TUBERCOLOSIS

Nama kelompok:

Tara Puteri Rizkiyah(21116056)

Sarah Devi (21116048)
No DIAGNOSA NOC NIC

1. The ineffectiveness Label : respiratory status : patency Label : airway management

of cleaning the of the airway Activities :
breath is related to After 2x24 hour nursing action, the 1. Position the patient to maximize
the accumulation of client’s airway is expected to be ventilation
secret effective again with an indicator 2. Dispose of secret by motivating the
scale : patient to cough or suck mucus
No Indicator A T 3. Instruck how to be able to effetively
cough
1. Respiratory 3 5 4. Position to relieve shortness of breath
frequency 5. Monitor respiratory status and
2. Respiratory rythm 4 5 oxygenation, as appropriate
3. Depth of 3 5
inspiration
4. Ability to release 4 5
secretion

Indicator scale :
1 a weight deviciation from the
normal range
2 a fairly-sufficiently severe
deviation from the normal
range
3 a moderate deviation from the
normal range
4 a mild deviation from the normal
range
5 no normal range deviation
NO DIAGNOSA NOC NIC

2. Acute pain is associated Label : level of pain Label : environmental management :

with persistent cough After nursing action for 2x24 hours convenience
and lung inflamation it is expected that the client’s pain Activities :
will decreases with the indicator 1. Provide separate rooms if there is
scale : a frequency and need for patients
No Indicator A T ( and families) to get calm and
1. Reported pain 3 5 rest if possible
2. Avoid interference that does not
2. Length of episode 3 5 persist and give time to rest
of pain 3. Create a supportive environment
3. Expression of 4 5 4. Provide a safe and clean
facial pain environment
5. Provide choices able to carry out
4. Unable to rest 3 5 activities and sosial visits

Indicator scale :
1 weight
2 quite heavy
3 moderate
4 mild
5 none
NO DIAGNOSA NOC NIC

3. Sleep disturbances Label : sleep Label : increased sleep

associated with shortness After 2x24 nursing actions it is Aktivities :
of breath and coughing expected that sleep can be effective 1. Determine sleep patterns or
again with an indicator scale : patient activities
2. Ertimate the patient sleep or
NO Indicator A T wake cycle according to
planning care
1. Hours to sleep 4 5 3. Monitor or record the patient
sleep patterns and the
2. Sleep patterns 3 5
amount of sleep
3. Sleep quality 3 5 4. Adjust the environment (eg,
light, noise, temperature,
4. Regular sleep 4 5 mattresses and beds) to
improve sleep.
Indicator scale : 5. Help to eliminate stressful
1 verry disturbed situations before going to bed
2 much disturbed
3. Quite disturbed
4 slightly disturbed
5 not disturbed