NURSING CARE FOR CLIENTS WITH PULMONARY TUBERCULOSIS & HEMAPTOE

NURSING CARE FOR CLIENTS WITH PULMONARY TUBERCULOSIS & HEMAPTOE

Understanding
Chronic infectious disease characteristic of tubular granuloma in lung.

Etiology
Mycobacterium tuberculosis (Amin, M., 1999).

Clinical Symptoms

1.        Fever (subfebris, sometimes 40 - 41 C, such as influenza fever.

2.       Cough (dry, productive, sometimes hemoptoe (rupture of blood vessels).

3.       Shortness of breath, if infiltration is half of the lung.

4.       Chest pain, if infiltration has to the pleura.

5.       Malaise, anorexia, thin body, headache, fever, muscle aches, night sweats.

Assessment (Doegoes, 1999)

1.       Activity / Rest

-          General weakness and fatigue.

-          Short breath with. Exertion.

-          Difficult to sleep with. Fever / night rash.

-          Nightmare.

-          Tachycardia, tachypnea / dyspnea.

-          Muscle weakness, pain and stiffness.

2.       Ego Integrity:

-          Feelings of helpless / hopeless.

-          Stress factor: new / old.

-          Feelings need help

-          Denial.

-          Anxious, irritable.

3.       Food / Liquids:

-          Loss of appetite.

-          Unable to digest.

-          Losing Weight.

-          Bad skin turgor, dry, muscle weakness, thin subcutaneous fat.

4.       Comfort / pain:

-          Chest pain while coughing.

-          Holding the affected area.

-          Behavior distraction.

5.       Breathing:

-          Cough (productive / non productive)

-          Shortness of breath.

-          History of tuberculosis

-          Increased number of breathing.

-          Asymmetry breathing movement.

-          Percussion: Dullness, decreased pleural fremitus filled with fluid).

-          The sound of breath: Ronkhi

-          Spuntum: green / purulent, yellowish, pink

6.       Safety:

-          The presence of immunosuppression conditions: cancer, AIDS, HIV positive.

-          Fever in acute condition.

7.        Social Interaction:

-          Feelings of isolation / rejection.

Nursing diagnoses

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

2.       Damage to gas exchange associated with alveolar-capillary membrane damage.

3.       Changes in nutrition: less than body needs associated with increased production of spuntum / cough, dyspnea or anorexia

4.       High risk of infection associated with inadequate primary defense, decreased ciliary outcome, stasis of secretion.

5.       Lack of knowledge about the condition, therapy and prevention associated with information less / inaccurate.

Intervention 1

Diagnosis Ineffective airway clearance is associated with thick / blood secretions.
Objectives: Airway cleanliness is effective.

Results Criteria:

Ø  Finding a comfortable position that facilitates increased air exchange.

Ø   Demonstrate an effective cough.

Ø  Declare a strategy to decrease the viscosity of secretions.

Action plan :

1.       Explain the client about the effective use of cough and why there is a buildup of secretions in the sal. Respiratory.
R / Expected knowledge will help develop client compliance with the teraupetik plan

2.       Teach the client about the proper method of controlling the cough.
R / uncontrolled cough is tiring and ineffective, causing frustration.

3.       Breathe deeply and slowly while sitting as straight as possible.
R / Allows wider lung expansion.

4.       Perform diaphragmatic breathing.
R / Diaphragmatic breathing decreases the frequency. Breathing and improving alveolar ventilation.

5.       Hold your breath for 3 - 5 seconds then slowly, remove as much as possible through the mouth.
Do a second breath, hold it and cough from the chest by doing 2 short and strong cough.
R / Increase the volume of air in the lungs facilitate secretion secretion expenditure.

6.       Auscultation of lung before and after client cough.
R / This assessment helps evaluate the effectiveness of client cough efforts.

7.       Teach client actions to decrease viscosity of secretions: maintain adequate hydration; Increase fluid intake 1000 to 1500 cc / day when not contraindicated.
R / thick secretions are difficult to dilute and can cause mucus blockages, leading to atelectasis.

8.       Push or give good oral care after coughing.
R / Good mouth hygiene improves the sense of well-being and prevents bad breath.

9.       Collaboration with other health teams:

-          With doctor, radiology and physiotherapy.

-          Giving the expectoran.

-          Giving antibiotics.

-          Chest photo consul.

R / Expextorant to ease the mucus out and evaluate the improvement of the client's condition for lung development.

Intervention 2

Diagnosis Damage to gas exchange is associated with alveolar-capillary membrane damage.
Objective: Effective gas exchange.

Results Criteria:

Ø  Demonstrate effective breathing frequency.

Ø  Experiencing repair of lung gases.

Ø  Adaptive overcomes the causal factors.

Action plan :

1.       Give a comfortable position, usually with the head height of the bed. Turn to the sick side. Encourage clients to sit as much as possible.
R / Increases maximum inspiration, increases lung extraction and ventilation on the non-painful side.

2.       Observe respiratory function, record respiratory rate, dyspnea or vital signs changes.
R / Distress breathing and alterations in vital signs may occur as a result of physiological stress and pain or may indicate syock occurrence in relation to hypoxia.

3.       Explain to the client that the action is done to ensure security.
R / What knowledge is expected to reduce anxiety and develop client adherence to a teraupetik plan.

4.       Explain to the client about the etiology / triggering factors of shortness or collapse of the lungs.
R / What knowledge is expected to develop client compliance with the teraupetik plan.

5.       Maintain calm behavior, help the patient to self control by using breathing more slowly and deeply.
R / Help clients experience the hypoxia physiological effects, which can be manifested as fear / anxiety.

6.       Collaboration with other health teams:
With doctors, radiology and physiotherapy.
Giving antibiotics.
Sputum examination and sputum culture
Chest X-ray Consul.
R / Evaluate the improvement of client's condition on lung development.

Intervention 3

Diagnosis Nutritional changes: less than body requirements associated with increased production of spuntum / cough, dyspnea or anorexia
Objectives: Adequate nutritional needs

Results Criteria:

Ø  Mention which foods are high in protein and calories

Ø  The food menu is served up

Ø  Increased weight without increased edema

Action plan

1.       Discuss the causes of anorexia, dyspnea and nausea.
R / By helping the client understand the condition can decrease anxiety and can help improve aa teruptive compliance.

2.       Teach and help clients to rest before eating.
R / Fatigue continues to decrease the desire to eat.

3.       Offer a small but frequent meal (six times a day plus extra).
R / Increased intra-abdominal pressure can decrease / suppress GI channels and decrease capacity.

4.       Restriction of fluids on food and avoid liquids 1 hour before and after meals.
R / fluid can be more on the stomach, decrease appetite and input.

5.       Organize foods with high protein / calories served at the time the client feels most like to eat them.
R / This increases the likelihood of clients consuming adequate amounts of protein and calories.

6.       Describe the need for increased food inputs of the following elements

a.       Vitamin B12 (eggs, chicken meat, shellfish).

b.      Folic acid (green leafy vegetables, beans, meat).

c.       Thiamine (beans, beans, oranges).

d.      Iron (offal, dried fruit, green vegetables, fresh beans).

R / Vitamin input should be increased to compensate for metabolic and vitamin storage depletion due to liver damage.

Consul with doctor / nutritional shlias when the client does not consume adequate nutrients.
R / High protein supplements, parenteral nutrition, total, or diet VIA NGT may be needed