NURSING CARE PLAN ASSESSMENT
SUBJECTIVE: The patient may report:
Past exposure to TB. Progressive fatigue Loss of appetite Unexplained weight loss.
OBJECTIVE:
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, with alveolocapillary
Promote good respiratory function and treat infection Promote comfort
INTERVENTION
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
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:
Breathing returned to normal rate and pattern Minimal or no signs of infection.
dilation and endothelial swelling. The incubation time for TB is 4 to 8 weeks. TB is usually asymptomatic in primary infection.
Objective- pale inappearancedyspneausesaccessorym uscleswhenbreath ingproductivecoug hRR=41cycles perminute
Ineffective airway clearance related to ineffective cough
After 8hours of nursinginterv entions, thepatient'ssecre tionswill bemobilizedand airwaywill showdecreasedins ecretions
Independent: •
Assess airway forpatency. •
Auscultate lungs forpresence of normalor adventitiousbreath sounds, as inthe following: o Decreased orabsent breathsounds o Wheezing
>Maintaining theairway is always thefirst priority,especially in cases of trauma, acuteneurologicaldecom pensation, orcardiac arrest.>These may indicatepresence of mucusplug or other majorairway obstruction.>These may indicateincreasing airwayresistance.>These
Effectiveness - Was thepatient able tomaintainpatent airway?-Was thepatient able tomobilize hersecretions?Was thepatient able tohave patentairway? Adequacy -Was all
o Coarse sounds Assess respirations;note quality, rate,pattern, depth,flaring of nostrils,dyspnea onexertion, evidenceof splinting, use of accessory muscles,and position forbreathing. •
Assess changes inmental status. •
Assess cough foreffectiveness andproductivity. •
Note presence of sputum; assessquality, color,amount, odor, andconsistency. Assist patient inperformingcoughing andbreathingmaneuvers. •
Instruct patient inthe following: o Optimalpositioning(sitting position) o Use of pillow orhand splintswhen coughing o Use of abdominalmuscles formore forcefulcough o Use of quad andhuff techniques o
may indicatepresence of fluidalong larger airways.>Abnormalityin dicates respiratorycompromise. >Increasinglethargy, confusion,restlessness, and/orirritability can beearly signs of cerebral hypoxia.>Consider possiblecauses forineffective cough(e.g., respiratorymuscle fatigue,severebronchosp asm, orthick tenacioussecretions).>T his may be aresult of infection,bronchitis, chronicsmoking, or othercondition. A sign of infection is discolored sputum(no longer clear orwhite); an odor ma ybe present.>These improveproductivity of thecough.>Directed coughingtechniques helpmobilize secretionsfrom smaller airwaysto larger airwaysbecause thecoughing is done atvarying times. Thesitting position andsplinting theabdomen
theplannednursin ginterventionsar e enough inachieving andmaintainingp atent airway?Was all theresources of the nurse liketime and effortare enough? Appropriateness -Was theinterventions mentioned areapplicable andbeneficial tothe patient? AcceptabilityWas thefamily willfullyaccepte d theinterventions done to thepatient.
Use of incentive spirometry o Importance of ambulation andfrequentpositionchanges •
Use positioning (if tolerated, head of bed at 45 degrees;sitting in chair,ambulation). •
Encourage oralintake of fluidswithin the limits of cardiac reserve. •
Demonstrate andteach coughing,deep breathing, andsplintingtechniques.Dep endent: •
Administer medications: o Mucolytics (e.g.Guaifenesin Bronchodilators(e.g. Albuterol)Collaborative: •
Consult respiratorytherapist for chestphysiotherapy andnebulizertreatments asindicated (hospitaland homecare/rehabilitationenvi ronments).
promotemore effectivecoughing byincreasingabdominal pressureand upwarddiaphragmaticmov ement. >These promotebetter lungexpansion andimproved airexchange.>Increased fluidintake reduces theviscosity of mucusproduced by thegoblet cells in theairways. It is easierfor the patient tomobilize thinnersecretions withcoughing.>Patient willunderstand therationale andappropriatetechnique s to keepthe airway clear of secretions. >Relievesrespiratorydiffic ulties byhydrolyzingglycosam inoglycans,tending to breakdown/lower theviscosity of mucincontaining bodysecretions/compon ents, therebydissolving thickmucus.>Reduces resistancein the respiratoryairway and increasesairflow to the
lungs.>Chestphysiothera pyincludes thetechniques of postural drainageand chest percussionto mobilizesecretions in smallerairways that cannotbe removed bycoughing orsuctioning.
