INTRODUCTION
population testing positive.
Background of the disease
Pulmonary tuberculosis, a chronic sub-acute or acute
respiratory disease commonly affecting the lungs characterized by
the formation of tuberculosis formation in the tissues which tend to
undergo cessation, necrosis and calcification. It is also known as
poor man’s disease or consumption disease. The causative agent in
this disease is Mycobacterium Tuberculosis, a rod shaped bacteria.
The disease is transmitted by deliberate inoculation of
microorganisms by droplet. This disease is transmitted to other
people through the inhalation of organisms directly into the lungs
from contaminated air. According to the department of Health
(DOH) PTB is the 6th cause of mortality and morbidity in the
Philippines as of 2007. (Navales, Handbook of Common
Communicable and Infectious disease revised edition, pages 280-
281.)
This disease can be acquired easily by person being in contact
with an infected one, when living in a crowded area like the
squatter’s area and when having poor nutrition. It is commonly
present in third world or developing countries like Philippines.
In 2004, mortality and morbidity statistics included 14.6
million chronic active cases, 8.9 million new cases, and 1.6 million
deaths, mostly in developing countries. In addition, a rising number
of people in the developed world are contracting tuberculosis
because their immune systems are compromised by
immunosuppressive drugs, substance abuse, or AIDS. The
distribution of tuberculosis is not uniform across the globe with
about 80% of the population in many Asian and African countries
testing positive in tuberculin tests, while only 5-10% of the US
(http://en.wikipedia.org/wiki/Pulmonary_tuberculosis)
OBJECTIVES
GENERRAL OBJECTIVES:
Student-centered objectives:
We students of Don Mariano Marcos Memorial State
University affiliated at Ilocos Training and Regional Medical Center
Medical Ward two at 7:00am -3:00pm shift aim to develop our
knowledge and skills to provide effective and efficient nursing care
that will lead us in the promotion of health and prevention of the
disease during the researchers’ duration of stay in the hospital.
The case presentation will aid as a guideline of the student
nurses in assessing and rendering proper nursing care to patients with
the same problem or disease.
Furthermore, this study allows the students to learn the nature
of the disease as well as the management that would be helpful and
therapeutic to the patient.
SPECIFIC OBJECTIVES
Client-centered objectives:
• To be able to establish rapport with the patient through
interactions and conversations during their stay in the hospital.
• To be able to provide the needed nursing managements PATIENT’S PROFILE
appropriate for her condition in
Name: Patient T
• collaboration with other health care professionals.
Age: 66 years old
• To be able to conduct patient health education the patient
Sex: Male
about her condition in a manner that the client understands or
Address: Bauang, City of San Fernando, La Union
in line with the patient’s learning capacity.
Civil status: Married
• To identify, secure and provide the needs of the patient.
Race: Asian
• To ensure the safety of the patient within the duration of
Nationality: Filipino
hospital stay of the student nurse.
Culture: Ilocano
• To organize and rank the identified and prioritized problems
Religious Affiliation: Roman Catholic
according to any mode of prioritization used.
Education Attainment: High School Undergraduate
• To provide a set of Nursing Care Plan which is the blueprint
Birth day: August 20, 1947
or book guide in providing effective and efficient nursing care
Birthplace: San Fernando, La Union
that is applicable until the time of discharge.
Chief complaint: DOB
Admitting Physician: Dr. Cheryl Joy Biado
Family-centered objectives:
Date and time of admission: October 6, 2019 @3:00 AM
Date and time of assessment: October 9, 2019 @ 9:00am to
• To educate significant others in providing nursing
12:00pm (Physical assessment and interview)
interventions within and after time of discharge upon client
October 10, 2019 @ 9:00 am to 12:00pm
and watchers reaches home.
(Continuation of the interview)
• To provide a set of Nursing Care Plan which the blueprint or
book guide for the significant others in providing effective
and efficient nursing care that is applicable in the time of HISTORY OF PRESENT ILLNESS
discharge and after. One year prior to admission, patient had productive cough but
unable to expectorate and take Robitussion but the cough wasn’t
relieved.
Nine months prior to admission the patient claimed that he
experienced loss of appetite, low grade fever especially in the
afternoon that is relieved by Tepid Sponge Bath, can’t sleep at night
due to productive cough and sometimes Difficulty of Breathing but
relieved by nebulizer.
Seven months prior to admission, he was admitted at
Communicable Disease Ward for two weeks with a chief complaint
of DOB associated by non- productive cough, low grade fever
especially in the afternoon, night sweat and easily fatigue ability.
Diagnostic test done such as Electrocardiograph (ECG), Complete
Blood Count (CBC), X-ray, Gram Stain Culture and sensitivity
(GSCS), Acid Fast Bacilli (AFB) and diagnosed with Pulmonary
Tuberculosis and Hypertension (HPN). Salbutamol, Budesonide,
Metoprolol, Losartan and Rifampicin was his medications.
Three weeks prior to admission, patient experienced Difficulty
of Breathing and fever so they brought him to LORMA and stayed
there for two days. Diagnostic procedure such as Chest X-ray and
ECG revealed extensive bilateral PTB with moderate to massive
right side plural effusion and right bundle branch block was noted on
Electrocardiograph. They suggested him to consult a pulmonologist
and cardiologist within 12 days, but his relatives declined due to
financial constraints and decided to bring the patient to another
institution for further treatment.
PAST HEALTH HISTORY
This is the third time of the patient to be hospitalized. The first
was on March 2019 at ITRMC were he was diagnosed with PTB and
HPN. He has no known allergy. He usually take OTC drugs such as
paracetamol for fever. He doesn’t experience any injuries or
accidents. He can’t recall if he had undergone childhood
immunizations.
FAMILY HEALTH HISTORY
His mother died at the age of 70 due to asthma while his father
died at the age of 74 due to HPN. His elder brother at the age of 65
because of PTB
SOCIAL HISTORY
Patient T was an active smoker and alcohol drinker since he
was 15 years old. His friends and him drink a bottle of red horse
every day. He smokes one pack of smoke a day. He stopped drinking
in 2011 where as smoking was stopped on February 2019.

Due to financial problem, the patient stayed at home for 10

days and brought to ITRMC on September 27.2019 @ 3:00pm due to
Difficulty of Breathing accompanied by his eldest daughter and wife
and admitted.
COURSE OF CONFINEMENT
October 5, 2019 3:50 am
Patient T arrived at the Emergency Room of ITRMC with
chief complaint of DOB. His initial vital signs were as follows:
BP:140/90, PR:110, RR:29, Temp:37℃ , SPO2: 94%.The patient
weighs 44kgs. He was seen and examined by Dr Cuyao, orders were
made and carried out for admission.
4:35 am Nurse’s Notes
ER nurse on duty hooked an IVF of d5LRS X 20 gtts/min.
Patient was on CBC, Na+, K+, BUN Crea and also for Chest Tube
Thoracostomy (CTT) insertion.
3:00 am – 4:00 pm Nurse’s Notes
O2 inhaler was administered via nasal cannula. Doctor ordered
intralipid 500cc/bottle x 6 hours for temperature: 37.8℃ , salbutamol
+ ipratropium neb. q6, Rifampicin 2 tabs OD pre breakfast. Patient T
was position at high back rest.
9:10 am Nurses Notes
Patient was still on inhaler at 1-2 pm with S/P CTT insertion
and has a 500cc CTT output. (+) pain at CTT site and he is for chest
X-ray (CXR). Tramadol 1 amp IV PRN was given for pain plus
lactulose 30cc given once a day (OD) if no pain to 2-3 days. Lasartan
was hold and was for NGT insertion however relatives refused.
October 6,2019 1:00 – 2:00 pm
Patient T with an ongoing Intravenous Fluid (IVF) of D5LRS
X 20gtts/min still on O2 via nasal cannula and for repeat CXR and
sputum AFB. Doctor instructed patient to have high protein and
calorie diet. Vital signs taken were as follows: BP:110/80mmHg, PR:
82 bpm, RR: 33bpm. Temp: 36℃ and CTT output of 2 bottles.
October 7, 2019 3:00 am
Patient was still on O2 x 1-2 1pm via nasal cannula with a vital signs
of BP:110/70, PR:86bpm, RR:29bpm, Temp: 36.7℃ and CTT
output of 1 bottle. Has an ongoing IVF of PLRS x 30 gtts/min
infusing well at the left arm .CTT bottle was changed and wound
dressing was done. Drugs plus nursing intervention was continue
administering.
13 AREAS OF ASSESSMENT
I. PSYCHOSOCIAL STATUS
Patient T is an Ilokano, working as a zeepney driver for 7
years. He is a Roman Catholic and believes in superstitions and
quack doctors such as “albularyo” but believe more on medical
management when disease become complicated. He lived in semi-
concrete bungalow house with 5 bedrooms. Patient affiliated with
social agencies like SSS . Patient T is a father of 5, living with his
wife. He’s a breadwinner for the family but now that he is old, the
children finance his hospitalization as well as his medical needs.
Patient T is 66 years old and is married. Two months Prior to
admission, he manage to do work independently however due to are clean. He also practices proper waste segregation. One of his
health problem he now depend on his wife and children. Patient is hobbies is gardening, he even showed us his collection of kalachuchi
not sexually active since the wife being menopause and for him and orchids. Patient is completely thankful that even if they are in the
being old and sick. Patient T was circumcised when he was 12 years city, their place is away from factories. During the assessment, the
old. patient verbalized that he wants to go home soon because he misses
his grandchildren and worried that his plants are not getting enough
care. He uses fertilizers and pesticides for his plants.
II. MENTAL STATUS
The patient was seen awake. He is coherent, conversant and
IV. SENSORY STATUS
responds appropriately to verbal and non-verbal stimuli. She is well
oriented to her current illness, time, date, and people around her.
During the interview, he was able to express his feelings and uses
A. Visual Acuity
clear words. He speaks with confidence. The patient converses with
Patient is using corrective device such as reading
eyes open and maintains eye contact. The patient is calm, alert, and
glasses. His specs are 200 on the right eye and 175 on the
expressive. Facial expressions are congruent with subjects. Speech is
left eye. He was able to distinguish and name the objects
audible with moderate loudness. Speech is fluent. There is usually a
(ballpen, cellphone, and syringe) that was shown to him. He
flow of conversation with pauses. Thought is organized and
was able to read the words ( Apple, and Chandelier) at a
congruent with behavior and nonverbal cues. He can also remember
distance of approximately 2 meters.
his past and present experiences that happened. He was able to repeat
the three words I asked her to remember after taking her vital signs.
B. Auditory
Short and long term memory is intact. He is a high school
Ears are symmetrical, equal size and fully formed.
undergraduate.
Both ears has cerumen. Ears are firm without lumps, non-
tender and no pain is elicited with palpation of the auricle or
mastoid process. He was able to repeat the phrase “cooking
III. ENVIRONMENTAL STATUS
time” on the whisper test. Also, he was able to hear the beep
Patient and his family lives along the main road and 5 to 7 of the thermometer at a distance of approximately 1 meters.
minutes away from the town proper. They have a quiet and safe
neighborhood. As being used to doing chores, patient T, is quite C. Olfactory
particular with cleanliness. He makes sure that their house and yard
 It is symmetrical, midline, and proportional to face.
No lesions noted and color is consistent with facial
complexion. Patient did not feel pain upon palpation, no
tenderness noted or break in contour. Patient was able to
distinguish the smell of vinegar on Cracklings and alcohol
on an unlabeled bottle.
D. Gustatory
Lips are dark in color and moist with no lesions.
Patient’s teeth is not complete, he only have 21 teeth left. 7
teeth on the upper and 14 on the lower part. Remaining teeth
are yellowish in color with tar. He has no and not using
dentures. Halitosis noted. He was able to discriminate the
tastes of the three food we introduced to him. Sweet (Max
red), sour and salty (Cracklings), and bitter (dark chocolate).
E. Tactile
Patient has ability to discriminate sharp and dull by
applying pressure of pen in the extremities. He is able to feel
pain stimuli as evidenced by reaching and guarding the site
of pain. He can also differentiate common objects by touch
through shape and texture such as cup and fork
V. MOTOR STATUS
As shown above, the upper and lower extremities are rated 4/5
which means that there is movement against resistance but less than
normal.There is no involuntary muscle observed. Muscles felt
smooth and firm and no pain upon palpation. Patient needs assistance
in sitting upright because pain occurs on the site of his CTT.
VI. NUTRITIONAL STATUS
Patient is on DAT with SAP. Patient verbalized that he
eats poorly because he always has no appetite. Before he was
even hospitalized patient claimed that his eating habits has
changed. He no longer enjoys the food he used to like. He
used to eat three times daily with snacks in between. He
even mentioned that he loves vegetables. He prefer it more
than meat dishes. Patient claimed that he lose weight during
the occurrence of his disease. He used to be 58 kg but upon
admission he weighs 41 kg. According to his BMI (16.60) he
is underweight. He showed me some of his photos that was
taken a year ago and I can tell that the disease got a good
chunk of hin. He used to look well fleshed but now he’s
skinny..
VII. ELIMINATION STATUS
Patient's usual stool is yellowish in color, hard in
consistency. He defecates twice a day. He doesn’t strain
himself when he defecates. During hospitalization he only
pooped once in a day. As to his hydration status, he
verbalized that he drinks at least 8 glasses of water a day. He
drinks soda but not that often. His urine is orange in color
due to his medications. He urinates 3 to 4 times a day. He
needs assistance when going to toilet.

VIII. FLUID AND ELECTROLYTE STATUS
Patient has an ongoing PLRS X 1000 mL regulated at KVO.
She is not always thirsty, her mouth's mucous membrane is
not dry, her skin turgor goes back immediately, no presence
of edema. The patient has a normal capillary refill with a
capillary refill of less than 2 seconds. Her electrolyte results
on the 12th of February, 2019 are as follows:
• Sodium Na (+): 146.5 mmol/L (NV: 135-148
mmol/L)
• Potassium K (+): 3.91 mmol/L (NV: 3.50-5.30
mmol/L)
IX. CIRCULATORY STATUS
Upon assessment on the circulatory status of the patient, her
pulse rates were: radial pulse 83 beats per minute, carotid
pulse 88 beats per minute, temporal pulse 78 beats per
minute, apical pulse 85 beats per minute. Her pulse was
characterized as bounding pulse with a grade of +4. Heart
sounds was normal. Her blood pressure during the
assessment was 110/80 mmHg. The client has a brown color,
pink nail beds and dark lips. No signs of pallor. Neck veins
do not appear full.
X. Respiratory Status
Patient N is a non-smoker, no one in their house smoke. She
claimed that she doesn’t have asthma. During assessment her
posture is upright and relaxed. Facial expression is relaxed.
Skin color is appropriate tone for race, no cyanosis or pallor
noted. Respiratory rate is 20 breaths per minute with regular
rhythm and not using of accessory muscles. Her oygen
saturation is 98%. No clubbing of finger nails. Upon
auscultating her lungs, assessment showed that she had no
presence of abnormal breath sounds.
XI. Body Temperature
The patient have not experienced increased in temperature,
she stated that she doesn’t feel hot. The patient’s temperature
during assessment was 37.1 °C, axillary site. She was
thankful that her room has air-conditioning.
XII. Integumentary Status
Patient is brown in color and has a good skin turgor which
goes back immediately. Skin temperature is cool and
appropriate to the environment. Moisture is consistent
through out, with evenly smooth skin texture. Hair is thick
and well distributed across the scalp. No lice or nits noted.
Nails are smooth and translucent, and consistent in color and
thickness. Supraclavicular and posterior cervical
lymphadenopathy noted on the left side of the body. A
diagonal full-thickness wound is noted on left breast due to
surgical incision. Hemovac drain is inserted in her chest with
a negative pressure. An amount of 30 mL, bright red
discharge, is noted during assessment. Elastic bandage is
wrapped around her chest with a dry and intact wound
dressing. Patient N claimed that her wound has healed
without complications. On the healing process she noted that
her wound appeared pink to red which is a sign of healthy
healing.

XIII. Rest and Comfort

Patient affirmed that she sleeps 7 to 8 hours before

hospitalization. During her stay in the hospital, she was able
to sleep well and even when her sleep was disturbed because
of vital signs monitoring, she have no trouble going back to
sleep. During assessment she’s feeling moderate pain on her
operation site. She rated it as 5/10. She claimed that she has
high tolerance of pain. She only get to feel pain when she’s
moving. A week after she got out of the hospital, she started
doing simple chores like sweeping and watering plants.
Patient has recuperated well with her surgery. She verbalized
that she’s going to take care of herself more so that she can
keep the recurrence of hear disease at bay.