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Assessment

Nursing Diagnosis

NURSING CARE PLAN FOR PULMONARY TUBERCULOSIS


Inference
Outcome
Nursing
Rationale
Interventions

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

Cough is the most


common symptom of
pulmonary
tuberculosis. It may
produce yellowish or
greenish colored
sputum especially
during the day.
Eventually, the
sputum may be
streaked with blood.
Furthermore, a
person with PTB
may experience
fatigue and loss of
energy. It may affect
his or her ability to
expectorate
secretions, too. Aside
from that, difficulty
of breathing signifies
that there may be an
accumulation of
secretion in the
bronchial cavity of
the lungs.

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.

-Place client in high


fowlers position and
encourage reposition
every two hours.

- 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.

-Warm fluids help in


loosening the
secretions while cold
liquids triggers
cough more often.

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.

- Through the aid of


gravity and
percussion secretions
are readily expelled.
- It provides baseline
data for future
comparison in the
evaluation of disease
condition.
- PTB can be
transmitted through
droplet inhalation
and 6 months
compliance to
medication is needed
in order to be treated
with it.