NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for After 24 hours, the patient will be Independent: Independent: After 24 hours, the patient will be
“Nadlaw ko infection r/t able to; able to;
toybagik nga inadequate 1. Maintain patient 3. Most hospitalized patient is
kimmutong nak ti primary  Identify interventions and healthcare in a compromise immune  Identify interventions
permi.” defenses. to prevent/reduce personnel state and at a higher risk of to prevent/reduce
risk of spread of isolations exposure to infectious risk of spread of
Objective: infection. precautions. disease. infection.
 Weight 2. 4.
Identify other at Those exposed may require
loss of  Demonstrate risks, such as a course of drug therapy to  Demonstrate
about 10 techniques/initiate household prevent development of techniques/initiate
kg lifestyle changes to members and infection. lifestyle changes to
 Fatigue promote safe friends. 5. May help patient promote safe
 Productive environment. 3. Review necessity understand need for environment.
Cough of infection protecting others while
control acknowledging patient’s GOAL WAS PARTIALLY
measures. Put sense of isolation and MET.
in temporary social stigma associated
respiratory with communicable
isolation if diseases.
indicated. 6. Febrile reactions are
4. Monitor indicators of presence of
temperature as infection.
indicated. 7. Monitors adverse effects of
5. Liver function drug therapy
studies: including hepatitis.
AST/ALT. Dependent:
1. Initial therapy of
Dependent: uncomplicated pulmonary
disease usually includes
four drugs, e.g., four
1. Administer anti-
primary drugs or
infective agents.
combination of primary
2. Primary Drugs:
and secondary drugs.
Rifampicin,
Ethambutol,
Pyrazinamide,
Isoniazid,
Streptomycin
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Objective Data: Ineffective After 12 hours, the patient will be Independent. Independent: After 12 hours, the patient will be
 Productive airway able to; able to;
Cough clearance r/t  Maintain patent airway. 1. Note the ability to 1. Expectoration may be  Maintain patent airway.
infection as  Expectorate sputum expectorate mucus difficult when secretions  Expectorate sputum
evidenced by without assistance. and cough are thick, cloudy, without assistance.
productive  Demonstrate behaviors effectively. sometimes bloody because  Demonstrate behaviors
cough to improve or maintain Document the of infection. to improve or maintain
airway clearance. amount of sputum 2. Positioning may help lung airway clearance.
 Participate in treatment and character. expansion and decreases  Participate in treatment
regimen. 2. Place patient in a respiratory effort. regimen.
semi-fowlers 3. High fluid intake may help
position. Assist to thin secretions, making GOAL WAS MET.
client with them to expectorate.
coughing and
breathing exercise.
3. Maintain fluid
intake of at least Dependent:
2.5 liters unless
contraindicated. 1. Prevents drying
mucous membranes and helps
Dependent: thin secretions.
2. Bronchodilators
may help to improve oxygen
1. Humidify inspired
delivery and corticosteroids
oxygen.
may be useful in the presence
2. Administer
of extensive involvement with
medications:
profound hypoxemia.
Bronchodilators
and
Corticosteroids.