Nursing Care Plan for Pulmonary Tuberculosis
Nursing Diagnosis : Ineffective Airway Clearance
Ineffective airway clearance
Definition
Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
Defining Characteristics:
- Dyspnea;
- diminished breath sounds;
- orthopnea;
- adventitious breath sounds (crackles, wheezes);
- cough, ineffective or absent;
- sputum production;
- cyanosis;
- difficulty vocalizing;
- wide-eyed;
- changes in respiratory rate and rhythm;
- restlessness
Related Factors:
Environmental
- Smoking;
- smoke inhalation;
- second-hand smoke
Obstructed Airway
- Airway spasm;
- retained secretions;
- excessive mucus;
- presence of artificial airway;
- foreign body in airway;
- secretions in bronchi;
- exudate in alveoli
Physiological
- Neuromuscular dysfunction;
- hyperplasia of bronchial walls;
- chronic obstructive pulmonary disease;
- infection;
- asthma;
- allergic airways
Tuberculosis (TB)
Tuberculosis (TB) is an infectious disease usually caused by Mycobacterium tuberculosis (MTB) bacteria. The bacterium Mycobacterium tuberculosis causes tuberculosis (TB), a contagious, airborne infection that destroys body tissue. Pulmonary TB occurs when M. tuberculosis primarily attacks the lungs. However, it can spread from there to other organs. Pulmonary TB is curable with an early diagnosis and antibiotic treatment.
- cough up phlegm
- cough up blood
- have a consistent fever, including low-grade fevers
- have night sweats
- have chest pains
- have unexplained weight loss
Nursing Diagnosis for Pulmonary Tuberculosis :
Ineffective airway clearance related to thick, sticky secretions.
Goals :
- Effective airway
Objective data:
- Respiration rate: 16 – 20 times/minute
- Secretions come out when coughing
- Ronchi reduced
Subjective data:
- The client says: shortness of breath is reduced
Nursing Intervention
1. Assess respiratory function, for example; breath sounds, rate, rhythm, depth and use of accessory muscles.
Rational :
Decreased breath sounds may indicate atelectasis. Crackles, wheezing indicate accumulation of secretions/inability to clear the airway which can lead to use of accessory muscles of respiration and increased work of breathing.
2. Note the ability to expel mucus/cough effectively; note the character, the amount of sputum, the presence of hemoptysis.
Rational :
Difficult expulsion, if the secretions are very thick (eg the effect of infection and/or inadequate hydration). Thick bloody sputum or bright blood results from lung (cavity) damage or bronchial injury and may require further evaluation/intervention.
3. Give a semi-Fowler or Fowler position. Help the client to cough and do deep breathing exercises.
Rational :
Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation opens the area of atelectasis and increases the movement of secretions into the large airway for expulsion.
4. Clear secretions in the mouth and trachea; suction as needed.
Rational :
Prevent obstruction/aspiration. Suction may be required if the patient is unable to expel secretions.
5. Maintain fluid intake of at least 2500 ml/day unless contraindicated.
Rational :
High fluid intake helps to loosen secretions, making secretions easier to expel.
6. Humidify the inspired air/oxygen.
Rational :
Prevents drying of mucous membranes; assist in the dilution of secretions.
Reference :
- Arthur C. Guyton and John E. Hal. (1997).
- Brunner & Suddarth. (1996).
- Marylin E. Doengoes. (2000).
- Slyvia & Lorainne. (1992).
