1

Chapter I INTRODUCTION

Rationale and Background of the Study Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, an aerobic acid-fast bacillus. Although it is most frequently a pulmonary disease, more than 15% of patients experience extra pulmonary TB that can infect the meninges, kidneys, bones, or other tissues. Pulmonary TB can range from a small infection of bronchopneumonia to diffuse intense inflammation, necrosis, pleural effusion, and extensive fibrosis (Sommers, et al., 2007). Tuberculosis (TB) is still a major public health concern in the Philippines, ranking as the sixth (previously fifth) leading cause of morbidity and mortality based on recent local data. Globally, the Philippines is ninth, previously ranked seventh, among 22 high burden countries and ranks third, previously second, in the Western Pacific region based on its national incidence of 133 new sputum smear-positive cases per 100,000 population in 2004 (from 145 new cases per 100,000 in 2002). The Philippine Health Statistics recorded a total of 27,000 deaths from tuberculosis, at the turn of the century. The National Tuberculosis Program (NTP) reported 130,000 to 140,000 TB cases, mainly discovered and treated in government health units, of which 60% are highly infectious smear-positive cases. As of 2004, the case detection rate (CDR) improved from 53% in 2003 to 68% and the cure rate increased from

75% in 2003 to 80.6%. Both are however still below global targets of 70% and 85% respectively (DOH, 2010). Tuberculosis in the country exacts serious economic consequences caused by loss of income due to disability and premature death. Based on the incidence, mortality data, and the 1997 Philippine population by age and gender, assuming duration of illness at 2.2 years, Peabody and colleagues estimated that 514,000 years of healthy life or disability adjusted life years (DALYs) are lost, due to illness and premature death from TB each year, affecting predominantly males and the most productive age group. The actual number of DALYs may be higher due to under reporting or misreporting (DOH, 2010). The health seeking behavior of patients with tuberculosis is highly variable as shown in the 1997 National Prevalence Survey. In this study by Tupasi, patients with symptoms suggestive of TB took no action (43%), self-medicated (31.6%) or consulted a health care provider (25.4%), which includes private medical practitioners (11.8%), public health centers (7.5%), private hospitals (4.4%) and traditional healers (1.7%). disease, 32.9% did nothing (DOH, 2010). According to DOH, of the 7,000 reported cases of Pulmonary Tuberculosis in Central Visayas, 50% belongs to Cebu City. The prevalence of tuberculosis is highest among the poor, elderly and urban dwellers. Among those confirmed to have the

Objectives of the Study The main goal of this study is to gather comprehensive information about Pulmonary Tuberculosis. It delves further into the core of the illness, its causes and effects and the problems that arise from this disease and the appropriate nursing management of such problem. This study is specifically aimed to obtain knowledge about Pulmonary Tuberculosis identifying its definition, the etiologic and precipitating factors, anatomy and physiology of the organs involved, its pathophysiology, its presenting signs and symptoms, the medical and surgical management and the specific nursing care to be implemented to manage the patients condition.

Significance of the Study This study is geared towards obtaining a thorough knowledge and skills necessary in caring for a patient with TB and this will be able to benefit the following entities: Patients. This study will aid in the provision of appropriate care needed by patients with Pulmonary Tuberculosis so that they will achieve their optimum level of health and to improve their level of functioning. Patients Significant Others. This study will provide them with the basic knowledge necessary to promote awareness to decrease communication in the household or in the immediate environment upon discharge.

Nursing Students. This study will aid the students in rendering optimum and quality care for their assigned patients and this will allow them to have a sense of fulfillment as they witness their patients recover from a morbid state. Nurse Educators. This study will make them aware of the strong and weak points of their students. With this, they can facilitate the improvement of the competency of the student nurse. Clinical Nurse Educators. The study will enable them to refine their care towards their patients by providing them with vital information about the patient and the disease condition in a thorough and organized manner. Society. This study will enable the people to be aware of the disease and this will give them a call to modify their lifestyles in order to prevent them from having the disease in the future. Future Researchers. They will have an idea regarding the quality of care that the nurses of today are providing to their patients.

Chapter II PATIENTS PROFILE

The following are the pertinent data about the patients personal information and medical history.

Patients Vitae A case of CRB, 27 years old, male, single, Roman Catholic and is a resident of Salinas Drive, Lahug, Cebu City Cebu. He is a native Cebuano and uses Bisaya as his primary language. He is an elementary graduate and works as a construction worker. The patient has a family history of hypertension on the paternal side and asthma on the maternal side. He consumes 15-20 sticks of cigarette daily and is a binge drinker. He reported to have used illicit drugs starting by age 21. Patient reported to have hired girls from Junquera Street. Past medical history revealed no previous medical and surgical conditions and no prior hospitalization was reported.

Background/History The patient was admitted at Vicente Sotto Memorial Medical Center for the first time. Four weeks prior to admission, patient developed non-productive cough and reported to have blood streaked sputum 2 days prior to admission. Patients mother was concerned because of the accompanying fatigue and sudden weight loss. Drenching night sweats and low-grade afternoon fever were

also reported. Patient reported that he has a close friend who shared the same manifestations with him and suspected that it is from him that he contracted the disease. When assessed about his BCG vaccination, no scar was noted on his right deltoid area and patients mother could not recall whether the vaccination was given. Patients lifestyle is significantly relevant to the development of Pulmonary Tuberculosis since it subjects him to the different risk factors of the disease.

Physical Assessment Findings This is the review of the physical assessment done to the patient which includes the physical, physiologic and psychological findings regarding the patients condition. Respiratory Patient experienced tachypnea at 29 cycles per minute and coarse rhonchi was heard upon auscultation. Blood streaked sputum and chest tightness with dull aching chest pain accompanying the cough was reported. Expansion of the lungs was not full because of chest pain and dyspnea upon exertion. Dullness upon percussion was noted on both lung fields. Non-productive cough was reported to have developed four weeks prior to admission. HEENT Patient reported to be experiencing mild, localized headache originating in the occipital area. Head is normocephalic and symmetrical. Yellow sclera was noted with normal visual acuity of both eyes reported. Periods of blurring of vision

were also reported. Sore throat was present and was reported to have started since the day of admission. No obvious deformities and lesions were noted upon assessment. Musculoskeletal Patient was bedridden because of severe weakness and generalized edema. Limited range of motion in both upper and lower extremities was noted and myalgia, back pain and stiffness were reported. No joint swelling and skeletal deformities were noted upon assessment. Cardiovascular Heart sounds were audible. The patients apical pulse was thready but regular in rhythm. Tachycardia was noted at 127 beats per minute. Patient reported to experience periods of palpitation. Blood pressure reading is within normal range at 110/60 mmHG and no neck vein distention was noted. Pedal pulses are present and equal on both sides. Gastrointestinal Some tenderness and rigidity were reported in the umbilical area. Patients bowel sounds revealed 15 clicks per minute in the right lower quadrant of the abdomen. Bowel movement is reported to occur daily commonly in the morning. Patient is prescribed Diet as Tolerated and is using diapers for voiding. Urinary catheter was attached with amber urine at moderate amount. Neurologic The patient was able to demonstrate and perform different facial expression. No paralysis was noted but weakness in both the upper and lower

extremities can be observed. He has equal but diminished sensation in all his extremities because of the edema. Sense of balance was not assessed because of patients condition. Memory and cognition is well and unaffected and reflexes were equal in both upper and lower extremities. Psychological Patient responded to questions carefully and correctly and has an appropriate affect. He is non-hostile and is cooperative in nursing interventions and responds to the situation accordingly. Patient is very hopeful about the prognosis of his case and is very cooperative in all the procedures performed to him.

Chapter III ANATOMY AND PHYSIOLOGY

The respiratory system is composed of the upper and lower respiratory tracts. Together, the two tracts are responsible for ventilation (movement of air in and out of the airways). The upper tract, known as the upper airway, warms and lters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange. Gas exchange involves delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as carbon dioxide, during expiration.

Anatomy of the Upper Respiratory Tract Upper airway structures consist of the nose, sinuses and nasal passages, pharynx, tonsils and adenoids, larynx, and trachea. Nose The nose is composed of an external and an internal portion. The external portion protrudes from the face and is supported by the nasal bones and cartilage. The anterior nares (nostrils) are the external openings of the nasal cavities. The internal portion of the nose is a hollow cavity separated into the right and left nasal cavities by a narrow vertical divider, the septum. Each nasal cavity is divided into three passageways by the projection of the turbinates (also called conchae) from the lateral walls. The nasal cavities are lined with highly vascular ciliated mucous membranes called the nasal mucosa. Mucus, secreted

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continuously by goblet cells, covers the surface of the nasal mucosa and is moved back to the nasopharynx by the action of the cilia (ne hairs). The nose serves as a passageway for air to pass to and from the lungs. It lters impurities and humidies and warms the air as it is inhaled. It is responsible for olfaction (smell) because the olfactory receptors are located in the nasal mucosa. This function diminishes with age. Paranasal Sinuses The paranasal sinuses include four pairs of bony cavities that are lined with nasal mucosa and ciliated pseudostratified columnar epithelium. These air spaces are connected by a series of ducts that drain into the nasal cavity. The sinuses are named by their location: frontal, ethmoidal, sphenoidal, and maxillary. A prominent function of the sinuses is to serve as a resonating chamber in speech. The sinuses are a common site of infection. Turbinate Bones (Conchae) The turbinate bones are also called conchae (the name suggested by their shell-like appearance). Because of their curves, these bones increase the mucous membrane surface of the nasal passages and slightly obstruct the air owing through them. Air entering the nostrils is deected upward to the roof of the nose, and it follows a circuitous route before it reaches the nasopharynx. It comes into contact with a large surface of moist, warm mucous membrane that catches practically all the dust and organisms in the inhaled air. The air is moistened, warmed to body temperature, and brought into contact with sensitive

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nerves. Some of these nerves detect odors; others provoke sneezing to expel irritating dust. Pharynx, Tonsils, and Adenoids The pharynx, or throat, is a tubelike structure that connects the nasal and oral cavities to the larynx. It is divided into three regions: nasal, oral, and laryngeal. The nasopharynx is located posterior to the nose and above the soft palate. The oropharynx houses the facial, or palatine, tonsils. The

laryngopharynx extends from the hyoid bone to the cricoid cartilage. The epiglottis forms the entrance of the larynx. The adenoids, or pharyngeal tonsils, are located in the roof of the nasopharynx. The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes guarding the body from invasion by organisms entering the nose and the throat. The pharynx functions as a passageway for the respiratory and digestive tracts. Larynx The larynx, or voice organ, is a cartilaginous epithelium-lined structure that connects the pharynx and the trachea. The major function of the larynx is vocalization. It also protects the lower airway from foreign substances and facilitates coughing. It is frequently referred to as the voice box and consists of the following: Epiglottisa valve ap of cartilage that covers the opening to the larynx during swallowing Glottisthe opening between the vocal cords in the larynx

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Thyroid cartilagethe largest of the cartilage structures; part of it forms the Adams apple

Cricoid cartilagethe only complete cartilaginous ring in the larynx (located below the thyroid cartilage)

Arytenoid cartilagesused in vocal cord movement with the thyroid cartilage

Vocal cordsligaments controlled by muscular movements that produce sounds; located in the lumen of the larynx

Trachea The trachea, or windpipe, is composed of smooth muscle with C-shaped rings of cartilage at regular intervals. The cartilaginous rings are incomplete on the posterior surface and give rmness to the wall of the trachea, preventing it from collapsing. The trachea serves as the passage between the larynx and the bronchi.

Anatomy of the Lower Respiratory Tract The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. Lungs The lungs are paired elastic structures enclosed in the thoracic cage, which is an airtight chamber with distensible walls. Ventilation requires movement of the walls of the thoracic cage and of its oor, the diaphragm. The effect of these movements is alternately to increase and decrease the capacity of

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the chest. When the capacity of the chest is increased, air enters through the trachea (inspiration) because of the lowered pressure within and inates the lungs. When the chest wall and diaphragm return to their previous positions (expiration), the lungs recoil and force the air out through the bronchi and trachea. The inspiratory phase of respiration normally requires energy; the expiratory phase is normally passive. Inspiration occurs during the rst third of the respiratory cycle, expiration during the latter two thirds. Pleura The lungs and wall of the thorax are lined with a serous membrane called the pleura. The visceral pleura covers the lungs; the parietal pleura lines the thorax. The visceral and parietal pleura and the small amount of pleural uid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. Mediastinum The mediastinum is in the middle of the thorax, between the pleural sacs that contain the two lungs. It extends from the sternum to the vertebral column and contains all the thoracic tissue outside the lungs. Lobes Each lung is divided into lobes. The left lung consists of an upper and lower lobe, whereas the right lung has an upper, middle, and lower lobe. Each lobe is further subdivided into two to ve segments separated by ssures, which are extensions of the pleura.

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Bronchi and Bronchioles There are several divisions of the bronchi within each lobe of the lung. First are the lobar bronchi (three in the right lung and two in the left lung). Lobar bronchi divide into segmental bronchi (10 on the right and 8 on the left), which are the structures identied when choosing the most effective postural drainage position for a given patient. Segmental bronchi then divide into subsegmental bronchi. These bronchi are surrounded by connective tissue that contains arteries, lymphatics, and nerves. `The subsegmental bronchi then branch into bronchioles, which have no cartilage in their walls. Their patency depends entirely on the elastic recoil of the surrounding smooth muscle and on the alveolar pressure. The bronchioles contain submucosal glands, which produce mucus that covers the inside lining of the airways. The bronchi and bronchioles are lined also with cells that have surfaces covered with cilia. These cilia create a constant whipping motion that propels mucus and foreign substances away from the lung toward the larynx. The bronchioles then branch into terminal bronchioles, which do not have mucous glands or cilia. Terminal bronchioles then become respiratory bronchioles, which are considered to be the transitional passageways between the conducting airways and the gas exchange airways. Up to this point, the conducting airways contain about 150 mL of air in the tracheobronchial tree that does not participate in gas exchange. This is known as physiologic dead space. The respiratory bronchioles then lead into alveolar ducts and alveolar sacs and then alveoli. Oxygen and carbon dioxide exchange takes place in the alveoli.

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Alveoli The lung is made up of about 300 million alveoli, which are arranged in clusters of 15 to 20. These alveoli are so numerous that if their surfaces were united to form one sheet, it would cover 70 square metersthe size of a tennis court. There are three types of alveolar cells. Type I alveolar cells are epithelial cells that form the alveolar walls. Type II alveolar cells are metabolically active. These cells secrete surfactant, a phospholipid that lines the inner surface and prevents alveolar collapse. Type III alveolar cell macrophages are large phagocytic cells that ingest foreign matter (e.g., mucus, bacteria) and act as an important defense mechanism.

Function of the Respiratory System The cells of the body derive the energy they need from the oxidation of carbohydrates, fats, and proteins. As with any type of combustion, this process requires oxygen. Certain vital tissues, such as those of the brain and the heart, cannot survive for long without a continuing supply of oxygen. However, as a result of oxidation in the body tissues, carbon dioxide is produced and must be removed from the cells to prevent the buildup of acid waste products. The respiratory system performs this function by facilitating life-sustaining processes such as oxygen transport, respiration and ventilation, and gas exchange. Oxygen Transport Oxygen is supplied to, and carbon dioxide is removed from, cells by way of the circulating blood. Cells are in close contact with capillaries, whose thin

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walls permit easy passage or exchange of oxygen and carbon dioxide. Oxygen diffuses from the capillary through the capillary wall to the interstitial uid. At this point, it diffuses through the membrane of tissue cells, where it is used by mitochondria for cellular respiration. The movement of carbon dioxide occurs by diffusion in the opposite directionfrom cell to blood. Respiration After these tissue capillary exchanges, blood enters the systemic veins (where it is called venous blood) and travels to the pulmonary circulation. The oxygen concentration in blood within the capillaries of the lungs is lower than in the lungs air sacs (alveoli). Because of this concentration gradient, oxygen diffuses from the alveoli to the blood. Carbon dioxide, which has a higher concentration in the blood than in the alveoli, diffuses from the blood into the alveoli. Movement of air in and out of the airways (ventilation) continually replenishes the oxygen and removes the carbon dioxide from the airways in the lung. This whole process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body is called respiration. Ventilation During inspiration, air ows from the environment into the trachea, bronchi, bronchioles, and alveoli. During expiration, alveolar gas travels the same route in reverse. Physical factors that govern air ow in and out of the lungs are collectively referred to as the mechanics of ventilation and include air pressure variances, resistance to air ow, and lung compliance.

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Chapter IV PSYCHOPATHOPHYSIOLOGY AND PSYCHODYNAMICS Schematic Diagram

Etiology: Mycobacterium Tuberculosis Risk Factors: close contact with someone who has TB, immunocompromised status, substance abuse, poverty, preexisting medical condition, living on overcrowded, substandard housing

Transmission of Mycobacterium Tuberculosis via Aerosolization Bacteria reaches susceptible site (Bronchi and Alveoli) and freely multiplies Cell-mediated immunity develops Phagocytes engulf many bacteria and TB-specific lymphocytes destroy the bacilli and normal tissue Inflammation develops Granulomatous Macrophages surround the granulomatous formation Formation of fibrous tissue mass Inflammation develops again resulting in further development of bronchopneumonia and tubercle formation Altered pulmonary physiology Impaired oxygenation and increased metabolism Mucupurulent sputum production Irritating cough

Necrotizes and forms a cheesy mass and becomes calcifies Collagenous scar formation Bacteria becomes dormant Reinfection and activation of dormant bacteria

Fatigue Anorexi a Weight loss Fever and Night sweats

Irritation of the lung parenchyma plus rupture of Ghons tubercles

Blood-streaked sputum (Hemoptysis

Release of cheesy material into the bronchi

Systemic Inflammatory

Figure 1. Psychopathophysiology of Pulmonary Tuberculosis.

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Tuberculosis (TB) is a highly communicable disease caused by Mycobacterium Tuberculosis. It is the most common bacterial infection worldwide. The organism is transmitted via aerosolization (i.e. and airborne route). When a person with active TB coughs, laughs, sneezes, whistles or sings, droplets become airborne and may be inhaled by others (Ignatavicius & Workman, 2006). TB begins when a susceptible person inhales mycobacteria and becomes infected. The bacteria are transmitted through the airways to the alveoli, where they are deposited and multiply. The bacilli also are transported via the lymph system and bloodstream to other parts of the body (kidneys, bones, cerebral cortex) and other areas of the lungs (Smeltzer, et al., 2008). The bacillus multiplies freely when it reaches a susceptible site (bronchi or alveoli). An exudative response occurs causing a nonspecific pneumonitis. With the development of acquired immunity, further growth of bacilli is controlled in most initial lesions. These lesions usually resolve and leave little or no residual bacilli. Only a small percentage of people initially infected will develop active TB (5% to 15 %) (Ignatavicius & Workman, 2006). The bodys immune system responds by initiating and inflammatory reaction. Phagocytes (neutrophils and macrophage) engulf many of the bacteria, and TB-specific lymphocytes destroy the bacilli and normal tissue. This tissue reaction results in the accumulation of exudates in the alveoli, causing bronchopneumonia (Smeltzer, et al., 2008). Cellmediated immunity develops 2 to 10 weeks after infection and is manifested by a positive reaction to a tuberculin skin test.

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Granulomas, new tissue masses of live and dead bacilli, are surrounded by macrophages, which form a protective wall around the granulomas. They are then transformed to a brous tissue mass, the central portion of which is called a Ghon's tubercle. The material (bacteria and macrophages) becomes necrotic, forming a cheesy mass. This mass may become calcied and form a collagenous scar. At this point, the bacteria become dormant, and there is no further progression of active disease. After initial exposure and infection, the person may develop active disease because of a compromised or inadequate immune system response. Active disease also may occur with reinfection and activation of dormant bacteria. In this case, the Ghon's tubercle ulcerates, releasing the cheesy material into the bronchi. The bacteria then become airborne, resulting in further spread of the disease. Then the ulcerated tubercle heals and forms scar tissue. This causes the infected lung to become more inamed, resulting in further development of bronchopneumonia and tubercle formation. Unless the process is arrested, it spreads slowly downward to the hilum of the lungs and later extends to adjacent lobes. The process may be prolonged and characterized by long remissions when the disease is arrested, only to be followed by periods of renewed activity. Approximately 10% of people who are initially infected develop active disease. Some people develop reactivation TB (also called adult-type TB). This type of TB results from a breakdown of the host defenses. It most commonly occurs within the lungs, usually in the apical or

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posterior segments of the upper lobes, or the superior segments of the lower lobes.

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Chapter V MANAGEMENT

The goals of clinical management of Pulmonary Tuberculosis include control of symptoms and degeneration and to prevent transmission of TB to other susceptible individuals.

Laboratory/Diagnostic Procedures Ideal First line tests include: complete history and physical assessment, chestx-ray, sputum smear and culture, bronchoscopy, chest CT scan, Tuberculin skin test, and biopsy of the affected tissue. For the purpose of organization, the actual diagnostic procedures performed to the patient are discussed below. Complete History and Physical Examination This is vital in order to create a baseline data of the patients current condition. This would be the basis for evaluation after medical interventions have been employed. Bronchoscopy Bronchoscopy is a technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for

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abnormalities such as foreign bodies, bleeding, tumors, or inflammation. Specimens may be taken from inside the lungs. The construction of bronchoscopes ranges from rigid metal tubes with attached lighting devices to flexible optical fiber instruments with real-time video equipment. Lung Biopsy Lung biopsy is a procedure for obtaining a small sample of lung tissue for examination. The tissue is usually examined under a microscope, and may be sent to a microbiological laboratory for culture. Microscopic examination is performed by a pathologist. A lung biopsy is usually performed to determine the cause of abnormalities, such as nodules that appear on chest x rays. It can confirm a diagnosis of cancer, especially if malignant cells are detected in the patient's sputum or bronchial washing. In addition to evaluating lung tumors and their associated symptoms, lung biopsies may be used to diagnose lung infections, especially tuberculosis and Pneumocystis pneumonia, drug reactions, and chronic diseases of the lungs such as sarcoidosis and pulmonary fibrosis. Chest CT scan CT scanningsometimes called CAT scanningis a noninvasive medical test that helps physicians diagnose and treat medical conditions. CT scanning combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. These cross-sectional images of the area being studied can then be examined on a computer monitor,

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printed or transferred to a CD. CT scans of internal organs, bones, soft tissue and blood vessels provide greater clarity and reveal more details than regular xray exams. Using a variety of techniques, including adjusting the radiation dose based on patient size and new software technology, the amount of radiation needed to perform a chest CT scan can be significantly reduced. A low-dose chest CT produces images of sufficient image quality to detect many lung diseases and abnormalities using up to 65 percent less ionizing radiation than a conventional chest CT scan. This is especially true for detecting and following lung cancer. Other diseases, such as the detection of pulmonary embolism and interstitial lung disease may not be appropriate for low-dose chest CT. Your radiologist will decide the proper settings to be used for your scan depending on your medical problems and what information is needed from the CT scan. If your child is to have a CT scan, the proper low-dose pediatric settings should be used.

Actual Acid-Fast Bacillus Smear and Culture The acid-fast staining method is used primarily to identify tubercle bacilli (M. tuberculosis). Acid-fast bacilli have a cell wall that resists decolorization by acid treatment that is, they retain the stain applied to the specimen, a small portion of which is smeared on a slide, even after treatment with an acid-alcohol solution. Because the tubercle bacillus is slow growing and culture results may take weeks, an acid-fast bacillus (AFB) smear aids in early detection of the

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organism and timely initiation of antituberculosis therapy. Interfering factors during the procedure include: Improper specimen collection and delay in sending specimen to the laboratory (Cavanaugh, B.M., 2003). Reference Value(s) Negative for AFB Patients Results Positive for AFB Clinical Significance Confirms the diagnosis of PTB Chest X-Ray Chest x-rays (CXR) are among the most frequently performed radiologic studies and yield a great deal of information about the pulmonary and cardiac systems. In cases where PTB is suspected, chest X-Rays determine presence and extent of disease. Interfering factors in the performance of chest x-rays include: Improper positioning, especially for views such as the oblique and lordotic films or for portable chest x-rays; Inability of client to take and hold deep breaths during the filming; Improper adjustment of the x-ray equipment to accommodate obese and thin clients, causing overexposure or underexposure and poor-quality films; Metal objects such as closures on undergarments or hospital gown within x-ray field (Cavanaugh, B.M., 2003).

Reference Value(s) Patients Results Clinical Significance Normal lung fields, cardiac Caseations and Reveals active size, structures, mediastinal inflammation are seen on Pulmonary and thoracic the X-ray; fibronodular Tuberculosis

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spine; infiltrates,

no

masses, shadowing noted in both areas of apices of the noted necrosis lungs; which and

collapse, pleural effusion, cavitation fractures of clavicles or revealed ribs, or abnormal elevation or flattening of the

sloughing of lung tissue

diaphragm Tuberculin Skin Test Tuberculin tests are skin tests that use a PPD or old tuberculin (OT) of the tubercle bacillus administered by intradermal injection (Mantoux) or multipuncture technique (Tine) to determine sensitization to the tuberculosis bacillus from a previous exposure, not the actual presence of the disease. A positive response of induration and erythema that appears at the site in 48 to 72 hours reveals the development of a cell-mediated immunity to the organisms or a delayed hypersensitivity caused by interaction of the sensitized T lymphocytes with the tuberculin antigen. The tests are used on children and adults to screen for or to diagnose active or dormant tuberculosis (Cavanaugh, B.M., 2003).

Reference Value(s) Patients Results Clinical Significance Negative response or Mantoux test: 8 cm Reveals exposure to minimal response, with no induration after 32 hours Mycobacterium exposure to tuberculosis Tine test: Less than 2 noted Tuberculosis bacteria

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mm

or

absence

of

induration around one or more of the

punctures in 4872 hr Mantoux test: Less than 5 mm or absence of induration and erythema in 2472 hr Pharmacologic Therapy Combination drug therapy is the most effective method of treating TB and preventing transmission. Active TB is treated with a combination of drugs to which the organism is sensitive. Therapy continues until the disease is under control. The use of multiple-drug regimens destroys organisms as quickly as possible and reduces the emergence of drug-resistant organisms. Current therapy uses isoniazid (INH) and rifampin throughout the therapy, pyrazinamide is added for the first 2 months. This protocol shortens the therapy from 6 to 12 months. Ethambutol or streptomycin may be added to the regimen as the fourth drug. For the patients individualized pharmacologic management, the following drugs were prescribed: HRZE (Rifampin, Isoniazid, Pyrazinamide, and Ethambutol) is a combination drug given to patients with Pulmonary Tuberculosis. These antibacterial drugs exert their different mechanism of actions as follow:

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Rifampin inhibits DNA-dependent RNA polymerase activity in susceptible cells. Rifampin interacts with bacterial RNA polymerase but does not inhibit the mammalian enzyme. At therapeutic levels, rifampin has demonstrated

bactericidal activity against both intracellular and extracellular Mycobacterium tuberculosis organisms. Rifampin has also bactericidal activity against slow and intermittently growing M. tuberculosis organisms. Rifampin cross resistance has been shown only with other rifamycins (Hodgson and Kizior, 2007). Isoniazid kills actively growing tubercle bacilli by inhibiting the biosynthesis of mycolic acids which are major components of the cell wall of M. tuberculosis. The exact mechanism of action by which pyrazinamide inhibits the growth of M. tuberculosis organisms is unknown. In vitro and in vivo studies have demonstrated that pyrazinamide is only active at a slightly acidic pH (pH 5.5) (Skidmore-Roth, 2007). Pyrazinamide is an antitubercular drug whose exact mechanism of action is unknown. It is either bacteriostatic or bactericidal against M. tuberculosis depending on drugs concentration at the infection site and the susceptibility of infecting bacteria (Venable, 2007). Ethambutol diffuses into actively growing M. tuberculosis such as tubercle bacilli. Ethambutol appears to inhibit the synthesis of one or more metabolites, thus causing impairment of cell metabolism, arrest of multiplication, and cell death. No cross resistance with other available antimicrobial agents has been demonstrated (Karch, 2007).

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HRZE was given to the patient once a day before breakfast through the oral route. Patients hypersensitive to ethionamide, niacin (nicotinic acid), other rifamycins (rifabutin and rifapentine), or other medications chemically related to rifampin, isoniazid, pyrazinamide, or ethambutol may be hypersensitive to this medication also (Drugs, 2011). Paracetamol (acetaminophen) is a pain reliever (nonopioid analgesic) and a fever reducer (antipyretic). This blocks pain impulses, probably by inhibiting prostaglandin or pain receptor sensitizers and may relieve fever by acting on the hypothalamic heat-regualting center (Venable, 2008). Paracetamol is used to treat many conditions such as headache, muscle aches, arthritis, backache, toothaches, colds, and fevers. It relieves pain in mild arthritis but has no effect on the underlying inflammation and swelling of the joint. The patient was prescribed with 500 mg 1 tab every 6 hours as necessary. Alcohol must be avoided while taking this medication since this increases the risk of liver damage while taking paracetamol (Skidmore-Roth, 2007). Spironolactone is a potassium-sparing diuretic that prevents the body from absorbing too much salt and keeps potassium levels from getting too low. It promotes water and sodium excretion and hinders potassium excretion thus lowering blood pressure and minimizing edema. Patient was prescribed 25 mg of spironolactone 1 tab two times a day. This drug must be used cautiously in patients with renal impairment or a history of peripheral neuropathy. Patients actual indication is for the alleviation of his generalized edema (Venable, 2008).

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Vitamin B Complex is a combination of B vitamins used to treat or prevent vitamin deficiency due to poor diet, certain illnesses, alcoholism, or during pregnancy. Vitamins are important building blocks of the body and helps in the maintenance of good health. B vitamins include thiamine, riboflavin, niacin/niacinamide, vitamin B6, vitamin B12, folic acid, and pantothenic acid. In patients with pulmonary tuberculosis, Vitamin B Complex is prescribed as prophylaxis for neuritis brought about by intake of Isoniazid. Patient is prescribed 1 tab once a day per orem. Caution is advised in patients with diabetes, alcohol dependence, or liver disease (Karch, 2007).

Nursing Management Nursing care of the patient is a vital part in promoting the patients wellness and recovery. The following are the actual nursing diagnosis identified by the researcher in caring for the patient diagnosed with Pulmonary Tuberculosis.

Impaired

Gas

Exchange

related

to

Altered

Pulmonary

Physiology

secondary to Progression of Tubercular Disease Maglisod lage ko usahay ug ginhawa choi, as verbalized. Objective assessment data include: dyspnea, tachycardia, hypercapnia, restlessness, hypoxia, irritability, confusion and hypoxemia. Following interventions, the patient should exhibit improved gas exchange as evidenced by ABG at baseline levels, absence of cyanosis and no changes in mental status.

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Impaired Gas Exchange is a state of excess or deficit in oxygenation and/or carbon dioxide elimantion at the alveolar capillary membrane (Newfield, et. al., 2007). In patients with Pulmonary Tuberculosis, the altered pulmonary physiology compromises respiration thus affecting the inspiration and expiration of respiratory gases (Smeltzer, et al., 2008). Lab results must be analyzed including ABG and hemoglobin and hematocrit as these will provide integral information to determine deficits in capacity and effect oxygen delivery. Patient must be positioned appropriately to optimize gas exchange as this facilitates chest expansion. Adequate nutrition must be maintained as this decreases energy demands for digestion and prevents constriction of chest cavity as a result of full stomach. Patient must be taught exercises such incentive spirometer or pursed lip breathing once every hour to promote opening of the alveoli. The patient must also be assisted with postural drainage and chest physiotherapy and turning to sides every 2 hours must be employed since position changes modify ventilation-perfusion relationships and enhance gas exchange (Newfield, et. al., 2007). Bronchodilators and mucolytic agents must be administered and monitoring of blood gases must be collaborated between the health care team as these are indicators of the efficiency of gas exchange. Patients resources must be reviewed and home situation regarding long-term management as this initiates appropriate home care planning and long-range support for the patient and the family (Newfield, et. al., 2007).

31

Ineffective Airway Clearance related to Increased Secretions secondary to Progression of Tubercular Disease Lisod lage kayo bay oy, naa pa gyud koy plema maglisud na nuon ko ug ginhawa gamay, as verbalized. Objective assessment data include: dyspnea, diminished breath sounds, adventitious breath sounds, ineffective cough, bloodstreaked sputum and restlessness. Following interventions, the patient should exhibit normal breathing patterns, as evidenced by patent airway and absence of cyanosis. Ineffective Airway Clearance is the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway (Newfield, et al., 2007). In patients with tuberculosis, copious tracheobronchial secretions are produced thus paving the way to the production of sputum (Smeltzer, et. al., 2008). The inability of patients to effectively clear out respiratory secretions is mainly brought about by fatigue, body weakness and ineffective cough (Ignatavicius & Workman, 2006). Respiratory rate, depth, and breath sounds must be monitored at least every 4 hours to provide basic indicators of respiratory effort. Patient must be turned to sides every 2 hours to facilitate postural drainage and adequate hydration must also be maintained to inhibit the production of mucus plugs and secretions must be suctioned as needed. Patient must be assisted in coughing, huffing and in deep breathing as these allow for greater lung expansion and ventilation as well as a more effective cough. Patient must also be assisted with clearing secretions from mouth or nose to remove tenacious secretions from

32

airways and oral hygiene must be performed every 4 hours to clear dried secretions and promote freshness of the mouth. Rest and relaxation must be promoted by scheduling treatments and activities with appropriate rest period to avoid overexertion and worsening of condition (Newfield, et. al., 2007). Prescribed medications must be provided to treat the underlying disease condition and appropriate consultations must be conferred as needed to promote cost-effective use of resources and appropriate follow-up must be provided by scheduling appointments before dismissal. The nurse must collaborate with appropriate health team members since appropriate coordination of services will best meet the patients needs with attention to the patients individuality (Newfield, et. al., 2007).

Fatigue related to Poor Tissue Oxygenation and Increased Metabolism secondary to Progression of Tubercular Disease Luya kayo akoang lawas choi as verbalized. Objective assessment data include: inability to restore energy even after sleep, lack of energy or inability to maintain usual level of physical activity, increased rest requirements, increased physical complaints, disinterest in surrounding and decreased performance. Following nursing interventions, patient will have decreased complaints of fatigue and he will be able to resume performance of normal routine.

33

Fatigue is an overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level. In patients with Pulmonary Tuberculosis, the altered pulmonary physiology affects the delivery of oxygen to the body tissues. Oxygen is vital in the formation of energy thus in cases of TB, fatigue is common. Medications prescribed to treat the condition may also contribute to fatigue (Smeltzer, et al., 2008). Contributory factors must be identified on a daily basis as this assists in identifying causative factors which then can be treated. Activities of daily living must be carefully planned as this will promote participation and sense of success. Stress reduction techniques must be instructed since mental and physical stress contributes greatly to a sense of fatigue. Frequent rest periods must be provided as this allows the patient to gradually increase strength and tolerance for activities. Sensory overload and/or deprivation must be avoided as sensory stimulation can deplete energy stores. Visitors must be limited as necessary and issues that will interfere with sleep such as pain must be addressed immediately (Newfield, et. al., 2007). Diet therapist must be collaborated for in-depth dietary assessment and planning since adequate and balanced nutrition assists in reducing fatigue. Encourage significant others to assist in patient care and together with the patient, they must be educated to avoid activities that will interfere with sleep or reduce quality of sleep. Patient must be referred for assistance with regular exercise plan since regular exercise decreases fatigue (Newfield, et. al., 2007).

34

Imbalanced Nutrition Less than Body Requirements related to Lack of Interest in Food "Mas ning niwang gyud kog samot pag-sulod nako diri sa hospital choi, dili nako ganahan mokaon man gud", as verbalized. Objctive cues include: pale conjuctival and mucous membrane, perceived inability to ingest food, loss of weight and lack of interest in food. Imbalance Nutrition: Less Than Body Requirements is a state in which an individual experiences an intake of nutrients insufficient to meet metabolic needs(Newfield, et. al., 2007). Due to decreased appetitite probably because of environmental factors and due to effeccts of the medication, the metabolic needs of the patient are compromised due to decreased intake of the vital nutrients needed for normal body functioning Include patient in collaboration efforts with dietitian/ nutritionist menu to achieve desired nutritional intake. Provide a rest period of at least 30 minutes prior to meal. Provide an environment that entices the patient to eat and facilitates the patients eating:Offer small, frequent feedings every 2 to 3 hours rather than just three meals per day. Allow the patient to assist with food choices and feeding schedules. Offer between-meal supplements. Focus on high-protein diet and liquids. Encourage significant others to bring special food from home. Make sure intake and output is balancing at least every 72 hours. Weigh daily the same time and in same-weight clothing. Have the patient empty bladder before weighing. Teach the patient this routine for continued weighing at home. Provide frequent positive reinforcement. Educate the patient on consuming nutrient-

35

dense foods. Refer, as necessary, to other health-care providers (Newfield, et. al., 2007).

Knowledge Deficit (Drug Regimen) related to Lack of Exposure and Information Misinterpretation "Wala bitaw ko kasabot ug para asa ning mga tambala choi ug wala sad ko kabalo ug mag-unsa ko", as verbalized. Objective cues include: verbalization of the problem, inappropriate behaviors related to the therapy and inaccurate follow-through of instructions. Deficient Knowledge is absence of deficiency of cognitive information related to a specific topic (Newfield, et.al., 2007). Due to lack of information exposure and limited access to information, deficiency in cognitive knowledge occurs. Identify how the patient perceives the impact of the situation and identify the patient's best methods for learning. Initiate teaching when patient is most amenable to receiving information and provide relevant information only. Always provide and environment conducive to learning. Design teaching plan specific to the patients deficit area and specific to the patients level of education. Include significant others in teaching sessions. Explain each procedure as it is being done, and give the rationale for procedure and the patients role. Provide positive reinforcement as often as possible for the patients progress. Have the patient restate, in his or her own words, cognitive materials during teaching session. Have repeat on each subsequent day until discharge. Ensure that basic needs

36

are taken care of before and immediately after teaching sessions. Pace teaching according to the patients rate of learning and preference during teaching session. Provide the patient with ample opportunity to ask questions. Collaborate with and refer the patient to appropriate assistive resources (Newfield, et. al., 2007).

FOCUS Charting Day 1 F: Fatigue D: Received patient lying on bed awake and conscious, with # 5 PNSS at 30 drops/minute infusing well at left arm with 700 cc remaining fluid, with Foley Bag catheter attached to UroBag draining moderate amounts of amber colored urine, inability to restore energy even after sleep, lack of energy or inability to maintain usual level of physical activity, increased rest requirements, increased physical complaints, disinterest in surrounding and decreased performance. A: Monitored and assessed for unusualities, identified causative factors of fatigue, carefully planned activities of daily living, instructed stress reduction techniques, provided frequent rest periods, avoided sensory overload and/or deprivation, limited visitors, addressed issues that interfere with sleep such as pain, clustered nursing care to minimize disruption of rest. R: Seen sleeping and resting comfortably.

37

Day 2 F: Ineffective Airway Clearance D: Received patient lying on bed awake and conscious, with # 6 PNSS at 30 drops/minute infusing well at left arm with 300 cc remaining fluid, with Foley Bag catheter attached to UroBag draining moderate amounts of amber colored urine, dyspnea, diminished breath sounds, adventitious breath sounds, ineffective cough, blood-streaked sputum and restlessness. A: Monitored respiratory rate, depth and breath sounds, turned to sides every 2 hours, assisted in coughing, huffing and deep breathing exercises, encouraged to clear secretions from mouth and nose, promoted oral hygiene, provided enough time for rest and relaxation, administered prescribed medications as ordered, collaborated with appropriate health care team member. R: Alleviated periods of dyspnea reported.

Day 3 F: Impaired Gas Exchange D: Received patient lying on bed awake and conscious, with # 7 PNSS at 30 drops/minute infusing well at left arm with 650 cc remaining fluid, with Foley Bag catheter attached to UroBag draining moderate amounts of amber colored urine, dyspnea, tachycardia, hypercapnia, restlessness, hypoxia, irritability, confusion and hypoxemia.

38

A: Monitored and assessed for any unusualities, analyzed lab results including ABG, Hemoglobin and Hematocrit, positioned appropriately to optimize gas exchange, maintained adequate nutrition, assisted in coughing, huffing and deep breathing exercises, turned to sides every 2 hours, provided enough time for rest and relaxation, administered prescribed medications as ordered, collaborated with appropriate health care team member. R: Alleviated periods of dyspnea and restlessness noted.

Discharge Summary A case of CB, 27 years old, male, single and is a resident of Salinas Drive, Lahug, Cebu City Cebu is admitted for the first time at Vicente Sotto Memorial Medical Center. Four weeks prior to admission, patient developed nonproductive cough and 2 days prior to admission, blood streaked sputum was observed accompanied by severe fatigue and sudden weight loss. After 3 days of nursing care, the patient will be able to verbalize and demonstrate behaviors that facilitate infection control and management of condition at home. The patient thenverbalized: Makauli najud ko choi pero unsa diay akoang dapat nga mga buhaton sa balay? Patient objective cues include: Received sitting on bed without IVF and other attachments, bedside table is cleaned and bags are packed, seen patient holding his prescription, productive cough still noted Assessment: Readiness for Enhanced Therapeutic Regimen Management related to Active Seeking Behavior to Improve Health

39

Interventions: Advise the patient to quit smoking, avoid excess alcohol intake, maintain adequate nutrition, and avoid exposure to crowds and others with upper respiratory infections; Teach appropriate preventive measures; Be sure the patient understands all medications, including the dosage, route, action, and adverse effects; Instruct the patient to abstain from alcohol while on INH, and refer for eye examination after starting, then every month while taking, ethambutol; Teach the patient to recognize symptoms such as fever, difficulty breathing, hearing loss, and chest pain that should be reported to healthcare personnel; Discuss the patients living condition and the number of people in the household; and Give the patient a list of referrals if she or he is homeless or economically at risk Evaluation: Salamat kaayo choi, mayo ni karon ke kahibalo nako ug unsay angay nga buhaton para dili ko makadamay ug ubang tao ug unya nakahibalo nako ug unsay akoang buhaton para mas madali ko ug mayo aning akoang kahimtang karon, as verbalized. Chapter VI Summary, Conclusion and Recommendations

Extent of Goal Achievement After three days of continuous nursing care, the patient

demonstrated improvements in his condition. The fatigue, the difficulty breathing, the edema and other physical symptoms were all alleviated because of the religious adherence to the therapeutic regimen. The patient demonstrated

40

independence in the performance of his activities of daily living and he has also started to gain responsibility with his therapy. The medical management and the nursing care have shown to be effective as evidenced by the improvements in the clients condition.

Conclusion Pulmonary Tuberculosis is a highly preventable and modifiable disease that can primarily be geared by health education. Public Health education strategies must be employed by the local and national government to prevent transmission and decrease the prevalence and incidence of the disease. Patients diagnose with pulmonary tuberculosis demand a great deal of medical concern because this disease if not managed as early as possible could be fatal. Holistic nursing care must be geared to the patient in order to direct his psychological and physiological needs. Significant others must also be taught as to how to properly intervene and manage the condition. Of great emphasis is Infection control. Pulmonary Tuberculosis is a long-term disease requiring long-term management. Follow-up and regular monitoring of the patient is an imperative to gain information as to the progress of the disease condition. The nurse must be able to assess the patients ability to continue therapy at home. Infection control procedures must also be instructed to prevent communication of the disease at the patients immediate environment upon discharge.

41

Furthermore, Pulmonary Tuberculosis is a highly manageable condition that if intervened appropriately will result to a fruitful and very good prognosis.

Recommendation Based on the results of the study, the researcher recommends the following: 1. A longer span of time allotted for the case study in order to have a longer nurse-patient interaction and more interventions performed. This will also allow the researcher to identify more problems experienced by patients with this disease and develop a more effective nursing plan. 2. An improved and more efficient plan of nursing care that focuses on the aspects mentioned or other than what was mentioned in this study should be developed. The researcher believes that this will offer a good comparison in order to provide knowledge in which area should the nurse prioritize to enhance the care for a patient with Pulmonary Tuberculosis. 3. Further researches on the topic to facilitate the discovery of a more efficient and effective means of managing patients diagnosed with Pulmonary Tuberculosis. This will provide a more comprehensive and updated knowledge in dealing with the condition. 4. Nurse practitioners and student nurses must try to enhance their clinical skills and update their empirical and theoretical knowledge on the management of Pulmonary Tuberculosis since new medical discoveries are available that increase the enhancement of prognosis of their clients.

42

Bibliography 1. Bennett and Plum. 1996. Cecil Textbook of Medicine, 20th Edition. Philadelphia: W.B. Saunders Company. 2. Cavanaugh, B.M. 2003. Nurses Manual of Laboratory and Diagnostic Tests, 4th Edition. Philadelphia: Elsevier Saunders. 3. Doenges et al. 2007. Nursing Care Plans, Nursing Diagnosis and Interventions, 6th Ed. Philadelphia: F.A. Davis Company. 4. Doenges, et al. 2008. Nurses Pocket Guide, 11th Edition. Philadelphia: F.A. Davis Company.

43 5. Estes, M.E. 2006. Health Assessment and Physical Education, 3rd

Edition. Singapore: Delmar Learning. 6. Gulanick, et al. 2010. Nursing Care Plans, 7th Ed. Philadelphia: Mosby. 7. Hodgson & Kizior. 2007. Nursing Drug Handbook. USA: Saunders. 8. Ignativicius and Workman. 2006. Medical-Surgical Nursing, 5th Edition. Philippines: W.B. Saunders Company. 9. Karch, AM. 2007. Nursing Drug Guide. Philadelphia: LWW. 10. Luckmann, J. 1997. Saunders Manual of Nursing Care. Philadelphia: W.B. Saunders Company. 11. Newfield, et. al. 2007. Coxs Clinical Application of Nursing Diagnosis, 5th Edition. Philadelphia: F.A. Davis Company.
12. Skidmore-Roth, L. 2007. Drug Guide for Nurses. USA: Mosby.

13. Smeltzer, et. al. 2008. Brunner and Suddarths Textbook of MedicalSurgical Nursing, 11th Edition. Philadelphia: LWW. 14. Sommers, et. al. 2007. Diseases and Disorders: A Nursing Therapeutics Manual, 3rd Edition. Philadelphia: F.A. Davis Company. 15. Suddarth, D.S. 1991. The Edition. Philadelphia: LWW. 16. Venable, S. 2008. Nurses Drug Guide. Philadelphia: LWW. Lippincott Manual of Nursing Practice, 5th

44

45

APPENDICES

Appendix A Cebu Normal University College of Nursing

APPROVAL FOR CASE STUDY

Name of Student: Edward Arlu Villamor Dinoy Year and Section: Semester: First Semester

IV D

Academic Year: 2011 - 2012

46

This is to certify that the student is approved to take the case of

C.B.

(Initials of Patient)

with a diagnosis of R/I: PTB Cavitary Supra Clavicular and Axillary Abscess
(Write the full diagnosis)

In Ward X as subject for case study in the undergraduate level.

Name and signature of clinical instructor: Mr. Alain Kenneth Ragay, RN, MAN Date of Approval: July 27, 2011

Appendix A ASSESSMENT TOOL

NURSING ADMISSION AND ASSESSMENT Name of Student: Edward Arlu V. Dinoy Clinical Assignment: VSMMC-Ward X Name of Clinical Ins.: Ragay, Alain Kenneth Inclusive Dates: Jun 27-Jul 01, 2011 A. General Admission Information Name of Patient: CBR Age: 27 Y.O. Sex: M Date: June 27, 2011 Time: 08:00 AM Mode: On Stretcher Allergies: None Known TPR: 36.8 C/127 BPM/27CPM BP: 110/60 mmHg HT: 53 WT: 55kg Diet: DAT Sleeping Habits: Sleeps very late at night and wakes up early in the morning CBC: Yes No Urinalysis: Yes No Property: Glasses(X) Contact Lenses(X) Dentures (X) Prosthesis(X) Ring(X) Watch(X) Money(X) Other: Cellphone/Mobile Phone Valuable to Business Office: None

47 Physical Appearance: Patient was slightly weak upon interview with 2 large wound dressings noted on the upper outer part of his thoracic area; with slightly edematous extremities; slightly yellowish skin color and icteric sclera and has a slightly wasted physical appearance Behavior Exhibited: Even though patient is slightly weak, he is conscious, awake and coherent and responds appropriately to questions asked; he is very eager in answering all of the questions and shows a genuine interest in the interaction Content of Conversation: We have talked about his present condition and we have also talked about his history and how he thought his history lead to his present condition. We have also talked about his future plans after discharge. Mary Joy P. Villalon, MD. Physician In-charge B. Admission Interview 1. Patients perception of reason for admission: Binuhatan man nako ni choi mao nga naa ko diri. Abusado man sad kayo ko sa akong lawas gud, as verbalized. 2. Patients symptoms as he/she sees them: Lisod kayo jud ug masakit na choi, maayo tong baskog-baskog pa kay makabuhat pa kag unsay gusto nimong buhaton, as verbalized. 3. Problems in daily living created by symptoms (as patient views them): Magkalisud nako ug buhat sa mga butang nga gusto nakong buhaton gyud tungod aning akoang kondisyon karon, as verbalized. 4. Past Medical History (especially as it relates to P.I.) Medical: No previous history of hospitalization Surgical: No previous history of hospitalization Allergies: No known food and drug allergies Medication: Essentialis 1 tab three times a day Traumatic Injuries: No history of any traumatic injuries Orthopedic: No history of any orthopedic injuries Other (psychiatric, etc.): No other significant past medical history 2. Habits Smoking: 15-20 sticks a day Alcohol: Binge Drinker Drugs: Confirmed Eating: irregular and variable pattern; depends on whats available Social Activity: Tambay ra ko Physical Exercise: 3x/week w/ weights Rest/ Sleeping: Usually sleeps by 3-4 AM and wakes up as early as 7:00 AM. He usually stays outside with his friends. Sexual: Active; started while he was 21 Y.O. has a history of using one of the Junquera Girls Elimination: Daily but timing varies; usually in the morning. 3. Social Economic History a. Native Language: Cebuano-Bisaya b. Education: High-school graduate at Lahug Night High School (2006); Vocational Course at Sacred Heart (2007-2010) c. Occupation: Extra at Constructions; Most of the time is a tambay d. Financial Status (what is the impact of current hospitalization) Actually, akoang mama gyud ang gabayad ug gagasto ani tanan choi, wala man koy kwarta gud, as verbalized. e. Civil Status: Married ______ Single ___X___ Divorced ______ Widow _______

a. b. c. d. e. f. g. a. b. c. d. e. f.

48 f. Living Situation: Lives alone _________________________ Live with others (specify): Mother, father, four brothers, one sister 4. Family History: Heart Disease, Cancer, TB, Mental Illness and Others (specify): Hypertension (Paternal); Asthma (Maternal) 5. Primary Physicians Admitting Diagnosis (indicate P = Probable and C = Confirmed): R/I: PTB Cavitary 1.) Supra Clavicular and Axillary Abscess (P) C. Nursing Review of Systems (circle the appropriate symptoms) 1. HEENT: Headaches Hearing Loss Visions Diplopia Eye pain Eye infection Blurring Epistaxis Sinus pain Facial pain Bleeding gums Dentures Sore throat Nasal-tracheal pain Other: No other problems 2. CARDIO-RESPIRATORY: Chest pain (site): Upper Left Chest pain with exertion Dyspnea on exertion Nocturnal dyspnea Edema Palpation Hypertension Known murmur Cough Sputum Hemoptysis Pleuritic Pain Diaphoresis Last X-ray: Results not yet available EKG: No abnormal findings. 3. GASTRO-INTESTINAL Thirst Nausea Vomiting Hematemesis Heartburn Flatulence Constipation Difficulty Swallowing Abdominal Pain Jaundice Diarrhea Tarry Stool Hemorrhoids Hernia Other: No other problems 4. GENITO-URINARY Dysuria Polyuria Frequency Urgency Nocturia Burning Hematuria Stones a. Female Genital Tract Menstrual History: Age of onset Frequency Regulation Duration Date of last period Post-menopausal bleeding Age Symptoms G P Ab Male Genital Tract Penile discharges Lesions Pain Testicular swelling Other: Possibility of STD Last Serology Test: Not Performed 3. MUSCULO-SKELETAL Muscle pain Extremity pain Joint pain Back pain Joint swelling Neck pain Stiffness Limited motion Redness Sprains Deformity Others: No other problems. X-rays: Not taken. 4. NERVOUS Convulsions Syncope Dizziness Vertigo Tremor Speech difficulty Limb paralysis Paresthesia Muscle Atrophy EEG: Not taken. X-ray: Not taken. Others: None 5. ENDOCRINE Goiter Tremor Heat or Cold intolerance

b. c.

49 Exopthalmus Voice change Change in body contour Polydipsia Infertility Other: No problems noted 6. EMOTIONAL Anxiety Depression Fear Anger Frustration Other: None noted. Nursing Observation 1. HEENT a. Symmetry: Head is normocephalic and symmetrical; no obvious deformities. b. Eyes and Pupils: Icteric sclera; symmetrical; normal visual acuity; no deformities. c. Ears: Positioned proportionally with the head; no obvious lesions and deformities. d. Mouth and Throat: Dry and pale mouth; no lesions noted; symmetrical appearance. e. Lymph nodes: No inflammation noted. 2. RESPIRATORY Depth and Rate: Slightly exaggerated breathing; slight tachypnea at 29CPM. Breath Sounds: Some abnormal breath sounds noted on auscultation Chest expansion: Symmetrical chest expansion noted. 3. CARDIO- VASCULAR Blood Pressure (R): 110/60 mmHg (L): 110/60 mmHG Lying: 110/60 mmHg Standing: 110/60 mmHg Apical pulse rate and regularity: 127 BPM, moderately fast; regular Pedal pulses rate per minute (R): 120 BPM (L): 120 BPM Neck vein distension: No neck vein distention noted. 4. CHEST Anterior chest: Wound dressing noted on upper outer left thorax Posterior chest: Not assessed, CBR status. Breasts Breasts and Axillae: No lesions noted on breasts and axillae Anterior Thorax: Wound dressing noted on upper outer thorax. Posterior Thorax: Not assessed, CBR status. 5. GASTRO-INTESTINAL Bowel Sounds: 20x per minute, intermittent gurgling sounds auscultated. Tenderness or rigidity: Some tenderness or rigidity reported on umbilical area. 6. URINARY Bladder: Not palpable; urine amber in color and in moderate amounts. 7. SKELETAL Joints: No inflammation and deformitie sobserved. Range of Motions: Slight limitation of range of motion on extremities noted due to edematous state. 8. NEURO a. Motor Function 1. Facial: Can move facial muscles without difficulty. 2. Extremities: Slight limitation with range of motion. b. Sensory Function (equal or not equal): Equal, symmetrical function. c. Equilibrium 1. Balance: Not assessed, CBR status. 2. Finger to nose: Not performed, painful when moving upper limbs.

a. b. c. a. b. c. d. a. b. c. 1. 2. 3. a. b. a. a. b.

50 d. Reflexes (equal or not equal) 1. Knees: Equal Reflexes Arms: Equal Reflexes 9. CRANIAL NERVE FUNCTION a. Olfactory nerve: (sensory) 1. Sense of smell (coffee, vanilla. Etc.) 1.1 Anosmia/Hyperosmia: Can smell any given scent without difficulty. b. Optic nerve: (sensory) 1. Sense of vision (Snellens chart, newspaper) 1.1 Myopia/Hyperopia : No problem with visual acuity; patient can clearly read some written texts but reports of blurring sometimes. c. Oculomotor: (motor) 1. Extra-ocular movements/ Pupil reaction to light 1.1 Right eye/Left eye: Can look through the six cardinal fields of gaze without difficulty; elevates eyelids; PERRLA noted. d. Trochlear: (motor) 1. Assess direction of gaze, upward and downward movement of eyeball: Can look through the six cardinal fields of gaze without difficulty. e. Trigeminal: (motor) Presence of corneal reflexes 1.1 Right eye Left eye: Positive; bilateral blinking of both eyes noted. 2. Ability to clench teeth: Able to clench teeth without difficulty. f. Abducens: (motor) 1. Assess direction of gaze, lateral movements of the eyeballs 1.1 Right eye/Left eye: Moves without difficulty. g. Facial: (Sensory and motor) 1. Sense of taste: Using back of tongue 1.1 Salty/Sweet: Can differentiate and identify both tastes easily. 2. Facial Expression 2.1 Smile/Puff out cheeks/Frown/Raise lower eyebrows: Can perform expressions without difficulty. h. Auditory nerve: (motor) 1. Sense of hearing 1.1 Right ear/Left ear: Can hear normally. i. Glossopharyngeal: (Sensory and motor) 1. Sense of taste: Using back of tongue 1.1 Salty/Sweet: Can differentiate and identify both tastes easily. 2. Ability to swallow (Use tongue blade to elicit gag reflex): j. Vagus: (Sensory and motor) 1. Hoarseness of voice: No hoarseness of voice noted. 2. Sensation of pharynx: Palate moves concomitantly when patient says ah. Let patient say ah and observe movement of palate and pharynx k. Spinal accessory: (motor) Movement of: 1.1 Head /Shoulder: Can move head and shrug shoulders but with slight difficulty. l. Hypoglossal: (motor)

1.

1.

51 1. Able to stick tongue to midline: Can stick tongue to midline without difficulty. 10. EMOTIONAL Communication: Responds to questions carefully and correctly. Mood/ Effect: Appropriate with situation even if slightly weak. Behavior: Responds accordingly and appropriately. B. Knowledge of Illness Learning Limitations: Patient and significant others dont understand the complexity of the patients condition and the possibility of complications and communication. Learning Needs: Importance of infection control and on the maintenance of proper hygiene; basic understanding of patients present condition. C. Nursing Impressions: A case of CRB, 27 Y.O. from Lahug, Cebu City admitted at VSMMC for the chief complaint of mass on right upper outer chest who was operated on june 26, 2011. Patient is suspected of having Hepatitis B and pulmonary tuberculosis as indicated by initial physical assessment and presenting signs and symptoms. Patient is brought to Ward X for co-managed care. D. Nursing Problems (in priority) 1. Impaired Gas Exchange related to Altered Pulmonary Physiology secondary to Progression of Tubercular Disease 2. Ineffective Airway Clearance related to Increased Secretions secondary to Progression of Tubercular Disease 3. Fatigue related to Poor Tissue Oxygenation and Increased Metabolism secondary to Progression of Tubercular Disease 4. Imbalanced Nutrition Less than Body Requirements related to Lack of Interest in Food 5. Knowledge Deficit (Drug Regimen) related to Lack of Exposure and Information Misinterpretation E. Discharge Planning 1. Probable Date: July 09, 2011 2. Destination: Lahug, Cebu City 3. Transportation: Public Utility Vehicle 4. Agencies and Equipment involved: VSMMC Out Patient Department 5. Diet: High in protein, carbohydrates and rich in vitamins for faster wound healing. 6. Medications: Provide health teaching and proper endorsements for take home medications. 7. Persons responsible for patient: Patients immediate famly. 8. Family conference: Necessary to coordinate care of client. 9. Anticipated problems: Risk for aggravated condition and infection. 10. Home visit: Vital if complications occur, can visit local health center.

a. b. c. 1. 2.

Rating scale 5 4 3 2 1

= = = = =

when the item gives much more than what is expected when the item gives more than what is expected when the item gives what is expected when the item gives less than what is expected when the item gives much less than what is expected

52

Signature of Student

Signature of Clinical Instructor