CASE Study Ptb

Pulmonary Tuberculosis

I INTRODUCTION A. Background of the Study Pulmonary tuberculosis, a chronic sub-acute or acute respiratory disease commonly affecting the lungs characterized by the formation of tubercles in the tissues which tend to undergo cessation, necrosis and calcification. It is also known as poor man’s disease or consumption disease. The causative agent in this disease is Mycobacterium Tuberculosis, a rod shaped bacteria. The disease is transmitted by deliberate inoculation of microorganisms by droplet. This disease is transmitted to other people through the inhalation of organisms directly into the lungs from contaminated

air. According to the department of Health (DOH) PTB is the 6th cause of mortality and morbidity in the Philippines as of 2007. (Navales, Handbook of Common Communicable and Infectious disease revised edition, pages 280-281.) This disease is can be acquired easily by person being in contact with an infected one, when you are living in a crowded area like the squatter’s area and when you have poor nutrition. It is commonly present in third world or developing countries like the Philippines. In 2004, mortality and morbidity statistics included 14.6 million chronic active cases, 8.9 million new cases, and 1.6 million deaths, mostly in developing countries. In addition, a rising number of people in the developed world are contracting tuberculosis because their immune systems are compromised by immunosuppressive drugs, substance abuse, or AIDS. The distribution of tuberculosis is not uniform across the globe with about 80% of the population in many Asian and African countries testing positive in tuberculin tests, while only 5-10% of the US population testing positive. (http://en.wikipedia.org/wiki/Pulmonary_tuberculosis)

B. Rationale for Choosing the Case The researchers decided to choose this case because they wanted to acquire more knowledge about Pulmonary Tuberculosis. They wanted to use the knowledge that they have acquired in promoting awareness to the people especially to the poor that they should seek for medical care in order to prevent the development and progression of PTB. The researchers also wanted to focus on preventive measures. PTB can cause Tuberculosis meningitis, a very rare and fatal disease and the researchers would not want that to happen, so they will focus more on information campaign as part of primary prevention of health. Presently our country has so many cases of PTB. C. 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, especially those with PTB and vulnerable individuals to seek medical care in order to prevent TBM. It will increase awareness about the importance of having a healthy lifestyle and clean environment. This study will elaborate the inter relatedness of environment, life style habits and acquiring Pulmonary Tuberculosis. D. Scope and Limitation 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 the medications, diagnostics, care plan, pathophysiology and discharge planning. This study is not limited to the PTB patients only, but it is for all people who are interested in PTB. We are more focused on primary prevention through health education because primary prevention is the true prevention. II CLINICAL SUMMARY A. General Data

• • • • • • • • • •

Name: Eufemia Bugoy y Cia Age: 46 y/o Birthplace: Pulangi, Albay Sex: Female Religion: Roman Catholic Civil Status: Married Address: Baras, Rizal Date Admitted: September 19, 2008 Time Admitted: 2:10 am Attending Physician: Dr. San Jose

A. Chief Complaint: The patient was admitted at Rizal Provincial Hospital last September 19, 2008 at 2:10 in the morning due to the complaint of difficulty of breathing (DOB). She was attended at the Emergency department and had taken a clinical history and physical assessment. She was transferred at the Medical Ward particularly in the isolation room of the hospital for further evaluation of the complaint. She was attended by Dr. San Jose, a resident physician of the said hospital.

B. History of Present Illness: Patient’s condition started about 6 months prior to consultation, as onset of cough, non-productive and an intermittent fever usually in the afternoon, moderate grade temperature which are not documented. According to her it was relieved by an intake of paracetamol. One week prior to admission the patient experienced worsening of the condition, she had productive cough nonbloody with whitish secretions. There is also difficulty of breathing and vomiting. The patient can’t eat properly because she has no appetite for food. She also experience stabbing pain on her chest according to the assessment it is 6/10 and it radiates to his back. The patient only took paracetamol for her fever. On the day of September 19, 2008 she was rushed to the hospital because of difficulty of breathing. Previously when she started experiencing these conditions, she does not seek for any medical care from the physician because according to her it is still tolerable. C. Past Medical History The patient had upper respiratory tract infection when she was a child, she cannot remember. Previously she was not hospitalized. She does not have complete immunizations because according to her it is not available in their place

during those days, She has no history of hypertension and Diabetes mellitus. Whenever she had any flu or cough, she uses herbal plants. She does not have any regular medical and dental check-ups. She does not have allergies to what ever kind of foods and medications as far as she knows. Whenever she had fever she takes Paracetamol and Bioflu. She does experience any severe accidents.

D. Familial History

Telesporo Cia, 75 Deceased

Eugenia Chavez 65 Deceased VA

Carlito, 75

Litsilda, 50

Flusofida, 48

Josephine, 42

Junior, 44

Eufemia, 46 PTB

Gaudiocio, 40

Blencio, 38

Arsenio, 50

Allan,25

Analyn, 23

Analiza, 19

Anabel, 22

Ana Marie, 15

Arnold, 10

Legends Male Female PTB Pulmonary Tuberculosis E. Physical Assessment CVA• Cerebro Vascular Attack Upon Admission VA • Vehicular Accidentto 3 spheres-(E4M6V5) GCS-15 oriented

• •

Date: September 19, 2008 Height: 62 inches Weight: 31.5 kilograms BMI: 12.5 (Severe Malnutrition)

V/S: BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-37.5 C LOC: Oriented

AREA A. SKULL 1. Size, shape and symmetry of the skull

TECHNIQUE

Inspection Palpation

NORMS

Rounded (normocephalic and

FINDINGS

Rounded(normocephalic);

ANALYSIS and INTERPRETATION

Normal

symmetrical, with frontal, parietal, and occipital prominences); Smooth skull contour

smooth skull contour

2. Presence of nodules, masses, and depressions

Palpation Inspection

Smooth, uniform consistence; absence of nodules or masses

Has no tenderness; no masses nor nodules

Normal

3. Facial Features

Inspection Palpation

Symmetric or slightly asymmetric facial features; palpebral fissure equal in size; symmetric nasolabial

Symmetrical and palpebral fissure equal in size, nasolabial folds are symmetrical

Normal

4. Presence of edema and hollowness in the eye.

Inspection

No edema and hollowness

Has Hollowness

Abnormal, Volume deficiency of fat within the orbit (the space inside of the bony eye socket). This condition of the patient is related to his nutritional status, she is malnourished. Her BMI is 12.5. (http://www.drmeronk.com/hollowed/under-eyehollows.html)

C. HAIR 1. Evenness of growth, thickness, or thinness of hair

Inspection Palpation

Evenly distributed and covers the whole scalp; Maybe thick or thin

Evenly distributed with no patches of hair loss; thick hair

Normal

2. Texture and oiliness over the scalp

Inspection Palpation

Silky; resilient hair

Silky, smooth and resilient hair

Normal.

3. Presence of infection and infestation

Inspection Palption

No infection and infestation

Presence of lice

Abnormal, There is pediculosis, a type of parasitic infection. Lice may be contracted

from infcetd clothes and direct contact with an infected person. The idea is that an oily substance, such as oil, smothers the lice and they may die. (Kozier, Fundamentals of Nursing 7th ed. Page 733)

D. FACE Facial features, symmetry of facial movements

Inspection

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

Symmetrical facial features while talking or elevating the eyebrow. Equal palpebral fissure, symmetrical nasolabial folds.

Normal

Inspection

Symmetrical and in line with each other; maybe black, brown or blond depending on race; evenly distributed

Symmetrical and aligned with each other; black; evenly distributed. Movements are symmetrical.

Normal

Inspection Palpation

Evenly distributed; turned outward

Turned outward eyelashes; hair equally distributed

Normal

IV. EYES A. EYEBROWS Hair distribution, alignment, skin quality and movement

B. EYELASHES Evenness of distribution and direction of curl

C. EYELIDS

Inspection

Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open; eyelids meet completely when the eyes are closed; symmetrical

Able to close the eyes and has the ability to blink.

Normal

1. Color, texture, and the presence of lesions in the bulbar conjunctiva

Inspection Palapation

Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers

Pale color; smooth in texture

Abnormal, pale conjunctiva may be related to the low RBC level of the patient. (Fundamentals of Nursing 5th edition by Taylor, page 642)

2. Color, texture, and the presence of lesions in the palpebral conjunctiva

Inspection Palpation

Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers

Pale

Abnormal, pale conjunctiva may be related to the low RBC level of the patient. (Fundamentals of Nursing 5th edition by Taylor, page 642)

Inspection

White in color; clear; no yellowish discoloration; some capillaries maybe visible

White sclera with some visible capillaries, anicteric sclera.

Normal

Inspection

No irregularities on

Clear and smooth in

Normal

Surface characteristics and position (in relation to the cornea, ability to blink, and frequency of blinking)

D. CONJUNCTIVA

E. SCLERA Color and clarity

F. CORNEA Clarity and texture

the surface; looks smooth; clear or transparent

texture

Inspection

Anterior chamber is transparent; no noted visible materials; color depends on the person’s race

Dark brown in color; transparent anterior chamber

Normal

1. Color, shape, and symmetry of size

Inspection

Color depends on the person’s race; size ranges from 3-7 mm, and are equal in size; equally round

Pupil size is 3mm.

Normal

2. Light reaction and accommodation

Inspection

Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual

Dilates when looking at far objects and constricts when looking at near objects. Constricts when there is light.

Normal

Inspection

Able to read newsprint

Nearsightedness (Myopia)

Abnormal, it is a refractive defect of the eye in which collimated light produces image focus in front of the retina when accommodation is relaxed. It is caused by an eyeball that is longer than normal, which may be a familial trait. Transient mayopia

G. IRIS Shape and color

H. PUPILS

I. VISUAL ACUITY 1. Near vision

occurs due to influenza, steroids, sever dehydration and large intake of antacids. (Black, Medical Surgical Nursing7th edition, page 1963).

J. LACRIMAL GLAND Palpability and tenderness of the lacrimal gland

Palpation

No edema or tenderness over lacrimal gland

No tenderness and edema noted.

Normal

Inspection

Both eyes coordinated, move in unison, with parallel alignment

Moves in Unison

Normal

Inspection

When looking straight ahead, client can see objects in the periphery

Can see objects in the periphery.

Normal

Inspection

Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees

Same color as the facial skin; tip of auricle aligned at the outer canthus of the eye.

Normal

K. EXTRAOCULAR MUSCLES Eye alignment and coordination

L. VISUAL FIELDS Peripheral visual fields

V. EARS A. AURICLES 1. Color, symmetry of size, and position

from vertical 2. Texture, elasticity and areas of tenderness

Palpation

Mobile, firm, and not tender; pinna recoils after it is folded

Smooth in texture, flexible and elastic pinna; no tenderness

Normal

Inspection

Normal voice tones audible

Can hear normal volume tones or words.

Normal

1.Any deviations in shape, size, or color and flaring or discharge from the nares

Inspection

Symmetric and straight; no discharge or flaring; Uniform color

Symmetric and straight; Uniform color with nasal flaring.

Abnormal, Nasal flaring suggests airway obstruction. Nasal discharge shows the presence of mucus secretions in the air tract.

2. Nasal septum (between the nasal chambers)

Inspection Palpation

Nasal septum intact and in midline

Nasal septum intact and in midline

Normal

3. Patency of both nasal cavities

Inspection

Air moves freely as the client breathes through the nares

Only left nares is patent. Right nares is with secretion.

Abnormal, not patent right nares show the presence of mucus secretions and would suggest there is an infection in the respiratory system.

4. Tenderness, masses, and displacements of bone and cartilage

Palpation

Not tender; no lesions

Nor tenderness nor lesions.

Normal

C. HEARING ACUITY TESTS 1. Client’s response to normal voice tones

VI. NOSE

VII. SINUSES Identification of the sinuses and for tenderness

Inspection

Not tender

Not painful when palpated

Normal

Inspection Palpation

Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse lips

Pink in color, dry and cracked lips

Abnormal, May suggest cellular dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

Inspection

Uniform pink color; moist, smooth, soft, glistening, and elastic texture

Pink color and dry.

Abnormal, May suggests dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

Inspection

32 adult teeth; smooth, white, shiny tooth enamel; smooth, intact dentures

Has 31 adult teeth. The patient has yellowish teeth. Have bad breath. Have tooth decay in the lower right second molars.

Abnormal, most unpleasant odors are known to arise from proteins trapped in the mouth which are processed by oral bacteria. The most common location for mouth-related halitosis is the tongue. (http://en.wikipedia.org/wiki/Halitosis). It is also related to dental carries and frequency

VIII. MOUTH A. LIPS Symmetry of contour, color and texture

B. BUCCAL MUCOSA Color, moisture, texture, and the presence of lesions

C. TEETH Color, number and condition and presence of dentures

of tooth brushing. D. GUMS Color and condition

Inspection

Pink gums; no retraction

Pink gums; has no visible retractions

Normal

1. Color and texture of the mouth floor and frenulum.

Inspection

pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness

Pink and moist. Tongue moves freely and no pain felt.

Normal

2. Position, color and texture, movement and base of the tongue

Inspection

Central position; pink color; smooth tongue base with prominent veins

Located and positioned in the center.

Normal

3. Any nodules, lumps, or excoriated areas

Palpation Inspection

Smooth with no palpable nodules, lumps, or excoriated areas

No tenderness nor masses

Normal

E. TONGUE/FLOOR OF THE MOUTH

F. PALATES and UVULA

1. Color, shape, texture and the presence of bony prominences

Inspection Palpation

Light pink, smooth, soft palate; lighter pink hard palate , more irregular texture

The hard palate has a lighter color than the soft palate; has quite rough texture

Normal

2. Position of the uvula and mobility (while examining the palates)

Inspection

Positioned in midline of soft palate

Positioned at the center of the oropharynx

Normal

1. Color and texture

Inspection

Pink and smooth posterior wall

Dry, pinkish in color.

Abnormal, May suggests dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

2. Size, color, and discharge of the tonsils

Inspection

Pink and smooth; no discharge; of normal size

Has no discharge; pinkish

Normal

3. Gag reflex

Inspection

Present

Present

Normal

Inspection

Quiet, rhythmic, and effortless respirations

Difficulty of breathing

Abnormal, labored breathing is a common manifestation affecting clients with cardiac and pulmonary disorders. It is related to obstructed airway. It also related to the decreased size of the lungs due to PTB. (Black, Medical Surgical Nursing7th edition,

G. OROPHARYNX and TONSILS

X. THORAX A. ANTERIOR THORAX 1. Breathing patterns

page 1566). 2. Temperature, tenderness, masses

3. Anterior thorax auscultation

Palpation

Auscultation

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

Has an intact skin; has equal warmth on both sides. No masses.

Normal

Bronchovesicular and vesicular breath sounds

Has crackles sounds on the upper thorax & lower thorax

Abnormal, crackles or rales are audible when there is a sudden opening of small airways that contain fluid. It is usually heard during inspiration. (Black, Medical Surgical Nursing7th edition, page 1756).

B. POSTERIOR THORAX 1. Shape, symmetry, and comparison of anteroposterior thorax to transverse diameter

Inspection Palpation

Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric

Has a anteroposterior to transverse diameter ratio of 1:2, elliptical in shape and symmetrical chest

Normal

2. Spinal alignment

Inspection

Spine vertically aligned

Has a vertical alignment

Normal

3. Temperature, tenderness, and masses

Palpation

Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

No masses nor tenderness; has equal warmth on each side

Normal

Vesicular and

Has crackles heard on

Abnormal, the condition is related to the

7. Posterior thorax

Auscultation

auscultation

bronchovesicular breath sounds

the anterior and middle part of right and left lungs. Diminished lung sound on the posterior right lung.

decreased size of the right lung and poor inspiratory effort due to pain. (http://www.nurse411.com/Heart_Lung_Sounds.asp)

XI. CARDIOVASCULAR A. AORTIC and PULMONIC AREAS

Auscultation

No pulsations

No pulsations felt

Normal

B. TRICUSPID AREA

Auscultation

No pulsations; no lift or heave

No pulsations of lifts

Normal

C. APICAL AREA

Auscultation

Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL

Has full pulsation

Normal

D. EPIGASTRIC AREA

Auscultation

Aortic pulsations

Has pulsation

Normal

E. CARDIOVASCULAR AREAS AUSCULTATION

Auscultation

S1: Usually heard at all sites

Has full and rapid pulsation. 84 bpm/minute.

Normal

Sounds on the aortic and pulmonic areas; has a lub sound on the apex and dub sounds on the tricuspid area.

Normal

Usually louder at the apical area S2: Usually heard at all sites Usually louder at the base of heart Systole: silent

Blood pressure is 90/70

Normal

interval; slightly shorter duration than diastole at normal heart rate (60 to 90 beats/min)

mm Hg.

Diastole: silent interval; slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults XII. CAROTID ARTERIES 1. Carotid artery palpation

XIV. AXILLAE

Palpation

Symmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from sitting to supine position; elastic arterial wall

Has weak pulsation. Symmetrical pulse.

Abnormal, decreased amount of blood volume passing the artery. (Black, Medical Surgical Nursing7th edition, page 1574).

1. Axillary, subclavicular, and supraclavicular lymph nodes

Inspection

No tenderness, masses, or nodules

Have no masses and nodules. Presence of a foul smelling odor.

Abnormal, The appocrine glands located in the axillae produces sweat. The secretion of these glands is odorless, but when decomposed or acted upon by bacteria in the skin, it takes on a musky, unpleasant odor. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 699)

1. Skin integrity

Inspection

Unblemished skin; uniform color

Uniform color and has no blemishes

Normal

2. Abdominal contour

Inspection

Flat, rounded(convex), or scaphoid(concave)

Has a concave abdomen.

Normal

3. Enlargement of liver or spleen

Inspection

No evidence of enlargement of liver or spleen

No enlargement of the spleen and liver seen

Normal

4.Symmetry of contour

Inspection

Symmetric contour

Has a symmetrical abdominal contour

Normal

5. Abdominal movements associated with respirations, peristalsis or aortic pulsations

Inspection

Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin persons at epigastric area

Abdominal movements noted when inhaling.

Normal

6. Vascular pattern

Inspection

No visible vascular

Has no blood vessels

Normal

XV. ABDOMEN

pattern

visible

XVI. MUSCULOSKELETAL SYSTEM

A. MUSCLES 1. Muscle size and comparison on the other side

Inspection

Proportionate to the body; even in both sides

Proportionate to the body; even in both sides

Normal

2. Fasciculation and tremors in the muscles

Inspection

No fasciculation and tremors

Has no fasciculation and tremors

Normal

3. Muscle tonicity

Palpation

Even and firm muscle tone

Weak muscle tone

Abnormal, possibly related to the amount of food that patient is eating. Possible exhaustion experienced by the patient when she coughs. (http://en.wikipedia.org/wiki/Muscle_weakness)

4. Muscle strength

Palpation

Has equal muscular strength on both sides

Weak muscle strength

Abnormal, possibly related to the amount of food that patient is eating. Possible exhaustion experienced by the patient when she coughs. (http://en.wikipedia.org/wiki/Muscle_weakness)

C. JOINTS 1. Joint swelling

Inspection

No swelling, no warmth, no redness, no pain, no crepitus

No swelling, no warmth, no redness, no pain, no crepitus

Normal

EXTREMETIES

Inspection, Palpation

No swelling, no warmth, no redness, no pain.

No edema, no pain when moved.

Normal

Neurologic Assessment: Category

Normal Findings

Actual Findings

Analysis and interpretation

Mental Status Level of Consciousness

Alert

Alert

Normal

Orientation

Oriented

Normal

Language test

Coherent

Oriented to person, time and place. Coherent

Recall

Able to remember

Able to state what happened to her in the past.

Normal

Normal

Cranial Nerves CN 1 Olfactory

Able to smell and recognize stimuli

Able to identify the scent of the alcohol

Normal

CN 11 Optic

20x20 vision, able to read, 3-5 mm [pupil size]

Pupil size is 3 mm, able to read, myopia or nearsightedness.

Abnormal, it is a refractive defect of the eye in which collimated light produces image focus in front of the retina when accommodation is relaxed. It is caused by an eyeball that is longer than normal, which may be a familial trait. Transient mayopia occurs due to influenza, steroids, sever dehydration and large intake of antacids. (Black, Medical Surgical Nursing7th edition, page 1963).

CN III, IV, VI Occulomotor Trochlear Abducens

(+) Extraoccular Movement (EOM); Lateral Upward and downward; pupils reactive to light.

CN V Trigeminal

Able to feel and clearly identify stimulus, with bilateral facial sensation. With active corneal reflex.

CN VII Facial CN VIII Vestibulocochlear

CN IX, X Glossopharyngeal Vagus

(+) Corneal reflex , Facial asymmetry

Pupils react to light. There is constriction and consensual accommodation. Able to move the eyes in any direction in unison.

Normal

Normal Able to feel my finger on her face while covering her eyes. Normal (+) Facial symmetry

Normal Able to hear clearly, can maintain balance

Can hear clearly and can walk. Normal

(+) gag reflex, uvula

Present gag reflex, able to

CN XI Accessory (Spinal)

CN XII Hypoglossal

at the center, soft palate rises Able to shrug shoulders against resistance and able to turn the head side and against resistance.

swallow and able to idebtify the taste of the food. Normal Can shrug shoulders against resistance and can turn the head fro right to right. Normal

Able to move tongue from side to side Able to protrude the tongue and move it side to side.

Muscle Strength

MNT Grading System:

Left Arm

(+5) Active motion against full resistance

+4 active motion against some resistance.

Abnormal, possibly related to the amount of food that patient is eating. Possible exhaustion experienced by the patient when she coughs. (http://en.wikipedia.org/wiki/Muscle_weakness)

Right Arm Left Leg Right Leg

(+5) Active motion against full resistance (+5) Active motion against full resistance (+5) Active motion against full resistance

+4 active motion against some resistance.

Abnormal

+4 active motion against some resistance. +4 active motion against some resistance.

Abnormal Abnormal

A. Patterns of Functioning The researchers utilized the Gordon’s typology in assessing the pattern of functioning of our patient in her life. How does she manages and takes care of herself based on Eleven Patterns.

Functional Health Pattern Prior to Hospitalization

Norms and Standards

Health perception- Health Management • The patient doesn’t have complete immunization because according to her it is not available during those days and having immunization during those years are expensive and they cannot afford it. • She was never been hospitalized. • No known allergies to any foods and drugs. She can eat fish, oyster and others. • Does not experience any accidents. • When she had a disease, she used herbal medicines like guava leaves, oregano, lagundi, etc. • For her, being healthy is important. A person is healthy when she is strong, she can do what she wants and does not experience any diseases. • She does not have any regular medical and dental check-ups. • When she is experiencing something wrong in her body, she does not tell it promptly because according to her it is tolerable. • She does not have a regular exercise, instead she cleans the house and washes the clothes of her family. • The patient is malnourished. • She takes a bath once a day and brushes her teeth once a day. • She does use lotion, shampoo and soap. • She washes her hands regularly but not always using soap. • When she feels discomfort in her body she also goes to the manghihilot because it is available on their area and it is more approachable. • She often forgot to cover her mouth and nose when someone sneezes and coughs in front of her. • A person has a disease when she eats little amount of food, when she is weak. • Health for her is important for proper functioning. • Whenever she is sick, she get’s money from her children especially to the eldest, which is working abroad. • She wears slippers while inside their house. She feels that her hygienic practices are adequate, and she feels clean and neat.

Measure for personal cleanliness and grooming, called personal hygiene, promote physical and psychological well-being. Various studies have confirmed that improved personal hygiene practices reduce illness rates. (Larson, 2002; Larson and Aiello, 2001). Personal hygiene practices vary widely among people. The time of the day one bathes and how often one shampoo or changes the bed linens, and sleeping garments are relatively unimportant. What is important is that personal care be carried out conveniently and frequently enough to promote personal hygiene. Illness, hospitalization and institutionalization generally require modifications in hygiene practices. In these situations, the nurse helps the patient to continue some hygiene practices, and can teach the patient and family members, when necessary, regarding hygiene. Nurses assist the patient with basic hygiene must respect individual patient preferences, providing only the care that patients cannot or should not provide for themselves. (Fundamentals of Nursing 5th edition by Taylor, page 1005). Malnutrition is the lack of sufficient nutrients to maintain healthy bodily functions and is typically associated with extreme poverty in economically developing countries. Most commonly, malnourished people either do not have enough calories in their diet, or are eating a diet that lacks protein, vitamins, or trace minerals. Medical problems arising from malnutrition are commonly referred to as deficiency diseases. Deficiency in micronutrients such as Vitamin A reduces the capacity of the body to resist diseases. Deficiency in iron, iodine and vitamin A is widely prevalent and represent a major public health challenge. An array of afflictions ranging from stunted growth, reduced intelligence and various cognitive abilities, reduced sociability, reduced leadership and assertiveness, reduced activity and energy, reduced muscle growth and strength, and poorer health overall are directly implicated to nutrient deficiencies. (http://en.wikipedia.org/wiki/Malnourishment)

The main purpose of washing hands is to cleanse the hands of pathogens (including bacteria or viruses) and chemicals which can cause personal harm or disease, particularly diarrhea and pneumonia. To maintain good hygiene, hands should always be washed after using the toilet, changing a diaper, tending to someone who is sick, or

• •

The patient is non-smoker and she does not drink any alcoholic beverages. She denies the use any illicit drugs.

handling raw meat, fish, or poultry, or any other situation leading to potential contamination. Hands should also be washed before eating, handling or cooking food. Conventionally, the use of soap and warm running water and the washing of all surfaces thoroughly, including under fingernails is seen as necessary. Alcohol rub sanitizers kill bacteria, multi-drug resistant bacteria (MRSA and VRE), tuberculosis, and viruses (including HIV, herpes, RSV, rhinovirus, vaccinia, influenza, and hepatitis) and fungus. (http://en.wikipedia.org/wiki/Hand_washing)

Herbalists treat many conditions such as asthma, eczema, premenstrual syndrome, rheumatoid arthritis, migraine, menopausal symptoms, chronic fatigue, and irritable bowel syndrome, among others. Herbal preparations are best taken under the guidance of a trained professional. Be sure to consult with your doctor or an herbalist before self-treating. Some common herbs and their uses are discussed below. Please see our monographs on individual herbs for detailed descriptions of uses as well as risks, side effects, and potential interactions. (http://www.umm.edu/altmed/articles/herbal-medicine000351.htm)

Nutritional Metabolic Pattern • She loves to eat pork, fish and vegetables. • She is not choosy when it comes to any cook and kind of food. • She eats 3x a day • She does not eat any junk foods. • She drinks 5 glasses of water a day. • For her, the amount of food she consumes is adequate. • She takes food supplement but it is not frequent. • During snack time, she usually eats banana because it is affordable and readily available in their place. • When her cough started, she is not eating the appropriate amount of food. • According to her husband, she usually eats 4 spoons of rice with viand only. It is due to her cough. • During her hospitalization, she is on diet as tolerated with aspiration precaution. • She eats food given by the hospital. • She is taking vitamin B6 and other medications.

Nutrition is a basic human need that changes throughout the life cycle and along the wellness-illness continuum. (Fundamentals of Nursing 5th edition by Taylor, page 1135) An adequate food intake consists of balance essentials nutrients: water, carbohydrates, fats, proteins, vitamins and minerals. Habits about eating are affected by many factors like financial and health conditions. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1171,1175) The middle aged adult should continue to eat a healthy diet, following the recommended portions of the 5 food groups, with special attention to protein, calcium and limiting consumption to cholesterol. Two to three liters of fluid should be included in the diet. Pre menopausal women need to ingest sufficient calcium and vitamin d to prevent osteoporosis. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1180,1181) An adult individual needs to balance energy intake with his or her level of physical activity to avoid storing excess body fat. Dietary practices and food choices are related to wellness and affect health, fitness, weight management, and the prevention of chronic diseases such as osteoporosis, cardiovascular diseases, cancer, and

diabetes. For adults (ages eighteen to forty-five or fifty), weight management is a key factor in achieving health and wellness. In order to remain healthy, adults must be aware of changes in their energy needs, based on their level of physical activity, and balance their energy intake accordingly. (http://www.faqs.org/nutrition/A-Ap/AdultNutrition.html) Inadequate nutrition is associated with marked weight loss, generalized muscle weakness, altered functional ability, increased susceptibility to infection, impaired pulmonary function and prolonged length of hospitalization. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1190). Elimination • She defecates twice a week and sometimes she feels pain and difficulty. • According to her the characteristic of her stool is hard, dry and colored dark brown. • She feels pain at her abdomen on the hypogastric and umbilical area. • She urinates 7x a day and does not feel any pain and difficulty. • Previously her defecation pattern is daily, but when her condition exacerbated, it is also affected.

Elimination can be affected by a person’s developmental stage, daily patterns, the amount and quality of fluid or food intake, the level of activity, lifestyle, emotional states, pathologic processes, medication, and procedures such as diagnostic test and surgery. Most people have individual pattern of elimination including frequency, timing considerations, position and place. For most people defecation is a private affair experienced easily only in the comfort of one’s own bathroom. Defecation may be difficult in shared hospital room with only a curtain for privacy. (Fundamentals of Nursing 5th edition by Taylor, page 1341) The frequency of defecation is highly individualized, varying from several times per day to two to three times per week. Sufficient bulk in the diet is necessary to provide fecal volume. Bland diets and lowfiber diets are lacking in the bulk and therefore create insufficient residue of waste products to stimulate the reflex for defecation. Lowresidue foods such as rice, eggs and lean meats move more slowly through the intestinal tract. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1228). Activity stimulates peristalsis, thus facilitating the movement of chime along the colon. (Fundamentals of Nursing 5th edition by Taylor, page 1229). A person’s urinary habits depend on social culture, personal habits and physical abilities. Urine collects in the bladder contains between 250 to 450 ml of urine. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1256). The excretory function of the kidney diminishes with age but usually not significant below normal levels unless disease intervenes.

With age, the number of functioning nephrons decreases to some degree, impairing the kidneys filtering abilities. The amount of flood intake affects the urinary frequency of an individual. Foods high in sodium or fluids high in sodium ca cause fluid retention because water are retained to maintain the normal concentration of the electrolyte. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 12581259). Activity and Exercise • She does not have any work, she is a plain house wife, who is in-charge of her children. • Her usual activity is cleaning the house, cooking and washing the clothes of her children. • She loves to listen to radio programs usually in the afternoon. • She likes to converse with her friends and neighborhood. • When she cleans, it is usually for 1 hour because she gets easily tired. • Her youngest child helps her in the household chores. • When after all the chores are done she will rest and watch television. • She does not involve her self in any vigorous activities. • However, she is aware that her activity is not enough, and she recognizes the importance of having regular exercise.

The human body was designed for motion, and regular exercise is necessary for its healthy functioning. Individuals who choose inactive lifestyles or who are forced into inactivity by illness or injury placed themselves at high risk for serious health problems. (Fundamentals of Nursing 5th edition by Taylor, page 1116) Vigorous physical activity is not always needed to achieve positive result. (Fundamentals of Nursing 5th edition by Taylor, page 1117) Lack of exercise, inactivity, or immobility related to illness, or injury place a person at high risk for serious health problems. Immobility can affect the major body systems. Like the benefits, a person receives from exercise, complications resulting from immobility differ occurrence and severity based on the patients age and overall health status. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1118). The wonderful tool of exercise can help teens become fit and healthy. Performing some form of physical activity daily will significantly boost your “basal metabolic rate”—the number of calories your body burns in order to keep you alive. By having a high metabolism, you burn calories 24 hours a day—even while you sleep! You can literally turn your body into a fat-burning machine! This has many benefits: With a strong metabolism comes a strong immune system. When you burn fat, the toxins are released into the bloodstream, and are quickly carried out of the body through sweat. This inoculates you against the probability of developing cancerous and diseased cells. Therefore, hard exercise—that makes you sweat— is very good for you. Exercise also helps to regulate the amount of insulin released into the bloodstream. Insulin is commonly referred to as “the fat-making hormone.” Its job is to metabolize blood sugar into energy. But too much insulin in the bloodstream keeps your body from burning stored fat. Years of an overworked pancreas—the organ that produces

insulin—can lead to “onset (type 2) diabetes.” However, if you use— burn—more calories than you consume, you significantly reduce the chances of developing this disease. Exercise can also help control other problems, such as: Sleep apnea, moodiness, stress, decreased energy, cardiovascular disease, high cholesterol and others. There are too many benefits to list here. But be assured that this tool can help you become a fit, stronger, disease-free, and overall healthier person. The main goal of aerobic exercise is to keep the heart elevated for an extended period of time for the purpose of strengthening the heart and lungs. The most common aerobic exercise is walking. Running is the quickest way to lose weight, because it burns many calories. It also tones your calves and thighs. However, to avoid extreme muscle aches or injuries, do not begin a running routine until you have performed two to three months of aerobic walking. (http://www.thercg.org/youth/articles/0201-tioe.html) Cognitive-perceptual • The patient is an elementary graduate. • She stops studying because of financial problem • She can read and write properly. • She is aware to different people or happening around her. • She can talk properly. • During the interview her voice is weak. • According to her she is sensitive to the feelings of the people around her. • There are no any blockages of communication noted. • She is not always reading any books like pocket books. • She can express her feelings appropriately. • She does not have any difficulty when it comes to communication.

Cognition is greatly affected by education. Those who study and develop their skills have better cognitive performances because they have been provided with different information and chances to develop their self. Perception is affected by the sensory diseases. Presence of any sensory abnormalities affects or halters perception that would affect proper communication. (Black, Medical Surgical Nursing7th edition, page 1880). Cognition involves a person’s intelligence, perceptual ability and ability to process information. It represents a progression of mental abilities from illogical to logical thinking, from simple to complex problem solving and from concrete to abstract ideas. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 359).

Sleep and Rest • The patient regularly sleeps at 8:00pm and wakes up at 1:00 pm. • She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough. • She usually sits because according to her she can breath more easily.

For no known reason, 8 hours of sleep a night has been the accepted standard for adults despite obvious variations seen in the general population. It is important however that a person follows a pattern of rest that maintains well-being. Many factors affect a person’s ability to rest. Illnesses and various life situations that causes physiological stress tends to disturb sleep. Sleep quality is also influenced by certain drugs Some decreases REM sleep

• • • • •

She takes a nap in the morning from 8 am to 11 am. She feels that her sleep and rest is inadequate. She sleeps together with her husband. They have a separate room from their children. Sleeping is important to her.

Self-perception • According to her there is something wrong in her health and body. • As a mother, she sometimes feels sad because she cannot do the previous things like going with her husband in the farm. • According to her husband she is a good mother and a good wife. • Her strength is her family, when there are any circumstances that involving any family member she is concerned and make some moves.

(barbiturates ,amphetamines and antidepressants) and some are seen to cause sleep problems (steroids, caffeine and asthma medications) (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1169-117). The National Sleep Foundation in the United States maintains that eight to nine hours of sleep for adult humans is optimal and that sufficient sleep benefits alertness, memory and problem solving, and overall health, as well as reducing the risk of accidents.[8] A widely publicized 2003 study[9] performed at the University of Pennsylvania School of Medicine demonstrated that cognitive performance declines with fewer than eight hours of sleep. It has also been shown that sleep deprivation affects the immune system and metabolism. In a study by Zager et al in 2007,[21] rats were deprived of sleep for 24 hours. When compared with a control group, the sleep-deprived rats' blood tests indicated a 20% decrease in white blood cell count, a significant change in the immune system. Scientists have shown numerous ways in which sleep is related to memory. In a study conducted by Turner, Drummond, Salamat, and Brown[28] working memory was shown to be affected by sleep deprivation. Working memory is important because it keeps information active for further processing and supports higher-level cognitive functions such as decision making, reasoning, and episodic memory. Turner et al. allowed 18 women and 22 men to sleep only 26 minutes per night over a 4-day period. Subjects were given initial cognitive tests while well rested and then tested again twice a day during the 4 days of sleep deprivation. On the final test the average working memory span of the sleep deprived group had dropped by 38% in comparison to the control group. (http://en.wikipedia.org/wiki/Sleep) Self concept is one’s mental image of oneself. A positive self concept is essential to a person’s mental and physical health. Individuals with a positive self concept are better able to develop and maintain interpersonal relationship and resist psychological and physical illness. Self concept involves all of these self perceptions, that is, appearance, values and beliefs that influences behaviors and that are referred to when using the words I or me. Body image is ho the person perceives the size, appearance and functioning of the body. If a person’s body image closely resembles one’s ideal body, the

•

She is simple.

Role-relationship • She was the fourth child in her family. • She is married to Arsenio and they have 6 children. • She is performing the trypical responsibilities of a plain house wife. • Her children have a good relationship to her. • She is being cared by her children who are very supportive to her. • Her husband is a good husband he is a provider who does everything for the family to have food. • She has a harmonious relationship with her brothers and sisters. Whenever there are any problems, they are helping each other. • She can form a healthy relationship with others. • She is the person who chooses her friends. • She is a very quite person. • She does not have any enemies.

Sexuality-reproductive • She is engage in sexual activity to her husband only. • Presently she is still active in her sex life.

individual is more likely to think positively about the physical and non-physical concept of self. Self concept is also affected by role-strains. People undergoing role-strains are frustrated because they feel or made to feel inadequate or unsuited to a role. Illness and trauma can also affect the self-concept. People responds to different stressors such as illness and alterations in function related to aging in a variety of ways: acceptance, denial, withdrawal and depression are common. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 957-962). Relationship to another person is a developed manner in which there is the sharing of self, showing care and putting trust. A healthy relationship affects an individual’s emotional development, it will facilitate the channeling of the ideas, feeling of joy an others. An interpersonal relationship is a relatively long-term association between two or more people. This association may be based on emotions like love and liking, regular business interactions, or some other type of social commitment. Interpersonal relationships take place in a great variety of contexts, such as family, friends, marriage, acquaintances, work, clubs, neighborhoods, and churches. They may be regulated by law, custom, or mutual agreement, and are the basis of social groups and society as a whole. A relationship is normally viewed as a connection between two individuals, such as a romantic or intimate relationship, or a parent-child relationship. All relationships involve some level of interdependence. People in a relationship tend to influence each other, share their thoughts and feelings, and engage in activities together. Because of this interdependence, anything that changes or impacts one member of the relationship will have some level of impact on the other member. Psychologists have suggested that all humans have a basic, motivational drive to form and maintain caring interpersonal relationships. According to attachment theory, relationships can be viewed in terms of attachment styles that develop during early childhood. These patterns are believed to influence interactions throughout adulthood by shaping the roles people adopt in relationships. (http://en.wikipedia.org/wiki/Intimate_relationship) Sexuality is defined not only by a person’s genetalia but also by attitudes and feelings. It can also be defined as learned behaviors in how a person reacts to his or her own sexuality and by how one

• • • •

She She She She

still have regular menstruation. is aware that she will have cessation of her menstruation. dresses appropriately, based on her gender. is also able to express her feminine attitudes.

Coping-stress • Whenever she has problem, she asks guidance from our Lord • She watches television as her stress management. • She always listen to radio programs when she feels lonely. • When she gets mad, she just keep quiet. • When she experiences coughing and difficulty of breathing she just relaxes and breathes deeply. • Her husband or children taps her back when she coughs. Value-belief • She is a Roman Catholic • She attends mass occasionally. • She always ask the guidance of our Lord • Whenever there are Christian events, like Holy week, she participates in the activities like fasting.

behaves in relationships with others. (Fundamentals of Nursing 5th edition by Taylor, page 931) Sexuality is a crucial part of a person’s identity. Sex is central to who we are, to our emotional well-being and to the quality of our lives. The world health organization defined sexual health as the integration of the somatic, emotional, intellectual and social aspect of sexual beings in ways that are positively enriching and that enhances personality, communication and love. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 973). During the middle adulthood both men and women experience decreased hormone production causing the climacteric, usually called menopausal in women. These events often affect the individuals selfconcept, body image and sexual identity. Women through the menopausal period experiences hot flushes, vasomotor instability, sleep disturbances, vaginal dryness, genital tract atrophy, mood changes and skin, hair changes. The incidence of osteoporosis and cardiovascular lipid changes also increases. The climacteric in the males is no as dramatic in the females; changes are more gradual. Sexual response love and play involve people’s emotional, psychologic, physical and spiritual make up, which plays a significant role in the satisfaction. Sexual desires fluctuates within each person and varies from person to person. If people suppresses or block out conscous sexual desires, they may not experience any physiological respose. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 975,980). Coping mechanisms which are behaviors used to decrease stress and anxiety. Many coping behaviors are learned, based on one’s family past experiences, and socio-cultural influences and expectations. (Fundamentals of Nursing 5th edition by Taylor, page 855)

Spiritual well-being is the condition that exists when the universal spiritual needs for meaning and purpose, love and belonging, and forgiveness are met. O’ Briens conceptual model of spiritual wellbeing in illness identified three empirical referents of spiritual wellbeing: personal faith, religious practice and spiritual contentment. Spiritual beliefs are of special importance to nurses because of the

• • •

• •

She believes in ghosts, and elementals. She seldom reads the bible. Does not always pray the rosary. She respects and obeys her husband. For her education is very important to her children, so she and her husband is doing all the efforts to send their children to school.

many ways they can influence a patient’s level of health and self-care behaviors. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 975,979). Spiritual well-being is manifested by a generally feeling of being alive, purposeful and fulfilled. People nurture or enhance their spirituality in many ways. Some focus on development of the inner self or world; others focus on the expression of their spiritual energy with others or outer world. Relating to one’s inner self or soul may be achieved through conducting an inner dialogue with a higher power or with one’s self through prayer or medications. The expression of a person’s spiritual energy to others is manifested in loving relationship with and service to others, joy and laughter and participation in religious services and associated fellow gatherings and activities and by expression of compassion, empathy, forgiveness and hope. (Kozier et.al, Fundamentals of Nursing 7th ed. Pages 996).

A. Activities of Daily Living ASPECT 1. Nutrition

2. Elimination

PRIOR TO HOSPITALIZATION Patient loves to eat meat, fish and vegetables. She eats anything that is being served to her. She does not eat junk foods. She is not taking food supplements like vitamins frequently. She eats 4 spoons of rice with viand because according to her it is due to her cough. She eats thrice a day. Patient voids 7 times a day, and defecate twice a week. She doesn’t experience any pain and difficulty in terms of urination. Previously her defecation pattern is daily, but when her condition exacerbated, it is also affected.

DURING HOSPITALIZATION The patient is on diet as tolerated with aspiration precaution. She eats dry, thickened food on a small frequent feeding. She is advised to chew food properly.

INTERPRETATION and ANALYSIS The patient can eat any food she wants as long as it is dry, thickened, and frothy. It should be in a small frequent feeding, as to avoid aspiration.

The patient does not defecate or urinated during the conduct of the interview.

The patient does not defecate for more than a week due to decreased gastric motility related to decrease physical activity. For most people defecation is a private affair experienced easily only in the comfort of one’s own bathroom. Defecation may be difficult in shared hospital room with only a curtain for privacy. (Fundamentals of Nursing 5th edition by

Taylor, page 975 & 979) 3. Exercise

Cleaning their house is the only activity she considered as her exercise. She does not have routine exercise. However, she is aware that her activity is not enough, and she recognizes the importance of having regular exercise. She loves to listen to radio programs usually in the afternoon. When after all the chores are done she will rest and watch television.

Deep breathing and coughing exercises are advised and performed. The patient has decreasing function as the disease progresses.

4. Hygiene

Patient takes a bath every day, brushes her teeth once a day. She wears slippers while inside their house. She feels that her hygienic practices are adequate, and she feels clean and neat. There is body odor noted. Patient is a non-smoker and denies use of illicit drugs. She does not drink alcohol.

Not applicable

Sleeping is important to her. She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough. She takes a nap in the morning from 8 am to 11 am. She sleeps together with her husband. The patient regularly sleeps at 8:00pm and wakes up at 1:00 pm. She feels that her sleep and rest is inadequate because of her

Not applicable

5. Substance Use

6. Sleep and Rest

The patient doesn’t use any prohibited substances like alcohol, cigarettes and illicit drugs.

The patient performs deep breathing exercise as instructed by the nurse.

The patient does not use any addictive substances. Illicit drugs are strictly prohibited in the hospital premises, even cigarette smoking and alcohol drinking.

conditions. 7. Sexual Activity

She dresses appropriately, based on her gender. She still has regular menstruation. She is engage in sexual activity to her husband only. Presently she is still active in her sex life

Not applicable

A. Patients Concept about Health, Illness and Hospitalization HEALTH The patient believes that being healthy is being strong, does not experience any sickness and energetic. - Health is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO definition

ILLNESS For the patient, an individual is weak and eats little amount of food. -Is a disease, sickness or the condition of being in a poor health, either physically or mentally. (Blackwell’s Nursing Dictionary)

HOSPITALIZATION The patient looks at hospitalization as the last recourse when one has an illness. For the patient, it is the place where an individual is being treated from severe cases. - Placement of an individual in a hospital for observation, diagnostic test, or treatment for some diseases. (Blackwell’s Nursing Dictionary)

B. Laboratory and Diagnostic Examination DATE Sept. 19, 2008

PROCEDURE Hemoglobin Hematocrit RBC count WBC Neutrophils Lymphocytes Basophils Monocytes Eosinophils Platelets

NORMS 120-160g/L 0.38-0.40 g/L 4’2-5.4x 1012 per liter 5-10x109/L 81.3% 10.2% 0.1% 7.5% 0.9% 150-450x109/L

RESULT

INTERPRETATION and ANALYSIS

Fasting Blood Sugar Urinalysis Creatinine

70-110 mg/dl

Na

135-145mmol/L

K

3.6-5.5mmol/L

Sputum Test/AFB

Negative

•

Electro Cardiogram

•

Chest X-ray

44.2-106.08 umol/L

The patient had undergone chest x-ray upon admission. The film shows presence of infiltrates or clouds. The right is smaller than the left lung, particularly the lower lobe of the right lung.

A. Impression/Diagnosis Dr. San Jose, the patient’s attending physician, who diagnosed the disease as Pulmonary tuberculosis. This diagnosis is supported by the pathognomonic signs that manifested by the patient. These include intermittent fever in the afternoon, difficulty of breathing, coughing, weight loss and chest pain. This diagnosis is supported by the following diagnostic exam such as Culture and Sensitivity of the sputum and chest x-ray.

B. Course in the Ward wheel chair. DATE September 19, 2008

The patient was accompanied by her husband and her children. While waiting for the doctor, she was placed in a MEDICAL PROCEDURES/ORDERS

-

History taking Physical assessment Neurological Assessment Chest-x-ray IVF of PNSS 1 liter 20 gtts/min to run for 12 hours. Medications • Nausil 1 ampule TIV stat, then every 6 hours.

NURSING ASSESSMENT and FUNCTION Upon admission: -GCS E4 V5 M6 - Vital signs BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-31.5 C - IV insertion done at the right arm, infusing well. -Due meds given - X-ray result obtained.

• • • • - Diet

B complex 2 ampules TIV stat Cefuroxime 500 mg/Cap Theophylline 1 cap TID Salbutamol and Guiafene Sin + tab TID PO as Tolerated with aspiration precaution.

- History taking - Physical assessment done - Neurologic assessment done -crackles noted upon auscultation. 2:40 AM -Received from ER to Medical surgical ward. - Placed in isolation room - Patient was oriented. - Kept rested -Advised relatives to use mask and hand washing regularly. - On DAT with AP

A. Ecologic Model Hypothesis The patient developed PTB thru the inhalation of mycobacterium tuberculosis due to being exposed to an environment, specifically in their community, where in some people around her have Pulmonary Tuberculosis. Not always covering her nose and doing proper hand washing are the practices that have predisposes the patient to develop the disease. She had come in close contact with people who had PTB. Agent

•

• Host

• •

Tuberculosis is a common and deadly infectious disease caused by mycobacterium mainly Mycobacterium tuberculosis. Mycobacterium tuberculosis. A rod-shaped organism. The disease is directly transmitted through inhalation of organisms directly into the lungs.

➢ 46 yrs old

Female Filipino, Roman Catholic ➢ Highest educational attainment: Elementary graduate. ➢ Living together with her family in Baras, Rizal ➢ Have incomplete vaccination. ➢ Practices hand washing but improper without soap. ➢ Takes a bath once a day and brushes teeth once. ➢ Does not always cover her nose and mouth in situations needed to. ➢ Does not have a regular medical check up. ➢ ➢

➢

Exposed to a person who is carrier of M. Tuberculosis.

Environment The patient resides in a crowded community where in cases with Tuberculosis is present. The present environment where she resides is not polluted. TB is an airborne infection. People who are most commonly infected are those who have repeated close contact with an infected person.

The researchers used the epidemiologic web causation model, in which this model focuses to the complex multi factorial causes of a disease.

Financial insufficiency.

Does not always cover her nose and mouth when exposed to a person who coug

Does not regularly take vitamins and minerals Does not have a regular medical check up.

HOST Educational attainment. Inadequate of knowledge about health management. . Infected of Tuberculosis Meningitis. Weakened immune system

Degeneration of healthy cells..

Lack of immunizations

Airborne transmission Does not practice proper hand washing.

ng a bath once a day and brushing teeth only once. Exposure to a carrier of M. tuberculosis.

Mayco Bacterium Tuberculosis Analysis PTB is caused by mycobacterium tuberculosis. This bacterium enters the host thru the nose and mouth. It first affects the alveoli of the lungs then this bacterium spreads thru the bloodstream. This bacterium migrates to other parts of the body. Hand washing has been the most effective means of preventing transfer. It is the true prevention. Not covering the nose and mouth when someone sneezes or coughs causes the bacteria in their sputum to travel through the air. The so called airborne transmission will now take place affecting the individual. Living in an unhealthy place predisposes the individual to develop certain diseases especially those within the respiratory system. (Brunner and Suddarth’s Textbook of Medical- Surgical Nursing 11th ed by Smeltzer et al p. 643) Conclusion and recommendation The researchers therefore conclude that PTB can be prevented if we always clean the environment, practicing proper hand washing, personal hygiene and use of personal protective equipments are the things that are very important. Personal discipline is a crucial factor. As nurses, they are focused on promoting wellness through health education especially to that of the poor.

II CLINICAL DISCUSSION OF THE DISEASE A. Anatomy and Physiology Respiration is the process by which living organisms take in oxygen and release carbon dioxide. The human respiratory system, working in conjunction with the circulatory system, supplies oxygen to the body's cells, removing carbon dioxide in the process. The exchange of these gases occurs across cell membranes both in the lungs (external respiration) and in the body tissues (internal respiration). Breathing, or pulmonary ventilation, describes the process of inhaling and exhaling air. The human respiratory system consists of the respiratory tract and the lungs. Respiratory tract The respiratory tract cleans, warms, and moistens air during its trip to the lungs. The tract can be divided into an upper and a lower part. The upper part consists of the nose, nasal cavity, pharynx (throat), and larynx (voice box). The lower part consists of the trachea (windpipe), bronchi, and bronchial tree. The nose has openings to the outside that allow air to enter. Hairs inside the nose trap dirt and keep it out of the respiratory tract. The external nose leads to a large cavity within the skull, the nasal cavity. This cavity is lined with mucous membrane and fine hairs called cilia. Mucus moistens the incoming air and traps dust. The cilia move pieces of the mucus with its trapped particles to the throat, where it is spit out or swallowed. Stomach acids destroy bacteria in swallowed mucus. Blood vessels in the nose and nasal cavity release heat and warm the entering air. Air leaves the nasal cavity and enters the pharynx. From there it passes into the larynx, which is supported by a framework of cartilage (tough, white connective tissue). The larynx is covered by the epiglottis, a flap of elastic cartilage that moves up and down like a trap door. The epiglottis stays open during breathing, but closes during swallowing. This valve mechanism keeps solid particles (food) and liquids out of the trachea. If something other than air enters the trachea, it is expelled through automatic coughing. Alveoli: Tiny air-filled sacs in the lungs where the exchange of oxygen and carbon dioxide occurs between the lungs and the bloodstream. Bronchi: Two main branches of the trachea leading into the lungs. Bronchial tree: Branching, air-conducting subdivisions of the bronchi in the lungs.

Diaphragm: Dome-shaped sheet of muscle located below the lungs separating the thoracic and abdominal cavities that contracts and expands to force air in and out of the lungs. Epiglottis: Flap of elastic cartilage covering the larynx that allows air to pass through the trachea while keeping solid particles and liquids out. Pleura: Membranous sac that envelops each lung and lines the thoracic cavity. Air enters the trachea in the neck. Mucous membrane lines the trachea and C-shaped cartilage rings reinforce its walls. Elastic fibers in the trachea walls allow the airways to expand and contract during breathing, while the cartilage rings prevent them from collapsing. The trachea divides behind the sternum (breastbone) to form a left and right branch, called bronchi (pronounced BRONG-key), each entering a lung. The lungs The lungs are two cone-shaped organs located in the chest or thoracic cavity. The heart separates them. The right lung is somewhat larger than the left. A sac, called the pleura, surrounds and protects the lungs. One layer of the pleura attaches to the wall of the thoracic cavity and the other layer encloses the lungs. A fluid between the two membrane layers reduces friction and allows smooth movement of the lungs during breathing. The lungs are divided into lobes, each one of which receives its own bronchial branch. Inside the lungs, the bronchi subdivide repeatedly into smaller airways. Eventually they form tiny branches called terminal bronchioles. Terminal bronchioles have a diameter of about 0.02 inch (0.5 millimeter). This branching network within the lungs is called the bronchial tree. The terminal bronchioles enter cup-shaped air sacs called alveoli (pronounced al-VEE-o-leye). The average person has a total of about 700 million gas-filled alveoli in the lungs. These provide an enormous surface area for gas exchange. A network of capillaries (tiny blood vessels) surrounds each alveoli. As blood passes through these vessels and air fills the alveoli, the exchange of gases takes place: oxygen passes from the alveoli into the capillaries while carbon dioxide passes from the capillaries into the alveoli. This process—external respiration—causes the blood to leave the lungs laden with oxygen and cleared of carbon dioxide. When this blood reaches the cells of the body, internal respiration takes place. The oxygen diffuses or passes into the tissue fluid, and then into the cells. At the same time, carbon dioxide in the cells diffuses into the tissue fluid and then into the capillaries. The carbon dioxide-filled blood then returns to the lungs for another cycle.

Breathing Breathing exchanges gases between the outside air and the alveoli of the lungs. Lung expansion is brought about by two important muscles, the diaphragm (pronounced DIE-a-fram) and the intercostal muscles. The diaphragm is a dome-shaped sheet of muscle located below the lungs that separates the thoracic and abdominal cavities. The intercostal muscles are located between the ribs. Nerves from the brain send impulses to the diaphragm and intercostal muscles, stimulating them to contract or relax. When the diaphragm contracts, it moves down. The dome is flattened, and the size of the chest cavity is increased. When the intercostal muscles contract, the ribs move up and outward, which also increases the size of the chest cavity. By contracting, the diaphragm and intercostal muscles reduce the pressure inside the lungs relative to the pressure of the outside air. As a consequence, air rushes into the lungs during inhalation. During exhalation, the reverse occurs. The diaphragm relaxes and its dome curves up into the chest cavity, while the intercostal muscles relax and bring the ribs down and inward. The diminished size of the chest cavity increases the pressure in the lungs, thereby forcing air out. A healthy adult breathes in and out about 12 times per minute, but this rate changes with exercise and other factors. Total lung capacity is about 12.5 pints (6 liters). Under normal circumstances, humans inhale and exhale about one pint (475 milliliters) of air in each cycle. Only about three-quarters of this air reaches the alveoli. The rest of the air remains in the respiratory tract. Regardless of the volume of air

breathed in and out, the lungs always retain about 2.5 pints (1200 milliliters) of air. This residual air keeps the alveoli and bronchioles partially filled at all times.

C. Drug Study GENERIC / BRAND NAME Theophylline

ACTION

CLASSIFICATI ON

INDICATION

CONTRAINDICATION

-The main mechanism of action of theophylline is that of adenosine receptor antagonism.

- Mild stimulant -Bronchodilator

- For chronic obstructive diseases of the airway. -COPD

- Hypersensitivity - Pregnant.

-Stomach stomach -pain -Diarrhea -Headache - Restlessness - Insomnia - Irritability

- Monitor patients’ heart rate. - Assess for CNS effects. - Teach the patient to avoid smoking. - Educate the importance of taking the right amount in the right time of medications. - Assess for any hypersensitivity.

Bronchodialtor

-Relief and prevention of bronchospasm in patients with reversible obstructive airway disease

-Contraindicated with hypersensitivity to albuterol. -Use cautiously with diabetes mellitus (large IV doses can aggravate diabetes and ketoacidosis).

-Dizziness, drowsiness, fatigue, headache. - vomiting, change in taste

- Assess for any hypersensitivity to albuterol. - Be cautious when driving. -Eat food is a small frequent way. - Maintain betaadrenergic blocker on stand by.

- Theophylline is a non-specific adenosine antagonist, antagonizing A1, A2, and A3 receptors almost equally, which explains many of its cardiac effects and some of its anti-asthmatic effects. SAlbutamol

- A short-acting β2adrenergic receptor agonist used for the relief of bronchospasm in conditions such as asthma and chronic obstructive pulmonary disease.

-Inhalation: Treatment of

SIDE EFFECTS

NURSING INTERVENTION

acute attacks of bronchospasm -Prevention of exercise-induced bronchospasm. Vitamin B

- Support and increase the rate of metabolism. - Maintain healthy skin and muscle tone - Enhance immune and nervous system function. - Promote cell growth and division including that of the red blood cells that help prevent anemia.

- Water soluble Vitamin

Cefuroxime

- Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. -Bacteria

- Antibacterial

- Encourage patient to take the vitamin regularly. - Encourage them to go to the doctor before drinking any vitamins.

- Treatment of infections caused by staphylococci and other microorganisms like klebsiella. - Treatment of susceptible infections of the lower respiratory tract

- Hypersensitivity to cefuroxime and other cephalosphorine.

- GI bleeding - Headache - Nausea - Dizziness - Vomiting - Increased BUN and Creatinine

- Observe for signs and symptoms of anaphylaxis during first dose; with prolonged therapy, monitor renal, hepatic, and hematologic function. - Educate the importance of taking the right amount in the right time of medications. - Assess for any hypersensitivity.

Guiafen

FLUIMUCIL (nausil)

eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested. - Most decongestants cause response from adrenoreceptor a1, chiefly responsible for vasoconstriction (a2 modulates adrenaline/noradre naline levels, b1 is the most stimulating and increases cardiac output, b2 dilates the bronchial walls, and b3 induces lipolysis). -Is any agent which dissolves thick mucus usually used to help relieve respiratory difficulties. (hydrolyzing glycosaminoglycan s: tending to break down/lower the viscosity of mucin-

- Decongestant - Expectorant

-Used to relieve congestion and to treat cough due to colds, flu, or hay fever.

- MEDICINE IS NOT RECOMMENDED if you have a history of severe high blood pressure, severe coronary artery disease, or if you have problems where the supply of blood and oxygen to the heart is reduced also known as ischemic heart disease.

- Nervousness, dizziness, trouble sleeping, nausea, vomiting and headache.

- Assess for any allergies. -Instruct the patient to consult a doctor when the side effects continues. - Be careful when driving or operating machines. - Instruct the patient that they should swallow the medication whole.

Mucolytic

-Acute & chronic respiratory tract affections w/ abundant mucus secretions. -Used in the treatment of wet cough.

-Contraindicated with asthmatic patients and patients with history of peptic ulceration.

-Urticaria, bronchospasm, nausea, vomiting. -Aerosol treatment: Rhinitis, stomatitis.

-Should be taken with food -The sachet should be dissolve into a glass of cold or warm water, and drink immediately. -Do not dissolve other medicines together with Fluimucil, since both Fluimucil and the other drug effect

containing body secretions/compon ents).

could be influenced or cancelled. - Assess for any allergies.

IV Fluid Treatment / Infusion

Classification

Indication

Contraindication

*Do not connect flexible plastic containers of intravenous solutions in series, i.e., do not piggyback connections. Such use could result in air embolism due to residual air being drawn from one container before administration of the fluid from a secondary container is completed.

*Hypovolemia *Heat-related emergencies Plain NSS

Isotonic

*CHF *Freshwater drowning *Diabetic ketoacidosis(DKA)

Nursing Responsibilities

*Pressurizing intravenous solutions contained in flexible plastic containers to increase flow rates can result in air embolism if the residual air in the container is not fully evacuated prior to administration. *Use of a vented intravenous administration set with the vent in the open position could result in air embolism. Vented intravenous administration sets with the vent in the open position should not be used with flexible plastic contain.

III NURSING PROCESS A. Long Term Objective After two month of intensive treatment the patient will not experience the signs and symptoms of PTB. The complications brought about by PTB will be prevented through proper participation to the different medical and nursing interventions. B. Problem List

CUES Subjective Cues: - Patient verbalized, “Matagal na akong inuubo. Wala namang plema. Nahihirapan akong huminga”. Objective Cues: - Presence of adventitious breath sound (Crackles) upon auscultation. -The patient is coughing without phlegm. - Oriented - GCS E4V5M6 - BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-37.5 C - Difficulty vocalizing - Has hallow eyes. - Bluish nail beds. Subjective: -The husband of the client verbalized, “Naku hindi na nawala ang lagnat ng asawa ko, pabalik-balik na lang”

NURSING PROBLEM Ineffective airway clearance related to retained secretions in the respiratory tract secondary to bacterial infection as evidenced by crackles upon auscultation.

RANK 1

Hyperthermia related to infection as evidenced by increased WBC

2

JUSTIFICATION Airway must be given the first attention as based on the rule of ABC which is Airway, Breathing and Circulation. In addition, difficulty of breathing can cause anxiety to the client that is why, immediate attention must be done. Addressing the problem to proper health care provider will give patent airway to the client. Oxygenation is a vital need for every cell, if there are any problems related to it can easily affect the functioning of the individual. ➢ Retained secretions can cause blockage of airway which will further cause difficulty of breathing (Fundamentals of Nursing 7th ed by Kozier et al. p. 1299) ➢

➢ This demands immediate treatment/care and

➢ Objective: -Flushed skin; warm to touch -Increase body temperature higher than normal range -Increased respiration -The patient is sweating -T: 37.5˚C Subjective: - The patient is only eating 4 spoons of rice with viand. - The relative verbalized “Hindi siya nakakakain ng maayus dahil sa

Imbalanced Nutrition: Less than Body Requirements related to inability to ingest food because of prolonged

3

subsequent medical attention, as they can result in delirium and convulsions. This is an actual problem that needs to addressed. Lack of action in this health care problem may cause dehydration which may later cause a bigger threat to the health of the client.

➢ This condition needs to be addressed immediately for the client to be able to gain enough strength in performing her usual activities. ➢ The body obtains energy in the form of calories from carbohydrates, protein and fat. The body

kanyang ubo”. Objective: - The patient weight is 31.5 kilograms. - Poor muscle tone. - Appears weak. - Minimal subcutaneous fat.

cough as evidenced by decreased BMI.

uses energy for voluntary activities such as walking and in involuntary activities such as breathing. (Fundamentals of Nursing 7th ed by Kozier et al.)

Subjective: - The husband verbalizes that her wife is easily getting tired. Her maximum work is one hour only, and then she would go to rest. - Her usual activities is cleaning the house, cooking and washing the clothes. Their children help her wife.

Activity intolerance related to inadequate oxygen supply as evidenced by easy fatigability.

4

➢

This nursing diagnosis is not life threatening and doesn’t need immediate attention, however, it can affect the body’s normal functioning ➢ Individuals who have inactive lifestyles or who are faced with inactivity because of illness or injury are at risk for many problems that can affect major body systems. Clients experience a significant decrease in the muscular strength and agility whenever they do not maintain a moderate amount of physical activity. (Fundamentals of Nursing 7th ed by Kozier et al. p. 1068). ➢

Subjective: - The patient regularly sleeps at 8:00pm and wakes up at 1:00 pm. - She usually sits because according to her she can breath more easily. - She takes a nap in the morning from 8 am to 11 am. - She is experiencing intermittent sleep disturbance because according to her she feels difficulty of breathing and cough.

Sleep Deprivation related to prolonged physical discomfort (dyspnea) as evidenced by inability to concentrate

5

➢

This condition doesn’t need immediate attention but needs to be addressed for sleep is a basic human need. ➢ A lack of rest for long periods can cause illness or worsening of existing illness. (Fundamentals of Nursing, 6th ed by Potter and Perry p. 1206)

A. Nursing Care Plan ASSESSMENT

NURSING DIAGNOSIS

BACKGROUND KNOWLDEGE

GOAL and OBJECTIVES

NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective Cues: - Patient verbalized, “Matagal na akong inuubo. Wala namang plema. Nahihirapan akong huminga”. Objective Cues: - Presence of adventitious breath sound (Crackles) upon auscultation. -The patient is coughing without phlegm. - Oriented - GCS E4V5M6 - BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-31.5 C - Difficulty vocalizing - Has hallow eyes. - Bluish nail beds.

Ineffective airway clearance related to retained secretions in the respiratory tract secondary to bacterial infection as evidenced by crackles upon auscultation.

Intermediate Cause: - Retained secretions in the respiratory tract. Intermediate Cause: - Inflammatory response Root Cause: - Bacterial infection of the respiratory system. Health Implication: This condition can cause Acute Respiratory Distress Syndrome (ARDS) which results from the combination of infection and inflammatory response. The lungs become quickly filled with fluid and become very stiff. This stiffness, combined with difficulties extracting oxygen due to the alveolar fluid

Goal: Within 4 hours of nursing intervention, the patient will be able to maintain patent airway through the mobilization of secretions as evidenced by productive cough. Objectives: 1. For 10 minutes, the relative will assess the physical condition of the client by accepting at least 4 nursing interventions to be done in the patient. 2. After 3 hours the client will be able to mobilize her secretions through the interventions done by the nurse at least 4. 3. After 50 minutes, the

Objective 1: IndependentFacilitative: 1. Obtain vital signs of the patient.

2. Observe for respiratory rate and rhythm; presence of nasal flaring; and use of accessory muscles when breathing like the diaphragm and coastal muscles. 3. Perform the Blanch Test.

4. Auscultate the lungs to note any lung sounds.

- Health status is regulated through homeostatic mechanisms. A change in V/S might indicate health change. (Taylor et.al, FON 5th ed. Page 523) -Nasal flaring and use of accessory muscles indicates increased effort is required for breathing.

- Blanch test reflects the adequacy of o2 circulation in the periphery. -Crackles are intermittent sounds that occur when air moves through airway that contain fluids. (Taylor et.al, FON 5th ed. Page 1386)

Objective 2: IndependentFacilitative: 1. Perform Chest physiotherapy.

-Tapping the chest can loosen the secretions. (Taylor et.al, FON 5th ed. Page 1251)

Dependent-Facilitative: 1. Suction secretion as

-Suction removes secretions through the use of a strong

Effectiveness - Was the patient able to maintain patent airway? -Was the patient able to mobilize her secretions? -Was the patient able to have patent airway? Adequacy -Was all the planned nursing interventions are enough in achieving and maintaining patent airway? -Was all the resources of the nurse like time and effort are enough? Appropriateness -Was the interventions mentioned are applicable and beneficial to the patient? Acceptability - Was the family willfully accepted the interventions done to the patient.

creates a need for ventilation. Septic shock is one potential complication. (Black, Medical Surgical Nursing 7th ed. Page 1896)

nurse will maintain patent airway of the patient through the performance of at least 3 interventions.

needed.

pressure.

2. Increase the amount of oral fluid intake as ordered by the doctor.

- Current data indicates that fluid restriction may actually reduce blood volume and decrease cerebral circulation. The lack of volume causes the blood to be thick and sluggish and may decrease the mobilization of nutrition and toxins out of the circulation. Patient should be maintained in a euvolemic state rather than a fluid-restricted state. (Black, MSN 7th ed. Page 2201) - They act on the respiratory tract, it opens narrowed airways. (Black, MSN 7th ed. Page 1652)

DependentSupplemental: 1. Administer bronchodilators as ordered.

Objective 3: IndependentFacilitative: 1. Elevate the head of the bed.

- For maximal lung expansion that will improve oxygen delivery.

2. Position the head in the midline of the body. -Position changes allow free movement of the diaphragm and expansion of the chest wall. (Taylor et.al, FON

5th ed. Page 1396)

Asessment

Nursing Diagnosis

Background Knowledge

Goal And Objectives

Nursing Interventions

Rationale

Evaluation EFFECTIVENESS

Subjective: -The husband of the client verbalized, “Naku hindi na nawala ang lagnat ng asawa ko, pabalik-balik na lang” Objective: -Flushed skin; warm to touch -Increase body temperature higher than normal range -Increased respiration -The patient is sweating -T: 37.5˚C

Hyperthermia related to inflammatory response as evidenced by warm to touch skin.

Etiology Immediate Cause: Inflammatory response of the body against microorganism s.

Intermediate Cause: Infection of M. Tuberculosis Root Cause: Weakened immune system.

After 30 minutes of nursing interventions, the client will be able to lessen temperature of at least 1˚C range from that of 39˚C41˚C to 38˚C-39˚C and be free of chills

1. After 1 minute of nursing intervention, the family of the client will be able to assess for the causative/ contributing factor/s and be able to participate in one intervention.

1. After 1 minute of nursing intervention, was the family of the client able to assess for the causative/ contributing factor/s?

INDEPENDENT • Identify underlying cause (eg. hypothalamic dysfunction, such as drug overdose and infection).

INDEPENDENT •

Monitor patient’s

• To know for the right treatment to be given.

Yes____ No_____ Why_____

• Temperature of 102˚F- 106˚F (38.9˚C-

2. After 12 minutes of nsg. Int., was the family of the client able to evaluate effects of hyperthermia and able to participate in at least 5 out of 7

Health Implication: Fevers of 104 F (40 C) or higher demand immediate home treatment and subsequent medical attention, as they can result in delirium and convulsions, particularly in children.

2. After 12 minutes of nursing interventions, the family of the client will be able to evaluate effects of hyperthermia and be able to participate in at least 3 out of 4 interventions.

vital signs. Give particular attention to the temperature.

•

Assess for presence of posturing or seizures. • Monitor/ record all sources of fluid loss such as urine.

•

Note presence/ absence of sweating as body attempts to increase heat loss by evaporation, conduction and diffusion. DEPENDENT •

Administer

41.1˚C) suggests acute infectious disease process. Fever pattern may aid in diagnosis; eg 24 hour period suggest septic episode, septic endocarditis or Tuberculosis (TB). Chills often precede temperature spikes. [Nursing Care Plans Edition 6, page 667. Copyright 2002 by Marilyn E. Doenges, RN, BSN, MA, CS] • To note for further care to be given.

•

Oliguria and/or renal failure may be occurring due to hypotension, dehydration. [NANDA]

interventions? Yes____ No_____ Why_____

3. After 15 minutes of nursing intervention, was the family of the client able to assist with measures to reduce body temperature and participate in at least 6 out of 7 interventions? Yes____ No_____ Why_____

•

Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat or sweat gland dysfunction. [NANDA]

4. Was the family of the client able to attain wellness after the 2 interventions? Yes____ No_____

antipyretics.

INDEPENDENT 3. After 15 minutes of nursing interventions, the family of the client will be able to assist with measures to reduce body temperature and participate in at least 3 out of 4 interventions.

• Provide tepid sponge baths; avoid use of alcohol.

Why_____ • Used to reduce fever by its central action on the hypothalamus; fever should be controlled in patients who are neutropenic or asplenis. However, fever may be beneficial in limiting growth of organisms and enhancing autodestruction of infected cells. [Nursing Care Plans Edition 6, page 667. Copyright 2002 by Marilyn E. Doenges, RN, BSN, MA, CS]

Efficiency: Were interventions done within the time frame? ___Yes ___ No, Why? _______________ Appropriateness: Were the interventions realistic to the norms? ___Yes ___ No, Why? _______________

•

DEPENDENT • Administer replacement fluids and

May help reduce fever. Note: use of ice water/ alcohol may cause chills, actually elevating temperature. In addition, alcohol is very drying to skin. [Nursing Care Plans Edition 6, page 667. Copyright 2002 by Marilyn E. Doenges,

Acceptability: Were the interventions accepted by the client and his family? ___Yes ___ No, Why? _______________

electrolytes.

RN, BSN, MA, CS]

Adequacy: Were all the plans adequate? ___Yes

• Provide highcalorie diet, tube feedings or parenteral nutrition.

INDEPENDENT 4. After 2 minutes of nursing intervention, the family of the client will be able to promote wellness and give 2 out of 2 interventions.

• Discuss importance of adequate fluid intake. • Review signs and symptoms of hyperthermia (eg. Flushed skin, increased body temperature, increased respiratory/heart rate).

• To support circulating volume and tissue perfusion. [NANDA]

___ No, Why?

• To meet increased metabolic demands. [NANDA]

• To prevent dehydration. [NANDA]

• Indicates need for prompt intervention.

A. Discharge Planning Medications

Continue Taking the Anti-TB drugs. The intensive phase is for 2 months and the maintenance phase is for 4 months. Medicines are readily available at the health center.

Exercise/Economic Factor Treatment Health Teaching Out patient Follow-up

Diet Spiritual/Sexual Activities

Practice deep breathing exercise and coughing exercises. Resume previous activities. Prevent extraneous work. Have a regular physical exercise like brisk walking for 30 minutes daily. For financial insufficiency, there are government drug stores available. The patient may continue her work in the factory. Follow faithfully the regimen for tuberculosis, especially the medications. Have a regular sputum test, as ordered by the doctor. You should practice hand washing regularly. Always cover the mouth and the nose when exposed to person who coughs or sneezes. You should not spit anywhere, instead spit in a single container to prevent transfer of M. Tuberculosis. Always have a regular check up at your nearest health center, at least once a week to monitor the progress of the treatment. The client should report immediately to the physician if there is difficulty of breathing, there is productive cough more than 5 days and there is chest pain and experiencing fatigue. The diet should be high caloric. Always drink a lot of water. Also eat fruits and vegetables. Don’t escape meals. If there are any food supplements available, consult it with the doctor. Eat vitamin c rich food to strengthen immune systems. Always pray for the guidance of the Lord. Spiritual health affects the wellness of an individual greatly. Strengthen relationship with Lord by showing love and respect to the people around you.