Post on 02-Dec-2014
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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
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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%). Among those confirmed to have the
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.
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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 patient’s 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.
Patient’s 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.
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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.
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Chapter II
PATIENT’S PROFILE
The following are the pertinent data about the patient’s personal
information and medical history.
Patient’s 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.
Patient’s mother was concerned because of the accompanying fatigue and
sudden weight loss. Drenching night sweats and low-grade afternoon fever were
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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 patient’s mother could not recall whether the vaccination
was given. Patient’s 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
patient’s 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
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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 patient’s 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. Patient’s
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
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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 patient’s 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.
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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
filters 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 (fine hairs). The nose
serves as a passageway for air to pass to and from the lungs. It filters impurities
and humidifies 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
flowing through them. Air entering the nostrils is deflected 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:
Epiglottis—a valve flap of cartilage that covers the opening to the larynx
during swallowing
Glottis—the opening between the vocal cords in the larynx
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Thyroid cartilage—the largest of the cartilage structures; part of it forms
the Adam’s apple
Cricoid cartilage—the only complete cartilaginous ring in the larynx
(located below the thyroid cartilage)
Arytenoid cartilages—used in vocal cord movement with the thyroid
cartilage
Vocal cords—ligaments 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 firmness 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 floor, 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 inflates 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 first 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 fluid 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 five segments separated by fissures, 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 identified 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 meters—the 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 fluid. 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 direction—from 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 flows 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 flow in and out of the lungs are
collectively referred to as the mechanics of ventilation and include air pressure
variances, resistance to air flow, and lung compliance.
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Chapter IV
PSYCHOPATHOPHYSIOLOGY AND PSYCHODYNAMICS
Schematic Diagram
Figure 1. Psychopathophysiology of Pulmonary Tuberculosis.
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
Inflammation develops
Phagocytes engulf many bacteria and TB-specific lymphocytes destroy the bacilli and normal tissue
Granulomatous
Macrophages surround the granulomatous
formation
Impaired oxygenation and increased
metabolism
Reinfection and activation of dormant bacteria
Release of cheesy material into the bronchi
Collagenous scar formation
Bacteria becomes dormant
Necrotizes and forms a cheesy mass and becomes
calcifies
Formation of fibrous tissue mass
Altered pulmonary physiology
Fatigue
Anorexia
Irritating cough
Mucupurulent sputum
production
Fever and Night sweats
Weight loss
Inflammation develops again resulting in further development of bronchopneumonia
and tubercle formation
Systemic Inflammatory
Blood-streaked sputum
(Hemoptysis
Irritation of the lung parenchyma plus rupture of
Ghon’s tubercles
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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 body’s 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). Cell-
mediated 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 fibrous 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 calcified 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 inflamed, 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, chest-
x-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 patient’s 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 scanning—sometimes called CAT scanning—is 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 x-
ray 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) Patient’s Results Clinical Significance
Negative for AFB Positive for AFB 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) Patient’s Results Clinical Significance
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Normal lung fields, cardiac
size, mediastinal
structures, and thoracic
spine; no masses,
infiltrates, areas of
collapse, pleural effusion,
fractures of clavicles or
ribs, or abnormal elevation
or flattening of the
diaphragm
Caseations and
inflammation are seen on
the X-ray; fibronodular
shadowing noted in both
apices of the lungs;
cavitation noted which
revealed necrosis and
sloughing of lung tissue
Reveals active
Pulmonary
Tuberculosis
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) Patient’s Results Clinical Significance
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Negative response or
minimal response, with no
exposure to tuberculosis
Tine test: Less than 2
mm or absence of
induration around one
or more of the
punctures in 48–72 hr
Mantoux test: Less than
5 mm or absence of
induration and erythema
in 24–72 hr
Mantoux test: 8 cm
induration after 32 hours
noted
Reveals exposure to
Mycobacterium
Tuberculosis bacteria
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.
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For the patient’s 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:
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).
28
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).
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
29
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. Patient’s
actual indication is for the alleviation of his generalized edema (Venable, 2008).
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 patient’s
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
30
“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.
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
31
these are indicators of the efficiency of gas exchange. Patient’s 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).
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, blood-
streaked 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
32
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
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 patient’s needs with attention to the patient’s 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
33
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.
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
34
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).
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 patient’s 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.
35
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-
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 patient’s deficit area and specific to the patient’s level of education. Include
significant others in teaching sessions. Explain each procedure as it is being
36
done, and give the rationale for procedure and the patient’s role. Provide positive
reinforcement as often as possible for the patient’s 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
are taken care of before and immediately after teaching sessions. Pace teaching
according to the patient’s 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
37
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.
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
38
Bag catheter attached to UroBag draining moderate amounts of amber colored
urine, dyspnea, tachycardia, hypercapnia, restlessness, hypoxia, irritability,
confusion and hypoxemia.
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 non-
productive 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
39
Assessment: Readiness for Enhanced Therapeutic Regimen Management
related to Active Seeking Behavior to Improve Health
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 patient’s 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,
40
the edema and other physical symptoms were all alleviated because of the
religious adherence to the therapeutic regimen. The patient demonstrated
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 client’s 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.
Patient’s 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 patient’s ability to continue therapy at home. Infection control
41
procedures must also be instructed to prevent communication of the disease at
the patient’s immediate environment upon discharge.
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 patient’s 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
42
management of Pulmonary Tuberculosis since new medical discoveries
are available that increase the enhancement of prognosis of their clients.
Bibliography
1. Bennett and Plum. 1996. Cecil Textbook of Medicine, 20th Edition.
Philadelphia: W.B. Saunders Company.
2. Cavanaugh, B.M. 2003. Nurse’s Manual of Laboratory and Diagnostic
Tests, 4th Edition. Philadelphia: Elsevier Saunders.
43
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.
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. Cox’s 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 Suddarth’s Textbook of Medical-
Surgical 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 Lippincott Manual of Nursing Practice, 5th
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16.Venable, S. 2008. Nurse’s Drug Guide. Philadelphia: LWW.
44
45
APPENDICES
Appendix A
Cebu Normal University
College of Nursing
APPROVAL FOR CASE STUDY
46
Name of Student: Edward Arlu Villamor Dinoy Year and Section: IV – D
Semester: First Semester Academic Year: 2011 - 2012
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 XName of Clinical Ins.: Ragay, Alain Kenneth Inclusive Dates: Jun 27-Jul 01, 2011
A. General Admission InformationName of Patient: CBR Age: 27 Y.O. Sex: MDate: June 27, 2011 Time: 08:00 AM Mode: On Stretcher Allergies: None Known
47
TPR: 36.8 C/127 BPM/27CPM BP: 110/60 mmHg HT: 5’3” WT: 55kg Diet: DATSleeping Habits: Sleeps very late at night and wakes up early in the morning
CBC: Yes No Urinalysis: Yes NoProperty: Glasses(X) Contact Lenses(X) Dentures (X)
Prosthesis(X) Ring(X) Watch(X) Money(X) Other: Cellphone/Mobile PhoneValuable to Business Office: None
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 appearanceBehavior 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 interactionContent 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 Interview1. Patient’s 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. Patient’s 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.)a. Medical: No previous history of hospitalizationb. Surgical: No previous history of hospitalizationc. Allergies: No known food and drug allergiesd. Medication: Essentialis 1 tab three times a daye. Traumatic Injuries: No history of any traumatic injuriesf. Orthopedic: No history of any orthopedic injuriesg. Other (psychiatric, etc.): No other significant past medical history
2. Habitsa. Smoking: 15-20 sticks a day Alcohol: Binge Drinker Drugs: Confirmedb. Eating: irregular and variable pattern; depends on what’s availablec. Social Activity: “Tambay ra ko” Physical Exercise: 3x/week w/ weightsd. Rest/ Sleeping: Usually sleeps by 3-4 AM and wakes up as early as 7:00
AM. He usually stays outside with his friends.e. Sexual: Active; started while he was 21 Y.O. has a history of using one of
the Junquera Girls f. Elimination: Daily but timing varies; usually in the morning.
3. Social Economic Historya. Native Language: Cebuano-Bisayab. Education: High-school graduate at Lahug Night High School (2006);
Vocational Course at Sacred Heart (2007-2010)
48
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 _______
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 Physician’s 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 EpistaxisSinus pain Facial pain Bleeding gums Dentures Sore throat Nasal-tracheal pain Other: No other problems
2. CARDIO-RESPIRATORY: Chest pain (site): Upper LeftChest pain with exertion Dyspnea on exertion Nocturnal dyspnea Edema Palpation Hypertension
Known murmur Cough Sputum HemoptysisPleuritic Pain DiaphoresisLast X-ray: Results not yet available EKG: No abnormal findings.
3. GASTRO-INTESTINAL Thirst Nausea Vomiting HematemesisHeartburn Flatulence Constipation Difficulty SwallowingAbdominal Pain Jaundice Diarrhea Tarry StoolHemorrhoids Hernia Other: No other problems
4. GENITO-URINARYDysuria Polyuria Frequency UrgencyNocturia Burning Hematuria Stonesa. Female Genital Tract – Menstrual History: Age of onset
Frequency Regulation Duration Date of last period Post-menopausal bleedingAge Symptoms
b. G P Abc. Male Genital Tract Penile discharges Lesions
Pain Testicular swellingOther: Possibility of STDLast Serology Test: Not Performed
3. MUSCULO-SKELETALMuscle pain Extremity pain Joint pain Back painJoint swelling Neck pain Stiffness Limited motionRedness Sprains DeformityOthers: No other problems.X-rays: Not taken.
4. NERVOUS
49
Convulsions Syncope Dizziness VertigoTremor Speech difficulty Limb paralysis ParesthesiaMuscle Atrophy EEG: Not taken. X-ray: Not taken. Others: None
5. ENDOCRINEGoiter Tremor Heat or Cold intoleranceExopthalmus Voice change Change in body contour Polydipsia Infertility Other: No problems noted
6. EMOTIONALAnxiety Depression FearAnger Frustration Other: None noted.Nursing Observation
1. HEENTa. 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. RESPIRATORYa. Depth and Rate: Slightly exaggerated breathing; slight tachypnea at
29CPM. b. Breath Sounds: Some abnormal breath sounds noted on auscultationc. Chest expansion: Symmetrical chest expansion noted.
3. CARDIO- VASCULARa. Blood Pressure (R): 110/60 mmHg (L): 110/60 mmHG
Lying: 110/60 mmHg Standing: 110/60 mmHgb. Apical pulse rate and regularity: 127 BPM, moderately fast; regularc. Pedal pulses rate per minute (R): 120 BPM (L): 120 BPMd. Neck vein distension: No neck vein distention noted.
4. CHESTa. Anterior chest: Wound dressing noted on upper outer left thoraxb. Posterior chest: Not assessed, CBR status.c. Breasts
1. Breasts and Axillae: No lesions noted on breasts and axillae2. Anterior Thorax: Wound dressing noted on upper outer thorax.3. Posterior Thorax: Not assessed, CBR status.
5. GASTRO-INTESTINALa. Bowel Sounds: 20x per minute, intermittent gurgling sounds auscultated.b. Tenderness or rigidity: Some tenderness or rigidity reported on
umbilical area.6. URINARY
a. Bladder: Not palpable; urine amber in color and in moderate amounts.7. SKELETAL
a. Joints: No inflammation and deformitie sobserved.b. Range of Motions: Slight limitation of range of motion on extremities
noted due to edematous state.8. NEURO
a. Motor Function
50
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.
d. Reflexes (equal or not equal)1. Knees: Equal Reflexes Arms: Equal Reflexes
9. CRANIAL NERVE FUNCTIONa. 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 (Snellen’s 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)
1. Presence of corneal reflexes1.1 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 eyeballs1.1 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 tongue1.1 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
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k. Spinal accessory: (motor)1. Movement of:
1.1 Head /Shoulder: Can move head and shrug shoulders but with slight difficulty.
l. Hypoglossal: (motor)1. Able to stick tongue to midline: Can stick tongue to midline without
difficulty.10. EMOTIONAL
a. Communication: Responds to questions carefully and correctly. b. Mood/ Effect: Appropriate with situation even if slightly weak.c. Behavior: Responds accordingly and appropriately.
B. Knowledge of Illness1. Learning Limitations: Patient and significant others don’t understand the
complexity of the patient’s condition and the possibility of complications and communication.
2. Learning Needs: Importance of infection control and on the maintenance of proper hygiene; basic understanding of patient’s 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 Disease2. Ineffective Airway Clearance related to Increased Secretions secondary to
Progression of Tubercular Disease3. Fatigue related to Poor Tissue Oxygenation and Increased Metabolism
secondary to Progression of Tubercular Disease4. Imbalanced Nutrition Less than Body Requirements related to Lack of
Interest in Food5. Knowledge Deficit (Drug Regimen) related to Lack of Exposure and
Information MisinterpretationE. Discharge Planning
1. Probable Date: July 09, 20112. Destination: Lahug, Cebu City3. Transportation: Public Utility Vehicle4. Agencies and Equipment involved: VSMMC Out Patient Department5. 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: Patient’s 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.
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Rating scale 5 = when the item gives much more than what is expected 4 = when the item gives more than what is expected 3 = when the item gives what is expected 2 = when the item gives less than what is expected 1 = when the item gives much less than what is expected
Signature of Student Signature of Clinical Instructor