion
din ako physiological
may heal, leaving scar • Provide the client
huminga” as signs of
tissue; may continue as • Teaching client to how to knowledge that he can
verbalized by • Client gain knowledge on intolerance.
an active granuloma, enhance activity tolerance apply and will enhance
the client. techniques to enhance
heal, then reactivate or his act. tolerance
activity tolerance.
may progress to necrosis, • Client
liquefaction, sloughing, • Client will manifest glow identified the
and cavitation of lung on the face and return of factors
tissue. The initial lesion pinkish color on the affecting
may disseminate bacteria fingernails. activity
Objective: directly to adjacent intolerance
• Client verbalizes
tissue, through the blood appreciation to the
Vital Signs: • Client
stream, the lymphatic interventions.
BP:130/80 gained
T:36.2 C system, or the bronchi.
knowledge on
PR:96 • Client reports
techniques to
RR:31 Most people who improvement of his
become infected do not activity tolerance.
Pallor develop clinical illness tolerance.
because the body’s
immune system brings • Client
the infection under manifested
control. However, the glow on the
incidence of tuberculosis face and
(especially drug resistant return of
varieties) is rising. pinkish color
Alcoholics, the homeless on the
and patients infected