- The patient weight is 31.5 kilograms.
- Poor muscle tone.
- Appears weak.
- Minimal subcutaneous fat.
cough as evidenced by
decreased BMI. uses energy for voluntary activities such as
walking and in involuntary activities such as breathing. (Fundamentals of Nursing 7th ed by Kozier et al.)
Subjective:
- The husband verbalizes that her wife is easily getting tired. Her maximum work is one hour only, and then she would go to rest.
- Her usual activities is cleaning the house, cooking and washing the clothes. Their children help her wife.
Activity intolerance related to inadequate oxygen supply as evidenced by easy fatigability.
4 ➢ This nursing diagnosis is not life threatening and doesn’t need immediate attention, however, it can affect the body’s normal functioning
➢ Individuals who have inactive lifestyles or who are faced with inactivity because of illness or injury are at risk for many problems that can affect major body systems. Clients experience a
significant decrease in the muscular strength and agility whenever they do not maintain a moderate amount of physical activity. (Fundamentals of Nursing 7th ed by Kozier et al. p. 1068).
➢ Subjective:
- The patient regularly sleeps at 8:00pm and wakes up at 1:00 pm.
- She usually sits because according to her she can breath more easily.
- She takes a nap in the morning from 8 am to 11 am.
- She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough.
Sleep Deprivation related to prolonged physical discomfort (dyspnea) as evidenced by inability to concentrate
5 ➢ This condition doesn’t need immediate attention but needs to be addressed for sleep is a basic human need.
➢ A lack of rest for long periods can cause illness or worsening of existing illness. (Fundamentals of Nursing, 6th ed by Potter and Perry p. 1206)
A. Nursing Care Plan ASSESSMENT NURSING
DIAGNOSIS BACKGROUND
KNOWLDEGE GOAL and
OBJECTIVES NURSING
INTERVENTION RATIONALE EVALUATION
Subjective Cues:
- Patient verbalized,
“Matagal na akong inuubo.
Wala namang plema.
Nahihirapan akong huminga”.
Objective Cues:
- Presence of adventitious breath sound (Crackles) upon auscultation.
-The patient is coughing without phlegm.
- Oriented - GCS E4V5M6 - BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-31.5 C
- Difficulty vocalizing
- Has hallow eyes.
- Bluish nail beds.
Ineffective airway clearance related to
retained
secretions in the respiratory tract secondary to bacterial infection as evidenced by crackles upon auscultation.
Intermediate Cause:
- Retained secretions in the respiratory tract.
Intermediate Cause:
- Inflammatory response Root Cause:
- Bacterial infection of the respiratory system.
Health Implication:
This condition can cause Acute Respiratory Distress Syndrome (ARDS) which results from the combination of infection and inflammatory response. The lungs become quickly filled with fluid and become very stiff. This stiffness, combined with difficulties extracting oxygen due to the alveolar fluid
Goal:
Within 4 hours of nursing intervention, the patient will be able to maintain patent airway through the mobilization of secretions as evidenced by productive cough.
Objectives:
1. For 10 minutes, the relative will assess the physical
condition of the client by
accepting at least 4 nursing interventions to be done in the patient.
2. After 3 hours the client will be able to mobilize her secretions through the interventions done by the nurse at least 4.
3. After 50 minutes, the
Objective 1:
Independent-Facilitative:
1. Obtain vital signs of the patient.
2. Observe for respiratory rate and rhythm; presence of nasal flaring; and use of accessory muscles when breathing like the
diaphragm and coastal muscles.
3. Perform the Blanch Test.
4. Auscultate the lungs to note any lung
1. Suction secretion as
- Health status is regulated through homeostatic mechanisms. A change in V/S might indicate health change. (Taylor et.al, FON 5th ed. Page 523) -Nasal flaring and use of accessory muscles indicates increased effort is required for breathing.
- Blanch test reflects the adequacy of o2 circulation in the periphery.
-Crackles are intermittent sounds that occur when air moves through airway that contain fluids.
(Taylor et.al, FON 5th ed. Page 1386)
-Tapping the chest can loosen the secretions.
(Taylor et.al, FON 5th ed. Page 1251) -Suction removes secretions through the use of a strong
Effectiveness - Was the patient able to maintain patent airway?
-Was the patient able to mobilize her secretions?
-Was the patient able to have patent airway?
Adequacy -Was all the planned nursing interventions are enough in achieving and maintaining patent airway?
-Was all the resources of the nurse like time and effort are enough?
Appropriateness -Was the
interventions mentioned are applicable and beneficial to the patient?
Acceptability - Was the family willfully accepted the interventions done to the patient.
creates a need for ventilation.
Septic shock is one potential complication.
(Black, Medical Surgical Nursing 7th ed. Page 1896)
nurse will maintain patent airway of the patient through the
performance of at least 3 interventions.
needed.
2. Increase the amount of oral fluid intake as ordered by the doctor.
Dependent-Supplemental:
1. Administer bronchodilators as ordered.
2. Position the head in the midline of the body.
pressure.
- Current data indicates that fluid restriction may actually reduce blood volume and decrease cerebral circulation.
The lack of volume causes the blood to be thick and sluggish and may decrease the mobilization of nutrition and toxins out of the circulation.
Patient should be maintained in a
euvolemic state rather than a fluid-restricted state. (Black, MSN 7th ed. Page 2201) - They act on the respiratory tract, it opens narrowed airways.
(Black, MSN 7th ed.
Page 1652)
- For maximal lung expansion that will improve oxygen delivery.
-Position changes allow free movement of the diaphragm and expansion of the chest wall. (Taylor et.al, FON
5th ed. Page 1396)
Asessment Nursing
Diagnosis Background
Knowledge Goal And
Objectives Nursing
Interventions Rationale Evaluation
Subjective:
-The husband of the client
verbalized,
“Naku hindi na nawala ang lagnat ng asawa ko, pabalik-balik na lang”
Objective:
-Flushed skin;
warm to touch -Increase body temperature higher than normal range -Increased respiration -The patient is sweating -T: 37.5˚C
Hyperthermia related to inflammatory response as evidenced by warm to touch response of the body against microorganism s.
Intermediate Cause:
Infection of M.
Tuberculosis Root Cause:
Weakened immune system.
After 30 minutes of nursing
interventions, the client will be able to lessen
temperature of at least 1˚C range from that of 39˚C-41˚C to 38˚C-39˚C and be free of chills
1. After 1 minute of nursing
intervention, the family of the client will be able to assess for the causative/
contributing factor/s and be able to participate in one
intervention.
INDEPENDENT
• Identify
underlying cause (eg.
hypothalamic
dysfunction, such as drug overdose and infection).
INDEPENDENT
• Monitor patient’s
• To know for the right treatment to be given.
• Temperature of 102˚F- 106˚F (38.9˚C-
EFFECTIVENESS
1. After 1 minute of nursing
intervention, was the family of the client able to assess for the causative/
2. After 12 minutes of nsg. Int., was the family of the client able to evaluate effects of
hyperthermia and able to participate in at least 5 out of 7
Health Implication:
Fevers of 104 F (40 C) or higher demand immediate home
treatment and subsequent medical attention, as they can result in delirium and convulsions, particularly in children.
2. After 12
minutes of nursing interventions, the family of the client will be able to evaluate effects of hyperthermia and be able to
participate in at least 3 out of 4 interventions.
vital signs. Give particular attention to the temperature.
• Assess for
presence of posturing or seizures.
• Monitor/ record all sources of fluid loss such as urine.
• Note presence/
absence of sweating as body attempts to increase heat loss by evaporation, conduction and diffusion.
DEPENDENT
• Administer
41.1˚C) suggests acute infectious
disease process. Fever pattern may aid in diagnosis; eg 24 hour period suggest septic episode, septic endocarditis or Tuberculosis (TB).
Chills often precede temperature spikes.
[Nursing Care Plans Edition 6, page 667.
Copyright 2002 by Marilyn E. Doenges, RN, BSN, MA, CS]
• To note for further care to be given.
• Oliguria and/or renal failure may be occurring due to hypotension,
dehydration. [NANDA]
• Evaporation is decreased by
environmental factors of high humidity and high ambient
temperature as well as body factors producing loss of ability to sweat or sweat gland
dysfunction. [NANDA]
interventions?
Yes____
No_____
Why_____
3. After 15 minutes of nursing
intervention, was the family of the client able to assist with measures to reduce body temperature and participate in at least 6 out of 7 the client able to attain wellness after the 2 interventions?
Yes____
No_____
3. After 15
minutes of nursing interventions, the family of the client will be able to assist with measures to reduce body temperature and participate in at least 3 out of 4 interventions.
antipyretics.
INDEPENDENT
• Provide tepid sponge baths; avoid use of alcohol.
DEPENDENT
• Administer replacement fluids and
• Used to reduce fever by its central action on the
hypothalamus; fever should be controlled in patients who are neutropenic or asplenis. However, fever may be
beneficial in limiting growth of organisms and enhancing autodestruction of infected cells.
[Nursing Care Plans Edition 6, page 667.
Copyright 2002 by Marilyn E. Doenges, RN, BSN, MA, CS]
• May help reduce fever. Note:
use of ice water/
alcohol may cause chills, actually elevating temperature. In addition, alcohol is very drying to skin.
[Nursing Care Plans Edition 6, page 667.
Copyright 2002 by Marilyn E. Doenges,
Why_____
Efficiency:
Were interventions done within the time frame? realistic to the norms? accepted by the client and his family?
___Yes ___ No, Why?
_______________
4. After 2 minutes of nursing
intervention, the family of the client will be able to promote wellness and give 2 out of 2 interventions.
electrolytes.
• Provide high-calorie diet, tube feedings or parenteral nutrition.
INDEPENDENT
• Discuss
importance of adequate fluid intake.
• Review signs and symptoms of
hyperthermia (eg.
Flushed skin, increased body temperature, increased
respiratory/heart rate).
RN, BSN, MA, CS]
• To support circulating volume and tissue perfusion.
[NANDA]
• To meet
increased metabolic demands.
[NANDA]
• To prevent dehydration. [NANDA]
• Indicates need for prompt
intervention.
Adequacy:
Were all the plans adequate? ___Yes ___ No, Why?
A. Discharge Planning
Medications Continue Taking the Anti-TB drugs. The intensive phase is for 2 months and the maintenance phase is for 4 months. Medicines are readily available at the health center.
Exercise/Economic Factor Practice deep breathing exercise and coughing exercises. Resume previous activities. Prevent extraneous work. Have a regular physical exercise like brisk walking for 30 minutes daily. For financial insufficiency, there are government drug stores available. The patient may continue her work in the factory.
Treatment Follow faithfully the regimen for tuberculosis, especially the medications. Have a regular sputum test, as ordered by the doctor.
Health Teaching You should practice hand washing regularly. Always cover the mouth and the nose when exposed to person who coughs or sneezes. You should not spit anywhere, instead spit in a single container to prevent transfer of M. Tuberculosis.
Out patient Follow-up Always have a regular check up at your nearest health center, at least once a week to monitor the progress of the treatment. The client should report immediately to the physician if there is difficulty of breathing, there is productive cough more than 5 days and there is chest pain and experiencing fatigue.
Diet The diet should be high caloric. Always drink a lot of water. Also eat fruits and vegetables. Don’t escape meals.
If there are any food supplements available, consult it with the doctor. Eat vitamin c rich food to strengthen immune systems.
Spiritual/Sexual Activities Always pray for the guidance of the Lord. Spiritual health affects the wellness of an individual greatly.
Strengthen relationship with Lord by showing love and respect to the people around you.