Beruflich Dokumente
Kultur Dokumente
Nursing Diagnosis
Evaluation
Subjective:
I had this recurrent
cough for almost a
month now and it
seems that I am
having difficulty in
breathing at times...)
verbatim of client.
Objective:
RR= 23 breaths/ min
PR= 95 beats/min
T= 37.5 degree
Celsius
Easy fatigability
Productive cough
Chills at night
Loss of appetite as
claimed
Chest X- ray and
sputum examination
revealed positive for
pulmonary
tuberculosis
Ineffective Airway
Clearance related to
presence of
bronchial infection
and secretion
After 8 hours of
nursing care, client
will be able to
readily expectorate
secretions and will
have absence or
decrease in
episodes of
dyspnea.
-Maintain infection
control through the
use of mask and
performance of hand
washing before and
after contact with
client.
- Maintain room or
environment free
from any sorts of
allergen.
- Teach and
encourage deep
breathing and
coughing exercises.
-Emphasize to
increase fluid intake
depending on
individual tolerability
or as indicated.
- Instruct to take
warm liquids instead
of cold ones.
-PTB is transmitted
via droplet inhalation
so proper precaution
should be performed
to avoid transmission
to other clients.
- Elevating the head
of the bed and
turning client every
two hours help in
decreasing the
pressure placed on
the diaphragm.
- Allergen may
trigger more
accumulation of
secretion due to
respiratory response.
- These exercises
hasten the expulsion
of sputum and aids in
maintaining airway
patency.
- Fluids help loosen
secretion in the
lungs.
After 8 hours of
nursing care, the
goal is partially met
as evidenced by
clients participation
to breathing and
coughing exercises
and ability to
expectorate sputum
upon evaluation; still
there are episodes of
dyspnea as claimed
by the client.
-Provide postural
drainage and
percussion.
-Monitor breathing
patterns and breath
sounds.
-Educate client and
family about disease
condition and the
need for compliance
with the therapeutic
regimen.