Quezon Institute Case Study

SOUTHEAST ASIAN COLLEGE INC. College of Nursing and Midwifery 6N Ramirez St. Quezon City

CASE STUDY PULMONARY TUBERCULOSIS CLASS III

Presented by: BACHO, CHRISTINE JOY BAUTISTA, JOSE RAPHAEL BORRAL, YASMIN COSTALES, ROSELYN MENDOZA, MARY ANN NEBRIL, ANDREW PABALAN, CAROL JANE PAGUIRIGAN, ANTONIO SOMBRITO, ETHEL ZAIDA

Submitted to: Mrs. Helen Loresco Clinical Instructor

TABLE OF CONTENTS I.

Introduction

II.

Objectives General Objective Specific Objective

III.

Theoretical Framework

IV.

Patient Profile

V.

Nursing History

VI.

13 Areas of Assessment

VII.

Anatomy and Physiology

VIII.

Pathophysiology

IX.

Laboratories and Diagnostic test

X.

Drug Study

XI.

Nursing Care Plan

XII.

Discharge Planning

XIII.

Bibliography

XIV.

Curriculum Vitae

ACKNOWLEDGEMENT: To God, the Father almighty, we thank Him for the guidance in everything, for giving us sense of direction, for understanding us, for the love and forgiveness. We want to extend our deepest gratitude to our family especially our parents, who serves as our inspiration, for providing us support, and always there through ups and down. We wish to extend our sincere thanks and deep appreciation to Quezon Institute and to our Clinical Instructor Mrs. Helen Loresco for giving us the opportunity to broaden our knowledge. Our sincere appreciation to our friends who supported us research materials for our case study. Big thanks to our patient, who has been cooperative and patient despite her condition.

I.

INTRODUCTION

Tuberculosis Tuberculosis is a contagious infection caused by Mycobacterium tuberculosis, which is carried through the air. Tuberculosis usually affects the lungs, but it can attack almost any area of the body. Since anti-tuberculosis antibiotics were developed in the 1940s, tuberculosis has been taken less seriously than it once was. A variety of factors, however, had made it a growing health concern, including shrinking public health resources, more people with weakened immune systems due to AIDS, increasing resistance to antibiotics and extreme poverty in many parts of the world. Worldwide, three million people die from tuberculosis every year. An estimated one out of every three people in the world has a dormant tuberculosis infection, although only five to 10 percent develop active tuberculosis. Symptoms When a microorganism infects a person's body, he or she usually becomes sick within one to two weeks, but not with tuberculosis. Except for very young children, people can have live bacteria "sleeping" inside their bodies for many years. The body's defense mechanisms prevented the bacteria from developing into full-scale tuberculosis, but have not killed the bacteria. These sleeping bacteria cannot be spread to other people. In the vast majority of people, the bacteria never cause problems. In five to 10 percent, however, the bacteria start to multiply and develop tuberculosis, usually within the first two years after infection. Although what causes the bacteria to become active is not known, it can happen because of an immune system weakened by advanced age, the use of corticosteroids or AIDS.

In this phase, an infected person feels sick and can spread the disease to other people. The bacteria that cause tuberculosis can live only in people. It cannot be carried by animals, insects, and soil or nonliving objects. The bacteria spread only through the air when a person coughs sneezes or speaks. The bacteria can stay in the air for several hours, making it possible for many other people to become infected with tuberculosis. The signs of tuberculosis may not appear to be serious at first. They include: •

Coughing, which produces a small amount of green or yellow sputum in the morning? As the disease gets worse, the sputum may be streaked with small amounts of blood.

•

Cold night sweats, which are heavy enough to wake a sleeper up and require a change of nightclothes or bed sheets

•

Not feeling well in general

•

A loss of energy and appetite

•

Weight loss over time

Sudden shortness of breath along with chest pain may be a sign that air or fluid has entered the space between the lungs and the chest wall (pneumothorax). For many people this is the first sign that leads them to seek a diagnosis. When a tuberculosis infection first occurs, the bacteria may travel from the lungs to the lymph nodes that drain the lungs. If the body is able to bring the infection under control at this stage, the bacteria become dormant. A dangerous complication for young children, whose immune systems are weaker and bodies are smaller, is that the lymph nodes can swell large enough to press on the bronchial tubes, causing a cough and possibly a collapsed lung. Sometimes, the bacteria spread up the lymph system to the lymph nodes in the neck, in which case, the infection may break through the skin and let loose pus.

In people with a fully functioning immune system, active tuberculosis is usually limited to the lungs (pulmonary tuberculosis). Tuberculosis that affects other parts of the body (extrapulmonary tuberculosis) comes from pulmonary tuberculosis that has spread through the blood. As in the lungs, the infection may not cause disease, but the bacteria may remain dormant in a very small scar. Latent organisms in these scars can reactivate later in life, leading to symptoms in the organs involved. In pregnant women, the tuberculosis bacteria may spread to the fetus and cause disease; however, such congenital tuberculosis is uncommon. If the tuberculosis infection occurs outside the lungs, it usually affects the kidneys and the lymph nodes. Symptoms of a tuberculosis infection elsewhere than the lungs tend to be vague and include: •

Fatigue

•

Poor appetite

•

Fevers that come and go

•

Sweats

•

Weight loss in some cases

•

Pain

Other types of tuberculosis include: •

Tuberculosis meningitis, which affects the tissues that cover the brain. This is life threatening. Symptoms include fever, a headache that does not go away, stiffness in the neck, nausea and sleepiness that can develop into a coma.

•

Tuberculoma, which affects the brain itself and forms a mass that causes headaches, seizures or muscle weakness

•

Tuberculous pericarditis, which affects the membrane that covers the heart (pericardium). This type of tuberculosis causes the pericardium to thicken. Sometimeswhich affects the membrane that covers the heart (pericardium). This type of tuberculosis causes the pericardium

to thicken. Sometimes fluid will leak from the layers of the pericardium into the space between the pericardium and the heart, making it harder for the heart to pump. It can cause swollen veins in the neck and difficulty breathing. •

Intestinal tuberculosis, which may not cause any symptoms but does create an abnormal mass of tissue that can be mistaken for cancer

•

Miliary tuberculosis, which is a life-threatening type of tuberculosis that occurs when a large number of bacteria are spread throughout the body in the bloodstream. It gets its name from the millions of tiny lesions formed, which are the size of millet, a tiny round seed. If it gets into the bone marrow, it can cause severe anemia and blood conditions that seem like leukemia.

Causes and Risk Factors In the United States and other developed countries, tuberculosis is more likely to affect older people. In poorer countries, it is a disease of young adults. People of European ancestry are somewhat less likely to get tuberculosis because the bacterium for it has existed a long time in Europe. People from other parts of the world, where tuberculosis is a newer disease, are at greater risk of developing it. In the United States, tuberculosis is more common among African Americans, Native Americans and immigrants from non-European countries. Poverty, poor nutrition, crowded living conditions, exposure to tuberculosis and lack of access to medical care all increase the risk of developing tuberculosis. Diagnosis Because the symptoms of tuberculosis can start out as vague and flu-like, tuberculosis is often discovered from a chest X-ray done for another reason or a positive tuberculin skin test that was done for routine screening. When symptoms suggest tuberculosis, a doctor may recommend the following tests:

•

A chest X-ray if it has not already been done. The results may show abnormalities but often look like those of many other diseases. An Xray alone cannot confirm tuberculosis.

•

A tuberculin skin test (also called a Mantoux test or purified protein derivative {PPD} test), if it has not already been done. This test shows that an infection by the bacteria has occurred at some point in the person's life, but it does not reveal if the infection is currently active. The test itself involves injecting a small amount of protein from tuberculosis bacteria between layers of the skin. About two days later the site is checked. If there is swelling larger than a certain size that feels firm when touched, the person has been infected with tuberculosis (the test is positive). Redness without swelling indicates that there is no infection.

•

A sputum sample to be analyzed in a laboratory for the presence of tuberculosis bacteria. The sample may also be used to grow a culture of the bacteria to make sure the test results are accurate.

In the event that other conditions (such as lung cancer) are suspected, the doctor may order a bronchoscopy, which uses an instrument to examine the bronchial tubes and get samples of mucus or lung tissue. If there are signs of tuberculosis meningitis, a doctor may take a sample of spinal fluid (do a spinal tap) to analyze for bacteria. Treatment is usually started if there is even a suspicion of tuberculosis meningitis because the analysis takes time and the condition is life threatening. Treatment Just as tuberculosis is slow to develop symptoms, it is slow to respond to the many antibiotics that can be used against it. Antibiotics must be taken for six months or longer - long after a person feels completely well - or the disease tends to return. Because many people find it difficult to take their drugs for a long time or tend to stop taking them when they feel better, many doctors recommend

that people with tuberculosis receive their drugs from a healthcare worker (directly observed therapy, DOT). Because this assures that treatment is being received, DOT treatments are usually shorter and given only two to three times a week. Two or more antibiotics that work in different ways are normally given to help kill bacteria resistant to a particular drug. A third and fourth drug may be given during the first intense phase of treatment to make it shorter and more effective. Surgery is usually not needed, but it may be used when a person has a particularly drug resistant infection or to drain infection from the lungs. If tuberculous pericarditis makes it hard for the heart to pump, the pericardium may need to be removed. A tuberculoma in the brain may also need to be removed with surgery. MORTALITY: TEN LEADING (10) LEADING CAUSES Number and rate/100,000 Population Philippines 5-Year Average (2000-2004) & 2005 5 Year Average (2000-2004) Number Rate 1. Diseases of the Heart 66,412 83.3 2. Diseases of the Vascular system 50,886 63.9 3. Malignant Neoplasm 38,578 48.4 4. Pneumonia 32,989 41.4 5. Accidents 33,455 42.0 6. Tuberculosis, all forms 27,211 34.2 7. Chronic lower respiratory 18,015 22.6 diseases 8.Diabetes Mellitus 13,584 17.0 9. Certain conditions originating in 14,477 18.2 the perinatal period 10. Nephritis, nephrotic syndrome 9.166 11.5 and nephrosis Cause

Note: Excludes ill-defined and unknown causes of mortality (R00-R99) n=23,235 * reference year ** External Causes of Mortality Last Update: June 29, 2009

2005* No. Rate 77,060 90.4 54,372 63.8 41,697 48.9 36,510 42.8 33,327 39.1 26,588 31.2 20,951

24.6

18,441

21.6

12,368

14.5

11,056

3.6

II. OBJECTIVES GENERAL OBJECTIVES: After six days experience in Quezon Institute, we Batchelor of Science in Nursing in fourth year level Group 71 of southeast Asian College Incorporated, aims to acquired necessary Knowledge, attitude and skills in caring Pulmonary tuberculosis patient. SPECIFIC OBJECTIVES: •

to acquire information and knowledge regarding Pulmonary tuberculosis

•

To provide health teachings to the patient with pulmonary tuberculosis patient.

•

To demonstrate positive attitude in the care of the patient with pulmonary tuberculosis patient.

•

To implement plan of care and evaluate the effectiveness of interventions rendered.

•

To give knowledge and orient the client and relatives about the disease.

•

to promote therapeutic communication with the client

III.

THEORETICAL FRAMEWORK Florence Nightingale’s Environmental theory In nightingale’s theory, she links health with five environmental

factors such as pure or fresh air, clean water, efficient drainage, cleanliness and light especially direct sunlight. She also stressed the importance of keeping the client warm, maintaining a noise free environment, and attending to the client’s diet in terms of assessing intake, timeliness of the food and its effect on the person. Virginia Henderson’s 14 Fundamental needs of nursing care It states that there are 14 fundamental needs in order to gain independence and health care discipline for you to become healthy. Henderson’s fundamental needs are as follow: Breathing normally, eating and drinking adequately, eliminating body waste, moving and maintaining desirable position, sleeping and resting, selecting suitable cloths, maintaining body temperature within normal range, keeping the body clean and well groomed to protect the integument, avoiding dangers in the environment and avoid injuring others, communicating with others in expressing emotions, needs fear or opinions, worshiping according to one’s faith, working in such a way that one feels a sense of accomplishments, playing or participating in various form of recreation, learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available health facilities. Those two theories focus on the act of utilizing the environment of the patient to assist him in his recovery and to gain independence and discipline to promote and maintain personal well being. Base on our case which is pulmonary tuberculosis, the patient needs environmental factors such as fresh air, clean water, efficient drainage, cleanliness and sunlight. The patient also needs the 14 fundamental needs in

order to gain independence and discipline in taking good care of his health as a person and environmental factors promotes early recovery.

IV.

PATIENT PROFILE

Case # 016088 Name: Mr. C (not his real name) Bed #: D-14 Birthday: March 24, 1976 Age: 32 years old Gender: male Address: #541 Gagalangin St., Tondo, Manila Occupation: merchandising officer Religion: Roman Catholic Nationality: Filipino Civil Status: Married Chief Complain: Body weakness, cough and fever Attending Physician: Dr. Ortiz Admitting Physician: Dr. Ortiz Date of admission: September 09, 2009 Time of Admission: 12:15 pm Admitting diagnosis: PTB3 Cat.II

V.

NURSING HISTORY Chief Complain: Body weakness, Cough and fever History of present illness: The condition started about two weeks Prior to Admission as

Progressive Difficulty of Breathing. He also experiences body weakness and a cough with on and off fever. With a vital signs of 27 cycles per minute for respiration, 98 beats per minute for pulse rate, 100/80mmHg for blood pressure and 37.4°C for temperature. Laboratory findings show a positive result for PTB3 category III. Since then, medical staff informed the patient’s partner and transferred to the ward. Past Medical History: The patient completed his Vaccines when he was a child but he experience to have fever, cough and colds. He does not have any allergy on food, animals, and drugs. Family history: His father had a history of PTB.

VI. THE 13 AREAS OF ASSESSMENT 1. SOCIAL STATUS Patient C is 33 year old, male and living with his family. He is married and her wife was the one who take care of him. Their origin is from Pampanga and now they are living at Pural, Juan Luna, Tondo Manila. He is devoted Roman Catholic and he is working as a merchandising officer and earning ten thousand a month. His recreational activities are watching T.V.; playing basketball with his friends and they are dependent on their parents. 2. MENTAL STATUS On our assessment for his mental status, we ask a certain questions and ask him to answer the questions as he could and to repeat the words we say. He is well oriented and conscious. He knows where he is; the current day and time, and he even recall his past events even when he is young. He graduated as a computer science. 3. EMOTIONAL STATUS As we observe to him, we don’t see any anxiety and he has a high adaptation mechanism on his illness. His relationship towards his family, to other patient and the health team members are good, he also says that he is happy most especially when he is with his family. 4. SENSORY PERCEPTION

•

Hearing – on assessing his hearing, we ask him to repeat the words that we say, with a distance of three feet, and according to our evaluation, his hearing ability is functioning well. And when we do palpation at the auricle there is no present of tenderness.

•

Vision – on assessing for vision, his eyes are symmetrical, black pupil, equal in size, and equally round.

•

Speech – on assessing for speech, while reading I ask him to speech out what is written and he able to speech it out. He speaks loud and clearly. And he is able to express his thoughts and feelings

•

Touch – on assessing for touch, he able to recognize smooth rough and pointed object things even his eyes are close. We used the linen for soft object, the Styrofoam for the rough object and end of pen for the pointed object.

•

Smell – for the smell, the external nose has no presence of tenderness or elision and discharge. It is also symmetrical in shapes, and he can able to identify different scent.

•

Taste – when we ask him if he able to distinguished the different taste?, he says that sometimes, the food that he eat are no taste, that’s why he is not eating regularly.

5. MOTOR ABILITY He can able to walk, move, sit and stand without assistance. When we have our interview, he is sitting at the bed while eating. And as we assess him, there are no signs of abnormal movements. 6. BODY TEMPERATURE On assessing body temperature, we used an axilla thermometer via axilla route and we obtain a temperature of 36 degrees Celsius which is in normal range.

7. RESPIRATORY STATUS Upon assessing the respiratory rate, the patient has 28 cpm and he has a difficulty of breathing. He have cough and the sputum is sticky and the color was grayish. He has a crackle sounds and an oxygen contraption which is labeled at 3Lpm. He is also using a nebulizer. 8. CIRCULATORY STATUS The pulse rate of the patient is 95bpm via radial pulse and has a blood pressure of 110/90 mmHg. Capillary refill is normal.

9. NUTRITIONAL STATUS Base on what he complain that sometime he have a poor appetite, because he does not taste the food that he is eating, and in our assessment, there is a present of weight loss, 60kilo gram from 68 kilo gram. His height was 5’6”. We also ask him if how many a meal does he eaten when he was at home, he said that it is three times a day accept the snacks. He also drinks more than 8 glasses, but when he have his disease he no longer do drink or eat just like the past. 10. ELIMINATION We ask him if his bowel habits and urination is good, and according to him, he can able to defecate. He has no problem in defecation and urination. He eliminates regularly, in urine 4-6 times a day, and in

defecation 1-2 times a day. He has no catheter or any contraption to ease elimination. 11. REPRODUCTIVE STATUS The breast of the patient is normal, there are no palpable lympnodes around his breast, there is also no presence of tenderness as we palpate. And according to him, he was been circumcised at the age of 12. 12. STATE OF PHYSICAL REST AND COMFORT When we ask him if he does feel comfortable in the hospital, he says that during his stay at home he can sleep in day time at least three hours and at night time, he can able to sleep at least eight hours, but when he was hospitalized, he can able to nap so he has a problem on his sleeping patterns, because he is easily to wake because of destructions like his cough.

13. STATE OF SKIN AND APPENDAGES In general appearance he clean, he have a brown complexion, no presence of lesions. His nails are cut, his hair also clean.

VII. ANATOMY AND PHYSIOLOGY The Human Respiratory System •

Air enters the nostrils

•

passes through the nasopharynx,

•

the oral pharynx

•

through the glottis

•

into the trachea

•

into the right and left bronchi, which branches and rebranches into

•

bronchioles, each of which terminates in a cluster of

•

alveoli

Only in the alveoli does actual gas exchange takes place. There are some 300 million alveoli in two adult lungs. These provide a surface area of some 160 m2 Breathing The diaphragm divides the body cavity into the •

abdominal cavity, which contains the viscera (e.g., stomach and intestines) and the

•

Thoracic cavity, which contains the heart and lungs.

The inner surface of the thoracic cavity and the outer surface of the lungs are lined with pleural membranes which adhere to each other. If air is introduced between them, the adhesion is broken and the natural elasticity of the lung causes it to collapse. This can occur from trauma. And it is sometimes induced

deliberately to allow the lung to rest. In either case, reinflation occurs as the air is gradually absorbed by the tissues. Because of this adhesion, any action that increases the volume of the thoracic cavity causes the lungs to expand, drawing air into them. •

During inspiration (inhaling), o

The external intercostals muscles contract, lifting the ribs up and out.

o •

The diaphragm contracts, drawing it down.

During expiration (exhaling), these processes are reversed and the natural elasticity of the lungs returns them to their normal volume. At rest, we breathe 15-18 times a minute exchanging about 500 ml of air.

•

In more vigorous expiration, •

The internal intercostals muscles draw the ribs down and inward

•

The wall of the abdomen contracts pushing the stomach and liver upward.

Under these conditions, an average adult male can flush his lungs with about 4 liters of air at each breath. This is called the vital capacity. Even with maximum expiration, about 1200 ml of residual air remain. The table shows what happens to the composition of air when it reaches the alveoli. Some of the oxygen dissolves in the film of moisture covering the epithelium of the alveoli. From here it diffuses into the blood in a nearby capillary. It enters a red blood cell and combines with the hemoglobin therein. At the same time, some of the carbon dioxide in the blood diffuses into the alveoli from which it can be exhaled.

XII. DISCHARGE PLANNING Medication 1. Take or administer medications daily, as prescribed 2. Monitor the effects of medications Exercise 1. Conserve energy by balancing activity with rest periods. 2. Change position at frequent intervals to prevent pressure sores. 3. Avoid activity in extremes of hot and cold, which increase the work of heart. 4. Gradual ambulation is encouraged to prevent risk of embolism due to immobility 5. Increase walking and other activities gradually, provided they do not cause unusual fatigue / dyspnea. Treatment 1. Encourage to comply with treatment regimen especially adhering to medical regimen of the prescribed medication. 2. Advise family members to attend to the needs and support patient to decrease anxiety and stress. 3. Encourage patient to increase self- care and responsibility for accomplishing the daily requirements of the therapeutic regimen. Health Teaching 1. Teach the client and his family about the disorder and self-care 2. Avoid fatigue, balance rest and activity. 3. Observed prescribed sodium restrictions 4. Obtain weight at the same time each day

OPD Follow-Up 1. Keep regular appointments with the physician 2. Notify the physician to report signs and symptoms like weight gain greater than 2-3 lbs/day, loss of appetite, unusual SOB with activity, swelling of the ankles, feet or abdomen, development of restless sleep. 3. Have medical follow-up as ordered, usually every 2 weeks until stable. Diet 1. Sodium-restricted diet is taught to prevent fluid excess 2. Encourage to eat frequent small feedings to minimize exertion and reduce GI blood requirements 3. Provide bland, low-calorie, low-residue with vitamin supplement 4. Encourage to eat potassium rich food like banana, potatoes, broccoli and green leafy vegetables. 5. Recommend avoidance of excessive amount of fluid 6. Avoid canned or processed foods 7. Adapt diet by examining nutrition labels to check sodium content per serving. 8. Avoid excesses in eating and drinking. Spirituality 1. Advise the patient to always communicate with God, be faithful enough and not to lose hope. Sexuality 1. Activities such as sexual intercourse should be avoided because this results physical exertion that can cause myocardial oxygen demand.

XIII. BIBLIOGRAPHY

http.//www.wikepedia.com http//www.yahoo.com ask.com Nurses pocket Guide Medical Surgical book Drug hand Book