Nursing Diagnosis for Pulmonary Tuberculosis (TB)
Nursing Diagnosis 1 :
Ineffective airway clearance related to:
- Thick or bloody secretions
- Fatigue
- Less coughing ability
- Tracheal / pharyngeal edema
Goals :
- Clear and effective airway after….days of treatment.
Expected Outcomes :
- The patient states that the cough is reduced, there is no shortness of breath and the secretions are reduced.
- Normal breath sounds (vesicular)
- Respiratory rate 16-20 breaths per minute (adults)
- No dyspnea
Nursing Interventions :
- Assess respiratory function, including voice, number, rhythm, and depth of breath as well as notes on the use of additional breathing muscles.
- Note the ability to expel secretions/cough effectively.
- Set a semi or high fowler sleeping position.
- Help the patient to practice coughing effectively and taking deep breaths. Clean secretions from the mouth and trachea, suction if possible.
- Give to drink approximately 2,500 ml / day (if there are no contraindications), recommend to drink in warm conditions.
Rationale:
- Changes in respiratory function and use of additional muscles indicate a disease condition that is still under full treatment.
- The inability to excrete secretions causes excessive buildup in the respiratory tract.
- The semi/high fowler position provides the opportunity for the lungs to develop optimally due to the diaphragm dropping down. Cough effectively facilitates expectoration of mucus.
- The patient in a condition of shortness of breath tend to breathe through the mouth which if not followed up will result in stomatitis.
- Water is used to replace the body's fluid balance due to a lot of fluid coming out through breathing. Warm water will facilitate the dilution of secretions through the conduction process which causes the arteries in the area around the neck to vasodilate and make it easier for fluid in the blood vessels to be bound by mucus/secretion.
Nursing Diagnosis 2 :
Ineffective breathing pattern related to decreased lung expansion secondary to fluid accumulation in the pleural space.
Goals :
- Within 3x24 hours after the intervention, the breathing pattern was effective again.
Expected Outcomes :
- The client is able to cough effectively.
- Rhythm, frequency, and depth of breathing were within normal limits, no accumulation of fluid was found on chest X-ray examination, breath sounds were clearly audible.
Nursing Interventions :
- Identify the causative factor.
- Assess respiratory function, noting respiratory rate, dyspnea, cyanosis, and changes in vital signs.
- Provide a high and oblique fowler/semifowler position on the affected side, help the client to practice deep breathing and cough effectively.
- Auscultate breath sounds.
- Assess chest expansion and trachea position.
- Collaboration for thoracentesis or WSD
- When WSD is installed: check the suction control and the correct amount of suction.
- Check the liquid level in the suction bottle and maintain it at the specified limit.
- Observe for air bubbles in the collection bottle.
- After the WSD is removed, cover the side of the inlet with sterile gauze and observe for signs that may indicate recurrent pneumothorax such as shortness of breath and pain.
Rationale :
- By identifying the cause, we can determine the type of pleural effusion so that appropriate action can be taken.
- Respiratory distress and changes in vital signs may occur as a result of physiological stress and pain or may indicate shock due to hypoxia.
- Fowler's position maximizes lung expansion and reduces effort to breathe. Maximal ventilation opens the area of atelectasis and increases the movement of secretions into the large airway for expulsion.
- Breath sounds may be decreased or absent in the area of collapse that includes one lobe, lung segment, or the entire lung area.
- Decreased lung expansion in the area of collapse. Tracheal deviation toward the healthy side in tension pneumothorax.
- Aims to evacuate fluid or air and facilitate maximal lung expansion.
- Aims to evacuate fluid or air and facilitate maximal lung expansion.
- The water in the collection bottle acts as a barrier that prevents atmospheric air from entering the pleura.
- Air bubbles during expiration indicate the expulsion of air from the pleura as expected. The bubbles usually decrease with increasing lung expansion. The absence of air bubbles may indicate optimal lung expansion or a blocked drainage tube.
- Early detection of important complications such as recurrent pneumothorax.
Nursing Diagnosis 3 :
Impaired gas exchange related to decreased effective lung tissue, atelectasis, alveolar-capillary membrane damage, and bronchial edema.
Goal
- Within 2x24 hours after being given gas exchange disorders do not occur.
Expected Outcomes :
- Reports decreased dyspnea.
- The client shows no symptoms of respiratory distress.
- Demonstrate improved ventilation and adequate tissue oxygen levels of arterial blood gases within the normal range.
Nursing Interventions :
- Assess for dyspnea, tachypnea, breath sounds, increased respiratory effort, thoracic expansion, and weakness.
- Evaluate changes in level of consciousness, note cyanosis, and changes in skin color, including mucous membranes and nails.
- Demonstrate and support lip breathing during expiration, especially for clients with fibrosis and lung parenchymal damage.
- Increase bed rest, limit activities, and assist with daily self-care needs according to the client's circumstances.
- Collaboration; Blood gas analysis
Rationale :
- Pulmonary TB causes widespread effects on the lungs from small bronchopneumonia to extensive diffuse inflammation, necrosis, pleural effusion, and extensive fibrosis. The effect on breathing varies from mild symptoms, to severe dyspnea, to respiratory distress.
- The accumulation of secretions and the reduction of healthy lung tissue can interfere with the oxygenation of vital organs and body tissues.
- Create a defense against the outside air to prevent collapse or narrowing of the airway so as to help spread air through the lungs and reduce shortness of breath.
- Reduces oxygen consumption during periods of respiratory depression and may reduce the severity of symptoms.
- Decreased O2 levels or saturation and increased PCO2 indicate the need for intervention or a change in therapy program.
Nursing Diagnosis 4 :
Imbalanced nutrition: less than body requirements related to nausea, productive cough.
Goals :
- Nutritional balance is maintained after….. days of treatment.
Expected Outcomes :
- The feeling of nausea is gone/reduced.
- The patient says his appetite has increased.
- The patient's weight has not decreased drastically and tends to be stable.
- The patient seems to be able to finish the portion of food provided.
- The results of laboratory analysis stated that blood protein / blood albumin was in the normal range.
Nursing Interventions:
- Document the patient's nutritional status, and record skin turgor, current weight, rate of weight loss, oral mucosal integrity, stomach tone, and history of nausea or diarrhea. Monitor intake-output and body weight optimally.
- Provide oral care before and after respiratory management.
- Encourage eating little, but often with a high-calorie and high-protein diet.
- Encourage the family to bring food from home, especially what the patient likes and then eat with the patient if there are no contraindications.
- Collaboration: Ask a nutritionist to determine the composition of the diet.
- Collaboration: Monitor laboratory examinations, for example: BUN, serum protein, and albumin.
Rationale:
- Become the data focus to determine the next action plan.
- Increase the comfort of the mouth area so that it will increase the feeling of appetite.
- Increase the patient's intake of food and nutrition, especially high protein levels that can improve the body's mechanisms in the healing process.
- Stimulate the patient to be willing to increase food intake which serves as a source of energy for healing.
- Determine the appropriate nutritional needs for the patient.
- Controls the effectiveness of the action especially with blood protein levels.
Nursing Diagnosis 5 :
Risk for spread of infection related to inadequate self-defense mechanisms, tissue damage, malnutrition, environmental exposure, lack of knowledge to prevent exposure to pathogens.
Goal
- Spread of infection does not occur during treatment
Expected Outcomes :
- The patient can demonstrate healthy behavior (covering mouth when coughing and sneezing)
- There were no signs of further infection.
- There is no family member/closest person who is infected with the disease like the patient.
Nursing Interventions :
- Assess disease pathology (active and inactive phases) and potential spread of infection through airborne droplets during coughing, sneezing, spitting, talking, laughing, etc.
- Identify the risk of transmission to other people such as family members and close friends. Instruct the patient when coughing / sneezing, then spit into a tissue.
- Advise the use of tissue to dispose of sputum. Reviewing the importance of controlling infection, for example by wearing a mask.
Rationale:
- To find out the real condition of the patient's problem in the inactive phase does not mean that the patient's body is free from tuberculosis germs.
- Reducing the risk of family members to be infected with the same disease as the patient.
- Storage of sputum in disinfected containers and the use of masks can minimize the spread of infection through droplets.
Nursing Diagnosis 6 :
Risk for low self-esteem related to negative image about illness, feelings of shame.
Goals :
- The patient's self-esteem can be maintained or there is no disturbance of self-esteem
Expected Outcomes :
- The patient demonstrates/shows positive aspects of himself.
- The patient is able to get along with others without feeling embarrassed.
Nursing Interventions :
- Review the patient's self-concept.
- Reward every action that leads to an increase in self-esteem.
- Explain about the patient's condition.
- Involve patients in every activity.
Rationale:
- Knowing the negative and positive aspects of self, allows nurses to determine further plans.
- Praise and attention will increase the patient's self-esteem.
- Knowledge of the condition of the self will be the basis for the patient to determine the needs for him.
- Patient involvement in activities will improve the patient's coping mechanisms in dealing with problems.
Nursing Diagnosis 7:
Knowledge deficit; regarding conditions, treatment rules related to lack of information about the process and management of home care.
Goal
- Within .... hours the client is able to carry out what has been informed.
Expected Outcomes :
- The client appears to have decreased the potential for transmitting the disease as indicated by the failure of client contact.
Nursing Interventions :
- Assess the client's ability to follow the learning (anxiety level, general fatigue, prior knowledge of the client and the right atmosphere).
- Explain the dose of the drug, the frequency of administration, the expected action, and the reasons why TB treatment is prolonged.
- Teach and assess client's ability to identify symptoms/signs of disease reactivation (hemoptysis, fever, chest pain, difficulty breathing, hearing loss, and vertigo).
- Emphasize the importance of maintaining a high protein and calorie intake of nutrients and adequate daily fluid intake.
Rationale:
- The success of the learning process is influenced by physical, emotional readiness, and a conducive environment.
- Increase the client's participation in the treatment program and prevent drug withdrawal because the client's physical condition improves before the therapy schedule is completed.
- Can demonstrate reactivation of the disease process and drug effects that require further evaluation.
- Diet high in calories and high in protein, and adequate fluids to meet the increased metabolic needs of the body. Health education about it will increase the client's independence in the treatment of his illness.
Reference :
- Doenges, 2000.
- Smeltzer, S.C., 2013
- Wilkinson Judith M, Ahern Nancy R, 2011
