RESUME THE BIG FIVE OF MOST DISEASE IN

FATMAWATI WARD OF SEKARWANGI

REGIONAL PUBLIC HOSPITAL

Arranged By

DEVI SETIAWAN

PROGRAM SI KEPERAWATAN
RAJAWALI BANDUNG
2019
 Big Five of most disease in Fatmawati Ward of Sekarwangi Hospital

1. Tuberculosis
2. Community acquired pneumonia
3. Chronic Obstructive Pulmonary Disease
4. Asthma Bronchiale
5. Pleural Effusion

I. Tuberculosis
a. Definition
Tuberculosis is a disease caused by mycobacterium tuberculosis complex.
b. Etiology
TB is caused by M tuberculosis, a slow-growing obligate aerobe and a
facultative intracellular parasite. Mycobacteria, such as M tuberculosis, are
aerobic, non–spore-forming, nonmotile, facultative, curved intracellular
rods measuring 0.2-0.5 μm by 2-4 μm
c. Pathophysiology
Infection with M tuberculosis results most commonly through exposure of
the lungs or mucous membranes to infected aerosols. When inhaled, droplet
nuclei are deposited within the terminal airspaces of the lung. The
organisms grow for 2-12 weeks, until they reach 1000-10,000 in number.
When a person is infected with M tuberculosis, the infection can take 1 of a
variety of paths, most of which do not lead to actual TB. The infection may
be cleared by the host immune system or suppressed into an inactive form
called latent tuberculosis infection (LTBI), with resistant hosts controlling
mycobacterial growth at distant foci before the development of active
disease. Patients with LTBI cannot spread TB.
The lungs are the most common site for the development of TB; 85% of
patients with TB present with pulmonary complaints. Extrapulmonary TB
can occur as part of a primary or late, generalized infection. An
extrapulmonary location may also serve as a reactivation site;
extrapulmonary reactivation may coexist with pulmonary reactivation.
d. Diagnostic test
 Bacteriology examination :
From sputum, pleural fluid or liquor cerebrospinal.
Sputum collection : sputum specimen collected in the spot, morning,
spot (SPS), or 3 sputum specimen from 3 consecutive days (for
admitted patients)
 Radiology examination
Obtain a chest radiograph to evaluate for possible TB-associated
pulmonary findings (demonstrated in the images below). A traditional
lateral and posteroanterior (PA) view should be ordered. In addition, an
apical lordotic view may permit better visualization of the apices and
increase the sensitivity of chest radiography for indolent or dormant
disease.
  Special examination
BACTEC, Polymerase chain reaction (PCR), Enzym linked
immunosorbent assay (ELISA)

e. Treatment And Medication

The purpose of tuberculosis medication is for healing the patient,

prevent motality, prevent relapse, lower the transmission rate and
prevention of drug resistance

For initial empiric treatment of TB, start patients on a 4-drug

regimen: isoniazid, rifampin, pyrazinamide, and either ethambutol or
streptomycin. Once the TB isolate is known to be fully susceptible,
ethambutol (or streptomycin, if it is used as a fourth drug) can be
discontinued. [1]
After 2 months of therapy (for a fully susceptible isolate), pyrazinamide
can be stopped. Isoniazid plus rifampin are continued as daily or
intermittent therapy for 4 more months. If isolated isoniazid resistance is
documented, discontinue isoniazid and continue treatment with rifampin,
pyrazinamide, and ethambutol for the entire 6 months. Therapy must be
extended if the patient has cavitary disease and remains culture-positive
after 2 months of treatment.

II. COMMUNITY ACQUIRED PNEMONIA

a. Definition
infection of the pulmonary parenchyma caused by various microorganisms
(bacteria, virus, fungal, parasite)

b. Etiology
Streptococcus pneumoniae, Haemophilus influenzae and Moraxella
catarrhalis, Mycoplasma pneumoniae, Respiratory viruses
 c. Diagnostic test
 Chest radiography
 Sputum Gram stain and/or culture
 Blood cultures
 Complete blood cell counts with differential
d. Treatment and Medication
Hospital admission, oxygen, intra fluid line for hydration, antipyretic,
analgesic and antibiotic

III. COPD
a. Definition
Chronic obstructive pulmonary disease (COPD) have symptoms of
chronic bronchitis and emphysema, but the classic triad also
includes asthma or a combination of the above (see the image below).

Chronic bronchitis is defined clinically as the presence of a chronic

productive cough for 3 months during each of 2 consecutive years (other
causes of cough being excluded).
Emphysema is defined pathologically as an abnormal, permanent
enlargement of the air spaces distal to the terminal bronchioles,
accompanied by destruction of their walls and without obvious fibrosis.
b. Etiology
 Cigarette smoking
 Environmental factors
 Airway hyperresponsiveness
 Intravenous drug use
 Immunodeficiency syndromes
 Connective tissue disorders

c. Diagnostic test
 Lung (pulmonary) function tests.
 Chest X-ray. A chest X-ray can show emphysema, one of the main
causes of COPD. An X-ray can also rule out other lung problems or
heart failure.
 CT scan. A CT scan of your lungs can help detect emphysema and
help determine if you might benefit from surgery for COPD. CT scans
can also be used to screen for lung cancer.
 Arterial blood gas analysis. This blood test measures how well your
lungs are bringing oxygen into your blood and removing carbon
dioxide.
 Laboratory tests. Laboratory tests aren't used to diagnose COPD, but
they may be used to determine the cause of your symptoms or rule out
other conditions.

d. Treatment and Medication

A diagnosis of COPD is not the end of the world. Most people
have mild forms of the disease for which little therapy is needed other than
smoking cessation. Even for more advanced stages of disease, effective
therapy is available that can control symptoms, reduce your risk of
complications and exacerbations, and improve your ability to lead an
active life. Smoking cessation, bronchodilators, antibiotics and lung
therapies.
IV. Asthma Bronchiale
a. Definition
Asthma is complex and involves airway inflammation, intermittent airflow
obstruction, and bronchial hyperresponsiveness. See the image below.

b. Etiology
Factors that can contribute to asthma or airway hyperreactivity may
include any of the following:
 Environmental allergens (eg, house dust mites; animal allergens,
especially cat and dog; cockroach allergens; and fungi)
 Viral respiratory tract infections
 Exercise, hyperventilation
 Gastroesophageal reflux disease
 Chronic sinusitis or rhinitis
 Aspirin or nonsteroidal anti-inflammatory drug (NSAID)
hypersensitivity, sulfite sensitivity
 Use of beta-adrenergic receptor blockers (including ophthalmic
preparations)
 Obesity
  Environmental pollutants, tobacco smoke
 Occupational exposure
 Irritants (eg, household sprays, paint fumes)
 Various high- and low-molecular-weight compounds (eg, insects,
plants, latex, gums, diisocyanates, anhydrides, wood dust, and fluxes;
associated with occupational asthma)
 Emotional factors or stress
 Perinatal factors (prematurity and increased maternal age; maternal
smoking and prenatal exposure to tobacco smoke; breastfeeding has
not been definitely shown to be protective)

c. Diagnostic test
You may also be given lung (pulmonary) function tests to determine how
much air moves in and out as you breathe. These tests may include:
 Spirometry. This test estimates the narrowing of your bronchial tubes
by checking how much air you can exhale after a deep breath and how
fast you can breathe out.
 Peak flow. A peak flow meter is a simple device that measures how
hard you can breathe out. Lower than usual peak flow readings are a
sign your lungs may not be working as well and that your asthma may
be getting worse. Your doctor will give you instructions on how to
track and deal with low peak flow readings.
Lung function tests often are done before and after taking a
medication called a bronchodilator (brong-koh-DIE-lay-tur), such as
albuterol, to open your airways. If your lung function improves with
use of a bronchodilator, it's likely you have asthma.

d. Treatment and Medication

Prevention and long-term control are key in stopping asthma
attacks before they start. Treatment usually involves learning to recognize
your triggers, taking steps to avoid them and tracking your breathing to
make sure your daily asthma medications are keeping symptoms under
 control. In case of an asthma flare-up, you may need to use a quick-relief
inhaler, such as albuterol.
Types of long-term control medications include:
 Inhaled corticosteroids.
 Leukotriene modifiers.
 Long-acting beta agonists.
 Combination inhalers.
 Theophylline.

V. Pleural Effusion
a. Definition
A pleural effusion is collection of fluid abnormally present in the
pleural space, usually resulting from excess fluid production and decreased
lymphatic absorption.

b. Etiology
The normal pleural space contains approximately 10 mL of fluid,
representing the balance between hydrostatic and oncotic forces in the
visceral and parietal pleural capillaries and persistent sulcal lymphatic
drainage. Pleural effusions may result from disruption of this natural
balance.
 Presence of a pleural effusion heralds an underlying disease
process that may be pulmonary or nonpulmonary in origin and,
furthermore, that may be acute or chronic. Although the etiologic spectrum
of pleural effusion can be extensive, most pleural effusions are caused by
congestive heart failure, pneumonia, malignancy, or pulmonary embolism.

c. Diagnostic test

Useful radiological findings of pleural effusions

(1) Bilateral effusion

Bilateral pleural effusion is commonly seen in heart failure. For

bilateral effusion with a normal heart size, the differential diagnosis
should include malignancy and, less commonly, lupus pleuritis and
constrictive pericarditis.

(2) Massive effusion more than half of hemithorax

The most frequent cause of massive pleural effusions is malignancy

(55%), followed by complicated parapneumonic or empyema (22%),
and tuberculosis (TB) (12%). If massive effusions are without
contralateral displacement of mediastinal structures, the endobronchial
obstructions by lung cancer or mediastinum fixation by mesothelioma
should be considered.

(3) Loculated effusion

The loculation of pleural space is caused by adhesions between

contiguous pleural surfaces. It occurs most frequently in conditions that
cause intense pleural inflammations, such as empyema, hemothorax, or
TB pleurisy. In patients with congestive heart failure after treatment,
the loculated effusion in fissure may simulate a mass, termed as the
vanishing tumor or pseudotumor in chest PA.
 (4) Combined pneumonia in lower lobe

The AP, PA, and lateral chest radiographs are not sensitive methods to
identify parapneumonic effusions in patients with pneumonia, because
all views missed more than 10% of significant effusions. The existence
of a lower lobe parenchymal consolidation concealed the identification
of some pleural effusions. Therefore, such considerations should be
used for obtaining additional imaging, such as thoracic ultrasonography
in patients with lower lobe parenchymal consolidations on plain film
radiographs

d. Treatment and Medication

Transudative effusions are managed by treating the underlying
medical disorder. However, regardless of whether transudative or
exudative, large, refractory pleural effusions causing severe respiratory
symptoms can be drained to provide symptomatic relief.
The management of exudative effusions depends on the underlying
etiology of the effusion. Pneumonia, malignancy, and TB cause most
exudative pleural effusions, with the remainder typically deemed
idiopathic. Complicated parapneumonic effusions and empyemas should
be drained to prevent development of fibrosing pleuritis. Malignant
effusions are usually drained to palliate symptoms and may require
pleurodesis to prevent recurrence.
Medications cause only a small proportion of all pleural effusions
and are associated with exudative pleural effusions. However, early
recognition of this iatrogenic cause of pleural effusion avoids unnecessary
additional diagnostic procedures and leads to definitive therapy, which is
discontinuation of the medication. Implicated drugs include medications
that cause drug-induced lupus syndrome (eg, procainamide, hydralazine,
quinidine), nitrofurantoin, dantrolene, methysergide, procarbazine, and
methotrexate.
I. Assessment

A. General data
Name : Mr. D
Age : 24 years old
Religion : Muslim
Civil Status : Single
Occupation : Factory Worker
Nationality : Indonesia
Admitting Diagnosis: Pulmonary Tuberculosis

B. Data analysis

Subjective:
“I had this recurrent cough for almost a month now and it seems that I am
having difficulty in breathing at times...” verbatim of client.

Objective:
 RR = 23 breaths/ min
 PR = 95 beats/min
 T = 37.5 degree Celsius
 Easy fatigability
 Productive cough
 Chills at night
 Loss of appetite as claimed
 Chest X- ray and sputum examination
 revealed positive for pulmonary tuberculosis

C. 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. D 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 patient’s skin was dry especially on the lower
extremities.

b. Measurement
Vital Signs :
 Temp : 37.5 C
 PR : 95 bpm
 RR : 23 bpm
 BP : 100/70 mmHg
Ht, wt :
 Height: 5’5”
 Weight: 101 lbs

c. Head to toe Assessment

BODY NORMAL ACTUAL ANALYSIS/
PARTS FINDINGS FINDINGS INTERPRETATION
A. HEAD
B. VISION
TESTING
C. EARS
D. NOSE Symmetric, No (+) dyspnea,
normal deformity, patient have
breathing, (+) cough which
able to difficulty reflex is not the
identify of only way to
familiar breathing. protect our
smell With runny airways which
nose causes patient
to have runny nose

E. CHEST Quiet (+) Presence of

rhythmic difficulty crackles caused
 and of by fluid often
effortless breathing, associated with
respirations; with inflammation or
full abnormal infection of the
symmetric sound in alveoli.
excursions the right Indicates
lower lobe respiratory
problems such
us TB,
Pneumohydrothorax
No air leak on

F. ABDOMEN Flat, Flat, Client is not well

rounded scaphoidal nourished.
(convex) or in shape It is also due to
scaphoids weight loss.

d. Chest X-ray / Diagnostic Exam

Impression: Pulmonary Tuberculosis (PTB)

II. Nursing Diagnosis

1. Ineffective Airway Clearance related

2. Risk for infection
3. Impaired Physical Mobility Imbalanced Nutrition; less than Body
Requirements
4. Activity Intolerance
 NURSING CARE PLAN FOR PULMONARY TUBERCULOSIS
Nursing Nursing
Assessment Inference Outcome Rationale Evaluation
Diagnosis Interventions
Subjective:
“I had this recurrent Ineffective Airway Cough is the most After 8 hours of Maintain infection PTB is transmitted After 8 hours of
cough for almost a Clearance related common symptom nursing care, client control through the via droplet nursing care, the
month now and it to presence of of will be able to use of mask and inhalation goal is partially
seems that I am bronchial infection pulmonary readily expectorate performance of so proper met
having difficulty in and secretion tuberculosis. It secretions and will hand precaution as evidenced by
breathing at times...) may have absence or washing before and should be client’s
verbatim of client. produce yellowish decrease in after contact with performed participation
or episodes of client. to avoid to breathing and
Objective: greenish colored dyspnea transmission coughing exercises
 RR= 23 breaths/ sputum especially to other clients. and ability to
min during the day. expectorate
 PR= 95 beats/min Eventually, the Place client in high Elevating the head sputum
 T= 37.5 degree sputum may be fowler’s position of the bed and upon evaluation;
Celsius streaked with and turning client still
 Easy fatigability blood. encourage every there are episodes
 Productive cough Furthermore, a reposition two hours help in of
 Chills at night person with PTB every two hours. decreasing the dyspnea as claimed
 Loss of appetite may experience pressure placed on by the client.
as claimed fatigue and loss of the diaphragm.
 Chest X- ray energy. It may
affect Maintain room or Allergen may
 sputum
his or her ability to environment free trigger more
examination
expectorate from any sorts of accumulation of
 revealed positive
secretions, too. allergen. secretion due to
for pulmonary
Aside respiratory
tuberculosis
from that, response.
difficulty
of breathing Teach and These exercises
signifies encourage deep hasten the
that there may be breathing and expulsion
an coughing exercises. of sputum and aids
accumulation of in
secretion in the maintaining
bronchial cavity of airway
the lungs. patency.

Emphasize to Fluids help loosen

increase fluid secretion in the
intake lungs.
depending on
individual
tolerability
or as indicated.

Instruct to take Warm fluids help

warm liquids in
instead loosening the
of cold ones. secretions while
cold
liquids triggers
cough more often.

Provide postural Through the aid of

drainage and gravity and
percussion. percussion
secretions
are readily
expelled.

Monitor breathing It provides

patterns and breath baseline
sounds. data for future
comparison in the
evaluation of
disease
condition.
Educate client and PTB can be
family about transmitted
disease through
condition and the droplet inhalation
need for and 6 months
compliance compliance to
with the medication is
therapeutic needed
regimen. in order to be
treated
with it.
III. 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. D religion is muslim, encourage the patient pray daily, go to
church regularly and increase his faith with God Almighty.

REFERENCES

1. Student of PSKI-B KF-UGM.2002. Translation of Nursing Diagnosis In

NANDA 2001-2002 Definition and Classification
2. [Guideline] Treatment of tuberculosis. MMWR Recomm Rep. 2003 Jun 20
3. Maclay JD, Rabinovich RA, MacNee W. Update in chronic obstructive
pulmonary disease 2008. Am J Respir Crit Care Med. 2009 Apr 1
4. Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med.
2014 Oct 23
5. Anderson WJ, Watson L. Asthma and the hygiene hypothesis. N Engl J Med.
2001 May 24
6. Diaz-Guzman E, Dweik RA. Diagnosis and management of pleural effusions: a
practical approach. Compr Ther. 2007