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Tuberculosis Nursing Care Plan - Ineffective Airway Clearance

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					                                                           NURSING CARE PLAN FOR PULMONARY TUBERCULOSIS
    Assessment           Nursing Diagnosis           Inference        Outcome          Nursing     Rationale                                            Evaluation
                                                                                    Interventions
Subjective:
                         Ineffective Airway      Cough is the most       After 8 hours of       -Maintain infection       -PTB is transmitted      After 8 hours of
“I had this recurrent    Clearance related to   common symptom of        nursing care, client   control through the       via droplet inhalation   nursing care, the
cough for almost a           presence of        pulmonary                will be able to        use of mask and           so proper precaution     goal is partially met
month now and it         bronchial infection    tuberculosis. It may     readily expectorate    performance of hand       should be performed      as evidenced by
seems that I am             and secretion       produce yellowish or     secretions and will    washing before and        to avoid transmission    client’s participation
having difficulty in                            greenish colored         have absence or        after contact with        to other clients.        to breathing and
breathing at times...)                          sputum especially        decrease in            client.                   - Elevating the head     coughing exercises
– verbatim of client.                           during the day.          episodes of                                      of the bed and           and ability to
                                                Eventually, the          dyspnea.                                         turning client every     expectorate sputum
Objective:                                      sputum may be                                   -Place client in high     two hours help in        upon evaluation; still
                                                streaked with blood.                            fowler’s position and     decreasing the           there are episodes of
RR= 23 breaths/ min                                                                             encourage reposition      pressure placed on       dyspnea as claimed
PR= 95 beats/min                                Furthermore, a                                  every two hours.          the diaphragm.           by the client.
T= 37.5 degree                                  person with PTB
Celsius                                         may experience                                                            - Allergen may
Easy fatigability                               fatigue and loss of                                                       trigger more
Productive cough                                energy. It may affect                           - Maintain room or        accumulation of
Chills at night                                 his or her ability to                           environment free          secretion due to
Loss of appetite as                             expectorate                                     from any sorts of         respiratory response.
claimed                                         secretions, too. Aside                          allergen.                 - These exercises
Chest X- ray and                                from that, difficulty                                                     hasten the expulsion
sputum examination                              of breathing signifies                          - Teach and               of sputum and aids in
revealed positive for                           that there may be an                            encourage deep            maintaining airway
pulmonary                                       accumulation of                                 breathing and             patency.
tuberculosis                                    secretion in the                                coughing exercises.
                                                bronchial cavity of                                                       - Fluids help loosen
                                                the lungs.                                                                secretion in the
                                                                                                -Emphasize to             lungs.
                                                                                                increase fluid intake
                                                                                                depending on
                                                                                                individual tolerability   -Warm fluids help in
                                                                                                or as indicated.          loosening the
                                                                                                                          secretions while cold
                                                                                                - Instruct to take        liquids triggers
                                                                                                warm liquids instead      cough more often.
                                                                                                of cold ones.
                       - Through the aid of
                       gravity and
-Provide postural      percussion secretions
drainage and           are readily expelled.
percussion.
                       - It provides baseline
                       data for future
-Monitor breathing     comparison in the
patterns and breath    evaluation of disease
sounds.                condition.

-Educate client and    - PTB can be
family about disease   transmitted through
condition and the      droplet inhalation
need for compliance    and 6 months
with the therapeutic   compliance to
regimen.               medication is needed
                       in order to be treated
                       with it.