CUES NURSING RATIONALE GOAL NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

SUBJECTIVE: Ineffective Immediate cause: Goal: After 8 hours After 8 hours of

airway Ineffective airway of nursing nursing
 Subjective: clearance clearance interventions, interventions,
“Nahihirapan related to the patient will did the patient
ako retained Intermediate demonstrate demonstrated
huminga” as secretions cause: behaviors to adequate and
verbalized by Cough and improve airway patent airway?
the
secretions clearance or
patient.
adequate and
OBJECTIVE: Root cause: patent airway.
RR: 28 PTB
HR: 91
Tuberculosis is an Objectives: INDEPENDENT:
infectious disease • To maintain Elevate head of Elevation of the
caused by TB adequate, the bed, have bed facilitates
bacteriaa patent, patient lean on respiratory
(Mycobacterium airway overbed table or function by use
tuberculosis) that sit on edge of the of gravity.
primarily affects bed.
the lungs. This
condition is known Keep
as pulmonary environmental Precipitators of
tuberculosis pollution to a allergic type of
(PTB). You may minimum like respiratory
also have dust, smoke and reactions that
tuberculosis in the feather pillows, can trigger or
bones, meninges, according to exacerbate
joints, genito- individual onset of acute
urinary tract, liver, situation. episode.
kidneys, intestines
and heart and this
is called extra-
pulmonary
tuberculosis.
Encourage or Provides patient
assist with with some
abdominal or means to cope
pursed lip with or control
breathing dyspnea and
exercises. reduce air
tapping.

• To mobilize Encourage deep- To maximize effort

secretions. breathing and
coughing exercises.

Encourage/support To improve lung

reduction/cessation function.
of smoking.

• To promote Encourage/provide To prevent or reduce

wellness. opportunities for fatigue.
rest; limit activities
to level of
respiratory
tolerance.

To reduce the
DEPENDENT: viscosity of
secretions.
Administer
expectorants/
Bronchodilators
as prescribed.