Tuberculosis_cs

TABLE OF CONTENTS Page I. Introduction A. Overview of the Case

2

B. Objective of the Study

2

C. Scope and Limitation of the Study

3

II. Health History A. Profile of Patient

4

B. Family and Personal Health History

5

C. History of Present Illness

5

D. Chief Complain

6

III. Developmental Data

7

IV. Medical Management A. Medical Orders and Laboratory Results

10

B. Drug Study

13

V. Pathophysiology with Anatomy and Physiology

16

VI. Nursing Assessment (System Review and Nursing Assessment II)

25

VII. Nursing Management A. Ideal Nursing Management (NCP)

26

B. Actual Nursing Management (SOAPIE)

31

VIII. Referrals and Follow-up

35

IX. Evaluation and Implications

36

X. Documentation

37

XI. Bibliography

38

XII. Rating scale

39

I. INTRODUCTION

Tuberculosis is a common and often deadly infectious disease caused by mycobacteria, mainly Mycobacterium tuberculosis. Tuberculosis usually attacks the lungs (as pulmonary TB) but can also affect the central nervous system, the lymphatic system, the circulatory system, the genitourinary system, the gastrointestinal system, bones, joints, and even the skin. Other mycobacteria such as Mycobacterium bovis, Mycobacterium africanum, Mycobacterium canetti, and Mycobacterium microti also cause tuberculosis, but these species are less common. The typical symptoms of tuberculosis are a chronic cough with bloodtinged sputum, fever, night sweats and weight loss. Infection of other organs cause a wide range of symptoms. The diagnosis relies on radiology (commonly chest X-rays), a tuberculin skin test, blood tests, as well as microscopic examination and microbiological culture of bodily fluids. Tuberculosis treatment is difficult and requires long courses of multiple antibiotics. Contacts are also screened and treated if necessary. Antibiotic resistance is a growing problem in (extensively) multi-drug-resistant tuberculosis. Prevention relies on screening programs and vaccination, usually with Bacillus Calmette-Guérin (BCG vaccine). Tuberculosis is spread through the air, when people who have the disease cough, sneeze or spit. One third of the world's current population have been infected with M. tuberculosis, and new infections occur at a rate of one per second.[1] However, most of these cases will not develop the full-blown disease; asymptomatic, latent infection is most common.

2

Scope of the Study 

The study focuses on surgical Ward patient, admitted at Polymedic General Hospital, Cagayan de Oro City, having the diagnosis of Pulmonary Tuberculosis.



Nature,

causes,

signs

&

symptoms,

pathophysiology,

medical

management, nursing management, and prognosis of the disease. 

Involves the ideal and actual nursing intervention appropriate to address the needs of Mrs. Nelia S. Castillano, the drug study of the medications given to her, the health teachings as well as referrals for Mrs. Nelia S. Castillano



Assessment of Mrs. Nelia S. Castillano personal health history, and history of present illness.

Limitation of the Study 

Limited only to the history of the patient which is comprised of the patient’s profile, family and personal health history, chief complaint and history of present illness.



Information being collected from the patient during the patient assessment and from her watchers.



The patient was only taken cared of for 2 days, starting from the 2nd day of her admission at Polymedic Genaral Hospital, Cagayan de Oro City.

II. Health History

3

CLIENT’S PROFILE Client’s Name: Age: Address: Civil Status: Sex: Nationality:

Filipino

Religion:

Roman Catholic

Educational Attainment: High School Graduate Height:

5’2”

Weight:

45 kg

Occupation:

House wife

Income:

none

Informant: Date of Admission: August 4, 2008 Time of Admission: 6:45 pm Chief Complaint:

Cough, Loss of appetite, Presence of blood in the sputum

Admitting Diagnosis: Koch Pulmonary Infection Pneumonia Attending Physician:

HISTORY OF PRESENT ILLNESS Chief Complaint: cough

4

Mrs. X a 56 yr. old female, Roman Catholic , Housewife, residing at Western Wao, Lanao Del Sur was admitted at Polymedic General Hospital for the first time last August 4, 2008. Two weeks prior to admission onset of cough productive with yellowish phlegm, + night sweats, + low grade fever, + poor appetite, this day noted blood stitched sputum hemophysis with back pain, associated with mass at left lower lip noted since 1986 when the area was constantly traumatized any protruding one tooth and later develop a mass, no bleeding noted.

Personal Health History In relation to the health history of the family,. has not undergone any previous hospitalization.

Family History (-) Hypertension (-) Diabetes Mellitus (+) Tuberculosis of Husband Past Medical History Patient Mrs. X., who is 56 yrs. Old, was admitted to Polymedic General Hospital last August 4, 2008 at 6:45 pm with chief complaint of cough, loss of appetite, presence of blood in the sputum.

5

Mrs. X has not undergone previous hospitalization. She is a nonsmoker, and non-alcoholic beverage drinker. She did not undergo any surgery and has no known food and drug allergies.

Chief Complaint Two weeks prior to admission onset of cough productive with yellowish phlegm, + night sweats, + low grade fever, + poor appetite, this day noted blood stitched sputum hemophysis with back pain, associated with mass at left lower lip noted since 1986 when the area was constantly traumatized any protruding one tooth and later develop a mass, no bleeding noted.

6

III. DEVELOPMENTAL THEORY 

Erik Erikson’s Theory of Psychosocial Development Erik H. Erikson (1963-1964), adapted and expanded Freud’s theory of

development to include the entire lifespan, believing eight stages of development. Erikson envision life as a sequence of levels of achievement. Each stage signals a task that must be achieved. The resolution of task can be complete, partial, or unsuccessful. Erikson believes that the greater the task achievement, the healthier the personality of the person; failure to achieve a task influence s a person’s ability to achieve the next task. These developmental tasks can be viewed as a series of crises, and successful resolution of these crises is supportive to the person’s ego. Failure to resolve the crises is damaging to the ego. Erikson’s eight stages reflect both positive and negative aspect of the critical life periods. The resolution of the conflicts at each stage enables the person to function effectively in society. Each phase has kits own developmental task, and individual must find a balance between. According to Erik Erikson’s developmental task. Mrs. Nelia S. Castillano, 56 years old, belongs to developmental task of older age, with a central task of integrity versus despair. As I observed, he was kin the positive resolution of development at her stage because according to his daughter he has a good relationship with his parent’s, brothers and sisters and most especially with his husband and children, she had raised them well and really tried her best to

7

support his children, she was a loving mother and even though he experienced an illness on her older stage of life, still she was able to show courage and strength while admitted in the hospital. she has a positive coping mechanism skill especially in participating during administration of medication. 

Robert J. Havighurst Developmental Task Theory Havighurst (1900-1991) theorized that the developmental task one must

accomplish throughout life. He described developmental task as doing those things that make up health and satisfactory growth kin society. The task are organically and socially determined. Accomplishing task at a lower level, or at an earlier stage, is the first step in the progression toward accomplishing task at later age. A developmental task is a task which arises at or about a certain period in the life of individual, successful achievements of which leads to his happiness and to success with later task, while failure leads to unhappiness in the individual, disapproval by society, and difficulty with later task. According to Havighurst developmental theory, Mrs..Nelia S. Castillano 56 years of age, belongs to a period of middle age which was achieving adult civic and social responsibility since she is a house wife blessed with six children and a supportive husband and family. 

Jean Piaget Cognitive Developmental Task Theory Piaget’s believes that cognitive structures are complete during the formal

operations period, from roughly 11 to 15 years. From the time formal operations characterize thinking throughout adulthood and are applied to more areas.

8

Egocentrism continue to decline; however these changes in its content and stability. Some may use post-formal operations strategies to assist them in understanding the contradictions that exist in both personal and physical aspects of reality. The experiences of the professional, social and personal life in the middle-aged persons will be reflected in their cognitive performance. The middleaged adult can imagine, anticipate, plan and hope. The patient is very positive, she always anticipate things that goes on smoothly and righteously. Despite of her, sickness she still keep her self happy and strong. 

Sigmund Freud Psychosocial Developmental Task. Psychosocial Development refers to the development of personality. It can

be considered se the outward expression of the inner self. It encompasses a persons temperament, feelings, character, traits, independence, self-esteem, self concept, behavior, ability to interact with others, and ability to adapt to life changes. The culminating stage of Psychosocial Development is Genital Stage ( 13 years and after ) were energy is directed toward attaining a mature sexual relationship. This stage involves a reactivation of the pregenital impulses. These impulses are usually displaced and the individual passes are usually displaced and the individual passes to the genital stage or maturity. An inability to resolve conflicts can result in sexual problems, such as frigidity, impotence and the inability to have satisfactory sexual relationship.

9

Our patients 56 years old, in her age right now, he encountered many things that made her strong.

IV. MEDICAL MANAGEMENT A. LABORATORIES CHEMISTRY Date: 08-05-08

Creatinine

Result 0.90

Normal range 0.70

Rationale within normal range

Fasting Blood Sugar

92.60

60-100mg/dL

within normal limit

X-RAY Date: 08-05-08 Impression: There is homogenous opacification of the right middle lobe. The rest of the lung field are clear the heart is not enlarged. Midline structures are not displaced. The diaphragms are intact te rest of the included structures are unremarkable. •

Pneumonia with lobar consolidation, right middle lobe.

URINALYSIS Date: 08-05-08 Specimen Color Appearance Glucose Protein Reaction Specific gravity

Result straw clear (-) Negative (-) Negative 6.0 1.005

Microscopic:

10

WBC RBC Epithelial mucous threads Urates Bacteria

6-8 3-6 none none none HEMATOLOGY Date: 08-05-08 Result

WBC RBC Hemoglobin Hematocrit MCV MCH MCHC LOW Platelet count Differential Count: Neutrophils Lymphocytes Monocytes Eosinophils Basophils RDW-CV

9.61 4.41 *11.4 37.0 83.9 *25.9 *30.8 262 *70.7 *19.0 5.8 4.4 0.1 13.3

Normal range

Rationale

8-10 3.69-5.90 11.70-14.00 34 - 44 70-97 26.10-33.30 32-35

normal normal LOW normal normal LOW

150-390

normal

55-62 20-40 4-10 1-6 0.50-1.0 11.5-14.5

11

B. MEDICAL ORDERS WITH RATIONALE DOCTOR’S ORDER August 4, 2008  Please admit at room of choice  To provide care and close under my service monitoring.  Secure consent  Consent is essential for any treatment; routine procedures are covered by a consent signed at admission.  DAT  TPR q 4 hours

 To restore caloric needs  Provide a baseline data for care. During this period of time, complications (hypotension, shock, pulmonary edema) may possibly develop.

 I and O q shift

 Accurate intake and output records detect early fluid excess or imbalances.

Laboratories: o Creatinine  Chest X-ray (done)  Urinalysis

 To assess kidney function.  To check lung status since patient complained shortness of breath.  A standard procedure; used to check abnormalities in the renal system

 Medications:  Moxifloxacin 400g Slow IV drip OD, ANST

 Sinecod 1tab TID PO

 This medication is Bactericidal: interferes with DNA replication, repair, transcription, and recombination in susceptible gram negative and grampositive bacteria, preventing cell production and leading to cell death.  This medication is for acute cough of any etiology for pre or post cough sedation 12

 Hemostan 500mg 1cap TID

 This medication is anti- hemorrhage and anti- fibrolyic for effective in various clinica and surgical cases

B. DRUG STUDY

MOXIFLOXACIN (Avelox) Date Ordered August 4, 2008 Classification Antibiotic Doses/Frequency/ Route IV drip OD ANST (-) Mechanism of Action Bactericidal: interferes with DNA replication, repair, transcription, and recombination in susceptible gram negative and gram-positive bacteria, preventing cell production and leading to cell death. Specific Indication Treatment of adults with CAP caused by susceptible strains. Contraindication Contraindicated in presence of allergy to flouroquinolones. Side Effects • Headache • Dizziness • Insomnia • Fatigue • Nausea • Diarrhea Nursing Management • Take drug once a day for a period required. If antacids are being taken, take drug 4H before or at least 8H after the antacid.

13

SINECOD Date ordered August 4, 2008 Classification Butamirate Citrate Dose/ Frequency/ Route 1tab TID PO

Mechanism of Action This medication is for acute cough of any etiology for pre or post cough sedation Specific Indication Cough Contraindication Pregnancy and lactation Side effects • drowsiness • nausea • vomiting • rash • urticaria • Liver damage Nursing Management • Assess patient’s fever: temperature, before and during therapy • Assess allergic reactions: rash, urticaria. If these occur, drug may have to be discontinued

14

HEMOSTAN Date Ordered August 4, 2008 Classification Haemostatics Doses/Frequency/ Route 500mg 1Cap TID Mechanism of Action This medication is anti- hemorrhage and anti-fibrolyic for effective in various clinica and surgical cases Specific Indication Used to reduce hemorrhage or presence of blood due to cough Contraindication There are no known contraindications Side Effects • Head ache . Nursing Management • Take medicine with juice for easily absorption

15

V. PATHOPHYSIOLOGY with Anatomy and Physiology Definition: Tuberculosis is a highly infectious chronic disease caused by the tubercle bacilli, Mycobacterium tuberculosis. Predisposing factors • Close contact with someone who has active TB specifically wife 

Immunocompromised status (weak immune system)

Precipitating factors Inhalation of air-borne nuclei containing tubercle bacilli

Bacteria are transmitted through the airways to the bronchioles and alveoli

Deposition and multiplication in the apices of the lungs

Bacilli transported via the lymph system and bloodstream to other parts of the body

Inflammatory reaction

fever Low-grade fever: 37.9oC

Neutrophils and macrophages engulf many bacteria TB-specific lymphocytes lyse the bacilli and normal tissue

Production of exudates in the alveoli Partial occlusion of the bronchi or alveoli

• Productive cough w/ greenish sputum • Phlegm crackles on R Lung

16

17

Interferes with the diffusion of oxygen and carbon dioxide

Dyspnea Shortness of breath

Areas of the lungs are inadequately ventilated

dyspnea

Decreased Oxygen-carrying capacity (Hypoxemia)

Tachypnea 34CPM dyspnea

Tissue hypoxia

Pallor Fatigue Weakness tachycardia dizziness

Development of active disease after initial exposure and infection

Low grade fever Night sweats Anorexia Weight loss

Ulceration of Ghon tubercle

Hemoptysis

Release of cheesy material into the bronchi

Ghon tubercle heals forming scar tissue

Productive cough of more than 2 weeks Whitish phlegm Parenchymal lesions on CXR

Inflammation of infected lungs

Spreading to the hilum of the lungs and later extends to adjacent lobes

Dyspnea Easy fatigability

18

ANATOMY AND PHYSIOLOGY Respiratory System The respiratory system consists of the airways, the lungs, and the respiratory muscles that mediate the movement of air into and out of the body. Within the alveolar system of the lungs, molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the gaseous environment and the blood. Thus, the respiratory system facilitates oxygenation of the blood with a concomitant removal of carbon dioxide and other gaseous metabolic wastes from the circulation. The system also helps to maintain the acid-base balance of the body through the efficient removal of carbon dioxide from the blood.

Structure of the Respiratory System 19

Upper airways 

Nasal Cavity The nasal cavity (or nasal fossa) is a large air-filled space above and

behind the nose in the middle of the face.The nasal cavity conditions the air to be received by the areas of the respiratory tract and nose. Owing to the large surface area provided by the conchae, the air passing through the nasal cavity is warmed or cooled to within 1 degree of body temperature. In addition, the air is humidified, and dust and other particulate matter is removed by vibrissae, short, thick hairs, present in the vestibule. The cilia of the respiratory epithelium move the particulate matter towards the pharynx where it is swallowed. 

Pharynx The pharynx is the part of the neck and throat situated immediately

posterior to the mouth and nasal cavity, and cranial, or superior, to the esophagus, larynx, and trachea.It is part of the digestive system and respiratory system of many organisms.Because both food and air pass through the pharynx, a flap of connective tissue called the epiglottis closes over the trachea when food is swallowed to prevent choking or aspiration. In humans the pharynx is important in vocalization.

20



Larynx The larynx (plural larynges), colloquially known as the voicebox, is an

organ in the neck of mammals involved in protection of the trachea and sound production. The larynx houses the vocal folds, and is situated just below where the tract of the pharynx splits into the trachea and the esophagus Sound is generated in the larynx, and that is where pitch and volume are manipulated. The strength of expiration from the lungs also contributes to loudness, and is necessary for the vocal folds to produce speech. During swallowing, the backward motion of the tongue forces the epiglottis over the laryngeal opening to prevent swallowed material from entering the lungs; the larynx is also pulled upwards to assist this process. Stimulation of the larynx by ingested matter produces a strong cough reflex to protect the lungs.

Lower airways 

Trachea The trachea extends from the larynx to the level of the 7th thoracic

vertebrae, where it divides 2 main bronchi, which is called the carina. It is a flexible, muscular 12-cm long air passage with c shaped cartilaginous rings. Along with other regions of the lower airways it is lined pseudo stratified columnar epithelium that contains goblet cells and Celia. Because the Celia beat upward, they tend to carry foreign particles and excessive mucus away from the lungs to the pharynx. The trachea (windpipe) divides into two main bronchi the left and the right, at the level of the sternal angle.

21



Bronchi and Bronchioles A bronchus is a caliber of airway in the respiratory tract that conducts air

into the lungs. No gas exchange takes place in this part of the lungs. . The right main bronchus is wider, shorter, and more vertical than the left main bronchus. The right main bronchus subdivides into three segmental bronchi while the left main bronchus divides into two. The lobar bronchi divide into tertiary bronchi. Each of the segmental bronchi supplies a bronchopulmonary segment. A bronchopulmonary segment is a division of a lung that is separated from the rest of the lung by a connective tissue septum.



Lungs The trachea divides into the two main bronchi that enter the roots of the

lungs. The bronchi continue to divide within the lung, and after multiple divisions, give rise to bronchioles. The bronchial tree continues branching until it reaches the level of terminal bronchioles, which lead to alveolar sacks. Alveolar sacs are made up of clusters of alveoli, like individual grapes within a bunch. The individual alveoli are tightly wrapped in blood vessels, and it is here that gas exchange actually occurs. Deoxygenated blood from the heart is pumped through the pulmonary artery to the lungs, where oxygen diffuses into blood and is exchanged for carbon dioxide in the hemoglobin of the erythrocytes. The oxygen-rich blood returns to the heart via the pulmonary veins to be pumped back into systemic circulation. Human lungs are located in two cavities on either side of the heart. Though similar in appearance, the two are not identical. Both are separated into

22

lobes, with three lobes on the right and two on the left. The lobes are further divided into lobules, hexagonal divisions of the lungs that are the smallest subdivision visible to the naked eye. The connective tissue that divides lobules is often blackened in smokers and city dwellers. The medial border of the right lung is nearly vertical, while the left lung contains a cardiac notch. The cardiac notch is a concave impression molded to accommodate the shape of the heart. Lungs are to a certain extent 'overbuilt' and have a tremendous reserve volume as compared to the oxygen exchange requirements when at rest. This is the reason that individuals can smoke for years without having a noticeable decrease in lung function while still or moving slowly; in situations like these only a small portion of the lungs are actually perfused with blood for gas exchange. As oxygen requirements increase due to exercise, a greater volume of the lungs is perfused, allowing the body to match its CO2/O2 exchange requirements. 

Alveoli An alveolus is an anatomical structure that has the form of a hollow cavity.

Mainly found in the lung, the pulmonary alveoli are spherical outcroppings of the respiratory bronchioles and are the primary sites of gas exchange with the blood. The lungs contain about 300 million alveoli[2]., representing a total surface area of approx. 70-90 square meters (m2). Each alveolus is wrapped in a fine mesh of capillaries covering about 70% of its area. The alveoli have radii of about 0.05 mm but increase to around 0.1 mm during inhalation. The alveoli consist of an epithelial layer and extracellular matrix surrounded by capillaries. In some alveolar walls there are pores between alveoli. There are three major alveolar cell types in the alveolar wall. •

Type I cells that form the structure of an alveolar wall

•

Type II cells that secrete surfactant to lower the surface tension of water and allows the membrane to separate thereby increasing the capability to exchange gases. Surfactant is continuously released by exocytosis. It forms an underlying aqueous protein-containing hypophase and an 23

overlying

phospholipids

film

composed

primarily

of

dipalmitoyl

phosphatidylcholine. •

Macrophages that destroy foreign material, such as bacteria.



Diaphragm The Diaphragm is a dome-shaped musculofibrous septum which

separates the thoracic from the abdominal cavity, its convex upper surface forming the floor of the former, and its concave under surface the roof of the latter. Its peripheral part consists of muscular fibers which take origin from the circumference of the thoracic outlet and converge to be inserted into a central tendon. The diaphragm is crucial for breathing and respiration. During inhalation, the diaphragm contracts, thus enlarging the thoracic cavity (the external intercostals muscles also participate in this enlargement). This reduces intrathoracic pressure: in other words, enlarging the cavity creates suction that draws air into the lungs. When the diaphragm relaxes, air is exhaled by elastic recoil of the lung and the tissues lining the thoracic cavity in conjunction with the abdominal muscles which act as an antagonist paired with the diaphragm's contraction an antagonist paired with the diaphragm's contraction.

24

The Lungs

1: Trachea 2: Pulmonary artery 3: Pulmonary vein 4: Alveolar duct 5: Alveoli 6: Cardiac notch 7: Bronchioles 8: Tertiary bronchi 9: Secondary bronchi 10: Primary bronchi 11: Larynx

25

Name:Nelia S. Castillano Temp: 36.8˚C Respiratory Rate: 22cpm Height: 5’2 cm EENT [ ] impaired vision [ ] blind [ ] pain redden [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion teeth Assess eyes ears nose [ ] throat for abnormality [ x ] no problem RESP: [ ] asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ x ] cough [ ] bradypnea [ ] shallow [ ] rhonchi [x ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ x] wheezing [ ] pain [ ] cyanotic Assess resp. rate, rhythm, pulse blood [ ] breath sounds, comfort [ ] no problem

Blood Pressure: 120/80mmHg Pulse Rate: 88 bpm Weight: 45kgs.

Mass at left lower lip since she was 35 years old • When the area was traumatize any protruding 1 loose tooth and later develop a mass

CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] mur mur [ ] tingling [ ] absent pulses [ ] pain Assess heart sounds, rate rhythm, pulse, blood Pressure, circ., fluid retention, comfort [x] No problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dyspagea [ ] rigidity [ ] pain Assess abdomen, bowel habits, swallowing Bowel sounds, comfort [x ] no problem GENITO – URINARY AND GYNE [ ] pain [ ] urine [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nucturia [ ] gyne bleeding [ ] discharge [ x ] no problem Assess urine frequency, control, color, odor, comfort

Cough

NEURO: [ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure [ ] lethargic [ ] assess motor, function, sensation, LOC, strength [ ] grip, gait, coordination, speech [x] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechie [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic moist Assess mobility, motion gait, alignment, joint function Skin color, texture, turgor, integrity [x ] no problem

26

VII. NURSING MANAGEMENT A. Ideal Nursing Care Plan 1. NURSING DIAGNOSIS: Ineffective airway clearance related to copious tracheobronchial secretions. Independent Interventions: 1. Assess respiratory function, e.g.,

1. Diminished breath sounds may

breath sounds, rate, rhythm and

reflect

depth;

accessory

wheezes indicate accumulation

muscles; ability to expectorate

of secretions/inability to clear

mucous/cough

airways that may lead to use of

use

of

effectively;

atelectasis.

Rhonchi,

character, amount of sputum,

accessory

muscles

and

presence of hemoptysis.

increased work of breathing. Secretions may be very thick because of the infection. Bloodtinged or frankly bloody sputum results from tissue breakdown (cavitations) in the lungs or bronchial ulceration.

2. Place patient in semi or high

2. Positioning helps maximize lung

Fowler’s position. Assist patient

expansion

and

with

respiratory

effort.

coughing

and

deep

breathing exercises.

decreases Maximal

ventilation may open atelectic areas, promote movement of secretions into larger airways for expectoration.

3. Clear secretions from mouth and trachea; suction as necessary.

3. Prevents obstruction/aspiration. Suctioning may be necessary if patient is unable to expectorate secretions.

4. Maintain fluid intake of at least

4. High fluid intake helps to thin

27

2500 ml/day.

and

loosens

pulmonary

secretions, making them easier to clear. 5. Elevate head of the bed/ change

5. To take advantage of gravity

position every 2 hours and prn.

decreasing

pressure

on

the

diaphragm. 6. Apply chest physiotherapy every

6. To remove bronchial secretions,

after nebulization.

improve ventilation, and increase the efficiency of the respiratory muscles.

7. Instruct client to avoid intake of

7. These can stimulate cough

very hot or cold foods/fluids. Dependent Intervention: 8. Administer humidify air/oxygen

8. Prevents

as prescribed by the physician.

drying

membranes;

of

mucous

helps

to

thin

secretions. 9. Administer

medications

as

9.

indicated:  Mucolytic agents

 Mucolytic agents reduce the

thickness

and

stickiness of pulmonary secretions

to

facilitate

clearance.  Bronchodilators

 Bronchodilators increase lumen

size

of

trcaheobronchial thus

the tree,

decreasing

resistance to airflow.  Corticosteriod

 May

be

presence

useful of

in

extensive

28

involvement with profound hypoxemia

and

when

inflammatory response is life-threatening.

2. NURSING DIAGNOSIS: Risk for impaired gas exchange related to thick viscous secretions. Independent Intervention: 1. Assess for dyspnea, tachypnea; abnormal/diminished

1. Pulmonary

tuberculosis

can

breath

cause a wide range of effects in

sounds; increasing respiratory

the lungs ranging from a small

effort;

patch of bronchopneumonia to

limited

chest

wall

expansion; and fatigue.

diffuse

intense

caseous

inflammation,

necrosis,

pleural

effusion, and extensive fibrosis, resulting in profound symptoms of respiratory distress. 2. Evaluate change in level of

2. Accumulation

of

consciousness. Note cyanosis

secretions/airway

compromise

and/or change in skin color,

can impair oxygenation of vital

including mucous membranes

organs and tissue.

and nail beds. 3. Demonstrate/encourage pursedlip breathing during inhalation.

3. Creates resistance against out flowing

air,

to

collapse/narrowing airways,

thereby

distribute lungs

air

and

prevent of

the

helping

to

throughout

the

relieving/reducing

shortness of breath.

29

4. Promote

bedrest/activity

4. Reducing

oxygen

restriction and assist with and

consumption/demand

care activities as necessary.

periods

of

compromise Dependent Intervention:

during respiratory

may

reduce

severity of symptoms.

5. Monitor serial ABG’s

5. Decreased (PaO2),

oxygen

and/or

content

saturation,

or

increased PaCO2 indicates need for/change

in

therapeutic

regimen. 6. Provide supplemental Oxygen.

6. Aids in correcting the hypoxemia that may occur secondary to decreased ventilation/diminished alveolar lung surface.

3. NURSING DIAGNOSIS: Altered Nutrition: less than body requirements related to anorexia. Independent Intervention: 1. Assess and document patient’s nutiritional

status

upon

admission, noting skin turgor,

1. Useful in defining degree/extent of

problem

and

appropriate

intervention.

current weight and degree of weight loss, integrity of oral mucosa, swallow, tones,

ability/inability presence

of

to bowel

history

of

nausea/vomiting or diarrhea. 2. Ascertain patient’s usual dietary patterns, likes/dislikes.

2. Helpful in identifying specific needs/strengths. Correlation of

30

individual

preferences

may

improve dietary intake. 3. Encourage

and

provide

for

frequent rest periods.

3. Helps

to

especially

conserve when

energy metabolic

requirements are increased with fever. 4. Provide oral care before and after respiratory treatments.

4. Reduces bad taste left from sputum or medication used for respiratory treatments that can stimulate vomiting center.

5. Encourage small frequent meals

5. Maximizes

nutrient

undue

intake

with foods high in protein and

without

fatigue

form

carbohydrates.

energy expenditure from eating large meals and reduces gastric irritation.

6. Encourage significant others to

6. Creates a more normal social

bring foods from home and to

environment during meal time

share meals with patient unless

and

contraindication.

cultural preferences.

helps

meet

personal,

Dependent Intervention 7. Refer for dietary consult.

7. Provides assistance in planning a diet with nutrient adequate to meet

patient’s

requirement

metabolic

and

dietary

preferences. 8. Consult with respiratory therapy

8. May

help

to

reduce

to schedule treatment 1-2 hours

incidence

of

nausea

before/after meals.

vomiting

associated

the and with

medications, or the effects of respiratory treatments on a full

31

stomach. 9. Monitor laboratory studies, eg., BUN,

serum

protein

9. Low values reflect malnutrition

and

and indicate need to change in

albumin. 10. Administer

therapeutic regimen antipyretics

as

10. Fever increases metabolism and

appropriate.

therefore calories consumption.

B. Actual Nursing Care Plan

1st Priority S O

“Galisud ko ug ginhawa usahay”  Productive cough with crackles and wheezing sound. 

Shortness of breath

A

 Green mucoid sputum Ineffective airway clearance

P

tracheobronchial secretion Short term: At the end of 15-20 minutes, the patient will be able to maintain

related

to

presence

of

copious

adequate airway patency. Long term: At the end of 8 hours, the patient will be able to demonstrate I

reduction of congestion with clear breath sound and noiseless respiration. Independent: 1. Patient was positioned in semi fowler to high fowler’s position. 2. Patient was assisted during coughing and deep breathing exercise. 3. Provided with adequate rest periods between activities Dependent:

E

1. Administer medication as needed. After 15 minutes, the patient was able to maintain adequate ventilation.

32

2nd Priority S O

NONE  Increase respiratory effort 

A P

Poor capillary refill;3 seconds

 Dyspnea (6/10) Risk for impaired gas exchange related to thick viscous secretion Short term: At the end of 15-20 minutes, patient will be able to report decrease dyspnea. Long term: At the end of 8 hours, the patient will be able demonstrate

I

adequate oxygenation of tissues and improve ventilation. Independent: 1. Demonstrate pursed-lip breathing during exhalation 2. Elevate head of bed as patient requires/tolerated. 3. Provide adequate bedrest and limit activity 4. Monitor Serial ABG/ Pulse oximetry.

E

After 20 minutes, the patient was able to report improve Breathing.

3rd

S O

“Nigamay gyud ako timbang karon kay dili kayo ko ganahan ug kaon”  Weight loss 

A P

Priority

Poor skin turgor

 Dry oral mucosa Altered nutrition; less than body requirements related to anorexia Short term: At the end of 8 hours, the patient will be able to receive adequate nutrients to maintain balance health. Long term: At the end of 1 week, the patient will be able to initiate behavior

I

changes to regain and maintain appropriate weight.. Independent:

33

1. Instruct the patient to eat in upright position. 2. Instruct the significant others to feed the client food rich in iron, protient and vitamin C. 3. Provide a clean and a pleasant environment conducive for eating. 4. Monitor patient intake and output 5. Provide frequent rest periods. E

After 8 hours, the patient was able to receive adequate nutrients to maintain balance health.

4th Priority S

“Ang una gyud nga Gi-TB sa amoa kay akong bana tapos wala ko nakabalo bahin ana nga sakit.” As verbalized by the patient.

O



Lack of information



Expressing feelings of concerns

Knowledge deficit related to unfamiliarity with disease process and new A

treatment methods.

P

At the end of 2 hours client will be able to verbalize understanding of disease process and treatment regimen.

I

Independent: 1. The client and significant others were taught for the following:

detection, transmission, signs/symptoms of relapse, and importance 2. Emphasized the importance of good nutrition. To help him motivates to take action and to strengthen the immune system to prevent complication. 3. Encouraged client and significant others to verbalized concerns, and answers questions factually. Provide opportunity to correct misconceptions and alleviate anxiety. 4. Emphasized the importance of maintaining high-protein,

carbohydrate and adequate fluid intake. Meeting metabolic needs 34

helps minimize fatigue and promote recovery 5. Provided a position of comfort and a quite environment for the client during interaction/discussion. This allows patient to concentrate on E

what is being discussed. At the end of 2 hours, client was able to verbalized understanding of the disease process, treatment regimen, and preventive measures to reduce the risk of complications.

VIII. Referrals and Follow up For the health problems of S.N. who has PTB, he should be referred accordingly to any hospital institution whenever symptoms of Dyspnea occur. Patient should contact his physician for immediate management of his disease. The patient should be instructed to have his follow-up check-up with his attending physician in the exact day at the exact time of schedule, even if he feels better, after being discharged from the hospital

IX. Evaluation and Implication During the 2nd day nursing care of the patient, Mr. X’ was able to manifest stable vital signs and signs and symptoms that may lead to the progress of the physical well-being of the patient. 35

After rendering health care service and doing necessary interventions to the patient. An improvement of Mr. X’s health status was observed as evidenced by normal vital signs and verbalization of normal breathing pattern. At the end of the shift, the interventions and procedures done to the patient were successful and the patient was able to participate actively to the treatment regimen. The disease of the patient implies that pulmonary tuberculosis develops in the minority of people whose immune systems do not successfully contain the primary infection. In this case, the disease may occur within weeks after the primary infection. Pulmonary tuberculosis may also lie dominant for years and reappear after the initial infection is contained. X. Documentation .

36

37

XI. Bibliography Douges, M.E. et.al., (2002). Nurse’s pocket guide: diagnosis, interventions & rationales. (8th Edition). Philadelphia: F.A. Davis Company. Douges,

M.E.

et.al.,

(2002).

Nursing

care

plan:

guidelines

for

individualizing patient care (6th Edition) Philadelphia: F.A. Davis Company. Gulandick, M. et.al., Nursing care plan. (3rd Edition) Ignatavicius, D.D. & Workman, M.L. (2006). Medical-surgical nursing: critical thinking for collaborative care. (5th Edition). St. Louis, Missouri: Elsevier Saunders. Kozier, B. et.al., (2004). Fundamentals of nursing: concepts, process & practice. (7th Edition). Philippines: Pearson Education South Asia PTE Ltd.

38

Smeltzer, S.C. & Bare, B.G. (2004).Textbook of medical-surgical nursing(10th Edition, Volume 2). Philadelphia: Lippincott Williams and Wilkins. pp 553-538. Spratto, G.R. & Woods, A.L. (1994). Nurse’s drug reference. USA: Delmar Publishers Incorporated. Ulrich & Canale. (2005). Nursing care planning guides. (6th Edition).

XII. Rating Scale A. WRITTEN

WEIGHT

RATING

39

I. Introduction

5

a. Overview of the Case b. Objective of the Study c. Scope and Limitation of the Study II. Health History

5

a. Profile of the Patient b. Family and Personal Health History c. Chief Complaint III. Developmental Data

5

IV. Medical Management

20

a. Medical Orders with Rationale

(10)

b. Drug Study

(10)

V. Pathophysiology with anatomy and physiology

10

VI. Nursing Assessment

10

a. Nursing System Review Chart

30

b. Nursing Assessment II

(10)

VII. Nursing Management

(20)

a. Ideal Nursing Management b. Actual Nursing Management VIII. Referrals and Follow-up

5

IX. Evaluation and Implication

5

X. Documentation

5

a. Documentation of Evidence of Care for 1 Week Rotation b. Organization/Grammar/Bibliography Total Score Equivalent Grade

40

41