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NURSING CARE PLAN FOR PULMONARY TUBERCULOSIS (GORDON'S FUNCTIONAL HEALTH PATTERN)
Pulmonary Tuberculosis - Definition, Etiology, Pathophysiology, Clinical Manifestations, Diagnostic Eexamination,
Prevention, Management / Treatment, Assessment and Gordon's Functional Health Patterns
Definition
Tuberculosis is a contagious infectious disease caused by Mycobacterium tuberculosis, an acid-resistant aerobic
bacillus transmitted through the air (airborne). In almost all cases of tuberculosis infection acquired through inhalation
of small particles of bacteria (approximately 1-5 mm).
Etiology
The cause of pulmonary tuberculosis are germs (bacteria) that can only be seen with a microscope, the
mycobacterium tuberculosis. Mycobacterial are aerobic bacteria, shaped stones that form spores.
Pathophysiology
Causes of pulmonary tuberculosis occurs because germs coughed out into droplet nuclei in the air. The infectious
particles can settle in free air for 1-2 hours, depending on the presence or absence of ultraviolet light, poor ventilation
and moisture. In a humid atmosphere and dark germs can hold for days to months. BCG infection particle is inhaled
by healthy people, it will stick to the airway or lungs. Germs will be encountered first by neutrophils, then just by
macrophages. Most of these particles will die or cleared by macrophages out of tracheal bronchial branch, along with
the movement of cilia in the secretions.
When germs settle in the lung tissue, it will multiply in the cytoplasm of macrophages. Here germs can be brought
into other organs. If, entered into the pulmonary artery occurs spreading to all parts of the lungs become miliary
tuberculosis.
Of primary nest will arise inflammation hilar lymph channels leading, and also followed by enlarged lymph nodes
virus. All this process takes 3-8 weeks.
Clinical Manifestations
Clinical symptoms of tuberculosis can be divided into two groups, namely respiratory symptoms and systemic
symptoms.
1. Respiratory symptoms

Cough for more than 3 weeks.

Coughing up blood.

Chest pain.
2. Systemic symptoms

Fever.

Other systemic symptoms: malaise, night sweats, anorexia and weight loss.
Diagnostic Examination

Sputum culture: positive for mycobacterium tuberculosis.

Ziehl-Neelsen: positive for acid fast bacilli.

Skin test (PPD, Mantoux, Pieces volumer) shows: past infection and the presence of anti-bodies, but does
not necessarily reflect active disease.

X-ray of the thorax: early lesions showed infiltration in the lung area above.

Histology or tissue culture: positive for mycobacterium tuberculosis.

Examination of lung function: decreased vital capacity, an increase in dead space, increasing the ratio of
residual air and total lung capacity, and decreased oxygen saturation secondary to parenchymal infiltration
or fibrosis, loss of lung tissue and pleural disease.
Management / Treatment
Assessment of treatment success was based on the results of bacteriological and clinical examination. Good cure
pulmonary tuberculosis will notice sputum smear (-), an improvement of radiology and relieve symptoms.
Complication

Coughing up blood.

Pneumothorax.


Crushed lungs.

Respiratory failure.

Heart failure.

Pleural effusion.
Prevention

Can be done by;

BCG vaccination in infants and children.

Preventive therapy.

Diagnosis and treatment of tuberculosis treatment (+) to prevent transmission.

Assessment
1. Identity of the patient
Consisting of name, age, gender, religion, and others.
2. Health History
The main complaint: Most cases encountered the client in with complaints of cough more than 3 weeks.
The main complaint history: Usually cough experienced more than 1 week accompanied by an increase in body
temperature, decreased appetite and body weakness.
Gordon's Functional Health Patterns
1. Health Perception and Management
View of the patient about the disease and how to deal with patients who carried the disease.
2. Nutritional metabolic
The ability of patients to consume food has decreased due to the lack of appetite / malaise.
3. Elimination
Patients with pulmonary TB is rare impaired bowel and bladder elimination.
4. Activity exercise
Usually, the patient experienced a decrease in activity associated with body weakness experienced.
5. Sleep - rest
Rest and sleep is often disturbed due to cough experienced at night.
6. Cognitive-perceptual
Memory pulmonary TB patients mostly found not impaired.
7. Self perception / self concept
Feelings receive from patients with the situation, most patients are not impaired self-concept.
8. Role Relationship
Changes in the pattern of relations role in responsibilities or changes in physical capacity to perform the role.
9. Se-uality reproductive
The patient's ability to perform in accordance with the gender roles. Most patients do not do se-ual because of the
weakness of the body.
10. Coping-stress tolerance
Defense mechanism used by patients is to seek help from others.
11. Value-Belief Pattern
The religion of the patient and patient compliance in performing religious teachings usually not impaired in patients
sisitem values and beliefs.

Pulmonary Tuberculosis (TB) - 3 Nursing Diagnosis, Interventions

and Rational
Nursing Diagnosis for Plan Tuberculosis (TB) : Ineffective airway clearance related to the
accumulation
of
purulent
secretions
in
the
airway.
Goal:

Airway

clearance

back

effectively.

Nursing Interventions:
Assess respiratory function, for example; breath sounds, speed and rhythm.
Give
the patient semi-Fowler's
position
or
high
Fowler
effectively
the patient to coughand deep breathing exercises.
Maintain fluid intake at least 2500 ml / day, except, contra indications.
Collaboration for the administration of drugs according to indications, mucolytic drugs.

assist

Rational:
Decreased breath sounds may indicate atelectasis, crackles, wheezing showed accumulation of
secretions inability to clean the airway.
The position helps maximize lung expansion and lower respiratory effort.
High input of fluids helps to thin the secretions, making it easily removed.
Mucolytic agents decrease the viscosity and adhesion of lung secretions for easy cleaning.
Nursing Diagnosis for Plan Tuberculosis (TB) : Imbalanced Nutrition Less than Body
Requirements related
to
the
production
of
sputum,
anorexia.
Goal:

Demonstrate

increased

weight.

Nursing Interventions:
Record the patient's nutritional status, record of skin turgor, weight and degree of
underweight, ability / inability to swallow, a history of nausea-vomiting.
Supervise the input or output and weight periodically.
Provide oral care before and after the act of breathing.
Encourage eating little and often with foods high in calories and high in protein.
Collaboration with a nutritionist to determine the composition of the diet.

Rational:
Useful in defining the degree / problems in determining appropriate intervention options.
Useful in measuring the effectiveness of nutrition and fluid support.
Lowering bad taste because the rest of the sputum or leftover medicines.
Maximize nutrient inputs as energy needs and decrease gastric irritation.
Provide assistance in planning a diet with adequate nutrients for metabolic and dietary needs.

Nursing Diagnosis for Plan Tuberculosis (TB) : Knowledge Deficit: on the conditions, rules of
action
and
displacement.
Goal:

To

declare

understanding

of

disease

processes

prognosis

and treatment needs.

Nursing Interventions:
Assess the patient's ability to learn. Example: the problem of weakness, the level
ofparticipation and the best environment.
Emphasize the importance of maintaining a high protein and carbohydrate diet and adequate
fluid intake.
Explain the drug dose, frequency, expected work and long treatment reasons
Emphasize to not drink alcohol and do not smoke.
Rational:
Learning depends on the emotional and physical readiness improved in individualstages.

Meet the metabolic needs, help minimize the weaknesses and improve healing.
Increase cooperation in the treatment program and prevent withdrawal of the drug