Risk for Infection | Nursing Care Plan for Tuberculosis

Risk factors may include

Inadequate primary defenses, decreased ciliary action and stasis of secretions

Tissue destruction, extension of infection

Lowered resistance, suppressed inflammatory process

Malnutrition

Environmental exposure

Insufficient knowledge to avoid exposure to pathogens

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Risk Control

Identify interventions to prevent or reduce risk of spread of infection.

Demonstrate techniques and initiate lifestyle changes to promote safe environment.

Nursing care plan intervention with rationale:

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.

Rationale: Helps client realize and accept necessity of adhering to medication regimen to prevent reactivation and complications. Understanding of how the disease is passed and awareness of transmission possibilities help client and significant other (SO) take steps to prevent infection of others.

2. Identify others at risk, such as household members, close associates, and friends.

Rationale: Those exposed may require a course of drug therapy to prevent development of infection.

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.

Rationale: Behaviors necessary to prevent spread of infection.

4. Review necessity of infection control measures, such as temporary respiratory isolation.

Rationale: May help client understand need for protecting others while acknowledging client’s sense of isolation and social stigma associated with communicable diseases. Note: AFB can

pass through standard masks; therefore, particulate respirators are required.

5. Monitor temperature, as indicated.

Rationale: Febrile reactions are indicators of continuing presence of infection.

6. Identify individual risk factors for reactivation of tuberculosis, such as lowered resistance associated with alcoholism, malnutrition, intestinal bypass surgery, use of immunosuppressant

drugs, presence of diabetes mellitus or cancer, or postpartum.

Rationale: Knowledge about these factors helps client alter lifestyle and avoid or reduce incidence of exacerbation.

7. Stress importance of uninterrupted drug therapy. Evaluate client’s potential for cooperation.

Rationale: Contagious period may last only 2 to 3 days after initiation of drug regimen, but in the presence of cavitation or moderately advanced disease, risk of spread of infection may

continue up to 3 months. Compliance with multidrug regimens for prolonged periods is difficult; therefore, DOT should be considered.

8. Review importance of follow-up and periodic reculturing of sputum for the duration of therapy.

Rationale: Aids in monitoring the effects of medications and client’s response to therapy.

9. Encourage selection and ingestion of well-balanced meals. Provide frequent small “snacks” in place of large meals as appropriate.

Rationale: Presence of anorexia or preexisting malnutrition lowers resistance to infectious process and impairs healing. Small snacks may enhance overall intake.