ASSESSMENT Subjective: Ma-plema at hirap akong huminga as verbalized by the patient Objective: -Frequent cough -Presence of wheezes during

auscultation -RR: 25cpm -Chest Xray & Sputum exam: Positive for PTB

DIAGNOSIS Ineffective airway clearance related to excessive and thickened mucus secretions secondary to disease process of pulmonary tuberculosis as manifested by: Subjective: Ma-plema at hirap akong huminga as verbalized by the patient Objective: -Frequent cough -Presence of wheezes during auscultation -RR: 25cpm -Chest Xray & Sputum exam: Positive for PTB

RATIONALE Microorganisms inhaled after having been released when infected person sneezes, coughs and talks

NSG GOAL Short term: After 15-30mins of nsg int., the patient will: -maintain airway patency -decrease secretions -decrease RR: 2123cpm Long term: After 8-10 hours of nursing care, client will be able to readily expectorate secretions and will have absence or decrease in episodes of dyspnea; decreased RR 12-20cpm

NSG INT 1. Monitor Vital Signs

RATIONALE 1. To obtain baseline data 2. To promote maximal inspiration

EVALUATION Short term: After 30mins of nsg int., the patient had: -maintained airway patency -decreased secretions -RR: 22cpm Long term:

2. Maintain high back rest

Aspiration of oropharyngeal secretions

3. Encourage deep breathing 4. Increase oral fluid intake

3. To maximize effort

Bacteria spreads in lungs and blood streams

4. To help liquefy secretions

5. Chest physiotherapy

Inflammatory response

Alveolar edema & exudate formation

6. Provide postural drainage and percussion.

Alveoli & respiratory bronchioles fill with serious

7. Maintain room or environment free from any

After 8 hours of nursing care, the goal is partially met as evidenced 5. Indirect by clients removal of participation to secretions breathing and coughing 6. Through the exercises and aid of gravity ability to and expectorate percussion sputum upon secretions evaluation; still are readily there are expelled. episodes of dyspnea as 7. Allergen claimed by the may trigger client; RR more 20cpm accumulatio

exudates, blood cells and fibrin bacteria

sorts of allergen.

n of secretion due to respiratory response.

Consolidation of lung tissue

Ineffective airway clearance Reference: Medical-Surgical by Brunner & Suddarths (p.677)