NURSING PATIENTS WITH PATIENTS WITH LUNG TUBERCULOSIS

(LUNG TB)

A. Assessment

1. Activity / rest.

Symptoms:

o General fatigue and weakness.

o Shortness of breath due to work.

o Difficulty sleeping at night or fever at night, chills and or sweating.

o Nightmare.

Sign:

o Takhikardi, tachipnoe, / dispnoe at work.

o Muscle fatigue, pain and tightness (in the advanced stages).

2. Ego Integrity.

Symptoms:

o The presence of old stress factors.

o Financial problems, home.

o Feelings of helpless / hopeless.

o Cultural population.

Sign:

o Denying. (especially during the early stages).

o Ancietas, scared, easily offended.

3. Food / liquid.

Symptoms:

o Anorexia.

o Unable to digest food.

o Decreased BB.
Sign:

o Poor skin turgor.

o Subcutaneous fat loss in muscles.

4. Pain / comfort.

Symptoms:

o Increased chest pain due to repeated coughing.

Sign:

o Take care of the affected area.

o Distraction, anxiety.

5. Breathing.

Symptoms:

o Productive or unproductive cough.

o Shortness of breath.

o A history of tuberculosis / exposure in injected individuals.

Sign:

o Increased breathing frequency.

o Asymmetrical respiratory development.

o Percussion and decrease in vocal fremitus, breath sounds decrease not bilaterally or unilaterally
(pleural effusion / pneomothorax) tubular breath sounds and / or pectoral whispers over large
lesions, krekels are noted above the lung apex during rapid inspiration after short cough (krekels -
posttusic).

o Sputum characteristics; purulent green, mucoid yellow or mixed with blood.

o Tracheal deviation (bronchogenic spread).

o No attention, easily aroused real, mental changes (advanced stages).

6. Security.

Symptoms:

o The presence of immune suppression conditions, for example; AIDS, cancer, HIV positive testing (+)
Sign:

o Low fever or acute heat illness.

7. Social interaction.

Symptoms:

o Feelings of isolation / rejection due to infectious diseases.

o Changes in the usual patterns in response / changes in physical capacity to carry out the role.

8. Counseling / learning.

Symptoms:

o Family history of TB.

o General disability / poor health status.

o Failure to improve / recurrence of TB.

o Not participating in therapy.

B. Nursing Diagnoses that Appear

1. Ineffective airway clearance associated with thick secretion / blood.

2. Damage to the gas exchange is related to damage to the alveolar-capillary membrane.

C. Intervention

Nursing Diagnosis 1.:

Ineffective airway clearance is associated with thick secretion / blood.

Objective: Effective airway hygiene.

Result criteria:

• Look for a comfortable position that facilitates increased air exchange.

• Demonstrate effective cough.

• State strategies to reduce the thickness of secretions.

Intervention:

• Explain the client about the effective use of cough and why there is a buildup of secretions in the
sal. Respiratory.

The expected R / Knowledge will help develop client compliance with the therapeutic plan.

• Teach the client about the proper method of controlling cough.

R / Uncontrolled cough is tiring and ineffective, causing frustration.

• Breathe deeply and slowly while sitting as straight as possible.

R / Enables wider lung expansion.

• Perform diaphragmatic breathing.

R / Respiratory diaphragm decreases frequency. breath and increase alveolar ventilation.

• Hold your breath for 3 - 5 seconds then slowly, exhale as much as possible by mouth. Take a
second breath, hold and cough from the chest by doing 2 short, strong coughs.

R / Increasing the volume of air in the lungs eases secretion of secretions.

• Pulmonary auscultation before and after the client coughs.

This R / Assessment helps evaluate the effectiveness of the client's coughing effort.

• Teach the client actions to reduce the viscosity of secretions: maintain adequate hydration;
Increases fluid intake by 1000 to 1500 cc / day if not contraindicated.

R / Thick secretions are difficult to dilute and can cause mucous obstruction, which leads to
atelectasis.

• Encourage or give good oral care after coughing.

R / good oral hygiene improves a sense of well-being and prevents bad breath.

• Collaboration with other health teams: With doctors: giving expectoran, giving antibiotics, thoracic
photo consul.

R / Expextorant to facilitate removing mucus and evaluating the improvement of the client's
condition for the development of the lung.

Nursing Diagnosis 2.:

Damage to the gas exchange is related to damage to the alveolar-capillary membrane.

Objective: Effective gas exchange.

Result criteria:

• Shows the frequency of effective breathing.

• Has improved gas exchange in the lungs.

• Adaptive coping with causative factors.

Intervention:

• Give a comfortable position, usually with elevated headboard. Back to the sick side. Encourage
clients to sit as much as possible.
R / Increase maximal inspiration, increase lung absorption and ventilation on the painless side.

• Observe respiratory function, record respiratory frequency, dyspnea or changes in vital signs.

R / Respiratory distress and changes in vital signs can occur as a result of physiological stress and
pain or may indicate the occurrence of shock in connection with hypoxia.

• Explain to the client that the action was taken to ensure security.

R / What knowledge is expected to reduce anxiety and develop client compliance with the
therapeutic plan.

• Explain to the client about the etiology / triggers for lung tightness or collapse.

R / What knowledge is expected to develop client compliance with the therapeutic plan.

• Maintain calm behavior, help the patient to self-control by using slower and deeper breathing.

R / Helps clients experience the physiological effects of hypoxia, which can be manifested as fear /
anxiety.

• Collaboration with other health teams: With doctors: antibiotics, sputum examination and sputum
culture, thoracic photo consul.

R / Evaluate the improvement of the client's condition for the development of the lung