CASE Study PTB
CASE Study PTB
CASE Study PTB
I INTRODUCTION
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
B. 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.
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 non-
bloody 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.
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.
E. Familial History
Female
F. Physical Assessment
• Upon Admission Date: September 19, 2008
• GCS-15 oriented to 3 spheres-(E4M6V5) Height: 62 inches
• V/S: BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-37.5 C Weight: 31.5 kilograms
• LOC: Oriented BMI: 12.5 (Severe Malnutrition)
4. Presence of edema Inspection No edema and Has Hollowness Abnormal, Volume deficiency of fat within
and hollowness in the hollowness the orbit (the space inside of the bony eye
socket). This condition of the patient is
eye. related to his nutritional status, she is
malnourished. Her BMI is 12.5.
(http://www.drmeronk.com/hollowed/under-eye-
hollows.html)
C. HAIR
2. Texture and oiliness Inspection Silky; resilient hair Silky, smooth and Normal.
Palpation
over the scalp resilient hair
3. Presence of infection Inspection No infection and Presence of lice Abnormal, There is pediculosis, a type of
Palption
and infestation infestation 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
IV. EYES
A. EYEBROWS
B. EYELASHES
C. EYELIDS
Surface characteristics Inspection Upper eyelids cover Able to close the eyes Normal
and position (in relation the small portion of and has the ability to
to the cornea, ability to the iris, cornea, and blink.
blink, and frequency of sclera when eyes are
blinking) open; eyelids meet
completely when the
eyes are closed;
symmetrical
D. CONJUNCTIVA
1. Color, texture, and Inspection Pinkish or red in color; Pale color; smooth in Abnormal, pale conjunctiva may be related
Palapation
the presence of lesions with presence of texture to the low RBC level of the patient.
in the bulbar conjunctiva small capillaries; (Fundamentals of Nursing 5th edition by
moist; no foreign Taylor, page 642)
bodies; no ulcers
2. Color, texture, and Inspection Pinkish or red in color; Pale Abnormal, pale conjunctiva may be related
Palpation
the presence of lesions with presence of to the low RBC level of the patient.
in the palpebral small capillaries; (Fundamentals of Nursing 5th edition by
conjunctiva moist; no foreign Taylor, page 642)
bodies; no ulcers
E. SCLERA
Color and clarity Inspection White in color; clear; White sclera with some Normal
no yellowish visible capillaries,
discoloration; some anicteric sclera.
capillaries maybe
visible
F. CORNEA
G. IRIS
Shape and color Inspection Anterior chamber is Dark brown in color; Normal
transparent; no noted transparent anterior
visible materials; chamber
color depends on the
person’s race
H. PUPILS
1. Color, shape, and Inspection Color depends on the Pupil size is 3mm. Normal
symmetry of size person’s race; size
ranges from 3-7 mm,
and are equal in size;
equally round
I. VISUAL ACUITY
1. Near vision Inspection Able to read Nearsightedness Abnormal, it is a refractive defect of the eye
in which collimated light produces image
newsprint (Myopia)
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).
J. LACRIMAL GLAND
K. EXTRAOCULAR
MUSCLES
L. VISUAL FIELDS
Peripheral visual fields Inspection When looking straight Can see objects in the Normal
ahead, client can see periphery.
objects in the
periphery
V. EARS
A. AURICLES
1. Color, symmetry of Inspection Color same as facial Same color as the Normal
size, and position skin; symmetrical; facial skin; tip of
auricle aligned with auricle aligned at the
outer canthus of eye, outer canthus of the
about 10 degrees eye.
from vertical
2. Texture, elasticity and Palpation Mobile, firm, and not Smooth in texture, Normal
areas of tenderness tender; pinna recoils flexible and elastic
after it is folded pinna; no tenderness
C. HEARING ACUITY
TESTS
1. Client’s response to Inspection Normal voice tones Can hear normal Normal
normal voice tones audible volume tones or words.
VI. NOSE
1.Any deviations in Inspection Symmetric and Symmetric and Abnormal, Nasal flaring suggests airway
shape, size, or color and straight; no discharge straight; Uniform color obstruction. Nasal discharge shows the
flaring or discharge from or flaring; Uniform with nasal flaring. presence of mucus secretions in the air
the nares color tract.
2. Nasal septum Inspection Nasal septum intact Nasal septum intact Normal
(between the nasal Palpation and in midline and in midline
chambers)
3. Patency of both nasal Inspection Air moves freely as Only left nares is Abnormal, not patent right nares show the
cavities the client breathes patent. Right nares is presence of mucus secretions and would
through the nares with secretion. suggest there is an infection in the
respiratory system.
4. Tenderness, masses, Palpation Not tender; no lesions Nor tenderness nor Normal
and displacements of lesions.
bone and cartilage
VII. SINUSES
VIII. MOUTH
A. LIPS
Symmetry of contour, Inspection Uniform pink color; Pink in color, dry and Abnormal, May suggest cellular dehydration.
color and texture Palpation soft, moist, smooth cracked lips (Black, Medical Surgical Nursing7th edition,
texture; symmetry of page 208).
contour; ability to
purse lips
B. BUCCAL MUCOSA
Color, moisture, texture, Inspection Uniform pink color; Pink color and dry. Abnormal, May suggests dehydration.
and the presence of moist, smooth, soft, (Black, Medical Surgical Nursing7th edition,
lesions glistening, and elastic page 208).
texture
C. TEETH
Color, number and Inspection 32 adult teeth; Has 31 adult teeth. The Abnormal, most unpleasant odors are known
condition and presence smooth, white, shiny patient has yellowish to arise from proteins trapped in the mouth
of dentures tooth enamel; teeth. Have bad which are processed by oral bacteria. The
smooth, intact breath. Have tooth most common location for mouth-related
dentures decay in the lower right halitosis is the tongue.
second molars. (http://en.wikipedia.org/wiki/Halitosis). It is
also related to dental carries and frequency
of tooth brushing.
D. GUMS
Color and condition Inspection Pink gums; no Pink gums; has no Normal
retraction visible retractions
E. TONGUE/FLOOR OF
THE MOUTH
1. Color and texture of Inspection pink color; moist; Pink and moist. Tongue Normal
moves freely and no
the mouth floor and slightly rough; thin
pain felt.
frenulum. whitish coating;
moves freely; no
tenderness
2. Position, color and Inspection Central position; pink Located and positioned Normal
texture, movement and color; smooth tongue in the center.
base of the tongue base with prominent
veins
F. PALATES and
UVULA
1. Color, shape, texture Inspection Light pink, smooth, The hard palate has a Normal
and the presence of Palpation soft palate; lighter lighter color than the
bony prominences pink hard palate , soft palate; has quite
more irregular texture rough texture
1. Color and texture Inspection Pink and smooth Dry, pinkish in color. Abnormal, May suggests dehydration.
posterior wall (Black, Medical Surgical Nursing7th edition,
page 208).
2. Size, color, and Inspection Pink and smooth; no Has no discharge; Normal
discharge of the tonsils discharge; of normal pinkish
size
X. THORAX
A. ANTERIOR THORAX
1. Breathing patterns Inspection Quiet, rhythmic, and Difficulty of breathing Abnormal, labored breathing is a common
effortless respirations 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,
page 1566).
2. Temperature, Palpation Skin intact; uniform Has an intact skin; has Normal
tenderness, masses temperature; chest equal warmth on both
wall intact; no sides. No masses.
tenderness; no
masses
3. Anterior thorax Auscultation Bronchovesicular and Has crackles sounds on Abnormal, crackles or rales are audible
auscultation vesicular breath the upper thorax & when there is a sudden opening of small
sounds lower thorax airways that contain fluid. It is usually heard
during inspiration. (Black, Medical Surgical
Nursing7th edition, page 1756).
B. POSTERIOR
THORAX
7. Posterior thorax Auscultation Vesicular and Has crackles heard on Abnormal, the condition is related to the
auscultation bronchovesicular the anterior and middle decreased size of the right lung and poor
breath sounds part of right and left inspiratory effort due to pain.
lungs. Diminished (http://www.nurse411.com/Heart_Lung_Sounds.asp)
lung sound on the
posterior right lung.
XI. CARDIOVASCULAR
A. AORTIC and Auscultation No pulsations No pulsations felt Normal
PULMONIC AREAS
E. CARDIOVASCULAR Auscultation S1: Usually heard at Has full and rapid Normal
AREAS all sites pulsation. 84
AUSCULTATION bpm/minute.
Usually louder at the
apical area Sounds on the aortic Normal
and pulmonic areas;
S2: Usually heard at has a lub sound on the
all sites apex and dub sounds
on the tricuspid area.
Usually louder at the
Normal
base of heart Blood pressure is 90/70
mm Hg.
Systole: silent
interval; slightly
shorter duration than
diastole at normal
heart rate (60 to 90
beats/min)
Diastole: silent
interval; slightly
longer duration than
systole at normal
heart rates
XII. CAROTID
ARTERIES
1. Carotid artery Palpation Symmetric pulse Has weak pulsation. Abnormal, decreased amount of blood
palpation volumes; full Symmetrical pulse. volume passing the artery. (Black, Medical
pulsations, thrusting Surgical Nursing7th edition, page 1574).
quality; quality
remains same when
the client breathes,
turns head, and
changes from sitting
to supine position;
elastic arterial wall
XIV. AXILLAE
1. Axillary, subclavicular, Inspection No tenderness, Have no masses and Abnormal, The appocrine glands located in
and supraclavicular masses, or nodules nodules. Presence of a the axillae produces sweat. The secretion of
lymph nodes foul smelling odor. 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)
XV. ABDOMEN
1. Skin integrity Inspection Unblemished skin; Uniform color and has Normal
uniform color no blemishes
XVI.
MUSCULOSKELETAL
SYSTEM
A. MUSCLES
3. Muscle tonicity Palpation Even and firm muscle Weak muscle tone Abnormal, possibly related to the amount of
food that patient is eating. Possible
tone
exhaustion experienced by the patient when
she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)
4. Muscle strength Palpation Has equal muscular Weak muscle strength Abnormal, possibly related to the amount of
food that patient is eating. Possible
strength on both
exhaustion experienced by the patient when
sides she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)
C. JOINTS
Mental Status
Cranial Nerves
CN 11 20x20 vision, able to Pupil size is 3 mm, able to Abnormal, it is a refractive defect of the eye in
Optic read, 3-5 mm [pupil read, myopia or which collimated light produces image focus in front
size] nearsightedness. 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 (+) Extraoccular Pupils react to light. There Normal
Occulomotor Movement (EOM); is constriction and
Trochlear Lateral Upward and consensual
Abducens downward; pupils accommodation. Able to
reactive to light. move the eyes in any
direction in unison.
CN V Able to feel and Normal
Trigeminal clearly identify Able to feel my finger on
stimulus, with her face while covering her
bilateral facial eyes.
sensation. With
active corneal reflex.
CN VII Normal
Facial (+) Corneal reflex , (+) Facial symmetry
Facial asymmetry
CN VIII
Vestibulocochlear Normal
Able to hear clearly, Can hear clearly and can
can maintain balance walk.
CN IX, X
Glossopharyngeal Normal
Vagus (+) gag reflex, uvula Present gag reflex, able to
at the center, soft swallow and able to
palate rises idebtify the taste of the
CN XI food.
Accessory (Spinal) Normal
Able to shrug
shoulders against Can shrug shoulders
resistance and able against resistance and can
to turn the head side turn the head fro right to
and against right.
resistance.
CN XII Normal
Hypoglossal 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 +4 active motion against Abnormal, possibly related to the amount of food
against full some resistance. that patient is eating. Possible exhaustion
resistance experienced by the patient when she coughs.
(http://en.wikipedia.org/wiki/Muscle_weakness)
Right Arm +4 active motion against Abnormal
(+5) Active motion some resistance.
against full
Left Leg resistance +4 active motion against Abnormal
some resistance.
Right Leg (+5) Active motion +4 active motion against Abnormal
against full some resistance.
resistance
(+5) Active motion
against full
resistance
G. 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.
Health perception- Health Management Measure for personal cleanliness and grooming, called personal
• The patient doesn’t have complete immunization because hygiene, promote physical and psychological well-being. Various
according to her it is not available during those days and studies have confirmed that improved personal hygiene practices
having immunization during those years are expensive and reduce illness rates. (Larson, 2002; Larson and Aiello, 2001).
they cannot afford it. Personal hygiene practices vary widely among people. The time of
• She was never been hospitalized. the day one bathes and how often one shampoo or changes the bed
linens, and sleeping garments are relatively unimportant. What is
• No known allergies to any foods and drugs. She can eat fish, important is that personal care be carried out conveniently and
oyster and others.
frequently enough to promote personal hygiene.
• Does not experience any accidents. Illness, hospitalization and institutionalization generally require
• When she had a disease, she used herbal medicines like guava modifications in hygiene practices. In these situations, the nurse helps
leaves, oregano, lagundi, etc. the patient to continue some hygiene practices, and can teach the
• For her, being healthy is important. A person is healthy when
she is strong, she can do what she wants and does not patient and family members, when necessary, regarding hygiene.
experience any diseases. Nurses assist the patient with basic hygiene must respect individual
• She does not have any regular medical and dental check-ups. patient preferences, providing only the care that patients cannot or
• When she is experiencing something wrong in her body, she should not provide for themselves.
does not tell it promptly because according to her it is (Fundamentals of Nursing 5th edition by Taylor, page 1005).
tolerable. Malnutrition is the lack of sufficient nutrients to maintain
• She does not have a regular exercise, instead she cleans the healthy bodily functions and is typically associated with extreme
house and washes the clothes of her family. poverty in economically developing countries. Most commonly,
malnourished people either do not have enough calories in their diet,
• The patient is malnourished.
or are eating a diet that lacks protein, vitamins, or trace minerals.
• She takes a bath once a day and brushes her teeth once a Medical problems arising from malnutrition are commonly referred to
day. as deficiency diseases. Deficiency in micronutrients such as Vitamin A
• She does use lotion, shampoo and soap. reduces the capacity of the body to resist diseases. Deficiency in iron,
• She washes her hands regularly but not always using soap. iodine and vitamin A is widely prevalent and represent a major public
• When she feels discomfort in her body she also goes to the health challenge. An array of afflictions ranging from stunted growth,
manghihilot because it is available on their area and it is more reduced intelligence and various cognitive abilities, reduced
approachable. sociability, reduced leadership and assertiveness, reduced activity
• She often forgot to cover her mouth and nose when someone and energy, reduced muscle growth and strength, and poorer health
sneezes and coughs in front of her. overall are directly implicated to nutrient deficiencies.
(http://en.wikipedia.org/wiki/Malnourishment)
• A person has a disease when she eats little amount of food, The main purpose of washing hands is to cleanse the hands of
when she is weak. pathogens (including bacteria or viruses) and chemicals which can
• Health for her is important for proper functioning. cause personal harm or disease, particularly diarrhea and pneumonia.
• Whenever she is sick, she get’s money from her children To maintain good hygiene, hands should always be washed after
especially to the eldest, which is working abroad. using the toilet, changing a diaper, tending to someone who is sick, or
• She wears slippers while inside their house. She feels that her handling raw meat, fish, or poultry, or any other situation leading to
hygienic practices are adequate, and she feels clean and neat. potential contamination. Hands should also be washed before eating,
• The patient is non-smoker and she does not drink any handling or cooking food. Conventionally, the use of soap and warm
alcoholic beverages. running water and the washing of all surfaces thoroughly, including
• She denies the use any illicit drugs. 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-medicine-
000351.htm)
Nutritional Metabolic Pattern Nutrition is a basic human need that changes throughout the life
• She loves to eat pork, fish and vegetables. cycle and along the wellness-illness continuum.
• She is not choosy when it comes to any cook and kind of food. (Fundamentals of Nursing 5th edition by Taylor, page 1135)
• She eats 3x a day An adequate food intake consists of balance essentials nutrients:
• She does not eat any junk foods. water, carbohydrates, fats, proteins, vitamins and minerals. Habits
about eating are affected by many factors like financial and health
• She drinks 5 glasses of water a day.
conditions. (Kozier et.al, Fundamentals of Nursing 7th ed. Page
• For her, the amount of food she consumes is adequate.
1171,1175)
• She takes food supplement but it is not frequent. The middle aged adult should continue to eat a healthy diet,
• During snack time, she usually eats banana because it is following the recommended portions of the 5 food groups, with
affordable and readily available in their place. special attention to protein, calcium and limiting consumption to
• When her cough started, she is not eating the appropriate cholesterol. Two to three liters of fluid should be included in the diet.
amount of food. Pre menopausal women need to ingest sufficient calcium and vitamin
• According to her husband, she usually eats 4 spoons of rice d to prevent osteoporosis. (Kozier et.al, Fundamentals of Nursing 7th
with viand only. It is due to her cough. ed. Page 1180,1181)
• During her hospitalization, she is on diet as tolerated with An adult individual needs to balance energy intake with his or her
aspiration precaution. level of physical activity to avoid storing excess body fat. Dietary
• She eats food given by the hospital. practices and food choices are related to wellness and affect health,
• She is taking vitamin B6 and other medications. 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/Adult-
Nutrition.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).
Activity and Exercise The human body was designed for motion, and regular exercise is
• She does not have any work, she is a plain house wife, who is necessary for its healthy functioning. Individuals who choose inactive
in-charge of her children. lifestyles or who are forced into inactivity by illness or injury placed
• Her usual activity is cleaning the house, cooking and washing themselves at high risk for serious health problems.
the clothes of her children. (Fundamentals of Nursing 5th edition by Taylor, page 1116)
Vigorous physical activity is not always needed to achieve positive
• She loves to listen to radio programs usually in the afternoon.
result.
• She likes to converse with her friends and neighborhood. (Fundamentals of Nursing 5th edition by Taylor, page 1117)
• When she cleans, it is usually for 1 hour because she gets Lack of exercise, inactivity, or immobility related to illness, or
easily tired. injury place a person at high risk for serious health problems.
• Her youngest child helps her in the household chores. Immobility can affect the major body systems. Like the benefits, a
• When after all the chores are done she will rest and watch person receives from exercise, complications resulting from
television. immobility differ occurrence and severity based on the patients age
and overall health status. (Kozier et.al, Fundamentals of Nursing 7th
• She does not involve her self in any vigorous activities.
ed. Page 1118).
• However, she is aware that her activity is not enough, and she
The wonderful tool of exercise can help teens become fit and
recognizes the importance of having regular exercise.
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)
Sleep and Rest For no known reason, 8 hours of sleep a night has been the
• The patient regularly sleeps at 8:00pm and wakes up at 1:00 accepted standard for adults despite obvious variations seen in the
pm. general population. It is important however that a person follows a
• She is experiencing intermittent sleep disturbance because pattern of rest that maintains well-being. Many factors affect a
according to her she feels difficulty of breathing and cough. person’s ability to rest. Illnesses and various life situations that
causes physiological stress tends to disturb sleep. Sleep quality is
• She usually sits because according to her she can breath more
also influenced by certain drugs Some decreases REM sleep
easily.
(barbiturates ,amphetamines and antidepressants) and some are
• She takes a nap in the morning from 8 am to 11 am. seen to
• She feels that her sleep and rest is inadequate. cause sleep problems (steroids, caffeine and asthma medications)
• She sleeps together with her husband. (Kozier et.al, Fundamentals of Nursing 7th ed. Page 1169-117).
• They have a separate room from their children. The National Sleep Foundation in the United States maintains
• Sleeping is important to her. 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)
3. Exercise Cleaning their house is the only Deep breathing and coughing The patient performs deep breathing
activity she considered as her exercises are advised and performed. exercise as instructed by the nurse.
exercise. She does not have routine The patient has decreasing function
exercise. However, she is aware that as the disease progresses.
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.
Na 135-145mmol/L
K 3.6-5.5mmol/L
• Electro Cardiogram
• Chest X-ray
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.
K. 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.
The patient was accompanied by her husband and her children. While waiting for the doctor, she was placed in a
wheel chair.
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
• 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.
•
Host
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
Does not regularly
Does not exposed to a person
take vitamins and
have a who coughs or
minerals
regular sneezes.
medical
check up.
Educationa
l Inadequate HOST
attainment of knowledge Infected of Weakened
. about health Tuberculosis immune Lack of
management Meningitis. system immunizations
..
Degen
eration Airborne
of transmission
health
y Does not
Taking a bath cells.. practice
once a day and proper
brushing teeth Exposure to a carrier hand
only once. of M. tuberculosis. washing.
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)
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.
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
Theophylline -The main - Mild stimulant - For chronic - Hypersensitivity -Stomach - Monitor patients’
mechanism of -Bronchodilator obstructive - Pregnant. stomach heart rate.
action of diseases of the -pain - Assess for CNS
theophylline is that airway. -Diarrhea effects.
of adenosine -COPD -Headache - Teach the patient to
receptor - Restlessness avoid smoking.
antagonism. - Insomnia - Educate the
- Irritability importance of taking
- Theophylline is a the right amount in
non-specific the right time of
adenosine medications.
antagonist, - Assess for any
antagonizing A1, hypersensitivity.
A2, and A3
receptors almost
equally, which
explains many of
its cardiac effects
and some of its
anti-asthmatic
effects.
SAlbutamol - A short-acting β2- - -Relief and -Contraindicated with -Dizziness, - Assess for any
adrenergic Bronchodialtor prevention of hypersensitivity to drowsiness, hypersensitivity to
receptor agonist bronchospasm in albuterol. fatigue, albuterol.
used for the relief patients with -Use cautiously with headache. - Be cautious when
of bronchospasm reversible diabetes mellitus - vomiting, driving.
in conditions such obstructive (large IV doses can change in taste -Eat food is a small
as asthma and airway disease aggravate diabetes frequent way.
chronic obstructive and ketoacidosis). - Maintain beta-
pulmonary -Inhalation: adrenergic blocker on
disease. Treatment of stand by.
acute attacks of
bronchospasm
-Prevention of
exercise-induced
bronchospasm.
Cefuroxime - Inhibits bacterial - Antibacterial - Treatment of - Hypersensitivity to - GI bleeding - Observe for signs
cell wall synthesis infections caused cefuroxime and other - Headache and symptoms of
by binding to one by staphylococci cephalosphorine. - Nausea anaphylaxis during
or more of the and other - Dizziness first dose; with
penicillin-binding microorganisms - Vomiting prolonged therapy,
proteins (PBPs) like klebsiella. - Increased BUN monitor renal,
which in turn - Treatment of and Creatinine hepatic, and
inhibits the final susceptible hematologic function.
transpeptidation infections of the - Educate the
step of lower respiratory importance of taking
peptidoglycan tract the right amount in
synthesis in the right time of
bacterial cell walls, medications.
thus inhibiting cell - Assess for any
wall biosynthesis. hypersensitivity.
-Bacteria
eventually lyse
due to ongoing
activity of cell wall
autolytic enzymes
(autolysins and
murein hydrolases)
while cell wall
assembly is
arrested.
Guiafen - Most - Decongestant -Used to relieve - MEDICINE IS NOT - Nervousness, - Assess for any
decongestants - Expectorant congestion and to RECOMMENDED if you dizziness, trouble allergies.
cause response treat cough due have a history of sleeping, nausea, -Instruct the patient
from to colds, flu, or severe high blood vomiting and to consult a doctor
adrenoreceptor a1, hay fever. pressure, severe headache. when the side effects
chiefly responsible coronary artery continues.
for disease, or if you have - Be careful when
vasoconstriction problems where the driving or operating
(a2 modulates supply of blood and machines.
adrenaline/noradre oxygen to the heart is - Instruct the patient
naline levels, b1 is reduced also known as that they should
the most ischemic heart swallow the
stimulating and disease. medication whole.
increases cardiac
output, b2 dilates
the bronchial
walls, and b3
induces lipolysis).
FLUIMUCIL -Is any agent Mucolytic -Acute & chronic -Contraindicated with -Urticaria, -Should be taken with
(nausil) which dissolves respiratory tract asthmatic patients bronchospasm, food
thick mucus affections w/ and patients with nausea, -The sachet should be
usually used to abundant mucus history of peptic vomiting. dissolve into a glass
help relieve secretions. ulceration. -Aerosol of cold or warm
respiratory -Used in the treatment: water, and drink
difficulties. treatment of wet Rhinitis, immediately.
(hydrolyzing cough. stomatitis. -Do not dissolve other
glycosaminoglycan medicines together
s: tending to break with Fluimucil, since
down/lower the both Fluimucil and
viscosity of mucin- the other drug effect
containing body could be influenced
secretions/compon or cancelled.
ents). - Assess for any
allergies.
IV Fluid
Treatment /
Classification Indication Contraindication Nursing Responsibilities
Infusion
B. Problem List
Subjective: Activity intolerance 4 This nursing diagnosis is not life threatening and
- The husband verbalizes that her wife related to inadequate doesn’t need immediate attention, however, it can
is easily getting tired. Her maximum oxygen supply as affect the body’s normal functioning
work is one hour only, and then she evidenced by easy Individuals who have inactive lifestyles or who are
would go to rest. fatigability. faced with inactivity because of illness or injury
- Her usual activities is cleaning the are at risk for many problems that can affect
house, cooking and washing the major body systems. Clients experience a
clothes. Their children help her wife. 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: Sleep Deprivation related 5 This condition doesn’t need immediate attention
- The patient regularly sleeps at to prolonged physical but needs to be addressed for sleep is a basic
8:00pm and wakes up at 1:00 pm. discomfort (dyspnea) as human need.
- She usually sits because according to evidenced by inability to A lack of rest for long periods can cause illness or
her she can breath more easily. concentrate worsening of existing illness. (Fundamentals of
- She takes a nap in the morning from Nursing, 6th ed by Potter and Perry p. 1206)
8 am to 11 am.
- She is experiencing intermittent
sleep disturbance because according
to her she feels difficulty of breathing
and cough.
C. Nursing Care Plan
EFFECTIVENESS
• Note presence/
absence of sweating as • Evaporation is
body attempts to decreased by 4. Was the family of
the client able to
increase heat loss by environmental factors
evaporation, conduction of high humidity and attain wellness after
the 2 interventions?
and diffusion. high ambient
temperature as well as
body factors Yes____
producing loss of
DEPENDENT ability to sweat or No_____
sweat gland
• Administer dysfunction. [NANDA] Why_____
antipyretics.
Efficiency:
• Used to reduce fever
Were interventions
by its central action on
done within the
the hypothalamus;
time frame?
fever should be
controlled in patients ___Yes
who are neutropenic
or asplenis. However, ___ No, Why?
fever may be
beneficial in limiting _______________
growth of organisms
and enhancing Appropriateness:
autodestruction of
infected cells. Were the
[Nursing Care Plans interventions
Edition 6, page 667. realistic to the
Copyright 2002 by norms?
INDEPENDENT Marilyn E. Doenges,
RN, BSN, MA, CS] ___Yes
• Provide tepid sponge
baths; avoid use of ___ No, Why?
3. After 15 minutes
alcohol.
of nursing _______________
interventions, the
family of the client Acceptability:
will be able to • May help reduce
assist with fever. Note: use of ice Were the
measures to water/ alcohol may interventions
reduce body cause chills, actually accepted by the
temperature and elevating client and his
participate in at temperature. In family?
least 3 out of 4 addition, alcohol is
interventions. very drying to skin. ___Yes
[Nursing Care Plans
Edition 6, page 667.
Copyright 2002 by ___ No, Why?
Marilyn E. Doenges,
DEPENDENT RN, BSN, MA, CS] _______________
• Administer Adequacy:
replacement fluids and
electrolytes. Were all the plans
adequate? ___Yes
• To support
circulating volume and ___ No, Why?
tissue perfusion.
• Provide high-calorie [NANDA]
diet, tube feedings or
parenteral nutrition.
• To meet increased
metabolic demands.
[NANDA]
INDEPENDENT
• Discuss importance of
4. After 2 minutes adequate fluid intake.
of nursing
intervention, the
family of the client • Review signs and • To prevent
will be able to symptoms of dehydration. [NANDA]
promote wellness hyperthermia (eg.
and give 2 out of 2 Flushed skin, increased
interventions. body temperature,
increased
respiratory/heart rate). • Indicates need for
prompt intervention.
D. 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 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.
Treatment Follow faithfully the regimen for tuberculosis, especially the medications. Have a regular sputum test, as
ordered by the doctor.
Health Teaching 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.
Out patient Follow-up 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.
Diet 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.
Spiritual/Sexual Activities 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.