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Submitted by : BSN 3

Group 3
Elegado , Homer
Espenida, Razel Anne
Fabrigas , Ronald
Gelidon, Remedios
Kanoon , Bashayer Ebrahim
Kuteng, Argyle

Lagua, Maryshylle Therese


Liquit, Brian
Lota, Jocelli Anne
Mabitasan , Florence
Christelle
Mallar , Adrian

I. PATIENT ASSESSMENT DATA BASE


A. GENERAL DATA
1. Patients Name: P.A
2. Address: Valenzuela City Philippines
3. Age: 27y/o
4. Sex: Male
5. Birth Date: September 28
6. Rank in the Family: 1st child
7. Nationality: Filipino
8. Civil Status: Separated
9. Date of Admission: March 12 , 2013 at 3:10pm
10. Order of Admission: Admit to AFB; secure consent for admission and management; IVF; D5NM 1Literx8; diet: DAT with SAP; diagnostic:
CBC, CXR-PA for official reading sputum AFBx3 sputum culture serum sodium; therapeutics cefuroxime 750mgxq8 (-)ANST; azithromycin
500mg ODx5days VS every 4hrs; I&O every shift please do daily CTT care; for CXR-PA for CTT insertion; metronidazole 750mgvial (-) ANST;
refer.
11. Admitting diagnosis: Pulmonary tuberculosis, relapse (+) smear
12. Attending Physician: Dr. Villanueva
B. CHIEF COMPLAINT:
Patient P.A was admitted to San Lazaro Hospital with a chief complaint of difficulty of breathing.
C. HISTORY OF PRESENT ILLNESS:
2 months and 2 weeks prior to admission, patient had episode of productive cough, yellowish sputum accompanied by pleuretic back pain (-) fever, DOB,
(-)hemoptysis, (+)night sweats,(+)weight loss, no consultation done , nor medication taken.
2 months prior to admission patient had persistence of symptoms now accompanied by fever more pronounce in the afternoon were he self-medicated
with paracetamol which afforded for fever.
2 weeks prior to admission there is still persistence of symptoms now accompanied by DOB more pronounce upon coughing (+) hemoptysis , there is
also noted weight loss by the mother. During this time, no consult nor medication were taken. Persistence of symptoms prompted consults our
constitution. CTT insertion was done at Valenzuela hospital few hours prior to admission.
D. PAST HEALTH HISTORY:
According to the patient, he is experiencing cough colds and fever.
E. FAMILY ASSESSMENT

NAME

RELATION

AGE

SEX

OCCUPATION

E.A

Mother

47y/o

Female

Housemaid

EDUCATIONAL
ATTAINMENT
High school graduate

F. SYSTEMS REVIEW - Gordons 11 Functional Health Patterns

1. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN: Clients Perception of Health: Patient perceives health as Nagagawa ko lahat pag
malakas ako.
Clients Perception about Illness: In contrast to health, he perceives illness as hindi sana ako iniwan ng pamilya ko kung wala akong sakit
Compliance with prescribed medications and treatment: He is not actively participates/cooperates with his treatment and does takes medication on
time.

2. NUTRITIONAL METABOLIC PATTERN


The smell of food stimulates the appetite of the patient; he usually eats vegetables, fish, chicken and meat and drinks 11 glasses of water a day.
Appetite: he eats 1 whole of the food served.he added Hinde ako makakain ng marami simula nang ma-confine ako

Usual Daily Menu: Before confinement


Food: 1 -2 cups of Rice, Fish, vegetables

Usual Daily Menu: During confinement


- 1/2 cup of rice. Fish/meat and vegetables

Water: 10-11 glasses of water per day


Beverage: he drinks soda , 2-3 times week

Water: 2-3 glasses of water per day


Beverage:

3. ELIMINATION PATTERN
Bowel habits: defecates three times a day before confinement. But during confinement, he only defecate once during our rotation.
Bladder: void 2-3 times during our shift.
Color: Yellowish color
Odor: Pungent
4. ACTIVITY EXERCISE PATTERN: A. Self-Care Ability

Before confinement

During Confinement

0- Feeding

0- Feeding

0- Toileting

II- Toileting

0- Dressing

II- Dressing

0- Bathing

III- Bathing

0- Bed Mobility

0- Bed Mobility

0-Grooming

II-Grooming

Legend:
O - Full self-care
I - Requires use of equipment or device
II - Requires assistance or supervision from another person

III - Requires assistance or supervision from another person and


equipment or device
IV - Is dependent and does not participate

5. COGNITIVE PERCEPTUAL PATTERN


A. Hearing: there is no hearing impairment, can hear clearly and able to comprehend with instructions when asked.
B. Vision: there is no visual impairment before confinement.
C. Sensory Perception: The patient responded when tapped in the shoulder.
6. SLEEP REST PATTERN:
Patient state that; He only sleeps for about 3-4 hours while he is on duty , During his day off he sleeps form 10pm to 6am. Now he is in the hospital he
sleeps 9pm to 5am.
7. SELF PERCEPTION AND SELF CONCEPT PATTERN:
The patient feels disappointed and at the same time worried because his mother only visits him once a week and he himself and his mother are
experiencing financial difficulties with regards to hospital fees. He complaints nahihirapan akong huminga
8. ROLE RELATIONSHIP PATTERN:
Initially, Patient P.A was able to do responsibilities as a oldest brother such as guiding his siblings by giving a piece of advice when they have a problem.
9. SEXUALLY REPRODUCTIVE PATTERN:
Patient is not sexually active.
10. COPING STRESS TOLERANCE PATTERN:

Patient frequently asks questions to minimize his anxiety or consults advice to his parents or friends whenever he has a problem and base his decisions
on it.
11. VALUE BELIEF PATTERN:
The patient is Catholic by faith but not an active church-goer. He doesnt believe to any superstitious beliefs.

G. HEREDO FAMILIAL ILLNESS:

GRANDMOTHER (DECEASED)

GRANDFATHER (DECEASED)

NO HEREDITARY KNOWN
ILLNESS

HYPERTENSION

MOTHER

FATHER

NO KNOWN HEREDITARY
ILLNESS

NO KNOWN HEREDITARY
ILLNESS

PATIENT
NO KNOWN HEREDITARY
ILLNESS

H. DEVELOPMENTAL HISTORY

THEORIST

ERICKSON

AGE

IDENTITY VS ROLE
CONFUSION

SEX

DEFINITION
Significant relations: peer
groups and role model

Male
Psychosocial virtues: fidelity
and loyalty

12-18 years old

PATIENT DESCRIPTION
Patient states that he can
make decisions on his
own especially with
regards to his education
and choosing friends.

Maladaptations and
malignancies: fanaticism repudiation
Male
FREUD
PUBERTY TO DEATH

Genital stage
12-18 years old

Sexual pleasure through


genitals
Behaviors:
-

Becomes
independent of
parents

Patient is able to maintain


genital hygiene and
knows what the word sex
is.

PIAGETS COGNITIVE
THEORY

Responsible for self


Develops sexual
identity, ability to love
and work

Reality, abstract
thought
Can deal with past,
present and future
Deductive reasoning

FORMAL OPERATIONS
Male
11-15 Years old

Able to comprehend and


follows instructions when
asked, can learn new
things easily.

I. PHYSICAL ASSESSMENT
A. General Survey
Upon Assessment, the patient appears restless with body weakness, dyspniec, diaphoretic, pale in appearance, presence of productive cough,
In her condition, the patient cant stand on her own she needs assistance when doing activities such as going to the bathroom and doing personal
hygiene such as bathing. He is conscious and coherent and was able to respond to questions appropriately. He wears ordinary clothes such as loose tshirt and shorts. He is in small frame. Has slight body odor and doesnt have any deformities. BMI = 11.2 kg/m2 base on the formula weight in kg/( height
in meters)2 which is below normal range as shown in the table below.
Category

BMI range kg/m2

Very severely
underweight

less than 15

Severely
underweight

from 15.0 to 16.0

Underweight

from 16.0 to 18.5

Normal (healthy
weight)

from 18.5 to 25

Overweight

from 25 to 30

Obese Class I
(Moderately obese)

from 30 to 35

Obese Class II
(Severely obese)

from 35 to 40

Obese Class III


(Very severely
obese)

over 40

B. Vital Signs:
Temperature: 36.C
Cardiac Rate: 109 bpm
Respiration: 48 bpm
Blood Pressure: 80/60 mmHg

C. Regional Exam:
1. Skin, Hair and Nails: The clients skin is of normal racial tone which is brown.
Hair is long until shoulder line and evenly distributed, sparse dandruff visible hair smooth and firm.
The clients nail shape is convex clubbing, not well-trimmed and slightly dirty. The nail is smooth and the nail bed is pink. The capillary refill is within 1
second.
2. Eyes: patient has no complains of blurring of vision or any visul problems; the eye brows are evenly distributed. Eyelids have effectively closure. The
Blink response is bilateral, eye balls are symmetrical, bulbar conjunctiva is clear, the sclera is white. The lacrimal apparatus are moist and non-tender.
3. Nose: The color of the clients nose is of racial tone which is brown. His septum is in the midline. Nostrils are both patent, nasal flaring noted,
Landmarks are visible. Sinuses are non-tender.
4. Ears: The color of the ear is of normal racial tone which is brown, it is symmetrical. The alignment of the pinna is symmetrical. The pinnas are elastic
and recoil when folded. The mastoid process is non-tender. The auditory canal contains some cerumen, the color is brown and there is an absent of
discharges.
5. Mouth and throat: The lips is symmetrical and appears to be pale, the consistency is smooth, buccal mucosa is pale, the tongue is in the midline, the
color is pink and it is smooth. The tongue movements are not that smooth. The color of the hard and soft palate is pale and is intact. The tonsils are not
inflamed. There is presence of mucous. Uvula is in the midline, gag reflex is present. The teeth has cavities on the upper and lower molar tooth. With
sores on the buccal cavity
6. Neck and lymph nodes: no pulsations visible, no thyroid enlargement upon palpation and inspection. No tenderness noted.

7. Thorax and lungs: The color of the chest is of normal racial tone which is brown. The patient appears dyspneic, crackles sounds heard during
auscultation. When palpated he doesnt feet any tenderness. Respiratory rate is 48 breaths per minute with visible ribs noted. Uses accessory

muscle when breathing.

9. Cardiovascular: The rhythm is regular. PMI is located in the apical pulse. Heart rate is 108 beats per minute.
10. Breast and axilla: Nipples are nearly equal bilaterally in size, no lesions, no abnormal discharges and tenderness.
11. Abdomen:
12. Extremities: The IV site is in his left arm.
13. Genitals: Not performed.
14. Rectum and anus: not performed.
15. Neurological/cranial nerves:

Olfactory: he is able to differentiate smell from that of an alcohol and perfume.


Optic: reacts on both sides.
Oculomotor: eyes move smoothly in a coordinated motion in all directions (the six cardinal fields).
Trochlear: Bilateral pupils constricts simultaneously when illuminated.
Trigeminal: temporal and masseter muscles contract bilaterally when chewing.
Abducens: pupils are equally rounded reactive to light and accommodation.
Facial nerve: patient is able to smile, frown, wrinkles forehead, shows teeth, puff out cheeks, purses lips, raises eyebrows, and closes eyes against
resistance in symetrical movement.
Vestibulocochlear: patient is able to hear whispered words from 1-2 feet.
Glossopharyngeal: has no difficulty in swallowing.
Vagus Nerve: the gag reflex is present.
Spinal Accessory nerve: there is symmetric, strong contraction of trapezius muscles when asked to shrug the shoulders against resistance. There is also
a strong contraction of sternocleidomastoid muscle on side opposite the turned face when turning the head against resistance.
Hypoglossal: can move tongue and can swallow without difficulties.

II.PERSONAL / SOCIAL HISTORY


a) Habits/Vices: watching television, eating.
b) Caffeine: none.
c) Smoking: 15 sticks a day
d) Alcohol: once a week/Hard liquuors
e) Tea: None.
f) Drugs: none
g) Lifestyle: none.
h) Social Affiliation: not a member of any organization.
i) Rank in the family: First Child
j) Travel: the patient did not travel within 6 months.
k) Educational attainment: high school graduate
III. ENVIRONMENTAL HISTORY
The patient lives in an urban squatter area. He lives with his mother . Their house is semi concrete and bungalow type. Walking distance from their
health center at about 500 meters; they use tricycle or jeepney as their transportation going to their town market and or hospitals.
Water source is from the water district and uses tap water for drinking. There is garbage collector truck twice a week to which they are disposing their
garbage. Used bottles, plastics, and papers are recycled and being sold.

IV. ANATOMY AND PHYSIOLOGY


The respiratory system (or ventilatory system) is a biological system consisting of specific
organs and structures used for the process ofrespiration in an organism. The respiratory
system is involved in the intake and exchange of oxygen and carbon dioxide between an
organism and the environment.
In air-breathing vertebrates, respiration takes place in the respiratory organs called lungs. The
passage of air into the lungs to supply the body with oxygen is known as inhalation, and the
passage of air out of the lungs to expel carbon dioxide is known as exhalation; this process is
collectively called breathing or ventilation. In humans and other mammals, the anatomical
features of the respiratory system include include trachea, bronchi,bronchioles, lungs, and
diaphragm. Molecules of oxygen and carbon dioxide are passively exchanged, by diffusion,
between the gaseous external environment and the blood. This exchange process occurs in
the alveoli air sacs in the lungs.

Lungs
The lungs are the main organs of the respiratory system. In the lungs oxygen is taken into
the body and carbon dioxide is breathed out. The red blood cells are responsible for picking up
the oxygen in the lungs and carrying the oxygen to all the body cells that need it. The red
blood cells drop off the oxygen to the body cells, then pick up the carbon dioxide which is a
waste gas product produced by our cells. The red blood cells transport the carbon dioxide
back to the lungs and we breathe it out when we exhale.
Trachea
The trachea is sometimes called the windpipe. The trachea filters the air we breathe and branches into the bronchi.
Bronchi
The bronchi are two air tubes that branch off of the trachea and carry air directly into the lungs

Alveoli

Is an anatomical structure that has the form of a hollow cavity. Found in the lung parenchyma, the pulmonary alveoli are the terminal ends of the
respiratory tree, which outcrop from either alveolar sacs or alveolar ducts, which are both sites of gas exchange with the blood as well.

V. INTRODUCTION

Pulmonary tuberculosis (TB) is bacteria that that attack your lungs. It is a potentially deadly disease, but it is curable if
you get medical help right away and follow your doctors instructions. The bacterium that causes TB is called
Mycobacterium tuberculosis.
Signs and symptoms:
low grade fever, fatigue, (+)hemoptysis , productive cough, night sweats, pallor, dyspnea, chest, pain, Elevated WBC
VII. LABORATORY TEST
o

TYPE OF EXAMINATION
RADIOLOGICAL REPORT
DATE: 02 26 13

Massive pneumohydrothorax is noted. Reticulohazed densities are


noted on right lung. Mid structure is deviated to the right. Heart is
not enlarged. The rest is unremarkable.

IMPRESSION

pTB, right with volume loss.


Massive pneumohydrothorax, left .

BLOOD CHEMISTRY
DATE: 03 12 13
EXAM NAME
WHITE BLOOD CELLS
RED BLOOD CELLS
HEMOGLOBIN
HEMATOCRIT

RESULT
9.95
3.44 ( L )
98.7 ( L )
0.304

UNIT
10^9/L
10^12/L
g/L

NORMAL VALUES
4.8 10.8
4.5 5.9
140 175
0.415 0.504

SIGNIFICANCE
Normal
It may indicate anemia
It may indicate anemia
It may indicate anemia or
lung disease

MCV
MCH
MCHC

88.39
28.73
32.50 ( L )

fL
pg
g/L

82 98
28 33
33 36

PLATELET COUNT
RDW

215
14.42 ( H )

10^9/L
%

150 400
11.4 14.0

NEUTROPHIL

0.80 ( H )

0.40 0.70

LYMPHOCYTE
EOSINOPHIL

0.10 ( L )
0.01 ( L )

0.19 0.48
0.02 0.08

MONOCYTE

0.80

0.0 0.15

BASOPHILS

0.01

0.00 0.05

Normal
Normal
It may indicate iron
deficiency
Normal
it will indicate that there is
a high red cells
distribution width. This
can be sign of anemia
and alcohol abuse.
It may indicate infection in
the body
It may indicate infection
It can occur due to steroid
use
It may indicate reduced
ability of body to work
It may indicate infection
or inflammation

BLOOD CHEMISTRY
DATE: 12 04 13
EXAM NAME
WHITE BLOOD CELLS

RESULT
14.70 ( H )

UNIT
10^9/L

NORMAL VALUES
4.8 10.8

RED BLOOD CELLS


HEMOGLOBIN
HEMATOCRIT

2.59 ( L )
77.6 ( L )
0.229

10^12/L
g/L

4.5 5.9
140 175
0.415 0.504

MCV
MCH
MCHC
PLATELET COUNT

88.00
29.94
33.85
518 ( H )

fL
pg
g/L
10^9/L

82 98
28 33
33 36
150 400

RDW

15.80 ( H )

11.4 14.0

SIGNIFICANCE
Increase WBC may
indicate infection
It may indicate anemia
It may indicate anemia
It may indicate anemia or
lung disease
Normal
Normal
Normal
It may indicate impaired
in circulation. The blood
may become viscous.
it will indicate that there is
a high red cells
distribution width. This

NEUTROPHIL

0.82 ( H )

0.40 0.70

LYMPHOCYTE
EOSINOPHIL

0.11 ( L )
0.01 ( L )

0.19 0.48
0.02 0.08

MONOCYTE
BASOPHILS

0.06
0.00

0.00 0.15
0.00 0.05

ROENTOGENOLOGICAL AND ULTRASOUND FINDINGS


DATE: 11 20 13
EXAMINATION: CHEST PA
Thin walled cystic lucencies seen in the upper lobe.
Fibrosis and reticular opacities seen in the right mid to lower
lobe.
Areas of loculatedlucencies devoid of lung markings are seen
in the left upper hemithorax.
An air fluid level also noted adjacent to homogenous
opacification in the left lower hemithorax.
A left sided CTT is noted with its tip at the lower hemithorax.
Heart cannot be assessed.
The right hemi diaphragm and costophrenic sulcus are intact.
Visualized bony thorax is unremarkable.

can be sign of anemia


and alcohol abuse.
It may indicate infection in
the body
It may indicate infection
It can occur due to steroid
use
Normal
Normal

IMPRESSION:
PTB, both lungs, with associated:
1. Bullae/bleb formations, right upper lobe
2. Loculated pneumothorax, left

VIII. DRUG STUDY

Generic Name: HRZE


(isoniazid+rifampicin+pyrazinamide+etambutol)
Brand Name:
Drug Classification: Anti-infective
Dosage: 2 tab
Indication: Treatment for tuberculosis
Mechanism of Action

Side Effect

Contraindication

Adverse Effect

Nursing Consideration

unknown, appears to
inhibit cell-wall
biosynthesis by
interfering with lipid
and DNA synthesis.

Nausea and
vomiting,
Headache

Drowsiness

Dizziness

Contraindicated in
patients with acute
hepatic disease or
isoniazid related liver
damage.

Peripheral
neuropathy
Fluid discoloration
Optic neuritis
hepatitis

instruct patient to
eat small amount
of food.
Promote adequate
rest
Advise patient to
sleep
Instruct patient to
slowly move when
sitting or standing.

IX. NURSING CARE PLAN


Assessment
Subjective:
nahihirapan akong
huminga
(dyspnea)

Objective:

Diagnosis
Ineffective airway
clearance related to
thick, viscous
secretions and poor
cough effort.

Planning
After 1hour of nursing
interventions the
patient will be able to
maintain airway
patency AEB

Intervention

Assess vital signs


especially RR

Auscultate breath
sounds

Position the
patient to a semi-

Rationale

Serves as
baseline data

Crackles sound
may indicate fluid
in the airway

An upright
position allows for
maximal lung

Evaluation
After 1hour of nursing
interventions the
patient had be able to
maintain airway
patency AEB

Tachypnea

Presence of
productive cough

Use accessory
muscle
Diaphoresis
crackles sound
during
auscultation
Tachycardia

fowlers

Position head
midline with
flexion
appropriately

expansion to
maximize
oxygenation for
cellular uptake.
To open/maintain
open airway in at
rest or
compromise
individual

To maximize effort

Encourage deepbreathing and


coughing exercise

Administer
mucolytics as
ordered

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective:
nahihirapan akong
gawin ang mga
bagay na nagagawa
ko ng maayos noon

Activity intolerance
related to imbalance
oxygen supply and
demand.

After 4 hours of
nursing interventions,
the patient will identify
techniques to enhance
activity tolerance.

Assess Vital
signs

Serves as a
baseline data.

determine level
of activity to
stand, move and
the amount of
necessary
assistance

To know when to
need assistance.

advised to have
in Increase
exercise/
activities
gradually

To reduce fatigue

Teach methods
to conserve
energy such as
stopping to rest
for 3 minutes
during a 10minute close
walk

Objectives:

body
weakness
Restlessnes
s
Having an
assistance
when
positioning
and
ambulation
Vital Signs:

HctHgb-

Plan care with


rest periods
between
activities

Advised to have
assistance with
self care needs
such as going to
the bathroom

Help limit oxygen


needs for
consumption.

To reduce fatigue

To prevent further

After 4 hours of
nursing interventions,
the patient had
identified techniques
to enhance activity
tolerance.

injury and to avoid


over exertion.

ASSESSMENT

NURSING
DIAGNOSIS

PLANNING

INTERVENTION

Subjective:

Impaired gas
exchange related to
destruction of
alveolar-capillary
membrane
(atelectasis)

After 30 minutes of
nursing interventions
the patient will be able
to demonstrate
improve ventilation
and adequate
oxygenation of tissue
by ABG within clients
normal limits and
absence of symptoms
of respiratory distress

Independent:

Dyspnea

Objective:
-

Restlessness
Pale mucous
membrane
Tachycardia
Diaphoretic
ABG
O2 saturation
86%

Assess vital signs


especially RR

Encourage
adequate rest and
limit activities to
within clients
tolerance

Promote calm
and restful
environment

Elevate head of
bed

Encourage
frequent position
changes and
deep breathing
exercise
Provide Oxygen
inhalation as
prescribed

RATIONALE

Serves as
baseline data

Help limit oxygen


needs or
consumption.

Help limit oxygen


needs or
consumption.

To maintain
airway

Promote optimal
chest expansion
and drainage
secretion

Provides
adequate
oxygenation

To reduce irritant
effect of airways

Keep
environment
pollutant free

Evaluation
After 30 minutes of
nursing interventions
the patient is able to
demonstrate improve
ventilation and
adequate oxygenation
of tissue by ABG
within clients normal
limits and absence of
symptoms of
respiratory distress

ASSESSMENT

NURSING
DIAGNOSIS

PLANNING

INTERVENTION

Subjective:

Imbalanced
nutrition less
than body
requirement
related to
inability to
absorb
nutrients/inability
to ingest foods.

After 24 hours of
nursing
intervention of
patient will
regain weight
and verbalizes
understanding or
necessary caloric
intake.

Diagnostic:

Hinde ako
makakain ng
marami simula
nang ma-confine
ako

Objective:
-

BMI = 11.2
Height 157
Weight 27.5
Weakness of
muscle
Sore buccal
cavity
% of total
meal: 30%

Obtain
nutritional
history;
include family
significant
others, or
caregiver in
assessment
Encourage
patient
participation
in recording
food intake
using daily
log.

Therapeutic:
Consult

RATIONALE

Patient
perception of
actual intake
may differ.

Determination
of types,
amount, and
pattern of
food or fluid
intake in
facilitated by
accurate
documentatio
n by patient
or caregiver
as intake
occurs,
memory is
insufficient.
Dietitians
have greater
understanding
of nutritional
value of foods
and may
helpful in
assessing

Evaluation

After 24 hours of
nursing
intervention of
patient had
regain weight
and verbalizes
understanding or
necessary caloric
intake.

dietitian for
fourth
assessment
and
recommendati
on regarding
food
preference
and nutritional
support.
Suggest ways
to assist
patient with
meal as
needed.
Suggest liquid
drinks for
supplemental
nutrition.
Discuss
possibly need
for parenteral
nutrition
support with
patient, family
and caregiver
and
appropriate.
Educative:
Review and
inform the
effort to
patient or
caregiver: the

specific ethnic
or cultural
foods.
Elevating the
head of bed
30 degree aid
in swallowing
and reduces
risk of
aspiration.
For hydration.

Entiral tube,
feeding are
preferred for
patient with a
functioning GI
tract.

Patient may
not
understanding
what as
involved in a
balance diet.

basis four
food groups,
as well as
need for
specific
minerals/
vitamins.

ASSESSMENT

NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Subjective:

Impaired skin
integrity related
to CTT insertion

After 3 hours of
nursing
intervention of
patient will
participate in
prevention
measures and
treatment
program

Diagnostic:

Healthy skin
varies from
individual to
individual but
should have
good turgor.
Normally
individual shift
their weight
off pressure
areas every
few minutes,
this occurs
more or less
automatically,
even during
sleep.
Moisture may
contribute to
skin
maceration
The incidence
and onset of
skin
breakdown is
directly
related to the
number of risk
factors
present.
A schedule

Objective:
-

BMI = 11.2
Height 157
Weight 27.5
Weakness of
muscle
Sore buccal
cavity
% of total
meal: 30%

Assess
general
condition of
the skin
Asses
awareness of
the sensation
of pressure
assess for
environmental
moisture
reaasess skin
often and
whenever the
patients
condition or
treatment
plan results in
an increased
number of risk
factors
Therapeutic:
encourage
implementatio
n and posting

Evaluation

After 3 hours of
nursing
intervention of
patient had
participated in
prevention
measures and
treatment
program

of a turning
schedule,
restricting
time in one
position to 2
hours or less
and
customizing
the schedule
to patients
routine and
caregivers
needs.
Fluid intakeof
2000ml/day
unless
medically
restricted.

Predisposing factor: Inhalation of infected


aerosol through droplet nuclei ( exposure to
infected clients by coughing, sneezing and
talking).

Lung
s

that does not


interfere with
the patients
and
caregivers
activities is
most likely to
be followed.
Hydrated skin
is less prone
to breakdown.

Alveoli ( where bacteria


deposited and
multiply).

Spread through the


lymphatic system.

Produces cavity filled with


s/sx: low grade fever, fatigue,
Bod
Blood
Regional
Mostcontain
primary
tubercles
May
bacilli
that heal by
cheese-like mass of
(+)hemoptysis , productive
y
stream
Lymph
Initiates
systemic
forming
scarsnodes
and calcify
can
be
reactivated
and lesion
tubercle
bacilli, dead
cough,Neutrophils
night
Gosweats,
backand
to pallor,
alveoli
(where
macrophages
Multiple drug
Medical
local
inflammatory
( ghon secondary
tubercles).
cause
Stimulates
bodys
immune
Insertion
of
WBCs
and
necrotic
lung
dyspnea,
chest,
pain,
bacteria
deposited
and
resistance.
management
( isolate and phagocytize
bacteria).
Necrotic
response