Nursing diagnosis: Ineffective airway clearance

NOC: Respiratory Status: Airway Patency

1. Maintain patent airway
2. Expectorate secretions without assistance.
3. Demonstrate behaviors to improve or maintain airway clearance.
4. Participate in treatment regimen, within the level of ability and situation.
5. Identify potential complications and initiate appropriate actions.

NIC: Airway Management

Independent:
1. Assess respiratory function, such as breath sounds, rate, rhythm, and depth, and use of
accessory muscles.
2. Note ability to expectorate mucus and cough effectively; document character and amount of
sputum and presence of hemoptysis.
3. Place client in semi- or high-Fowler’s position. Assist client with coughing and deep-breathing
exercises.
4. Clear secretions from mouth and trachea; suction as necessary.
5. Maintain fluid intake of at least 2500 mL/day unless contraindicated.
Collaborative
1. Humidify inspired oxygen.
2. administer medications, as indicated, for example: Mucolytic agents, such as acetylcysteine
(Mucomyst)
3. Bronchodilators, such as oxtriphylline (Choledyl) and theophylline (Theo-Dur)
4. Corticosteroids (prednisone)
5. Be prepared for and assist with emergency intubation.
Nursing diagnosis: Risk for impaired gas exchange
NOC: Respiratory status: Gas exchange
1. Report absence of or decreased dyspnea.
2. Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within
acceptable ranges.
3. Be free of symptoms of respiratory distress.

NIC: Respiratory Monitoring

Independent
1. Assess for dyspnea (using 0 to 10 [or similar] scale), tachypnea, abnormal breath sounds,
increased respiratory effort, limited chest wall expansion, and fatigue.
2. Evaluate change in level of mentation.
3. Note cyanosis or change in skin color, including mucous membranes and nailbeds.
4. Demonstrate and encourage pursed-lip breathing during exhalation, especially for clients with
fibrosis or parenchy- mal destruction.
5. Promote bedrest, or limit activity and assist with self-care activities as necessary.
Collaborative
1. Monitor serial ABGs and pulse oximetry.
2. Provide supplemental oxygen as appropriate.

Nursing diagnosis: Risk for Infection (spread/ reactivation)

NOC: Risk control: Infectious Process
1. Identify interventions to prevent or reduce risk of spread of infection.
2. Demonstrate techniques and initiate lifestyle changes to promote safe environment.

NIC: Infection Control

Independent
1. Review pathology of disease—active or inactive phases, dissemination of infection through
bronchi to adjacent tissues or via bloodstream and lymphatic system—and potential spread of
infection via airborne droplet during coughing, sneezing, spitting, talking, laughing, and
singing.
2. Identify others at risk, such as household members, close associates, and friends.
3. Instruct client to cough, sneeze, and expectorate into tissue and to refrain from spitting.
Review proper disposal of tissue and good hand-washing techniques. Request return
demonstration.
4. Review necessity of infection control measures, such as temporary respiratory isolation.
5. Monitor temperature, as indicated.
6. Identify individual risk factors for reactivation of tuberculosis, such as lowered resistance
associated with alcoholism, malnutrition, intestinal bypass surgery, use of immunosup-
pressant drugs, presence of diabetes mellitus or cancer, or postpartum.
7. Emphasize importance of uninterrupted drug therapy. Evaluate client’s potential for
cooperation.
8. Review importance of follow-up and periodic reculturing of sputum for the duration of
therapy.
9. Encourage selection and ingestion of well-balanced meals. Provide frequent small “snacks”
in place of large meals as appropriate.
Collaborative
1. Administer anti-infective agents, as indicated, for example:
2. Primary drugs: isoniazid (INH, Liniazid), rifampin (RIF, Rifadin, Rimactane), pyrazinamide
(PZA, Tebrazid), and ethambutol (Etbi, Myambutol) rufabutin (Mucobutin)
3. Investigational agents such as diarylquinoline (R207910)
4. Monitor laboratory studies, such as the following: Sputum smear results
5. Liver function studies, such as aspartate aminotransferase (AST), alinine aminotransferase
(ALT)
6. Notify local health department.

Nursing diagnosis: Imbalanced Nutrition: Less than body requirements

NOC: Nutritional status
Demonstrate progressive weight gain toward goal with normalization of laboratory values and
be free of signs of malnutrition. Initiate behaviors or lifestyle changes to regain and to maintain
appropriate weight.
 NIC: Nutrition Management
Independent
1. Document client’s nutritional status on admission, noting skin turgor, current weight and
degree of weight loss, integrity of oral mucosa, ability to swallow, presence of bowel tones,
and history of nausea, vomiting, or diarrhea.
2. Ascertain client’s usual dietary pattern and likes and dislikes.
3. Monitor intake and output (I&O) and weight periodically.
4. Investigate anorexia, nausea, and vomiting. Note possible correlation to medications. Monitor
frequency, volume, and consistency of stools.
5. Encourage and provide for frequent rest periods. Provide oral care before and after respiratory
treatments.
6. Encourage small, frequent meals with foods high in protein and carbohydrates.
7. Encourage SO to bring foods from home and to share meals with client unless contraindicated.
Collaborative
1. Refer to dietitian/nutritionist for adjustments in dietary composition.
2. Consult with respiratory therapy to schedule treatments 1 to 2 hours before or after meals.
3. Monitor laboratory studies, such as blood urea nitrogen (BUN), serum protein, and prealbumin
and albumin.
4. Administer antipyretics, as appropriate.

Nursing diagnosis: Risk for ineffective Self-Health Management

NOC: Self Management: Chronic Disease
1. Verbalize understanding of disease process, prognosis, and prevention.
2. Initiate behaviors or lifestyle changes to improve general well-being and reduce risk of
reactivation of TB.
3. Identify symptoms requiring evaluation and intervention
4. Describe a plan for receiving adequate follow-up care.
5. Verbalize understanding of therapeutic regimen and rationale for actions.
NIC: Learning Facilitation
Independent
1. Assess client’s ability to learn, such as level of fear, concern, fatigue, participation level; best
environment in which client can learn; how much content the client can learn; best media and
language to teach the client; and determine who should be included.
2. Provide instruction and specific written information for client to refer to, such as schedule for
medications and follow-up sputum testing for documenting response to therapy.
3. Encourage client and SO to verbalize fears and concerns. Answer questions factually. Note
prolonged use of denial.

NIC: Teaching : Disesase Process

1. Identify symptoms that should be reported to healthcare provider, such as hemoptysis, chest
pain, fever, difficulty breathing, hearing loss, and vertigo.
2. Emphasize the importance of maintaining high-protein and carbohydrate diet and adequate
fluid intake. (Refer to ND: imbalanced Nutrition: less than body requirements.)
3. Explain medication dosage, frequency of administration, expected action, and the reason for
long treatment period. Review potential interactions with other drugs and substances.
Emphasize reportable side effects.
4. Review potential side effects of treatment, such as dry mouth, gastrointestinal (GI) upset,
constipation, visual disturbances, headache, and orthostatic hypertension, and problem-solve
solutions.
5. Emphasize need to abstain from alcohol while on INH.
6. Refer for eye examination after starting and then monthly during the course of ethambutol
(EMB).
7. Encourage abstaining from smoking.
8. Review that TB is transmitted primarily by inhalation of airborne organisms but may also
spread through stools or urine if infection is present in these organ systems; also review
hazards of reactivation.
9. Discuss and reinforce concerns, such as treatment failure, drug-resistant TB, and relapse.
10. Refer to public health agency as appropriate.
Referensi:
Doenges, Marilyn., Moorhouse, Mary F., & Murr, Alice C. 2014. Nursing Care Plan:
Guidelines for Individualizing Client Care Across the Life Span 9th Edition. USA: F.A. Davis
Company