West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

Nursing
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Rationale Evaluation
Interventions
Ineffective airway Inability to clear Monitor vital signs To obtain progress on
clearance related to secretions or The client will be able especially the the health status of
the accumulation of obstructions from the to demonstrate respiratory rate (rate the pt.
exudates in the respiratory tract to effective airway and rhythm) and use
alveoli maintain airway. clearance as of accessory muscles
evidenced by
Tuberculosis is a coughing up of clear, Auscultate breath Bronchospasm is
reportable white sputum, sounds and air present with
communicable demonstrate movements. obstructions in the
disease. It is chronic effortless breathing airway and may be
and is characterized (deep inhalation and manifesting
by formation of shallow expiration adventitious
tubercles or having normal ABG breathsounds
granulomas in the levels
lungs.
The first time the Observe signs of Respiratory
client is infected with respiratory distress dysfunction is
Tb is said to be a (tachypnea/bradypne variable dependent
primary infection. The a,cyanosis) upon stage of chronic
sites of this primary process in addition to
infection are usually acute process that
located in the apices precipitated
or near of the pleurae hospitalization.
of the lower lobes.
The primary infection Position head at Elevation of head
site may undergo a midline with flexion facilitates respiratory
process of necrotic appropriate for age function by use of
degeneration (semi to high gravity and keeping
(caseation) which fowler’s) the head in midline
produces cavities opens and maintains
filled with a airway
cheeselike mass of
tubercle bacilli, dead Teach patient Provided the patient
WBCs and necrotic diaphragmatic or with means to cope
lung tissue. In time, pursed-lip breathing with and control
this material liquefies dyspnea and reduce
and may rain into the air-trapping.
tracheobronchial tree
and coughed as Observe characteristic Cough can be
sputum. of cough and assist persistent but
with measures to ineffective, especially
Sources: improve effectiveness if the patient is
Nurse’s Pocket Guide, of cough. elderly, acutely ill, or
Doenges 9th ed debilitated. It is
(2004) page 69 effective in an upright
or head-down
Harrison’s Principles position after chest
of Internal Medicine percussion.
11th Ed, Braunwald
Et.al Perform chest Postural drainage &
physiotherapy every percussion are an
Medical- after PAI important part of the
Surgical Nursing, treatment for removal
Polaski, Tatro of sticky secretions
and improve
ventilation of bottom
lung segments.

Collaborative:
Administer oxygen To provide oxygen
therapy via nasal supply that the body
prongs at 2.5 demands.
liters/min
Administer Decreases mucosal
bronchodilators, and edema and smooth
antibiotics as ordered. muscle spasm by
bronchodilation.

For control of
respiratory infections.

To prevent allergic
reaction by inhibiting
the release of
histamine, reducing
severity and
frequency of airway
spasm, respiratory
inflammation and
dyspnea.

Monitor ABGs, pulse Establish baseline for

oximetry and chest x- monitoring
ray. progression/regressio
n of disease process

Source:
Nursing Care Plans,
6th Ed, Doenges Et
al.