Assessment Diagnosis Planning Intervention Rationale Evaluation
Objective Data: Nutrition: After 8 hours of 1. Document Useful in After 8 hours
Weight - 10 kg imbalanced, less NSG Intervention patient’s defining of NSG
Loss of than body the px will be; nutritional degree or Intervention
appetite requirements status on extent of the px was;
May be related to Demonstrate admission, problem and
Weight 10%– Fatigue progressive weight noting skin appropriate 1.Seen
20% below Frequent gain toward goal turgor, choice of independe
ideal for frame cough/sputum with normalization current intervention ntly eating
and height production; of laboratory weight and s. and ready
Reported lack dyspnea values and be free degree of to gain
of interest in Anorexia of signs of weight loss, nutritional
food, altered Insufficient malnutrition. integrity of weight.
taste sensation financial resources Initiate oral mucosa,
Poor muscle to behaviors/lifestyle ability or
ne changes to regain inability to
and/or to maintain swallow,
appropriate weight. presence of
bowel tones,
history
of nausea an
d vomiting
or diarrhea.
2. Investig
ate May affect
anorexia dietary
and nausea choices
and and
vomiting, identify
and note areas for
possible problem
correlation solving to
to enhance
medication intake and
s. Monitor utilization
frequency, of
volume, nutrients.
consistency
of stools.
3.Encourage
and provide
for frequent
rest periods.
Helps
conserve
energy,
especially
when
metabolic
requirement
s are
increased
by fever.
4. Provide
oral care
before
and after Reduces
respirator bad taste
y left from
treatment sputum
s. or
medicati
ons used
for
respirato
ry
treatmen
5.Encourage ts that
small, can
frequent
meals with
stimulate
foods high in the
protein and vomiting
carbohydrat
center.
es.
Maximizes
nutrient
intake
without
undue
fatigue/ener
gy
6. expenditure
Encourag from eating
e SO to large meals,
and reduces
bring
gastric
foods irritation.
from
home
and to
share
meals
with
patient Creates a
unless more
contraind normal
icated. social
environm
ent
during
7.Refer to mealtime
dietitian for , and
adjustments
helps
in dietary
composition. meet
personal,
cultural
preferen
ces.
Provides
assistance in
planning a
diet with
nutrients
adequate to
meet
patient’s
metabolic
requirement
s, dietary
preferences,
and financial
resources
post
discharge.
Assessment: Objective Data: presence of dry wounds both on upper and lower extremities
Diagnosis: Risk for infection
Planning: After 8 hrs. of NSG Intervention the px will be able to avoid and prevent infection.
Evaluation: After 8 hrs. of NSG Intervention the px avoided and prevented infection.
Nursing Interventions Rationale
Review pathology of disease Helps patient realize or accept necessity of
(active and inactive phases; adhering to medicationregimen to prevent
dissemination of infection reactivation or complication. Understanding
through bronchi to adjacent of how the disease is passed and awareness
tissues or via bloodstream of transmission possibilities help patient and
and/or lymphatic system) and SO take steps to prevent infection of others.
potential spread of infection
via airborne droplet during
coughing, sneezing, spitting,
Nursing Interventions Rationale
talking, laughing, singing.
Identify others at risk like Those exposed may require a course of drug
household members, close therapy to prevent spread or development of
associates and friends. infection.
Instruct patient to cough or Behaviors necessary to prevent spread of
sneeze and expectorate into infection.
tissue and to refrain from
Nursing Interventions Rationale
spitting. Review proper
disposal of tissue and
good hand
washing techniques.
Encourage return
demonstration.
Review necessity of infection May help patient understand need for
control measures. Put protecting others while acknowledging
Nursing Interventions Rationale
patient’s sense of isolation and social stigma
in temporary respiratory associated with communicable diseases. AFB
isolation if indicated. can pass through standard masks; therefore,
particulate respirators are required.
Monitor temperature as Febrile reactions are indicators of continuing
indicated. presence of infection.
Identify individual risk factors Knowledge about these factors helps patient
Nursing Interventions Rationale
for reactivation of alter lifestyle and avoid or reduce incidence
tuberculosis: lowered of exacerbation.
resistance associated with
alcoholism, malnutrition,
intestinal bypass surgery, use
of immunosuppressive drugs,
corticosteroids, presence
of diabetes
Nursing Interventions Rationale
mellitus, cancer, postpartum.
Assessment: Subjective data: Hirap akong huminga as verbalized by the patient.
Diagnosis: Ineffective Airway Clearance
Planning: After 8 hrs. of NSG intervention the px will be able to;
- Prevent DOB
- Have an effective airway clearance
Evaluation: After 8 hrs. of NSG Intervention the px was seen;
- No signs of DOB
- Have an effective airway clearance as evidenced by inhalation and exhalation
(breathing exercise)
Nursing Interventions Rationale
Diminished breath sounds may reflect
Assess respiratory atelectasis. Rhonchi, wheezes indicate
function noting breath sounds, rate, accumulation of secretions and inability
rhythm, and depth, and use of to clear airways that may lead to use of
accessory muscles. accessory muscles and increased work
of breathing
Note ability to expectorate mucus Expectoration may be difficult when
and cough effectively; document secretions are very thick as a result of
character, amount of sputum, infection and/or inadequate
Nursing Interventions Rationale
hydration. Blood-tinged or frankly
bloody sputum results from tissue
breakdown (cavitation) in the lungs or
presence of hemoptysis.
from bronchial ulceration and may
require further evaluation or
intervention.
Place patient in semi or high- Positioning helps maximize lung
Fowler’s position. Assist patient with expansion and decreases respiratory
coughing and deep-breathing effort. Maximal ventilation may open
Nursing Interventions Rationale
atelectatic areas and promote
exercises. movement of secretions into larger
airways for expectoration.
Prevents obstruction and aspiration.
Clear secretions from mouth and
Suctioning may be necessary if patient
trachea; suction as necessary.
is unable to expectorate secretions.
Nursing Interventions Rationale
Maintain fluid intake of at least 2500 High fluid intake helps thin secretions,
mL/day unless contraindicated. making them easier to expectorate.
Prevents drying of mucous membranes
Humidify inspired air and oxygen
and helps thin secretions.
Administer medications as indicated:
Mucolytic agents: acetylcyste Reduces the thickness and stickiness of
pulmonary secretions to facilitate
Nursing Interventions Rationale
ine (Mucomyst); clearance.
Bronchodilators: oxtriphyllin Increases lumen size of the
tracheobronchial tree, thus decreasing
e (Choledyl), theophylline
resistance to airflow and improving
(Theo-Dur);
oxygen delivery.
May be useful in presence of extensive
involvement with profound hypoxemia
Corticosteroids (prednisone).
and when inflammatory response is life-
threatening.
Nursing Interventions Rationale
Intubation may be necessary in rare
Be prepared for/assist with cases of bronchogenic TB accompanied
emergency intubation. by laryngeal edema or acute
pulmonary bleeding.
