Pulmonary Tuberculosis (TB) - 3 Nursing Diagnosis, Interventions and Rational

Nursing Diagnosis for Plan Tuberculosis (TB) : Ineffective airway clearance related to the accumulation of purulent secretions in the airway.

Goal: Airway clearance back effectively.

Nursing Interventions:

• Assess respiratory function, for example; breath sounds, speed and rhythm.
• Give the patient semi-Fowler's position or high Fowler effectively assist the patient to cough and deep breathing exercises.
• Maintain fluid intake at least 2500 ml / day, except, contra indications.
• Collaboration for the administration of drugs according to indications, mucolytic drugs.

Rational:

• Decreased breath sounds may indicate atelectasis, crackles, wheezing showed accumulation of secretions inability to clean the airway.
• The position helps maximize lung expansion and lower respiratory effort.
• High input of fluids helps to thin the secretions, making it easily removed.
• Mucolytic agents decrease the viscosity and adhesion of lung secretions for easy cleaning.

Nursing Diagnosis for Plan Tuberculosis (TB) : Imbalanced Nutrition Less than Body Requirements related to the production of sputum, anorexia.

Goal: Demonstrate increased weight.

Nursing Interventions:

• Record the patient's nutritional status, record of skin turgor, weight and degree of underweight, ability / inability to swallow, a history of nausea-vomiting.
• Supervise the input or output and weight periodically.
• Provide oral care before and after the act of breathing.
• Encourage eating little and often with foods high in calories and high in protein.
• Collaboration with a nutritionist to determine the composition of the diet.

Rational:

• Useful in defining the degree / problems in determining appropriate intervention options.
• Useful in measuring the effectiveness of nutrition and fluid support.
• Lowering bad taste because the rest of the sputum or leftover medicines.
• Maximize nutrient inputs as energy needs and decrease gastric irritation.
• Provide assistance in planning a diet with adequate nutrients for metabolic and dietary needs.

Nursing Diagnosis for Plan Tuberculosis (TB) : Knowledge Deficit: on the conditions, rules of action and displacement.

Goal: To declare understanding of disease processes / prognosis and treatment needs.

Nursing Interventions:

• Assess the patient's ability to learn. Example: the problem of weakness, the level of participation and the best environment.
• Emphasize the importance of maintaining a high protein and carbohydrate diet and adequate fluid intake.
• Explain the drug dose, frequency, expected work and long treatment reasons
• Emphasize to not drink alcohol and do not smoke.

Rational:

• Learning depends on the emotional and physical readiness improved in individual stages.
• Meet the metabolic needs, help minimize the weaknesses and improve healing.
• Increase cooperation in the treatment program and prevent withdrawal of the drug.

Sample of Nursing Care Plan Tuberculosis (TB)

Nursing Care Plan and Nursing Diagnosis for Tuberculosis (TB)

Pulmonary tuberculosis

Pulmonary tuberculosis (TB) is a contagious bacterial infection that involves the lungs, but may spread to other organs.

Symptoms
The primary stage of TB usually doesn't cause symptoms. When symptoms of pulmonary TB occur, they may include:

• Cough (usually cough up mucus)
• Coughing up blood
• Excessive sweating, especially at night
• Fatigue
• Fever
• Unintentional weight loss

Other symptoms that may occur with this disease:

• Breathing difficulty
• Chest pain
• Wheezing

Prevention

TB is a preventable disease, even in those who have been exposed to an infected person. Skin testing (PPD) for TB is used in high risk populations or in people who may have been exposed to TB, such as health care workers.

A positive skin test indicates TB exposure and an inactive infection. Discuss preventive therapy with your doctor. People who have been exposed to TB should be skin tested immediately and have a follow-up test at a later date, if the first test is negative.

Prompt treatment is extremely important in controlling the spread of TB from those who have active TB disease to those who have never been infected with TB.

Some countries with a high incidence of TB give people a BCG vaccination to prevent TB. However, the effectiveness of this vaccine is controversial and it is not routinely used in the United States.

People who have had BCG may still be skin tested for TB. Discuss the test results (if positive) with your doctor.

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Nursing Care Plan Pulmonary Tuberculosis (TB)

Nursing Diagnosis Pulmonary Tuberculosis

1. Ineffective airway clearance

2. Impaired gas exchange

3. Risk for infection

4. Imbalanced Nutrition Less then Body Requirements

5. Knowledge deficit

Source : http://all-nurses.blogspot.com/2011/10/nursing-care-plan-pulmonary.html

Impaired Gas Exchange of Tuberculosis

 Nursing Diagnosis - Impaired Gas Exchange of Pulmonary Tuberculosis

Tuberculosis, MTB, or TB (short for tubercle bacillus) is a common, and in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. Tuberculosis typically attacks the lungs but can also affect other parts of the body. It is spread through the air when people who have an active TB infection cough, sneeze, or otherwise transmit their saliva through the air. Most infections are asymptomatic and latent, but about one in ten latent infections eventually progresses to active disease which, if left untreated, kills more than 50% of those so infected.

The classic symptoms of active TB infection are a chronic cough with blood-tinged sputum, fever, night sweats, and weight loss (the latter giving rise to the formerly prevalent term "consumption"). Infection of other organs causes a wide range of symptoms. Diagnosis of active TB relies on radiology (commonly chest X-rays) as well as microscopic examination and microbiological culture of body fluids. Diagnosis of latent TB relies on the tuberculin skin test (TST) and/or blood tests. Treatment is difficult and requires administration of multiple antibiotics over a long period of time. Social contacts are also screened and treated if necessary. Antibiotic resistance is a growing problem in multiple drug-resistant tuberculosis (MDR-TB) infections. Prevention relies on screening programs and vaccination with the bacillus Calmette–Guérin vaccine.

Nursing Diagnosis - Impaired Gas Exchange of Pulmonary Tuberculosis


related to:

• reduced effectiveness of the surface of the lung,
• atelectasis,
• alveolar capillary membrane damage,
• secretions are thick,
• bronchial edema.

with the expected outcomes:

• Reported dyspnea did not occur.
• Showed improvement adequate ventilation and oxygenation of tissues with blood gas analysis in the normal range.
• Free from symptoms of respiratory distress.

Nursing Interventions - Impaired Gas Exchange of Pulmonary Tuberculosis

a. Assess dyspnea, tachypnea, abnormal breath sounds. Increased respiratory effort, chest expansion limitations and weaknesses.

b. Evaluation of the level of consciousness-changing, noted signs of cyanosis and discoloration of the skin, mucous membranes, and nail color.

c. Demonstrate / encourage you to exhale with disiutkan lips, especially in patients with fibrosis or parenchymal damage.

d. Suggest to bedrest, limit and auxiliary activities as needed.

e. Monitor blood gas analysis.

f. Collaboration: Give oxygen as indicated.

Rational:

a. Pulmonary tuberculosis may lead to widespread coverage in the lungs that comes from bronchopneumonia which extends into inflammation, necrosis, pleural effusion and widespread fibrosis with symptoms of respiratory distress.

b. Secret accumulation can interfere with oxygenation in vital organs and tissues.

c. Increased resistance to air flow to prevent the collapse of the airway.

d. Reduce oxygen consumption in the period of respiration.

e. Decrease in oxygen saturation (PaO2) or increased PaC02 show the need for further treatment. Inadequate or changing therapy.

f. Help correct the hypoxemia that occurs secondary alveolar hypoventilation and decreased lung surface.

Family Nursing Diagnosis - Nursing Care Plan for Tuberculosis

Nursing Diagnosis that may arise in families with tuberculosis disease are:

a. Nutrition less than body requirements related to anorexia
b. Risk for Infection related to the secret is out
c. Ineffective airway clearance related to the accumulation of excessive secretions.
d. Disruption of gas exchange related to the decreased oxygen supply

In formulating nursing diagnoses in the family need to be a priority issue and a matter of priority criteria.

Priority issues

Things that need to be considered in the priority issues are as follows:
a. Not possible, the problems of health and nursing are found in the family can be addressed simultaneously.
b. Need to consider the problems that can threaten the lives of families like the problem of disease.
c. Need to consider the response and attention to family nursing care to be provided.
d. Family involvement in solving problems they face.
e. Family resources that can support problem solving health / family nursing.
f. Family and cultural knowledge.

Criteria for priority problems

Some of the criteria in priority setting problems:
1. Nature of the problem, are grouped into: health threats, is ill or unwell and crisis situations.

2. Possible problems can be changed, is the likelihood of success to reduce the problem or prevent a problem when it's done nursing and medical interventions.
Factors that may affect the problem of TB can be changed are:
a. Knowledge and action for the problem of tuberculosis.
b. Family resources, such as finance, personnel, facilities and infrastructure.
c. Care resources, including the knowledge and skills in handling the problem of tuberculosis.
d. Community resources, can be in the form of facilities, organization.

3. Potential problems of tuberculosis, to prevent, is the nature and severity of problems that will arise and TB can be reduced or prevented through nursing and health measures.
Things that need to be considered in view of the potential problem of prevention of tuberculosis are:
a. Severity / difficulty of the problem, this is related to severity of disease or tuberculosis that showed the prognosis and severity of tuberculosis suffered by family members.
b. Action has been and is being run, is an act to prevent and treat tuberculosis in order to improve the health status of the family.
c. The duration of the problem, severity of problems associated with tuberculosis in the family and the potential problems to be prevented.
d. The existence of high-risk groups within the family or a group of highly sensitive adds to the potential to prevent problems.

4. Prominence of the tuberculosis problem, is how families see and assess the tuberculosis problem in terms of severity and urgency to be addressed through nursing and medical interventions.

Nursing Care Plan for Tuberculosis

Tuberculosis Nursing Care Plan includes general and specific objectives based on problems that come with the criteria and standards that refer to the cause. Furthermore formulate action-oriented nursing criteria and standards.

There are several levels of objectives in the planning of nursing according to Friedman (1998: 64). Short-term goals that are measurable, immediate and specific. And long-term goal which is the final level of the broad purposes stated expected by nurses and families to be reached.

The purpose of nursing care in a family with tuberculosis:

A. Short term goals include:
Once the information is given to the families of tuberculosis, the family is able to recognize the problem of tuberculosis, is able to take decisions and be able to care for family members suffering from tuberculosis.

Evaluation criteria:
a. Verbal response, the family is able to mention the understanding, the signs and symptoms, causes, treatment and prevention of transmission of tuberculosis.
b. Effective response, the family able to care for family members suffering from tuberculosis.
c. Psychomotor response, the family is able to modify the environment for people with tuberculosis.

Evaluation standards:
Definition, signs and symptoms, causes, prevention of tuberculosis, prevention of transmission and ways of treatment of tuberculosis.

2. Long-term goals
Problem of TB in the family can be resolved / reduced after nursing actions.

Intervention phase begins with the completion of treatment planning. Like the opinion of Friedman (1998: 67). During the implementation of nursing interventions, new data is continuously flowing into. Because this information (the response from the client, the situation changes, etc.) were collected, nurses need to be quite flexible and can adapt to review the family situation by making modifications to the plan without a plan. In choosing nursing actions depending on the nature of the problem and the resources available for solving.

Nursing Interventions - TB Nursing Care Plan are as follows:

1. Instruct patient to cough / sneeze and remove the tissue and avoid spitting in any place.
2. Urge families to provide nutritious food.
3. Weight control periodically
4. Encourage the patient to eat little but often with a high-carbohydrate diet and high protein.
5. Encourage the patient to take medication regularly.

Implementation - Nursing Care Plan for Tuberculosis

Implementation of nursing actions on the family, based on the nursing plan has been prepared.
Things that need to be considered in the implementation of nursing actions against families with tuberculosis are:

a. Family of resources (financial)
Resources (financial) that are expected to adequately support the healing process to family members suffering from tuberculosis

b. Levels of family education
Family education level may affect the family in identifying problems kemampuam tuberculosis and making decisions about appropriate actions against family members suffering from tuberculosis.

c. Customs applicable
Customs prevailing effect on the ability of families in caring for family members suffering from tuberculosis

d. Response and acceptance of family
Response and acceptance of family is very influential in healing as families are able to provide motivation.

e. Facilities and infrastructure that exist in the family
In the presence of both facilities and infrastructure that will allow families to the family in providing care and treatment to family members suffering from tuberculosis.