Student Nurses’ Community NURSING CARE PLAN ASSESSMENT SUBJECTIVE: The patient may report: •
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Past exposure to TB. Progressive fatigue Loss of appetite Unexplained weight loss.
OBJECTIVE: •
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Cough that may be nonproductiv e at first but later produces sputum and progresses to hemoptysis. Crackles Pleuritc pain Dyspnea
DIAGNOSIS
INFERENCE
PLANNING
Ineffective breathing pattern related to acute infection and decreased lung capacity.
The risk of TB is a higher in older people who have close contact with a newly diagnosed TB patient, those who have TB before, gastrectomy patients, and those affected with diabetes mellitus. The aging process weakens the immune system, further increasing the likelihood of tubercular infection in older adults.
After 8 hours of nursing intervention the patient will:
Transmission occurs when droplet nuclei are produced form an infected person’s coughs or sneezes. If inhaled, tubercle bacillus settles in the alveolus and infection occurs,
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Promote good respiratory function and treat infection Promote comfort
INTERVENTION •
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Monitor respiratory status, including vital signs, breath sounds, and skin color.
Administer oxygen therapy as ordered.
Monitor ABG levels and oxygen saturation as ordered.
Place the patient in semi-fowlers position and place the diaphragm in proper position to contract. Collect sputum samples as ordered.
RATIONALE •
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Respiratory status assessment helps gauge the patient’s severity and whether it’s progressing. To provide relief from symptoms of hypoxemia and hypoxia. ABG levels and continuous pulse oximetry measures the blood’s oxygen content and are good indicators of the lung’s ability to oxygenate the blood. To increase chest expansion and to alleviate dyspnea.
To monitor the progress of the disease and treatment.
EVALUATION
After 8 hours of nursing intervention the patient was able to: •
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Breathing returned to normal rate and pattern Minimal or no signs of infection.
Student Nurses’ Community
with alveolocapillary dilation and endothelial swelling. The incubation time for TB is 4 to 8 weeks. TB is usually asymptomatic in primary infection.
