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Name of Patient : Mr.

Edgardo Durano Age : 53 years old Sex : Male Impression: COPD with probable Pneumonia vs PTB vs CRF

Room # : IsoM4( Basement Ward) Date of Admission: Sept. 27,2010 Complaints: Cough Physician: Dr. Nelson G. Chu

Nursing Care Plan


Problem/Cues Nursing Diagnosis Scientific Basis Objectives of Care Nursing Interventions Rationale

Physiologic overload: Cough

Ineffective airway clearance related to Objective retained Cues: tracheo- productive bronchial cough with secretions yellowish as to whitish manifested sputum by thick - dullness viscous over right sputum and left lung field - hollow eyes - presence of adventitiou s breath sounds Vital Signs: T- 36.1C P- 103bpm R-24cpm BP110/80mmhg

Copious secretions obstructs the airways of many patients with tuberculosis and interfere with adequate gas exchange. Constriction of bronchioles contributes to difficulty in breathing due to airway passages is narrowed.

After 8 Measures to hours of expectorate holistic ecretions nursing easily: care the patient will 1. Monitore be able to d vital expectorate signs secretions particular readily as ly on RR to achieved patient airway 2. Noted ability to expectora te mucus/co ugh effectivel y (character, amount, presence of hemoptysis) 3. Placed patient in high fowlers position.

1. Serves as baseline data (Source: Nurses Pocket Guide Doenges) 2. Expectoratio n maybe difficult when secretions are thick as a result of infection (Source: Nurses Pocket Guide Doenges) 3. Promotes optimal chest expansion and drainage of

Subjective Cues: Gi sige pa man kug ubo day nya naa

Source: MedicalSurgical Nursing Smeltzer Vol. 1 11th edition

jud plema

secretions. (Source: Nurses Pocket Guide Doenges) 4. Assisted in coughing and breathing exercise. Cleared secretions from mouth and trachea 4. Prevents obstruction / aspiration and promotes lung expansion. (Source: Nurses Pocket Guide Doenges)

5. Maintaine 5. High fluid d fluid intake intake helps atleast secretion 2500ml/da making y them to expectorat e easily (Source: Nurses Pocket Guide Doenges) 6. Alternated 6. Because it care compensate activities for with increased periods of 02 demand rest required by activity (Source: Nurses Pocket Guide Doenges) 7. Administered broncho7. It relieves bronchoconstrictio

dilators as n prescribed (Source: Nurses Pocket Guide Doenges

Name of Patient : Mr. Edgardo Durano Age : 53 years old Sex : Male Impression: COPD with probable Pneumonia vs PTB vs CRF

Room # : IsoM4( Basement Ward) Date of Admission: Sept. 27,2010 Complaints: Cough Physician: Dr. Nelson G. Chu

Nursing Care Plan Problem/Cues Nursing Diagnosis Scientific Basis In a patient with tuberculosis dyspnea is always accompanied by chest pain, crackles and productive cough; this is due to constriction of airways that result to insufficient delivery of 02 in the lungs Objectives of Care After 8 hours of holistic nursing care the patient will be able to establish a normal and effective respiratory pattern Nursing Interventions Measures to establish patent airway: 1. Encouraged 1. To assist slower and client in deeper restaking pirations. control the situatio n (Source: Nurses Pocket Guide Doenges) 2. Maintained calm attitude while dealing with the client 2. To limit level of anxiety (Source: Nurses Pocket Guide Doenges) Because this may cause abdomi -nal distenti Rationale

Physiologic deficit: Dyspnea

Ineffective breathing pattern related to Objective insufficient Cues: supply of - shortness of 02 as breath evidenced - difficulty in by breathing difficulty in - nasal flaring breathing - altered chest excursion - lying in high fowlers position - 02 sat of 8788% @ 2L/min

Subjective Cues: Maglisod pa man kug ginhawa day murag kuwang pa ang oxygen

Source: Signs and symptoms a 2n1 reference for nurses Lipincott and Wilkins

3. Instructed to 3. avoid over eating gas forming foods

on (Source: Nurses Pocket Guide Doenges) 4. Encouraged 4. To adequate ret limit periods fatigue between (Source: activities Nurses Pocket Guide Doenges) 5. Assisted client in relaxation techniques (breathing exercise) 5. To promot e relaxati on (Source: Nurses Pocket Guide Doenges) 6. To clear secretion s (Source: Nurses Pocket Guide Doenges)

6. Suctioned airway as needed.

7. Adminis7. This tered oxygen help to as ordeed support clients respirati on (Source: Nurses Pocket Guide

Doenges

Name of Patient : Mr. Edgardo Durano Age : 53 years old Sex : Male Impression: COPD with probable Pneumonia vs PTB vs CRF

Room # : IsoM4( Basement Ward) Date of Admission: Sept. 27,2010 Complaints: Cough Physician: Dr. Nelson G. Chu

Nursing Care Plan Problem/Cues Nursing Diagnosis Scientific Basis Increased capillary permeability allows plasma protein to leak into interstitial space wherein the protein exerts its pulling effect, causing interstitial edema Objectives of Care After 8 hours of holistic nursing care the patient will be able to stabilize fluid volume as evidenced by free of signs of edema Nursing Interventions Measures to minimize/reduce edema 1. Monitored weight 1. Serves as compara -tive baseline (Source: Nurses Pocket Guide Doenges) 2. To prevent peak in fluid level (Source: Nurses Pocket Guide Doenges) 3. To calculat e fluid balance (Source: Nurses Pocket Rationale

Physiologic deficit: Edema

Fluid volume excess related to Objective Cues: increased - Edema on capillary both feet permeability - Decreased hgb=6.9g/dl - Decreased hct=23.4 - Decreased urine output - Decreased albumin= 14.3mg/dl

2.

Monitored fluid intake

Subjective Cues: Nang-hupong man ako tiil day banhud gani kung mabitay

Source: MedicalSurgical Nursing health and illness perspectives vol.1 8th edition

3.

Recorded I and O

Guide Doenges) 4. Elevated feet 4. To allow circulat ion (Source: Nurses Pocket Guide Doenges) Provided 5. To quiet minimi environment ze anxiety (Source: Nurses Pocket Guide Doenges) Changed the 6. To patients reduce position tissue pressur e and risk of skin breakd own (Source: Nurses Pocket Guide Doenges) Administered 7. It aids diuretics as in prescribed formati on and excretio n of urine (Source:

5.

6.

7.

Nurses Pocket Guide Doenges

Name of Patient : Mr. Edgardo Durano Age : 53 years old Sex : Male Impression: COPD with probable Pneumonia vs PTB vs CRF

Room # : IsoM4( Basement Ward) Date of Admission: Sept. 27,2010 Complaints: Cough Physician: Dr. Nelson G. Chu

Nursing Care Plan Problem/Cues Nursing Diagnosis Scientific Basis Patients with Tuberculosis are often debilitated from prolonged chronic illness and impaired nutritional status. Due to persistent coughing and sputum production it causes fatigue, anorexia, and weight loss to the patient Objectives of Care Nursing Interventions Rationale

Physiologic deficit: Fatigue

Objective Cues: - Weak - Inability perform activities alone - Body malaise - Slightly irritable - Always lying in bed sleeping

Activity intolerance related to imbalance between 02 supply and demand as to evidenced by fatigue

After 8 Measures to hours of relieve fatigue: holistic nursing 1. Adjusted care the activities patient will be able to participate actively and willingly to desired activties 2.

1. To prevent overexertion (Source: Nurses Pocket Guide Doenges)

Subjective Cues: Kapoy man day di ko ganahan mo lihok

Increased 2. To exercise/ac conserve tivity energy gradually (Source: Nurses Pocket Guide Doenges) Provided rest periods between activities 3. To prevent fatigue (Source: Nurses Pocket Guide Doenges) 4. To protect

3.

Source: MedicalSurgical Nursing Smeltzer Vol. 1 11th edition

4. Assisted

with activities and provided assistive devices

client from injury (Source: Nurses Pocket Guide Doenges) 5. Enhance ability to participa te in activities (Source: Nurses Pocket Guide Doenges)

5. Promoted comfort measures and provided relief of pain

6. To prevent 6. Assisted injuries client in (Source: learning and Nurses demonsPocket trating Guide appropriate Doenges) safety measures 7. To enhance 7. Encourage sense of d client to well maintain being positive (Source: attitude; Nurses suggested Pocket use of Guide relaxation Doenges techniques (visualization, guided imagery)

Name of Patient : Mr. Edgardo Durano Age : 53 years old Sex : Male Impression: COPD with probable Pneumonia vs PTB vs CRF

Room # : IsoM4( Basement Ward) Date of Admission: Sept. 27,2010 Complaints: Cough Physician: Dr. Nelson G. Chu

Nursing Care Plan Problem/Cues Nursing Diagnosis Scientific Basis The patients willingness to eat may be alter by fatigue from coughing and sputum production. Due to interruption upon eating or from metallic taste, the patients ability to eat food is reduced Objectives of Care Nursing Interventions Rationale

Imbalanced nutrition: less than body Objective Cues: requirements related to - Pale persistent conjunctiva - Pale mucous cough and mucus membrane - Poor muscle production tone - Decreased capillary - Loss of appetite - Loss of hair - Sore tonsils Physiologic deficit: Loss of appetite

Measures to After 8 increase hours of appetite: holistic nursing 1. Monitored care the weight patient will be able to exhibit gradual lifestyle change as evidenced by increase appetite

1. Serves as compara -tive baseline (Source: Nurses Pocket Guide Doenges)

Subjective Cues: Sige lang kug ubo day mao wa nakoy gana mukaon

Source: MedicalSurgical Nursing Smeltzer Vol. 1 11th edition

2. Discussed 2. To eating habits, appeal including patients food likes preference and dislikes (Source: Nurses Pocket Guide Doenges) 3. Promoted pleasant relaxing environment 3. To enhan ce intake (Source:

Nurses Pocket Guide Doenges) 4. Prevented/ minimize unpleasant odor 4. May have negativ e effect on appetite (Source: Nurses Pocket Guide Doenges) 5. To increase appetite (Source: Nurses Pocket Guide Doenges) 6. To improv e body weight (Source: Nurses Pocket Guide Doenges)

5. Provided oral care before and after meals

6. Instructed small meals and snacks

7. Provided 7. To adequate rate prevent and timely dehydra fluid intake tion (Source: Nurses Pocket Guide Doenges