552 SECTION 5 Problems of Oxygenation: Ventilation

Oxygen therapy, hydration, nutritional support, and therapeutic positioning are part of your nursing management.

AMBULATORY AND HOME CARE. Teach the patient about the importance of taking every dose of the prescribed antibiotic, any drug-drug and food-drug interactions for the prescribed antibi-otic, and the need for adequate rest to maintain progress toward recovery. Tell patients that it may be several weeks before their

usual vigor and sense of well-being return. A prolonged period of convalescence is especially necessary for the older adult or chronically ill patient.

Teaching should also include information about available influenza and pneumococcal vaccines. Patients can receive the pneumococcal vaccine and influenza vaccine at the same time in different arms.

NURSING DIAGNOSIS Impaired gas exchange related to fluid and exudate accumulation at the capillary-alveolar membrane as evidenced by decreased breath sounds, abnormal arterial blood gases, restlessness, confusion, and somnolence.

PATIENT GOALS 1. Maintains adequate alveolar oxygen-carbon dioxide exchange 2. Clears lungs of fluids and exudates

OUTCOMES (NOC) INTERVENTIONS (NIC) AND RATIONALESRespiratory Status: Gas Exchange Respiratory Monitoring PaO2 _____ PaCO2 _____ Oxygen saturation _____ Chest x-ray findings _____

Auscultate breath sounds, noting areas of decreased/absent ventilation, and presence of adventitious sounds to obtain ongoing data on patients response to therapy.

Monitor rate, rhythm, depth, and effort of respirations to determine respiratory status. Monitor for increased restlessness, anxiety, and air hunger to detect increasing hypoxemia. Monitor patients ability to cough effectively to promote secretion removal.

Oxygen Therapy Administer supplemental oxygen as ordered to promote adequate oxygenation. Set up oxygen equipment and administer through a heated, humidified system to prevent drying of the

respiratory tract. Monitor the effectiveness of oxygen therapy (e.g., pulse oximetry, ABGs). Monitor patients anxiety related to need for oxygen therapy to provide explanations and reassurance. Periodically check oxygen delivery device to ensure that the prescribed concentration is being delivered.

Measurement Scale1 = Severe deviation from normal range2 = Substantial deviation from normal range3 = Moderate deviation from normal range4 = Mild deviation from normal range5 = No deviation from normal range

Dyspnea at rest _____ Dyspnea with mild exertion _____ Restlessness _____ Cyanosis _____

Measurement Scale1 = Severe2 = Substantial3 = Moderate4 = Mild5 = None

NURSING DIAGNOSIS Ineffective breathing pattern related to inflammation and pain as evidenced by dyspnea, tachypnea, nasal flaring, altered chest excursion

PATIENT GOAL Demonstrates effective respiratory rate, rhythm, and depth of respirationsOUTCOMES (NOC) INTERVENTIONS (NIC) AND RATIONALESRespiratory Status: Ventilation Ventilation Assistance Respiratory rate _____ Respiratory rhythm _____

Monitor respiratory and oxygenation status to determine change in status. Position to minimize respiratory efforts (e.g., elevate the head of the bed and provide overbed table

for patient to lean on) to reduce oxygen needs. Encourage slow deep breathing, turning, and coughing to promote effective breathing pattern. Monitor for respiratory muscle fatigue to provide additional support if needed. Assist with incentive spirometer as appropriate to promote alveolar ventilation. Administer medications (e.g., bronchodilators and inhalers) that promote airway patency and gas

exchange.

Tidal volume _____ Depth of inspiration _____

Measurement Scale1 = Severe deviation from normal range2 = Substantial deviation from normal range3 = Moderate deviation from normal range4 = Mild deviation from normal range5 = No deviation from normal range

Dyspnea at rest _____ Restlessness _____ Somnolence _____ Impaired cognition _____

Measurement Scale1 = Severe2 = Substantial3 = Moderate4 = Mild5 = None

NURSING CARE PLAN 28-1Patient with Pneumonia

553CHAPTER 28 Lower Respiratory Problems

EVALUATIONThe expected outcomes for the patient with pneumonia are pre-sented in NCP 28-1.

TUBERCULOSIS

Tuberculosis (TB) is an infectious disease caused by Mycobac-terium tuberculosis. It usually involves the lungs, but can also occur in other parts of the body. TB is the worlds second most common cause of death from infectious disease, after HIV/acquired immunodeficiency syndrome (AIDS).1 Worldwide, TB occurs disproportionately in the poor, the underserved, and minorities. In the United States persons at risk include the homeless, residents of inner-city neighborhoods, foreign-born persons, older adults, those in institutions (long-term care facil-ities, prisons), IV injecting drug users, persons at poverty level, and those with poor access to health care.12 Immunosuppres-sion from any etiology (e.g., HIV infection, malignancy, long-term corticosteroid use) increases the risk of TB infection. The prevalence of TB is higher in areas of the United States where there is a large population of Native Americans, such as Arizona and New Mexico (see Cultural and Ethnic Health Disparities box). Health care workers with increased exposure to TB are considered at high risk.

The incidence of TB worldwide declined until the mid-1980s when HIV disease emerged. The major factors that have con-tributed to the resurgence of TB have been (1) high rates of TB among patients with HIV infection and (2) the emergence of multidrug-resistant (MDR) strains of M. tuberculosis. The rates of TB are now slowly declining again.

Once a strain of M. tuberculosis develops resistance to isonia-zid and rifampin, it is defined as multidrug-resistant tuberculosis (MDR-TB). Resistance results from several problems, including incorrect prescribing, lack of public health case management, and patient nonadherence to the prescribed regimen.13

Etiology and PathophysiologyM. tuberculosis is a gram-positive, acid-fast bacillus that is usu-ally spread from person to person via airborne droplets pro-duced by speaking and coughing. Brief exposure to a few tubercle bacilli rarely causes an infection. TB is more commonly spread by repeated close contact (within 6 inches of the persons mouth)

with the infected person. TB is not highly infectious, and trans-mission usually requires close, frequent, or prolonged exposure. The disease cannot be spread by hands, books, glasses, or dishes.

The very small droplets, 1 to 5 m in size, contain M. tuber-culosis. Because they are so small, the particles remain airborne indoors for minutes to hours. Once inhaled, these small particles lodge in the bronchiole and alveolus. Factors that influence the likelihood of transmission include the (1) number of organ-isms expelled into the air, (2) concentration of organisms (small spaces with limited ventilation would mean higher concentra-tion), (3) length of time of exposure, and (4) immune system of the exposed person. M. tuberculosis replicates slowly and spreads via the lymphatic system. The organisms find favorable environ-ments for growth primarily in the upper lobes of the lungs, kid-neys, epiphyses of the bone, cerebral cortex, and adrenal glands.

ClassificationThe classification system for TB14 is presented in Table 28-8. TB infection occurs when the bacteria are inhaled but there is an effective immune response and the bacteria become inactive. The majority of people mount effective immune responses to

NURSING DIAGNOSIS Acute pain related to inflammation and ineffective pain management and/or comfort measures as evidenced by patient report of pleuritic chest pain and presence of pleural friction rub, shallow respirations

PATIENT GOAL Reports control of pain following relief measuresOUTCOMES (NOC) INTERVENTIONS (NIC) AND RATIONALESPain Control Pain Management Reports pain controlled _____ Described causal factors _____ Uses nonanalgesic relief measures _____ Uses analgesics appropriately _____

Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to determine appropriate interventions.

Encourage patient to monitor own pain and to intervene appropriately to allow independence and prepare for discharge.

Measurement Scale1 = Never demonstrated2 = Rarely demonstrated3 = Sometimes demonstrated4 = Often demonstrated5 = Consistently demonstrated

Teach use of nonpharmacologic techniques (e.g., relaxation, guided imagery, music therapy, distraction, and massage) before, after, and, if possible, during painful activities; before pain occurs or increases; and along with other pain relief measures to relieve pain and reduce the need for analgesia.

Use pain control measures before pain becomes severe because mild to moderate pain is controlled more quickly.

Medicate before an activity to increase participation, but evaluate the hazard of sedation to help minimize pain that will be experienced.

NURSING CARE PLAN 28-1contdPatient with Pneumonia

Of the reported TB cases in the United States, 82% occur in racial and ethnic minorities.

Asians have the highest TB rate of any ethnic group in the United States. Native Hawaiian and other Pacific Islanders have the second-highest TB rate.

African Americans have 45% of the TB cases in U.S.-born persons. Of all the TB cases in the United States, 59% occur in foreign-born

persons. This rate is 10 times higher than U.S.-born persons. The percentage of foreign-born persons with multidrug-resistant TB

has increased from 25% in 1993 to 77% in 2008. Eleven U.S. states (California, Connecticut, Hawaii, Iowa, Massachu-

setts, Minnesota, Nebraska, New Hampshire, New Jersey, Utah, and Vermont) have 70% of their total cases of TB among foreign-born persons.

CULTURAL AND ETHNIC HEALTH DISPARITIES

Tuberculosis

Source: Centers for Disease Control and Prevention: Reported tuberculosis in the United States. Available at www.cdc.gov/tb/statistics/reports/2008/default.htm.