NURSING CARE PLAN

DATE/ ASSESSMENT NURSING DIAGNOSIS PLAN OF NURSING INTERVENTION EVALUATION

SHIFT CARE
S/O Ineffective airway Within 8 hours 1. Auscultated
J - with O2 clearance related to span of nursing breath sounds & assessed air
A inhalation retained secretions care will be able movement to ascertain
N via nasal secondary to PTB. to: status & note progress.
U cannula 2. Elevated head of
A - crackling PTB is a chronic, a.) expectorate the bed/change position every
R sound recurrent, infection caused secretions 2 hours & prn to take
Y heard by some bacteria. The advantage of gravity
upon lung common TB popular in the b.) demonstrate decreasing pressure on the
24-26, aus- Philippines & other Asian intervention diaphragm & enhancing
cultation countries is Pulmonary such as deep drainage of ventilation to
2 - intermitte (lung), due to M. breathing diff. lung segments.
0 nt cough Tuberculosis. A person 3. Encouraged deep
1 noted who acquired this kind of breathing & coughing
0 - unpro- bacteria from a person by exercise
ductive sneezing, coughing, promotes optimal chest
cough talking, will enter to the expansion & drainage of
- weak lungs and may grow to secretions.
- RR- produce secretions. These 4. Encouraged
24bpm secretions may lodge to increase fluid intake
airways if not coughed up. ®to help liquefy secretions
There will be an 5. Encouraged/provi
ineffective airway ded warm versus cold liquids
clearance. as appropriate.
6. Provided
supplemental humidification,
if needed (nebulizer, O2
inhalation)
7. Provided back
tapping after nebulization to
move the secretions in the
lungs.