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CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY

COLLEGE OF NURSING

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION


(Subjective & (Dependent,
Objective) Independent &
Collaborative)
Subjective: Ineffective breathing PTB occurs when M. After 6 hours of nursing Independent: >Maintaining the After 6 hours of nursing
“naa mani sha pattern related to tuberculosis primarily interventions, the >assessed airway for airway is always the interventions, the
pneumonia sir” as fatigue secondary to attacks the lungs. patient will be able to: patency first priority, especially patient was able to
verbalized by the pneumonia A person with PTB may >Sustain respiratory in cases of trauma, display patency of
patient. experience fatigue and rate within normal acute neurological airway as manifested
Objective: loss of energy. It may range: RR= 12-20 cpm decompensation. by:
>Decreased breath affect her ability to >Tolerate performance >auscultate lungs for >These may indicate >Patients’ RR is within
sound expectorate secretions. of simple, day to day presence of normal or presence of mucus plug normal range: RR=20
>Crackle sound noted Aside from that, activities. adventitious breath cpm
>Elevated shoulders difficulty in breathing >Demonstrate proper sounds >secretions decreased
>Decreased fremitus signifies that there may breathing exercises. -decreased breath >these may indicate >Patients’ fatigue was
>Vital Signs: be an accumulation of >Decrease fatigue sound increase airway alleviated.
R= 25 cpm secretions in the resistance
BP= 110/80 mmHg bronchial cavity of the -coarse sounds >These may indicate
lungs. Collaborative: fluid along larger
Administer medications airways.
Source: Medical as prescribed by the
Surgical Nursing 13th physician.
edition by Brunner and
Siddhart