Gordon’s Health Pattern

HEALTH PERCEPTION/HEALTH MANAGEMENT NUTRITIONAL/METABOLIC ELIMINATION

RR= 26bmp
Cough x 2 weeks with difficulty breathing HR= 110 bpm
Low grade afternoon fever x 2 weeks with profuse BP= 127/75
nocturnal sweating T= 37.5C
X-ray showed infiltrated middle right lung with signs of Oxygen saturation 98%
cavitation Height : 137.16 cm
Sputum smear positive for mycobacterium tuberculosis Weight 49 kg
bacilli BMI: 26 (OVERWEIGHT)
Lost of appetite

ACTIVITY/EXERCISE ELIMINATION VALUE-BELIEF

Feels tired all the time

COGNITIVE/PERCEPTUAL SLEEP/REST SELF-PERCEPTION/SELF-CONCEPT

Expressed worry about treatment that he might not

afford the medicine.
Cannot smell food

ROLE/RELATIONSHIP SEXUAL/REPRODUCTIVE COPING/STRESS TOLERANCE

Married with 2 children Stated that it is his first time experiencing this kind of
illness but felt worried because he cough out blood.

NURSING CARE PLAN

Name of the Client: X Age/Sex: _32 M _ Ward: _____________ Room #: _________ Bed #: ______
Chief Complaint: __Cough x 2 weeks and difficulty breathing_____ Attending Physician: ____________________________
Admitting Diagnosis or Impression: __________________________________________________________________

Date Cues Need Nursing Diagnosis Patient Outcome Nursing Interventions Implementations Evaluation
/Time
Subjective: H Ineffective airway At the end of 8 hour A. Assess respiratory function 1 May 7, 2023 @ 3:00 pm
May * “makakapoy E clearance related to shift the patient will R: Physical examination may reveal Goal Met
7, ang mag ubo” A thick viscus and be able to : increased respiratory rate, After the 8 hour shift the patient
2023 L sometimes bloody * demonstrate irregular breathing rhythm, and was able to:
@ Objective: T secretions and poor effective clearing of additional breath sounds (Selvia et * demonstrate effective clearing of
7:00 * cough x 2 H cough effort as secretions without al., 2022). Diminished breath secretions without assistance.
am weeks with evidence by assistance. sounds may reflect atelectasis. * verbalized understanding of
dyspnea P abnormal * verbalize Rhonchi, wheezes indicate behaviors to improve or maintain
7-3 * thick, E respiratory rate and understanding of accumulation of secretions and airway clearance as instructed.
shift yellowish R dyspnea behaviors to improve inability to clear airways that may
viscous, and C or maintain airway lead to the use of accessory
sometimes E Domain 11 clearance as muscles and increased work of
bloody P Safety/Protection instructed. breathing.
phlegm T Class II Physical CATHRYNA MAE C. GAYLAN ST.N
* poor cough I Injury B. Note to the ability to 2
effort O NDx 00031 expectorate mucus and cough
* RR: 26 cpm N effectively document character,
* CXR showed / amount of sputum, and presence
infiltrate in H of hemoptysis.
middle right E R: Expectoration may be difficult
lung with A when secretions are very thick as a
signs of L result of infection and/or
cavitation T inadequate hydration. Blood-
* Sputum H tinged or frankly bloody sputum
smear exam results from tissue breakdown
positive for M (cavitation) in the lungs or from
mycobacteriu A bronchial ulceration and may
m tuberculosis N require further evaluation or
bacilli A intervention.
G
E C. Ascultate lungs fields 3
M R: Decreased airflow occurs in
E areas consolidated with fluid or
N secretions. Bronchial breath
T sounds can also occur in
N consolidated areas. Crackles,
rhonchi, and wheezes are heard
upon inspiration and expiration in
response to fluid accumulations,
thick secretions, and airway
obstruction.

D: Place client into semi-fowler’s 4

position or high-fowler’s position
R: Positioning helps maximize lung
expansion and decreases
respiratory effort. Maximal
ventilation may open atelectatic
areas and promote the movement
of secretions into larger airways for
expectoration.

E: Assist the client with coughing 5

and deep breathing exercises
R: Sputum in the airway can be
mobilized through coughing. A
study evaluation showed that after
effective physiotherapy and
coughing, there was a change in
breathing rhythm from irregular to
regular on the second day of the
afternoon session (Selvia et al.,
2022).

F: Clear secretions from mouth to 6

trachea
R: Clear secretions from mouth
and trachea; suction as necessary.
Suctioning prevents obstruction
and aspiration. Suctioning may be
necessary if the client is unable to
expectorate secretions. Persons
performing endotracheal
suctioning on clients who have
suspected or confirmed active
tuberculosis should wear
particulate respirators.

G: Maintain fluid intake of at least 7

2500 mL/day unless
contraindicated.
R: High fluid intake helps thin
secretions, making them easier to
expectorate.

H: Administer medications as 8
indicated
R: Mucolytic agents reduces the
thickness and stickiness of
pulmonary secretions to facilitate
clearance.

I: Administer humidified inspired 9

air and oxygen
R: This prevents the drying of
mucous membranes and helps thin
secretions. Humidifiers can reduce
the risk of the respiratory passages
being infected by mycobacterium
tuberculosis, the origin of the
disease.

J: Encourage well balanced diet 10

R: TB may cause a loss of appetite
and weight loss. Teach patients to
eat small frequent snacks if they
cannot tolerate larger meals. A
nutritious diet will help in
preventing malnutrition.