ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: Ineffective airway clearance STG: Independent: STO:

“Nahihirapan akong huminga
at inuubo po ako na may
kasamang madilaw na
Plema” as verbalized by the
patient
OBJECTIVE:
 RR: 26cpm
 Bilateral Crackles
 Use of accessory muscles
when breathing
 Productive yellow cough
R/T presence of secretions
AEB crackles on both lung
fields.
After 1 hour of nursing
intervention, the pt. will be
able to cough up secretions
effectively.
LTG:
After 8 hour of nursing
intervention the patient will
be able to verbalize effective
airway clearance as
characterized by:
a. absence of cough
b. lessened secretions
c. improved breath sounds
from coarse to fine.
>Assessed airway patency
>Assessed cough for
effectiveness and
productivity
>Monitored V/S
>Auscultated breath sounds.
>Observed for signs of
respiratory distress
(increased
rate, use of accessory
muscles)
>positioned patient to semi
fowlers/sitting position.
Goal fully met.
After 1 hour of nursing
intervention, The patient is
able to cough up secretions
effectively.
LTO:
Goal fully met.
After 8 hour of nursing
intervention the patient was
able to verbalize effective
airway clearance as
characterized by:
a. absence of cough
b. lessened secretions
c. improved breath sounds
from coarse to fine.

>encouraged to increase fluid

intake at least 2000ml/day

>encouraged breathing
exercise

Dependent:
>administered
isoniazid, rifampicin,
pyrazinamide, and
ethambutol

>provided information about

necessity of raising
expectorants versus
swallowing them
ASSESSMENT
SUBJECTIVE:
“pabalik – balik lang ang
lagnat ko” as verbalized by
the patient
OBJECTIVE:
>Flushed skin; warm to
touch->Increase body
temperature higher than
normal range->Increased
respiration
-The patient is sweating
DIAGNOSIS PLANNING INTERVENTION EVALUATION
Hyperthermia related to STG: Independent STG:
inflammatory response as After 30 minutes of nursing >Monitor vital Goal fully met.
evidenced by warm to touch intervention, the patient will signs.
skin. be able to lessen After 1 hour of nursing
temperature of at least 1˚C. >Provide tepid intervention, the patient’s
sponge bath. temperature decreased from
LTG: Do not use 38.2 ˚C to 37.1C as evidenced
After 4 hour of nursing alcohol. by decreased diaphoresis and
intervention the patient’s calm breathing.
temperature will return to >Remove excess
normal range with a temp clothing and LTG:
between 36.5 ˚C – 37.5 ˚C covers. Goal fully met.

VS are as follows: >Promote a well- After 4 hours of

-T: 38.2˚C ventilated area nursing intervention the
-PR: 72 to patient. patient’s temperature
-RR:26 returned to normal range
-BP: 120/90 >Advise patient with a temp between 36.5 ˚C
to increase oral – 37.5 ˚C
fluid intake.

>Maintain bed
rest.

>Provide high-
calorie diet.

>Educate and
advise SO to do TSB when
patient feels hot.
--make sure that armpits and
groins were included in the
TSB

>monitored VS and
rechecked

Dependent:
>Provide antipyretic
medication as indicated