Respiratory Care Plans
PART I: Medical-Surgical Nursing
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with oral anticoagulant therapy, potential side effects, and foods and medications to consider during therapy
Desired Outcome:
Before hospital discharge, the patient verbalizes knowledge of the pre- scribed anticoagulant, potential side effects, and foods and medications to consider while receiving oral anticoagulant therapy.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s health care literacy (language, reading, comprehension). Assess culture and culturally specific learning needs.
This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate.
Determine the patient’s knowledge of oral anticoagulant therapy. As appropriate, discuss the medication name; purpose; dose; schedule;
precautions; food-drug, herb-drug, and drug-drug interactions; and potential side effects.
Knowledgeable patients are more likely to adhere to the therapeutic regimen.
Teach the potential side effects/complications of anticoagulant therapy:
easy bruising, prolonged bleeding from cuts, spontaneous
nosebleeds, bleeding gums, black and tarry or bloody stools, vaginal bleeding, and blood in urine and sputum.
This information increases patients’ awareness of side effects and complications to report to their health care providers for timely intervention.
Discuss the importance of laboratory testing and follow-up visits with the health care provider.
Laboratory testing helps ensure that the blood clotting time stays within therapeutic range. To promote safety, patients need close
management by health care providers while undergoing anticoagulant therapy.
Explain the importance of informing all health care providers (including dentist) that the patient is taking an anticoagulant.
Suggest the patient wear a medical alert tag or otherwise carry identification informing health care providers about the anticoagulant therapy.
These actions help ensure that patients are not given drugs or therapies that will have adverse effects on anticoagulant therapy, causing greater risk for hemorrhaging or clotting.
Teach the patient to notify the health care provider when ingesting large amounts of foods high in vitamin K or a subsequent change in the usual dietary pattern.
Foods high in vitamin K (e.g., asparagus, avocados, beef liver, broccoli, cabbage, soybeans, lettuce, olive oil, and canola oil) can interfere with anticoagulation.
Caution the patient that a soft-bristle rather than hard-bristle toothbrush and electric rather than straight or safety razor should be used during anticoagulant therapy.
These devices minimize risk of injury that could cause severe bleeding.
Instruct the patient to consult the health care provider before taking over-the-counter or prescribed medications that were used before initiating anticoagulant therapy.
Aspirin, cimetidine, trimethaphan, and macrolides are among the many medications that enhance response to warfarin. Medications that decrease response include antacids, diuretics, oral contraceptives, and barbiturates, among others.
PATIENT-FAMILY TEACHING AND DISCHARGE PLANNING
When providing patient-family teaching, focus on sensory information, avoid giving excessive information, and initiate a visiting nurse referral for necessary follow-up teaching.
Include verbal and written information about the following.
Note: Rehabilitation and family teaching concepts for fat
emboli are nonspecific.
ADDITIONAL NURSING DIAGNOSES/PROBLEMS:
“Perioperative Care” p. 45
“Prolonged Bedrest” p. 61
“Venous Thrombosis/Thrombophlebitis” p. 186
PART I: Medical-Surgical Nursing
the risk.
✓
Signs and symptoms of thrombophlebitis: calf swelling;
tenderness or warmth in the involved area; slight fever;
and distention of distal veins, coolness, edema, and pale color in the distal affected leg.
✓
Signs and symptoms of pulmonary embolism: sudden onset of dyspnea and anxiety, nonproductive cough or hemoptysis, palpitations, nausea, syncope.
crossing legs, and constrictive clothing.
✓
Medications, including drug name, dosage, purpose,
schedule, precautions, and potential side effects. Also
discuss drug-drug, herb-drug, and food-drug interactions.
133
Pulmonary Tuberculosis 13
OVERVIEW/PATHOPHYSIOLOGY
Tuberculosis (TB) is an infectious disease caused primarily by
Mycobacterium tuberculosis. In 2011, nearly 9 million personsaround the world became sick with TB, the majority of whom have latent tuberculosis infection (LTBI), in which the bac- teria are in the body (usually the lungs) in a dormant form that neither causes disease nor is communicable to other persons. A small proportion of persons (about 10%) with LTBI will develop active TB in their lifetimes.
For many years (from 1953 to 1984), reported cases of TB in the United States decreased almost 6% each year, and there was a general perception that TB was no longer a problem.
This decline was due to many factors, including improved living conditions (less crowding and better ventilation), better nutrition, and antituberculosis drugs. As a result, the public health infrastructure to support TB control weakened as other diseases, for example, human immunodeficiency virus (HIV)/
acquired immunodeficiency syndrome (AIDS), became more prominent. It was not until the late 1980s that the link between TB and HIV/AIDS became apparent as was manifested par- tially by multidrug-resistant (MDR) TB outbreaks occurring in seven hospitals between 1990 and 1992, resulting in many cases of LTBI, TB disease, and death. In addition, reported cases of TB increased 20% between 1985 and 1992. After the hospital outbreaks and subsequent administrative and legisla- tive support to control TB, cases have steadily declined again in most areas of the country. In 2011, there were fewer than 11,000 reported cases of TB in the United States, more than half of which were among foreign-born persons. Worldwide, however, TB remains a leading cause of death in undeveloped countries and in persons who are HIV infected, with the World Health Organization estimating that approximately one third of the world’s population is infected with M. tuberculosis.
M. tuberculosis is transmitted by the airborne route via
minute, invisible particles called
droplet nuclei. Whenindividuals with TB disease of the lungs or throat cough, sneeze, speak, or sing, their respiratory secretions harbor TB organisms that are expelled into the air and transform quickly into tiny droplet nuclei that can remain suspended in air for several hours, depending on the environment (especially
ventilation). In order to become infected, another person must breathe the air containing the droplet nuclei. A person’s natural defenses of the nose and upper airway and immune system will often prevent sufficient numbers of organisms from reaching the alveoli to cause infection. In fact, it generally takes 5 to 200 organisms implanted in the alveoli to cause LTBI. When organisms reach the alveoli, they are ingested by macrophages. Some of the bacilli spread through the blood- stream when the macrophages die; however, the immune system response usually prevents the individual from develop- ing TB disease. Although the majority of TB cases are pulmo- nary (85%), TB can occur in almost any part of the body or as disseminated disease. About half of people with LTBI who develop active TB (5%) will do so within the first year or two after infection. The remainder (5%) will develop active TB within their lifetimes.
HEALTH CARE SETTING
Primary care or long-term care, with possible hospitalization (acute care) resulting from complications
ASSESSMENT
For an accurate diagnosis of TB, a complete medical and psychosocial history should be taken along with a physical examination that includes a tuberculin skin test or an inter- feron gamma release assay (IGRA) blood test (there are cur- rently two Food and Drug Administration [FDA]–approved IGRA tests available: the QuantiFERON®-TB Gold (QFT-G) and T-SPOT®), chest x-ray and CT scan examinations, and sputum examination (including acid-fast bacilli [AFB] smears, cultures, and drug sensitivity studies).
Signs and symptoms:
TB is often suspected based on a group of symptoms that may include productive prolonged cough, fever, and night sweats, as well as chest pain, hemop- tysis, chills, loss of appetite, unintended weight loss over a short period of time, and tiredness.
Note: Close contacts of the patient require identification so that they can undergo evaluation for the presence of LTBI.
TB is reportable to the Public Health Department.
PART I: Medical-Surgical Nursing
radiographic evidence of prior, healed TB; weight loss of 10%
or more of ideal body weight; and other medical conditions, including diabetes mellitus, silicosis, end-stage renal disease, some types of cancers, elders, infants, and certain immunosup- pressive therapies. Persons who have emigrated from areas of the world with high rates of TB are also more likely to have LTBI than persons born in the United States.
DIAGNOSTIC TESTS
Tuberculin skin test or intradermal injection of antigen (purified protein derivative [PPD]):
This test uses a PPD of mycobacterial organisms that is administered intradermally and interpreted as positive or negative using measured milli- meters of induration. The test is considered positive when an area of induration 10 mm or greater is present within 48-72 hr after injection. High-risk categories such as persons with HIV infection and recent exposure are considered positive with 5 mm or greater induration. Those who are immunocompro- mised and some patients with active TB may have a negative PPD test, even in the presence of active TB disease. A positive PPD test indicates LTBI and is not diagnostic for active disease.
Interferon gamma release assays (IGRAs):
Until recently, the only way to diagnose LTBI was with the tuberculin skin test (TST). Since 2001 an alternative to the TST, the IGRA blood test, has been approved by the FDA. This whole-blood interferon gamma assay requires only one patient visit for a
ratories implement the requirements for specimen evalua- tion. Two IGRA blood tests are currently available: the QuantiFERON®-TB Gold (QFT-G) test and the T-SPOT®
test. These tests have high specificity (greater than 95%) and are not affected by prior vaccination with Bacille Calmette- Guérin (BCG).
Acid-fast stain:
Detection of AFB in stained smears exam- ined under a microscope usually provides the first bacterio- logic clue of TB. Smear results should be available within 24 hr of specimen collection. AFB in the smear may be myco- bacteria other than M. tuberculosis; many patients can have TB and have a negative smear. Specimens are generally col- lected by asking the patient to expectorate sputum into a cup;
however, tracheal washing, bronchoscopy, thoracentesis of pleural fluid, and lung biopsy are other options.
Chest x-ray examination:
Involvement is most characteris- tically evident in the apex and posterior segments of the upper lobes. Although not diagnostically definitive, it will reveal calcification at the original site, enlargement of hilar lymph nodes, parenchymal infiltrate, pleural effusion, and cavitation.
Patients with HIV infection may have an atypical radio- graphic presentation of TB. Any abnormality on an AIDS patient’s chest x-ray film should be considered possible TB until ruled out.
Gastric washings:
May reveal presence of tubercle bacilli secondary to swallowed sputum. Gastric washings are usually used for children who cannot expectorate sputum.
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the spread of TB and the procedure for Airborne Infection Isolation (AII)
Desired Outcome:
Following instruction, the patient and significant others verbalize how TB is spread and measures necessary to prevent the spread.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s health care literacy (language, reading, comprehension). Assess culture and culturally specific information needs. Then teach the patient about TB and the mechanism by which it is spread (respiratory droplet nuclei).
This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate. A well-informed patient is more likely to adhere to precautions against spreading the disease.
Post a notice of isolation/airborne precautions on the patient’s room door.
Until antimicrobial therapy is successful as indicated by AFB smears, AII (or “airborne precautions” in the nomenclature of Standard Precautions) requires a private room with special ventilation that dilutes and removes airborne contaminants and controls the direction of airflow. The negative pressure is monitored continuously or checked and recorded daily while the patient is isolated in this room.
Patients should wear a regular surgical mask if it is necessary to leave the room.