NURSING CARE PLAN FOR PULMONARY TUBERCULOSIS

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective: Risk for Due to the To Instruct patient Behaviors necessary to After 4 to 6
The wife Infection destruction reduce to cough or prevent spread of infection. weeks, patient
verbalized that related to of lung tissue the risk sneeze and will feel
the patient has the becoming of spread expectorate into relieved of
been coughing coughing worst, the of TB tissue and to coughing
with blood of blood sign of bacilli refrain from blood and
streaked for coughing out infection. spitting. Review being febrile.
more than two blood is a proper disposal
weeks already. visible sign of of tissue and
tissue good hand
Objective: destruction washing
Initial and techniques.
assessment by inflammation Encourage
nurse showed in the airway return
that patient is as the TB demonstration.
febrile bacilli can
spread Review necessity May help patient understand
through the of infection need for protecting others
destructed control while acknowledging
tissue. measures. Put in patient’s sense of isolation
temporary and social stigma associated
respiratory with tuberculosis.
isolation if
indicated.

Monitor Febrile reactions are

temperature as indicators of continuing
indicated. presence of infection.

Review second-line drugs may be

importance of required when infection is
follow-up and resistant to or intolerant of
periodic primary drugs or may be
reculturing of used concurrently with
sputum for the primary anti tubercular
duration of drugs. MDR-TB requires
therapy. minimum of 18–24 months
 therapy with at least three
drugs in the regimen known
to be effective against the
specific infective organism
and which patient has not
previously taken.

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective: Ineffective Patient has To demonstrate Assess respiratory Diminished Patient shows
The wife Airway present poor behaviors to function noting breath sounds visible signs of
verbalized that Clearance cough effort and improve airway breath sounds, may reflect improved
the patient has bloody clearance. rate, rhythm, and atelectasis. airway
been coughing secretions and is depth, and use of Rhonchi, wheezes clearance
with blood evident by accessory indicate
abnormal muscles. accumulation of
Objective: respiratory rate secretions and
Initial and breath inability to clear
assessment by sounds resulting airways that may
the nurse to an ineffective lead to use of
showed that airway clearance accessory muscles
patient has and increased
difficulty of work of breathing
breathing
Place patient in Positioning helps
semi or high- maximize lung
Fowler’s position. expansion and
Assist patient decreases
with coughing respiratory effort.
and deep- Maximal
breathing ventilation may
exercises. open atelectatic
areas and
promote
movement of
secretions into
larger airways for
expectoration.

Clear secretions Prevents

from mouth and obstruction and
trachea; suction aspiration.
as necessary. Suctioning may be
necessary if
patient is unable
to expectorate
secretions.
Maintain fluid
 intake of at least High fluid intake
2500 mL/day helps thin
unless secretions,
contraindicated. making them
easier to
expectorate.

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective: Imbalanced Imbalanced Demonstrate Ascertain Helpful in Patient will gain
The wife verbalized Nutrition: nutrition progressive patient’s usual identifying weight
that the patient has Less Than may be weight gain dietary specific needs
been coughing with Body related to toward goal pattern. and strengths.
blood streaked and Requirements fatigue due with Include in Consideration
has on and off fever. to visible normalization selection of of individual
evidence of of laboratory food. preferences
Objective: patient values and be may improve
being free of signs dietary intake.
Temperature is at lethargic of
38.9 degrees celcius and malnutrition. May affect
Initial assessment by sweating, in Investigate dietary
the nurse showed addition, anorexia and choices and
that patient is patient is nausea and identify areas
sweating and frequently vomiting and for problem
lethargic. The patient coughing note possible solving to
weighs 52kg with blood correlation to enhance
production medications. intake and
which Monitor utilization of
results to frequency, nutrients.
lack of volume,
interest in consistency of
food. stools.

Encourage and
provide for
frequent rest Helps
periods. conserve
energy,
especially
when
metabolic
requirements
are increased
Provide oral by fever.
care before
and after
respiratory Reduces bad
treatments. taste left from
 sputum or
medications
used for
respiratory
treatments
that can
stimulate the
vomiting
center.

Encourage Maximizes
small, nutrient
frequent intake without
meals with undue
foods high in fatigue/energy
protein and expenditure
carbohydrates from eating
. large meals
and reduces
gastric
irritation.

Drug data Classification Mechanism of Indication Contraindication Adverse reactions Nursing

action responsibility
Generic Name: Classification: Decreases Relief of Renal Minimal GI upset. Do not take for >10
Paracetamol, Non-narcotic fever by a mild-to- Insufficiency Methemoglobinemi days for pain in
Acetaminophen analgesic, hypothalamic moderate Anemia a adults, or more
Antipyretic effect leading pain; Hemolytic Anemia than 3 days for
Brand Name: to sweating treatment Neutropenia fever in adults.
Biogesic, Panadol, and of fever. Thrombocytopenia Monitor CBC, liver
Tylenol vasodilation Pancytopenia and renal
Inhibits Leukopenia functions.
pyrogen Urticaria Take with food or
effect on the CNS stimulation milk to minimize GI
hypothalamic- Hypoglycemic coma upset.
heat- Jaundice Report cyanosis,
regulating Glissitis shortness of breath
centers Drowsiness and abdominal
Does not Liver Damage pain as these are
cause signs of toxicity.
ulceration of Report paleness,
the GI tract weakness, and
and causes no heartbeat skips
anticoagulant Report abdominal
 action. pain, jaundice,
dark urine,
itchiness, or clay-
colored stools.
It may cause urine
to become dark
brown or wine-
colored.
Report pain that
persists for more
than 3-5 days
Avoid alcohol.
This drug is not for
regular use with
any form of liver
disease.

Drug data Classification

Mechanism Indications Contraindications Adverse Nursing responsibilities
of actions reactions
Generic Therapeutic: Tranexamic Patients hypersensitivity Nausea Before:
Name hemostatic acid with to tranexamic Vomiting
Tranexamic agents competitiv hemophilia acid or any of the Diarrhea Monitor blood pressure, pulse,
Acid ely inhibits for short- ingredients Hypotension and respiratory status as
Pharmacologi activation term use acquired Thromboemb indicated by severity of
Brand Names c: fibrinolysis of (two to defective color olic, e.g., bleeding.
Lysteda® inhibitors plasminoge eight days) vision, since this arterial, Monitor for overt bleeding every
Cyklokapron® n thereby To reduce prohibits venous, 15–30 min.
reducing or prevent measuring one embolic; Monitor neurologic status
conversion hemorrhage endpoint that Neurologic, (pupils, level of consciousness,
of during and should be e.g., visual motor activity)
plasminoge following followed as a impairment, Notify physician of leg pain
n to tooth measure of convulsions, hemorrhage, edema,
plasmin extraction. toxicity headache, hemoptysis, dyspnea, or chest
(fibrinolysi Treatment subarachnoid mental status pain.
n), an of severe hemorrhage changes; Monitor platelet count and
enzyme localized active myoclonus; clotting factors prior to and
that bleeding intravascular Rash periodically throughout therapy
degrades secondary clotting in patients
fibrin clots, to
fibrinogen, hyperfibrino During:
and other lysis,
plasma including Stabilize IV catheter to minimize
proteins, epistaxis, thrombophlebitis. Monitor site
including hyphema, closely.
the or After:
 procoagula hypermenor
nt factors V rhea Instruct patient to notify the
and VIII. (menorrhagi nurse immediately if bleeding
In patients a) and recurs or if thromboembolic
with hemorrhage symptoms develop.
hereditary following Caution patient to make position
angioedem certain changes slowly to avoid
a, surgical orthostatic hypotension.
inhibition procedures
of the Treatment
formation of
and activity hereditary
of plasmin angioedema
by
tranexamic
acid may
prevent
attacks of
angioedem
a by
decreasing
plasmin-
induced
activation
of the first
compleme
nt protein

Drug data Classification Mechanism Indications Contraindications Adverse Nursing responsibilities

of actions reactions
Myrin-P Anti TB May Tuberculosis Hypersensiti CNS: Monitor vital
Forte Agents interfere and atypical vity to drug. confusion, signs
Each with mycobacterial • In the dizziness (especially
tablet synthesis infections presence of EENT: optic blood
contains of one or caused by alcoholism, neuritis, pressure)
ethambuto more Mycobacteriu optic blurred vision, • Instruct
l HCl 275 bacterial m tuberculosis neuritis, decreased patient to
mg, metabolites impaired visual acuity, expect side
rifampicin , hepatic eye pain, red- effects of anti-TB drugs
150 mg, altering function and green color • Instruct
isoniazid RNA severe renal blindedness patients or
75 mg and synthesis insufficiency, GI: nausea, relatives to
pyrazinami during cell hyperuricem vomiting, inform any
de 400 division. ia and/or abdominal signs of
mg. gouty pain adverse
arthritis Hematologic: reactions
unless the thrombocytop
doctor enia
determines Hepatic:
that it may hepatitis
be used. Metabolic:
hyperuricemia
Musculosklet
al: joint pain,
gouty arthritis
Respi: bloody
sputum
Others:
anaphylaxis