Pulmonary Tuberculosis - 4 Nursing Diagnosis, Interventions and Rationale
1. Impaired Gas Exchange related to the presence of risk factors:
- Reduced the effectiveness of surface lung, atelectasis.
- Damage to the alveolar capillary membrane.
- Thick secretions.
- Bronchial edema.
- Decreased endurance, decreased ciliary function, secretions were settled.
- Tissue damage due to the spread of infection.
- Malnutrition.
- Contaminated by the environment.
- Lack of knowledge about infectious germs.
- Nothing is explained.
- Interpretation is incorrect, inaccurate.
- The information obtained is not exhaustive.
- Lack of knowledge / cognitive.
Fatigue.
- Frequent coughing, sputum production existence.
- Dyspnea.
- Anorexia.
- Impairment of financial capability (family).
Nursing Diagnosis and Rationale for Pulmonary Tuberculosis
1. Impaired Gas Exchange
Nursing Interventions :
Independent
1. Assess dyspnoe, tachypnea, abnormal respiratory sounds. Increased respiration, chest expansion limitations and fatigue.
Rationale: Pulmonary TB can cause widespread reach the lungs from becoming widespread bronchopneumonia inflammation, necrosis, and widespread efusion pleural fibrosis with symptoms of respiratory distress.
2. Evaluation of changes in the level of consciousness, noting signs of cyanosis and changes in the skin, mucous membranes and nail color.
Rationale: The accumulation of secretions may interfere with oxygenation in vital organs and tissues.
3. Demonstrate / encourage the patient to exhale with the mouth, especially on the client with fibrosis or parenchymal damage.
Rationale: The increasing resistance of air flow to prevent airway collapse and reduce the residue of the lungs.
4. Suggest to bedrest / reduce activity
Rationale: Reducing the consumption of oxygen in the respiration period.
Collaboration
5. Monitor BGA.
Rationale: Decreased oxygen (PaO 2), saturation or increased PaCO2 indicate the need for more adequate treatment or a change in therapy.
6. Provide supplemental oxygen.
Rationale: Helps corrects hypoxemia secondary which reduces pulmonary ventilation and reduced tension.
2. Risk for Infection
Independent
1. Review of the pathology of disease in phase active / inactive, the spread of infection through the bronchi in the surrounding tissue, or through the bloodstream or lymphatic system and potential infection through coughing, sneezing, laughing, kissing or singing.
Rationale : Helps clients to want to understand and accept the given therapy to prevent complications.
2. Identifying people at risk for infections such as family members, friends, people in the association.
Rationale : Tells them to prepare themselves to receive preventive therapy.
3. Encourage clients to accommodate their sputum when coughing.
Rationale : This custom is to prevent transmission of infection.
4. Use a mask every action.
Rationale : To reduce the risk of spreading infection.
5. Monitor temperature.
Rationale : Febris an indication of infection.
6. Emphasized not to discontinue therapy undertaken.
Rationale : infectious period can occur only 2-3 days after the onset of chemotherapy but in circumstances has occurred cavity or disease has continued for up to three months.
3. Knowledge Deficit
Independent
1. Assess the client's ability to learn, for example : level of anxiety, attention, fatigue, level of participation, the environment that allows clients to learn, how much is already known, the right media and who is trustworthy.
Rationale : The ability to learn related to emotional state and physical readiness. Success depends on the ability of the client sebatasmana.
2. Identify the signs that can be reported to the doctor for example : hemoptysis, chest pain, fever, breathing difficulties, loss of hearing, vertigo.
Rationale : Indicates the progress of the disease or the side effects of treatment that requires immediate evaluation.
3. Emphasizing the importance of dietary intake of high-calorie and high in protein and adequate fluid intake.
Rationale : Sufficient metabolic needs, reduce fatigue, adequate fluid intake helps thin the sputum.
4. Provide specific information in writing to the client and family, for example : taking medication schedule.
Rationale : Written information can remind the client about the information that has been given. Repetition of information can help remind clients.
5 Explaining the drug dose, frequency, and the need for action is expected in the long term therapy.
Rationale: Repeating counseling about the potential interactions between drugs taken with drugs / other substances.
Increasing the participation of the client and family therapy to abide by the rules and prevent the occurrence of drug withdrawal.
6 Explain to patients about the side effects of treatment that may arise, for example: dry mouth, constipation, visual disturbances, headache, increase in blood pressure.
Rational: to prevent doubts about the treatment and improve the client's ability to undergo therapy.
7. Giving a boost to the client and family to express anxiety / concerns and provide honest answers to questions. Do not try to deny the statement.
Rationale: Provides the opportunity to change the view that one and relieve anxiety. Denial of feelings will exacerbate the adverse health coping mechanisms.
9 Review of TB transmission (eg, generally via inhalation of air containing bacteria, but may also be transmitted through urine if infection of the urinary system) and the risk of recurrence.
Rationale: Knowledge that can considerably reduce the risk of transmission / recurrence. Complications associated with inadequate healing of TB include: formation of abscesses, emphysema, pneumothorax, fibrosis, pleural effusion, empyema, bronkhiektasis, hemoptysis, GI ulceration, bronchopleural fistula, laryngeal tuberculosis, and the transmission of germs.
4. Imbalanced Nutrition: Less Than Body Requirements
Independent
1. Assess and communicate the nutritional status of clients and families as recommended : Record the skin turgor, weight measurement, oral mucosal integrity, ability and inability to swallow, the presence of bowel sounds, a history of nausea, vomiting or diarrhea.
Rationale : Used to define the extent of the problem and intervention.
2. Assess the client's preferred diet / disliked.
Rationale : Helps interventions specific needs, increasing the dietary intake of clients.
3. Monitor intake and output periodically.
Rationale : Measuring the effectiveness of nutrition and fluids.
4. Note the presence of anorexia, nausea, vomiting, and specify if it has something to do with the medication. Monitors the volume, frequency, consistency of bowel movements.
Rational : It can determine the type of diet and identifying the solution to increase the intake of nutrients.
5. Encourage bedrest.
Rationale : Helps save energy, especially when the occurrence of metabolic fever.
6. Perform oral care before and after therapy respiration.
Rationale : Reduces bad taste from sputum or drugs used for treatment that can stimulate vomiting.
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