Nursing Care Plan

Px’s Name: july ann Cadion Diagnosis: Pulmonary

Tuberculosis
Age: 27y/o Gender: female Room#: 7 pay2ward

ASSESSMENT DIAGNOSIS PALNNING INTERVENTION RATIONALE EVALUATION

Subjective: ` Ineffective Short term goal: • Assessed • Provides a basis ` At the end of
airway clearance respiratory for evaluating the shift, the
“Difficulty of related to poor During my 6hrs rate. adequacy of client was able to
breathing” c/c. cough effort nursing ventilation. display patency
Persistent cought possibly intervention, the of airway as
evidence by client will be able manifested by:
Objective: abnormal breath to: • Noted chest • Use of
sounds and movement; accessory • Client’s
• Abnormal dyspnea. • Sustain use of muscles of respiratory rate is
breath respiratory accessory respiration may within normal
sounds: wet rate within muscles occur in response range: RR-19
crackles. normal during to ineffective bpm.
range: RR = respiration. ventilation.
• Dyspnea; 12-20 cpm. • Secretions
use of • Crackles decreased.
accessory • Display indicate
muscles for decreasing • Auscultated accumulation of • Client’s
respiration: amount of breath secretions and restlessness was
elevated secretion. sounds; inability to clear alleviated and
shoulders. noted areas airways. remained calm.
• Allay with
• Restless restless- presence of • Expectorations
ness. adventitiou may be different
• Vital signs: s sounds. when secretions
are very thick.
BP - 90/60 Long term goal:
hhmg • Documente
Tº - 36.5ºc During the d • Positioning
RR - 26 cpm client’s stay at respiratory helps maximize
PR - 75 bpm the hospital he secretions: lung expansion.
will be able to character
maintain patent and amount • To maintain
airway as of sputum. adequate airway
evidenced by: patency.
• Maintained
• Normal patient on
respiration as moderate
evidenced by high back
absence of rest.
dyspnea and
adventitious • Checked for
breath sounds obstruction
(wet crackles). s:
accumulatio
• Normal n of
breathing secretions.
pattern: RR = 12-
20 cpm. • Take
medications
• Absence of as ordered
bronchial by the
secretions. physician.

• Allay restless-
ness