XIV.

PROBLEM LIST

A) Actual Problems

Problem No. Nursing Diagnoses Date Identified

1 Ineffective Airway clearance September 22, 2020
2 Acute Pain September 22, 2020
3 Activity Intolerance September 22, 2020

B) Potential Problems

Problem No. Nursing Diagnoses Date Identified

Risk for Ineffective Therapeutic Regimen
1 September 22, 2020
Management
2 Risk for Infection (Transmission) September 22, 2020
XV. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective airway Short Term Goal: Assess respirations: Both rapid, shallow After a week of nursing
clearance related to After 4 hours of nursing note quality, rate, breathing patterns and intervention, the patient
“Ubo ako ng ubo”as retained secretions as intervention, the patient pattern, depth, and hypoventilation affect breathing returned to
verbalized by the evidence by cough and will be able to maintain breathing effort. gas exchange. normal rate and
patient. restlessness. airway patency and pattern.
clear secretions readily. Monitor vital signs. With initial hypoxia and
Objective: hypercapnia, blood
•Cough pressure, heart rate,
•Restlessness Long Term Goal: and respiratory rate all
•Pale After 8 hours of nursing rise. As the hypoxia
intervention the patient and/or hypercapnia
promote good become more severe,
Vital Sings: respiratory function. BP may drop, heart
T= 36.7 oC rate tends to continue
P= 78 bpm to be rapid with
R= 30bpm arrhythmias, and
B/P= 110/70 mmHg respiratory failure may
ensue with the patient
unable to maintain the
rapid respiratory rate.

Assess for changes in Restlessness is an

orientation and early sign of hypoxia.
behavior. Chronic hypoxemia
may result in cognitive
changes such as
memory changes.

Assess patient’s ability Retained secretions

to cough effectively to impair gas exchange.
clear secretions. Note
quantity, color, and
consistency of sputum.

Maintain oxygen This provides for

administration device adequate oxygenation.
as ordered, attempting
to maintain oxygen
saturation at 90% or
greater.

Position with proper This promotes lung

body alignment for expansion and
optimal respiratory improves air exchange.
excursion.

Anticipate need for Early intubation and

intubation and mechanical ventilation
mechanical ventilation are recommended to
if patient is unable to prevent full
maintain adequate gas decompensation of the
exchange. patient.

Teach the patient These facilitate

appropriate deep adequate air exchange
breathing and coughing and secretion
techniques. clearance.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain related to Short Term Goal: Bed rest with fowler or For proper breathing, After 12 hours of
“Sumasakit yung chest pain as evidence After 4 hours of nursing semi-fowler position. and reduce hypoxia. nursing interventions,
dibdib ko lalo na kapag by grimace and interventions the the patient felt
umuubo ako” as guarding behavior. patient will be able to Observer and monitor To identify changes and improvement with his
verbalized by the rest in a semi or fowler V/S acts as a baseline. chest, verbalized
patient. position. relieved pain, rested
and coped up with pain
Long Term Goal: Administer medications To relieve the pain. and do some relaxation
After 8 hour of nursing as ordered. techniques.
Objective: intervention the patient
Grimace Can rest and cope with Encourage adequate To prevent fatigue that
Guarding behavior pain and do some rest periods. can impair ability to
relaxation technique.. manage or cope with
•Pain scale: 7/10 pain.

T= 36.7oc Instruct the patient to Help to decrease the

P= 78 bpm do relaxation perception and
R= 30bpm techniques such as response to pain. To
B/P= 110/70 mmHg deep and slow control the situation
breathing, distraction and increase positive
behavior, assist as attitude
needed.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Activity intolerance Short term Goal: Establish guidelines Motivation and After 48 hours of
“Nahihirapan akong related to imbalance After 4 hours of nursing and goals of activity cooperation are nursing intervention the
huminga kapag between oxygen supply intervention the patient with the patient and/or enhanced if the patient patient is able to
pagod.”As stated by and demand as will have normal pulse SO. participates in goal
maintain activity level
the patient. evidence by rate, systemic blood setting
cardiopulmonary pressure and within capabilities as
status. respiratory response. Evaluate the need for Coordinated efforts are evidenced by normal
additional help at more meaningful and vital signs during
Long term Goal: home. effective in assisting activity, as well as
Objective: After 8 hours of nursing the patient in absence of weakness,
intervention the patient conserving energy. pain, and difficulty
R= 30bpm will be able to do ADLs
accomplishing tasks.
alone and to participate Have the patient Helps in increasing the
in self-care activities. perform the activity tolerance for the intervention
more slowly, in a longer activity.
time with more rest or
pauses, or with
assistance if
necessary.

Gradually increase Gradual progression of

activity with active the activity prevents
range-of-motion over exertion.
exercises in bed,
increasing to sitting and
then standing.

Dangle the legs from Prevents orthostatic

the bed side for 10 to hypotension.
15 minutes.

Refrain from Patient with limited

performing activity tolerance need
nonessential activities to prioritize important
or procedures. taks first.
Assist with ADLs while
avoiding patient
dependency.

Assist with ADLs while Assisting the patient

avoiding patient with ADLs allows
dependency. conservation of energy.
Carefully balance
provision of assistance;
facilitating progressive
endurance will
ultimately enhance the
patient’s activity
tolerance and self-
esteem.

Provide bedside Use of commode

commode as indicated. requires less energy
expenditure than using
a bedpan or ambulating
to the bathroom.

Encourage physical Helps promote a sense

activity consistent with of autonomy while
the patient’s energy being realistic about
levels. capabilities.

Instruct patient to plan Activities should be

activities for times planned ahead to
when they have the coincide with the
most energy. patient’s peak energy
level. If the goal is too
low, negotiate.

Encourage This helps the patient

verbalization of feelings to cope.
regarding limitations. Acknowledgment that
living with activity
intolerance is both
physically and
emotionally difficult.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

“nalilito ako kung Risk for ineffective Short term Goal: Allow patient’s Patients who After 12 hours of
anong gamut ang therapeutic regimen After 1 hour of nursing participation in planning participate in their care nursing intervention the
inumin ko" as stated by management related to intervention the patient the treatment program. have a greater chance patient will verbalize
complexity of will absorb or recognize of obtaining a positive
the patient . how important to follow
therapeutic regimen as the desired health- result.
evidence by verbalized related activity. the treatment plan and
Objective: difficulty with Tell the patient about Patients who how would affect his
Confused prescribed regimen Long term Goal: the advantages of understand the heath if he will not
After 2 hours of nursing adhering to the effectiveness of the comply.
intervention the patient prescribed regimen. suggested treatment to
will understand the reduce risk or to
effect of not following promote health are
the implementation of more likely to engage
the treatment plan. in it.

Explain the regimen Patients are more likely

properly yet easy to
understand by the
patient. Suggest long-
acting medications and
eliminate unnecessary
medications.
to disregard
medications if they are
to be taken multiple
times daily.

Coordinate the therapy This approach

to the patient’s lifestyle. promotes compliance.
A “one size fits all” is
usually ineffective.

Avoid unnecessary
clinic visits. The physical
requirements of going
 to an appointment, the
financial costs incurred
(loss of day’s work,
child care), the
negative feelings of
being “talked down to”
by healthcare providers
not fluent in the
patient’s language, as
well as the commonly
long waits can cause
patients to withdraw
themselves from follow-
ups.
Develop with the
patient a method of Rewards may consist
rewards that follow of verbal recognition,
successful follow- monetary rewards,
through. special privileges

Develop a system for

the patient to observe Self-monitoring is a key
his or her own component of a
progress. successful change in
behavior.

Explain that side

effects or negative side This determines if
effects of the treatment something needs to be
can be managed or revised.
eliminated.

Focus on the behavior

that will make the Behavior change is
greatest contribution to never easy. Efforts
the therapeutic effect. should be directed to
activities known to
result in specific
Initiate referral to a benefits.
support group if the
patient lacks sufficient Groups that come
support system in the together for common
following prescribed support and knowledge
treatment regimen. can be helpful,
especially to patients
coping with chronic
Involve significant illness.
others in explanations
and teaching. Involving significant
Encourage their others promotes
support and assistance support and assistance
in following plans. in strengthening
appropriate behaviors
and promoting lifestyle
modification.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for Infection Short Term Goal: Review pathology of Helps patient realize/ After 12 hours of
“ubo ako ng ubo, Transmission related to After 12 hours of disease and potential accept necessity of nursing interventions,
natatakot ako baka airborne transmission nursing interventions, spread of infection via adhering to medication the patient was able to
exposure as evidence the patient will be able airborne droplet during regimen to prevent
mahawaan ko pamilya verbalized and
by Infection of to Identify interventions coughing, sneezing, reactivation/complicatio
ko as stated by the pulmonary tuberculosis to prevent/reduce risk spitting, talking, n. Understanding of acknowledged on what
patient. as health threat. of spread of infection laughing and singing. how the disease is to do to prevent/reduce
passed and awareness risk of spread of
Objective: Long term Goal: of transmission infections.
After 72 hours of possibilities help .
T= 36.70C nursing intervention the client/SO take steps to
patient demonstrate prevent infection of
P= 78 bpm
techniques/initiate others.
R= 30bpm lifestyle changes to
B/P= 110/70 mmHg promote safe Identify others at risk; Those exposed may
environment. e.g., household require a course of
members, close drug therapy to prevent
associates/friends. spread/development of
infection.

Instruct client to Behaviors necessary to

cough/sneeze and prevent spread of
expectorate into tissue infection.
and to refrain from
spitting. Review proper
disposal of tissue and
good hand-washing
techniques. Requests
return demonstration.

Review necessity of May help patient

infection control understand need for
measures protecting others while
acknowledging client’s
sense of isolation and
social stigma
associated with
communicable
diseases.

Monitor temperature as Febrile reactions are

indicated. indicators of continuing
presence of infection.

Identify individual risk Knowledge about these

factors for reactivation factors helps patient
of tuberculosis alter lifestyle and
avoid/reduce incidence
of exacerbation.

Stress importance of Contagious period may

uninterrupted drug last only 2-3 days after
therapy. Evaluate initiation of drug
patient’s potential for regimen, but in the
cooperation. presence of cavitation
or moderately
advanced disease, risk
of spread of infection
may continue up to
3months. Compliance
with multidrug
regimens for prolonged
periods is difficult, so
directly observed
therapy (DOT) should
be considered.
Review importance of Aids in monitoring the
follow-up and periodic effects of medication
reculturing of sputum and patient’s response
for duration of therapy. to therapy.

Encourage Presence of anorexia

selection/ingestion of and/or preexisting
well-balanced meals. malnutrition lowers
Provide frequent small resistance to infectious
“snacks” in place of process and impairs
large meals as healing. Small snacks
appropriate. may enhance overall
intake.

Collaborative

Administer anti- The goals for treatment

infective agents as of TB are to cure the
ordered for treatment individual and to
minimize transmission
to other persons. It is
essential that treatment
be tailored, and
supervision be based
on each client’s clinical
and social
circumstances. DOT
may be the most
effective way to
maximize the
completion of therapy.

Monitor laboratory Client who has three

studies; e.g., Sputum consecutive negative
smear results. sputum smears (takes
3-5months), is adhering
to drug regimen, and is
asymptomatic will be
classified as a non-
transmitter.

Notify local health Required by law, and

department should be reported
within 1week of
diagnosis. Helpful in
identifying contacts to
reduce spread of
infection. Treatment
course is long and
usually handled in the
community with public
health nurse
monitoring.