Pulmonary Tuberculosis

Pulmonary Tuberculosis

INTRODUCTION A. Background of the Study Pulmonary tuberculosis, a chronic sub-acute or acute respiratory disease commonly affecting the lungs characterized by the formation of tubercles in the tissues which tend to undergo cessation, necrosis and calcification. It is also known as poor man’s disease or consumption disease. The causative agent in this disease is Mycobacterium Tuberculosis, a rod shaped bacteria. The disease is transmitted by deliberate inoculation of microorganisms by droplet. This disease is transmitted to other people through the inhalation of organisms directly into the lungs from contaminated air. According to the department of Health (DOH) PTB is the 6 th cause of mortality and morbidity in the Philippines as of 2007. This disease is can be acquired easily by person being in contact with an infected one, when you are living in a crowded area like the squatter’s area and when you have poor nutrition. It is commonly present in third world or developing countries like the Philippines. In 2004, mortality and morbidity statistics included 14.6 million chronic active cases, 8.9 million new cases, and 1.6 million deaths, mostly in developing countries. In addition, a rising number of people in the developed world are contracting tuberculosis because their immune systems are compromised by immunosuppressive drugs, substance abuse, or AIDS. The distribution of tuberculosis is not uniform across the globe with about 80% of the population in many Asian and African countries testing positive in tuberculin tests, while only 5-10% of the US population testing positive. B. Rationale for Choosing the Case The researchers decided to choose this case because they wanted to acquire more knowledge about Pulmonary Tuberculosis. They wanted to use the knowledge that they have acquired in promoting awareness to the people especially to the poor that they should seek for medical care in order to prevent the development and progression of PTB. The researchers also wanted to focus on preventive measures. PTB can cause Tuberculosis meningitis, a very rare and fatal disease and the researchers would not want that to happen, so they will focus more on information campaign as part of primary prevention of health. Presently our country has so many cases of PTB.

C. Significance of the Study This study will help the nursing profession by providing information about the proper management and care for PTB patient. It will also educate the people, especially those with PTB and vulnerable individuals to seek medical care in order to prevent TBM. It will increase awareness about the importance of having a healthy lifestyle and clean environment. This study will elaborate the inter relatedness of environment, life style habits and acquiring Pulmonary Tuberculosis. D. Scope and Limitation of the Study This study is focused on the nursing aspect of care to those patients who have Pulmonary Tuberculosis. This study will only be used in the nursing profession. The researchers only focused their attention on the medications, diagnostics, care plan, pathophysiology and discharge planning. This study is not limited to the PTB patients only, but it is for all people who are interested in PTB. We are more focused on primary prevention through health education because primary prevention is the true prevention. I.

HEALTH HISTORY

A. Demographic Data: 1. Name: Orly Calinawan Reyes 2. Gender: Male 3. Age: 37 4. Birth date: October 08, 1972 5. Civil status: Single

6. Nationality: Filipino 7. Religion : Roman Catholic 8. Address : Sulok, Panapaan 3 Bacoor, Cavite

9. Occupation:

B. Source and Reliability of Information:

C. Chief Complaint: The patient was diagnosed pulmonary tuberculosis March 4, 2009 at the Health Center in Panapaan. The patient was due to the complaint of difficulty of breathing (DOB) and cough for more than 1 month. He was attended at that day in Health Center and had taken a clinical history and physical assessment. D. History of Present Illness: Patient’s condition started about 1 month prior to consultation, as onset of cough, non-productive and an intermittent fever usually in the afternoon, moderate grade temperature which are not documented. According to him it was relieved by an intake of paracetamol. One week prior to admission the patient experienced worsening of the condition, he had productive cough bloody with whitish secretions. There is also difficulty of breathing, and weakening. The patient can’t eat properly

because he has no appetite for food. He also experience stabbing pain on her chest according to the assessment it is 6/10 and it radiates to his back. The patient only took paracetamol for her fever. On the day of March 4, 2009 he was rushed to the health center because of difficulty of breathing. Previously when he started experiencing these conditions, he does not seek for any medical care from the physician because according to him it is still tolerable. E. Past Medical History: The patient had no any upper respiratory tract infection when he was a child. Previously he was not hospitalized. He does not have complete immunizations because according to him it is not available in their place during those days, he has no history of hypertension and Diabetes mellitus. Whenever he had any flu or cough, he uses herbal plants. He does not have any regular medical and dental check-ups. He does not have allergies to what ever kind of foods and medications as far as she knows. Whenever he had fever he takes Paracetamol and Bioflu. He does experience any severe accidents. F. Family History:

G. Socio-economic:

H. Developmental History:

I. Review of System: 1. Physical Assessment AREA A. SKULL

TECHNIQUE

NORMS

FINDINGS

ANALYSIS and INTERPRETATION

1. Size, shape and symmetry of the skull

Inspection Palpation

Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour

Rounded(normocephalic) ; smooth skull contour

Normal

2. Presence of nodules, masses, and depressions

Palpation Inspection

Smooth, uniform consistence; absence of nodules or masses

Has no tenderness; no masses nor nodules

Normal

3. Facial Features

Inspection Palpation

Symmetric or slightly asymmetric facial features; palpebral fissure equal in size; symmetric nasolabial

Symmetrical and palpebral fissure equal in size, nasolabial folds are symmetrical

Normal

Inspection

No edema and hollowness

Has Hollowness

Abnormal, Volume deficiency of fat within the orbit (the space inside of the bony eye socket). This condition of the patient is related to his nutritional status, she is malnourished. Her BMI is 12.5. (http://www.drmeronk.com/hollowed/undereye-hollows.html)

1. Evenness of growth, thickness, or thinness of hair

Inspection Palpation

Evenly distributed and covers the whole scalp; Maybe thick or thin

Evenly distributed with no patches of hair loss; thick hair

Normal

2. Texture and oiliness over the scalp

Inspection Palpation

Silky; resilient hair

Silky, smooth and resilient hair

Normal.

3. Presence of infection and infestation

Inspection Palption

No infection and infestation

Presence of lice

Abnormal, There is pediculosis, a type of parasitic infection. Lice may be contracted from infcetd clothes and direct contact with an infected person. The idea is that an oily substance, such as oil, smothers the lice and they may die. (Kozier, Fundamentals of Nursing 7th ed. Page 733)

Inspection

Symmetric or slightly asymmetric facial features; palpebral fissures

Symmetrical facial features while talking or elevating the eyebrow. Equal palpebral fissure,

Normal

4. Presence of edema and hollowness in the eye.

C. HAIR

D. FACE Facial features, symmetry of facial movements

equal in size; symmetric nasolabial folds

symmetrical nasolabial folds.

Inspection

Symmetrical and in line with each other; maybe black, brown or blond depending on race; evenly distributed

Symmetrical and aligned with each other; black; evenly distributed. Movements are symmetrical.

Normal

Inspection Palpation

Evenly distributed; turned outward

Turned outward eyelashes; hair equally distributed

Normal

Inspection

Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open; eyelids meet completely when the eyes are

Able to close the eyes and has the ability to blink.

Normal

IV. EYES A. EYEBROWS Hair distribution, alignment, skin quality and movement

B. EYELASHES Evenness of distribution and direction of curl C. EYELIDS Surface characteristics and position (in relation to the cornea, ability to blink, and frequency of blinking)

closed; symmetrical D. CONJUNCTIVA 1. Color, texture, and the presence of lesions in the bulbar conjunctiva

Inspection Palapation

Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers

Pale color; smooth in texture

Abnormal, pale conjunctiva may be related to the low RBC level of the patient. (Fundamentals of Nursing 5th edition by Taylor, page 642)

2. Color, texture, and the presence of lesions in the palpebral conjunctiva

Inspection Palpation

Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers

Pale

Abnormal, pale conjunctiva may be related to the low RBC level of the patient. (Fundamentals of Nursing 5th edition by Taylor, page 642)

Inspection

White in color; clear; no yellowish discoloration; some capillaries maybe visible

White sclera with some visible capillaries, anicteric sclera.

Normal

Inspection

No irregularities on the surface; looks smooth; clear or

Clear and smooth in texture

Normal

E. SCLERA Color and clarity

F. CORNEA Clarity and texture

transparent G. IRIS Inspection

Anterior chamber is transparent; no noted visible materials; color depends on the person’s race

Dark brown in color; transparent anterior chamber

Normal

1. Color, shape, and symmetry of size

Inspection

Color depends on the person’s race; size ranges from 37 mm, and are equal in size; equally round

Pupil size is 3mm.

Normal

2. Light reaction and accommodation

Inspection

Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual

Dilates when looking at far objects and constricts when looking at near objects. Constricts when there is light.

Normal

Inspection

Able to read newsprint

Nearsightedness (Myopia)

Abnormal, it is a refractive defect of the eye in which collimated light produces

Shape and color

H. PUPILS

I. VISUAL ACUITY 1. Near vision

image focus in front of the retina when accommodation is relaxed. It is caused by an eyeball that is longer than normal, which may be a familial trait. Transient mayopia occurs due to influenza, steroids, sever dehydration and large intake of antacids. (Black, Medical Surgical Nursing7th edition, page 1963). J. LACRIMAL GLAND Palpability and tenderness of the lacrimal gland

Palpation

No edema or tenderness over lacrimal gland

No tenderness and edema noted.

Normal

Inspection

Both eyes coordinated, move in unison, with parallel alignment

Moves in Unison

Normal

Inspection

When looking straight ahead, client can see objects in the periphery

Can see objects in the periphery.

Normal

K. EXTRAOCULAR MUSCLES Eye alignment and coordination

L. VISUAL FIELDS Peripheral visual fields

V. EARS A. AURICLES 1. Color, symmetry of size, and position

Inspection

Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees from vertical

Same color as the facial skin; tip of auricle aligned at the outer canthus of the eye.

Normal

2. Texture, elasticity and areas of tenderness

Palpation

Mobile, firm, and not tender; pinna recoils after it is folded

Smooth in texture, flexible Normal and elastic pinna; no tenderness

Inspection

Normal voice tones audible

Can hear normal volume tones or words.

Normal

Inspection

Symmetric and straight; no discharge or

Symmetric and straight; Uniform color with nasal

Abnormal, Nasal flaring suggests airway obstruction. Nasal discharge shows the presence of mucus secretions in the air

C. HEARING ACUITY TESTS 1. Client’s response to normal voice tones

VI. NOSE 1.Any deviations in shape, size, or color and flaring or

discharge from the nares

flaring; Uniform color

flaring.

tract.

2. Nasal septum (between the nasal chambers)

Inspection Palpation

Nasal septum intact Nasal septum intact and and in midline in midline

Normal

3. Patency of both nasal cavities

Inspection

Air moves freely as the client breathes through the nares

Only left nares is patent. Right nares is with secretion.

Abnormal, not patent right nares show the presence of mucus secretions and would suggest there is an infection in the respiratory system.

Palpation

Not tender; no lesions

Nor tenderness nor lesions.

Normal

Inspection

Not tender

Not painful when palpated

Normal

Inspection Palpation

Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse lips

Pink in color, dry and cracked lips

Abnormal, May suggest cellular dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

4. Tenderness, masses, and displacements of bone and cartilage VII. SINUSES Identification of the sinuses and for tenderness VIII. MOUTH A. LIPS Symmetry of contour, color and texture

B. BUCCAL MUCOSA Color, moisture, texture, and the presence of lesions

Inspection

Uniform pink color; moist, smooth, soft, glistening, and elastic texture

Pink color and dry.

Abnormal, May suggests dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

Inspection

32 adult teeth; smooth, white, shiny tooth enamel; smooth, intact dentures

Have 31 adult teeth. The patient has yellowish teeth. Have bad breath. Have tooth decay in the lower right second molars.

Abnormal, most unpleasant odors are known to arise from proteins trapped in the mouth which are processed by oral bacteria. The most common location for mouth-related halitosis is the tongue. It is also related to dental carries and frequency of tooth brushing.

Inspection

Pink gums; no retraction

Pink gums; has no visible retractions

Normal

1. Color and texture of the mouth floor and frenulum.

Inspection

pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness

Pink and moist. Tongue moves freely and no pain felt.

Normal

2. Position, color and

Inspection

Central position; pink

Located and positioned in the

Normal

C. TEETH Color, number and condition and presence of dentures

D. GUMS Color and condition

E. TONGUE/FLOOR OF THE MOUTH

texture, movement and base of the tongue

color; smooth tongue base with prominent veins

center.

Palpation Inspection

Smooth with no palpable nodules, lumps, or excoriated areas

No tenderness nor masses

Normal

1. Color, shape, texture and the presence of bony prominences

Inspection Palpation

Light pink, smooth, soft palate; lighter pink hard palate , more irregular texture

The hard palate has a lighter color than the soft palate; has quite rough texture

Normal

2. Position of the uvula and mobility (while examining the palates)

Inspection

Positioned in midline of soft palate

Positioned at the center of the oropharynx

Normal

1. Color and texture

Inspection

Pink and smooth posterior wall

Dry, pinkish in color.

Abnormal, May suggests dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

2. Size, color, and discharge of the tonsils

Inspection

Pink and smooth; no discharge; of normal size

Has no discharge; pinkish

Normal

3. Gag reflex

Inspection

Present

Present

Normal

3. Any nodules, lumps, or excoriated areas

F. PALATES and UVULA

G. OROPHARYNX and TONSILS

X. THORAX A. ANTERIOR THORAX 1. Breathing patterns

Inspection

Quiet, rhythmic, and effortless respirations

Difficulty of breathing

Abnormal, labored breathing is a common manifestation affecting clients with cardiac and pulmonary disorders. It is related to obstructed airway. It also related to the decreased size of the lungs due to PTB. (Black, Medical Surgical Nursing7th edition, page 1566).

2. Temperature, tenderness, masses

Palpation

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

Has an intact skin; has equal warmth on both sides. No masses.

Normal

Auscultation

Bronchovesicular and vesicular breath sounds

Has crackles sounds on the upper thorax & lower thorax

Abnormal, crackles or rales are audible when there is a sudden opening of small airways that contain fluid. It is usually heard during inspiration. (Black, Medical Surgical Nursing7th edition, page 1756).

1. Shape, symmetry, and comparison of anteroposterior thorax to transverse diameter

Inspection Palpation

Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric

Has a anteroposterior to transverse diameter ratio of 1:2, elliptical in shape and symmetrical chest

Normal

2. Spinal alignment

Inspection

Spine vertically aligned

Has a vertical alignment

Normal

3. Anterior thorax auscultation

B. POSTERIOR THORAX

3. Temperature, tenderness, and masses

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

No masses nor tenderness; has equal warmth on each side

Normal

Auscultation

Vesicular and bronchovesicular breath sounds

Has crackles heard on the anterior and middle part of right and left lungs. Diminished lung sound on the posterior right lung.

Abnormal, the condition is related to the decreased size of the right lung and poor inspiratory effort due to pain.

A. AORTIC and PULMONIC AREAS

Auscultation

No pulsations

No pulsations felt

Normal

B. TRICUSPID AREA

Auscultation

No pulsations; no lift or heave

No pulsations of lifts

Normal

C. APICAL AREA

Auscultation

Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL

Has full pulsation

Normal

D. EPIGASTRIC AREA

Auscultation

Aortic pulsations

Has pulsation

Normal

E. CARDIOVASCULAR AREAS AUSCULTATION

Auscultation

S1: Usually heard at all sites

Has full and rapid pulsation. 84 bpm/minute.

Normal

Usually louder at the apical area

Sounds on the aortic and pulmonic areas; has a lub

7. Posterior thorax auscultation

Palpation

XI. CARDIOVASCULAR

S2: Usually heard at all sites

sound on the apex and dub sounds on the tricuspid area.

Usually louder at the base of heart

Blood pressure is 90/70 mm Hg.

Normal

Normal

Systole: silent interval; slightly shorter duration than diastole at normal heart rate (60 to 90 beats/min) Diastole: silent interval; slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults XII. CAROTID ARTERIES 1. Carotid artery palpation

Palpation

Symmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from

Has weak pulsation. Symmetrical pulse.

Abnormal, decreased amount of blood volume passing the artery. (Black, Medical Surgical Nursing7th edition, page 1574).

sitting to supine position; elastic arterial wall XIV. AXILLAE 1. Axillary, subclavicular, and supraclavicular lymph nodes

Inspection

No tenderness, masses, or nodules

Have no masses and nodules. Presence of a foul smelling odor.

Abnormal, The appocrine glands located in the axillae produces sweat. The secretion of these glands is odorless, but when decomposed or acted upon by bacteria in the skin, it takes on a musky, unpleasant odor. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 699)

1. Skin integrity

Inspection

Unblemished skin; uniform color

Uniform color and has no blemishes

Normal

2. Abdominal contour

Inspection

Flat, rounded(convex), or scaphoid(concave)

Has a concave abdomen.

Normal

3. Enlargement of liver or spleen

Inspection

No evidence of enlargement of liver or spleen

No enlargement of the spleen and liver seen

Normal

4.Symmetry of contour

Inspection

Symmetric contour

Has a symmetrical abdominal contour

Normal

5. Abdominal movements associated with respirations, peristalsis or aortic pulsations

Inspection

Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic

Abdominal movements noted when inhaling.

Normal

XV. ABDOMEN

pulsations in thin persons at epigastric area 6. Vascular pattern

Inspection

No visible vascular pattern

Has no blood vessels visible

Normal

1. Muscle size and comparison on the other side

Inspection

Proportionate to the body; even in both sides

Proportionate to the body; even in both sides

Normal

2. Fasciculation and tremors in the muscles

Inspection

No fasciculation and tremors

Has no fasciculation and tremors

Normal

3. Muscle tonicity

Palpation

Even and firm muscle tone

Weak muscle tone

Abnormal, possibly related to the amount of food that patient is eating. Possible exhaustion experienced by the patient when she coughs.

4. Muscle strength

Palpation

Has equal muscular strength on both sides

Weak muscle strength

XVI. MUSCULOSKELETAL SYSTEM

A. MUSCLES

(http://en.wikipedia.org/wiki/Muscle_weakness)

Abnormal, possibly related to the amount of food that patient is eating. Possible exhaustion experienced by the patient when she coughs. (http://en.wikipedia.org/wiki/Muscle_weakness)

C. JOINTS

1. Joint swelling

Inspection

No swelling, no warmth, no redness, no pain, no crepitus

No swelling, no warmth, no redness, no pain, no crepitus

Normal

EXTREMETIES

Inspection, Palpation

No swelling, no warmth, no redness, no pain.

No edema, no pain when moved.

Normal

Neurologic Assessment: Category

Normal Findings

Actual Findings

Analysis and interpretation

Mental Status Level of Consciousness

Alert

Alert

Normal

Orientation

Oriented

Normal

Language test

Coherent

Oriented to person, time and place. Coherent

Recall

Able to remember

Able to state what happened to her in the past.

Normal

Normal

Cranial Nerves CN 1 Olfactory

Able to smell and recognize stimuli

Able to identify the scent of the alcohol

Normal

CN 11 Optic

20x20 vision, able to read, 3-5 mm [pupil size]

Pupil size is 3 mm, able to read, myopia or nearsightedness.

Abnormal, it is a refractive defect of the eye in which collimated light produces image focus in front of the retina when accommodation is relaxed. It is caused by an eyeball that is longer than normal, which may be a familial trait. Transient mayopia occurs due to influenza, steroids, sever dehydration and large intake of antacids. (Black, Medical

CN III, IV, VI Occulomotor Trochlear Abducens

(+) Extraoccular Movement (EOM); Lateral Upward and downward; pupils reactive to light.

Surgical Nursing7th edition, page 1963).

CN V Trigeminal

CN VII Facial CN VIII Vestibulocochlear

Able to feel and clearly identify stimulus, with bilateral facial sensation. With active corneal reflex.

Normal Pupils react to light. There is constriction and consensual accommodation. Able to move the eyes in any direction in unison.

Normal Able to feel my finger on her face while covering her eyes.

(+) Corneal reflex , Facial asymmetry

(+) Facial symmetry

Normal

Able to hear clearly, can maintain balance

Can hear clearly and can walk.

Normal

Present gag reflex, able to

CN IX, X Glossopharyngeal Vagus

(+) gag reflex, uvula at the center, soft palate rises

CN XI Accessory (Spinal)

Able to shrug shoulders against resistance and able to turn the head side and against resistance. Able to move tongue from side to side

swallow and able to idebtify the taste of the food. Can shrug shoulders against resistance and can turn the head fro right to right.

Able to protrude the tongue and move it side to side.

Normal

Normal

Normal

CN XII Hypoglossal Muscle Strength

MNT Grading System:

Left Arm

(+5) Active motion against full resistance

+4 active motion against some resistance.

Right Arm

(+5) Active motion against full resistance

+4 active motion against some resistance.

Abnormal

Left Leg

(+5) Active motion against full resistance (+5) Active motion against full resistance

+4 active motion against some resistance. +4 active motion against some resistance.

Abnormal

Abnormal, possibly related to the amount of food that patient is eating. Possible exhaustion experienced by the patient when she coughs. (http://en.wikipedia.org/wiki/Muscle_weakness)

Right Leg

Abnormal

2. Laboratory Studies / Diagnostics Classification of TB: •

Pulmonary:

Category 1.2HRZE / 4HR Smear (+) SPUTUM EXAMINATIN RESULTS / WEIGHT RECORD

4/22/09

DATE OF EXAMINATON 3/02/09 4/22/09

RESULT 3+ 0

WEIGHT (kg) 50 kg 50 kg

6/10/09

6/10/09

1+

7/15/09 9/15/09

7/16/09 8/18/09 9/09/09

+5 0 0

55 kg 55 kg 58 kg 58 kg

MONTH O 2 3

DUE DATE

4

5 6 7

Laboratory and Diagnostic Examination DATE Sept. 19, 2008

PROCEDURE Hemoglobin Hematocrit RBC count WBC Neutrophils

NORMS 120-160g/L 0.38-0.40 g/L 4’2-5.4x 1012 per liter 5-10x109/L 81.3%

RESULT

INTERPRETATION and ANALYSIS

Lymphocytes Basophils Monocytes Eosinophils Platelets Fasting Blood Sugar Urinalysis Creatinine

10.2% 0.1% 7.5% 0.9% 150-450x109/L 70-110 mg/dl

Na

135-145mmol/L

K

3.6-5.5mmol/L

Sputum Test/AFB

Negative

44.2-106.08 umol/L

3. Other Assessment Tools •

Electro Cardiogram

•

Chest X-ray The patient had undergone chest x-ray upon admission. The film shows presence of infiltrates or clouds. The right is smaller than the left lung, particularly the lower lobe of the right lung.

J. Functional Assessment: The researchers utilized the Gordon’s typology in assessing the pattern of functioning of our patient in her life. How does she manages and takes care of herself based on Eleven Patterns. Functional Health Pattern Prior to Hospitalization

Norms and Standards

Health perception- Health Management • The patient doesn’t have complete immunization because according to her it is not available during those days and having immunization during those years are expensive and they cannot afford it. • She was never been hospitalized. • No known allergies to any foods and drugs. She can eat fish, oyster and others. • Does not experience any accidents. • When she had a disease, she used herbal medicines like guava leaves, oregano, lagundi, etc. • For her, being healthy is important. A person is healthy when she is strong, she can do what she wants and does not experience any diseases. • She does not have any regular medical and dental check-ups. • When she is experiencing something wrong in her body, she does not tell it promptly because according to her it is tolerable. • She does not have a regular exercise, instead she cleans the house and washes the clothes of her family. • The patient is malnourished. • She takes a bath once a day and brushes her teeth once a day. • She does use lotion, shampoo and soap. • She washes her hands regularly but not always using soap. • When she feels discomfort in her body she also goes to the manghihilot because it is available on their area and it is more approachable. • She often forgot to cover her mouth and nose when someone sneezes and coughs in front of her.

Measure for personal cleanliness and grooming, called personal hygiene, promote physical and psychological well-being. Various studies have confirmed that improved personal hygiene practices reduce illness rates. (Larson, 2002; Larson and Aiello, 2001). Personal hygiene practices vary widely among people. The time of the day one bathes and how often one shampoo or changes the bed linens, and sleeping garments are relatively unimportant. What is important is that personal care be carried out conveniently and frequently enough to promote personal hygiene. Illness, hospitalization and institutionalization generally require modifications in hygiene practices. In these situations, the nurse helps the patient to continue some hygiene practices, and can teach the patient and family members, when necessary, regarding hygiene. Nurses assist the patient with basic hygiene must respect individual patient preferences, providing only the care that patients cannot or should not provide for themselves. (Fundamentals of Nursing 5th edition by Taylor, page 1005). Malnutrition is the lack of sufficient nutrients to maintain healthy bodily functions and is typically associated with extreme poverty in economically developing countries. Most commonly, malnourished people either do not have enough calories in their diet, or are eating a diet that lacks protein, vitamins, or trace minerals. Medical problems arising from malnutrition are commonly referred to as deficiency diseases. Deficiency in micronutrients such as Vitamin A reduces the capacity of the body to resist diseases. Deficiency in iron, iodine and vitamin A is widely prevalent and represent a major public health challenge. An array of afflictions ranging from stunted growth, reduced intelligence and various cognitive abilities, reduced sociability, reduced leadership and assertiveness, reduced activity and energy, reduced muscle growth and strength, and poorer health overall are directly implicated to nutrient

• • • • • •

A person has a disease when she eats little amount of food, when she is weak. Health for her is important for proper functioning. Whenever she is sick, she get’s money from her children especially to the eldest, which is working abroad. She wears slippers while inside their house. She feels that her hygienic practices are adequate, and she feels clean and neat. The patient is non-smoker and she does not drink any alcoholic beverages. She denies the use any illicit drugs.

deficiencies. (http://en.wikipedia.org/wiki/Malnourishment) The main purpose of washing hands is to cleanse the hands of pathogens (including bacteria or viruses) and chemicals which can cause personal harm or disease, particularly diarrhea and pneumonia. To maintain good hygiene, hands should always be washed after using the toilet, changing a diaper, tending to someone who is sick, or handling raw meat, fish, or poultry, or any other situation leading to potential contamination. Hands should also be washed before eating, handling or cooking food. Conventionally, the use of soap and warm running water and the washing of all surfaces thoroughly, including under fingernails is seen as necessary. Alcohol rub sanitizers kill bacteria, multi-drug resistant bacteria (MRSA and VRE), tuberculosis, and viruses (including HIV, herpes, RSV, rhinovirus, vaccinia, influenza, and hepatitis) and fungus. (http://en.wikipedia.org/wiki/Hand_washing)

Herbalists treat many conditions such as asthma, eczema, premenstrual syndrome, rheumatoid arthritis, migraine, menopausal symptoms, chronic fatigue, and irritable bowel syndrome, among others. Herbal preparations are best taken under the guidance of a trained professional. Be sure to consult with your doctor or an herbalist before self-treating. Some common herbs and their uses are discussed below. Please see our monographs on individual herbs for detailed descriptions of uses as well as risks, side effects, and potential interactions. (http://www.umm.edu/altmed/articles/herbal-medicine-000351.htm) Nutritional Metabolic Pattern • She loves to eat pork, fish and vegetables. • She is not choosy when it comes to any cook and kind of food. • She eats 3x a day • She does not eat any junk foods. • She drinks 5 glasses of water a day. • For her, the amount of food she consumes is adequate. • She takes food supplement but it is not frequent. • During snack time, she usually eats banana because it is affordable and readily available in their place. • When her cough started, she is not eating the appropriate amount of food. • According to her husband, she usually eats 4 spoons of rice with viand only. It is due to her cough.

Nutrition is a basic human need that changes throughout the life cycle and along the wellness-illness continuum. (Fundamentals of Nursing 5th edition by Taylor, page 1135) An adequate food intake consists of balance essentials nutrients: water, carbohydrates, fats, proteins, vitamins and minerals. Habits about eating are affected by many factors like financial and health conditions. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1171,1175) The middle aged adult should continue to eat a healthy diet, following the recommended portions of the 5 food groups, with special attention to protein, calcium and limiting consumption to cholesterol. Two to three liters of fluid should be included in the diet. Pre menopausal women need to ingest sufficient calcium and vitamin d to prevent osteoporosis. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1180,1181) An adult individual needs to balance energy intake with his or her level of physical activity to avoid storing excess body fat. Dietary practices and food

• • •

During her hospitalization, she is on diet as tolerated with aspiration precaution. She eats food given by the hospital. She is taking vitamin B6 and other medications.

Elimination • She defecates twice a week and sometimes she feels pain and difficulty. • According to her the characteristic of her stool is hard, dry and colored dark brown. • She feels pain at her abdomen on the hypogastric and umbilical area. • She urinates 7x a day and does not feel any pain and difficulty. • Previously her defecation pattern is daily, but when her condition exacerbated, it is also affected.

choices are related to wellness and affect health, fitness, weight management, and the prevention of chronic diseases such as osteoporosis, cardiovascular diseases, cancer, and diabetes. For adults (ages eighteen to forty-five or fifty), weight management is a key factor in achieving health and wellness. In order to remain healthy, adults must be aware of changes in their energy needs, based on their level of physical activity, and balance their energy intake accordingly. Inadequate nutrition is associated with marked weight loss, generalized muscle weakness, altered functional ability, increased susceptibility to infection, impaired pulmonary function and prolonged length of hospitalization. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1190). Elimination can be affected by a person’s developmental stage, daily patterns, the amount and quality of fluid or food intake, the level of activity, lifestyle, emotional states, pathologic processes, medication, and procedures such as diagnostic test and surgery. Most people have individual pattern of elimination including frequency, timing considerations, position and place. For most people defecation is a private affair experienced easily only in the comfort of one’s own bathroom. Defecation may be difficult in shared hospital room with only a curtain for privacy. (Fundamentals of Nursing 5th edition by Taylor, page 1341) The frequency of defecation is highly individualized, varying from several times per day to two to three times per week. Sufficient bulk in the diet is necessary to provide fecal volume. Bland diets and low-fiber diets are lacking in the bulk and therefore create insufficient residue of waste products to stimulate the reflex for defecation. Low-residue foods such as rice, eggs and lean meats move more slowly through the intestinal tract. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1228). Activity stimulates peristalsis, thus facilitating the movement of chime along the colon. (Fundamentals of Nursing 5th edition by Taylor, page 1229). A person’s urinary habits depend on social culture, personal habits and physical abilities. Urine collects in the bladder contains between 250 to 450 ml of urine. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1256). The excretory function of the kidney diminishes with age but usually not significant below normal levels unless disease intervenes. With age, the number of functioning nephrons decreases to some degree, impairing the kidneys filtering abilities. The amount of flood intake affects the urinary frequency of an

individual. Foods high in sodium or fluids high in sodium ca cause fluid retention because water are retained to maintain the normal concentration of the electrolyte. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1258-1259). Activity and Exercise • She does not have any work, she is a plain house wife, who is incharge of her children. • Her usual activity is cleaning the house, cooking and washing the clothes of her children. • She loves to listen to radio programs usually in the afternoon. • She likes to converse with her friends and neighborhood. • When she cleans, it is usually for 1 hour because she gets easily tired. • Her youngest child helps her in the household chores. • When after all the chores are done she will rest and watch television. • She does not involve her self in any vigorous activities. • However, she is aware that her activity is not enough, and she recognizes the importance of having regular exercise.

The human body was designed for motion, and regular exercise is necessary for its healthy functioning. Individuals who choose inactive lifestyles or who are forced into inactivity by illness or injury placed themselves at high risk for serious health problems. (Fundamentals of Nursing 5th edition by Taylor, page 1116) Vigorous physical activity is not always needed to achieve positive result. (Fundamentals of Nursing 5th edition by Taylor, page 1117) Lack of exercise, inactivity, or immobility related to illness, or injury place a person at high risk for serious health problems. Immobility can affect the major body systems. Like the benefits, a person receives from exercise, complications resulting from immobility differ occurrence and severity based on the patients age and overall health status. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1118). The wonderful tool of exercise can help teens become fit and healthy. Performing some form of physical activity daily will significantly boost your “basal metabolic rate”—the number of calories your body burns in order to keep you alive. By having a high metabolism, you burn calories 24 hours a day— even while you sleep! You can literally turn your body into a fat-burning machine! This has many benefits: With a strong metabolism comes a strong immune system. When you burn fat, the toxins are released into the bloodstream, and are quickly carried out of the body through sweat. This inoculates you against the probability of developing cancerous and diseased cells. Therefore, hard exercise—that makes you sweat—is very good for you. Exercise also helps to regulate the amount of insulin released into the bloodstream. Insulin is commonly referred to as “the fat-making hormone.” Its job is to metabolize blood sugar into energy. But too much insulin in the bloodstream keeps your body from burning stored fat. Years of an overworked pancreas—the organ that produces insulin—can lead to “onset (type 2) diabetes.” However, if you use—burn—more calories than you consume, you significantly reduce the chances of developing this disease. Exercise can also help control other problems, such as: Sleep apnea, moodiness, stress, decreased energy, cardiovascular disease, high cholesterol

and others. There are too many benefits to list here. But be assured that this tool can help you become a fit, stronger, disease-free, and overall healthier person. The main goal of aerobic exercise is to keep the heart elevated for an extended period of time for the purpose of strengthening the heart and lungs. The most common aerobic exercise is walking. Running is the quickest way to lose weight, because it burns many calories. It also tones your calves and thighs. However, to avoid extreme muscle aches or injuries, do not begin a running routine until you have performed two to three months of aerobic walking. Cognitive-perceptual • The patient is an elementary graduate. • She stops studying because of financial problem • She can read and write properly. • She is aware to different people or happening around her. • She can talk properly. • During the interview her voice is weak. • According to her she is sensitive to the feelings of the people around her. • There are no any blockages of communication noted. • She is not always reading any books like pocket books. • She can express her feelings appropriately. • She does not have any difficulty when it comes to communication.

Cognition is greatly affected by education. Those who study and develop their skills have better cognitive performances because they have been provided with different information and chances to develop their self. Perception is affected by the sensory diseases. Presence of any sensory abnormalities affects or halters perception that would affect proper communication. (Black, Medical Surgical Nursing7th edition, page 1880). Cognition involves a person’s intelligence, perceptual ability and ability to process information. It represents a progression of mental abilities from illogical to logical thinking, from simple to complex problem solving and from concrete to abstract ideas. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 359).

Sleep and Rest • The patient regularly sleeps at 8:00pm and wakes up at 1:00 pm. • She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough. • She usually sits because according to her she can breath more easily. • She takes a nap in the morning from 8 am to 11 am. • She feels that her sleep and rest is inadequate. • She sleeps together with her husband. • They have a separate room from their children. • Sleeping is important to her.

For no known reason, 8 hours of sleep a night has been the accepted standard for adults despite obvious variations seen in the general population. It is important however that a person follows a pattern of rest that maintains wellbeing. Many factors affect a person’s ability to rest. Illnesses and various life situations that causes physiological stress tends to disturb sleep. Sleep quality is also influenced by certain drugs Some decreases REM sleep (barbiturates ,amphetamines and antidepressants) and some are seen to cause sleep problems (steroids, caffeine and asthma medications) (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1169-117). The National Sleep Foundation in the United States maintains that eight to nine hours of sleep for adult humans is optimal and that sufficient sleep benefits alertness, memory and problem solving, and overall health, as well as reducing

the risk of accidents.[8] A widely publicized 2003 study[9] performed at the University of Pennsylvania School of Medicine demonstrated that cognitive performance declines with fewer than eight hours of sleep. It has also been shown that sleep deprivation affects the immune system and metabolism. In a study by Zager et al in 2007,[21] rats were deprived of sleep for 24 hours. When compared with a control group, the sleep-deprived rats' blood tests indicated a 20% decrease in white blood cell count, a significant change in the immune system. Scientists have shown numerous ways in which sleep is related to memory. In a study conducted by Turner, Drummond, Salamat, and Brown[28] working memory was shown to be affected by sleep deprivation. Working memory is important because it keeps information active for further processing and supports higher-level cognitive functions such as decision making, reasoning, and episodic memory. Turner et al. allowed 18 women and 22 men to sleep only 26 minutes per night over a 4-day period. Subjects were given initial cognitive tests while well rested and then tested again twice a day during the 4 days of sleep deprivation. On the final test the average working memory span of the sleep deprived group had dropped by 38% in comparison to the control group. (http://en.wikipedia.org/wiki/Sleep) Self-perception • According to her there is something wrong in her health and body. • As a mother, she sometimes feels sad because she cannot do the previous things like going with her husband in the farm. • According to her husband she is a good mother and a good wife. • Her strength is her family, when there are any circumstances that involving any family member she is concerned and make some moves. • She is simple.

Self concept is one’s mental image of oneself. A positive self concept is essential to a person’s mental and physical health. Individuals with a positive self concept are better able to develop and maintain interpersonal relationship and resist psychological and physical illness. Self concept involves all of these self perceptions, that is, appearance, values and beliefs that influences behaviors and that are referred to when using the words I or me. Body image is ho the person perceives the size, appearance and functioning of the body. If a person’s body image closely resembles one’s ideal body, the individual is more likely to think positively about the physical and non-physical concept of self. Self concept is also affected by role-strains. People undergoing role-strains are frustrated because they feel or made to feel inadequate or unsuited to a role. Illness and trauma can also affect the self-concept. People responds to different stressors such as illness and alterations in function related to aging in a variety of ways: acceptance, denial, withdrawal and depression are common. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 957-962).

Role-relationship • She was the fourth child in her family. • She is married to Arsenio and they have 6 children. • She is performing the trypical responsibilities of a plain house wife. • Her children have a good relationship to her. • She is being cared by her children who are very supportive to her. • Her husband is a good husband he is a provider who does everything for the family to have food. • She has a harmonious relationship with her brothers and sisters. Whenever there are any problems, they are helping each other. • She can form a healthy relationship with others. • She is the person who chooses her friends. • She is a very quite person. • She does not have any enemies.

Sexuality-reproductive • She is engage in sexual activity to her husband only. • Presently she is still active in her sex life. • She still have regular menstruation. • She is aware that she will have cessation of her menstruation. • She dresses appropriately, based on her gender. • She is also able to express her feminine attitudes.

Relationship to another person is a developed manner in which there is the sharing of self, showing care and putting trust. A healthy relationship affects an individual’s emotional development, it will facilitate the channeling of the ideas, feeling of joy an others. An interpersonal relationship is a relatively long-term association between two or more people. This association may be based on emotions like love and liking, regular business interactions, or some other type of social commitment. Interpersonal relationships take place in a great variety of contexts, such as family, friends, marriage, acquaintances, work, clubs, neighborhoods, and churches. They may be regulated by law, custom, or mutual agreement, and are the basis of social groups and society as a whole. A relationship is normally viewed as a connection between two individuals, such as a romantic or intimate relationship, or a parent-child relationship. All relationships involve some level of interdependence. People in a relationship tend to influence each other, share their thoughts and feelings, and engage in activities together. Because of this interdependence, anything that changes or impacts one member of the relationship will have some level of impact on the other member. Psychologists have suggested that all humans have a basic, motivational drive to form and maintain caring interpersonal relationships. According to attachment theory, relationships can be viewed in terms of attachment styles that develop during early childhood. These patterns are believed to influence interactions throughout adulthood by shaping the roles people adopt in relationships. (http://en.wikipedia.org/wiki/Intimate_relationship) Sexuality is defined not only by a person’s genetalia but also by attitudes and feelings. It can also be defined as learned behaviors in how a person reacts to his or her own sexuality and by how one behaves in relationships with others. (Fundamentals of Nursing 5th edition by Taylor, page 931) Sexuality is a crucial part of a person’s identity. Sex is central to who we are, to our emotional well-being and to the quality of our lives. The world health organization defined sexual health as the integration of the somatic, emotional, intellectual and social aspect of sexual beings in ways that are positively enriching and that enhances personality, communication and love. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 973). During the middle adulthood both men and women experience decreased hormone production causing the climacteric, usually called menopausal in women. These events often affect the individuals self-concept, body image and

Coping-stress • Whenever she has problem, she asks guidance from our Lord • She watches television as her stress management. • She always listen to radio programs when she feels lonely. • When she gets mad, she just keep quiet. • When she experiences coughing and difficulty of breathing she just relaxes and breathes deeply. • Her husband or children taps her back when she coughs. Value-belief • She is a Roman Catholic • She attends mass occasionally. • She always ask the guidance of our Lord • Whenever there are Christian events, like Holy week, she participates in the activities like fasting. • She believes in ghosts, and elementals. • She seldom reads the bible. • Does not always pray the rosary. • She respects and obeys her husband. • For her education is very important to her children, so she and her husband is doing all the efforts to send their children to school.

sexual identity. Women through the menopausal period experiences hot flushes, vasomotor instability, sleep disturbances, vaginal dryness, genital tract atrophy, mood changes and skin, hair changes. The incidence of osteoporosis and cardiovascular lipid changes also increases. The climacteric in the males is no as dramatic in the females; changes are more gradual. Sexual response love and play involve people’s emotional, psychologic, physical and spiritual make up, which plays a significant role in the satisfaction. Sexual desires fluctuates within each person and varies from person to person. If people suppresses or block out conscous sexual desires, they may not experience any physiological respose. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 975,980). Coping mechanisms which are behaviors used to decrease stress and anxiety. Many coping behaviors are learned, based on one’s family past experiences, and socio-cultural influences and expectations. (Fundamentals of Nursing 5th edition by Taylor, page 855)

Spiritual well-being is the condition that exists when the universal spiritual needs for meaning and purpose, love and belonging, and forgiveness are met. O’ Briens conceptual model of spiritual well-being in illness identified three empirical referents of spiritual well-being: personal faith, religious practice and spiritual contentment. Spiritual beliefs are of special importance to nurses because of the many ways they can influence a patient’s level of health and self-care behaviors. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 975,979). Spiritual well-being is manifested by a generally feeling of being alive, purposeful and fulfilled. People nurture or enhance their spirituality in many ways. Some focus on development of the inner self or world; others focus on the expression of their spiritual energy with others or outer world. Relating to one’s inner self or soul may be achieved through conducting an inner dialogue with a higher power or with one’s self through prayer or medications. The expression of a person’s spiritual energy to others is manifested in loving relationship with and service to others, joy and laughter and participation in

religious services and associated fellow gatherings and activities and by expression of compassion, empathy, forgiveness and hope. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 996).

G. Activities of Daily Living ASPECT 1. Nutrition

2. Elimination

3. Exercise

PRIOR TO HOSPITALIZATION Patient loves to eat meat, fish and vegetables. She eats anything that is being served to her. She does not eat junk foods. She is not taking food supplements like vitamins frequently. She eats 4 spoons of rice with viand because according to her it is due to her cough. She eats thrice a day. Patient voids 7 times a day, and defecate twice a week. She doesn’t experience any pain and difficulty in terms of urination. Previously her defecation pattern is daily, but when her condition exacerbated, it is also affected.

DURING HOSPITALIZATION The patient is on diet as tolerated with aspiration precaution. She eats dry, thickened food on a small frequent feeding. She is advised to chew food properly.

INTERPRETATION and ANALYSIS The patient can eat any food she wants as long as it is dry, thickened, and frothy. It should be in a small frequent feeding, as to avoid aspiration.

The patient does not defecate or urinated during the conduct of the interview.

The patient does not defecate for more than a week due to decreased gastric motility related to decrease physical activity. For most people defecation is a private affair experienced easily only in the comfort of one’s own bathroom. Defecation may be difficult in shared hospital room with only a curtain for privacy. (Fundamentals of Nursing 5th edition by Taylor, page 975 & 979)

Cleaning their house is the only activity she considered as her exercise. She does not have routine exercise. However, she is aware that her activity is not enough, and she recognizes the importance of having regular exercise. She loves to listen to radio programs usually in the afternoon. When after all the chores are done she will rest and watch television.

Deep breathing and coughing exercises are advised and performed. The patient has decreasing function as the disease progresses.

The patient performs deep breathing exercise as instructed by the nurse.

4. Hygiene

Patient takes a bath every day, brushes her teeth once a day. She wears slippers while inside their house. She feels that her hygienic practices are adequate, and she feels clean and neat. There is body odor noted. Patient is a non-smoker and denies use of illicit drugs. She does not drink alcohol.

Not applicable

6. Sleep and Rest

Sleeping is important to her. She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough. She takes a nap in the morning from 8 am to 11 am. She sleeps together with her husband. The patient regularly sleeps at 8:00pm and wakes up at 1:00 pm. She feels that her sleep and rest is inadequate because of her conditions.

Not applicable

7. Sexual Activity

She dresses appropriately, based on her gender. She still has regular menstruation. She is engage in sexual activity to her husband only. Presently she is still active in her sex life

Not applicable

5. Substance Use

The patient doesn’t use any prohibited substances like alcohol, cigarettes and illicit drugs.

The patient does not use any addictive substances. Illicit drugs are strictly prohibited in the hospital premises, even cigarette smoking and alcohol drinking.

II.

ANATOMY AND PHYSIOLOGY

III.

PATHOPHYSIOLOGY

IV.

CONCEPT MAPPING

HEALTH The patient believes that being healthy is being strong, does not experience any sickness and energetic. - Health is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO definition

V.

PROBLEM LIST

VI.

NURSING CARE PLAN

ASSESSMENT

Subjective Cues: - Patient verbalized, “Matagal na akong inuubo. Wala namang plema. Nahihirapan akong huminga”. Objective Cues: - Presence of adventitious breath

NURSING DIAGNOSIS Ineffective airway clearance related to retained secretions in the respiratory tract secondary to bacterial infection as evidenced by crackles upon auscultation.

ILLNESS For the patient, an individual is weak and eats little amount of food. -Is a disease, sickness or the condition of being in a poor health, either physically or mentally. (Blackwell’s Nursing Dictionary)

BACKGROUND KNOWLDEGE Intermediate Cause: - Retained secretions in the respiratory tract. Intermediate Cause: - Inflammatory response Root Cause:

GOAL and OBJECTIVES Goal: Within 4 hours of nursing intervention, the patient will be able to maintain patent airway through the mobilization of secretions as evidenced by productive cough.

HOSPITALIZATION The patient looks at hospitalization as the last recourse when one has an illness. For the patient, it is the place where an individual is being treated from severe cases. - Placement of an individual in a hospital for observation, diagnostic test, or treatment for some diseases. (Blackwell’s Nursing Dictionary)

NURSING INTERVENTION

Objective 1: Independent-Facilitative: 1. Obtain vital signs of the patient.

2. Observe for respiratory rate and rhythm; presence

RATIONALE

EVALUATION

- Health status is regulated through homeostatic mechanisms. A change in V/S might indicate health change. (Taylor et.al, FON 5th ed. Page 523)

Effectiveness - Was the patient able to maintain patent airway? -Was the patient able to mobilize her secretions? -Was the patient able to have patent airway?

-Nasal flaring and use of accessory muscles

Adequacy -Was all the planned

sound (Crackles) upon auscultation. -The patient is coughing without phlegm. - Oriented - GCS E4V5M6 - BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-31.5 C - Difficulty vocalizing - Has hallow eyes. - Bluish nail beds.

- Bacterial infection of the respiratory system. Health Implication: This condition can cause Acute Respiratory Distress Syndrome (ARDS) which results from the combination of infection and inflammatory response. The lungs become quickly filled with fluid and become very stiff. This stiffness, combined with difficulties extracting oxygen due to the alveolar fluid creates a need for ventilation. Septic shock is one potential complication. (Black, Medical Surgical Nursing 7th ed. Page 1896)

Objectives: 1. For 10 minutes, the relative will assess the physical condition of the client by accepting at least 4 nursing interventions to be done in the patient. 2. After 3 hours the client will be able to mobilize her secretions through the interventions done by the nurse at least 4. 3. After 50 minutes, the nurse will maintain patent airway of the patient through the performance of at least 3 interventions.

of nasal flaring; and use of accessory muscles when breathing like the diaphragm and coastal muscles. 3. Perform the Blanch Test.

4. Auscultate the lungs to note any lung sounds.

Objective 2: Independent- Facilitative: 1. Perform Chest physiotherapy.

Dependent-Facilitative: 1. Suction secretion as needed.

2. Increase the amount of oral fluid intake as ordered by the doctor.

indicates increased effort is required for breathing.

- Blanch test reflects the adequacy of o2 circulation in the periphery. -Crackles are intermittent sounds that occur when air moves through airway that contain fluids. (Taylor et.al, FON 5th ed. Page 1386) -Tapping the chest can loosen the secretions. (Taylor et.al, FON 5th ed. Page 1251) -Suction removes secretions through the use of a strong pressure. - Current data indicates that fluid restriction may actually reduce blood volume and decrease cerebral circulation. The lack of volume causes the blood to be thick and sluggish and may decrease the mobilization of nutrition and toxins out

nursing interventions are enough in achieving and maintaining patent airway? -Was all the resources of the nurse like time and effort are enough? Appropriateness -Was the interventions mentioned are applicable and beneficial to the patient? Acceptability - Was the family willfully accepted the interventions done to the patient.

Dependent-Supplemental: 1. Administer bronchodilators as ordered.

of the circulation. Patient should be maintained in a euvolemic state rather than a fluid-restricted state. (Black, MSN 7th ed. Page 2201) - They act on the respiratory tract, it opens narrowed airways. (Black, MSN 7th ed. Page 1652) - For maximal lung expansion that will improve oxygen delivery.

Objective 3: Independent-Facilitative: 1. Elevate the head of the bed. 2. Position the head in the midline of the body.

VII.

MEDICAL- SURGICAL MANAGEMENT

-Position changes allow free movement of the diaphragm and expansion of the chest wall. (Taylor et.al, FON 5th ed. Page 1396)

GENERIC/ BRAND NAME

ACTION

Ethambutol

-Ethambutol is bacteriostatic against actively growing TB bacilli, it works by obstructing the formation of cell wall. -Mycolic acids attach to the 5'-hydroxyl groups of Darabinose residues of arabinogalactan and form mycolylarabinogalactanpeptidoglycan complex in the cell wall. - It disrupts arabinogalactan synthesis by inhibiting the enzyme arabinosyl transferase. -Disruption of the arabinogalactan synthesis inhibits the

CLASSIFICATION

INDICATION

CONTRAINDICATION

SIDE EFFECTS

NURSING INTERVENTION

formation of this complex and leads to increased permeability of the cell wall.

Isoniazid

-Isoniazid is a prodrug and must be activated by bacterial a catalaseperoxidase enzyme called KatG.[5] KatG couples the isonicotinic acyl with NADH to form isonicotinic acylNADH complex.

-rashes -abnormal liver function tests -hepatitis -sideroblastic -anemia -peripheral neuropathy -mild central nervous system (CNS) effects, drug

-This complex binds tightly to ketoenoylreductase known as InhA, thereby blocking the natural enoylAcpM substrate and the action of fatty acid synthase. -This process inhibits the synthesis of

-interactions resulting in increased phenytoin (Dilantin) or disulfiram (Antabuse) levels and intractable seizures -Peripheral

mycolic acid, required for the mycobacterial cell wall. A range of radicals are produced by KatG activation of Isoniazid, including nitric oxide[6] which has also been shown to be important in the action of another antimycobacterial prodrug PA-824.[7] -Isoniazid is bactericidal to rapidly-dividing mycobacteria but is bacteriostatic if the mycobacterium is slow-growing Isoniazid inhibits the P450 system.

neuropathy and CNS effects are associated with the use of isoniazid and are due to pyridoxine (vitamin B6) depletion, but are uncommon at doses of 5 mg/kg. -Persons with conditions in which neuropathy is common (e.g., diabetes, uremia, alcoholism, malnutrition, HIV-infection), as well as pregnant women and persons with a seizure disorder, may be given

pyridoxine (vitamin B6) (10-50 mg/day) with isoniazid. -Hepatotoxicity can be avoided with close clinical monitoring of the patient, specifically nausea, vomiting, abdominal pain and appetite. -Isoniazid is metabolized by the liver mainly by acetylation and dehydrazination. The Nacetylhydrazine metabolite is believed to be responsible for the hepatotoxic effects seen in

patients treated with isoniazid. The rate of acetylation is genetically determined. Approximately 50% of blacks and Caucasians are slow inactivators; the majority of Inuit and Asians are rapid inactivators. The half-life in fast acetylators is 1 to 2 hours while in slow acetylators it is 2 to 5 hours. Elimination is largely independent of renal function, however the half-life may be prolonged in liver disease. The rate of

acetylation has not been shown to significantly alter the effectiveness of isoniazid. However, slow acetylation may lead to higher blood concentrations with chronic administration of the drug, with an increased risk of toxicity. Isoniazid and its metabolites are excreted in the urine with 75 to 95% of the dose excreted in 24 hours. Small amounts are also excreted in saliva, sputum and feces. Isoniazid is removed by hemodialysis

and peritoneal dialysis.[9] Headache, poor concentration, poor memory and depression have all been associated with isoniazid use. The frequency of these side effects is not known, and the association with isoniazid is not well validated. On the other hand, all patients and health-care workers should be aware of this serious adverse effect, especially if suicidal thinking or behavior occurs.[10][11][12]

INH therapy will decrease the efficacy of hormonal birth control when combined with Rifampin.

VIII.

DISCHARGE HEALTH TEACHING

IX.

PROGRESS NOTES