Time Chart

7:00-3:00 am F> Risk for infection related to lowered resistance/suppressed inflammatory

process secondary to pulmonary tuberculosis

D> Received with an intact D5W @ 1L x 16 hours. With VS as follows: T-37.9 C,

PR- 110 bpm, RR- 25 cpm, BP- 120/80 mmHg, SPO2- 92%. With productive cough.
”Nahihirapan na ako huminga kakaubo”.

A> Monitored VS especially temperature as indicated. Reviewed necessity of

infection control measures. Identified individual risk factors for reactivation of
TB: lowered resistance associated with smoking. Provided clean, well-
ventilated environment. Provided for isolation as indicated. Maintained sterile
technique for all invasive procedures. Instructed to cough or sneeze and
expectorate into tissue and to refrain from spitting. Stressed the importance
of uninterrupted drug therapy

R> After 4 hours of nursing intervention, the patient was able to identify
different ways to prevent or reduce risk of spread of infection

DATA GOALS/ ACTION/ NURSING RATIONALE RESPONSE &

Expected outcomes INTERVENTIONS EVALUATION
Subjective findings: STG: within Dxtc: After __8____hr/s of
”Nahihirapan na ako ___4___hour/s of NI the  Monitored  Febrile reactions are NI, the patient was
huminga kakaubo” as patient will be able to temperature as indicators of able to identify different
verbalized by the identify different ways to indicated continuing presence ways on how to
patient prevent or reduce risk of of infection prevent or reduce risk
infection  For the sake of of infection
Objective findings: as manifested/evidenced  Reviewed necessity protecting other as manifested by
-With VS as follows: T- by: identifying preventive of infection control people while identifying preventive
37.9 C, PR- 110 bpm, measures such as taking measures. Put in acknowledging measures such as
RR- 25 cpm, BP- prescribed medicine, temporary patient’s sense of taking prescribed
120/80 mmHg, SPO2- covering of mouth with respiratory isolation isolation associated medicine, covering of
92%. tissue when sneezing or as indicated with communicable mouth with tissue
-with productive cough coughing and the  Identified individual disease when sneezing or
importance of risk factors for  Knowledge about coughing and the
Focus/ Nursing Dx: handwashing reactivation of TB: these factors helps importance of
(PE/S) lowered resistance patient alter lifestyle handwashing
Risk for infection associated with and avoid or reduce STG: fully/partially/un
related to lowered smoking incidence of MET
resistance/suppressed  Identified others at exacerbation
inflammatory process risk like household
secondary to members, close  Those exposed may
pulmonary tuberculosis associates and required a course of
friends drug therapy to
LTG: after _3__days of prevent spread or
NI the patient will be able Txc: development of After ___8___hr/s of
to be free of sign and  Provided clean, infection NI, the patient was
symptoms related to well- ventilated able to be free of signs
infection as manifested environment  To atleast provide and symptoms related
by absence of possible  Provided for comfort in patient to infection
signs and symptoms isolation as as manifested by
related to infection indicated  To reduce the risk of normal findings and
 Maintained sterile cross-contamination result of test
technique for all  To prevent further STG: fully/partially/un
invasive procedures infection MET
Edx:
 Instructed patient to
cough or sneeze
and expectorate into  Behaviors necessary
tissue and to refrain to prevent spread of
from spitting infection
 Stressed the
importance of
uninterrupted drug
therapy  Compliance with
multidrug regimens
for prolonged periods
is difficult, so DOT
should be considered