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by: DuAnitha Stage: Revises3 ChapterID: 0000850451 Date:5/2/09 Time:18:58:47

CHAPTER
69
Nursing care of patients with
tuberculosis
Robert J Pratt and Johan van Wijgerden
INTRODUCTION
In many regions of the world, people with TB are embarked on a
perilous journey that frequently terminates in death, either follow-
ing acute illness or at the end stage of chronic debilitating ill-
health. Nurses are able to support patients during all phases of this
journey and their interventions can make the defining contribution
to the provision of good quality care which influences the likeli-
hood of more positive patient health outcomes.
The role of the nurse in providing person-centred care to
patients with TB is reviewed in this chapter by using the experi-
ence of a patient case study. A problem-solving approach serves
as a dynamic and holistic organizing structure to assess, plan, imple-
ment, and evaluate individualized nursing care for this patient. In
addition, an international system of nursing diagnoses is illustrated
as a framework for enhancing the clarity of the nursing process.
This system also provides examples of how the most frequently
identified healthcare needs and problems identified in patients with
TB facilitate the development of a nursing care plan with appropri-
ate patient-centred outcomes and associated evidence-based
nursing interventions.
THE ROLE OF THE NURSE
The international definition of nursing,
1
shown in Box 69.1,
describes a range of activities that illustrate the uniqueness and core
essence of the contribution by nurses to meaningful and effective
healthcare. Without competent nursing management, the care
and treatment of people with TB will be substantially impoverished
and their chances of recovery diminished.
Patients with TB are cared for in a variety of settings, including
acute care facilities, outpatient departments, TB and respiratory
medicine clinics, and specialist primary and community care TB
services. Many patients will need to access care in all of these envir-
onments at one time or another during the course of their illness.
Thus, for example, patients are frequently admitted to hospital
for investigation, diagnosis, and initiation of treatment and, follow-
ing discharge, they receive continuing care from community and
primary TB services. Most patients are predominantly cared for
in the community. Nurses provide much of the ongoing care rele-
vant to each patient during the different stages of their illness and in
all healthcare settings. Furthermore, nurses in TB clinics and other
services frequently manage and coordinate an indispensable hub of
multidisciplinary care and support. Nurses also act as advocates and
guides for patients journeying through the complexities of modern
multiagency healthcare services.
In addition, through communication, nurses can instruct the
patient, relatives, and the community in the nature of TB, thereby
encouraging early presentation for diagnosis and compliance with
anti-TB treatment regimens, and to reduce the stigmatizing effects
of the disease, particularly in regions where TB is associated in local
beliefs with HIV infection.
PERSON-CENTRED CARE
The nursing process has evolved during the past several decades
and is now used by nurses throughout the world as an organizing
framework for providing individualized person-centred care. This
process is cyclical and ongoing and is generally used in conjunction
with various theoretical nursing models or philosophies.
2
The
stages of the nursing process are holistic, in the sense that each stage
is intimately interconnected with the other stages and is explicable
only by reference to the whole. This process, similar to those used
in problem-solving and scientific reasoning, incorporates assess-
ment, diagnosis, planning, implementation, and evaluation phases
(Fig. 69.1).
NURSING ASSESSMENT
There are two components to a comprehensive nursing assessment.
The first component is a systematic collection of subjective
(described by the patient) and objective (observed by the nurse)
assessment data. This is done by taking a nursing health history
and examining the patient. Detailed guidelines on conducting
nursing health assessments are widely available,
3
and Box 69.2 pro-
vides an abbreviated format of the assessment.
The second component of the nursing assessment is an analysis
of the data and its use in a meaningful way to formulate an easily
understandable and precise nursing care plan. One way this can
be done is by making use of nursing diagnoses to plan and evaluate
patient-centred outcomes and associated nursing interventions.
NURSING DIAGNOSES
Nursing diagnostic statements are clinical judgements about indi-
vidual, family, or community responses to actual or potential health
problems and life processes,
4
and are the logical culmination of the
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analysis of the assessment data. They include a description of the
functional behaviours that can be improved through nursing inter-
ventions and the causative factors of those aspects of patient beha-
viour that nurses need to improve or influence. There are two
ways to formulate a nursing diagnosis. A two-part system consists
of the nursing diagnosis and the related to statement, with the latter list-
ing those aetiological factors relevant to the diagnosis. A three-part
system, known as the PES (problemetiologysymptoms) system
(Table 69.1), includes the above, plus a statement of the defining
characteristics which are the various signs and symptoms identified
during the nursing assessment and used to make the diagnosis.
To take an example, a patient with active pulmonary TB could
be diagnosed with hyperthermia related to infection, disease, dehy-
dration, and an increased metabolic rate and with defining character-
istics including fever (core body temperature elevated at least
0.81.1

C) above the persons normal temperature (> 38

C), or
hyperthermia (body temperature > 40

C) with flushed or hot skin,

increased respiratory rate, and tachycardia.
In another example, the analysis of the nursing assessment data
may indicate a diagnosis of ineffective therapeutic regimen manage-
ment, defined as a daily programme of life-incorporating treat-
ment of the illness that fails to meet the necessary specific health
goals.
5
In the patient described in the case study presented below,
the defining characteristics (signs and symptoms) associated with the
diagnosis of ineffective therapeutic regimen management include
choices of daily life style inadequate for meeting goals of antiretro-
viral and (potentially) anti-TB treatment, admission by the patient
that he did not take action to include the treatment regimen in
his daily routine, and his admission of difficulty with following
the prescribed drug regimen. The related factors (aetiology) include
a lack of understanding of his illness and treatment, the complexity
of the drug regimen, homelessness, and a chaotic lifestyle.
In the most widely used system, the North American Nursing
Diagnosis Association-International (NANDA-International),
5
pro-
vision is made for five categories of diagnosis, listed in Table 69.2.
The formulation of a nursing diagnosis as a standardized state-
ment for expressing the results of the assessment of the problems
and needs of a patient provides a uniform way of identifying,
describing, focusing on, and dealing with the problems and needs
and is an ideal framework on which to base the nursing process.
Once identified and documented, the nursing diagnosis provides
direction for the remainder of the nursing process. Today, standar-
dized nursing diagnostic statements continue to evolve into dynamic
conceptual systems that guide the classification of nursing diagnoses
into a widely used international one.
5,6
By using nursing diagnoses
and standardized descriptions of nursing interventions and patient
outcomes, nurses around the world are enabled to use the same
language to systematically document their work with patients,
families, and communities.
6
PLANNING CARE
Following the assessment and the formulation of the nursing diag-
nosis, a plan of care is developed in partnership with the patient.
As patients usually have multiple diagnoses, these must be
Nursing
process
Nursing
diagnosis
Evaluation
Implementation
Assessment
Systems
examination
Nursing
history
Planning
Interventions
Outcomes
Fig. 69.1 The nursing process. International Council of Nurses. Definition
of Nursing. ICN website accessed January 10, 2007. [http://www.icn.ch/
definition.htm]
Box 69.2 Nursing assessment
/| |n|erv|ew ver|||e||e de|e |rom ||e pr|mery soJr.e |pe||en|; end
se.ondery soJr.es ||em||y |ee|||.ere pro|ess|one|s med|.e| re.ords;
ere e||.||ed
NJrs|nq |ee||| ||s|ory

E|oqrep||.e| |n|orme||on

Reesons |or see||nq |ee|||.ere

Pe||en| expe.|e||ons

Presen| |||ness or |ee||| .on.erns

Hee||| |em||y env|ronmen|e| end psy.|oso.|e| ||s|ory

Sp|r||Je| |ee|||

H|s|ory o| e||erq|es d|e|ery res|r|.||ons re|even| med|.e| ||s|ory

P|ys|.e| exem|ne||on

v||e| s|qns re.ords

0||er o|je.||ve meesJremen|s mede eq |e|q|| we|q|| spJ|Jm

.oJq| d|ep|ores|s

Lxem|ne||on o| e|| |ody sys|ems |n e sys|eme||. menner

Box 69.1 International definition of nursing
NJrs|nq en.ompesses eJ|onomoJs end .o||e|ore||ve .ere o| |nd|v|dJe|s
o| e|| eqes |em|||es qroJps end .ommJn|||es s|.| or we|| end |n e||
se|||nqs NJrs|nq |n.|Jdes ||e promo||on o| |ee||| preven||on o| |||ness
end ||e .ere o| ||| d|se||ed end dy|nq peop|e /dvo.e.y promo||on o| e
se|e env|ronmen| reseer.| per||.|pe||on |n s|ep|nq |ee||| po||.y end |n
pe||en| end |ee||| sys|ems meneqemen| end edJ.e||on ere e|so |ey
nJrs|nq ro|es
ln|erne||one| CoJn.|| o| NJrses
l
Table 69.1 Three-part PES diagnostic statement
4
P (Problem) E (Etiology) S (Symptoms)
|e nursing
diagnosis ||e|e|; e
.on.|se |erm or
p|rese ||e|
represen|s e
pe||ern o| re|e|ed
.Jes
|e related to |e.|ors
|e ||e re|e|ed .eJses
or .on|r||J|or |o ||e
pro||em
Defining
characteristics
s|e|emen|
sJmmer|.|nq
symp|oms
|den||||ed dJr|nq
||e nJrs|nq
essessmen|
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prioritized when developing the care plans. Thus, for example, imme-
diate severe respiratory problems which may be life-threatening have
a greater priority than many other patient problems and needs. There
are two aspects to the development of the care plan: formulating
measurable outcomes and planning nursing interventions.
Outcomes
Outcomes describe individual, family, or community states, beha-
viours, or perceptions measured along a continuum in response to
nursing interventions.
7
There are two methods of developing relevant
and appropriate outcomes. They can be selected from the set of stan-
dardized patient outcomes in the Nursing Outcomes Classification,
7
or, as demonstrated in the care plan described below, individualized
patient outcome statements relevant to the nursing diagnosis can be
developed. Outcomes incorporate a time frame for achievement
and, as they are the criteria used for evaluation, an indication of how
achievement will be measured is described in the care plan.
Nursing interventions
Once outcomes have been developed and agreed, nursing interven-
tions that facilitate their achievement are planned and implemented.
Planning and using nursing interventions based on good quality
evidence of effectiveness is of importance to ensure that the desired
outcomes of care are achieved. Identifying, appraising, and incorpor-
ating the best currently available research into evidence-based nursing
practice promotes clinically effective quality care.
As in the case of nursing diagnoses and outcomes, a comprehen-
sive set of standardized nursing interventions, known as the
Nursing Intervention Classification, has been developed,
8
and is
linked to both the NANDA-International diagnoses and the
Nursing Outcomes Classification referred to earlier.
Outcomes of care and associated nursing interventions that have
been developed in collaboration with the patient provide a clear
structure for the effective audit of nursing practice, facilitate better
patient adherence to therapeutic regimens, and keep the patient at
the centre of the care process.
IMPLEMENTATION AND EVALUATION
The care plan is then implemented and all interventions and
responses are carefully documented. The outcomes of care are
evaluated on a regular basis and care is re-planned as necessary.
USING A NURSING CARE PLAN
The use of a nursing care plan is best illustrated by a case study.
The one presented here is based on the experience of Jason,
a patient who requires in-patient care and further support in the
community, and illustrates the development of a patient-centred
nursing care plan that incorporates those diagnoses, outcomes,
and interventions frequently identified and developed for patients
with active pulmonary TB, the commonest form of the disease
seen in clinical practice. More comprehensive examples of devel-
oping care plans by using nursing diagnoses, patient outcomes,
and nursing interventions are described in standard nursing text-
books,
4,5,7,8
and an online care plan constructor is available from
the evolve website (http://evolve.elsevier.com/ackley/ndh).
CASE STUDY
Jason is a 26-year-old homeless man who presented to the accident
and emergency department of his local hospital complaining of
a constant cough, haemoptysis, low-grade intermittent fever, and
night sweats for the past month. He states that he has been progres-
sively unwell for the past 6 months, during which time he has lost a
considerable amount of body weight and has become increasingly
fatigued and anxious. He smokes 40 cigarettes a day and states that
he is an alcoholic. Jason has a past history of injecting drug use.
Two years ago he was treated for pneumonia caused by the fungus
Pneumocystis jiroveci. On testing, he was found to be infected with
human immunodeficiency virus (HIV) and was started on antiretro-
viral treatment, but he stated that he rarely took his prescribed HIV
medications and had not taken any medication for the past 2 months.
Jason appeared acutely ill and he was admitted for investigation
and treatment. His blood pressure was low, but within normal limits,
and he had a low-grade fever and some dyspnoea. He was coughing
and sounded congested and said he was too weak to cough up respi-
ratory secretions. Because his presentation clearly suggested a respira-
tory infection, a chest radiograph was taken and a specimen of his
sputum was sent to the laboratory for microscopy and culture. Blood
samples were obtained for assessment of his plasma HIV RNA level
(viral load) and CD4 T-lymphocyte cell count. He was admitted
to a respiratory isolation room and infection prevention precautions
were taken to prevent nosocomial transmission of airborne micro-
organisms. On his second in-patient day, the laboratory reported
a large number of acid-fast bacilli in his sputum, a peripheral blood
CD4 T-lymphocyte cell count of 400 cells/mm
3
and a high HIV
viral load. He was therefore diagnosed as having active HIV-related
pulmonary TB and he was started on anti-TB therapy.
Table 69.2 Categories of nursing diagnoses
5
Category Refers to statement
about
Example (diagnosis)
/.|Je|
d|eqnos|s
/ |ee||| pro||em ||e|
|es |een |den||||ed |e
e.|Je||y ex|s|s end w|||
|ene||| |rom nJrs|nq
|n|erven||on
le||qJe dJe |o edven.ed
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d|eqnos|s
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pe||en| |s e| e ||q|er ||en
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deve|op|nq |n ||e neer
|J|Jre
lne||e.||ve e|rwey
.|eeren.e re|e|ed |o
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men||es|ed |y en
|ne||e.||ve .oJq|
Poss|||e
d|eqnos|s
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|eve |J| w||.| .enno|
|e .on||rmed Jn||| more
|n|orme||on |s o||e|ned
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s|e|e
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d|eqnos|s
/ .|Js|er o| nJrs|nq
d|eqnoses seen |oqe||er
R|s| o| ||e re|o.e||on
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|rens|er |o e |onq|erm
.|ron|. |n|e.||oJs
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e| e ||q| |eve| o|
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ed|eren.e |o en||E
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2CC8 P|||ede|p||e N/ND/ 2CC7 :4: pp
713
CHAPTER
69 Nursing care of patients with tuberculosis
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Jasons nursing assessment was completed and an analysis of the
assessment data indicated the following initial nursing diagnoses:
1. ineffective therapeutic regimen management;
2. risk for infection;
3. fatigue;
4. impaired gas exchange;
5. ineffective airway clearance;
6. imbalanced nutrition;
7. hopelessness; and
8. ineffective health maintenance.
A discussion with Jason resulted in agreement on beneficial
health outcomes and the related interventions needed to achieve
these goals. These were then incorporated into an initial nursing
care plan (Table 69.3).
Because of potential problems with interactions between antiretro-
viral and anti-TB drugs, the physician decided not to recommence
antiretroviral therapy until Jason had successfully completed his
anti-TB treatment. The most frequent drug interactions are seen
between rifamycins (rifampicin, rifabutin) used to treat TB and both
protease inhibitors and non-nucleoside reverse transcriptase inhibitors
Table 69.3 Care plan
NJrs|nq d|eqnos|s l lne||e.||ve ||erepeJ||. req|men meneqemen|
De||n|||on Pe||ern o| reqJ|e||nq end |n|eqre||nq |n|o de||y ||v|nq e proqremme |or |ree|men| o| |||ness end ||s seqJe|ee ||e| |s
Jnse||s|e.|ory |or mee||nq spe.|||. |ee||| qoe|s
De||n|nq .|ere.|er|s||.s C|o|.es o| de||y ||v|nq |ne||e.||ve |or mee||nq qoe|s o| en||E |ree|men| ||e s|e|emen| o| ||e pe||en| ||e| |e d|d no| |e|e
e.||on |o |n.|Jde ||s en||re|rov|re| |ree|men| req|men |n de||y roJ||ne end ||e| |e |ed d||||.J||y w||| |o||ow|nq ||e pres.r||ed
drJq req|men
Re|e|ed |e.|ors
|ee||o|oqy;
L|m||ed Jnders|end|nq o| ||e d|seese end ||s |ree|men| .omp|ex||y o| ||e drJq req|men |ome|essness end .|eo||. |||es|y|e
Outcomes
|.r||er|e |or eve|Je||on;
Pe||en| w||| |||me |reme |o |e spe.|||ed;

D|s.Jss reesons |or noned|eren.e eq se||s|e.||on w||| .Jrren| |||es|y|e end reed|ness |or .|enqe Jnders|end|nq
o| |mpor|en.e o| |ree|men| req|men sJppor| |rom so.|e| serv|.es edeqJe|e ||nen.es |or |reve| |o e||end .||n|. eppo|n|men|s

/..ep| end .oopere|e w||| ||e edm|n|s|re||on o| ||s med|.e||ons w|||e |n |osp||e| end |or .ommJn||y serv|.e errenqemen|s
|or d|re.||y o|served en||E ||erepy w|en d|s.|erqed |rom |osp||e|

/||end e|| .||n|. |o||owJp eppo|n|men|s

SpJ|Jm m|.ros.opy neqe||ve |or /lE w||||n 2 wee|s o| .ere p|en |e|nq |mp|emen|ed
Interventions

Rev|ew se||meneqemen| s|re|eq|es end re|e|ed oJ|.omes

Prov|de eppropr|e|e end re|even| edJ.e||one| sJppor| |o pe||en| |o re|n|or.e ||s Jnders|end|nq o| ||e need |or ed|eren.e |o
||s en||E ||erepy end en||re|rov|re| |ree|men| w|en || |s re.ommen.ed

Rev|ew me||ods o| .on|e.||nq |ee||| prov|der|s; |or .|enqes |n med|.e||on req|men end/or me||od o| |n.orpore||nq
||e req|men |n|o e.||v|||es o| de||y ||v|nq

He|p pe||en| |o errenqe de||y s.|edJ|e |o ed|ere |o d|re.||y o|served |ree|men| |D0; errenqemen|s end |o e||end .||n|.
|o||owJp eppo|n|men|s

Re|er pe||en| |o so.|e| serv|.es |or re|even| |ene|||s end |e|p w||| e..ommode||on

Re|er pe||en| |o eppropr|e|e sJppor| qroJps eq /|.o|o||.s /nonymoJs |//; |or |e|p w||| des|red |||es|y|e .|enqes

Re|er pe||en| |o Hlv//lDS sJppor| orqen|.e||on |or qroJp ess|s|en.e |n ed|eren.e |o en||re|rov|re| ||erepy w|en re.ommen.ed

Re.ord ||e e||e.||veness o| meneq|nq ||e en||E drJq req|men

NJrs|nq d|eqnos|s 2 R|s| |or |n|e.||on
De||n|||on /| |n.reesed r|s| |or |e|nq |nveded |y pe||oqen|. orqen|sms |end oppor|Jn|s||. |n|e.||ons; Po|en||e| r|s| |or noso.om|e|
|rensm|ss|on o| Mycobacterium tuberculosis
Re|e|ed |e.|ors
|ee||o|oqy;
Hlvre|e|ed |mmJnosJppress|on |Jr||er exe.er|e|ed |y e.||ve pJ|monery d|seese pro.ess SpJ|Jm m|.ros.opy pos|||ve |or
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pJ|monery |es|on on red|oqrep|
Outcomes
|.r||er|e |or eve|Je||on;

Resp|re|ory |so|e||on end |n|e.||on .on|ro| pre.eJ||ons e||e.||ve |n preven||nq noso.om|e| |rensm|ss|on o| M. tuberculosis |o
|ee|||.ere personne| pe||en|s end v|s||ors

De.rees|nq |n|e.||v||y resJ|||nq |rom en||E ||erepy

Coopere||on w||| .ons|s|en| .oJq| |yq|ene meesJres

Interventions

lmp|emen| resp|re|ory |so|e||on |e ess|qn |o mon||ored neqe||ve pressJre room

/dm|n|s|er en||E ||erepy

Prov|de eppropr|e|e end re|even| edJ.e||one| sJppor| |o pe||en| |o |e.||||e|e ||s Jnders|end|nq o| ||e need |or
ed|er|nq |o resp|re|ory |so|e||on end Js|nq .oJq| |yq|ene meesJres

lmp|emen| eppropr|e|e |n|e.||on preven||on pre.eJ||ons |or e|r|orne |rensm|||ed m|.roorqen|sms |des.r||ed |n de|e||
|n C|ep|er 68;
NJrs|nq d|eqnos|s : le||qJe
De||n|||on /n overw|e|m|nq end sJs|e|ned sense o| ex|eJs||on end de.reesed .epe.||y |or p|ys|.e| end men|e| wor| e| JsJe| |eve|
De||n|nq .|ere.|er|s||.s lne|||||y |o res|ore enerqy even e||er s|eep |e.| o| enerqy or |ne|||||y |o me|n|e|n JsJe| |eve| o| p|ys|.e| e.||v||y |n.reese |n
res| reqJ|remen|s ||redness |ne|||||y |o me|n|e|n JsJe| roJ|es .omp|e|n|s o| en Jnrem||||nq end overw|e|m|nq |e.| o|
enerqy |e||erq|. or ||s||ess per.e|ved need |or edd|||one| enerqy |o e..omp||s| roJ||ne |es|s .omprom|sed .on.en|re||on
|e.| o| |n|eres| |n sJrroJnd|nqs |n|rospe.||on de.reesed per|ormen.e .omprom|sed ||||do drows|ness |ee||nq o| qJ||| |or no|
|eep|nq Jp w||| respons|||||||es |ne|||||y |o .on.en|re|e wee|ness
Re|e|ed |e.|ors
|ee||o|oqy;
S|eep depr|ve||on |dJe |o .ons|en| .oJq||nq end |ree|||nq d||||.J|||es; me|nJ|r|||on poor p|ys|.e| .ond|||on d|seese s|e|e
|e.||ve pJ|monery E; end edven.ed Hlv d|seese
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Outcomes
|.r||er|e |or eve|Je||on;
Pe||en| w||| |||me |reme |o |e spe.|||ed;

lden|||y po|en||e| |e.|ors ||e| eqqreve|e end re||eve |e||qJe

Repor| |n.reesed enerqy end |mproved we|||e|nq

Use en enerqy .onserve||on p|en |o o||se| |e||qJe

Use en enerqy res|ore||on p|en |o o||se| |e||qJe

Interventions

/ssess sever||y o| |e||qJe e.||v|||es end symp|oms esso.|e|ed w||| |n.reesed |e||qJe e|||||y |o per|orm e.||v|||es o| de||y
||v|nq |/DL;

Lve|Je|e edeqJe.y o| nJ|r|||on end s|eep pe||erns

De|erm|ne w||| .o||eeqJes w|e||er ||ere ere p|ys|.e| or psy.|o|oq|.e| .eJses o| |e||qJe ||e| .oJ|d |e |ree|ed
eq depress|on med|.e||on e||e.|

Prov|de ess|s|en.e w||| /DL es needed

0redJe||y mo||||.e ||e pe||en| es d|seese s|e|e |mproves

Re|er |o nJ|r|||on|s|/d|e||||en |or nJ|r|||one| essessmen|

NJrs|nq d|eqnos|s 4 lmpe|red qes ex.|enqe
De||n|||on Lx.ess or de||.|| |n oxyqene||on end/or .er|on d|ox|de e||m|ne||on e| ||e e|veo|er.ep|||ery mem|rene
De||n|nq .|ere.|er|s||.s v|sJe| d|s|Jr|en.es dyspnoee e|norme| er|er|e| ||ood qes |eve|s |ypox|e |rr||e|||||y s|eep|ness res||essness |ypo or
|yper.epn|e |e.|y.erd|e .yenos|s e|norme| s||n .o|oJr |pe|e dJs|y; |ypoxeem|e |eede.|e on ewe|en|nq e|norme| re|e
r|y||m end dep|| o| |ree|||nq d|ep|ores|s e|norme| er|er|e| ||ood pH nese| ||er|nq
Re|e|ed |e.|ors
|ee||o|oqy;
ven|||e||onper|Js|on |m|e|en.e e|veo|er.ep|||ery mem|rene .|enqes
Outcomes
|.r||er|e |or eve|Je||on;
Pe||en| w||| |||me |reme |o |e spe.|||ed;

Demons|re|e |mproved ven|||e||on end edeqJe|e oxyqene||on es ev|den.ed |y ||ood qes |eve|s w||||n norme|
pereme|ers |or ||e| pe||en|

Me|n|e|n .|eer |Jnq ||e|ds end reme|n |ree o| s|qns o| resp|re|ory d|s|ress

Repor| Jnders|end|nq o| oxyqen sJpp|emen|e||on end o||er ||erepeJ||. |n|erven||ons

Interventions

Mon||or

Resp|re|ory re|e dep|| end e||or| |n.|Jd|nq Jse o| e..essory mJs.|es nese| ||er|nq end e|norme| |ree|||nq
pe||erns

Pe||en|s |e|ev|oJr end men|e| s|e|Js |or ||e onse| o| res||essness eq||e||on .on|Js|on end |e||erqy

0xyqen se|Jre||on .on||nJoJs|y |y meens o| pJ|se ox|me|ry

/r|er|e| ||ood qes resJ||s

0|serve |or

Cyenos|s

S|qns o| psy.|o|oq|.e| d|s|ress eq enx|e|y eq||e||on |nsomn|e

/ss|s| w||| deep |ree|||nq exer.|ses end en.oJreqe pe||en| |o per|orm .on|ro||ed .oJq||nq

/dm|n|s|er |Jm|d|||ed oxyqen es ordered |y ||e p|ys|.|en ||roJq| en eppropr|e|e dev|.e eq nese| .ennJ|e or
ven|Jr| mes| |e|m |or oxyqen se|Jre||on |eve| o| C';

ee.| ||e pe||en|

How |o per|orm pJrsed||p |ree|||nq end .on|ro||ed d|ep|reqme||. |ree|||nq end |ow |o Jse ||e |r|pod pos|||on

How |o Jse pJ|se ox|me|ry |o no|e |mprovemen|s |n oxyqene||on w||| ||ese |ree|||nq |e.|n|qJes

|e |mpor|en.e o| no| smo||nq |o|e..o

Re|er ||e pe||en| |o e p|ys|o||erep|s| |or |ree|||nq exer.|ses end .on|ro||ed .oJq||nq

Re|er ||e pe||en| |o smo||nq .esse||on serv|.es |o |e|p ||e pe||en| s|op smo||nq |o|e..o
NJrs|nq d|eqnos|s b lne||e.||ve e|rwey .|eeren.e
De||n|||on lne|||||y |o .|eer se.re||ons or o|s|rJ.||ons |rom ||e resp|re|ory |re.| |o me|n|e|n e .|eer e|rwey
De||n|nq .|ere.|er|s||.s Dyspnoee d|m|n|s|ed |ree|| soJnds or||opnoee edven||||oJs |ree|| soJnds |re|es .re.||es r|on.|| w|ee.es; |ne||e.||ve
or e|sen| .oJq| spJ|Jm prodJ.||on .yenos|s d||||.J||y vo.e||.|nq w|deeyed .|enqes |n resp|re|ory re|e end r|y||m end
res||essness
Re|e|ed |e.|ors
|ee||o|oqy;
o|e..o smo||nq re|e|ned resp|re|ory se.re||ons ex.ess|ve mJ.Js se.re||ons |n |ron.|| exJde|es |n e|veo||
Outcomes
|.r||er|e |or eve|Je||on;
Pe||en| w||| |||me |reme |o |e spe.|||ed;

Demons|re|e e||e.||ve .oJq||nq end .|eer |ree|| soJnds end |e |ree o| .yenos|s end dyspnoee

Me|n|e|n e pe|en| e|rwey e| e|| ||mes

Re|e|e |o me||ods |or en|en.|nq se.re||on remove|

Unders|end ||e s|qn|||.en.e o| .|enqes |n spJ|Jm |o |n.|Jde .o|oJr .|ere.|er emoJn| end odoJr

lden|||y end evo|d spe.|||. |e.|ors ||e| |n||||| e||e.||ve e|rwey .|eeren.e
Interventions

Mon||or

Eree|| soJnds resp|re|ory re|e dep|| end e||or| o| |ree|||nq

Pe||en|s |e|ev|oJr end men|e| s|e|Js end no|e ||e onse| o| res||essness eq||e||on .on|Js|on end |e||erqy

0xyqen se|Jre||on .on||nJoJs|y |y meens o| pJ|se ox|me|ry

/r|er|e| ||ood qes resJ||s

0|serve |or spJ|Jm no||nq .o|oJr odoJr end vo|Jme

/ss|s| w||| deep |ree|||nq exer.|ses end en.oJreqe pe||en| |o per|orm .on|ro||ed .oJq||nq

Ln.oJreqe ||e pe||en| |o Jse en |n.en||ve sp|rome|er

(Continued)
715
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Table 69.3 Care plan(contd)

Pos|||on pe||en| |o op||m|.e resp|re||on eq |eed o| |ed e|eve|ed 4b

end repos|||oned e| |ees| every 2 |oJrs or |n ||e .ese o|

Jn||e|ere| |Jnq d|seese e||erne|e e sem|low|ers pos|||on w||| e |e|ere| pos|||on |w||| e lC

lb

e|eve||on end qood |Jnq down;

|or 6CC m|nJ|es

Prov|de pos|Jre| dre|neqe

Re|er pe||en| |o p|ys|o||erep|s| |or pos|Jre| dre|neqe per.Jss|on end v||re||on es ordered |y ||e p|ys|.|en

e|e |n|e.||on .on|ro| pre.eJ||ons |o preven| noso.om|e| |rensm|ss|on o| M. tuberculosis w|en ess|s||nq pe||en| w||| e|rwey
.|eeren.e |e pe||en| |o |e |n eJ|ome||.e||y mon||ored neqe||ve pressJre |so|e||on room end |ee|||.ere s|e|| |o
Jse persone| resp|re|ory pro|e.||on .orre.||y |see C|ep|er 68;

/ss|s| w||| .|eer|nq se.re||ons |rom p|erynx |y o||er|nq ||ssJes end qen||e sJ.||on o| ||e ore| p|erynx || ne.essery

/dm|n|s|er oxyqen || end es ordered |y ||e p|ys|.|en

/dm|n|s|er pres.r||ed med|.e||ons eq |ron.|od||e|ors end |n|e|ed s|ero|ds end o|serve |or s|de e||e.|s eq |e.|y.erd|e or enx|e|y

Prov|de ore| .ere every 4 |oJrs |Js|nq e so|| |oo|||rJs|;

Ln.oJreqe e.||v||y end em|J|e||on es |o|ere|ed l| Jne||e |o em|J|e|e ||e pe||en| |Jrn |n |ed |rom s|de |o s|de e| |ees| every
2 |oJrs
NJrs|nq d|eqnos|s 6 lm|e|en.ed nJ|r|||on |ess ||en |ody reqJ|remen|s
De||n|||on ln|e|e o| nJ|r|en|s |nsJ|||.|en| |o mee| me|e|o||. needs
De||n|nq .|ere.|er|s||.s Eody we|q|| < 2C' Jnder |dee| we|q|| pe|e .onjJn.||ve| end mJ.oJs mem|renes sore |n||emed |J..e| .ev||y repor|ed or
ev|den.e o| |e.| o| |ood repor|ed |nedeqJe|e |ood |n|e|e |ess ||en re.ommended de||y e||owen.e |RD/; |e.| o| |n|eres| |n
|ood .ep|||ery |req||||y d|err|oee |ypere.||ve |owe| soJnds m|s|n|orme||on
Re|e|ed |e.|ors lne|||||y |o |nqes| or d|qes| |ood or e|sor| nJ|r|en|s |e.eJse o| ||o|oq|.e| psy.|o|oq|.e| or e.onom|. |e.|ors
Outcomes
|.r||er|e |or eve|Je||on;
Pe||en| w||| |||me |reme |o |e spe.|||ed;

Proqress|ve|y qe|n we|q|| |owerd des|red qoe|

/.||eve e we|q|| w||||n ||e norme| renqe |or |e|q|| end eqe

Re.oqn|.e |e.|ors .on|r||J||nq |o Jnderwe|q||

lden|||y nJ|r|||one| reqJ|remen|s

ConsJme edeqJe|e emoJn|s o| |ood

Ee |ree o| s|qns o| me|nJ|r|||on

Interventions

Mon||or

lor s|qns o| me|nJ|r|||on

We|q|| |y we|q||nq ||e pe||en| de||y |n e.J|e .ere end wee||y |n ex|ended .ere Jnder ||e seme .ond|||ons

S|e|e o| ore| .ev||y prov|de qood ore| |yq|ene |e|ore end e||er mee|s

De|erm|ne |ee|||y |ody we|q|| |or eqe end |e|q||

Re|er pe||en| |o e d|e||||en |or .omp|e|e nJ|r|||one| essessmen| || lC' Jnder |ee|||y |ody we|q|| or || rep|d|y |os|nq we|q||

0|serve ||e e|||||y o| ||e pe||en| |o ee| |||me |nvo|ved mo|or s||||s v|sJe| e.J||y end e|||||y |o swe||ow ver|oJs |ex|Jres o| |ood;

Prov|de .ompen|ons||p e| mee|||mes |o en.oJreqe edeqJe|e nJ|r|||one| |n|e|e

0||er sme|| qJen||||es o| |ood served |n en eppe||.|nq |es||on e| |reqJen| |n|erve|s

Prov|de nJ|r|||one| sJpp|emen|s es pres.r||ed

/dm|n|s|er en||eme||.s end ene|qes|.s es pres.r||ed end es needed |e|ore mee|s

NJrs|nq d|eqnos|s 7 Hope|essness
De||n|||on SJ|je.||ve s|e|e |n w||.| ||e pe||en| sees ||m||ed or no e||erne||ves or persone| .|o|.es eve||e||e end |s Jne||e |o mo||||.e
enerqy on ||s or |er own |e|e||
De||n|nq .|ere.|er|s||.s Pess|v||y de.reesed .onverse||on de.reesed emo||ons ver|e| .Jes |eq sey|nq l .en| or s|q||nq l|| never or ||ere |s no
|J|Jre; .|os|nq o| eyes enorex|e de.reesed responses |o s||mJ|| |n.reesed/de.reesed s|eep |e.| o| |n|||e||ve |e.| o|
|nvo|vemen| |n .ere pess|ve|y e||ow|nq .ere s|rJqq|nq |n response |o spee|er |Jrn|nq ewey |rom spee|er repor||nq |ee||nq
|os| Jne||e |o .ope e|endoned
Re|e|ed |e.|ors /|endonmen| pro|onqed res|r|.||on o| e.||v||y .ree||nq |so|e||on |oss o| |e||e|s |n |rens.enden| ve|Jes/0od |onq|erm s|ress
|e|||nq or de|er|ore||nq .|ron|. p|ys|o|oq|.e| end/or psy.|o|oq|.e| .ond|||on neqe||ve |||e v|ew per.ep||on o| demends ||e|
overw|e|m persone| resoJr.es
Outcomes
|.r||er|e |or eve|Je||on;
Pe||en| w||| |||me |reme |o |e spe.|||ed;

D|s.Jss |ee||nqs end per||.|pe|e |n .ere

Me|e pos|||ve s|e|emen|s |eq l .en or l w||| |ry;

Se| ||emse|ves qoe|s

Me|e eye .on|e.| w||| end |o.Js on ||e spee|er

Me|n|e|n eppropr|e|e eppe|||e |or eqe end p|ys|.e| |ee|||

S|eep eppropr|e|e |enq|| o| ||me |or eqe end p|ys|.e| |ee|||

Lxpress .on.ern |or o||er peop|e

ln|||e|e e.||v||y
Interventions

Lxp|ore pe||en|s de||n|||on o| |ope end ess|s| |n |den|||y|nq soJr.es o| |ope

Mon||or po|en||e| |or sJ|.|de end || eppropr|e|e re|er pe||en| |o psy.||e|r|. serv|.es

/ss|s| pe||en| |n |den|||y|nq reesons |or ||v|nq

De|erm|ne eppropr|e|e epproe.| |o sJppor||nq ||e pe||en| |esed on ||e Jnder|y|nq .ond|||on or s||Je||on .on|r||J||nq
|o |ee||nqs o| |ope|essness eq proqress|ve .|ron|. ||| |ee||| so.|e| .|r.Jms|en.es |one||ness

/ss|s| w||| pro||em so|v|nq end de.|s|on me||nq

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used to treat HIV disease. Because of the increased risk of peripheral
neuropathy, caution is also warranted if patients are taking isoniazid
and the antiretroviral drugs stavudine or didanosine. Both rifampicin
and isoniazid, as discussed in Chapter 59, are essential first-line anti-
TB drugs, making it difficult to effectively treat both TB and HIV
disease simultaneously.
In Jasons case, it was felt safe to postpone re-starting antiretroviral
therapy as his CD4 T-lymphocyte cell count was over 350
cells/mm
3
. Had Jason had a CD4 T-lymphocyte cell count between
100 and 200 cells/mm
3
it is likely that his antiretroviral therapy would
have resumed after 2 months of anti-TBtreatment or as soon as possible
if the CD4 T-lymphocyte cell count was less than 100 cells/mm
3
.
9
While this case report refers to HIV-related pulmonary TB, the
same principles of nursing apply to all types of the disease, including
non-pulmonary manifestations, with the latter also requiring specific
management of, for example, orthopaedic, neurological, genitouri-
nary, and dermatological problems in appropriate care settings.
CONCLUSIONS
Although all patients are different, those with active TB frequently
experience a range of common health problems. The nursing
response to patients with these problems is not a haphazard activ-
ity but rather a systematically planned approach based on the
analysis of good quality patient assessment data. This in turn
drives the development of relevant nursing diagnoses, patient
outcomes, and nursing interventions. The use of international
classifications for nursing practice to depict patient phenomena
and associated nursing interventions and outcomes provides a
shared terminology to describe the elements of nursing practice.
As TB occurs throughout the world, and as nursing science con-
tinues to evolve in different parts of the world, the principle of
the nursing diagnoses as an organizing framework for caring for
patients with this disease is ideal. It allows nurses wherever they
work to compare practice across clinical settings, patient popula-
tions, geographical regions, or time. The nursing care plan
described in this chapter is not meant to be all-inclusive but sim-
ply to demonstrate how it might be used in any patient setting.
Further resources to support the use of nursing diagnoses are
listed in the references.
Preventing the nosocomial transmission of Mycobacterium
tuberculosis in all healthcare environments is an important role
for professional nurses. Evidence-based infection prevention and
control measures for minimizing this risk are describe in detail
in Chapter 68.
REFERENCES
1. International Council of Nurses. Definition of nursing.
Accessed 10 January 2007. Available at URL: http://
www.icn.ch/definition.htm
2. Fawcett J. Contemporary Nursing Knowledge: Analysis and
Evaluation of Nursing Models and Theories, 2nd edn.
Philadelphia: Davis, 2005.
3. Weber JR. Nurses Handbook of Health Assessment, 5th
edn. Philadelphia: Lippincott Williams & Wilkins,
2004.
4. Ackley BJ, Ladwig GB. Nursing Diagnosis Handbook,
7th edn. St. Louis: Mosby Elsevier, 2006.
5. North American Nursing Diagnosis Association-
International (NANDA-I). Nursing Diagnoses:
Definitions and Classification, 20072008. Philadelphia:
NANDA, 2007.
6. International Council of Nurses. International
Classification for Nursing Practice. Accessed 10 January
2007. Available at URL:http://www.icn.ch/icnp.htm
7. Moorhead S, Johnson M, Maas M (eds). Nursing
Outcomes Classification (NOC), 3rd edn. St. Louis:
Mosby, 2003.
8. McCloskey Dochterman J, Bulechek GM. Nursing
Interventions Classification (NIC), 4th edn. St. Louis:
Mosby, 2004.
9. Pozniak AL, Miller RF, Lipman MCI, et al. British
HIV Association (BHIVA) treatment guidelines for
TB/HIV infection 2005. Accessed 10 March 2007.
Available at URL:http://www.bhiva.org

/ss|s| ||e pe||en| |o |oo| e| e||erne||ves end |o se| qoe|s |mpor|en| |o ||m or |er

Ln.oJreqe pe||en| |o per||.|pe|e |n qroJp e.||v|||es

ee.| e||erne||ve .op|nq s|re|eq|es

Re|er pe||en| |o e re|even| sJppor| qroJp

Use |JmoJr es eppropr|e|e

Ln.oJreqe ||e |em||y end o||er peop|e |mpor|en| |o ||e pe||en| |o express ||e|r .ere |ope end e||e.||on |or ||e pe||en|
NJrs|nq d|eqnos|s 8 lne||e.||ve |ee||| me|n|enen.e
De||n|||on lne|||||y |o |den|||y meneqe or see| oJ| |e|p |o me|n|e|n |ee|||
Re|e|ed |e.|ors |r/|; lne||e.||ve |em||y .op|nq per.ep|Je|.oqn|||ve |mpe|rmen| |.omp|e|e or per||e| |e.| o| qross end/or ||ne mo|or s||||s; |e.| o|
s|qn|||.en| e||ere||on |n .ommJn|.e||on s||||s |wr|||en ver|e| end/or qes|Jre|; Jne.||eved deve|opmen|e| |es|s |e.| o|
me|er|e| resoJr.es dys|Jn.||one| qr|ev|nq d|se|||nq sp|r||Je| d|s|ress |ne|||||y |o me|e de|||ere|e end ||oJq|||J| jJdqemen|s
|ne||e.||ve |nd|v|dJe| .op|nq
Outcomes
|.r||er|e |or eve|Je||on;
Pe||en| w||| |||me |reme |o |e spe.|||ed;

D|s.Jss |eer o| |ee||| req|men or ||o.|s |o |mp|emen||nq ||

lo||ow mJ|Je||y eqreed |ee|||.ere me|n|enen.e p|en

Mee| qoe|s |or |ee|||.ere me|n|enen.e

Interventions

/ssess

|e pe||en|s |ee||nqs ve|Jes end reesons |or no| |o||ow|nq ||e pres.r||ed p|en o| .ere

lem||y pe||erns e.onom|. |ssJes end .J||Jre| pe||erns ||e| |n||Jen.e ed|eren.e |o ||e med|.e| req|men

He|p ||e pe||en| |o de|erm|ne |ow |o errenqe e de||y s.|edJ|e ||e| |n.orpore|es ||e new |ee|||.ere req|men eq |e||nq
med|.e||on d|e| .||n|. eppo|n|men|s sJperv|sed ||erepy

Re|er ||e pe||en| |o so.|e| serv|.es |or e.onom|. end |oJs|nq sJppor|

lden|||y re|even| sJppor| qroJp |o prov|de ed|eren.e sJppor| |or pe||en| |e e |Jddy sJppor| sys|em

He|p ||e pe||en| .|oose e |ee|||y |||es|y|e eq .esse||on o| .|qere||e smo||nq end e|.o|o| e|Jse
/dep|ed |rom /.||ey & Ledw|qs NJrs|nq D|eqnos|s Hend|oo|
4
717
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69 Nursing care of patients with tuberculosis
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