ASSESSMENT DIAGNOSIS PLANNNING INTERVENTION INTERVENTION

Subjective: Ineffective airway Short term: Independent: GOAL MET

clearance related After 4 hours of  Assess

Complai to secrections in
the bronchi as
evidenced by
nursing interventions,
the patient will be able
to:
respirator
status, noting
rate and
Short term:
After 4 hours of
nursing

ns of dyspnea and
bilateral
wheezing.
Verbalize
understanding of
cause(s) and

breath sounds.
Assess the
ability to cough
interventions, the
patient was able to
verbalize

persistent therapeutic
management regimen.
effectively to
expel mucus
from the
understanding of
cause(s) and
therapeutic

coughing
airways.
Long Term:  Place client in management
After week of nursing high fowler’s regimen.
interventions, the position and

for the patient will be able to:

 Maintain
airway
encourage
reposition
every two
Long term:
After one week of

last 3 patency.
•Expectorate/
clear secretions

hours.
Teach and
encourage
nursing
interventions, the
patient was able to:

months readily.
 Demonstrate
behaviors to
deep
breathing and
coughing
 maintain
airway
patency as
 Complains of persistent
improve or exercises. evidenced
coughing
maintain clear  Encourage by
 Shortness of breath
airway. patient to respiratory
 Fever, headache, and rate of 20
body pains increase fluid
intake. cpm, and
 Anorexia absence of
 History of hypertension  Educate client
about disease dyspnea and
and diabetes mellitus adventitious
condition and
the need for breath
Objective: sounds
Vital signs compliance
with the  Clear
RR: 24 cpm secretions
PR: 86 bpm therapeutic
regimen readily as
BP: 130/80 mmHg evidenced
Temp: 37 C by absence
Dependent: of bronchial
Lab results secretions.
Hb: 10.2 g/dl  Demonstrat
RBS: 275 mg/dl  Administer
medications as e breathing
TLC: 17000 cells/mm3 and
indicated.
coughing
NURSING RESPONSIBILITIES
Assist TB Treatment

1. Initiate antibiotic therapy.

Antibiotics are used to treat tuberculosis. The patient will likely be prescribed a combination of the
following medications for empiric treatment:

Isoniazid

 Rifampin
 Pyrazinamide
 Ethambutol
 Streptomycin
2. Emphasize the need for strict treatment adherence.
These medications must be taken consistently for 4-6 months to work. It is risky to stop taking the
drugs too soon or without consulting a doctor, as this may lead to drug-resistant TB.

3. Boost lung expansion.

Lung expansion and secretion mobility can be increased through pursed-lip and deep breathing,
coughing, and aerobic exercises. Offer an incentive spirometer to aid in lung expansion.

4. Suction when needed.

Suctioning may be required if the patient can’t expectorate secretions. The prevention of airway
blockage and aspiration is aided by clearing the airways.
5. Place the patient in an upright position.
The patient can breathe more effectively in a semi- or high-Fowler’s position, which allows the
lungs to expand.

6. Mobilize secretions.

A flutter valve and fluids can mobilize secretions. Unless otherwise instructed, advise the patient to
drink plenty of fluids to thin secretions, facilitating expectoration.

7. Conserve energy.
Induce a calm and relaxing atmosphere. Encourage rest to lower the demand for oxygen
consumption.

8. Administer medications as ordered.

Provide supportive medications as prescribed. These may include pain medication, oxygen, inhaled
or oral steroids, and mucolytics, which may help relieve discomfort with breathing and persistent
coughing.

Control Transmission

1. Encourage vaccinations.
The Bacillus Calmette-Guerin (BCG) TB vaccine is used in some nations (not the United States).
Children in countries with high TB prevalence are typically given the vaccination to protect against
meningitis and miliary tuberculosis, a severe form of TB. The vaccine reduces the accuracy of TB
skin testing.

2. Get screening tests when exposed.

Encourage individuals who were exposed to patients with TB to undergo screening tests.

3. Educate the patient about cough and sneeze etiquette.

Teach the patient to cover their mouth and nose when coughing or sneezing. While sneezing or
coughing, turn the face away and use the fold of the elbow. Discard used paper tissues appropriately.

4. Maintain proper sanitation.

The risk of contracting TB infection and illness increases with malnutrition, congestion, poor air
circulation, and poor sanitation. Educate the patient and family members on hand hygiene.

5. Implement airborne precautions.

TB is transferred from one person to another through the air. When a patient with TB coughs,
speaks, laughs, sings, or sneezes, the air is contaminated with TB germs. Anyone near a person who
has TB disease runs the risk of inhaling TB germs into their lungs. Instruct the patient to wear a
surgical mask during transportation for tests within the hospital or after discharge when traveling to
medical appointments.

6. Isolate the patient.

Negative pressure rooms should be used to isolate people who may have TB. When properly
ventilated, the negative pressure prevents aerosol within the room from escaping to the rest of the
facility.

7. Wear the appropriate PPE.

Healthcare workers must don the recommended personal protective equipment (PPE), such an an
N95 respirator that has been fit-tested and certified by NIOSH.

8. Alert the health department.

Reports of latent or active TB must be reported to local health departments.

9. Monitor for signs of infection in caregivers and visitors.

Those who live with a patient with active TB are at high risk for contracting the disease and may
also require treatment. Stress the need to keep people who are immunocompromised, children, and
pregnant visitors away from close contact with the patient.

MANAGEMENT AND INTERVENTIONS

Management and Interventions:

1. Medication Management:
 Administer anti-TB medications as prescribed, often a combination of drugs such as isoniazid, rifampin, ethambutol,
streptomycin and pyrazinamide.
 Monitor and manage medication side effects.
  Emphasize the importance of medication adherence to prevent drug resistance.
2. Monitoring and Assessment:
 Regularly assess respiratory status, including monitoring for symptoms like cough, sputum production, and chest pain.
 Conduct periodic chest X-rays to evaluate treatment progress.
 Monitor for signs of medication toxicity and side effects.
3. Patient Education:
 Educate patients about the importance of completing the full course of treatment.
 Provide information on potential side effects and when to report them.
 Emphasize infection control practices to protect others.
4. Psychosocial Support:
 Offer emotional support to patients, as a TB diagnosis can be stressful.
 Address any stigma associated with TB in the community.
 Facilitate support groups or counseling services.
5. Nutritional Support:
 Ensure adequate nutrition to support the immune system and medication efficacy.
 Collaborate with dietitians to address any nutritional deficiencies.
6. Follow-Up and Continuity of Care:
 Arrange follow-up appointments to monitor treatment response.
 Coordinate care transitions and ensure continuity of care.
7. Contact Tracing:
 Collaborate with public health authorities to conduct contact tracing for individuals exposed to TB.
 Provide education and screening for identified contacts.