compilation of grand case

8/8/2019 compilation of grand case

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Introduction

As it was written and said by the many, disease and illness have plagued

human race since ancient time. Through years, people were full of queries and

speculations that why some individuals become sick physically weak while

other remain healthy. Why a condition turns out to a severe one? Why an organ

complicates another at a later time? From that, people became more curious on

how it can affect the body and how it can be cured.

Various disease and illness exist nowadays, just like on this case that the

researchers studied. Through its complexity they were puzzled on, how can

these bacteria affects the body? What manifestation and complications may

arise? This brings their attention to focus. From this study, they can then fully

understand the cause, its schematic flow and how it can alter a persons body.

Pulmonary Tuberculosis, a chronic sub-acute or acute respiratory disease

commonly affecting the lungs characterized by the formation of tubercles in the

tissue which tend to undergo cessation, necrosis and calcification. It is also

known as a poor mans disease or consumption disease. The causative agent in

this disease is Mycobacterium tuberculosis, a rod shaped bacteria that has

plagued humans since the Neolithic times. The bacteria usually attack the lungs,but they can also damage other parts of the body. TB spreads through the air

when a person with TB on the lungs or throat coughs, sneezes or talks.

If left untreated, each person with active TB disease will infect an average

of 10 to 15 people every year. But people infected with TB bacilli will not

necessarily become sick, only if the immune system " walls off " the TB bacilli

which, protected by a thick waxy coat, can lie dormant for years. When the

immune system is weakened, the chances of becoming sick are greater.

Global and Regional Incidence

Tuberculosis continues to be a major health problem worldwide. In 2008,

the World Health Organization (WHO) estimated that the largest number of new

TB cases occurred in the South-East Asia Region, which accounted for 35% of

incident cases globally. However, the estimated incidence rate in sub-Saharan

Africa is nearly twice that of the South-East Asia Region with over 350 cases per

100, 000 populations.

An estimated 1.7 million people died from TB in 2009. The highest number

of deaths was in the Africa Region. More than 90% of TB cases occur in

developing nations that have poor hygiene and health-care resources, and high

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numbers of people infected with HIV. The highest case rates occur in non-white

males over 30 years of age and non-white females over 60.

National and Regional Incidence

TB is one of the top 10 leading cause of morbidity and mortality rates in

the country. In 2007, the Philippines recorded over 86,000 TB cases based on

the 2009 World Health Organization Report but the trend is increasing as for this

year, it is estimated that 133 people out of 100, 000 population has TB.

Cebu, Philippines - has the highest number of cases of tuberculosis in the

region while Central Visayas is included in the top 10 regions nationwide with the

highest incidence rate of TB cases.

The Philippines ranks 9th worldwide in the incidence of the ordinary TB

disease which can easily be treated. And remember, a new infection occurs

every second.

Risk Factors for TB:

Low socioeconomic status

Homelessness Alcoholism

HIV patient

Weakened immune system

Crowded living conditions

Person who frequently travel to place with high incidence rate

Health-care workers

Ethical Consideration

Oral informed consent was obtained from the patient and her significant

others for the case discussion and physical assessment. The study was

approved by the Clinical Instructor and the staff of CUMC Station 4.

Study Design and Data Collection

Interview was conducted and answered by the patient and her significant

others.

Rationale for Choosing the Case

The researchers decided to choose this case because they wanted to:

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Acquire more knowledge about Pulmonary Tuberculosis.

Know the factors why and how the patient was affected by PTB.

Use the acquired knowledge in promoting awareness to the people (to

seek for medical care in order to prevent the progression of the disease).

Significance of the Study

This study will help the nursing profession by providing information about

the proper management and care for PTB patient. It will also educate the people

to seek medical care in order to prevent PTB.

It will increase awareness about the importance of having a healthy

lifestyle and clean environment. And will also elaborate the inter relatedness of

lifestyle habits, environment and acquiring Pulmonary Tuberculosis.

Objectives

After the completion of this study, the researchers will have been able to:

Perform the thorough assessment and implementation of care to a PTB

patient.

Review the background of the disease and the signs and symptoms.

Reassess the risk factors, the diagnostic procedures and the needed

medical treatment.

Formulate nursing care plan based on the nursing process.

Perform the needed nursing care and intervention to better the health of

the patient.

Provide information about the disease: occurrence and contributing

factors.

Give health teachings and the importance of family involvement to better

the health of the patient.

Scope and Limitations of the Study

This study is focused on the nursing aspect of care to those patients who

have Pulmonary Tuberculosis. This study will only be used in the nursing

profession.

The researchers only focused their attention on medications, diagnostics,

nursing care plan, pathophysiology and discharge planning.

This study is not limited to PTB patients only, but it is also for all people

who are interested in PTB. We are more focused on primary preventions through

health teachings because primary prevention is the true prevention.

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Authors Contributions

The group did their interview and physical assessment last January 04,

2011. Discussion and interpolations was raised. Each of the authors was given

assignments and submitted their drafts. And final brain-storming was

scheduled.

Conceptual Frameworks

This study is anchored on these following theories:

Abraham Maslow's Hierarchy of Needs

Maslow's hierarchy of needs is often portrayed in the shape of a pyramid,

with the largest and most fundamental levels of needs at the bottom, and the

need forself-actualization at the top.

Florence Nightingales Environmental Theory

The act of utilizing the environment of the patient to assist in his recovery

Focuses on changing and manipulating the environment in order to put the

patient in the best possible conditions for nature to act. Identified 5 environmentalfactors: fresh air, pure water, efficient drainage, cleanliness/sanitation and

light/direct sunlight. Considered a clean, well-ventilated, quiet environment

essential for recovery.

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http://en.wikipedia.org/wiki/Self-actualizationhttp://en.wikipedia.org/wiki/Self-actualization


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Deficiencies in these 5 factors produce illness or lack of health, but with a

nurturing environment, the body could repair itself.

SITUATION

Man needs care, has capacity to

mend

Health altered condition

Environment inefficient drainage,

poor sanitation

Nursing holistic approach

ACTION

- Attended physiologic needs (e.g.

supplement air, adequate water,

etc.)

- Medication regimen

- Provided with clean, quiet and well

ventilated environment

- Nursing care and intervention

This model will help the researchers to compare and contrast their

findings based on the patients condition and how those needs being attended.

Conclusion

Findings from our study indicate that knowledge and awareness of PTB

are still unsatisfactory in Filipino population.

Gender issues should be considered in promoting patients' health-care.

Results of this study are derived from Patient X, but could be discussed also in

relation to other similar condition.

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Clients Profile

A. Demographic Data

This is a case of Patient X, a 17-year-old single female and a Roman Catholic

affiliate residing at Opol, Misamis Oriental. Admitted at Capitol University Medical

City last January 2, 2011 at 5:30pm Station 4; room 421.

B. Vital Signs

The client has the following vital signs and physical exam during the series of

Vital Signs E.R. Admission

assessment

1st week of

assessment

2nd week of

assessment

Blood Pressure

(lying)

150/60 mmHg 100/60 mmHg 100/70 mmHg

Respiratory rate 37cpm 36cpm 34cpm

Pulse rate 120bpm 108bpm 102bpm

Temperature

(Axillary)

37.5 C 39.6 C 36.5 C

O2 saturation 92% 98% 99%

C. Health Perception Assessment:

1. Health Perception and Health Management (Pertinent Clinical History

and Physical examination, Chief complaint, History of Present Illness,

Previous Hospitalization/ Surgeries, other health problems and things done to

manage health)

Chief complaint:

Cough/Fever

History of present illness:

Condition started since 4 months prior to admission as onset ofhard and

productive cough with yellowish phlegm, no shortness of breath, sought

consultation at community health center and sputum test was done. A result of

negative PTB and was given a medication (unremembered brand) for cough,

regimen was not completed due to financial stability and the condition was

getting well.

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Mouth:

Patients lips and gums was pale, tongue is midline with complete teeth.

Pharynx:

Tonsils are not inflamed.

Neck:

Trachea is midline.

Skin:

General color of the patient is pale, with rough texture, with poor skin

turgor, and temperature was warm.

Week 2 (January 11, 2011)

The patient takes in 5-6 glasses of water a day. The client eats 3 meals in

a day with fair appetite and a combination of 1 cup of rice with different viand,

served with DAT with strict aspiration precaution. Upon assessment, the client

had pale skin and body nourishment was maintained. She has an ongoing

intravenous fluid of PLR1L regulated at 20gtts/min, infusing well at the left arm.

Mouth:Patients lips, gums and mucosa were pale; tongue is midline with

complete teeth.

Pharynx:

Tonsils are not inflamed.

Neck:

Trachea is midline.

Skin:

General color of the patient is pallor, still with rough texture, with poor skin

turgorand temperature on normal range.

3. ELIMINATION PATTERN


Patient X has a normal elimination pattern. She defecates once a day or

every other day with moderate amount, formed light brown in color. No

discomforts in the usual bowel pattern.

There was no problem in control upon urination. She urinates 4-5 times a

day with yellowish colored urine for about 150 200cc per urination.


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This week the patient defecated 4 times per week with soft brown stool in

moderate amount. No discomforts in the usual bowel pattern.

There was no problem in control upon urination. She urinates 3-5 times a

day with yellowish colored urine for about 150 200cc per urination.

4. ACTIVITY AND EXERCISE PATTERN


According to the SO the patient has a sedentary lifestyle, her leisure

activities include watching television and listening to music.

Cardiovascular Status:

There was no signs of chest pain, point of maximal impulse best

appreciated at 5th ICS left midclavicular line, heart sounds were distinct and

regular in intervals. Peripheral pulses were symmetrical with Capillary refill time

of 2 seconds.

Respiratory Status:

Breathing Pattern is irregular with 31 cycles per minute, asymmetrical lung

expansion at right lung field; rales at right lung field are heard upon auscultation,with productive cough, plenty of yellowish sputum. The patient is on Oxygen

inhalation regulated at 2 LMP via nasal cannula.

Activities of daily living:

The patient is in assist with person to Feeding, bathing, dressing,

grooming, meal preparations, cleaning, laundry, toileting, bed mobility, chair/toilet

transfer, ambulation and in active-passive R.O.M. The reasons for ADL/mobility

limitations are due to weakness in the lower extremities as well as due to IVF line

connected to the patient.


Cardiovascular Status:

There was no signs of chest pain, point of maximal impulse best

appreciated at 5th ICS left midclavicular line, heart sounds were distinct and

regular in intervals. Peripheral pulses were symmetrical with Capillary refill time

of 2 seconds.

Respiratory Status:

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Breathing Pattern is irregularwith 34 cycles per minute, asymmetrical lung

expansion at right lung field, rales are minimally heard upon auscultation, with

less productive cough of yellowish sputum. Oxygen inhalation was removed.

Activities of daily living:

The patient is in assist with person to Feeding, bathing, dressing,

grooming, meal preparations, cleaning, laundry, toileting, bed mobility, chair/toilet

transfer, ambulation and in active-passive R.O.M. The reasons for ADL/mobility

limitations are due to weakness in the lower extremities as well as due to IVF line

connected to the patient.

5. COGNITIVE- PERCEPTUAL PATTERN


The client was conscious and oriented to time/person/place. The patients

capillary refill is 2-3 seconds.

The client was calm and relaxed. The clients primary language is Bisaya

and she dropped out of school during her 1st year in high school due to illness.

Week 2 (January 11, 2011)The client was conscious and oriented to time/person/place. The patients

capillary refill is 2 seconds.

The client was calm in emotional state. The clients primary language is

Bisaya and she dropped out of school during her 1st year in high school due to

illness.

6. SLEEP-REST PATTERN


When she was not yet admitted, her usual sleep/rest pattern was 6-8hours

a day. The longest time for her to rest is eight hours. And now that she is sick,

she normally rest for about 4-6hours which is inadequate on her body needs as

verbalized by the patient. Relieving the cough with medication as prescribed and

providing calm environment was one of the ways to make the patient rest.


There was already an improvement of the clients sleep and rest pattern

patient can sleep for 6-8 hours according to the SO. Relieving the cough with

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medication as prescribed and providing calm environment was one of the ways

to make the patient rest.

7. SELF- PERCEPTION AND SELF-CONCEPT PATTERN


Luyahan ug kapoi pud, as patient described herself was worried with her

conditio . The patient feels the she reduced weight since illness/ hospitalization.

The clients non-verbal actions showed minimal self expression.


Okay, raman ako pamati, as verbalized the patient. The patient feels

good and positive that she will be well. The Clients non-verbal behavior showed

that she was eager to participate in achieving health goals.

8. SEXUALITY REPRODUCTIVE PATTERN

Week 1 and Week 2 (January 4&11, 2011)

The patient has irregular menstrual pattern. Her Last Menstrual Period

(LMP) was October 2010, 2 months delayed. No history of birth control use. No

monthly self breast exam. Breasts are bilaterally equal; surfaces are smooth withno lesions, tenderness and masses.

9. COPING-STRESS TOLERANCE PATTERN


The financial difficulty was one of the clients stresses other than her

illness.


The financial difficulty was one of the clients stressors other than her

illness. She usually managed stress by doing diversional activities such as

watching TV and listening to music. She finds time with herself in her room to

relax and rest. She uses her family and friends as her support groups and they

are very helpful emotionally.

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11. VALUE-BELIEF PATTTERN


The client is a Roman Catholic affiliate; believes that faith and miracle was

very vital in her life. Hospitalization does not interfere, visit prayer meeting was

done.


The client is a Roman Catholic; hospitalization would not interfere in any

medical intervention.


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Anatomy and Physiology

UPPER RESPIRATORY TRACT

Respiration is defined in two ways. In common usage, respiration refers to

the act of breathing, or inhaling and exhaling. Biologically speaking, respiration

strictly means the uptake of oxygen by an organism, its use in the tissues, and

the release of carbon dioxide. By either definition, respiration has two main

functions: to supply the cells of the body with the oxygen needed for metabolism

and to remove carbon dioxide formed as a waste product from metabolism. This

lesson describes the components of the upper respiratory tract.

The upper respiratory tract conducts air from outside the body to the lower

respiratory tract and helps protect the body from irritating substances. The upper

respiratory tract consists of the following structures:

The nasal cavity, the mouth, the pharynx, the epiglottis, the larynx, and the

upper trachea. The oesophagus leads to the digestive tract.

One of the features of both the upper and lower respiratory tracts is themucociliary apparatus that protects the airways from irritating substances, and is

composed of the ciliated cells and mucus-producing glands in the nasal

epithelium. The glands produce a layer of mucus that traps unwanted particles as
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they are inhaled. These are swept toward the posterior pharynx, from where they

are swallowed, spat out, sneezed, or blown out.

Air passes through each of the structures of the upper respiratory tract on

its way to the lower respiratory tract. When a person at rest inhales, air enters via

the nose and mouth. The nasal cavity filters, warms, and humidifies air. The

pharynx or throat is a tube like structure that connects the back of the nasal

cavity and mouth to the larynx, a passageway for air, and the esophagus, a

passageway for food. The pharynx serves as a common hallway for the

respiratory and digestive tracts, allowing both air and food to pass through before

entering the appropriate passageways.

The pharynx contains a specialized flap-like structure called the epiglottis

that lowers over the larynx to prevent the inhalation of food and liquid into the

lower respiratory tract.

The larynx, or voice box, is a unique structure that contains the vocal

cords, which are essential for human speech. Small and triangular in shape, the

larynx extends from the epiglottis to the trachea. The larynx helps control

movement of the epiglottis. In addition, the larynx has specialized muscular foldsthat close it off and also prevent food, foreign objects, and secretions such as

saliva from entering the lower respiratory tract.

The larynx, or voice box, is a unique structure that contains the vocal

cords, which are essential for human speech. Small and triangular in shape, the

larynx extends from the epiglottis to the trachea. The larynx helps control

movement of the epiglottis. In addition, the larynx has specialised muscular folds

that close it off and also prevent food, foreign objects, and secretions such as

saliva from entering the lower respiratory tract.

LOWER RESPIRATORY TRACT

The lower respiratory tract begins with the trachea, which is just below the

larynx. The trachea, or windpipe, is a hollow, flexible, but sturdy air tube that

contains C-shaped cartilage in its walls. The inner portion of the trachea is called

the lumen.

The first branching point of the respiratory tree occurs at the lower end of

the trachea, which divides into two larger airways of the lower respiratory tract

called the right bronchus and left bronchus. The wall of each bronchus contains


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substantial amounts of cartilage that help keep the airway open. Each bronchus

enters a lung at a site called the hilum. The bronchi branch sequentially into

secondary bronchi and tertiary bronchi.

The tertiary bronchi branch into the bronchioles. The bronchioles branch

several times until they arrive at the terminal bronchioles, each of which

subsequently branches into two or more respiratory bronchioles.

The respiratory bronchiole leads into alveolar ducts and alveoli. The

alveoli are bubble-like, elastic, thin-walled structures that are responsible for the

lungs most vital function: the exchange of oxygen and carbon dioxide.

Each structure of the lower respiratory tract, beginning with the trachea,

divides into smaller branches. This branching pattern occurs multiple times,

creating multiple branches. In this way, the lower respiratory tract resembles an

upside-down tree that begins with one trachea trunk and ends with more than

250 million alveoli leaves. Because of this resemblance, the lower respiratory

tract is often referred to as the respiratory tree.

THE LUNGS

The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity.

There are two lungs that occupy a significant portion of this cavity.
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The diaphragm is a broad, dome-shaped muscle that separates the

thoracic and abdominal cavities and generates most of the work of breathing.

The inter-costal muscles, located between the ribs, also aid in respiration. The

internal intercostal muscles lie close to the lungs and are covered by the external

intercostal muscles.

The lungs are cone-shaped organs that are soft, spongy and normally

pink. The lungs cannot expand or contract on their own, but their softness allows

them to change shape in response to breathing. The lungs rely on expansion and

contraction of the thoracic cavity to actually generate inhalation and exhalation.

This process requires contraction of the diaphragm.

To facilitate the movements associated with respiration, each lung is

enclosed by the pleura, a membrane consisting of two layers, the parietal pleura

and the visceral pleura.

The parietal pleura comprise the outer layer and are attached to the chest

wall. The visceral pleura are directly attached to the outer surface of each lung.

The two pleural layers are separated by a normally tiny space called the pleural

cavity. A thin film of serous or watery fluid called pleural fluid lines and lubricatesthe pleural cavity. This fluid prevents friction and holds the pleural surfaces

together during inhalation and exhalation.


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I. Pathophysiology

Mycobacterium Tuberculosis

Small airborne

Droplet spread

Subsequentphagocytosis by

macrophages

Predisposing factors:

Age

Heredity

Precipitating factors:

Repeated contact

with infected

persons

Part of low

income

population(lack

of medical care)

Low Body

weight (37 kg)

Environment

Infectious droplet settle throughout

airways and majority are trapped in

the upper parts of the airway

Successful control of

infection

Bacterial cell

division still

Inhallation

of particles

Progression of active

disease(Primary progressive

TB

Bacteria in droplets

that bypass

mucocilliary systemand reach alveoli

NOTE:

Outcome isdetermined by

quality of host

defense andm cobacteria

Complement system

also performsphagocytosis(Protein

C3

Binds to cell wall and

enhances recognition of

mycobacterium bymacro ha es

Rapidly surrounded

and engulfed bymacrophages

Production of protolytic enzymes

and cytokines by macrophages in

an attempt to control bacteria

DX: (+)

tuberculin skin

test

Cytokines attracts T

lymphocytes to the

site(synthesized T cells)

Microorganisms continue to

grow until cell-mediated

immune response is fully

Constitutescell mediated

Immunity

Formation of granulomas

around the M. Tuberculosisorganism

Limits replication

Spread Of

mycobacteria

Arrest of phagosome

Bacilli

replication

Low grade

Fever

Weight

loss

AnorexiaSleep

Hyperhid

rosis

>Paracetamol


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Acquired immunity leads to further

growth of bacilli and devpt. Of

active infection

Drainage of necrotic materials into thetrachiobronchial tree(eruption of

coughing,formation of lesions ) Primary

infection

Bronchopneumonia develops in the

lung tissue (Phagocytosed tubercle

bacilli are ingested by macrophages)

General:

Anorexia

Vomitting

Weight loss

Low grade fever

with chills(39.6C)

Bacterial cell wall binds

with macrophages

Necrotic degeneration occurs(production of

cavities filled with cheese like mass of tuberclebacilli, dead WBCs, necrotic lung tissue)

Tubercle bacilli immunity develops(2-6 weeks after infection). Maintains

in the body as long as living bacilli

remains in the body.

As infection progresses in

which immune response wasnot capable of destroying it

Pulmonary:

Dyspnea (31-34

CPM)

productive cough

with yellowish

phlegm)

Hemoptysis(blood

Lesions may calcify (GhonsComplex ) and forms scars and

may heal over period of time.

Signs and Symptoms:

Productive

cough

Mucus

consolidation

Dyspnea

Rales

Rupture of alveolar-capillary beds

Hemoptysis

>Fluimucil

>Combivent

>Benadryl

>Ceftriaxone


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With medical Treatment:

Early detection and

diagnosis of case

Multi-antibacterial

Therapy

Without Medical treatment :

Reactivation of

tubercle bacilli(due

to repeatedexposure to infected

individuals,

immunosuppression

)

NO reccurence Recurrence

Good

Prognosis

Bad

Prognosis

LEGEND:

INFECTION

PROCESS

IMMUNOLO

GIC

PROCESS OF

LUNGS and

Treatment

Medications

NOTES ANDEXPLANATI

ONS

SYMPTOMS

PRESENTED

BY PATIENT

WHILE

ASSESSMEN

T

Continuation at

next page

>Fixcom>Peprasan

>Levoflaxacin


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Laboratory and Diagnostics

X-ray

An X-ray is a quick, painless test that produces images of the structures

inside your body particularly your bones. X-ray beams can pass through your

body, but they are absorbed in different amounts depending on the density of the

material they pass through. The air in your lungs shows up as black. Fat and

muscle look like varying shades of gray.

CHEST X-RAY PA (December 28, 2010 at COMC)

Nodule hazed densities altered in both lungs more in the Right partially

obscuring the bilateral cardiac margins.

Heart is not enlarged.

Aorta is not dilated.

Diaphragm and both costrophrenic sulci are intact.

The rest of the visualized chest structures are unremarkable.

Impression:

PTB, far advanced, bilateral

CHEST X-RAY (January 5, 2011 at CUMC)

Reticulo nodular densities are seen in both lungs, more confluent on the

Right.

Heart is within normal limits in size.


Diaphragm and sulci are intact.


Impression:

Pulmonary Tuberculosis VS. Pneumonia Bilateral

CHEST X-RAY (January 9, 2010 at CUMC)

Follow up study since 1/5/11 shows no significant interval change in the

previously noted reticulo nodular densities in both lungs, more confluent

on the Right.

Heart is within normal limits in size.


Diaphragm and sulci are intact.



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Impression:

To consider Pulmonary Tuberculosis Bilateral. Please correlate clinically.

Complete Blood Count

A complete blood count (CBC), also known as full blood count (FBC) or

full blood exam (FBE) or blood panel, is a test requested by a doctor or other

medical professional that gives information about the cells in a patient's blood. A

lab technician (diploma holder) or technologist (bachelor holder) performs the

requested testing and provides the requesting Medical Professional with the

results of the CBC. A CBC is also known as a "hemogram".

COMPLETE BLOOD COUNT (January 2, 2011)

TEST RESULT REFERENCE INDICATION INTERPRETATION

WBC 16,7005,000-10,000

Cell/mm

Determines anyinflammation andinfection.

Result is above thenormal range whichindicates presenceinfection.

RBC 4.184.2-5.010^6/L

Determines thepresence ofbleeding.

Result is belownormal range, thusindicating presenceof bleeding.

Hemoglobin 10.711.7-14.5

g/dL

Usually done to a pt.with renal disease to

determine if thekidneys ability toreleaseerythropoietin factoris already affected

Result is below thenormal range, thus

the patientexperiencedbleeding causinganemia.

Hematocrit 32.034.1-44.3

gm%

Used to measureRBC number andvolume. It is anintegral part of theevaluation of anemicpatients.

Result is below thenormal range thus,showing anemia anddue to blood loss.

MCV 70.6 80.0-96.0 fL

Determines anychronic bacterialinfection or viralinfection.

Result is below thenormal range ,implicatingpresence of infection

MCH 21.9 27.0-31.0 pg


Result is below thenormal range,implicatingpresence of infection

MCHC 31.132.0-36.0

g/dL

Determines anychronic bacterialinfection or viral

infection.

Result is below thenormal range,implicating

presence of infection

Lymphocyte 17.0 18-45 %



Segmenters 81.0 45-70 % Determines anychronic bacterial

The result is abovethe normal range.


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infection or viralinfection.

Indicates presenceof infection.

Monocyte 1.0 4-8 %

Determines anyacute bacterialinfection.


presence of infection

Eosinophil 1.0 2-3 %

Determines anyacute bacterialinfection.


Platelet 566,000174,000-390,00010^3/L

To diagnose and/ormonitor bleeding andclotting disorders.

Results above thenormal range,implicating tendencyof acute infection.


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WBC 19,0005,000-10,000

Cell/mm


Result is above thenormal range whichindicates presence

infection.

RBC 3.334.2-5.010^6/L

Determines thepresence of bleeding.



g/dL

Usually done to a pt.with renal disease todetermine if thekidneys ability torelease erythropoietinfactor is alreadyaffected

Result is below thenormal range, thusthe patientexperiencedbleeding causinganemia.


gm%

Used to measure RBCnumber and volume. Itis an integral part ofthe evaluation ofanemic patients.

Result is below thenormal range thus,showing anemiaand due to bloodloss.

MCV 70.1 80.0-96.0 fL


Result is below thenormal range,implicatingpresence ofinfection

MCH 22.9 27.0-31.0 pg



MCHC 32.2 32.0-36.0 g/dL


Result is normalrange. Indicatingabsence ofbacterial infection.


Determines any

chronic bacterialinfection or viralinfection.

Result is below the

normal range,implicatingpresence ofinfection

Segmenters 82.0 45-70 %


The result is abovethe normal range.Indicates presenceof infection.

Monocyte 1.0 4-8 %

Determines any acutebacterial infection.


presence ofinfection




Platelet 635,000 174,000- To diagnose and/or Results above the


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390,00010^3/L

monitor bleeding andclotting disorders.

normal range,implicatingtendency of acuteinfection.


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WBC 23,2005,000-10,000

Cell/mm



infection.

RBC 3.574.2-5.010^6/L




g/dL

Usually done to a pt.with renal disease todetermine if thekidneys ability torelease erythropoietinfactor is already

affected



gm%



MCV 69.9 80.0-96.0 fL



MCH 22.4 27.0-31.0 pg



MCHC 32.1 32.0-36.0 g/dL


Result is normal.Indicating absenceof bacterialinfection.


Determines anychronic bacterial


Result is below thenormal range,

implicatingpresence ofinfection




Monocyte 2.0 4-8 %


Result is below thenormal range,implicatingpresence of

infection




Platelet 675,000 174,000-390,000

To diagnose and/ormonitor bleeding and

Results above thenormal range,


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10^3/L

clotting disorders. implicatingtendency of acuteinfection.



WBC 22,1005,000-10,000

Cell/mm


Result is above thenormal range whichindicates presenceinfection.

RBC 3.974.2-5.010^6/L


Result is belownormal range, thusindicating presence

of bleeding.


g/dL

Usually done to a pt.with renal disease todetermine if thekidneys ability torelease erythropoietinfactor is alreadyaffected



gm%

Used to measure RBCnumber and volume. Itis an integral part of

the evaluation ofanemic patients.

Result is below thenormal range thus,showing anemia

and due to bloodloss.

MCV 74.0 80.0-96.0 fL



MCH 23.7 27.0-31.0 pg


Result is below thenormal range,implicatingpresence of

infection

MCHC 32.1 32.0-36.0 g/dL









The result is abovethe normal range.

Indicates presenceof infection.

Monocyte 4.0 4-8 %



Eosinophil 1.0 2-3 % Determines any Result is below the


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chronic bacterialinfection or viralinfection.

normal range,implicatingpresence ofinfection

Platelet 657,000174,000-390,00010^3/L

To diagnose and/or

monitor bleeding andclotting disorders.

Results above the

normal range,implicatingtendency of acuteinfection.


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WBC 23,5005,000-10,000

Cell/mm



infection.

RBC 4.034.2-5.010^6/L




g/dL

Usually done to a pt.with renal disease todetermine if thekidneys ability torelease erythropoietinfactor is already

affected



gm%



MCV 74.5 80.0-96.0 fL



MCH 24.0 27.0-31.0 pg



MCHC 32.2 32.0-36.0 g/dL






Result is normal.Indicating absence

of bacterialinfection.




Monocyte 2.0 4-8 %



Eosinophil 2.0 2-3 %Determines any acutebacterial infection.


Platelet 728,000 174,000-390,00010^3/L

To diagnose and/ormonitor bleeding andclotting disorders.

Results above thenormal range,implicating


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tendency of acuteinfection.

HEMATOLOGY

January 2, 2011

ABO TYPING B Rh+

Blood Chemistry Test

Blood Chemistry is needed to assess a wide range of conditions and the

function of organs. It also a test to check electrolytes, the minerals that help keep

the bodys fluid level in balance, and are necessary to help the muscles, heart,

and other organs work properly. This also helps assess kidney function and

blood sugar, and other substances in the blood.

CLINICAL CHEMISTRY

January 2, 2011

Test Result Reference

Creatinine 0.70 0.60-1.30 mg/dL

SGPT 25.10 10-40 Iu/LSodium 125.50 135-148 mmol/L

Potassium 3.07 3.5-5.3 mmol/L

Interpretation: The result of the Potassium and Sodium are slightly decreased.

So the patient is hypokalemic and hyponatremic, a condition in which the

concentration of potassium and sodium in the blood is low

January 5, 2011

Test Result ReferenceUric Acid 4.60 2.6-7.2

Sodium 129.90 135-148 mmol/L

Potassium 3.95 3.5-5.3 mmol/L

Interpretation: The result of the Sodium is still decreased but compared to

previous laboratory result (01/02/11); it has increased by 0.88. Still the patient is

hyponatremic.

January 6, 2010


FBS 104.00 75-115


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Interpretation: The FBS result is within normal range.

January 8, 2011


Potassium 4.25 3.5-5.3 mmol/LInterpretation: The Potassium is within normal Range.

AFB Stain

AFB smears and cultures are used to determine whether you have an

active Mycobacterium tuberculosis infection, an infection due to another member

of the Mycobacterium family, orTB-like symptoms due to another cause. They

are used to help determine whether the TB is confined to the lungs (pulmonary)

or has spread to organs outside the lungs (extrapulmonary). AFB cultures can be

used to monitor the effectiveness of treatment and can help determine when a

patient is no longer infectious.

AFB STAIN REPORT

January 3, 2010 January 6, 2011

Result

Interpretation

Result Grading No of fields

examine

More than 10 AFB/oil immersion field Positive 3+ 20

1-10 AFB 10 AFB/oil immersion field Positive 2+ 5010-99 AFB in 100 oil immersion field Positive 1+ 100

1-9 AFB in 100 oil immersion field Scanty Record

actual #

200

No AFB in 100 oil immersion field Negative 0 100

January 6, 2011

Specimen sputum

Result No microorganism seen

Polymorphonuclear cells few

Epithelial cells few

Positive

Grade 3+

Specimen Sputum
http://www.labtestsonline.org/understanding/conditions/tuberculosis-2.htmlhttp://www.labtestsonline.org/understanding/conditions/tuberculosis-2.html


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CULTURE REPORT (January 7, 2011)

Preliminary Report

Findings: No growth after 2 days of incubation

Urinalysis

A physical, microscopic, or chemical examination of urine. The specimen

is physically examined for color, turbidity, and specific gravity. Then it is spun in a

centrifuge to allow collection of a small amount of sediment, which is examined

microscopically for blood cells, casts, crystals, pus, and bacteria. Chemical

analysis may be performed to measure the pH and to identify and measure the

levels of ketones, sugar, protein, blood components, and many other substances.

URINALYSIS (January 3, 2011)

Color Orange

Transparency Hazy

Reaction 6.0

Sp gravity 1.015Sugar negative

Protein trace

PUS cell 3-6 cells/HFP

RBC 0-2 cells/HPF

EPITHELIAL CELLS

Squamous epithelial moderate

Bacteria moderate

MUCUOS THREADS few

Fecalysis

Fecalysis is also known as stool analysis. It refers to a series of laboratory

tests done on fecal samples to analyze the condition of a person's digestive tract

in general. Among other things, a fecalysis is performed to check for the

presence of any reducing substances such as white blood cells (WBCs), sugars,

or bile and signs of poor absorption as well as screen for colon cancer.


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FECALYSIS (January 3, 2011)

Consistency soft

Color dark brown

RBC

Pus cells

Ascaris

Hook worm

Amoeba No Parasite seen

Trichuris

Fat globules

Bacteria


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Nursing Care Management

ASSESSMENT DATA(Subjective and Objective

Cues)

NURSING DIAGNOSIS(Problem and Etiology)

GOALS ANDOBJECTIVES

NURSING INTERVENTIONS ANDRATIONALE

EVALUATION

Subjective:Galisod ko ug ginhawatungod sa akong ubo, asverbalized by the patient.

Objective/s:

Productive cough noted,yellowish in color

RR= 31 cpm, tachypnea(16-24cpm)

O2 saturation= 98%

With O2 inhalation vianasal cannula at 2LPM

Lab:

CXRAY = Dec. 28, 2010@COMC

CXRAY = Jan. 5, 2011@CUMC

Impression: PTB Far advanced bilateral

(Right lung)

Ineffective AirwayClearance related toaccumulation ofsecretions at the rightlower field of the lungs.

Short term:Within 15 minutes ofNursing Care andinterventions, patient will:

Maintain orimproved airwaypatency.

Expectorate/clearsecretions readily.

Long term:Within 1-2 daysof Nursing Care andinterventions, patient will:

improve oxygenexchange.

INDEPENDENT:1. Auscultate breath sounds andassess air movement.R: to ascertain status and noteprogress.2. Position head midline with flexionappropriate for age/condition.R: to open or maintain openairway in at-rest or compromisedindividual.3. Elevate head of the bed/ changeposition every 2hours.R: to take advantage of gravitydecreasing pressure on thediaphragm and enhancingdrainage of ventilation to differentlung segments.4. Encourage deep-breathing andcoughing exercises.

R: to promote lung expansion.5. Increase fluid intake to at least2000 ml/day within level of cardiac

After 30 minutes ofNursing Care andinterventions, GOALWAS PARTIALLYMET, patient was ableto maintain airwaypatency andexpectorate/ clearsecretions readily.

After 2-3 days ofNursing Care andinterventions, GOALWAS MET, patientwas:

Able to improveoxygen exchang asevidenced by removal

of 02 supplementationlast Jan. 9, 2011.


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tolerance; encourage/provide warmversus cold liquids as appropriate.R: to help liquefy secretions.6. Monitor vital signs, noting bloodpressure/pulse changes.R: to note any changes/complications.

7. Encourage and provideopportunities for rest; limit activities

to level of respiratory tolerance.R: to prevent and lessen fatigue.

COLLABORATIVE:1. Give expectorant/bronchodilatorsas ordered (Combivent neb. + 1ccNSS, Nebulization every 8 hours).R: to treat underlying conditions.


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NURSING CARE MANAGEMENT


Cues)

NURSINGDIAGNOSIS

(Problem andEtiology)

GOALS ANDOBJECTIVES


EVALUATION

SUBJECTIVE:Dili naku gaka-hurot akongpagkaon, wala koi gana, asverbalized by the patient.

OBJECTIVES:

Weight= 37.5 kg(17/Female ; normal 39-41kg)BMI= 17.9)

Height= 147 cm

BMI= 17.9 (NormalBMI: 18.5 24.5)

Pale conjunctiva and mucusmembrane

inability to consume fullshare of food

IVF: PLR@20gtts/min

LAB: Clinical chemistry:Jan 2,2011

Na = 125.50 Below normalrange(135-148mmol/L)K = 3.07: Below normal

Imbalanced Nutrition:less than bodyrequirements relatedto lack of interest in

food.

Short term:Within 8 hours of NursingCare and interventions,patient will:

Regain normalappetite

Increase foodintake.

Long term:Within 2 weeks ofNursing Care andInterventions, patient will:

Demonstrateprogressive weightgain toward goal.

Displaynormalization oflaboratory values.

IINDEPENDENT:1. Assess the weight; Followingprotocol in weighing a patientR: to establish baseline

parameters.2. Ascertain understanding ofindividual nutritional needsR: to determine informationalneeds of the client.3. Discuss eating habits, includingfood preferences,intolerance/aversions.R: to appeal to clientslikes/dislikes.

After 8 hours of NursingCare and interventions,GOAL WAS MET, patientwas able to improve

appetite and consumed fullshare of food.

After 2 weeks of NursingCare and interventions,GOAL PARTIALLY MET,

Patient was able togain weight of450gm(Stillunderweight18.35Kg, Normal:18.5Kg Female 17years old)

LAB: ClinicalchemistryJan 5,2011 Na levelfrom 125.50 to

129.90 increase by4.4mmol/L


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range(3.5-5.3mmol/L) K level from 3.07 to3.95 increase by0.88mmol/L



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ASSESSMENT DATA(Subjective andObjective Cues)

NURSINGDIAGNOSIS


GOALS ANDOBJECTIVES


EVALUATION

SUBJECTIVE:Gapamugnaw ko, medyolabad akong ulo, initakong paminaw sa lawasas verbalized by the

patient.

OBJECTIVE:

Febrile; Temp=39.6C

Flushed skin ; warm totouch

Tachypnea RR =31cpm(Normal 16 24cpm)

Tachcardia =108bpm(Normal 60 100bpm)

Hyperthermia relatedto disease process.

Short term:Within 30 to 60 minutes ofnursing care andinterventions the patient willbe able to:

Maintain coretemperature withinnormal range andlower bodytemperature from39.6C-36.5C.

Demonstratebehaviors to monitorand promotenormothermia.

Long term:Within 2-3days nursing careand interventions the patientwill be able to:

Be free of

INDEPENDENT:1. Vital signs taken and recordR: to note any changes and/orcomplications and as baseline.2. Perform TSB to lower down Body

temperature to normal: (36.5 37.5C)3. Maintain bed rest.R: to reduce metabolic demands/oxygen consumption4. Provide adequate sleep.R: to regain back body strength.5. Provide adequate fluid intake.R: to prevent dehydration.

COLLABORATIVE:1. Administer medications, as indicated,such as antipyretics and antibiotics (forinfection).R: to treat underlying cause.

After 1hour of nursing careand interventions, patientstemperature was loweredfrom 39.6 to 36.9 degreeCelsius and demonstrated

behaviors to monitor andpromote normothermia.GOAL WAS MET

After 2-3days nursing careand interventions, thepatient able to:

Free fromcomplications andfree from seizures


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complications suchas infection.

Be free of seizureactivity.


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R: to promote muscle tone



Cues)


GOALS ANDOBJECTIVES


EVALUATION

SUBJECTIVE: Gakaulaw ko sa akong

sakit as verbalized bypatient.

OBJECTIVES:

Developmental changes

Functional impairment

Physical illness

Delayed educationalattainment: Drop out fromschool during 1st year in

highschool.

Situational low selfesteem related to socialrole changes.

Long term:Within 2weeks ofnursing care andintervention the patientwill be able to:

Acknowledgefactors that leadto possibility offeelings of lowself esteem.

Verbalize view asworthwhile,important personwho functionswellinterpersonally

Demonstrate selfconfidence bysetting realistic

INDEPENDENT:1. Assess nonverbal body language.R: incongruencies betweenverbal/nonverbal communicationsrequire clarification.2. Identify previous adaptations toillness/disruptive events in life.R: May be predictive of currentoutcome.3. Ascertain sense of control. Clienthas over self and situation todetermine clients trust to self.4. Identify the strength of the clientR: to reinforce self-view5. Encourage verbalization offeelings.R: to promote positive sense of

self.

COLLABORATIVE:

After 2 weeks of nursingcare and intervention,GOAL WASPARTIALLY MET, thepatient was be able to:

Acknowledgedfactors that leadto possibility offeelings of lowself esteem.

Verbalized viewas worthwhile,important personwho functionswellinterpersonally.

Demonstratedself confidenceby setting


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goals and activelyparticipating in lifesituation.

1. Promote attendance in therapy orinvolvement of familyR: to provide appropriate supportto client.

realistic goalsand activelyparticipating inlife situation.


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Identify/use availableresources.

participation in planning and evaluatingprocess.R: enhances commitment to plan,optimizing outcomes.

Identify/use availableresources.



Cues)


GOALS ANDOBJECTIVES


EVALUATION

SUBJECTIVE:Galisud ko ug ginhawa sahay,tungod sa akong plemas asverbalized by the patient.

OBJECTIVE:

Tachypnea; RR= 31cpm

Productive cough noted

Abnormal skin color (pale)

Impaired gas exchangerelated to retainedbronchial secretions.

Short term:Within 5-10 minutes ofnursing care andintervention the patientwill be able to:

Maintain airwaypatency.

Long term:Within 1-2days nursingcare and interventionsthe patient will be ableto:

Demonstrate

improvedventilation and

INDEPENDENT:1. Monitor vital signs and cardiacrhythm.R: to note any changes and/orcomplications.2. Note respiratory rate, depth,pursed-lip breathing; and areas ofpallor/cyanosis; for example,peripheral (nailbeds).R: to assess respiratoryinsufficiency.3. Elevate head of bed/position clientappropriately; provide airwayadjuncts, as indicated.

R: to maintain airway.4. Maintain adequate intake andoutput, but avoid fluid overload.

After 5-10 minutes ofnursing care andintervention, patientmaintained airwaypatency as evidencedby RR=30cpm. GOALWAS PARTIALLYMET.

After 1-2days nursingcare and interventionsthe patient able to:

Demonstrateimproved

ventilation andadequateoxygenation


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adequateoxygenationwithin clientsnormal limits andabsence ofsymptoms ofrespiratorydistress.

Participate intreatmentregimen (e.g.,

breathingexercises,effectivecoughing, anduse of oxygen)within level ofability/ situation.

R: for mobilization of secretions.5. Provide adequate rest and limitactivities to within client tolerance.Promote calm/ restful environment.R: helps limit oxygen needs/consumption.6. Provide psychological support,active-listen questions/concernsR: to reduce anxiety.7. Keep environmentallergen/pollutant free

R: to reduce irritant effect of dustand chemicals on airways.8. Emphasize the importance ofnutritionR: in improving stamina andreducing the work of breathing.

COLLABORATIVE:1. Encourage frequent positionchanges and deep breathing/coughing exercises.R: Promotes optimal chestexpansion and drainage ofsecretions.2. Administer medications, asindicated (e.g. bronchodilators)R: to treat underlying conditions.

3. Provide supplemental oxygen asindicated by laboratory results andclient symptoms/situation.

within clientsnormal limitsand absence ofsymptoms ofrespiratorydistress.

Participate intreatmentregimen (e.g.,breathingexercises,

effectivecoughing, anduse of oxygen)within level ofability/ situation.


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R: to improve respiratory function/oxygen-carrying capacity.



Cues)


GOALS ANDOBJECTIVES


EVALUATION

RISK FACTORS:

Febrile; Temp= 39.6C

Lowered resistance/suppressed inflammatoryresponse

Productive cough noted

Somnolence (lethargy)

Infection related toinadequate primarydefenses (decreasedciliary action/stasis ofsecretions).

Short term:Within 30minutes to 1hour of nursing care andintervention the patientwill be able to:

Maintain coretemperaturewithin normalrange.

Be afebrile.

Long term:Within 2-3days ofnursing care andintervention the patientwill be able to:

Verbalizeunderstanding of

INDEPENDENT:1. Vital signs taken and recorded.R: to note any changes and/orcomplications.2. Stress proper hand hygiene by allcaregivers betweentherapies/clients.R: a first-line of defense againsthealthcare-associated infections(HAI).3. Provide for respiratory isolation,as indicated.R: reduces risk of cross-contamination.4. Encourage early ambulation, deepbreathing, coughing exercises, and

position changes.R: for mobilization of secretionsand prevention of aspiration/

After 30minutes to 1hour of nursing care andintervention, the patientmaintained a coretemperature withinnormal range, and wasafebrile as evidenced bybody temperature of36.9C. GOAL WASMET.

After 2-3days of nursingcare and intervention,GOAL WAS MET, thepatient able to:

Verbalize

understanding ofindividualcausative/ risk


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individualcausative/ riskfactor(s).

Identifyinterventions toprevent/ reducerisk of infection.

respiratory infections.5. Maintain adequate hydration.R: to avoid bladder distention/urinary stasis.

COLLABORATIVE:1. Administer/ monitor medicationregimen and note clients response.R: to determine effectiveness oftherapy/ presence of side effects.2. Emphasize necessity of taking

antivirals/ antibiotics, as directed(e.g., dosage and length of therapy).R: premature discontinuation oftreatment when client begins tofeel well may result in return ofinfection and potentates drug-resistant strains.

factor(s).

Identifyinterventions toprevent/ reducerisk of infection.


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Cues)

NURSING DIAGNOSIS(Problem and

Etiology)

GOALS ANDOBJECTIVES

NURSING INTERVENTIONSAND RATIONALE

EVALUATION

SUBJECTIVE:

Lisud e-ginhawa, asverbalized by the patient.

OBJECTIVES:

RR= 36 cpm

Pallor noted

with O2 inhalation of 2 LMPvi nasal cannula

productive cough noted withyellowish in color.

Ineffective Breathing

Pattern related toimbalance betweenoxygen supply anddemand.

Short term:

Within 2-3 hours ofNursing Care andinterventions, patient will:

Establish a normaland effectiverespiratory pattern.

INDEPENDENT:

1. Auscultate chest, notingpresence and character of breathsounds, presence of secretions.R: Note any changes/complications.2. Elevate HOB as appropriate.R: to promote physiological/psychological ease of maximalinspiration.3. Encourage slower/deeperrespirations, use of purse-liptechnique, and so on.R: to assist the client in takingcontrol of the situation.4. Maintain a calm attitude whiledealing with the client and SO/s.R: to limit the level of anxiety.

5. Assist the client in the use ofrelaxation techniques andencourage position of comfort.

After 2-3 hours of

Nursing Care andinterventions, GOALWAS MET, patient wasable to established anormal and effectiverespiratory pattern.


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R: Promotes optimal chestexpansion and drainage ofsecretions.6. Assist client to learn breathingexercise; diaphragmatic,abdominal breathing, inspiratoryresistive, as pursed-lip asindicated.

7. Encourage adequate restperiods between activities to

prevent fatigue.R: to meet increased metabolicdemands.

COLLABORATIVE::1. Administer oxygen at lowestconcentration indicated forunderlying pulmonary conditionand respiratory distress: O2inhalation regulated at 2 LPM vianasal cannula.R: to offset increased oxygendemandsand consumption.


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Cues)

NURSINGDIAGNOSIS


GOALS ANDOBJECTIVES


EVALUATION

SUBJECTIVE:Mag mata-mata ko usahay, diliko maka tulog dali sa akongubo, as verbalized by thepatient.

OBJECTIVE:

inadequate hours of sleep:

Before admission: 6 8hours

During admission: 4 6hou

Disturbed SleepPattern related topresence of coughand fever.

Long term:Within 8 hours ofNursing Care andinterventions, patientwill:

Achievesoptimalamounts ofsleep asevidenced byrestedappearance,verbalizationof feelingrested, andimprovement

in sleeppattern.

INDEPENDENT:1. Observe and/or obtain feedback fromclient and SO/s regarding usual bedtime,rituals/routines, number of hours of sleep,time of arising and environmental needs,to determine usual sleep pattern andprovide comparative baseline.2. Identify circumstances that interruptsleep and frequency.R: to be able to provide baseline forcomparison.3. Arrange care to provide foruninterrupted periods for rest.R: determines ability to participate inplanning/ executing care.4. Provide quiet environment and comfortmeasures.

R: helps limit oxygen needs/consumption.5. Recommend midmorning nap if one is

After 8 hours ofNursing Care andinterventions, GOALWAS MET, patient wasable to achieved anoptimal amounts ofsleep as evidenced byrested appearance,verbalization of feelingrested andimprovement in sleeppattern.


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required.R: Napping, especially in the afternoon,can disrupt normal sleep patterns.


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compilation of grand case

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