SOUTHEAST ASIAN COLLEGE INC.

A CASE STUDY OF Pulmonary Tuberculosis

By: ALEGRE, Mary Edith M. BSN 421 Group 1

Submitted to: Mrs. Lucy de Leon (Clinical Instructor)

I.

Introduction

A. Background of the study

This whole case study is about to discussed Pulmonary Tuberculosis (TB) and few of Pneumothorax and Hydrothorax. This case will tackle about the disease, patients health and of course nursing intervention. Tuberculosis (abbreviated TB for tubercle bacillus or Tuberculosis) is a common and often deadly infectious disease caused by mycobacteria, in humans 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 in humans. Tuberculosis is spread through the air, when people who have the disease cough, sneeze, or spit. Most infections in human beings will result in asymptomatic, latent infection, and about one in ten latent infections will eventually progress to active disease, which, if left untreated, kills more than half of its victims. The classic symptoms of tuberculosis are a chronic cough with blood-tinged sputum, fever, night sweats, and weight loss. Infection of other organs causes a wide range of symptoms. Demographic incidence Tuberculosis (TB) is a deadly disease. It is the worlds No. 1 cause of death around the world; about 3 million persons die of TB every year. It is one of the 10 top killer diseases in the Philippines; 75 Filipinos die of TB every day.

Pneumothorax, or collapsed lung, is a potential medical emergency caused by accumulation of air or gas in the pleural cavity, occurring as a result of disease or injury, or spontaneously.

Kind: Closed Pneumothorax Air escapes in pleural space from a puncture or tear in an internal respiratory structure such as bronchus, bronchioles, and alveoli. Classification: Spontaneous the cause is Unknown, could be result of another disease such as COPD, PTB and Cancer. Chest wall is intact; blebs/bulla is rapture causing collapse lungs. A hydrothorax is a condition that results from serous fluid accumulating in the pleural

cavity.

B. Objective
General The general objective of this case study is to broaden our knowledge about the disease and develop skills on how to render the best possible care to a patient suffering from Pulmonary Tuberculosis. Specific To be able to define Pulmonary Tuberculosis as well as on how it is acquired, factors, signs and symptoms. To be able to know the pathophysiology of Pulmonary Tuberculosis. To be able to know the other problems that the client is suffering right now not only PTB but also Pneumothorax and Hydrothorax To gain more information about patients condition. To apply skills learned in the classrooms to actual handling and caring of a patient who suffered from Pulmonary Tuberculosis. To determine the possible nursing intervention that will be a great help in patients prognosis. To be able to give the appropriate health teaching and better understanding of the disease to the patient, family and significant others.

Patients Biographic Data

Name: A.E.P Sex: Female Age: 33 years old Status: Single Date of Birth: November 6, 1979 Religion: Roman Catholic Occupation: Unemployed Chief Complaint: Body Weakness/ Dizziness Date of Admission: Nov. 30, 2012 Diagnosis: > PTB 5, Cat 3 > Anemia secondary to chronic illness Attending Physician: Dr. A. Ortiz

Nursing History
The patient complained of Body Weakness and Dizziness upon admission. Madalas akong nanghihina tyaka nahihilo ako.

Chief Complaint: Body Weakness and Dizziness is the patients chief complaint.

Medical Diagnosis: The medical diagnosis of the patient is PTB 5 Cat 3 and also Anemia secondary to Chronic Illness.

History of the Patients Illness According to the patient, 1 week prior to admission she is suffering from body weakness and dizziness most of the time especially during late in the afternoon and at night.

Past History: According to the patient, she is brought to the hospital because of her body weakness. She does not have any allergy to foods and medications. The immunization that she can still remember is only Tetanus Toxoid. She is also not taking any multivitamins.

Family History: They have a history of PTB which is the illness of her father before he died. They have no history of Diabetes, Heart disease, Blood disorders and Cancer.

Personal and Social History: The patient claimed that she has no vices up to the present such as cigarette smoking, alcoholic drinking and substance abuse.

13 Areas of Assessment
1. Social Status Ms. A is 33 yrs. Old, born on November 6, 1979. She resides at Imus Cavite together with her live-in partner. They have no children as of now. Her siblings support Ms. As medical expenses and other financial needs. Due to present illness her lifestyle is affected. Before she had this disease patients was socially active, but at present she was not able to mingle with her neighbors, go to other places where she wants to go, and cannot serve to the church where she used to do it during her younger years. Mrs. A also stated that she do not smoke and drink alcohol. Analysis: Social status includes family relationships/friendships that state the patients support system in time of stress and in time of need. It meets a fundamental human need for social ties, making life less stressful and social support buffers the negative effects of stress, thus indicating indirectly contributing to good health outcomes. (Friedman and Smith 1988

2. Mental Status Ms. A is oriented to time, place and person. She can identify things or names being asked. She can recall recent and remote memories she experienced. She is able to read and write. She is responsive and answers to the questions being asked. Analysis: The content of the patient message should make sense. The ability to read and write should match the patients educational level. The patient should be able to correctly respond to questions and to identify all the objects as requested. The patient should be able to evaluate and act appropriately in situations requiring judgment. (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes)

3. Emotional Status Ms. A is cooperative and relaxed while performing the interview. She stated that she does not feel any fear regarding her condition. She accepted it and stated that every individual has an end. She believes that everything has a reason and said that everything is in Gods plan. Ms. A just prayed that she would not suffer too much pain from her condition. Analysis: The old adult is in the stage where an issue of ego integrity vs. despair arises. Integrity manifests with wisdom and feelings of satisfaction with ones life while despair arises from remorse about what could have been. The presence of despair causes life to be viewed as meaningless. (Source: Nursing CEU.com: The process of human development)

4. Sensory Perception Ms. A is not using reading glasses due to blurring of vision. Her hearing ability is normal using whisper test with distance of two feet. Her sense of smell is normal and she can distinguish foul and fresh odor. Her lips are light brown in color. Her tongue is slightly pink and she can taste whatever food she eats. Analysis: Each of the five senses becomes less efficient in older adult hood. Changes result in loss of visual acuity, less power of adaptation to darkness and dim light, decreased in accommodation to near and far objects. The loss of hearing ability related to aging affects people over age 65. Gradual loss of hearing is more common among man than women, perhaps because men are more frequently in noisy work environments. Older people have a poorer sense of taste and smell and are less stimulated by food than the young. Loss of skin receptors takes place gradually, producing an increased threshold for sensations of pain, touch, and temperature. (Fundamental of Nursing 7th edition Barbara Kozier)

5. Motor Stability Ms. A is not comfortable with her condition. Her gait is slight staggering with weakness on legs so she needs support when standing up and walking. She finds walking, sitting, or changing positions difficult. Mrs. V tries to perform things alone if she can but admitted that she needs the help or assistance of another person often. Analysis: Late adulthood is in the stage where neuron loss continues with associated decrease in cerebral flow. Reaction times slow due to decreased levels of neurotransmitter. Gait and balance are affected with decreased proprioception. (Focus on Pathophysiology by Bullock and Henze). The patient with ascites maybe short of breath and uncomfortable from enlarge abdomen. (Brunner and Suddarths Textbook of Medical-Surgical Nursing)

6. Body Temperature During the assessment, Ms. A has a body temperature of 38.1C at the axillary area using a digital thermometer. The patients temperature is abnormal. Analysis: Normal axillary temperature is within 36.4C to 37.4C. (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes)

7. Respiratory Status

During the assessment, the patient has a respiratory status is 26bpm.

Analysis: Normal respiratory rate for adults is 12-20cpm. Average is 18. In terms of pattern, normal respirations must be regular and even in rhythm. The normal depth of respirations is non exaggerated and effortless (Health assessment and physical examination 3rd edition Mary Ellen Zator Estes)

8. Circulatory Status

During the assessment, Ms. A had a blood pressure of 110/80 and pulse pressure of 87bpm. No signs of heart enlargement.

Analysis: Normal cardiac rate for an adult is 60-100 beats per minute while the normal blood pressure is 120/80 mmHg. The working capacity of the heart diminishes with aging. The heart rate of older people is slow to respond to stress and slow to return to normal after stress. Reduced arterial elasticity results in diminished blood supply to the parts of the body especially the extremities. (Kozier et. al, 2004)

9. Nutritional Status Prior to admission Ms. A meal intake is two to three times a day. The food served is usually vegetables, fish, and sometimes meat. During hospitalization, her diet was full meal. She is also advised to increase her oral fluid intake.

10. Elimination Status

Ms. A usually defecates one to two times a day. She urinates 4-6 times

a day with the range of 800-1,200ml. She does not feel any discomfort or pain whenever she defecates or urinates. Analysis: An individual usually defecate one to two times a day or every 2 days and urinates 30 cc/hr. (Nutrition by Alex Abelos)

11. Reproductive Status Ms. A had her first menstrual period at age 12. Her first sexual contact is when she was 18 years old and had only one sexual partner. According to the patient, there were no signs of abnormalities in her vagina, she refuses to assess her perineum area.

12. Sleep-Rest Pattern She usually sleeps 7 to 8 hours a day. She stated that sometimes her sleep is interrupted when nurse get vital signs early in the morning. She usually watches television at home during rest hours and also during admission.

Analysis: Sleep refers to altered consciousness with general slowing of physiologic process while rest refers to relaxation and calmness, both mental and physical. A typical sleeper will pass through 7 to 9 hours of sleep and take a rest using some relaxation activities such as reading, telling stories and others. (Nursing Fundamentals by Rick Daniels)

13. State of Skin Appendages Ms. As skin is brown in color and dry. Her hair is thin, fine and black. Her conjunctiva is slightly pale, and sclera is white in color.

Analysis: Obvious changes occur in the integumentary system (skin, hair, nails) with age. The skin becomes drier and more fragile, the hair loses color, the finger nails and toe nails become thickened and brittle, and in woman over 60, facial hair increases. These integumentary system changes accompany progressive losses of subcutaneous fat and muscle tissue, muscle atrophy, and loss of elastic fibers. (Fundamental of Nursing 7th edition by Barbara Kozier) The palpebral conjunctiva should appear pink and moist. Normally, the skin is a uniform whitish pink or brown color, depending on the patients race. Normally, the nails have a pink cast in light-skinned individuals and are brown in dark-skinned individuals. (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes)

Theoretical Framework
FLORENCE NIGHTINGALE ENVIRONMENTAL THEORY

Ai r
Nutrition Ventilation

ENVIRO
Cleanliness

MS. A

NMENT
Bedding

Light

Florence Nightingale was born to a wealthy and intellectual family. She was known as the Lady with the Lamp. She believed she was called by God to help others to improve the well being of mankind Nightingale is viewed as the mother of modern nursing. She synthesized information gathered in many of her life experiences to assist her in the development of modern nursing. Her contribution to the nursing profession was her Environmental Theory in which the nurses role is to place the client in the best position for nature to act upon him, thus encouraging healing. Nightingale viewed the manipulation of the physical environment as a major component of nursing care. She identified ventilation and warmth, light, noise, variety, bed and bedding, cleanliness of the rooms and walls, and nutrition as major areas of the environment the nurse could control. When one or more aspects of the environment are out of balance, the client must use increased energy to counter the environmental stress. These stresses drain the client of energy needed for healing. The social and psychological environment of the individual also influences these aspects of physical environment. I as a student nurse and part of the medical field has the role of providing nursing care with the help of the institutions and personnel involve curing the illness and lowering down the factors causing the patients disease with the help of Nightingales Environmental Theory.

Anatomy and Physiology

UPPER RESPIRATORY TRACT Respiration is defined in two ways. In common usage, respiration refers to the act of breathing, or inhaling and exhaling. Biologically speaking, respiration strictly means the uptake of oxygen by an organism, its use in the tissues, and the release of carbon dioxide. By either definition, respiration has two main functions: to supply the cells of the body with the oxygen needed for metabolism and to remove carbon dioxide formed as a waste product from metabolism. This lesson describes the components of the upper respiratory tract. The upper respiratory tract conducts air from outside the body to the lower respiratory tract and helps protect the body from irritating substances. The upper respiratory tract consists of the following structures: The nasal cavity, mouth, pharynx, piglottis, larynx, and upper trachea; the oesophagus leads to the digestive tract. One of the features of both the upper and lower respiratory tracts is the mucociliary apparatus that protects the airways from irritating substances, and is composed of the ciliated cells and mucus-producing glands in the nasal epithelium. The glands produce a layer of mucus that traps unwanted particles as they are inhaled. These are swept toward the posterior pharynx, from where they are swallowed, spat out, sneezed, or blown out. Air passes through each of the structures of the upper respiratory tract on its way to the lower respiratory tract. When a person at rest inhales, air enters via the nose and mouth. The nasal cavity filters, warms, and humidifies air. The pharynx or

throat is a tube like structure that connects the back of the nasal cavity and mouth to the larynx, a passageway for air, and the esophagus, a passageway for food. The pharynx serves as a common hallway for the respiratory and digestive tracts, allowing both air and food to pass through before entering the appropriate passageways. The pharynx contains a specialised flap-like structure called the epiglottis that lowers over the larynx to prevent the inhalation of food and liquid into the lower respiratory tract. The larynx, or voice box, is a unique structure that contains the vocal cords, which are essential for human speech. Small and triangular in shape, the larynx extends from the epiglottis to the trachea. The larynx helps control movement of the epiglottis. In addition, the larynx has specialised muscular folds that close it off and also prevent food, foreign objects, and secretions such as saliva from entering the lower respiratory tract. LOWER RESPIRATORY TRACT The lower respiratory tract begins with the trachea, which is just below the larynx. The trachea, or windpipe, is a hollow, flexible, but sturdy air tube that contains C-shaped cartilage in its walls. The inner portion of the trachea is called the lumen. The first branching point of the respiratory tree occurs at the lower end of the trachea, which divides into two larger airways of the lower respiratory tract called the right bronchus and left bronchus. The wall of each bronchus contains substantial amounts of cartilage that help keep the airway open. Each bronchus enters a lung at a site called the hilum. The bronchi branch sequentially into secondary bronchi and tertiary bronchi. The tertiary bronchi branch into the bronchioles. The bronchioles branch several times until they arrive at the terminal bronchioles, each of which subsequently branches into two or more respiratory bronchioles. The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli are bubble-like, elastic, thin-walled structures that are responsible for the lungs most vital function: the exchange of oxygen and carbon dioxide. Each structure of the lower respiratory tract, beginning with the trachea, divides into smaller branches. This branching pattern occurs multiple times, creating multiple branches. In this way, the lower respiratory tract resembles an upside-down tree that begins with one trachea trunk and ends with more than 250 million alveoli leaves. Because of this resemblance, the lower respiratory tract is often referred to as the respiratory tree.

Discharge Plan (METHODS)

M- Medications
Medications should be taken as ordered and prescribed by the physician to avoid complications and help mange the condition of the patient. There are a lot of main anti-Tuberculosis medications such as: Isoniazid, Rifampicin, Ethambutol and Pyrazinamide.

E- Exercise
Instruct the patient to have a time for deep breathing exercise everyday for several times at home to help achieved maximal lung expansion and for relaxation. Start with exercises that you are already comfortable doing. Starting slowly makes it less likely that you will injure yourself. Immediately stop any activities that might causes undue fatigue, increased shortness of breath or chest pain.

T- Treatment
Remind the importance of taking the medication in the right time and dose. Sleep in a room with good ventilation. Limit your activity to avoid fatigue. Frequent rest is advice. Maintained wound integrity on the surgical site.

H- Health Teachings
Advise to take the medication on time and with the right dosage. Semi-fowlers position is advice most of the time for breathing relaxation. Avoid close contact with others until the doctor finds it Okay. Advise the client to turn your head when coughing. Keep tissues with you and cover your mouth when you cough then throws the tissues used in the plastic bag.

Keep your hands clean. Maintain proper hygiene. Isolate techniques are one of the best ways to prevent the spread of the bacteria: separation of dining ware. Advise the relatives to clean the environment regularly since it is one of the factor that contribute to the speared of bacteria.

O- Out- patient follow- up

Most of the treatment to cure Pulmonary Tuberculosis can be given at home but must be taken as explained by the health care worker. The family has the responsibility to check the status of the patient and the progress of it.

D- Diet
Diet as tolerated is advice by the attending physician, to sustain his nutritional needs. High protein diet for tissue repair - meat and green leafy vegetables.

S- Spiritual practice
Ms. As religion is Catholic, encourage the patient pray daily, go to church regularly and increase his faith with God Almighty.

PATHOPHYSIOLOGY
Pathophysiology of Kochs Disease (Tuberculosis) Predisposing Factors: -Age Precipitating Factors: -Repeated close contact w/ infected persons - Recurrence of infection

Exposure or inhalation of infected Aerosol through droplet nuclei (exposure to infected clients by coughing, sneezing, talking) Tubercle bacilli invasion in the apices of the Lungs or near the pleurae of the lower lobes Bronchopneumonia develops in the lung tissue (Phagocytosed tubercle bacilli are ingested by macrophages) bacterial cell wall binds with macrophages arrest of a phagosome which results to bacilli replication Necrotic Degeneration occurs (production of cavities filled with cheese-like mass of tubercle bacilli, dead WBCs, necrotic lung tissue) drainage of necrotic materials into the tracheobronchial tree (eruption of coughing, formation of lesions)

PRIMARY INFECTION Lesions may calcify (Ghons Complex) and form scars and may heal over a period of time

Tubercle bacilli immunity develops (2 to 6 weeks after infection) (maintains in the body as long as living bacilli remains in the body) Acquired immunity leads to further growth Of bacilli and development of ACTIVE INFECTION

SIGNS AND SYMPTOMS Pulmonary Symptoms: -Dyspnea -productive cough -Hemoptysis (blood tinge sputum) -Chest pain that is pleuritic or dull -Chest tightness -Crackles present on auscultation General Symptoms: - Fatigue - anorexia - Weight loss - low grade fever with chills & sweats (often at night)

With Medical Intervention > Early detection/ diagnosis of the disease > Multi-antibacterial therapy > Fixed- dose therapy > TB DOTS (Direct Observed Therapy) Recurrence

Bad Prognosis Reactivation of the tubercle bacilli (Due to repeated exposure to infected Individuals, Immunosuppression)

SECONDARY INFECTION

Severe occurrence of lesions in the lungs Cavitation in the lungs occurs

SEVERE OCCURRENCE OF INFECTION

Client becomes clinically ill