NCP PTB
NCP PTB
auscultation -RR: 25cpm -Chest Xray & Sputum exam: Positive for PTB
DIAGNOSIS Ineffective airway clearance related to excessive and thickened mucus secretions secondary to disease process of pulmonary tuberculosis as manifested by: Subjective: Ma-plema at hirap akong huminga as verbalized by the patient Objective: -Frequent cough -Presence of wheezes during auscultation -RR: 25cpm -Chest Xray & Sputum exam: Positive for PTB
RATIONALE Microorganisms inhaled after having been released when infected person sneezes, coughs and talks
NSG GOAL Short term: After 15-30mins of nsg int., the patient will: -maintain airway patency -decrease secretions -decrease RR: 2123cpm Long term: After 8-10 hours of nursing care, client will be able to readily expectorate secretions and will have absence or decrease in episodes of dyspnea; decreased RR 12-20cpm
EVALUATION Short term: After 30mins of nsg int., the patient had: -maintained airway patency -decreased secretions -RR: 22cpm Long term:
3. To maximize effort
5. Chest physiotherapy
Inflammatory response
After 8 hours of nursing care, the goal is partially met as evidenced 5. Indirect by clients removal of participation to secretions breathing and coughing 6. Through the exercises and aid of gravity ability to and expectorate percussion sputum upon secretions evaluation; still are readily there are expelled. episodes of dyspnea as 7. Allergen claimed by the may trigger client; RR more 20cpm accumulatio
sorts of allergen.