Monday, August 16, 2010

Nursing Care Plan | NCP Tuberculosis

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, an aerobic acid-fast bacillus. Although it is most frequently a pulmonary disease, more than 15% of patients experience extrapulmonary TB that can infect the meninges, kidneys, bones, or other tissues. Pulmonary TB can range from a small infection of bronchopneumonia to diffuse intense inflammation, necrosis, pleural effusion, and extensive fibrosis.

Although TB was thought to be preventable and treatable, the number of cases increased during the late 1980s. In 1990, more than 25,000 cases were reported in the United States, which was a 10% increase from the previous year. The increase was thought to be due to a high infection rate in patients with the human immunodeficiency virus (HIV) and patients who were exposed to others hospitalized with TB, as well as a new strain of the disease that is resistant to traditional drugs such as isoniazid (INH) and rifampin. Recent decreases are due to intensive public health efforts to prevent and control the disease.
Nursing care plan
TB is transmitted by respiratory droplets through sneezing or coughing by an infected person. Most infected persons have had a sustained exposure to the active agent, rather than a single one. The M. tuberculosis bacilli are inspired into the respiratory tract and usually lodge in the lower part of the upper lobe or the upper part of the lower lobe. The TB bacilli need high levels of oxygen to survive. When they reach the lungs, they multiply rapidly.
Mycobacteria that are not destroyed lie dormant until there is a decrease in the host’sresistance. Of individuals who inhale mycobacteria 5% develop clinical TB at that time, 95% have been infected and have no clinical symptoms but enter a latent phase and are at risk to develop TB later.

Nursing care plan assessment and physical examination
Ask patients about a previous history of TB or Hodgkin’s disease, diabetes mellitus, leukemia, gastrectomy, silicosis (a disease resulting from inhalation of quartz dust), and immunosuppressive disorders. A history of corticosteroid or immunosuppressive drug therapy can also increase the likelihood of TB infection. Other risk factors include a history of multiple sexual partners and abuse of drugs or alcohol. Determine if the patient has had recent contact with a newly diagnosed TB patient or has resided in any type of long-term facility. Take an occupational history as well to determine if the patient is a healthcare worker and therefore at risk.

Ask the patient to describe any symptoms. The patient often reports generalized weakness and fatigue, activity intolerance, and shortness of breath on exertion. Anorexia and weight loss occur because of altered taste and indigestion. The patient may also describe difficulty sleeping, chills or night sweats (or both), and either a productive or a nonproductive cough.

The patient looks acutely ill on inspection, with muscle wasting, poor muscle tone, loss of subcutaneous fat, poor skin turgor, and dry flaky skin. When you auscultate the chest, you may hear a rapid heart rate, rapid and difficult breathing, and stridor. Diminished or absent breath sounds may be present bilaterally or unilaterally from pleural effusion or pneumothorax. Tubular breath sounds or whispered pectoriloquies may be heard over large lesions, as may crackles over the apex of the lungs during quick inspiration after a short cough.

The sputum appears green, purulent, yellowish, mucoid, or blood tinged. The patient may have pain, stiffness, and guarding of the affected painful area. Accumulation of secretions can decrease oxygenation of vital organs and tissues. You may note cyanosis or a change in skin color, mucous membranes, or nail beds and changes in mental status, such as distraction, restlessness, inattention, or marked irritability.

Patients dependent on alcohol or drugs, those who are economically disadvantaged, and those who live in crowded conditions are at risk. The living environment needs careful assessment. Ask about living conditions, including the number of people in the household. Patients may have recent or long-standing stress factors, financial concerns, and feelings of helplessness or hopelessness. They may experience feelings of alienation or rejection because they have a communicable disease and are in isolation. They may have changes in patterns of responsibility, physical strength, and capacity to resume roles because of TB. Assess the patient’s ability to cope. Assess the degree of anxiety or depression about the illness, the change in health status, and the change in roles.

Nursing care plan primary nursing diagnosis: Risk of infection related to tissue inflammation and infiltration caused by the TB bacilli.

Nursing care plan intervention and treatment plan
Because TB typically becomes resistant to any single-drug therapy, patients generally receive a combination of drugs. The most common combination of drugs prescribed in the United States is INH, rifampin, pyrazinamide, and either ethambutol or streptomycin. Some experts recommend up to 9 months of drug therapy, whereas patients with drug-resistant strains of TB may require as much as 18 months of treatment. Intravenous fluids, total parenteral nutrition, and food supplements may be needed for those with nutritional compromise. Humidity and oxygen are administered to correct hypoxia and to decrease the thickness of secretions. Emergency intubation and mechanical ventilation may be needed in extreme cases.

Teach the patient how and when to take medication and to complete the course of drug therapy because one of the primary reasons for the development of drug-resistant TB strains is the failure of patients to complete medication regimens. If you suspect that the patient may not adhere to the medication regimen, a home health referral is important after the patient is discharged.

Nursing priorities are to maintain and achieve adequate ventilation and oxygenation; prevent the spread of infection; support behaviors to maintain health; promote effective coping strategies; and provide information about the disease process, prognosis, and treatment needs.

Use respiratory isolation precautions (masks only) for all patients with pulmonary TB who require hospitalization. Whenever they leave their rooms or receive treatment from the hospital staff, patients should wear masks to help prevent transmission of TB. The masks need to fit tightly and not gap. Teach the patient to cover the mouth when coughing and to dispose of all tissues. For patients with excessive secretions or those who are unable to cooperate with respiratory isolation, gowns and gloves may be necessary for hospital staff. The nurse should always remember to wash the hands before and after patient contact.

Position the patient in a Fowler or semi-Fowler position, and assist with coughing and deepbreathing exercises. Demonstrate and encourage pursed-lip breathing on expiration, especially for patients with fibrosis or parenchymal destruction. Promote bedrest and activity restrictions, and assist with self-care activities as needed.

Teach the patient and family how to use proper protection methods to prevent infection or reinfection. In the case of treatment at home, the family has probably already been exposed to the patient before diagnosis, so wearing masks is not necessary. Advise the family members that they need regular TB testing to ensure that they have not contracted TB. Teach the patient about complications of TB, such as recurrence and hemorrhage, and the need for
proper nutrition.

Nursing care plan discharge and home health care guidelines
Advise the patient to quit smoking, avoid excess alcohol intake, maintain adequate nutrition, and avoid exposure to crowds and others with upper respiratory infections. Teach appropriate preventive measures. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Instruct the patient to abstain from alcohol while on INH, and refer for eye examination after starting, then every month while taking, ethambutol. Teach the patient to recognize symptoms such as fever, difficulty breathing, hearing loss, and chest pain that should be reported to healthcare personnel. Discuss the patient’s living condition and the number of people in the household. Give the patient a list of referrals if she or he is homeless or economically at risk.

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