Doctor’s order Rationale

8/21/10
10:30pm
 TPR q 4
 BP q 2 H
 Low salt diet
 CBC/Platelet,BT, Urea, HGT, na, K,
SGPT
 U/A
 Chest x-ray, PA view
 ECG
 In am- FBS, Colesterol, Lipid profile
 HDL- LDL, BUN, Uric acid
8:00pm
 Plain NSS, L- KVO rate
Meds.
 aptopril 25mg
 Ranitidine 50mg q 8 Hours IVTT-
ANST(-- )
 Furosemide 60 mg, IVTT now-then
40 mg q 8 Hours with BP precaution
 Fosinopril (BP now) 10 mg, tab OD.
PO
 Ceftriaxone 1 gm q 12 Hours IVTT
ANST( )
 Imdur – 3o mg one half tab OD –pm
 Salbutamol(Duavent)- one half neb
+ 1 cc NSS neb. q 8 Hours
 Insert FBC F16 attach to euro bag
catheter
 I and O q shift
 Refer to Dr. L. Sabal for admittion
 Refer accordingly
11:00pm
 Another captopril 25mg now
 Close watch
8/31/2010
 Aldactone O.D
 For 12 lead ECG
12:45am
 IVF to follow with PNSSiL @ same
rate
9/1/10
12:00pm
 For AFB (Acid Fast Bronchi)
sputum smear
 Ultrasound, FUB profile
 Ranitidine IVTT q 8 hrs
 Maalox q 1 tab TID
9/2/20
3:45pm
 MGH per request
 Maalox
 Lasix
 Phantaloc 20 mg
Diagnosis: Risk for infection
Related factor: Inadequate primary defenses, decrease cillary action/stasis of secretion
Tissue destruction/ extension of infection
Lowered resistance/suppressed inflammatory process
Malnutrition
Environmental exposure
Insufficient knowledge to avoid exposure of pathogens
Nursing Interventions: Rationale

Independent

1. Instruct client to cough/sneeze and ● Behavior’s necessary to prevent spread

expectorate into tissue and to refrain of infection.
from spitting. Review proper disposal
tissue and good hand washing
technique.
● May help client understand need for
2. Review necessity of infection control protecting other acknowledging client’s
measure. sense of isolation and social stigma
associated with communicable diseases.

● Knowledge about this factors help client

3. Identify individuals risk factors for
alter lifestyle and avoid/reduce incidence
reactivation of tuberculosis
of exacerbation.

● Aids in monitoring the effect of

4. Review importance of follow-up and
medication and client response to therapy.
periodic reculturing of sputum for the
duration of therapy

5. Encourage selection/ingestion of ● Presence of anorexia and /or preexisting

well balanced meals. malnutrition lowers resistance to infectious
process and impairs healing.
Dependent
● The goals for treatment of TB are to cure
1. Administer anti-infective agent as
the individual and to minimize transmission
indicated
to other person.
2. Monitor laboratory studies (sputum
● Client who has 3 consecutive negative
smear result)
sputum smears(takes 3-5 months) is
adhering to drug regimen.
Diagnosis: Ineffective airway clearance
Related factors: thick, viscous, or bloody secretion
Fatigue, poor cough effort
Tracheal/pharyngeal edema
Nursing Interventions
Independent:
1. Place client in semi fowler’s
position. Assist client with coughing
and deep breathing exercise
2. Clear secretion from mouth and
trachea, suction as necessary.
3. Maintain fluid intake of atleast
2500ml/day unless contraindicated
4. Note ability to expectorate
mucus/cough effectively, document
character, amount of sputum,
presence of hemoptysis
5. Asses respiratory function
Dependent:
1. Humidify inspired air/oxygen
2. Be prepared for emergency
intubation
Rationale
● positioning help maximize lung
expansion and decreases respiratory
effort.
●prevent obstruction/aspiration.
●high fluid intake may help thin secretions,
making them easier to expectorate.
●expectoration maybe difficult when
secretion are very thick as a result of
infection.
● diminish breath sounds may reflect
atelectasis.
● prevent dying of mucus membranes,
helps thin secretion.
● intubation maybe necessary in rare
cases of bronchogenic TB accompanied
by laryngeal edema.
Diagnosis: Risk for impaired gas exchange
Related factors: Decrease in effective lung surface, atelectasis
Destruction of alveolar capillary membrane
Thick, viscous secretion
Bronchial edema
Nursing Intervention
Independent
1. Asses for dyspnea(using 0-10
scale), tachypnea, abnormal
diminished breath sound.
2. Evaluate change and level of
mentation note cyanosis or change
in skin color.
3. Demonstrate/encourage purse lip
breathing during exhalation.
4. Promote bed rest/limit activity and
assist with self care activities as
necessary
Dependent
1. Monitor serial ABG/pulse oximetry.
2. Provide supplemental oxygen as
appropriate.
Rationale
●Pulmonary TB can cause a wide range of
effect in the lungs.
● Accumulation of secretions/airway
compromise can impair oxygenation of
vital organs and tissue.
● Creates resistance against outflowing air
to prevent collapse
● Reducing oxygen consumption/demand
during periods of respiratory compromise
may reduce severity of symptoms
● Decrease oxygen content or saturation
or increase PaCo2 indicates need for
intervention.
● Aids in correcting hypoxemia that may
occur secondary to decrease
ventilation/diminished alveolar lung
surface.