Question

The client comes in to the Emergency Room with complaints of difficulty breathing, productive cough, malaise, and night sweats. He is currently living in a 1 bedroom apartment with his wife, brother, sister-in-law and 3 small children. His vital signs are as follows: T 100.5 F, P 88, RR 20, BP 132/65, SpO2 89% on room air, weight is 99 lbs. He complains of chest pain 8/10. He is diagnosed with active tuberculosis (TB).

• Discuss 3 priorities for nursing care for this client and explain the rationale for each.
• Explain why adherence to TB treatment can be challenging for clients and their families. Discuss 3 strategies that could be used to help the client be compliant with his drug therapy.
• The client states, "I would rather go home and take my medication." List three goals for the client before he can be discharged home.
• Develop a teaching plan for a client that requires a daily sputum collection for acid-fast bacteria (AFB) for the next three days. The client asks, "Why don't you just collect all three and leave me alone?" Provide a response to this question.
• The physician orders isoniazid, 15 mg/kg IV daily. The dose is diluted in a total volume of 500 ml normal saline. The provider orders the infusion over 2 hours. The drop factor on the tubing is 15 drops per 1 ml. What is the dose of isoniazid to be administered if the pharmacy sends a vial labeled 100 mg of isoniazid per 1 ml? (Round any answer to the nearest tenth) What is the IV pump rate?

Answer 1

3 priority nursing care for a client with C/O difficulty breathing, productive cough, malaise, and night sweats, vital signs: T 100.5 F, P 88, RR 20, BP 132/65, SpO2 89% and chest pain of 8/10.

Ans: Three priority wise nursing care may include:

1. Pain relief - as pain can have a negative effect on other vital signs. Pain may increase the heart rate,breathing and blood pressure too. So pain must be adressed first.

2. Improving the gas exchange and breathing pattern to improve the SPO2 level - difficulty in breathing and productive cough may be the major reasons for low SPo2 that inturn may lead to hypoxia of vital organs. Gas exchange and breathing can be promoted with supplemental oxygen, a comfortable fowler's or semi fowler's position and Suctioning to remove secretions.

3. Reducing hyperthermia - Fever indicates an active infection and persistent hyperthermia can cause further damage to body tissues. So nursing care measures for symptomatic management of hyperhermia with proper I.V antibiotics on physician's advice  may help to bring down body temperature.

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Explain why adherence to TB treatment can be challenging for clients and their families. Discuss 3 strategies that could be used to help the client be compliant with his drug therapy.

Ans: Non adherence to anti tuberculosis treatment is not uncommon among TB patients. Some of the reasons for this may be, poor communication between healthcare providers and patients causing inadequate understanding about the disease and treatment strategies and the length of treatment, loss of employment due to myths in the society followed by  financial difficulties, lack of access to health care services, social stigma and discrimination, side effects of the anti TB drugs and beliefs in traditional healing system. .

Strategies that could help in improving compliance with therapy may include:

1. Health education: teach the client and family that regular intake and completing the treatment regimen gives them the best chance to get fully cured and also will protect the community from the spread of TB.

2. Supervision and support: Periodic home visits or patients visit to the health care facility may help in continued follow up on patient's adherence to treatment schedule may help to keep a track. Also support the patient by recognising and managing the side effects of anti TB drugs.

3.Removing the barriers to treatment: by ensuring that the drugs are delivered at affordable costs or free of cost as per government policies, prompt detection and managment of drug reactions and promoting peer group support,

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The client states, "I would rather go home and take my medication." List three goals for the client before he can be discharged home.

1. Preventing the spread: to follow respiratory isolation protocols (eg:wearing mask, proper disposal of used tissues and mask), avoiding close contacts,make sure family members are tested negative for TB.

2.Proper adherance to treatmenrt regimen: make sure that multi drug regimen is started and patient is tolerating with it. Patient should be medically stable.

3.High risk individuals: Small children and elderly in the family,if expoused to the patient already, then the patient should undergo 3 consecutive AFB smears and the count should show a decline in the bacilli count.

4. Follow up plan: establish a plan for periodic follow up before discharge and make sure the client understands that.

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Develop a teaching plan for a client that requires a daily sputum collection for acid-fast bacteria (AFB) for the next three days.

Teaching plan should include the following points:

1. Best time in the day to collect sputum for AFB is early in the morning upon waking up.

2. Collect the specimen before brushing

3. To keep the specimen away from direct sunlight as UV rays from sun may kill the TB bacteria and alter the test results.

4.Take several deep breaths and then cough deeply from the chest into the container.

4. Specimen should not be contaminated with saliva of secretions from the nose.

5. Transport the specimen to the lab as soon as possible each day and not to hold for 3 days to transport all three specimen bottles together.

6. If there's delay in transportation refridgerate and store the specimen until its ready to be transported.

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Response to the client statement of taking all 3 specimens together: "The sputum test results are to be accurate. Collecting multiple sputum specimens can help to obtain a more accurate result and helps to understand the current health status too."

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The physician orders isoniazid, 15 mg/kg IV daily. The dose is diluted in a total volume of 500 ml normal saline. The provider orders the infusion over 2 hours. The drop factor on the tubing is 15 drops per 1 ml. What is the dose of isoniazid to be administered if the pharmacy sends a vial labeled 100 mg of isoniazid per 1 ml?

Clients body weight = 99lbs= 45kgs approximately

Dosage ordered by physician = 15mg/kg/day = 15 x 45 = 675mg of Isoniazid per day

Dose of Isoniazid send from pharmacy = 100mg of isoniazid per ml

Amount of drug to be taken from the vial for a day = 675 / 100 = 6.75ml. That can be rounded to the nearest tenth as 6.8ml.

Now the physicians order is to dilute required dose of isoniazid in 500 ml NS and administer over 2hrs

So from the vial send from pharmacy you need to take 6.8 ml and mix in 500 ml of NS

Now we have 506.8 ml of Ns to be run over 2 hrs and the drop factor is 15drops

So drops/minute = (Total volume / time in minutes ) X drop factor

= (506.8 / 120) x 15 = 63.3 = 63 drops per minute.

So the infusion can be set at the rate of 63 drops per minute.