- Deficient Knowledge related to misinterpretation of information and unfamiliarity with information resources as evidenced by request for information and Inaccurate follow-through of instructions
- Imbalanced Nutrition less Than Body Requirements related to Dyspnea, Frequent coughing and financial or socioeconomic factors as evidenced by expressed lack of interest in food and Muscle wasting
- Ineffective Airway Clearance related to Secretions that may be thick, bloody, or viscous and inflammation of the airway as evidenced by Irregular breathing and productive, chronic cough
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Verbalizes poor understanding -Seeks additional information -Denial of a need to learn Objective Data: -Inaccurate demonstration or teach-back of instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment -Avoiding eye contact or remaining silent during teaching | Deficient Knowledge related to misinterpretation of information and unfamiliarity with information resources as evidenced by request for information and Inaccurate follow-through of instructions | Patient will participate in the learning process by asking questions and seeking more information. Patient will verbalize an understanding of their treatment plan by verbalizing their medication regimen and follow-up appointments. Patient will initiate necessary lifestyle changes to prevent transmitting the disease to others | 1. Provide written instructions and an after-visit summary. Provide written details including medication schedules, laboratory testing requirements, and follow-up appointment dates to help relieve any burden of remembering specific details in large amounts. 3. Encourage questions and clarifications. Correcting misunderstandings with the patient and their family will help in preventing misconceptions. Encourage questions to develop trust and ensure thorough comprehension. 4. Explain medication dosages and possible adverse effects. Antibiotic treatment for TB is long; 6 months at the least. Reiterate the importance of not stopping treatment as the bacteria may become resistant, causing multidrug-resistant TB (MDR TB). Serious side effects include liver toxicity, ototoxicity, skin reactions, and more. Explain to contact their doctor if side effects become bothersome. 5. Review how TB is transmitted and reactivation. Knowledge of how an illness is transmitted to other persons will help in preventing the further spread of the disease. Reactivation can occur in patients with weak immune systems and chronic conditions such as HIV, diabetes, or cancer. | Patient participated in the learning process by asking questions and seeking more information. Patient verbalized an understanding of their treatment plan by verbalizing their medication regimen and follow-up appointments. Patient initiated necessary lifestyle changes to prevent transmitting the disease to others |
| Subjective Data: verbalizes not interested to eat food Objective Data: -Muscle wasting -Imbalanced electrolytes | Imbalanced Nutrition less Than Body Requirements related to Dyspnea, Frequent coughing and financial or socioeconomic factors as evidenced by expressed lack of interest in food and Muscle wasting | Patient will demonstrate progressive weight gain toward their individual goal. Patient will display normalization of nutritional laboratory values. Patient will verbalize an improvement in appetite | 1. Monitor intake and output and weigh regularly. Documenting the % of meals consumed along with progress in gaining weight will help determine the effectiveness of nutritional support and interventions. 2. Encourage adequate rest and sleep periods. Conserving energy will help in slowing metabolic processes, especially when the patient is febrile. 3. Encourage small, frequent meals high in fats and protein. Smaller meals require less effort than forcing larger ones, ultimately leading to maximized nutritional intake. 4. Refer to a dietician if necessary. Dieticians will provide accurate adjustments in dietary composition, and in planning a diet with adequate nutrients to meet metabolic requirements, dietary preferences, and financial constraints. 5. Monitor BUN, serum protein, iron, and albumin. Abnormal values indicate malnutrition and may point to a need for further intervention or a change in the therapeutic regimen. 6. Manage side effects of medications. Nausea, vomiting, GI upset, and anorexia are common side effects of TB medications. Administer closer to bedtime if possible to minimize upset. Antiemetics may be required to allow for adequate food intake. | Patient will demonstrate progressive weight gain toward their individual goal. Patient will display normalization of nutritional laboratory values. Patient will verbalize an improvement in appetite |
| Subjective Data: Dyspnea Objective Data: -Adventitious breath sounds -Abnormal respiratory rate, rhythm, and depth -Declining oxygen saturation -Ineffective or absent cough reflex -Copious mucus production -Hypoxemia -Restlessness – Orthopnea | Ineffective Airway Clearance related to Secretions that may be thick, bloody, or viscous and inflammation of the airway as evidenced by Irregular breathing and productive, chronic cough | Patient will display a patent airway as evidenced by unlabored breathing and clear breath sounds. Patient will demonstrate effective clearing of secretions without assistance. Patient will demonstrate and verbalize understanding of behaviors to improve or maintain airway clearance as instructed. | 1. Place the patient in Fowler’s position. Semi or high-Fowler’s position can increase the lung capacity, therefore allowing the patient to breathe more effectively. 2. Instruct on the use of respiratory devices. An incentive spirometer expands the lungs and encourages deep breathing. A flutter valve can mobilize secretions. 3. Suction when necessary. If the patient is unable to expectorate secretions, suctioning may be necessary. Clearing the airways helps in preventing obstruction and aspiration. 4. Administer oxygen if necessary. Oxygen may be needed if a patient is having extreme dyspnea. Oxygen saturation levels that fall below 95 may require the assistance of oxygen delivered by nasal cannula or oxygen masks. 5. Advise the patient to increase their fluid intake unless advised otherwise. Proper hydration helps in thinning secretions, making expectoration easier. | Patient displayed a patent airway as evidenced by unlabored breathing and clear breath sounds. Patient demonstrated effective clearing of secretions without assistance. Patient demonstrated and verbalized understanding of behaviors to improve or maintain airway clearance as instructed. |