Tuberculosis Nursing Care Plan - Ineffective Airway Clearance

Assessment

Nursing Diagnosis

NURSING CARE PLAN FOR PULMONARY TUBERCULOSIS Inference Outcome Nursing Rationale Interventions

Evaluation

Subjective: “I had this recurrent cough for almost a month now and it seems that I am having difficulty in breathing at times...) – verbatim of client. Objective: RR= 23 breaths/ min PR= 95 beats/min T= 37.5 degree Celsius Easy fatigability Productive cough Chills at night Loss of appetite as claimed Chest X- ray and sputum examination revealed positive for pulmonary tuberculosis

Ineffective Airway Clearance related to presence of bronchial infection and secretion

Cough is the most common symptom of pulmonary tuberculosis. It may produce yellowish or greenish colored sputum especially during the day. Eventually, the sputum may be streaked with blood. Furthermore, a person with PTB may experience fatigue and loss of energy. It may affect his or her ability to expectorate secretions, too. Aside from that, difficulty of breathing signifies that there may be an accumulation of secretion in the bronchial cavity of the lungs.

After 8 hours of nursing care, client will be able to readily expectorate secretions and will have absence or decrease in episodes of dyspnea.

-Maintain infection control through the use of mask and performance of hand washing before and after contact with client.

-Place client in high fowler’s position and encourage reposition every two hours.

- Maintain room or environment free from any sorts of allergen. - Teach and encourage deep breathing and coughing exercises.

-Emphasize to increase fluid intake depending on individual tolerability or as indicated. - Instruct to take warm liquids instead of cold ones.

-PTB is transmitted via droplet inhalation so proper precaution should be performed to avoid transmission to other clients. - Elevating the head of the bed and turning client every two hours help in decreasing the pressure placed on the diaphragm. - Allergen may trigger more accumulation of secretion due to respiratory response. - These exercises hasten the expulsion of sputum and aids in maintaining airway patency. - Fluids help loosen secretion in the lungs.

-Warm fluids help in loosening the secretions while cold liquids triggers cough more often.

After 8 hours of nursing care, the goal is partially met as evidenced by client’s participation to breathing and coughing exercises and ability to expectorate sputum upon evaluation; still there are episodes of dyspnea as claimed by the client.

-Provide postural drainage and percussion.

-Monitor breathing patterns and breath sounds. -Educate client and family about disease condition and the need for compliance with the therapeutic regimen.

- Through the aid of gravity and percussion secretions are readily expelled. - It provides baseline data for future comparison in the evaluation of disease condition. - PTB can be transmitted through droplet inhalation and 6 months compliance to medication is needed in order to be treated with it.