Name of Patient: Patient X Age: Ward: Bed#:

Chief Complaint: cough for more than 2 weeks and difficulty in breathing Diagnosis: Pulmonary Tuberculosis
Physician:
Date/
Time Cues Need Nursing Patient Outcome Nursing Implementation Evaluation
Diagnosis Intervention
Subjective Health Ineffective Within 8 hours of  Explain to the .
 Experienced low Perception- airway clearance nursing patient on
grade afternoon Health related to intervention: how to cough 2
fever for 2 weeks Management Pulmonary and breathe
Pattern Tuberculosis as  Patient will properly
 First time to evidenced by exhibit R: Patient will
experience this kind difficulty of increased gas understand the
of illness and breathing exchange techniques to 3
worried about the keep the airway
treatment due to R: Pulmonary  Secretions will clear
financial constraints tuberculosis (TB) be coughed up
is a bacterial by the patient.  Encourage
infection of the
patient to
Objective lungs that can 4
drink more
 Admitted to the cause chest pain,
water
hospital due to dyspnea, and
R: Fluid intake
cough for more than severe coughing.
helps to prevent
2 weeks and dryness of throat
difficulty of breathing 1
 Productive  Inform the
coughing; poor patient to
cough effort have light
 Looks older than activities
stated age R: Coughing
 Diagnosed with requires enough
Pulmonary energy and may
Tuberculosis consume an
extra effort to the
patient
 Encourage
the patient to
take a few
deep breaths.
R: This helps the
patient suggest
use of deep
breathing
exercise and
relaxtion
technique