A Case Study of

Pulmonary Tuberculosis
In Partial fulfillment of the requirements in NCM 104

Prepared By:

chelle BSN IV-B

October 17, 2009

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.

hydrothorax

is

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.

C. Scope and delimitation

The scope of this study will focus on Pulmonary Tuberculosis with a few discussions of pneumothorax and hydrothorax. The study covers the background of the disease, the anatomy, pathology, mode of transmission, pathophysiology and as well as its complications. All information needed to come up with this case study was taken from patient, patients family (mother and sister), patients chart, laboratory result, physical assessment, books and internet.

D. Theoretical Framework
FLORENCE NIGHTINGALE ENVIRONMENTAL THEORY
Ai Nutritio Ventilati

Cleanline ss

ENVIRO MR. ADL NMENT

Light

Beddi ng

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. These aspects of physical environment are also influenced by the social and psychological environment of the individual. 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 to cure the illness and lower down the factors causing the patients disease with the help of Nightingales Environmental Theory.

II.Clinical summary
A. General data
Name: Mr. ADL Age: 24 years old Religion: Roman Catholic Civil Status: Single Occupation: Car washer Nationality: Filipino Ethnic Group: Ilonggo Admitting Diagnosis: Pulmonary Tuberculosis, Pneumohyrothorax Right Sources of Information: Patient, Patient chart and the Significant Others (Mother and the sister)

Reliability: 90% Reliable

B. Chief complaint
The patient complained of difficulty of breathing.

C. History of present illness

The information that I gathered are second hand as they came from the patient mother and sister. Due to unknown reason, the patient refused to be interviewed even though based on my observation; he has a capability to answer my questions. Last two months, the family observed Mr. ADL is loosing weight and decrease of appetite but instead of eating foods he his more on vices. Then his condition became worsened according to familys observation. A month prior to admission, the patient condition became more at it worst and his cough became productive with intermittent spots of blood in the sputum upon coughing. He also starting to have night sweat started becoming sluggish and spending lots of time sleeping. He was advice by the family to have a check-up and visit the nearest hospital or clinic but he refuse everything that his familys concerned, as verbalized by Mr. ADLs sister. Based on the statement of his mother, two days prior to admission Mr. ADL experience body weakness, fatigue, and on the day of admission last August 21, 2009 in Rizal Provincial Hospital, suddenly he was complaining of difficulty of breathing, one hour after he ate his lunch.

D. Past medical history

Referring to the statements made by his sister, Mr. ADL was diagnosed with Pulmonary Tuberculosis (PTB) last 2004, 6 years ago. He entered a rehabilitation program sponsored by the local government in Cavite that will provide the beneficiates with 100% coverage on the six months duration in curing the disease. The six months duration in curing the disease became successful, he was cured by the medication given by the sponsored but due to vices like smoking and active drinking of liquor the disease from the past became active again. By 2005 the patient has finger clubbing and through the course of my interview, it was confirmed that at early age, my patient was suspected of heart problem; Mahina daw po ang puso niya. Lahat din naman kami, normal na sa amin ang mababa ang dugo (blood pressure) mga 90/70, as verbalized by the patients sister per word.

E. Familial history
Last 2002, 8 years ago when his father died from heart attack. I observed that Mr. ADL has a clubbing finger, through the course of interview it was confirm that all of the siblings have a heart problem. Then two of his uncle died from respiratory diseases, one is from Tuberculosis and another is from lung cancer. His sister also said that it was Mr. ADL twice to be confined in a hospital with a serious condition.

F. Psychosocial health
1. Psychosocial Health a. Coping Pattern

Patient used silence; he is making an observation to the student nurse who is assigned to him. b. Interaction Pattern The patient ignores my kind interview due to unknown reasons but he cooperated when I obtain Vital Signs, afternoon care, giving medications, and physical assessment. c. Cognitive Pattern According to the mother, Mr. ADL knows already his condition because he already suffered it before, last 2004, 6 years ago. But this time it is more complicated. d. Self Concept In my observation, the patient looks shy. He just mind his own self maybe because he is still in pain due to Chest tube thoracostomy attached on his right chest. e. Emotional Pattern The patient looks sad and weak maybe because of the pain that he is experiencing right now and the disease that he is suffering.

2. Socio-Cultural Health a. Cultural Pattern The patient was evidently proud of his ethnicity during their familys conversation. b. Significant Relationship

According to the Mother, she doesnt have an idea about sexual activity of Mr. ADL; she only knew that Mr. ADL is single and no girlfriend as of now. c. Recreation Pattern Mr. ADL plays basketball with his friends; they also participated in any championship as one team in their barangay, this is good for recreation. He also has a good voice, according to his sister. d. Economic Mr. ADL is a car washer. He is working since 2006, 4 years ago, week days; it is near to their house, and earning 150 pesos per day. He shares some of his earnings to his mother as one of their resources of foods.

3. Spiritual Health a. Religious Beliefs Mr. ADL is a Roman Catholic, sometimes he visit the church, one ride of jeep from their house, twice a month. b. Values and valuing Mr. ADL is close to his mother. He lives with his mother from the time he was born to the time he is where right now. All good values that he has was educated by his mother but during his adolescence stage he became abusive in his body, he became active with many kinds of vices that are influenced by his friends, these is the reason why he got the disease Tuberculosis.

G. Review of system

The data gathered are all coming from the mother as it was the patient subjective complaint. SYSTEM General Skin Head Eyes & Ears Nose Throat & Mouth Neck Breast Respiratory CVS GIT GUT Extremities Neurologic Hematologic Endocrine Psychiatric

Generalized body weakness Dry Runny nose, with discharges Dry mouth Difficulty of breathing, dyspnea upon exertion. Cough Dyspnea upon exertion and chest pain Constipated at times, defecate every other day. Joint pain Weakness Excessive night sweating Depression, Ignores kind interview

H. Physical assessment

a. General appearance/survey: Patient appeared weak looking but was somehow coherent in a high fowlers position due to CTT attach to his right chest. Mr. ADL ignores my kind interview but he is willing to cooperate when it comes in taking vital signs, physical assessment and giving medication which is important. The patients skin was dry especially on the lower extremities. IVF of D5NM 1L + 1 amp of Moriavit at 50cc level was attached to his right hand.

b. Measurement FIDINGS (Ht, wt) Vital Signs Height: 55 Weight: 101 lbs Temp: 36.0 C PR: 90 bpm RR: 29 bpm BP: 100/70 mmHg NORMAL VALUES BMI Temp: 37 C PR: 60-100 bpm RR: 16-20 bpm BP: 120/80 mmHg ANALYSIS/ INTERPRETATION BMI below normal as a result of malnutrition With some abnormal findings in the respiratory rate. Increase RR; difficulty of breathing (decrease Oxygen supply in the body)

c. Head to toe Assessment BODY PARTS A. HEAD a. Skull NORMAL FINDINGS Rounded (normocephali c, with frontal, parietal and occipital prominences) Evenly distributed; ACTUAL FINDINGS Normoceph alic ANALYSIS/ INTERPRETATI ON Normal findings

b. Hair

Evenly

Typical hair type of men

c. Face

thick hair; silky resilient hair; no infestation or infection; variable amount of body hair

distributed

Normal findings

d. Eye/vision 4.1 Eyeball 4.2 Lid margins

4.3 Conjunctiva

Symmetric Symmetric facial facial features, features palpebral fissures equal in size, symmetric nasolabial folds Round, uniform in Shape is size round; size equal Close symmetrical Protects eyes, anteriorly meet at the medial and lateral corners Smooth and of eye. pale Delicate membrane; covers part of the outer surface of the eyeball Outermost tunic, thick white connective tissue.

Normal findings Normal findings

Undernourished, lack of vitamins

4.4 Sclera

Normal findings Appears white

4.5 Pupils

Normal findings

Normal pupil constriction Normal findings

4.6 Eyebrow, lashes, color, symmetry, quality of hair, placement 4.7 Eye movement in all

Pupils constrict when looking at near objects,

Normal findings

directions

pupils converge when object is moved towards the nose Hair evenly distributed, intact skin Equal movement

Hair evenly distributed, intact skin Equal movement

B. VISION TESTING a. Visual field

When looking Client can Normal straight ahead see from his peripheral vision clients can see periphery objects in periphery Able to read newspaper Same color as facial skin, pinna recoils after it is folded Dry ear wax grayish-tan color or sticky wet cerumen in various shades of brown/ pearly gray color; semitranspare nt Responds to moderately loud voice tone Symmetric, Able to read Normal visual newspaper findings Same color as facial skin, pinna recoils after it is folded Wet and sticking cerumen with transparent color Normal ear features

b. Visual acuity C. EARS a. Pinna

b. External canal

Normal findings

c. Hearing acuity

Responds to Normal findings moderately loud voice tone No (+) dyspnea,

D. NOSE

normal breathing, able to identify familiar smell

deformity, (+) difficulty of breathing. With runny nose

patient have cough which reflex is not the only way to protect our airways which causes patient to have runny nose. Gums darkened due to smoking history Needs dental work

E. MOUTH/LIPS a. Gums b. Teeth

Pink gums; moist firm texture 32 adult teeth smooth, white yellowish shiny tooth enamel Central position, pale in color Pink and smooth; freely movable Pink and smooth posterior wall

Dark gums Yellowish with few cavities and some missing teeth

c. Tongue

d. Palate-hard/soft e. Oropharynx/ Tonsil

Central No remarkable position, findings pale in color Pale in color No remarkable findings Pale posterior wall Hollow in appearance No remarkable findings

F. CHEECKS

G. NECK H. CHEST a. Anterior b. Posterior

Lymph nodes Lymph freely movable nodes freely movable Quiet rhythmic (+) and effortless difficulty of respirations; breathing, full symmetric with excursions abnormal sound in the right

Indicates malnutrition, due to weight loss Normal findings Presence of crackles caused by fluid often associated with inflammation or infection of the alveoli.

lower lobe

I. HEART J. BREAST

Full and symmetric

Localized pain around thoracosto my site. Full and symmetric

Indicates respiratory problems such us TB, Pneumohydroth orax No air leak on drainage system: manageable incision pain. Normal findings

K. ABDOMEN

Flat, rounded (convex) or scaphoids Equal in size on both sides of the body; no muscle atrophy; normally firm; smooth coordinated movements Equal in sixe on both sides of the body; no muscle atrophy; normally firm; smooth coordinated movements

Flat, scaphoidal in shape Equal in size but muscular atrophy evident. Unable to move freely due to pain in incision site. With muscular atrophy evident. Occationally stands up for short time. (2 days postop)

L. UPPER EXTREMETIES

Client is not well nourished. It is also due to weight loss. Client is not well nourished Struggling movements due to wounds, incision pain. Client is not well nourished Weakness and pain hinder client from actively moving around.

M. LOWER EXTREMETIES

I. Activities of daily living

Before Hospitalization Skipping meals most of the time, During Hospitalization Moderate decrease of the Analysis/ Interpretation Due to medication given

a. Fluid & Nutrition

according to the significant others. Mr. ADL is more on vices. His fluid preferences are water, softdrinks and liquor. Mr. ADL drinks 34 glass of water a day and can consume Liquor of 3-4 beer a day. He is more on bread in the morning; vegetables and fish most of their meals. Mr. ADL usually voids large amount of urine, 5-7 x a day. Defecates at least once a day. Doing his job as a car washer was his form of exercise everyday.

appetite; can as side effects consume about such as; of the foods Combivent and given. Rifampicin, there is a decrease of appetite. Diet as tolerated was advised to Mr. ADL The pt was trained to take DAT diet to sustain his nutritional needs.

b. Elimination

Usually voids 2-4 times a day. Mr. ADL defecates every other day. There is no exercise at all because of CTT attached on his abdomen. He habitually sits on bed during confinement. Restricted on bed; the patient cant take a bath due to CTT done in his right. All hygienic activities are assisted by There is a decrease bowel movement due to decrease appetite. Patients daily exercise is limited because of body weakness and CTT attach on his abdomen. Dependence related to restricted mobility after surgical procedure.

c. Safety, Activity & Exercise

d. Hygiene & Comfort

e. Rest & Sleep

The patient takes a bath once a day and brushes his teeth twice a day.

f. Substance Abuse

SO. The patient sleeps more or less than 5 hours a day. Mr. ADL is more on vices. He is fun of drinking San Miguel Beer and can consume 3-4 glasses everyday. He also smokes at least 12-18 sticks of Hope everyday. According to the Mother, she doesnt have an idea about sexual activity of Mr. ADL; she only knew that Mr. ADL is single and no girlfriend as of now. The patient sleeps irregularly. 30 minutes of sleeps then awake again. Restricted on vices during hospital confinement as recommended by the attending physician due to treating of TB. Due to inadequate rest the patient may have decrease body resistance. Restricted vices will lead to immediate cure of TB.

g. Sexual Activity

Restricted sexual activity. Restricted sexual activity during confinement.

J. Laboratory / Diagnostic Exam

a. Hematology report

August 21,

2009 Test Hemoglobin Results 110 g/L Normal Value 140 170 g/L Analysis Decrease Insufficient oxygen circulating in the bloodstream. Indicates Anemia due to blood loss after surgery.

Hematocrit

0.33

0.40 0.50

WBC

15.2 x 10

5.0 10.0 x 10

Neutrophils Lymphocytes

0.78 0.21

0.45 0.65 0.25 0.40

Monocytes

0.01

0.02 0.06

Platelets

320

150 - 450

Decrease Insufficient oxygen circulating in the bloodstream. Indicates Anemia due to blood loss after surgery. Increase Leukocytosis Indicates infection Increase Acute bacterial infection Decrease low absolutely lymphocyte concentration, associated with increase rates of infection Decrease Depleted in overwhelming bacterial infection Normal

b. Chest X-ray

August 21,

2009 Impression: Pulmonary Tuberculosis (PTB) Right sided Pneumohydrothorax

c. Urinalysis

August 21, 2009 Yellow S/I Fubid

Color: Transparency:

Chemical Strips

Reaction: Specific Gravity: Albumin:

5.2 1.025 (above normal) dehydration and contamination Trace

Microscopic WBC RBC Epithelial Cells Mucus treads Amorphous Urates d. RT Hemithorax 8-12 1-3 Rare Moderate Plenty August 22, 2009

Ultrasound done on the right hemithorax, there is a significant fluid in the right lower hemithorax. Minimal fluid is seen with leculations noted of about 36cc. Echoes noted within probably due to air. Impression: Minimal leculated hydrothorax, right
e. Urinalysis

August 22, 2009 Yellowish brown Soft No Ova, parasite seen 4-8 0-1 Plenty bacterial infection August 23,

Color: Consistency: Microscopic: WBC RBC Bacteria

f. Radiological Report

2009 Impression: Pulmonary Tuberculosis, Left Pneumohydrothorax, Right

K. Surgical procedure
Mr. ADL has a fluid (hydrothorax) in his right lung, but when Chest Tube Thoracostomy was performed last August 22, 2009, there was no fluid extracted, the fluid was noted in the right lung.

Chest Tube Thoracostomy Returns (-) pressure to the internal pleural space Remove abnormal accumulation of air Serves as lung while healing is ongoing. The insertion of chest tube permits removal of the air or bloody fluid and allows re-expansion of the lungs and restoration of the normal negative pressure in the pleural space. Because air rises, a chest tube inserted to remove air is usually placed anteriorly through the 2nd ICS. A chest tube inserted to remove fluids is placed posteriorly in the 8th and 9th ICS because fluid tends to flow to the bottom of the pleural space. Chest Drainage Container A waterseal at the end of a chest tube is essential to allow air to escape through the tube but prevent air from traveling back up the tube and into the pleural space. The waterseal drainage system is placed below the level of the patients chest, taking advantage of the force or gravity to promote drainage and prevent backflow of bottle contents into the pleural space.

L. Final diagnosis
PTB with Pneumothorax and Hydrothorax, Right

M. Course in the ward

August 21, 2009 2:00pm 10:00pm

Admitted a 24 years old male accompanied by relatives with a complained of difficulty of breathing. Vital signs are taken and recorded with a BP: 100/70 mmHg, HR: 81 bpm, RR: 35 bpm Seen and examined by Dra. Magtoto Consent signed and secured Tuberculin skin test done; due at 3:30 pm IVF of D5NM 1L + 1 ampule of Lysmix inserted and regulated with 31 gtts/min Laboratory requested by the attending physician such as; Urine analysis, Ultrasound of right lung, BUN and Creatinine, and chest X-ray Transferred to Charity Medical Ward, bed 22 Endorsed

August 22, 2009 2:00pm 10:00pm Received on bed with an IVF of D5NM 1L + 1 ampule of Lysmix @ 600ml level Conscious and coherent Vital signs are taken and recorded with blood pressure of 100/70 mmHg A febrile 36.5 NPO was advice 2:30pm Consent signed and secured 3:00pm Undergone CTT @ right lung Vital signs recheck Needs attended Endorsed August 23, 2009 2:00pm 10:00pm Received on bed with an IVF of D5NM 1L + 1 ampule of Moriavit X 8 hours @ consuming level Vital signs taken and recorded with Blood Pressure of 100/70 mmHg 4:00pm Cefuroxime 200mg TIV after negative skin test

6:00pm Vital signs recheck with no significance finding Needs attended Endorsed August 24, 2009 2:00pm 10:00pm Received on bed with an IVF of 1L @ 400cc level Vital signs taken and recorded BP: 90/60 mmHg, PR: 90 bpm, RR: 29 bpm and Temperature: 36.6 C With abnormal RR: 29 bpm Diet as tolerated maintained Due medication given and recorded 4:00pm Cefuroxime 200mg TIV after negative skin test 7:00pm Rifampicin 1 tablet before dinner Vital signs recheck with no significance finding Needs attended Endorsed August 25, 2009 2:00pm 10:00pm Received on bed alert, coherent, cooperative. With an IVF of D5NM 1L + 1 ampule of Moriavit @ 700cc level and regulated with 31 gtts/min on the right hand Vital signs taken and recorded Afternoon care rendered Health teaching done Medication given Needs attended No other complaints Endorsed

III. Clinical discussion of the disease

A. 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.

IV. Nursing problem list

Ineffective Airway Clearance Ineffective Breathing Pattern Risk for Infection Imbalanced Nutrition; less than Body Requirements Activity Intolerance Impaired Physical Mobility Anxiety

Nursing Priority: 1. Ineffective Airway Clearance

2. Risk for infection 3. Impaired Physical Mobility

VI. Drug Study

Generic Name: CEFUROXIME Brand Name: CEFTIN Classification Action 2ND generation cephalosporin A 2nd generation cephalosporin that binds to bacterial cell membranes and inhibits cell wall synthesis. 200 mg TIV q8 hours ANST (-) Indication Treatment of susceptible infection due to group B streptococcus, E. coli, H. influenza etc. Adverse Effect Allergic reaction, oral candidiasis, mild diarrhea, mild abdominal cramping. Nursing Consideration Ask the patient if he has a history of allergies to drugs, particularly to cephalosporin and penicillin.

Generic Name: IPRATROPIUM BROMIDE Brand Name: COMBIVENT, DOUNEB Classification Action Anti-cholinergic bronchodilator An anti-cholinergic that blocks the action of acetylcholine at parasympathetic sites in bronchial smooth muscles.

q4 hours Indication Nursing Consideration Hypotension, Monitor Vital signs insomnia, metallic or Monitor intake and unpleasant taste, output palpitations, urine reaction. Adverse Effect

Maintenance treatment of bronchospasm due to chronic obstruction pulmonary disease (COPD), bronchitis, emphysema, asthma.

Generic Name: RIFAMPICIN Brand Name: MYRIN-P FORTE Classification Action Antituberculosis Inhibits RNA synthesis, decreases tubercle bacilli replication

2 Tablets before lunch and 1 tablet before dinner Indication Initial phase treatment and retreatment of all forms of TB in category I and II patients caused by susceptible strains of mycobacterium. Adverse Effect Disorder of the blood and lymphatic system, immune system, metabolism and nutrition, CNS, eye, GI, skin and tissues, renal, fever, dryness of mouth. Nursing Consideration Explain to the patient to expect a orange color of urine. Monitor I & O.

Generic Name: TRAMADOL 50 mg Brand Name: ULTRAM Classification Action Analgesic, centrally-acting

Indication

Adverse Effect
CNS: dizziness, vertigo, anxiety, sleep disorder, migraine. GI: nausea and vomiting, constipation, abdominal pain, anorexia. OTHERS: rash, sweating, hypotension, urinary retention.

An analgesic that binds Uses for management of to mu-opoid receptors moderate to moderately and inhibits reuptake severe pain. of norepinephrine and serotonin. Reduces the intensity of pain stimuli reaching sensory nerve ending.

Nursing Consideration Monitor vital signs especially Blood pressure. Monitor input and output. Assist with ambulation if dizziness and vertigo occurs.

Drug: LYSMIX 20 ml / amp TID Classification Contents Per amp- L-lysine Parenteral nutritional monohydrochloride 20mg, Lproducts histamin monoHCl 4mg, dlMultivitamins with minerals methionine 10mg, thiamine used as dietary HCl (Vit. B1) 1mg, riboflavin supplements

Indication Nutritional supplements

Dossage Adult: 1 amp BID TID Lysmix 20 ml x 5s

(Vit. B2) 100mcg, pyridoxine HCl (Vit. B6) 100mcg, taurine 4mg, dextrose 100mg.

Generic Name: AMINO ACID Brand Name: MORIAVIT Classification Action Calorics (Nutritional Drug) Provides a substrate for protein synthesis or increases conservation of

20ml/ Ampule TIV q8 hrs Indication Total Parenteral Nutrition Adverse Effect CNS: Fever GI: Flushing GU: Osmotic dieresis Metabolic: Nursing Intervention Monitor body temperature every 4 hours.

existing body protein.

electrolytes imbalance, weight gain Musculoskeletal: Osteoporosis

Obtain baseline electrolyte, glucose, BUN, calcium and phosphorus levels before giving drugs.

VII. 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 us: Isoniazid, Fifampicin, Ethambutol and Pyrazinamide.

E- Exercise

Instruct the patient to have a time for deep breathing exercise everyday for several times at home to helps 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 is one of the best way to prevent the speared 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.

Discuss to the client and significant others the cardinal signs of infection such as; redness, heat, induration, swelling and separation of drainage.

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
Mr. ADLs religion is Catholic, encourage the patient pray daily, go to church regularly and increase his faith with God Almighty.

Gordons Functional Health Pattern

Before Hospitalization He always goes to the health center whenever he feels sick, and takes the medications on time. He usually eats 5-6 times a day. He loves eating fruits and vegetables. And usually drinks 4-5 glass of water a day. During Hospitalization He always takes the medication on time and he realized the good effect of always consulting a doctor. He only eats 3-4 times a day, Diet as tolerated, And water demand was increased due to his present condition, usually 810 glass a day.

Health Perception/Management

Nutritional-Metabolic Pattern

Elimination Pattern

He usually urinates 3-4 He urinates 5-6 times a times a day and defecates day and defecates once a at least once a day. day. He just spend his time talking with his wife, eating ,listening to radio, ,reading newspaper and sleeping

Activity-Exercise pattern He spends his time watching TV, reading newspapers, sleeping and eating. He loves completing the puzzle in the newspaper. Sleep-Rest Pattern He usually sleeps 6-7 hours a day.

He has 7-8 hours of sleep a day and can sleep very well.

Cognitive-Perceptual Pattern

He was very active ,responsive , and very talkative.Can understand and speaks well.

He was still active and alert,talkative,responds very well to every question we asks.Can speak and communicate well. He just take sponge bath,slightly wellgroomed,no gel,still has high

Self Perception/Concept

He takes a bath everyday,always wellgroomed & puts on gel.He

has a high self-esteem

self-esteem.

Role-Relationship Pattern He was very responsible & He cant do the thing he always trying to support his used to do at home. His son own family always support him during he''s in the hospital Sexuality-Reproductive Pattern Coping-Stress Tolerance Refused to answer refused to answer

Whenever he feels He just eat and sleep as stressed or has a problem, much as he can to relieve he just completes the stress answer in the puzzle, Read the newspaper and sometimes go to somewhere to relieve the stress The client goes to church twice a week with his family & always pray. He cant go to church but he still pray & has strong faith in God.

Value-Belief Pattern