Nursing Care Plans Pulmonary Tuberculosis TB Nursing diagnosis ineffective Airway Clearance related to Thick, viscous, or bloody secretions

Fatigue, poor cough effort Tracheal or pharyngeal edema Nursing goal: Respiratory Status: Airway Patency Nursing Intervention Nursing Care Plans Pulmonary Tuberculosis TB

Airway Management: Assess respiratory function, such as breath sounds, rate, rhythm, and depth, and use of accessory muscles. Rationale Diminished breath sounds may reflect Atelectasis. Rhonchi and wheezes indicate accumulation of secretions and inability to clear airways, which may lead to use of accessory muscles and increased work of breathing. Note ability to expectorate mucus and cough effectively; document character and amount of sputum and presence of Hemoptysis Rationale Expectoration may be difficult when secretions are very thick as a result of infection or inadequate hydration. Blood tinged or frankly bloody sputum results from tissue breakdown in the lungs and may require further evaluation and intervention Place client in semi- or high Fowlers position. Assist client with coughing and deep-breathing exercises Rationale Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open Atelectasis areas and promote movement of secretions into larger airways for expectoration. Clear secretions from mouth and trachea, suction as necessary. Rationale Prevents obstruction and aspiration. Suctioning may be necessary if client is unable to expectorate secretions. Maintain fluid intake of at least 2,500 ML/day unless contraindicated Rationale High fluid intake helps thin secretions, making them easier to expectorate Humidify inspired oxygen Rationale Prevents drying of mucous membranes and helps thin secretions Administer medications, as indicated, for example: Mucolytic agents, such as acetylcysteine (Mucomyst) Rationale Reduces the thickness and stickiness of pulmonary secretions to facilitate clearance Bronchodilators, such as oxtriphylline (Choledyl) and theophylline (TheoDur) Rationale Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery Corticosteroids (prednisone) Rationale May be useful in the presence of extensive involvement with profound hypoxemia and when inflammatory response is life-threatening Be prepared for and assist with emergency intubation Rationale Intubation may be necessary in rare cases of bronchogenic TB accompanied by laryngeal edema or acute pulmonary bleeding. Evaluation (Expected Out Come) Nursing Care Plans Pulmonary Tuberculosis TB Nursing diagnosis ineffective Airway Clearance: Maintain patent airway. Expectorate secretions without assistance. Demonstrate behaviors to improve or maintain airway clearance. Participate in treatment regimen, within the level of ability and situation. Identify potential complications and initiate appropriate actions.

NURSING DIAGNOSIS: Gas Exchange, risk for impaired Risk factors may include Decrease in effective lung surface, atelectasis Destruction of alveolar-capillary membrane Thick, viscous secretions Bronchial edema Possibly evidenced by [Not applicable; presence of signs and symptoms establishes anactual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL: Respiratory Status: Gas Exchange (NOC) Report absence of/decreased dyspnea. Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within acceptable ranges

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, treatment, prevention, self-care, and discharge needs May be related to Lack of exposure to/misinterpretation of information Cognitive limitations Inaccurate/incomplete information presented Possibly evidenced by Request for information Expressed misconceptions about health status Lack of or inaccurate follow-through of instructions/behaviors Expressing or exhibiting feelings of being overwhelmed DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL: Knowledge: Illness Care (NOC) Verbalize understanding of disease process/prognosis and prevention. Initiate behaviors/lifestyle changes to improve general well-being and reduce risk of reactivation of TB. Identify symptoms requiring evaluation/intervention. Describe a plan for receiving adequate follow-up care. Verbalize understanding of therapeutic regimen and rationale for actions

Nursing care plans 1. Objectives Verbalization of inaccurate information Asking of questions Diagnosis: Deficient knowledge related to misinterpretation on information Rationale: knowledge deficit is a lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion. (NCP Book by Gulanick & Myers 6th Edition pp 116) Short Term Goal After 2 days of NI Patient will demonstrate motivation to learn, and identify perceived learning needs. And verbalize understanding of desired content Long Term Goal After 4 days of NI patient will be able follow the given/taught instructions Interventions 1. Determine who will be the learner. Patient, mother, sister. Insufficient knowledge

Many patients may view themselves as dependent on the watchers and may not be willing to learn