PTB

ACKNOWLEDGEMENT
The completion of this case study on Pulmonary Tuberculosis could not have been possible without
the participation and assistance of so many people whose names may not all be enumerated. Their
contributions are sincerely appreciated and gratefully acknowledged. However, I would like to express
my deep appreciation and indebtedness particularly to the following: Ms Sabitra Sapkota, Ms Muna
Shrestha for their endless support, kind co-operation, and constant motivation during our posting and
understanding spirit during my case presentation.
I sincerely thank to Hospital Director, Doctors, Matron and all the staffs of Norvic International Hospital. I
would also gratitude the librarian of my college for providing me necessary books. I am also grateful to
my colleagues, seniors and all those who have contributed with their valuable suggestion.
Above all , with most astonishingly I like to express special thanks to Mr. Rajendra Khatri and his family
members as exclusive of them, it would not be feasible for me to complete my case study, as lots of
information needed for case study provided by them and their cooperation during nursing care
enhanced me to nurture my nursing skills competently and accomplish my objectives.
Thanking you
Sima Thapa
BN 1 st year (8th Batch)
Roll no :- 31
Table of Content
Page 1 of 76
Background of the Study.............................................................................................................................3
OBJECTIVES:.................................................................................................................................................4
Patient profile..............................................................................................................................................5
History Taking..............................................................................................................................................6
Physical Examination.................................................................................................................................10
DEVELOPMENTAL TASK..............................................................................................................................13
Anatomy physiology of Respiratory System:..............................................................................................13
Disease portion..........................................................................................................................................18
Definition...................................................................................................................................................18
Classifications of Pulmonary Tuberculosis.................................................................................................18
Incidence and prevalence rate...................................................................................................................19
Risk Factors................................................................................................................................................21
Causative Organism...................................................................................................................................21
Pathophysiology........................................................................................................................................21
Symptoms:.................................................................................................................................................23
Diagnostic Tests:........................................................................................................................................23
Medical Management...............................................................................................................................25
Surgical Management................................................................................................................................29
Nursing Management................................................................................................................................30
Application of nursing theory....................................................................................................................35
Prevention:................................................................................................................................................38
Complications............................................................................................................................................39
Prognosis:-.................................................................................................................................................40
Daily progress report.................................................................................................................................40
Drugs used in my patient...........................................................................................................................45
Drugs in detail ...........................................................................................................................................45
Discharge teaching :..................................................................................................................................65
Diversional therapy Used for my Patient during Hospitalization:...............................................................67
Summary :.................................................................................................................................................68
What I learned from case study :...............................................................................................................69
Conclusion :...............................................................................................................................................70
Bibliography...............................................................................................................................................71
Page 2 of 76
Background of the Study
This whole case study is about to discuss Pulmonary Tuberculosis (TB) .This case will tackle about the
disease, patients health and of course nursing intervention. Tuberculosis (TB) is one of the top 10
causes of death worldwide. In 2015, 10.4 million people fell ill with TB and 1.8 million died from the
disease (including 0.4 million among people with HIV). Over 95% of TB deaths occur in low- and middle-
income countries. Six countries account for 60% of the total, with India leading the count, followed by
Indonesia, China, Nigeria, Pakistan and South Africa. In 2015, an estimated 1 million children became ill
with TB and 170 000 children died of TB (excluding children with HIV). TB is a leading killer of HIV-
positive people: in 2015, 35% of HIV deaths were due to TB. Globally in 2015, an estimated 480 000
people developed multidrug-resistant TB (MDR-TB). TB incidence has fallen by an average of 1.5% per
year since 2000. This needs to accelerate to a 45% annual decline to reach the 2020 milestones of the
"End TB Strategy". An estimated 49 million lives were saved through TB diagnosis and treatment
between 2000 and 2015. Ending the TB epidemic by 2030 is among the health targets of the newly
adopted Sustainable Development Goals. Tuberculosis (TB) is caused by bacteria (Mycobacterium
tuberculosis) that most often affect the lungs. Tuberculosis is curable and preventable.TB is spread from
person to person through the air. When people with lung TB cough, sneeze or spit, they propel the TB
germs into the air. A person needs to inhale only a few of these germs to become infected. About one-
third of the world's population has latent TB, which means people have been infected by TB bacteria but
are not (yet) ill with the disease and cannot transmit the disease.
People infected with TB bacteria have a 10% lifetime risk of falling ill with TB. However, persons with
compromised immune systems, such as people living with HIV, malnutrition or diabetes, or people who
use tobacco, have a much higher risk of falling ill.When a person develops active TB disease, the
symptoms (such as cough, fever, night sweats, or weight loss) may be mild for many months. This can
lead to delays in seeking care, and results in transmission of the bacteria to others. People with active TB
can infect 1015 other people through close contact over the course of a year. Without proper
treatment, 45% of HIV-negative people with TB on average and nearly all HIV-positive people with TB will
die.
[ CITATION Mar \l 1033 ]
Page 3 of 76
OBJECTIVES:
General objectives
The general objective of this case study is to broaden our knowledge about the disease and develop
skills on how to render the best possible care to a patient suffering from Pulmonary Tuberculosis.
Specific objectives
To present a thorough Nursing Health History, Physical Assessment, and the interpretation of the
laboratory examination done on the patient.
To discuss the anatomy and physiology, pathophysiology of the patients condition, usual clinical
manifestations and possible complications of this condition.
To be able to know the other problems that the client is suffering right now not only PTB but also
Pneumothorax and Hydrothorax
To have knowledge to the client medication and be familiar to that medication.
To formulate a workable nursing care plan on the subjective and objective cues gathered through
nurse-patient interaction to be able to help the patient recover.
To apply skills learned in the classrooms to actual handling and caring of a patient who suffered from
Pulmonary Tuberculosis
To determine the possible nursing intervention that will be a great help in patients prognosis
To be able to give the appropriate health teaching and better understanding of the disease to the
patient, family and significant others.
Page 4 of 76
Patient profile
Name: - Rajendra Khatri
Age:-81 years
Sex: - Male
Ward :- General
Bed no:-230
IPD no :-OR74125561
Date of Admission: - 15 /May /2017
Old Diagnosis: - Chronic Obstructive Pulmonary Disease
PTB (Pulmonary Tuberculosis)
Final diagnosis: - Reactivation Tuberculosis (inadequately treated PTB chronic tuberculosis)
Attending Physician:- Dr. Saurabh Sharma
Admitting institute:- Norvic International Hospital
Page 5 of 76
History Taking
Biological Information
Name: Rajendra Khatri
Age:-81 years
Sex: - Male
Religion:- Hindu
Education: - Illiterate
Address: Chandragiri
Civil Status: Married
No. of Children:-4
Occupation: Welder
Nationality: Nepali
Date of admission: 15 /May /2017
Date of Interview: 21/May /2017
Chief Complain or reason for hospitalization:
Generalized Body Weakness since 9 days, continuous cough since 10 days (productive in nature, whitish
in color, and foul smelling not containing blood ).History of PTB 9 month back (taken cat 1 regimen for 4
months but many time he ignored to visit because was relieved ) He also gave history of fever since 3
days but temperature not recorded. History of anorexia and occasional vomiting non bloody . He also
had weight loss in last 6/7 months . No history of DM, HTN
Sources of Information:
Patient, Patient chart and the Significant Others (Son and Daughter in law)
Present illness:
The information that I gathered are mostly second hand as they came from the patient son and daughter
in law because of his inability to hear clearly and also due to his disease condition.
Patients condition started few weeks prior to consultation, as onset of cough, productive and an
intermittent fever usually in the afternoon which is not documented. According to his son it was relieved
by an intake of paracetamol. One week prior to admission the patient experienced worsening of the
condition, he had productive cough non-bloody with whitish secretions which was foul in smelling. There
is also difficulty of breathing and vomiting. The patient cant eat properly because he has no appetite for
food. He also experience stabbing pain on his chest and it radiates to his abdomen. The patient only took
paracetamol for his fever. On the day of, 2017 May 15 he was rushed to the hospital because of difficulty
Page 6 of 76
of breathing and heaviness in chest . Previously when he started experiencing these conditions, he
doesnt seek for any medical care from the physician because according to him it was tolerable
Past health History:
The patient had COPD (Chronic Obstructive Pulmonary Disease) since 2 years and PTB (Pulmonary
Tuberculosis) since 9 months. Previously he was hospitalized in kalimiti Chest Hospital. He does not have
complete immunizations because according to him it is not available in their place during those days, he
has no history of hypertension ,Diabetes mellitus and surgery . Whenever he had any flu or cough, he
uses herbal plants. He does not have any regular medical and dental check-ups. He does not have
allergies to whatever kind of foods and medications as far as he knows. According to him he had injury
in his big toes when he was young.
Familial History:
His wife dead 3 years back from accident when his wife was returning from ceremony .He lives in joint
family. There are 3 members in his family
FAMILY BACKGROUND TOTAL NO. OF FAMILY: 3
S Names of family Relation with Age Education Occupation Health

N members patient status
1. Bimala khatri Son 45years literate Retired army HTN
Now runs
cyber
2. Bimal khatri Son 35 years literate Abroad DM ,HTN
3. Sharmila khatri Daughter 30 years Literate House wife Piles
4. Aasha khatri Daughter 2years literate House wife Piles
5.. Rajendra Khatri Patient Self 81 years illitrate Welder Is
diseased.
Page 7 of 76
Family Tree
Index
Female
Patient
Dead
Male
Socio-economic history:
Total family income : no income of my patient , family income is Rs. 90,000 /month
Source of income : Abroad
Availability of food ( sufficient food): sufficient
Life style
No of meals taken in a day: twice
Meal timing: morning (9 to 10 am) and evening (around 9 pm)
Page 8 of 76
Food allergies: no any
Food dislikes: no any
Habits: smoking/ drinking alcohol/ drugs: He has smoked half a pack of cigarettes daily for more then 50
years with occasional alcohol intake.
Elimination habit: irregular and constipated
Personal care habit: havent taken bath for few months
Rest and sleep habit: on and off sleep usually disturbed
Recreational habit: watching television,
Environmental History
Type of drainage system: close drainage system
Type of latrine : water sealed
Source of drinking water: tap water
kitchen room style : Separate
Types of fuel used in cooking: L. P Gas as well as firewoods
Page 9 of 76
Physical Examination
1. General Inspection:
State of consciousness: alert , ill looking
Facial expression: tensed and sad
Gait: limping
Nutritional status: thin
Behavior :- appropriate reaction to situations
Cleanliness :- poorly groomed
Speech :- slow , few words at times
2. Measurements
Height : 5 feet 2 inch(1.574800m)
Weight: 40 kg
Body temperature:97.20F
Pulse: 112/ m
Respiration : 24b/m
Blood pressure: 140/90 mm of Hg
3. Examination of head, face, neck:
Inspect head for:
Color and texture of hair: white and thin hair , baldness present
Cleanliness: oily
Pediculosis : not present
Abrasions / injuries/ other: no any injuries or abrasions
Inspect eyes for:
Swelling of eyelids: no swelling
Discharge : no foreign body and no ulcers
Color of sclera/ conjunctiva: Pale color; smooth in texture
Page 10 of 76
Corneal/ lens opacity: transparent
Pupil size / reaction to light: pupils are round and uniform in size, constricts when light approach and
dilates when light is removed
Eye movement: equal and normal movement of both the eyes
Vision problem: not present
Inspect ears for:
Appearance : both ears are equally symmetrical
Discharge/ pain: no any discharge nor pain
Wax / redness of external auditory canals: wax presents
Hearing problems: no any hearing problems
Inspect nose for:
Discharge : no any discharge
Blockage : no
Bleeding : no bleeding from nose
Septal defect : no defect present, centrally located
Problem with smelling : no any problem with smelling
Inspect neck for:
Mobility : smooth and full range of movement, no stiffness of neck
Palpate neck for:
Enlarged lymph nodes : no enlarged lymph nodes
Enlarged thyroid nodes : no enlarged thyroid gland
Enlarged neck veins : enlarged neck veins
Inspect mouth for:
Color of lips/ mucous membrane : dry and brown
Sores / cracks / missing teeth, dental carries, bridge : dental carries and 9 teeth present
Page 11 of 76
Enlarged tonsils: no enlarged tonsils present
Oral hygiene : foul smell , poor oral hygiene
4. Examination of chest:
Inspect chest for:
Shape of the chest : pigeon shaped
Equal movement of chest during breathing : present
Difficulty in breathing : SOB
Auscultate chest for:
Breathing sounds (front and back) : crept and wheezing sound present
Heart sound ( 4 areas) : no murmur sound present
Percussion of the chest: deep resonant sound over the lungs
5. Examination of Abdomen:
Inspect the abdomen for:
Size : normal according body structure
Shape: flat
Enlarged veins : Enlarged veins
Auscultate abdomen for:
Bowel sounds : slow , presents
Percussion of abdomen: tympanic and dullness
Palpate abdomen for:
Enlarged liver : no enlargement
Enlarged spleen : no enlargement
Tenderness : no tenderness of abdomen
Masses : no masses found
6.Examination of limbs:
Inspect / Palpate limbs for:
Joint mobility / tenderness / redness / swelling / temperature : normal joint mobility
Page 12 of 76
Texture of skin- dryness and elasticized
Color of nails : slightly yellow
Palpate axillae/ groins for:
Enlarged lymph nodes : no enlarged lymph noods
7. Examination of back:
Inspect back for:
Position of spine / movement: spine is in the midline
Condition of skin/ prone to bedsore : dry , whitish skin exfoliated like dandruff
8. Examination of genitalia:
Inspect genitalia for:
Sores : pt says there is pain while micturation.
Discharge :
Hygiene :
IMPRESSION:
During physical examination of the patient, findings are:
Tensed and sad face
Dental carries and few missed teeth
Pigeon shaped chest
Dry skin
Abdominal pain
B/L chest pain
Toe nail discoloration due to injury
SOB and wheezing sound
Page 13 of 76
DEVELOPMENTAL TASK
My patient was 81 years old. So he belonged to the later adulthood (over 60 /65years ).
Ego Integrity vs. Despair(psycho-social crisis ) :- Integrity versus despair is the eighth and final stage of
Erik Eriksons stage theory of psychosocial development. This stage begins at approximately age 65 and
ends at death.As we grow older (65+ yrs) and become senior citizens, we tend to slow down our
productivity and explore life as a retired person. It is during this time that we contemplate our
accomplishments and can develop integrity if we see ourselves as leading a successful life.Erik Erikson
believed if we see our lives as unproductive, feel guilt about our past, or feel that we did not accomplish
our life goals, we become dissatisfied with life and develop despair, often leading to depression and
hopelessness. Success in this stage will lead to the virtue of wisdom. Wisdom enables a person to look
back on their life with a sense of closure and completeness, and also accept death without fear.
As he begins to reflect back on his life, he finds that he experiences feelings of satisfaction . In addition to
a career as a welder that he raised four children . He made valuable contributions to society, successfully
raised a family and every time he thinks of his grandchildren he realizes that he has given something to
the world that will ultimately outlast her.
Developmental task of older adults
According to book According to the patient

Adjusting to decreasing physical Present
health and strength.
Adjusting to retirement and reduced income. Present
Nurturing one another as husband and wife. Wife dead 3 years back
Maintaining contact with children and Present
grandchildren
Meeting social and civic responsibilities He had good friend circle , but since he had TB, his
neighbor refuse to meet him .
Establishing satisfactory housing arrangements. Present
Affiliating with ones age group. Present
Adjusting to death of spouse. Present
Finding meaning in life in the face of death. Present
Page 14 of 76
Anatomy physiology of Respiratory System:
RESPIRATION:
Respiration is the physiological process, the process is involved in exchange of gases between body cells
and the external environment, supply of oxygen to the tissues and excretion of carbon dioxide occurs
only through respiration. The normal respiratory rate is about 15-20 /minutes.
FUNCTIONS OF THE RESPIRATORY SYSTEM
The system transport air into the lungs and to facilitate the diffusion of oxygen into the blood
stream. It also receives waste carbon dioxide from the blood and exhales it.
It regulates homeostatic of pH through the regulation of CO2.
The respiratory organs protects from inhaled pathogens and irritating substances.
The first part of respiratory system (nose) also works as a smelling organ.
It excretes carbon dioxide and water vapour.
It maintains the acid base in the blood.
ORGANS OF THE RESPIRATORY SYSTEM
Nose
Pharynx
Larynx Upper respiratory tract
Trachea
Bronchi
Bronchioles Lower respiratory tract
Lungs
Diaphragm
Intercostal Muscles Respiratory muscles
Page 15 of 76
Respiratory
Description Function
Organs
-respiratory function
-Sense of smell
The nose is the primary opening for the respiratory
system, made of bone, muscle, and cartilage. The nasal The nasal cavity warms the air as it
Nose and Nasal cavity is a cavity within your nose filled with mucus enters, acting as filtration and
Cavity membranes and hairs. purifying the air by removing any
dust, pollen, and other
contaminants, before it passed to
the inner body.
Inhaling air through the mouth

allows more inhalation, as the oral
cavity is far larger than the nasal
Also called the oral cavity, the mouth is the secondary
cavity. The air also has less distance
exterior opening for the respiratory system. Most
to travel, meaning more air can
Mouth commonly, the majority of respiration is achieved via
enter your body and be used faster.
the nose and nasal cavity, but the mouth can be used if
The oral cavity has no hairs or
needed.
filtering techniques, meaning the air
you inhale does not undergo the
filtration process.
The pharynx is a wide muscular tube, situated from the

base of the skull to the level of 6th cervical vertebra. It
lies behind the nose, mouth and larynx. Length: 12-
Air that is inhaled enters the
14cm Width: upper parts widest 3.5cm
pharynx, where it descends into the
STRUCTURE/PARTS OF PHARYNX
larynx via a diversion from the
epiglottis.
1. Nasopharynx: The upper or nasal part of pharynx is
Pharynx known as nasopharynx. It lies behind the nasal cavity.
As the pharynx is used for
swallowing food as well as
2. Oropharynx: The middle or oral part of pharynx is
breathing, the epiglottis ensures that
known as oropharynx. It lies behind the mouth.
air can pass into the trachea, and
that food enters the esophagus.
3. Laryngopharynx: The lower or laryngeal part of
pharynx is known as laryngopharynx. It lies behind the
larynx.
Page 16 of 76
Larynx is the organ for production of voice, also known
as voice box.
Position of larynx: The larynx lies in the anterior

midline of the neck, extending from the roof of the
tongue and the hyoid bone to the trachea. In adult
male, it lies in front of the 3rd, 4th, 5th and 6th cervical
vertebra.
Size- Male: 44 mm, Female: 36 mm
It is larger in males, called Adam's apple.
STRUCTURE OF LARYNX
The larynx is composed of several irregularly shaped Aside from allowing us the ability of
cartilages attached to each other by ligaments and speech, the larynx also acts as a
membranes. The larynx is composed nine cartilages defense mechanism. If any food
Larynx
which are three unpaired and three paired. passes into the esophagus when
swallowing, the larynx produces a
Unpaired strong cough reflex.
Thyroid cartilage
Cricoid cartilage
Epiglottis
Paired
Arytenoid cartilages
Corniculate cartilages
Cuneiform cartilage
Trachea Also known as the wind pipe, the trachea is a tube The main respiratory function of the
made of cartilage rings that are lined with pseudo trachea is to provide a clear and
stratified ciliated columnar epithelium. unhindered airway for air to enter
and exit the lungs. Inside the
Length: 10-15cm Width: 2-3cm trachea, small hairs reside upon the
inner walls. These hairs catch dust
and other contaminants from
inhaled air, which are later expelled
Page 17 of 76
via coughing.
The bronchi connect the wind pipe

to the lungs, allowing air from
external respiratory openings to pass
The bronchi are two tubes stemming off of the end of
Bronchi efficiently into the lungs. Once in the
the trachea. Each tube is connected to a lung.
lungs, the bronchi begin to branch
out into secondary, smaller bronchi,
coined tertiary bronchi.
Tertiary bronchi divide to even smaller, narrower tubes Bronchioles lead to alveolar sacs,
Bronchioles
known as bronchioles. which are sacs containing alveoli.
Alveoli have extremely thin walls,

which allow the exchange of oxygen
Alveoli are hollow, individual cavities that are found and carbon dioxide to take place
Alveoli
within alveolar sacs. within the lungs. There are
estimated to be three million alveoli
in the average lung.
The diaphragm contracts to expand

the space inside the thoracic cavity,
whilst moving a few inches inferiorly
into the abdominal cavity. Whilst
The diaphragm is an important muscle of respiration this is happening, the intercostals
Diaphragm
which is situated beneath the lungs. muscles also contract, which moves
the rip cage up and out. The
contractions force air into the lungs,
by creating a negative pressure
through expansion.
Physiology of Gas Exchange
Page 18 of 76
Anatomy of respiratory system and organ functions cannot be complete if you dont understand the
transition between CO2 and O2. Once air has been inhaled, it passed through the airways until it reaches
the alveoli within the lungs. Alveolus are surrounded by capillaries, through which the gasses enter and
exit. Carbon dioxide enters the alveolus, where oxygen is extracted and passed back into the body. The
constant blood flow prevents saturation of the blood, allowing for optimal transfer. The following picture
better illustrates the process:
Disease portion
Definition
Pulmonary tuberculosis (TB) is a contagious bacterial infection that mainly involves the lungs
parenchyma, but can also affect the central nervous system, the lymphatic system, the circulatory
system, the genitourinary system, the gastrointestinal system, bones, joints, and even the skin (extra
pulmonary TB). It is characterized by pulmonary infiltrates , formation of granulomas with fibrosis and
cavitations .
Page 19 of 76
Fig :- Granuloma in lung tissue
Characteristics of Mycobacterium tuberculosis:
Mycobacterium Tuberculosis- Organism is rod shaped ,aerobic.

Non motile,gram positive acid fast micro organism.
Reproductive very slowly in human body.
Destroyed by heat, burning , boiling for 15 minutes,autoclaving, pasteurizing.
Ultraviolet rays are very effective and strong sun rays can kill this organism
Classifications of Pulmonary Tuberculosis
1.Exposure but No Evidence of Infection
class 1 have been exposed to TB, but their subsequent tuberculin skin test results are negative. The
follow-up course of action for people in this category depends on several factors, including how recent
and extensive the exposure was and the overall health of the individual. Significant exposure within the
past 3 months warrants a follow-up skin test at about 10 weeks after exposure. Sometimes, treatment is
started while waiting for the skin test results, particularly in individuals with HIV or young children.
2.Latent Infection but No Disease
Class 2 identifies those people who have a positive reaction to the tuberculin skin test but no symptoms
or other evidence of TB on a chest x-ray or additional testing. People in this category do not feel sick and
cannot spread the disease at this stage, but if left untreated, latent TB has the potential to develop into
active disease, or class 3 TB. Recommended treatment varies depending on a number of factors. For
example, people with HIV and infants and children less than 5 have an increased risk of developing class
3 TB, so they may warrant additional or longer treatment regimens.
3.Active Tuberculosis
Page 20 of 76
Class 3 includes anyone with active TB based on the presence of symptoms or positive laboratory testing.
Typical symptoms include a persistent cough that may produce blood or mucus, fever, chills, night
sweats, pain in the chest, loss of appetite, weight loss and weakness. A diagnosis of active TB can be
confirmed via a number of lab tests, the most important of which is identifying the presence of
Mycobacterium tuberculosis -- the bacteria that causes TB -- in the body. The most common way to
diagnose active pulmonary TB is by finding the bacteria in a sample of sputum.
4.Inactive or Suspected Tuberculosis
Class 4 TB identifies people who had active TB in the past but no longer show any evidence of active
disease. Their skin tests are positive and chest x-rays may be abnormal, but they have no symptoms and
their lab tests are negative
5. Extrapulmonary Tuberculosis It is when tuberculosis extends its infection to other parts of the aside
from the pulmonary cavity. The most fatal location is the central nervous system and its infection to the
bloodstream. Other locations may include the lymphatic system, the bones and joints and at times the
genitourinary system.
(May 18, 2015 http://www.livestrong.com/article/104821-first-signs-tuberculosis/)
Incidence and prevalence rate
Around one third of worlds population has tuberculosis and that between 2002 and 2020 an estimated
1000 million people will become newly infected. Tuberculosis (TB) remains one of the major public
health problems in Nepal. In 2014, total of 37,025 cases of TB were registered. Among them, 51 % were
pulmonry TB. Most cases were reported among the middle aged group with the highest among 15-
24 year of age (20%). The childhood TB is low at 2%.
Figure Age wise Distribution Trend of Total TB cases (NSP case only)
Female were twice as more than Male (M/F ratio of 0.5) reported to have TB. The CNR- case rate
notification (all forms) was 136 / 100,000, which was stable without any significant changes for last 5
years.
Page 21 of 76
Figure :-Sex Distribution of Total Registered TB cases(NSP only)
TB-HIV co-infection rate in Nepal is 2.4% (HIV among TB)
TB program In Nepal was able to save 31,187 lives this year nationally, but still 1049 deaths
were reported among general TB cases. The overall treatment success rates (all forms) nationally
of drug susceptible TB was 91% with 1.1% failure rates, 2% defaulted rates and 3.3% death rates. The
treatment success rates of NSP- new smear positive were 91% compared to 83% in retreatment
cases (relapse + Lost to follow up+ failure), 95% In NSN ve and 95% EP- extra pulmonary cases.
[ CITATION Ann71 \l 1033 ]
Risk Factors
1. Children,
2. Aged people,
3. Malnourished people,
4. Smoker and drug user,
5. Immune compromised people such as HIV/AIDS, chemotherapy, diabetes,
6. Overcrowded and unhygienic living area,
7. International travelers,
8. Health care provider.
Page 22 of 76
Causative Organism
Pulmonary TB is caused by M. tuberculosis which is a rod-shaped bacteria with a waxy capsule. It is non-
motile (requires external forces, such as coughing for example, to move from place to place), does not
form spores, and is aerobic.
According to book According to patient

M. tuberculosis Present
Pathophysiology
Inhalation of droplet infected with Mycobacterium Tuberculosis
It is trapped first in the upper airways, where the primary defenses

is activated referring to the mucus- secreting goblet cell and the
cilia.
When the initial prevention of infection is not successful, the

bacteria reaches and deposits itself in the lung periphery usually
in the lower part of the upper lobe or the upper part of the lower
lobe; specifically in the alveoli.
Progression of
infection may lead to
latent stage to active
The bacteria is quickly surrounded by polymorphonuclear
stage depending on
leukocytes and engulfed by the alveolar macrophages
both the virulence of
Some mycobacterial organisms are carried off by the lymphatics to the bacteria and the
the hilar lymp nodes microbicidal ability of
the alveolar
macrophages
It is now called as the Ghon Complex ,but it rarely results in the
spread to other body organs.
As macrophages (epithelial cells) engulf the bacteria, these cells join

and form into giant cells that encircle the foreign cell
As a result of hypersensitivity to the organism, inside the giant cells

caseous necrosis occurs (granular chessy appearance)
Page 23 of 76
There is then the proliferation of T- lymphocytes in the surrounding of
the central core of the caseous necrosis
causing some lesions.
Fibrosis and calcification happens as the lesion ages resulting to

granuloma formation called as tubercle
Collagenous scar tissue encapsulates the tubercle to separate the

organisms from the body
As the process progress the bacteria may or may not be killed and it
continue to grow and multiply resulting to a cell mediated immunity
(which can be detected through PPD
Pulmonary tuberculosis
For poorly immunocompromised clients, the necrotic tissue

liquefies and the fibrous walls losses its structural integrity
The semiliquid necrotic material is drained into the bronchous or in

the nearby blood vessel, leaving an air- filled cavity at the original site
If drained in the bronchous If drained into a vessel, it

as purulent discharge, it could enter the blood stream
could infect other people or in the lymphatic system;
through droplet where new caseous
transmission. granulomas may form
EXTRAPULMONARY
TUBERCULOSIS
Page 24 of 76
Symptoms:

Cough (sometimes producing phlegm) 2-3 weeks Present
Hemoptysis Absent
Excessive sweating, especially at night Absent
Fatigue Present
Fever Present
Unintentional weight loss Present
Breathing difficulty Present
Chest pain Present
Wheezing Present
Anorexia Present
Anemia in some Present
Diagnostic Tests:

History taking and physical examinations Done
Sputum examination for Acid-Fast Bacilli (AFB -- (Sent at gyntop but due because machine was
smear) not working ) *
Chest x-rays Done
CT scan --
TB culture of sputum or other specimen -- ( )*
tuberculin skin test (also called a PPD test) --
Gene expert test Done
Thoracentesis --
Bronchoscopy --
Biopsy of the affected tissue (rare) --
Finding on My Patient
HAEMATOLOGY
15th may 20th may 22th may Reference Range

Total Leukocyte 14710cell/cumm 10900 cell/cumm 10340 cell/cumm (4000-11000)
count 85% 82% 80 % (40-70)
Neutrophils 14% 15% 16% (20-40)
Lymphocytes 01% 02% 02% (2-10)
Monocytes 00% 01% 02% (01-06)
Eosinophils 00% 00% 00% (0-01)
Basophils 10.2gm% 9.0gm% 9.1gm% (13.5-17.5)
HB% 364000 cell/cumm 344000cell/cumm 364000cell/cumm (150000-400000)
Page 25 of 76
Platelets Count 32.1% 28.8% 29.2% (38.8-50.0)
PCV 3.92% 3.45millon/cumm 3.51million/cumm (4.5-5.5)
RBC 81.9fl 83.5fl 83.2fl (81.2-95.1)
MCV 26pg 26.1pg 25.9pg (27-32)
MCH 31.8% 31.3% 31.2% (31.5-34.5)
MCHC
Biochemistry
15th may 20th may 22th may Reference Range

Blood Sugar (R) 127mg/Dl 127mg/d/L - (70-140)
S.Urea 41mg/dL 24 mg/dL 40mg/dl (16-49)
S.Creatinine 1.1mg/d/L 0.9 mg/dL 0.9 mg/dl (0.7-1.3)
S.Sodium 134 mEq/l 134 mEq/l 137mEq/l (135-145)
S.Potassium 4.1 mEq/l 4.0 mEq/l 3.9 mEq/l (3.5-5.5)
S.Bilirubin(total) - 0.7 mg/dl 1.1 mg/dl (up to -1.2)
S.Bilirubin Conjugated - 0.3 mEq/l 0.8 mEq/l (0.0-0.4)
S.SGOT - 14U/L 16U/L (Up to -40)
S.SGPT - 11U/L 12U/L (Up to -41)
S.Alkaline Phosphate - 50U/L 48U/L (40-130)
s.Total Proteins - 6.71g/dL 6.71g/dL (6.4-8.3)
S.Albumin - 2.55g/dL 2.44g/dL (3.5-5.2)
S.Globulin - 4.16g/dL 4.27g/Dl (2.0-3.5)
Chest x- ray .
Post TB fibrosis ,secondary bacterial infection .
Pulmonary fibrosis (literally "scarring of the lungs") is a respiratory disease in which scars are formed in
the lung tissues, leading to serious breathing problems. Scar formation, the accumulation of excess
fibrous connective tissue (the process called fibrosis), leads to thickening of the walls, and causes
reduced oxygen supply in the blood. As a consequence patients suffer from perpetual shortness of
breath.
Page 26 of 76
Fig:- x-ray showing a reticular (net-like) pattern of increased interstitial lung markings in the peripheries
of both lungs
Gene expert
Mycobacterium tuberculosis =yes sensitive to Rifampicin
Medical management
According to book
Persons with TB can be cured through regular and complete intake of the prescribed anti TB
medications. Because patients frequently stop taking their medications before completing treatment,
the Directly Observed Treatment, Short-course (DOTS) strategy is recommended.
Registration category
Medicine taken Sputum result type
patients who have not done treatment of tuberculosis positive New case
before or taking anti tubercular drugs for less than 4 Or
weeks negative
Those who have completed the treatment positive Relapsed
Sputum test positive after continuous treatment for 5 Positive Failure after
month or smear negative after continuous treatment for Or treatment:
2 months & extra pulmonary T.B. Negative
Page 27 of 76
Discontinued treatment for 60 days or more positive Treatment after
Or defaulter
negative
Those who have completed Cat- 2 yet having sputum positive chronic
smear positive
Sputum result classification category
Positive New case of severe form of extra pulmonary TB, I.e. Category 1
meningitis, pericarditis, peritonitis, B/L or extensive
pleural effusion , spinal , intestinal , genitourinary .
Treatment after defaulter Category 2

Relapsed
Failure after treatment
negative New (sputum smear negative) or extra pulmonary Category 3
TB i.e. lymph node ,unilateral pleural effusion ,
bone ,peripheral joints or skin TB.
Category 1 (Fixed dose combination)
Treatment period- Total 6 months

o 2 months (60 doses) :- Intensive phase. (HRZE)
Tab. Isoniazide-75 mg+

Tab. Rifampicin-150 mg+
Tab. Pyrazinamide -400 mg+
Tab. Ethambutol -275 mg.
o Continuation phase (4 months)= 120 doses. (HR)

Isoniazide 75 mg+
Rifampicin 150 mg.

o Intensive phase (3 months)
Inj. Streptomycin I.M. daily 60 doses+ Tab. HRZE 90 doses.

Tab. Isoniazide 75 mg+
Tab. Rifampicin 150 mg+
Tab. Pyrazinamide 400 mg+
Tab. Ethambutol 275 mg.
Page 28 of 76
o Continuation phase (150 doses) (HRE).
Tab. Ethambutol 275 mg

o Intensive phase (2 months)

Tab. Pyrazinamide 400 mg+
o Continuation phase 4 months (120 doses) (HR).

Sputum Examination
Type of disease Sputum results at 2/3 months management
Category 1 (sputum Negative at 2 months Start continuation phase

smear positive)
Positive at 2 months Add intensive phase for 1 month then
start continuation phase
Positive at 5 months Re- examine sputum; if positive again,
start Cat 2.
Category 1( sputum Negative at 2 months Start continuation phase
negative & extra
pulmonary T.B.) Positive at 2 months Re- examine sputum; if positive again,
start Cat 2
Category 2 Negative at 3 months Start continuation phase
Positive at 3 months Add intensive phase for 1 month then

start continuation phase
Positive at 5 months Re- examine sputum; if positive again,
continue Cat 2, send culture &refer to
DOTS+ centre
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Management of patients with sputum smear positive who have discontinued the treatment.
(category 1)
*= patient should receive 60 doses of intensive phase.
**= re-starting the previous category.
*** = if treatment period exceeds 5 months; it is indicated as failure.
**** = either sputum sample or the patient needs to be referred for DOTS clinic for DST.
RAD= Return after defaulter
Treatment Treatment Sputum Sputum Re-register treatment

period left test result
< 1 month < 2 weeks no - - continue*
2-8 weeks no - - Re-start **

> 8 weeks yes positive RAD Re-start**
negative RAD? Continue*?

1-2 months < 2 weeks no - - Continue*
2-8 weeks yes positive - One month add
negative - Continue same*
> 8 weeks yes positive RAD Start Cat 2
negative RAD Continue*
> 2 months < 2 weeks no - - Continue*

2-8 weeks yes positive -*** Start Cat 2
negative - Continue*
> 8 weeks yes positive RAD Start Cat 2
Management of patients who have discontinued treatment, relapsed or failure of treatment
(Category 2)
Treatment Treatment Sputum Sputum Re-register treatment

period left test result
< 1 month < 2 weeks no - - Continue*
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2-8 weeks no - - Re-start**
> 8 weeks yes positive RAD Re-start**
negative RAD? Continue*
1-2 months < 2 weeks no - - Continue*
2-8 weeks yes positive - 1 month add

> 8 weeks yes positive RAD Re-start***
> 2 months < 2 weeks no - - Continue*
2-8 weeks yes positive - Start Cat 2****
> 8 weeks yes positive RAD Continue****
Surgical management
Surgery is rarely used to treat tuberculosis (TB). But it may be used to treat extensively drug-resistant TB
(XDR-TB) or to treat complications of an infection in the lungs or another part of the body.Surgery is used
to:
- Repair lung damage, such as serious bleeding that cannot be stopped any other way, or repeated
lung infections other than TB.
- Remove a pocket of bacteria that cannot be killed with long-term medicine treatment.
Surgery has a high success rate, but it also has a risk of complications, which may include infections other
than TB and shortness of breath after surgery.
Surgery for TB outside the lungs
Surgery sometimes may be needed to remove or repair organs damaged by TB in parts of the body other
than the lungs (extrapulmonary TB) or to prevent other rare complications, such as:
TB infection of the brain (TB meningitis). Surgically place a tube (shunt) that drains excess fluid from
the brain to prevent a buildup of pressure that can further damage the brain.
TB infections of the heart (TB pericarditis). Remove or repair the infected sac around the heart.
TB infection of the kidneys (renal TB). Either remove infected kidney or repair the kidney or other
parts of the urinary system.
TB infection of the joints. Repair damaged areas of your spine or joints (orthopedic surgery).
Page 31 of 76
According to patient
Since my patient has not continued the previous treatment when he had PTB 9 month back , he was
kept in cat 1 regimen on 19th may and advised to treat in kalimati Chest hospital for further DOTS
treatment .
NURSING MANAGEMENT
Nursing Assessment
1. The nurse performs a complete history and physical examination.

2. Clinical manifestations of fever, anorexia, weight loss, night sweats, fatigue, cough, and sputum
production prompt a more thorough assessment of respiratory functionfor example, assessing the
lungs for consolidation by evaluating breath sounds (diminished, bronchial sounds, crackles),
fremitus, egophony, and dullness on percussion.
3. Enlarged, painful lymph nodes may be palpated as well. The nurse also assesses the patients living
arrangements, perceptions and understanding of TB and its treatment, and readiness to learn.
4. Determine the patients self efficacy to learn and apply new knowledge .
5. Assess ability to learn or perform desired health related care .
6. Identify the learner: the patient, family significant other or care giver .
Nursing Diagnosis
Based on the assessment data, the nursing diagnoses may include
1. Ineffective airway clearance related to copious tracheobronchial secretions

2. Hyperthermia related to the reaction to infection .
3. Imbalanced nutritional requirement , less than body requirements related to anorexia
4. Constipation related to lack of activity .
5. Deficient knowledge about treatment regimen and preventive health measures related to Cognitive
limitations
POTENTIAL COMPLICATIONS
1. Malnutrition
2. Adverse side effects of medication therapy: hepatitis, neurologic changes (deafness or neuritis), skin
rash, gastrointestinal upset
3. Multidrug resistance
4. Spread of TB infection (miliary TB)
Planning and Goals
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The major goals for the patient include maintenance of a patent airway, reduce temperature ,
Demonstrate progressive weight gain toward goal with normalization of laboratory values and be free of
signs of malnutrition, Patient maintains passage of soft, formed stool at a frequency perceived as
normal by the patient. increased knowledge about the disease and treatment regimen and adherence
to the medication regimen, and absence of complications.
NURSING INTERVENTIONS
1. PROMOTING AIRWAY CLEARANCE
Nursing Interventions Rationale

Assess respiratory function noting breath sounds, Diminished breath sounds may reflect atelectasis.
rate, rhythm, and depth, and use of accessory Rhonchi, wheezes indicate accumulation of
muscles. secretions and inability to clear airways that may
lead to use of accessory muscles and increased
work of breathing
Note ability to expectorate mucus and cough Expectoration may be difficult when secretions are
effectively; document character, amount of very thick as a result of infection and/or
sputum, presence of hemoptysis. inadequate hydration. Blood-tinged or frankly
bloody sputum results from tissue breakdown
(cavitation) in the lungs or from bronchial
ulceration and may require further evaluation or
intervention.
Place patient in semi or high-Fowlers position. Positioning helps maximize lung expansion and
Assist patient with coughing and deep-breathing decreases respiratory effort. Maximal ventilation
exercises. may open atelectatic areas and promote
movement of secretions into larger airways for
expectoration.
Clear secretions from mouth and trachea; suction Prevents obstruction and aspiration. Suctioning
as necessary may be necessary if patient is unable to
expectorate secretions
Maintain fluid intake of at least 2500 mL/day High fluid intake helps thin secretions, making
unless contraindicated. them easier to expectorate.
2. Maintain normal body temperature

Observation of vital signs, especially temperature, To determine interventions.
as indicated.
Identify the triggering factors. Determination and management of the underlying
cause are necessary to recovery.
Determine the patients age and weight. Extremes of age or weight increase the risk for the
inability to control body temperature.
Adjust and monitor environmental factors like Room temperature may be accustomed to near
room temperature and bed linens as indicated. normal body temperature and blankets and linens
Page 33 of 76
may be adjusted as indicated to regulate
temperature of the patient.
Eliminate excess clothing and covers Exposing skin to room air decreases warmth and
increases evaporative cooling.
Give antipyretic medications as prescribed Antipyretic medications lower body temperature
by blocking the synthesis of prostaglandins that act
in the hypothalamus.
Ready oxygen therapy for extreme cases. Hyperthermia increases the metabolic demand for
oxygen
3. To maintain appropriate weight.

Document patients nutritional status on Useful in defining degree or extent of problem
admission, noting skin turgor, current weight and and appropriate choice of interventions.
degree of weight loss, integrity of oral mucosa,
ability or inability to swallow, presence of bowel
tones, history of nausea and vomiting or diarrhea.
Ascertain patients usual dietary pattern. Include in Helpful in identifying specific needs and
selection of food. strengths. Consideration of individual preferences
may improve dietary intake.
Monitor I&O and weight periodically Useful in measuring effectiveness of nutritional
and fluid support.
Provide oral care before and after respiratory Reduces bad taste left from sputum or
treatments. medications used for respiratory treatments that
can stimulate the vomiting center.
Encourage small, frequent meals with foods high Maximizes nutrient intake without undue
in protein and carbohydrates. fatigue/energy expenditure from eating large
meals, and reduces gastric irritation.
4. Establish normal bowel habit .
Nursing intervention Rationale

Check on the usual pattern of elimination, It is very crucial to carefully know what is
including frequency and consistency of stool. normal for each patient. The normal frequency
of stool passage ranges from twice daily to once
every third or fourth day. Dry and hard feces are
common characteristics of constipation
Check out usual dietary habits, eating habits, Irregular mealtime, type of food, and
eating schedule, and liquid intake. interruption of usual schedule can lead to
constipation.
Assess the patients activity level. Sedentary lifestyle such as sitting all day, lack of
exercise, prolonged bed rest and inactivity
contribute to constipation.
Classify current medications usage that may lead A lot of drugs can slow down peristalsis. Opioids,
to constipation. antacids with calcium or aluminum base,
antidepressants, anticholinergics,
Page 34 of 76
antihypertensives, general anesthetics,
hypnotics, and iron and calcium supplements can
cause constipation.
Consider the degree to which the patient responds Ignoring the urge to defecate eventually leads to
to the urge to defecate. chronic constipation because the rectum no
longer senses or responds to the presence of
stool. The longer the stool stays in the rectum,
the drier and harder it becomes. This will make
the stool difficult to pass.
Encourage the patient to take in fluid 2000 to 3000 Sufficient fluid is needed to keep the fecal mass
mL/day, if not contraindicated medically. soft. But take note of some patients or older
patients having cardiovascular limitations
requiring less fluid intake
Assist patient to take at least 20 g of dietary fiber Fiber adds bulk to the stool and makes
(e.g., raw fruits, fresh vegetable, whole grains) per defecation easier because it passes through the
day. intestine essentially unchanged.
Urge patient for some physical activity and Movement promotes peristalsis. Abdominal
exercise. Consider isometric abdominal and gluteal exercises strengthen abdominal muscles that
exercises. facilitate defecation.
Encourage a regular period for elimination. Most people defecate following the first daily
meal or coffee, as a result of the gastrocolic
reflex.
5. ADVOCATING ADHERENCE TO TREATMENT REGIMEN
Nursing intervention Rationale

Assess patients ability to learn. Note level of Learning depends on emotional and physical
fear, concern, fatigue, participation level; best readiness and is achieved at an individual pace.
environment in which patient can learn; how
much content; best media and language; who
should be included.
Provide instruction and specific written Written information relieves patient of the
information for patient to refer to schedule for burden of having to remember large amounts
medications and follow-up sputum testing for of information. Repetition strengthens learning.
documenting response to therapy.
Explain medication dosage, frequency of Enhances cooperation with therapeutic
administration, expected action, and the reason regimen and may prevent patient from
for long treatment period. Review potential discontinuing medication before cure is truly
interactions with other drugs and substances. affected. Directly observed therapy (DOT) is the
treatment of choice when patient is unable or
unwilling to take medications as prescribed.
Encourage abstaining from smoking. Although smoking does not stimulate
recurrence of TB, it does increase the likelihood
of respiratory dysfunction or bronchitis.
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6. . Monitor and manage
vital sign regularly
Complications
- Use standard precautions and wear gloves, gowns when providing direct care to the patient.
- Maintain effective hand wash after giving care to patient.
- Nurse and visitors must wear an N-95 mask while entering the patient room.
- Dispose all PPE (Personal Protective Equipment) carefully in different colored bin.
- Provide isolation care until the patient is no longer contagious.
Malnutrition
side effects of medications, liver function test to be done
- Give medicine in empty stomach , food affects absorption.
- Rifampicin increase metabolism of blockers,anti cougulants , oral contractive pill,digoxin, verapamil
- Inform patient that rifampicin discolours urine, colours eye lens.
- Monitor for liver and kidney function
Sputum culture to see response and adherence to therapy.
Isoniazid: Peripheral neuritis
Streptomycin : Tinnitus
Pyrazinamide : Hepatotoxicity
Ethambutol: Blurred vision
Evaluation
1. Maintains a patent airway by managing secretions with hydration ,humidification, coughing, and
postural drainage
2. Adheres to treatment regimen by taking medications as prescribed and reporting for follow-up
screening
3. Participates in preventive measures
- Disposes of used tissues properly

- Encourages people who are close contacts to report for testing
- Adheres to hand hygiene recommendations
4. Maintains activity schedule
5. Exhibits no complications
6. Maintains adequate weight or gains weight if indicated
7. Takes supplemental vitamins (vitamin B), as prescribed, to minimize peripheral neuropathy
8. Avoids use of alcohol
Page 36 of 76
Application of nursing theory
OREMS THEORY OF SELF CARE DEFICIT ACCORDING TO NURSING PROCESS
The self care deficit theory proposed by Orem is a combination of three theories, i.e.
- theory of self care

- theory of self care deficit and
- the theory of nursing systems.
In the theory of self care, she explains self care as the activities carried out by the individual to maintain
their own health.
The self care agency is the acquired ability to perform the self care and this will be affected by the basic
conditioning factors such as age, gender, health care system, family system etc.
Therapeutic self-care demand is the totality of the self care measures required.
The self care is carried out to fulfill the self-care requisites.
There are mainly 3 types of self care requisites such as universal, developmental and health deviation
self care requisites.
Here , I applied Orems theory while caring the patient during hospitalization in General Ward
Self care
R R
Therapeutic self
Self care R
care demand
capabilities
<
R R
Nursing
Nurse capabilities
A conceptual framework for nursing (R = relation ,<Deficit relationship current or project)
Page 37 of 76
1. BASIC CONDITIONING FACTORS
Age
81 year
Gender Male
Health state Feeling weak, due to disease condition therapeutic self care demand
Development state Integrity vs. Despair
Sociocultural orientation No formal education, Nepali, Hindu
Health care system Institutional health care
Family system Married, wife dead live with childrens
Patterns of living At home with childrens
Environment Rural area
resources Son , daughter in law , daughter .
2.UNIVERSAL SELF-CARE REQUISITES
Air Breathing difficulty, cough present , spo2 =87 % at room area , pigeon
shaped chest .
Water Fluid intake is insufficient, some dehydration present , dryness of skin

present .
Food Loss of appetite ,Hb 9.1gm%, BMI = 16.22 (underweight.).Food intake
Page 38 of 76
is not adequate or the diet is not nutritious.
Elimination No passage of stool for 3 days .
Activity/ rest Pain in chest and abdomen ,wakes often , sleep on and off
Activity level has come down due to pain and aging
Social interaction Communication with son and daughter is not well , dislikes his family
member but like his neighbors
Prevention of hazards Floor was dry and clean but slippery , ward was congested and no
proper ventilation , side rails kept .
Promotion of normalcy Change in behavior and disturbance in memory since 2 years .
3. DEVELOPMENTAL SELF-CARE REQUISITES
Maintenance of
developmental environment Able to feed self but need assistance , Difficult to perform the
dressing, toileting etc , Doesnt perform brushing and bathing
Prevention/ management of the Angry with family members , wants to get married .
conditions threatening the normal
development
4. HEALTH DEVIATION SELF CARE REQUISITES
Adherence to medical regimen

Refuse to take medication and any other investigations
Awareness of potential problem associated Not aware about the actual disease process.
with the regimen Not compliant with the diet and prevention of hazards. Not
aware about the side effects of the medications
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Modification of self image to incorporates Often time refuses to take oxygen and wear mask .
changes in health status
Adjustment of lifestyle to accommodate Pain tolerance not achieved , occasional alcohol intake ,still
changes in the health status and medical smokes.
regimen.
Nursing diagnosis
1. Infective breathing pattern related to decreased lung capacity.

2. Fluid volume deficit related to lack of fluid intake
3. Imbalanced nutrition , less than body requirement related to anorexia
4. Constipation related to immobility
5. Self care deficit related to aging
6. Ineffective pain control related to lack of utilization of pain relief measures.
7. Deficient knowledge related to lack of recall and physical / cognitive limitations .
Outcome and plan
1. Maintenance of patient airway

2. Reduce pain
3. Patient will eat nutritious food .
4. Regular bowel habit will be instituted
5. Patient will recognize the need for medication and understand the treatment
6. Improve self care
Implementation
Theory of nursing system
1. Wholly compensatory system

2. Partly compensatory system
3. Supportive educative system
I applied the partly compensatory system and supportive educative in my patient as he was mentally
and physically able to perform activity of daily living and was able to fulfill his basic needs himself. Only
he needs partial support due to aging process.
DESIGN OF NURSING SYSTEM: partly compensatory and supportive educative.
GUDIANCE: Assess the various hindering factors for self care and how to tackle them.
SUPPORT:
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Provide all the articles needed for self care, near to the patient and ask the family members also
to give the articles nears to him.
Keep at rest in semi flowers position.
Encourage early ambulation.
Provide clear liquids in small amounts when oral intake is resumed and progress diet as
tolerated.
Give frequent mouth care with special attention for protection of the lips.
Provide quiet and peaceful environment.
Administered, medicine as prescribed in the cardex.
Provide diversion and psychological support to the patient (listening music, news, reading
newspaper)
TEACHING: Taught the family members and patient about personal hygiene, nutrition, fluid intake
and its value, light exercise, infection and prevention, and importance of continuity of medicine and
risk of recurrence of disease .
Prevention:
1. Avoid spend long periods of time in enclosed rooms with anyone who has active TB until that person
has been treated for at least 2 weeks.
2. Use protective measures and cover face with n-95 mask.
3. Avoid direct face to face contact and maintain a safe distance.
4. Carefully dispose infected person sputum in a covered bin.
5. Maintain standard hand hygiene after any work of the TB patient.
6. Avoid sharing personal belongings with infected person.
7. Use negative pressure room where infected air out those rooms regularly.
8. If someone lives with active TB patient, help and encourage the person to follow treatment
instructions.
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9. People who have been exposed to TB should have a skin test as soon as possible and have a follow-
up test at a later date, if the first test is negative.
10. BCG vaccination to prevent TB. But, the effectiveness of this vaccine is limited.
Complications
Despite successful cure of TB, chronic complications can arise from anatomic alterations at disease sites.
Examples include
Aspergilloma
An aspergilloma, also known as a mycetoma or fungus ball, is a clump of mold which exists in a body
cavity such as a paranasal sinus or an organ such as the lung. By definition, it is caused by fungi of the
genus Aspergillus. The most common organ affected by aspergilloma is the lung. Aspergilloma mainly
affects people with underlying cavitary lung disease such as tuberculosis, sarcoidosis, bronchiectasis,
cystic fibrosis and systemic immunodeficiency. Aspergillus fumigatus, the most common causative
species, is typically inhaled as small (2 to 3 micron) spores. The fungus settles in a cavity and is able to
grow free from interference because critical elements of the immune system are unable to penetrate
into the cavity. As the fungus multiplies, it forms a ball, which incorporates dead tissue from the
surrounding lung, mucus, and other debris.
Bronchiectasis:-
Bronchiectasis is a disease in which there is permanent enlargement of parts of the airways of the lung.
Wall damage due to tub. Granulation tissue
Pneumothorax :-
A pneumothorax is an abnormal collection of air in the pleural space that causes an uncoupling of the
lung from the chest wall.
Pleurisy
Pleurisy is a condition in which the pleura a membrane consisting of a layer of tissue that lines the
inner side of the chest cavity and a layer of tissue that surrounds the lungs becomes inflamed. Also
called pleuritis, pleurisy causes sharp chest pain (pleuritic pain) that worsens during breathing.
Pleural effusion
Pleural effusion, sometimes referred to as water on the lungs, is the build-up of excess fluid between
the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the
inside of the chest cavity and act to lubricate and facilitate breathing. Normally, a small amount of fluid is
present in the pleura.
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Empyema:- purulent fluid in pleural cavity
Rupture of Tuberculosis lesion in pleural cavity
Extensive lung destruction

Laryngitis,
HIV related opportunistic infections.
Prognosis:-
According to book .
Tuberculosis is a curable disease. Progress of tuberculosis from infection to frank illness involves
overcoming of the immune system defences by the bacteria. As the bacteria start to multiply, it affects
the immune system and finally overwhelms it to cause the disease.
Once diagnosed, with effective, adequate and appropriate therapy with anti tubercular drugs, treatment
is possible and so is cure.
Daily progress report
According to patient .
2017/15/5
Vital sign T= 99.8 0F

P= 98b/min
R= 28b/min
Bp =140/90 mm of Hg
Ventilation Spo2 :-93% at nasal cannula (4 l /min )
Diet Normal diet
Elimination No passage of stool
Medication INJ clavam1.2 mg IV TDS D1
Tab Medomol 500 mg TDS
INJ RL 3 pint IV over 24 hour
Tab alpan 40 mg OD
Syp polybin 10 ml TDS
Report Patient was received from emergency ward at 5pm. He was conscious but seems
weak and lethargic.CBC, RFT, RBS sent from ER, Report collected. Chest X-Ray
done from ER. Sputum for AFB I , MTB culteure collected . INJ Rl 2 pint
continues. Prescribed medication \were carried out. Oxygen at 4 l.
2017/16/5
Page 43 of 76
Vital signs T= 98. 80F
P= 92b/min
R= 26b/min
Bp =140/80 mm of Hg
Ventilation Spo2 :-93% at nasal cannula (4 l /min )
Diet High protein diet
Tab alpan 40 mg OD
Remarks Sputum AFB I , II sent to GYNTOP
2017/17/5

P= 92b/min
R= 26b/min
Bp =140/80 mm of Hg
Ventialition Spo2 :-97% at nasal cannula (4l/min )
Tab alpan 40 mg OD
Remarks Sputum Gene Expert Test sent in HERD NEPAL. Report collected
2017/18/5

P= 92b/min
R= 26b/min
Bp =140/80 mm of Hg
Ventilation Spo2 :-97% at nasal cannula (4l/min )
Elimination No , gases present
Tab alpan 40 mg OD
Remarks Strick intake output.
Plan to start ATT drugs
Page 44 of 76
2017 /19/5

P= 92b/min
R= 26b/min
Bp =140/80 mm of Hg
Ventilation Spo2 :-97% at nasal cannula
Elimination Fullness of abdomen ,farting , no passage of stool .
Medication Tab Medomol 500 mg TDS
INJ RL 3 pint IV over (9am 6 pm )
Tab AKT -4 1 sachet OD at 7 am
Tab alpan 40 mg OD
Tab B long 100 mg OD at 7 am
Tab olanzapine mg HS 8pm
Tab serenace 25 mg BD
Remarks Intake -2550ml
Output- 1600 ml
AKT started .
Psychiatric consultation :- (reports )
Pt seen over talkative, not oriented to time, place and person, quarrels in family
on and off.
History of: - disturbance of memory since 2 years. Change in behavior.
Impression :- DEMENTIA (SENILE TYPE )
DELIRIUM IN DEMENTIA.
2017 /20/5

P= 90 b/min
R= 26b/min
Bp =140/80 mm of Hg
Elimination Once , soft in consistency
Medication INJ RL 2 pint IV over (9am 6 pm )
Tab AKT -4 sachet OD at 7 am
Tab alpan 40 mg OD
Mevicol satchet glass of water HS
Remarks Intake -2700 ml
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Output- 1600 ml
CBC RFT LFT done report collected
2017 /21/5

P= 92b/min
R= 26b/min
Bp =140/80 mm of Hg
O2 off for 15 min then spo2 was 89% at RA
Tab alpan 40 mg OD
Output- 1100 ml
2017 /22/5

P= 92b/min
R= 26b/min
Bp =140/80 mm of Hg
Tab alpan 40 mg OD
Output- 1000 ml
CBC,RFT,LFT DONE report collected .
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2017 /23/5
Vital signs T= 100 0F

P= 92b/min
R= 26b/min
Bp =120/70 mm of Hg
Ventilation Spo2 :-98% at nasal cannula ( 2 l/min )
Tab alpan 40 mg OD
Output- 1150 ml
2017 /24/5
Vital signs T= 97.40F

P= 88b/min
R= 28b/min
Bp =140/90 mm of Hg
Ventilation Spo2 :-97% at nasal cannula ( 2 l / min )
Diet Normal diet
Medication Tab AKT -4 1 sachet OD at 7 am
Tab alpan 40 mg OD
Tab olanzapine 2.5mg HS 8pm
Mevicol satchet glass of water SOS
Remarks Intake :-2700
Output :-1150
Can be discharged from psychiatric side
Plan for discharge tomorrow .
2017 /25/5

P= 94b/min
R= 24b/min
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Bp =130/80 mm of Hg
Ventilation Spo2 :-98% at nasal cannula ( 2 l / min )
Medication Tab AKT -4 1 sachet OD at 7 am
Tab alpan 40 mg OD
Mevicol satchet glass of water SOS
Remarks Discharge
Tab AKT -4 1 sachet OD at 7 am continue
Tab alpan 40 mg OD continue
Syp polybin 10 ml TDS continue
Tab B long 100 mg OD at 7 am continue
Follow up in Dr B Shrivastva OPD after 7 days with CBC ,RFT, LFT report
Drugs used in my patient
1. Tab AKT -4 1 sachet

2. Tab B long 100 mg
3. Tab Medomol 500 mg
4. Syp polybin 10 ml
5. Tab olanzapine 2.5 mg
6. INJ RL 3 pint IV over
7. Tab alpan 40 mg
8. INJ clavam1.2 mg
9. Mevicol satchet
10. Tab serenace 25 mg
Drugs in detail .
1. AKT-4
AKT-4 kit is an anti-tuberculosis drug containing: 1 (tab) - Ethambutol Hydrochloride 800 mg + isoniazid
300 mg. 2 (tabs) - pyrazinamide 750 mg. 1 (cap) - rifampicin 450 mg.
Mechanism of action
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Preventing growth of bacteria that causes tuberculosis.
Suppressing the growth of tuberculosis causing bacteria.
Killing wide range of infection causing bacteria.
Inhibiting the growth of bacterial cell wall.
Dosage
Ethambutol :
- 4055 kg :-800 mg (14.520.0 mg/kg)

- 5675 kg :-1200 mg (16.021.4 mg/kg)
- 76-90 kg :-1600 mg (17.821.1 mg/kg)
- >90 kg :-1600 mg
Isoniazide :-5 mg/kg (usual dose 300 mg)
Pyrazinamide : -(weight-based dosing)
- 4055 kg :-1000 mg (18.225.0 mg/kg)

- 5675 kg :-1500 mg (20.026.8 mg/kg)
- 76-90 kg :-2000 mg (22.226.3 mg/kg)
- >90 kg :-2000 mg
Rifampicin : 10 mg/kg (usual dose 600 mg)
Indications
Isoniazid is used in the treatment of tuberculosis (tb)Isoniazid is an antibiotic. It works by killing the
bacteria that causes tuberculosis.
Rifampicin is used in the treatment of tuberculosis (tb) and leprosy.Rifampicin is an antibiotic. It
works by killing the bacteria that cause infections.
Ethambutol is used in the treatment of tuberculosis (tb).Ethambutol is an antibiotic. It works by
slowing the growth of bacteria that causes tuberculosis.
Pyrazinamide is used in the treatment of headache, dental pain, osteoarthritis, myalgia, arthralgia,
rheumatic fever, rheumatoid arthritis, post operative pain and fever.Pyrazinamide is a non-steroidal
anti-inflammatory drug (NSAID). It works by blocking the release of certain chemical messengers that
cause fever, pain, swelling, and blood clots.
Other
Bacterial infection of membranes covering the brain

Contagious disease of skin
Bacterial infection of membranes covering the spinal cord
Contagious disease of mucous membrane
Contraindications
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Acute gout or hyperuricaemia
Alcohol
Allergic reactions
Breastfeeding
Children aged below 3 years
Hypersensitivity
Side effects
Ethambutol : retrobulbar optic neurits (vision problem)

Isoniazide : hepatocellular jaundice, peripheral neuropathy in bilateral foot.
Pyrazinamide : jaundice, hyperuricemia so can precipitate gout.
Rifampicin : Jaundice, Flu like syndrome, rashes, decreased platelet count, orange coloured urine
Nursing considerations
The red-coloured capsule must be taken either 1 hour before breakfast or 2 hours after breakfast.
After taking the capsule the patient must not eat anything (except water) for at least an hour. The
remaining 3 tablets can be taken with food. These tablets can be taken together, i.e., all three with
breakfast or lunch or dinner. The 3 tablets can also be taken separately after different meals, but the
timings should be maintained.
During the course of these medicine, the patient's urine, tears, sweat may turn orange. This is a
normal event and patients must not panic. When in doubt, patients must consult their health
provider.
Along with AKT-4, many patients may need supplements for Vitamin B6(Pyridoxine) and Folic Acid.
Diabetics must monitor their blood sugars regularly while taking anti-tubercular treatment.
Certain groups of patients like elderly, diabetics, pre-existing liver disease, chronic alcohol use, etc.
must monitor their Liver Function Tests regularly while taking anti-tubercular treatment.
2. B Long
Trade name:-B long
Generic name: Pyridoxine (100 MG)
Vitamin B6 plays an important role in the body. It is needed to maintain the health of nerves, skin, and
red blood cells.
Mechanism of actions
Modifying the electrical activity thus relaxing and slowing overactive heart muscles.
Vitamin B6 is the collective term for a group of three related compounds, pyridoxine (PN), pyridoxal
(PL) and pyridoxamine (PM), and their phosphorylated derivatives, pyridoxine 5'-phosphate (PNP),
pyridoxal 5'-phosphate (PLP) and pyridoxamine 5'-phosphate (PMP). Although all six of these
compounds should technically be referred to as vitamin B6, the term vitamin B6 is commonly used
interchangeably with just one of them, pyridoxine. Vitamin B6, principally in its biologically active
coenzyme form pyridoxal 5'-phosphate, is involved in a wide range of biochemical reactions,
including the metabolism of amino acids and glycogen, the synthesis of nucleic acids, hemogloblin,
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sphingomyelin and other sphingolipids, and the synthesis of the neurotransmitters serotonin,
dopamine, norepinephrine and gamma-aminobutyric acid (GABA).
Dosage
Adult:-100-300 mg
Child 1-2 mg/kg/day
Indications
vitamin B6 deficiency
peripheral neuropathy in those receiving isoniazid (isonicotinic acid hydrazide, INH)
High cholesterol
Heart disease
hereditary disorders (such as xanthurenic aciduria, cystathioninuria, hyperoxaluria,
homocystinuria).
Contraindications
hypersensitivity
Side effects
Paresthesia
Flushing
Warmth
Lethargy
Dysfunction of nerves resulting in numbness
Nursing Considerations
Before using this drug, make sure about patient current list of medications, over the counter
products (e.g. vitamins, herbal supplements, etc.), allergies, pre-existing diseases, and current health
conditions (e.g. pregnancy, upcoming surgery, etc.).
To avoid vitamin supplements unless directed by prescriber.
Some health conditions may make patient more susceptible to the side-effects of the drug. Notify
doctor if experiencing burning, tingling, or numb feeling or any other side effects.
Ask to take as directed by doctor . Dosage is based on your condition.
lood studies Hct ,Hgb
To increase meat, bananas, potatoes, whole grains cereals in diet.
3. Paracetamol
Generic name: paracetamol
Trade name: medomol
Group: Non Steroidal Anti Inflammatory Drugs (NSAID)
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Mechanism of action:
It reduces the temperature by resetting the temperature regulating centre to normal when it is
deranged.It blocks the pain centre in thalamus. It inhibits synthesis of prostaglandins and prevents
sensitization of pain and receptors to histamine, bradykinin, and 5HT agents mediators of pain and
inflammation. It has analgesic, antipyretic and anti inflammatory action.
Dose:-
500mg- 1 gm orally 3-4 times daily.

Children: 15mg\kg\day repeated every 6 hours when necessary
Indication
Fever
Mild to moderate pain
Contraindications and precaution
Hepatic and renal dysfunction

Alcohol dependence
Preexisting anemia
Adverse effects
Occasionally skin rashes and allergic reaction
Rarely blood disorders (neutropenia, thrombocytopenia and agranulocytosis)
Nephropathy and neuropathy on prolonged use and overdose
GI irritation
Nursing consideration:-
Urine may become dark, reddish brown in colour so instruct patient about this as the change is
due to medicine.
Poisoning may occur if taken more than 10 gm at a time.
Tell the patient not to take medicine more than 10 day without medical approval
Keep the medicine above the child reach because paracetamol poisoning may occur to children
with minimum dose because of low hepatic enzymes.
4. Polybion
Mechanism of Action
Metabolizing carbohydrate thus maintains normal growth.

Maintaining many tissues of the body to prevent vitamin B2 deficiency.
Producing antibodies and hemoglobin by keeping blood sugar level in normal range.
Helping tissue in respiration and metabolism of fats, protein thus lowers blood cholesterol by
inhibiting the synthesis of LDL.
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Increasing the effects of the inhibitory neurotransmitter gamma-aminobutyric acid.
Pharmacokinetics
Absorbed from the gastrointestinal tract. Metabolized in the tissues, becoming a co-enzyme form -
adenosylcobalamin which is the active form of cyanocobalamin. Excreted in bile and urine.
Composition
Capsule Syrup Injection

Each capsule contains Each 5 ml contains Each 2 ml ampoule contains
Thiamine Mononitrate 10 mg Nicotinamide (15 MG) Thiamine HCl 10 mg
Riboflavine 10 mg Cyanocobalamin (2 Riboflavine Sodium
Pyridoxine HCl 3 mg MCG) Phosphate 4 mg
Ascorbic acid 150 mg Pyridoxine (0.75 MG) Pyridoxine HCl 4 mg
Nicotinamide 100 mg Sorbitol (70%) Cyanocobalamin 8 mcg
Cyanocobalaim 15 mcg Riboflavin (2.5 MG) Nicotinamide 40 mg
Calcium Pantothenate 50 mg Thiamine (2 MG) D-Panthenol 6 mg
Folic acid 1.5 mg Lysine (375 MG)
Biotin 100 mcg D-Panthenol (3 MG)
Dosage:
One capsule daily or as directed by the physician.

One teaspoonful 2-3 times daily or as directed by the Physician.
One ampoule once daily by intramuscular or slow intravenous injection or as advised by physician.
Indications
Polybion Syrup is used for the treatment, control, prevention, & improvement of the following diseases,
conditions and symptoms:
Anemia
Alzheimer's disease
Attention deficit hyperactivity disorder
Vitamin b12 deficiency
Pernicious anemia
Thiamine deficiency
Neurological disorders
Heart problem
Eye disorders
Migraine headache
Hyperhomocysteinemia
Neurological disturbances
Mental problems
Convulsions
Pregnancy complications
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Homocystinuria
High cholesterol
Diarrhea
Arthritis
Vitamin b3 deficiency
Central nervous system depressant
Bacterial and fungal infections
Bacterial spores
Cough
Cold
Analgesic
Contraindications
Active peptic ulcer

Acute myocardial infarction
Allergic reactions
Breastfeeding
Cardiac arrhythmias
Diabetes mellitus
Hypersensitivity to Vitamin B1
Side-effects
Swelling
Rapid weight gain
Diarrhea
Itching or mild rash
Restlessness
Itching of skin
Before using this drug, make sure about patient current list of medications, over the counter
products (e.g. vitamins, herbal supplements, etc.), allergies, pre-existing diseases, and current health
conditions (e.g. pregnancy, upcoming surgery, etc.).
Some health conditions may patient more susceptible to the side-effects of the drug. Notify doctor if
experiencing burning, tingling, or numb feeling or any other side effects .
Ask to take as directed by doctor . Dosage is based on your condition.
Tell your doctor if your condition persists or worsens.
Protect from light
5. Injection RL
Generic Name: sodium chloride, sodium lactate, potassium chloride, and calcium chloride
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Dosage Form: injection, solutionLactated Ringer's Injection, USP is a sterile, nonpyrogenic solution
containing isotonic concentrations of electrolytes in water for injection.
It is administered by intravenous infusion for parenteral replacement of extracellular losses of fluid and
electrolytes.
Compositions
Each 100 mL of Lactated Ringer's Injection USP contains:

Sodium Chloride USP 0.6 g; Sodium Lactate 0.31 g
Potassium Chloride USP 0.03 g; Calcium Chloride Dihydrate USP 0.02 g
Water for Injection USP qs
Dosage
As directed by a physician and is dependent upon age, weight, clinical condition of the patient and
laboratory determinations.
Indications
This solution is indicated for use in adults and pediatric patients as a source of electrolytes and water
for hydration.
Contraindication
severe metabolic acidosis or alkalosis, and in severe liver disease or anoxic states which affect lactate
metabolism.
Side effects
allergic reactions, such as localized or generalized hives and itching, swelling of the eyes, face, or
throat, coughing, sneezing, or difficulty breathing.
Other side effects of Lactated Ringer's Injection may include fever,
infection at injection site, or
redness/red streaking and swelling from the site of injection.
Fluid administration should be based on calculated maintenance or replacement fluid requirements

for each patient.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior
to administration, whenever solution and container perm
Solutions containing lactate should be used with great care in patients with metabolic or respiratory
alkalosis, and in those conditions in which there is an increased level or an impaired utilization of
lactate, such as severe hepatic insufficiency.
The administration of intravenous solutions can cause fluid and/or solute overload resulting in
dilution of serum electrolyte concentrations, overhydration, congested states or pulmonary edema.
The risk of dilutional states is inversely proportional to the electrolyte concentration. The risk of
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solute overload causing congested states with peripheral and pulmonary edema is directly
proportional to the electrolyte concentration.
Solutions containing sodium ions should be used with great care, if at all, in patients with congestive
heart failure, severe renal insufficiency, and in clinical states in which there is sodium retention with
edema.
Solutions containing potassium ions should be used with great care, if at all, in patients with
hyperkalemia, severe renal failure, and in conditions in which potassium ions retention is present.
In patients with diminished renal function, administration of solutions containing sodium or

potassium ions may result in sodium or potassium retention.
Solutions containing calcium ions should not be administered through the same administration set
as blood because of the likelihood of coagulation.
Frequent laboratory determinations and clinical evaluation are essential to monitor changes in blood
glucose and electrolyte concentrations, and fluid and electrolyte balance during prolonged
parenteral therapy.
6. Olanzapine
Generic Name: olanzapine
Brand Name: ZyPREXA, ZyPREXA Zydis
Olanzapine belongs to a class of drugs called atypical antipsychotics. It works by helping to restore the
balance of certain natural substances in the brain.
Zyprexa and its generic, olanzapine, are available in a tablet (2.5 milligrams (mg), 5 mg, 7.5 mg, 10 mg,
15 mg and 20 mg) and a disintegrating tablet (5 mg, 10 mg, 15 mg, 20 mg) that dissolves in the mouth.
There is also an immediate-release injection that comes in 10 mg vials.
May mediate antipsychotic activity by both dopamine and serotonin type 2 (5-HT2 ) antagonists ,may
antagonize muscarinic receptors ,histaminic and alpha adrenergic receptors
Dosage
Usual Adult Dose for Schizophrenia:
Initial dose: 5 to 10 mg orally once a day

Target dose: 10 mg orally once a day within the first several days; further dose adjustments, if
needed, should occur at intervals of not less than 1 week in 5 mg increments/decrements
Maximum dose: 20 mg orally once a day
For the Treatment of Depressive Episodes Associated with Bipolar I Disorder when used in Combination
with Fluoxetine:
Initial dose: 5 mg orally once a day (with fluoxetine 20 mg)
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Dose adjustments: Should be made with the individual components within the dose range of 5 to
12.5 mg as indicated according to efficacy and tolerability
Maximum dose: 12.5 mg per day (with fluoxetine 50 mg per day)
Usual Adult Dose for Depression:
Initial dose: 5 mg orally once a day (with fluoxetine 20 mg)

Dose adjustments: Should be made with the individual components within the dose range of 5 to 20
mg as indicated according to efficacy and tolerability
Maximum dose: 18 mg per day (with fluoxetine 50 mg per day)
Usual Adult Dose for Agitated State:
Immediate-Release Injection:
Initial dose: 10 mg IM once; dose range 2.5 to 10 mg IM

Subsequent doses up to 10 mg may be given every 2 hours for agitation that persists following the
initial dose
Maximum number of doses: 3 doses in 24 hours; additional doses in patients with clinically
significant postural hypotension are not recommended
Indications
Olanzapine is used to treat certain mental/mood conditions( such as schizophrenia, bipolar

disorder).
used in combination with other medication to treat depression.
decrease hallucinations and help to think more clearly and positively about self, feel less agitated,
and take a more active part in everyday life.
Contraindications
breast cancer
Diabetes
increased prolactin in the blood
high cholesterol
High Amount of Triglyceride in the Blood
excessive fat in the blood
Extreme Loss of Body Water
Overweight
Decreased White Blood Cells
Decreased Neutrophils a Type of White Blood Cell
Having Thoughts of Suicide, Parkinson Symptoms
Abnormal Movements of Face Muscles and Tongue
Neuroleptic Malignant Syndrome
Lower Seizure Threshold
closed angle glaucoma
Side Effects
Drowsiness
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dizziness
lightheadedness
stomach upset
dry mouth
constipation
increased appetite, or weight gain
Tell your doctor all the medications you are taking, including over-the-counter (OTC) drugs, herbal
products, dietary supplements, and recreational drugs, as well as any known allergies to
medications, foods, and other substances.
Zyprexa can be taken on an empty stomach, food has no significant effect on the way the drug
works. Advice patient to take the tablet once a day, at the same time every day so patient
remember it.
While using Zyprexa it's important to drink plenty of water each day.
Zyprexa may make patient sleepy, so advice don't drive a car or operate any machinery.
In addition, educate not to drink alcohol while taking this drug, since it can add to the drowsiness
already caused by Zyprexa.
It's also important to let the physician know if patient is using tobacco products since cigarette
smoking might decrease Zyprexa's effectiveness.
Taking olanzapine with other drugs that make patient sleepy or slow breathing which can cause
dangerous or life-threatening side effects. Ask doctor before giving a sleeping pill, narcotic pain
medicine, prescription cough medicine, a muscle relaxer, or medicine for anxiety, depression, or
seizures.
7. Alpan
Trade name :-alpan
Generic name :-Pantoprazole
Pantoprazole is a proton pump inhibiter or H+/K+ATPase enzyme inhibitors
mechanism of action
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pantoprazole binds to the H+/K+ ATPase enzyme system of the parietal cell ,suppressing
secretion of hydrogen ion (H+) gastric lumen.
Dose
20 40 mg OD or BD before meal
Indication
peptic ulcer or gastric ulcer
duodenal ulcer
stress ulcer gastritis
NSAIDs and corticosteroids induced gastritis
Aspiration
Anti microbial therapy
Contraindication
Hypersensitivity to pantoprazole
Inadequate vitamin B 12
Osteoporosis
Sever liver disease
Hypo magnesium
Side effect
Flatulence
Abdominal or stomach pain
Dry mouth
Diarrhea
Dizziness
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Nausea
Vomiting
Increase urination
Fruit like breath odor
Nursing consideration
Give tablet without regard to meals ,tablet should not be crush ,chew or split
Refrigerate vial ,protection from light .
Do not freeze reconstituted vials once diluted , the salutation is stable for 12 hours at room
temperature .
Explains important of taking drug exactly as prescribed .
tell patient to take the medicine before meals.
8. Clavam
Trade name :-Clavam
Generic name : Amoxicillin , Clavulanic Acid
Pharmacokinetics
Clavulanic acid has a high affinity for and binds to certain -lactamases that generally inactivate
amoxicillin by hydrolyzing its -lactam ring. Combining clavulanate potassium with amoxicillin extends
the antibacterial spectrum of amoxicillin to include many bacteria normally resistant to amoxicillin and
other penicillins and cephalosporins.
Composition
Clavam Injection Clavan tablet

Amoxycillin (1000 MG) Amoxicillin(500mg) ,
Clavulanic Acid (200 MG) Clavulanic Acid(125mg)
Mechanism if action
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Amoxycillin Clavulanic Acid
Amoxicillin Kills Bacteria By Interfering With The Clavulanic Acid Blocks The Activity Of A Chemical
Production Of The Bacterial Cell Wall. As A Result, (beta-lactamase), Which Is Secreted By Bacteria To
The Bacterial Cell Wall Is Weakened, The Cell Protect Themselves From Antibiotic Drugs Like
Swells And Then Ruptures Amoxicillin, Thereby Allowing The Antibiotics To
Act Against The Bacteria.
Dosage
Oral
Upper and lower respiratory tract infections
- Adult: Based on amoxicillin dose, 250-500 mg every 8 hours or 500-750 mg every 12 hours.
- Child: Based on amoxicillin dose: 125-250 mg every 8 hours. Children weighing <40 kg: 20-40
mg/kg/day in divided doses every 8 hours. Infants <3 months: up to 30 mg/kg/day in divided doses
every 12 hours.
Oral
Otitis media
mg/kg/day in divided doses every 8 hr. Infants <3 months: up to 30 mg/kg/day in divided doses
every 12 hours.
Oral
Sinusitis
mg/kg/day in divided doses every 8 hr. Infants <3 months: up to 30 mg/kg/day in divided doses
every 12 hours.
Oral
Skin and soft tissue infections
every 12 hours.
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Oral
Susceptible infections
every 12 hours.
Oral
Dental abscesses
- Adult: Based on amoxicillin dose: 3 g as a single dose, followed by another dose 8 hours later.
Oral
Acute uncomplicated urinary tract infections
- Adult: Based on amoxicillin dose: 3 g as a single dose, followed by another dose 10-12 hours later.
Oral
Severe or recurrent respiratory tract infections
- Adult: Based on amoxicillin dose: 3 g bid.
Oral
Uncomplicated gonorrhoea
- Adult: Based on amoxicillin dose: 3 g as a single dose with 1 g of oral probenecid.
Oral
Prophylaxis of endocarditis
- Adult: Based on amoxicillin dose: 2 or 3 g as a single dose. To be taken 1 hour before the dental
procedure.
Oral
H.pylori infection
- Adult: Based on amoxicillin dose: 0.75-1 g bid or 500 mg tid. To be taken with metronidazole or
claithromycin and a PPI or ranitidine bismuth citrate.
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Parenteral
Susceptible infections
- Adult: Based on amoxicillin dose: 500 mg every 8 hr. In severe infections, may increase to 1 g every 6
hours. Can be given via IM inj or slow IV injection over 3-4 minutes or IV infusion over 30-60
minutes.
- Child: <10 years: 50-100 mg/kg/day in divided doses.
Indication
Amoxycillin Clavulanic Acid

Amoxicillin Is Used To Treat Bacterial Infections Of Clavulanic Acid Is Used To Increase The Effect Of
The Respiratory Tract, Genital And Urinary Tract, Certain Antibiotics (amoxicillin) To Treat Bacterial
Skin And Soft Tissue, Ear, Nose And Throat, Heart, Infections Of The Respiratory Tract, Urinary Tract,
Blood, Teeth, And Gums. Ear, Nose And Throat, Skin And Soft Tissues, Bone
And Joints, And To Prevent Infections After Surgery.
It Is Never Used Alone To Treat Infections.
Contraindication
History of cholestatic jaundice or hepatic dysfunction associated with Amoxicillin and Clavulanate
Hypersensitivity to any penicillin
Penicillin hypersensitivity
Side effects
Amoxicillin Clavulanic Acid

Diarrhea, Urge To Vomit, And Vomiting, Skin Rash. Diarrhea, Inflammation Of The Large Intestine,
You May Also Experience Diarrhea, Stomach Upset, Causing Diarrhea With Blood And Mucus In Stools,
Seizures, Decrease In White Blood Cells, Prolonged Stomach Pain, Fever, Thrush (fungal Infection Of
Bleeding Time, Swelling, Hypersensitivity, Stomach The Vagina, Mouth And Skin Folds), Urge To Vomit,
Pain Or Severe Diarrhea (possibly With Bleeding), Vomiting, Hypersensitivity Reactions Like Fever,
Yellow Eyes Or Skin, Flu, Loss Of Appetite, Unusual Skin Rash And Hives (red, Itchy Bumps On Skin),
Bleeding Of Skin Or Bruising Or Skin Discoloration, Liver Dysfunction And Toxicity, And Jaundice.
Rashes And Itching, Blistering Of The Skin, Mouth,
Eyes, Or Genitals, Wheezing, Difficulty In
Breathing, Feeling Dizzy, Swelling Of Face, Neck Or
Tongue, Pain Or Burning While Urinating With
Darker Urine.
Nursing Consideration
Consult your doctor immediately if you develop watery or bloody diarrhea during or after this
medication
Diarrhea is a common problem
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Do not take it for more than 2 weeks
Do periodic assessment of renal, hepatic or hematopoietic functions
Hepatic dysfunction
If you use other drugs or over the counter products at the same time, the effects of Clavam Injection
may change. This may increase your risk for side-effects or cause your drug not to work properly. Tell
the docter about all the drugs, vitamins, and herbal supplements to prevent or manage drug
interactions. Clavam Injection may interact with the following drugs and products:
- Allopurinol
- Chloramphenicol
- Macrolides
- Oral contraceptives
- Probenecid
- Sulfonamides
- Tetracyclines
9. Movicol Sachet
Trade name :- Movicol Sachet
Generic name :-Macrogol , Sodium Chloride , Sodium Bicarbonate , Potassium Chloride
Composition: Macrogol(13.81 G) , Sodium Chloride(350.7 Mg) , Sodium Bicarbonate(178.5 Mg) ,

Potassium Chloride(46.6 Mg)
Macrogol is an inert substance that passes through the gut without being absorbed into the body. It
relieves constipation because it causes the water it is taken with to be retained in the bowel instead
of being absorbed into the body. This increases the water content and volume of the stools in the
bowel, making them softer and easier to pass.
Dosage
Constipation
- A dose of Movicol is 1 sachet dissolved in 125 ml ( pint) of water.Take this 13 times a day
according to the severity of your constipation.
Fecal impaction
- A dose of 8 sachets a day of Movicol is needed for the treatment of faecal impaction. Each
sachet dissolved in 125ml ( pint) of water.The 8 sachets should be taken within 6 hours for up to 3
days if required. If you have a heart condition, do not take more than 2 sachets in any one
hour.
Indications
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Helping people who have been constipated for a long time to have a comfortable bowel
movement.
Relieving more severe constipation known as faecal impaction, where there is a build up of
compressed and hardened stools (faeces) in the rectum, as a result of chronic constipation.
Contraindication
Children under the age of 12 years

Congestive heart failure
Crohn's disease
Hypersensitivity
Intestinal obstruction
Intestinal perforation
Liver cirrhosis
Plasma-potassium concentration
People with a hole in the gut (intestinal perforation).
People with a blockage in the gut (intestinal obstruction) caused by a structural or functional
disorder of the gut wall.
Renal impairment
Severe renal impairment
Sodium retention and oedema
Side effects
Abdominal pain.
Diarrhoea.
Feeling sick.
Vomiting.
Swelling or bloating of the abdomen.
Abdominal rumbling and gurgling sounds due to movement in the intestines.
Wind (flatulence).
Anal discomfort.
Headache.
Disturbances in the levels of electrolytes (particularly potassium) in the blood. See important
information section above.
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Nursing considerations
Do not store your Movicol above 25C.

Keep out of the sight and reach of children.
Stop taking this medicine and consult your doctor if you begin to feel weak, fatigued, breathless,
very thirsty with a headache, or get swollen ankles while taking this medicine. These symptoms may
indicate that your fluid and electrolyte levels are disturbed and your doctor may need to take a
blood test to check for this.
If the powder becomes discoloured or show any other signs of deterioration, consult
your pharmacist who will tell you what to do
may develop excessive diarrhoea, which can lead to dehydration. If this occurs, stop taking Movicol
and drink plenty of fluids.
Tell your doctor or pharmacist if you are taking, have recently taken or might take any other
medicines.Some medicines, e.g. anti-epileptics, may not work as effectively during use with Movicol.
Give the proper instructions ie :-Open the sachet and pour the contents into a glass. Add about
125ml or pint of water to the glass. Stir well until all the powder has dissolved and the Movicol
solution is clear or slightly hazy then drink it. If you are taking Movicol for faecal impaction it may be
easier to dissolve 8 sachets in 1 litre of water
10. Serenace
Trade Name: Serenace
Generic Nmae:- Haloperidol
Serenace 0.25 mg Tablet is an antipsychotic drug
Mechanism of Action
Haloperidol is a drug that has the capability to affect the mental state. Its precise mechanism of
action is unknown, but it acts on the neurotransmitter (chemical messenger) dopamine in the brain.
It blocks dopamine receptors and causes an increased turnover of dopamine in the brain, which has
a sedative effect. With medium-term administration, it causes decreased release of dopamine and
this, combined with the dopamine receptor blockade, leads to the antipsychotic effect of
Haloperidol. Haloperidol also blocks dopamine receptors in other areas of the brain, which may lead
to certain physical side effects (tremor, slow movements, alteration in muscle tone) and altered
release of some hormones.
Dosage
Parenteral administration
Agitation and aggressiveness associated with acute psychosis:
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2-10mg IM or IV initially
Adults
moderate symptoms: 1-5mg/day
severe symptoms: 5-10mg/day
daily doses should be titrated against response and may be as high as 100mg
Elderly and debilitated
1-3mg/day is usually sufficient
Children
Haloperidol is only appropriate for severely aggressive or hostile children, or for the treatment of
Tourette syndrome.
1-3mg/day (use liquid 10-30 drops)
maintenance dose is usually 0.05mg/kg/day
Indication
Schizophrenia
psychosis due to brain damage or mental deficiency
senile psychosis
manic phase of manic depressive illness
Tourette syndrome
delusions
hallucinations
confused states
tremulousness
aggressive behaviour
Contraindications
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Pre-existing coma
acute stroke.
Severe intoxication with alcohol or other central depressant drugs.
Known allergy against haloperidol or other butyrophenones or other drug ingredients.
Known heart disease, when combined will tend towards cardiac arrest.
side effects
sedation
postural hypotension (lightheadedness on standing)
increased heart rate
dry mouth
blurred vision
pupil constriction
constipation
nausea
urinary retention
sexual adverse effects
weight gain
increase in blood suger
Instruct patient to take drug exactly as prescribed, not to double dose to compensate for missed
ones and to avoid abrupt withdrawal of this drug to minimize risk of EPS
Instruct patient to take antacids 2 hours before or after this drug
Advice patient to avoid hazardous activities until drug response is determined because dizziness and
blurred vision are common. Remind patient to avoid OTC preparations because serious drug
interactions may occur; avoid also the use of alcohol and other CNS depressants since increased
drowsiness may occur
Advice patient to shift positions slowly because orthostatic hypotension may occur. Due to the
danger of hypotension, tell patient to avoid hot tubs, hot showers, tub baths and to take extra
precautions during hot weather to prevent heat stroke.
Tell patient to report sore throat, malaise, fever, bleeding, mouth sores and other adverse reactions
Teach patient to use good oral hygiene, frequent rinsing of mouth to prevent candidiasis. Sugarless
gum may be used for dry mouth.
Advice patient to use a sunscreen and sunglasses to prevent burns.
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Discharge teaching :
Discharge Teaching is an integral part of nursing process. It is the nurse's responsibility to plan the
patient continuity of care at home. Discharge teaching can help to prevent the secondary complication,
promote health and maintain normal life style and to prevent complication. It is the most important
aspect in providing holistic nursing care.
Objectives of discharge teaching plan:
To promote and maintain health as well as prevent from illness in home after discharge.
To consider primary health care concept in health teaching plan.
To provide need based health care and education
Discharge Teaching was provided on:
Nutrition
Calorie dense foods:
The best foods for TB patients would need to be high in calorie and nutrient rich to meet up rising
metabolic demands and to prevent further weight loss. Calorie dense foods include banana, cereal
porridge sooji or a halwa,wheat and porridge or drink, khichdi and so on.
Protein rich foods:
Increased protein needs are met by including groundnut, gingelly chikki or laddoo, or dry fruit and
nut mixes. If not able to eat due to poor appetite, the dry fruits and nuts can be powdered finely and
mixed into a milkshake or added to the roti or phulka to give more energy and protein. Eggs, paneer ,
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tofu, soya chunks are other protein rich foods that are easily absorbed as well. These can be diced
into small pieces or grated and added to soups or porridges or milkshakes.
Vitamin A, E, C:
Some of the best foods for TB patients include the yellow orange fruits and vegetables such as
orange, mango, papaya, sweet pumpkin, carrots which are rich in Vitamin A, while Vitamin C is
obtained from fresh fruits including guava, amla, orange, tomato, sweet lime, lemon, capsicum.
Vitamin E is usually found in wheat germ, nuts, seeds and vegetable oils.
B complex vitamins:
Most B complex vitamins are found in whole grain cereals and pulses, nuts and seeds. For non-
vegetarians, B complex can be obtained from eggs, fish, especially sea fish like salmon, tuna,
mackerel, sardines, chicken and lean cuts of meat.
When to visit health institution
Fever of 100.4F (38C) or higher, or as directed by your provider
Bloody material (sputum) that is coughed up from your lungs and into your mouth
Worsening or recurring night sweats
Increased coughing
Prevent the spread of TB
Make sure that your family, friends, and the people you work with are tested.
Keep your hands clean. Be sure to wash them every time you use them to cover your mouth when
you cough.
Sleep in a room alone and with good air flow (ventilation).
When you cough or sneeze, take steps to prevent the spread of TB:
o Cover your mouth and nose with a tissue.
o Put your used tissue in a closed bag and throw it away.
o If you don't have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands.
o Wash your hands often with soap and warm water for 20 seconds. If soap and water are not
available, use an alcohol-based hand gel.
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Remember to take your medicines:
Get involved in the Directly Observed Treatment, Short-course (DOTS) program.
Take your medicine at the same time every day. Each night, put out the pills for the next day. Mark a
calendar each day you take your pills.
Create reminders. Ask a family member or friend to remind you to take your pills.
Keep medicines where you will see them
Limit your activity to avoid feeling tired. Plan frequent rest periods.
Follow up: since relapse rate is high and recurrent infection tends to occur if not followed instruction
properly .
It is very important to have regular check ups at the clinic at least monthly.
Blood tests can be done to make sure the medications are not harming the liver
Chest x-rays may be done to see if there is improvement.
Sputum tests will be done to ensure medications are working. The sputum results also help decide
when a patient is no longer infectious and can return to his/her normal
Diversional therapy Used for my Patient during Hospitalization:
Diversional Therapy is a kind of therapy which diverts the mind of person. It is used in parallel with
medicine for the treatment of the sick person because during illness a person has more concerned about
his condition. This may lead to mental or emotional upset. Diversional therapy helps to divert the mind
to other areas, so it is so very useful for the sick person. So this diversion therapy is necessary for the
patient. I used the following therapies in my patient.
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1. Talk therapy:
I tired him to involve in family, relatives, friends, Neighborhood conversation. The process I used was
talking questions about his family, loved ones, like dislike. He showed good involvement in the
conversation.
2. Reinforcement therapy:
I always talk to him and gave a positive feedback upon his small progress. I used touched and
praise him to show the positive reinforcement.
3. Imaginary:
Thinking positively helps to divert ones mind. I advised him to imagine good things. I told him to take
everything positively.
4. Other process
I encourage him to listen radio, music watch television like news, and by reading newspaper may help to
divert mind. I encourage patient to communicate with his family and friends as he can. Also advised his
family members to be with him and share their experience so that he may think it as a normal thing. I
allowed the patient to share his feelings with the visitors and the other patient.
Thus I tried to manage stress and divert his mind by using different techniques.
Summary :
My patient Rajendra Khatri aged 81 yrs was admitted on 15th may /2017 at Norvic International
Hospital in bed no. 230 with the diagnosis of Reactivation Tuberculosis .He had chief complain of
generalized body weakness, cough ,fever anorexia ,occasional vomiting and weight loss
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I collected subjective and objective data for my case study by history taking and physical examination. I
collected more information through lab investigations and by asking with the doctors who was looking
after him. I compared his developmental task with the task present in book. During hospitalization I
provided the basic nursing care according to his health needs. I also provided him knowledge about the
disease condition and its cause ,management and prevention .During hospitalization and during
discharge I provided him health teaching on nutrition, rest and sleep, exercise, medication and follow up
care. Prognosis of disease condition was good and he went home healthy after recovery with the
treatment and medical management. Patient was discharged on 25th may /2017
I am satisfied by doing case study as I got opportunity to know about the disease of my patient and apply
my theoretical knowledge into practice and patient condition improved day by day. I gained knowledge
to solve the different type of problem in the ward setting.
What I learned from case study :
Case study is the very good method of learning about nursing practice as well as related disease in
depth. It gives us comparative study of the patient with book in real situation. When I am providing care
to my patient, I have studied a lot of books. I have consulted with working staffs, friends and my patient
and his visitors to get detail information of this disease. During this period I learned many things, I
learned:
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To provide appropriate nursing care using nursing process.
To prioritize patient health needs.
To provide client care using holistic approach.
To upgrade knowledge on disease.
To compare sign and symptoms, diagnosis, treatment according to book and in my patient.
To apply nursing theory in practical area.
To maintain and promote health status of patient.
About stress and its management
I also got to know about hospital policy
Conclusion :
Case study is one of the most important parts of nursing practice. It is also a best method of learning.
Case study concerned with the individualized care, which helps to provide holistic nursing care, including
physiological, psychological, social and cultural traditional beliefs.
According to our curriculum, I had taken a case of Reactivation Tuberculosis. I tried my best to provide
good nursing care to my patient during hospitalization. I maintained good relationship with the patient
and his family members. As result, they helped and co-operated with me.
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I studied the normal developmental task of old age from book and co-related it with patient. I also
studied about pulmonary tuberculosis and the risk factors, the diagnostic test; therapeutic management
and clinical manifestation were analyzed. I got a good opportunity to gain new knowledge and practice
through this method of study. Therefore, I am satisfied with my case study.
Bibliography
1. (2070/71). Annual Report . Thimi,Bhaktapur: National Tuberculesis Centre.
2. (July 10, 2015 By Maria Mona ). http://nursingexercise.com/pulmonary-tuberculosis-disease-

causes-test/.
3. http://www.drugbook.in/movicol-sachet1381gm.html. (Sep 24, 2013, Sep ).
4. March 2017 www.who.int/mediacentre/factsheets/fs104/en/.
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5. May 18, 2015 http://www.livestrong.com/article/104821-first-signs-tuberculosis/.
6. Muna Sharma, K. P. (2015). Medical Surgical Nursing page no 55-59. Samilsha publication Pvt.Ltd.
7. Nursing drug reference 28th edition. mosby's 2015 page no :- 887-880, 1004-1005.
8. sharon lewis, l. b. (n.d.). medical surgiclal nursing 9th edition. page no 554-558.
9. Suzanne C. Smeltzer, B. G. Medical Surgical Nursing page no :568-572 (12th ed., Vol. I). Lippincott
Williams and Wilkins.
10. Tuitui, R. Poket book of drugs. Makalu Publication House page no:6 ,50-55,168.
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ACKNOWLEDGEMENT

[ CITATION Mar \l 1033 ]

Name: - Rajendra Khatri

Date of Admission: - 15 /May /2017

Old Diagnosis: - Chronic Obstructive Pulmonary Disease

PTB (Pulmonary Tuberculosis)

Final diagnosis: - Reactivation Tuberculosis (inadequately treated PTB chronic tuberculosis)

Attending Physician:- Dr. Saurabh Sharma

Admitting institute:- Norvic International Hospital

Name: Rajendra Khatri

Civil Status: Married

Date of admission: 15 /May /2017

Date of Interview: 21/May /2017

Chief Complain or reason for hospitalization:

Past health History:

FAMILY BACKGROUND TOTAL NO. OF FAMILY: 3

S Names of family Relation with Age Education Occupation Health

Source of income : Abroad

Availability of food ( sufficient food): sufficient

No of meals taken in a day: twice

Meal timing: morning (9 to 10 am) and evening (around 9 pm)

Food dislikes: no any

Elimination habit: irregular and constipated

Personal care habit: havent taken bath for few months

Rest and sleep habit: on and off sleep usually disturbed

Recreational habit: watching television,

Type of drainage system: close drainage system

Type of latrine : water sealed

Source of drinking water: tap water

kitchen room style : Separate

Types of fuel used in cooking: L. P Gas as well as firewoods

State of consciousness: alert , ill looking

Facial expression: tensed and sad

Nutritional status: thin

Behavior :- appropriate reaction to situations

Cleanliness :- poorly groomed

Speech :- slow , few words at times

Height : 5 feet 2 inch(1.574800m)

Blood pressure: 140/90 mm of Hg

3. Examination of head, face, neck:

Inspect head for:

Pediculosis : not present

Abrasions / injuries/ other: no any injuries or abrasions

Inspect eyes for:

Swelling of eyelids: no swelling

Discharge : no foreign body and no ulcers

Color of sclera/ conjunctiva: Pale color; smooth in texture

Eye movement: equal and normal movement of both the eyes

Vision problem: not present

Inspect ears for:

Appearance : both ears are equally symmetrical

Discharge/ pain: no any discharge nor pain

Wax / redness of external auditory canals: wax presents

Hearing problems: no any hearing problems

Inspect nose for:

Discharge : no any discharge

Bleeding : no bleeding from nose

Septal defect : no defect present, centrally located

Problem with smelling : no any problem with smelling

Inspect neck for:

Mobility : smooth and full range of movement, no stiffness of neck

Palpate neck for:

Enlarged lymph nodes : no enlarged lymph nodes

Enlarged thyroid nodes : no enlarged thyroid gland