topic is PE ( Pulmonary Edema)
Nassau Community College
Nursing Department
NUR 105
“D” Record Sample used only for learning how to write a “D” Record
Student Name: ________________________ Faculty:___________________________ Date: __________________
Medical Diagnosis: Tuberculosis
Pathophysiology-
TB disease is caused by Mycobacterium tuberculosis. If not treated properly, TB disease can be fatal. Mycobacterium tuberculosis is spread by small airborne droplets, called droplet nuclei, generated by the coughing, sneezing, talking, or singing of a person with pulmonary or laryngeal tuberculosis. These minuscule droplets can remain airborne for minutes to hours after expectoration. Introduction of M tuberculosis into the lungs leads to infection of the respiratory system; however, the organisms can spread to other organs, such as the lymphatics, pleura, bones/joints, or meninges, and cause extra pulmonary tuberculosis.
When a susceptible person inhales mycobacteria and becomes infected. The bacteria are transmitted through the airways to the alveoli, where they are deposited and begin to multiply. The bacilli also are transported via the lymph system and bloodstream to other parts of the body (kidneys, bones, cerebral cortex) and other areas of the lungs (upper lobes). The body’s immune system responds by initiating an inflammatory reaction. Phagocytes (neutrophils and macrophages) engulf many of the bacteria, and TB-specific lymphocytes lyse (destroy) the bacilli and nor-mal tissue. This tissue reaction results in the accumulation of exudate in the alveoli, causing bronchopneumonia. The initial infection usually occurs 2 to 10 weeks after exposure. Granulomas, new tissue masses of live and dead bacilli, are surrounded by macrophages, which form a protective wall. They are then transformed to a fibrous tissue mass, the central portion of which is called a Ghon tubercle. The material (bacteria and macrophages) becomes necrotic, forming a cheesy mass. This mass may become calcified and forma collagenous scar. At this point, the bacteria become dormant, and there is no further progression of active disease.
After initial exposure and infection, active disease may develop because of a compromised or inadequate immune system response. Active disease also may occur with reinfection and activation of dormant bacteria. In this case, the Ghon tubercle ulcerates, releasing the cheesy material into the bronchi. The bacteria then become airborne, resulting in further spread of the disease. Then the ulcerated tubercle heals and forms scar tissue. This causes the infected lung to become more inflamed, resulting in further development of bronchopneumonia and tubercle formation. Unless this process is arrested, it spreads slowly downward to the hilum of the lungs and later extends to adjacent tissues.
The common clinical manifestations are a bad cough that lasts 3 weeks or longer, pain in the chest, coughing up blood or sputum, weakness or fatigue, weight loss, no appetite, fever, sweating at night. In terms of contributing factors, TB is a worldwide public health problem that is closely associated with poverty, malnutrition, overcrowding, substandard housing, and inadequate health care. Mortality and morbidity rates continue to rise. (Brunner, 567)
Gerontological Considerations: Although older adults had higher rates of TB and mortality, for older adults who survived therapy, successful treatment outcomes were similar to those of younger adults. (J Am Geriatr Soc. 2011 May;59(5):851-7).
| Significant Diagnostic test Nursing Interventions(NI) for each test
*NI- no jewelry, UCG test prior
*NI- 3 sputum specimens should be used for detection of pulmonary tuberculosis, with specimens collected in the morning on consecutive days. | Medical Management- Identify the collaborative approach and why/how it helps.
First line medications- INH, rifampin (Rifadin), pyrazinamide, and ethambutol (Myambutol). Second-line medications Capreomycin (Capastat),ethionamide (Trecator), para-aminosalicylate sodium, andcycloserine (Seromycin). Additional potentially effective medications include otheraminoglycosides, quinolones, rifabutin, and clofazimine(Lamprene)
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| Anticipated Nursing Diagnosis/Problem: Nutrition, Imbalanced less than body requirements R/T increased caloric requirements 2 TB Supporting Data Night sweats, pain in the chest, severe cough, blood tinged sputum, weakness, fatigue, weight loss, no appetite, chills, and a fever Patient Goal Patient will consume 75% of breakfast and lunch while in my care. Nursing Interventions Ascertain likes and dislikes Promote an environment for eating Weigh pt weekly Lab- albumin, electrolytes, Iron, transferring, CBC Obtain vital signs Nutritional consults Periods of rest and sleep Meds- Anti-TB meds Assess for GI side effects Administer vitamins, PPI or H2 antagonist Provide oral care Encourage fluid intake Assess skin, nails, hair, mucus membranes Encourage small frequent meals Encourage rest | Anticipated Nursing Diagnosis/Problem: Risk for Ineffective Airway Clearance R/T thick Secretions 2 TB Supporting Data Bad for cough 3 weeks Large amounts of thick bloody secretions Chest X-ray indicates infection and secretions Bilateral lung fields with coarse crackles O2 Pulse Ox less than 95% Pain with coughing Patient Goal Patient will maintain a patent airway as evidenced by O2 sat >95% while in my care. Nursing Interventions Administer anti TB meds with patient teaching Perform Vital signs-TPR,BP Obtain Pulse Ox Auscultate Lungs Teach Coughing, Deep Breathing Encourage fluids Incentive spirometer(IS) Promote rest Maintain HOB elevated Assess mental status Assess color, sputum- color, amount, consistency Bronchodilators, mucolytics, cough suppressants/expectorants Teach pt to expectorate Keep suction at bedside | Anticipated Nursing Diagnosis/Problem: Social Isolation R/T Airborne Precautions Supporting Data Placed in a negative-pressure room Limited contact with health care staff Family Unable to visit for long periods N-95/high-efficiency particulate air filters are worn when people enter Patient unable to walk in halls Patient Goal Patient will verbalized alternate opportunities to promote increased interactions while in my care. Nursing Interventions Establish therapeutic nurse/pt relationship by: Calling pt by name, being truthful. Use the phone to call the patient Use therapeutic communication techniques: open ended questions, Clarification, Use silence, Therapeutic touch Encourage diversional activities - -Guide imagery -Deep breathing exercises -Music/TV Encourage personal belongings Identify community resources Assess support systems (family, community, spirituality) Assess developmental level Encourage staff interaction |
Other Nursing Diagnoses:
Infection transmission
References:
Use APA style format
PM 12/11, rev BMF 011818
