A

CASE STUDY

ON

PULMONARY TUBERCULOSIS

Submitted to:

FAITH A. CUERVO R.N.

BSN III CLINICAL INSTRUCTOR
VISAYAS COMMUNITY MEDICAL CENTER- ANNEX 1

In partial Fulfillment
Of the Requirements of the Subject:
NCM 103
CARE OF clients Across the Lifespan with Problems in Oxygenation,
Fluid,Electrolyte and Acid_base Balance, Metabolism and Endocrine

Submitted by:

KRISZANNIE D. ORMOC
STUDENT
BSN III-F

August 20 ,2010
 TABLE OF CONTENTS

PAGE

I. INTRODUCTION

II. GENERAL DATA

III. HEALTH ASSESSMENT

A. HEALTH HISTORY

A1.Biological data

A2.Reason for seeking Consultation

A3.Current Health Status

A4.Past Health History

A5.Family History

A6.Gordon’s Functional Health Pattern

A7.Psychosocial Profile

B. PHYSICAL EXAMINATION

IV. ANATOMY AND PHYSIOLOGY

CONCEPTUAL FRAMEWORK OF THE PHYSIOLOGY

OF PREGNANCY(for normal conditions) or CONCEPTUAL

FRAMEWORK OF THE PATHOPHYSIOLOGY OF

PREGNANCY (for abnormal conditions)

V. THEORITICAL FRAMEWORK OF THE PHYSIOLOGY

 OF PREGNANCY or PATHOPHYSIOLOGY OF PREGNANCY

VI. CLINICAL MANAGEMENT

A. MEDICAL MANAGEMENT

A1.LABORATORY AND DIAGNOSTIC EXAMINATIONS

A2.TREATMENT AND PROCEDURES

A3.MEDICATIONS

A4.DIET

B. NURSING MANAGEMENT

B1.NURSING CARE PLAN

B2.DISCHARGED PLAN

IX. CONCLUSION AND RECOMMENDATION

X. IMPLICATIONS OF THE STUDY TO:

A.NURSING EDUCATION

B.NURSING PRACTICE

C.NURSING RESEARCH
1
INTRODUCTION

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

commonly affecting the lungs characterized by the formation of tubercles in the tissues
which tend to undergo cessation, necrosis and calcification. It is also known as poor
man’s disease or consumption disease. The causative agent in this disease is
Mycobacterium Tuberculosis, a rod shaped bacteria. The disease is transmitted by
deliberate inoculation of microorganisms by droplet. This disease is transmitted to other
people through the inhalation of organisms directly into the lungs from contaminated air.
According to the department of Health (DOH) PTB is the 6th cause of mortality and
morbidity in the Philippines as of 2007.

This disease is can be acquired easily by person being in contact with an

infected one, when you are living in a crowded area like the squatter’s area and when you
have poor nutrition. It is commonly present in third world or developing countries like
the Philippines.

TB is a preventable disease, even in those who have been exposed to an infected

person. Skin testing (PPD) for TB is used in high risk populations or in people who may
have been exposed to TB, such as health care workers.

A positive skin test indicates TB exposure and an inactive infection. Discuss preventive
therapy with your doctor. People who have been exposed to TB should be skin tested
immediately and have a follow-up test at a later date, if the first test is negative.

Prompt treatment is extremely important in controlling the spread of TB from those who
have active TB disease to those who have never been infected with TB.

I decided to choose this case because I wanted to acquire more knowledge

about Pulmonary Tuberculosis. I wanted to use the knowledge that I have acquired in
promoting awareness to the people especially to the poor that they should seek for
medical care in order to prevent the development and progression of PTB. I also wanted
to focus on preventive measures. PTB can cause Tuberculosis meningitis, a very rare and
fatal disease and I would not want that to happen, so they will focus more on information
campaign as part of primary prevention of health. Presently our country has so many
cases of PTB.
2
GENERAL DATA

Received patient lying on bed,awake, conscious with #8 PNSS 1L @

10 gtts/min.infusing well @right hand,well oriented in time and place with the following
vital signs:
Temperature- 36.1 C , Pulse rate- 78bpm , Respiratory rate – 18cpm, Blood pressure –
110/60 mmHg.

BIOLOGICAL DATA

• Name: AM
• Age: 60 y/o
• Birthplace: Mandaue City
• Sex: Female
• Race: Filipino
• Religion: United Christian Christ of the Philippines
• Civil Status: Married
• Address: 3-005 Pagsabungan,Mandaue city
• Occupation: Social Worker
• Date Admitted: July 15,2010
• Time Admitted: 7:30 pm
• Attending Physician: Dr. Ruben Escarda

Chief Complaints:

The patient was admitted at Visayas Community Medical Center last

July 15,2010 at 7:30 in the evening due to the complaint of lack of appetite . She
was attended at the Emergency department and had taken a clinical history and
physical assessment. She was transferred at the Medical Ward . She was attended
by Dr. Ruben Escarda, a resident physician of the said hospital.
3

CURRENT HEALTH STATUS

Patients condition started two months prior to admission,noted to have

lack of appetite consuming only 4 tablespoons of rice, weigh loss from 70 kg to 58
kg,complained of body malaise persistence prompted admission.

PAST HEALTH HISTORY

The patient don’t have upper respiratory tract infection when she was a
child, she cannot remember.Previously she was hospitalized at Visayas Community
Medical Center due to Pulmonary Tuberculosis.she does not have complete
immunization because according to her it is not available in their place during these
days.She has no history of hypertension and diabetes mellitus but she has a family history
of lung cancer.Whenever she had any flu or cough ,she uses herbal plants or take a
rest.She does not have any regular medical and dental check-ups .She does not have
allergies to what ever kinds of foods and medications as far she knows.She experience
severe accident such as vehicular accident.She does not have any rituals before
sleeping,she sleeps only if she feels sleepy already and wake up 7 in the morning.

FAMILY HISTORY
4

PHSYCHOSOCIAL PROFILE

Mrs. AM lived in 3-005 Pagsabungan,Mandaue City, a social worker,

owns a sari-sari store.She was already a widow, she owns her house, the source of water
was electric pump.Mrs AM practiced exercise but don’t practiced healthy diet, don’t use
tobacco,prohibited drugs nor drink alcohol.Her house is far fom the hi-way, interms in
financial matter she has her sari-sari store where she can gets her daily living and her
children who have already stable job gives money if there is available.Mrs. AM religion
is UCCP she always have strong faith in God and believe that no matter what happen
God is always beside her guiding.

GORDON’S FUNCTIONAL HEALTH PATTERN

1. Health Perception - Health Management Function

Before patient viewed health as a normal state of daily living that is easy to maintain.
According to the patient, she considered herself as a healthy person because she felt
strong and happy. She didn’t have routine physical examination. While the patient is in
the hospital, she can’t define her health as healthy. She now perceives health as
something that needs to be maintained. According to her, she is now more cautious on the
food she takes in and the number of glasses of water she drinks. She tries her best her
best with any therapy that needs her cooperation. She puts effort in rehabilitating herself.
She complies with the therapeutic regimen.

2. Nutrition – Metabolic Pattern

Before, the patient ate all kinds of meat and vegetables. Fish and pork was usually
included on her meal. She didn’t take any food supplement. She drank 4 - 8 glasses of
water every day. She was fond of eating salty foods. She had good appetite and had no
food, no drug allergies and no eating discomfort. But now her diet is maintained on low
fat, low cholesterol diabetic diet. And she increases her fluid intake since she is
experiencing diarrhea.

3. Elimination Pattern

Patient states that before, she had a normal bowel movement of twice a day. Her stool
was solid and brown in color. She urinated at the average of four times a day with an
estimated amount of 500 cc. Her urine was clear. She had no sweating disorder. But now,
patient has diarrhea with 2 -4 times ½ cup episodes of watery stools. She frequently
urinates but with only small amount of urine with no change in color. She has no
sweating disorder.

4. Activity- Exercise Pattern

Patient woke up at 6am to prepare breakfast for her family. She did household chores
such as dusting, sweeping, and polishing the floor which she believed were other forms
of exercise. She also spent her spare time watching television and listening to the radio.
5. Sleep-Rest Pattern

The patient had an average of 6 -8 hours of continuous sleep. Her usual time to sleep was
10PM and woke up at 6AM. She didn’t have problems falling asleep and in her sleeping
environment. She states that music and warm milk helps her sleep. She took a nap in the
afternoon during weekends. But now, the patient now sleeps at an average of 6 -8 hours
from 10pm to 6am but wakes up every now and then due to her condition.

6. Cognitive Perceptual Pattern

Patient is conscious, responsive and coherent. She has no sensory perceptual

abnormalities. Patient can hear, has normal eye vision. Patient is able to read and write.
7. Self-Perception and Self-Concept Pattern

She described herself as healthy in mind and body. She felt strong. She took care of her
body properly. She always tried to look good. But now, the patient is now depressed
because of her condition and physical alterations. She feels weak.

8. Role-Relationship Pattern

Patient lives with her husband. She has strong bond with
siblings and parents. Since she and her husband had 4 children. Patient is unable to
perform effectively her role as a wife. She is dependent on her children. They prioritize
her condition and needs above all.
9. Sexuality-Reproductive Pattern

Patient had no difficulty or problems in expressing ones sexuality. She verbalizes that
she was sexually active when she was still younger. She had her first sexual contact at the
age of 24. She did not have multiple partners or any sexually transmitted disease. But
now, she verbalized that she cannot have intimate moments with her husband maybe
because of their age.

10. Coping-Stress Tolerance Pattern

When there was stressful event, she tried to find ways to stay calm. She handled stress
effectively by talking things over and diverting her attention by watching TV. She usually
expressed her feelings to her husband. And now, patient considers her condition very
stressful. She expresses her feelings to her husband and parents as one way to cope with
stress.

11. Value-Belief Pattern

Patient has strong religious belief. She is a Roman Catholic. She attended mass regularly
and prayed the rosary. Patient seeks God’s guidance for well being. Despite of her
condition, she remains faithful to God and optimistic. She gives more value to her family,
health and life.

HEALTH ASSESSMENT
ANATOMY AND PHYSIOLOGY
Respiration is the process by which living organisms take in oxygen and release carbon
dioxide. The human respiratory system, working in conjunction with the circulatory
system, supplies oxygen to the body's cells, removing carbon dioxide in the process. The
exchange of these gases occurs across cell membranes both in the lungs (external
respiration) and in the body tissues (internal respiration). Breathing, or pulmonary
ventilation, describes the process of inhaling and exhaling air. The human respiratory
system consists of the respiratory tract and the lungs.

Respiratory tract
 The respiratory tract cleans, warms, and moistens air during its trip to the lungs.
The tract can be divided into an upper and a lower part. The upper part consists of the
nose, nasal cavity, pharynx (throat), and larynx (voice box). The lower part consists of
the trachea (windpipe), bronchi, and bronchial tree.
The nose has openings to the outside that allow air to enter. Hairs inside the nose trap dirt
and keep it out of the respiratory tract. The external nose leads to a large cavity within the
skull, the nasal cavity. This cavity is lined with mucous membrane and fine hairs called
cilia. Mucus moistens the incoming air and traps dust. The cilia move pieces of the
mucus with its trapped particles to the throat, where it is spit out or swallowed. Stomach
acids destroy bacteria in swallowed mucus. Blood vessels in the nose and nasal cavity
release heat and warm the entering air.
Air leaves the nasal cavity and enters the pharynx. From there it passes into the larynx,
which is supported by a framework of cartilage (tough, white connective tissue). The
larynx is covered by the epiglottis, a flap of elastic cartilage that moves up and down like
a trap door. The epiglottis stays open during breathing, but closes during swallowing.
This valve mechanism keeps solid particles (food) and liquids out of the trachea. If
something other than air enters the trachea, it is expelled through automatic coughing.

Alveoli: Tiny air-filled sacs in the lungs where the exchange of oxygen and carbon
dioxide occurs between the lungs and the bloodstream.

Bronchi: Two main branches of the trachea leading into the lungs.

Bronchial tree: Branching, air-conducting subdivisions of the bronchi in the lungs.

Diaphragm: Dome-shaped sheet of muscle located below the lungs separating the
thoracic and abdominal cavities that contracts and expands to force air in and out of the
lungs.

Epiglottis: Flap of elastic cartilage covering the larynx that allows air to pass through the
trachea while keeping solid particles and liquids out.

Pleura: Membranous sac that envelops each lung and lines the thoracic cavity.

Air enters the trachea in the neck. Mucous membrane lines the trachea and C-shaped
cartilage rings reinforce its walls. Elastic fibers in the trachea walls allow the airways to
expand and contract during breathing, while the cartilage rings prevent them from
collapsing. The trachea divides behind the sternum (breastbone) to form a left and right
branch, called bronchi (pronounced BRONG-key), each entering a lung.

The lungs

The lungs are two cone-shaped organs located in the chest or thoracic cavity. The
heart separates them. The right lung is somewhat larger than the left. A sac, called the
pleura, surrounds and protects the lungs. One layer of the pleura attaches to the wall of
the thoracic cavity and the other layer encloses the lungs. A fluid between the two
88
membrane layers reduces friction and allows smooth movement of the lungs during
breathing.
The lungs are divided into lobes, each one of which receives its own bronchial branch.
Inside the lungs, the bronchi subdivide repeatedly into smaller airways. Eventually they
form tiny branches called terminal bronchioles. Terminal bronchioles have a diameter of
about 0.02 inch (0.5 millimeter). This branching network within the lungs is called the
bronchial tree.

The terminal bronchioles enter cup-shaped air sacs called alveoli (pronounced al-VEE-o-
leye). The average person has a total of about 700 million gas-filled alveoli in the lungs.
These provide an enormous surface area for gas exchange. A network of capillaries (tiny
blood vessels) surrounds each alveoli. As blood passes through these vessels and air fills
the alveoli, the exchange of gases takes place: oxygen passes from the alveoli into the
capillaries while carbon dioxide passes from the capillaries into the alveoli.
This process—external respiration—causes the blood to leave the lungs laden with
oxygen and cleared of carbon dioxide. When this blood reaches the cells of the body,
internal respiration takes place. The oxygen diffuses or passes into the tissue fluid, and
then into the cells. At the same time, carbon dioxide in the cells diffuses into the tissue
fluid and then into the capillaries. The carbon dioxide-filled blood then returns to the
lungs for another cycle.

Breathing

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

55
the lungs always retain about 2.5 pints (1200 milliliters) of air. This residual air keeps the
alveoli and bronchioles partially filled at all times.
 77
CONCEPTUAL FRAMEWORK OF THE PATHOPHYSIOLOGY
Etiology /Risk Factor Causative agent
-close contact to someone with TB -Mycobacterium Tuberculae
-immigrant from countries with a -Staphyloccocus Aureus
high prevalence of TB -Mycobacterium Avium
-living in crowded substandard
housing

MYCOBACTERIUM TUBERCLE

DRIED DROPLET NUCLEI

INFLAMMATION IN ALVEOLI

Phagocytosis (neutrophils and

macrophages)

TB specific lymphocytes lyses

Accumulation of exudates in the

alveoli

Pulmonary Tuberculosis

THEORITICAL FRAMEWORK OF THE PATHOPHYSIOLOGY

TB begins when a specific person inhales mycobacterium and become infected.The

bacteria are transmitted through the airways to the alveoli,Where they are deposited and
begin t multiply.The bacilli also are transported via the lymph system and bloodstream to
other parts of the body and the upper ares to the lungs.The body’s immune system
responds by inflating an inflammatory reaction.Phagocytes engulf many of the bacteria
 66
and TB specific lymphocytes lyse (destroy) the bacilli and normal tissue.This tissue
reaction results in the accumulation and exudates in the alveoli ,causing
bronchopneumonia.The initial infection usually occurs 2 to 10 weeks after exposure.

LABORATORY AND DIAGNOSTIC EXAMINATIONS

URINALYSIS

MICROSCOPIC RESULT UNITS

COLOR yellow
APPEARANCE Clear
Ph 6.0
SPECIFIC GRAVITY 1.005
PROTEIN NEG(-)
GLUCOSE NEG(-)
MICROSCOPIC
RBC 0-1 /hpf
WBC 0-1 /hpf
EPITHELIAL CELLS FEW
AMORPHOUS FEW
MATERIAL
BACTERIA FEW

CLINICAL CHEMISTRY SECTION

TESTNAME RESULT UNITS REFERENCE

RANGE
SODIUM 137 mmol/L 136-146
POTASSIUM 3.0 L mmol/L 3.5-5.3
CREATININE 0.35 L Mg/dL 0.5-1.5
URIC ACID 9.36 H Mg/dL 2.4-5.7
SGPT 36 H U/L 1-31

HEMATOLOGY SECTION
TEST NAME RESULT UNITS REFERENCE
RANGE
WBC 9.61 K/UL 4.1-10.9
• Sgmenters 70.10 % 47.0-80.0
• Lymphocytes 18.40 % 13.0-40.0
• Monocytes 9.20 % 2.0-11.0
 • Eosinophils 2.10 % 0-5.0
• Basophils 0.20 % 0-2.0

RBC 3.97 L M/UL 4.0-5.2

Hemoglobin 11.70 L G/dL 12.0-16.0
Hematocrit 34.90 L % 36.0-46.0
MCV 87.90 FL 80.0-100.0
MCH 29.50 Pg 26.0-34.0
MCHC 33.50 G/dL 31.0-36.0
RDW-SD 42.40 FL 37.0-54.0
RDW-CV 13.6 % 11.0-16.0
Platelet 221.00 K/UL 140.0-440.0
MPV 9.50 FL 0-100.0

TREATMENT AND PROCEDURES

Treatment

The goal of treatment is to cure the infection with drugs that fight the TB bacteria.
Treatment of active pulmonary TB will always involve a combination of many drugs
(usually four drugs). All of the drugs are continued until lab tests show which medicines
work best.

The most commonly used drugs include:

• Isonizid
• Rifampin
• Pyrazinamide
• Ethambutol

Other drugs that may be used to treat TB include:

• Amikacin
• Ethionamide
• Moxifloxacin
• Para-aminosalicylic acid
• Streptomycin

You may need to take many different pills at different times of the day for 1 year or
longer. It is very important that you take the pills the way your health care provider
instructed.

When people do not take their tuberculosis medications as recommended, the infection
becomes much more difficult to treat. The TB bacteria may become resistant to
treatment, and sometimes, the drugs no longer help treat the infection.
When there is a concern that a patient may not take all the medication as directed, a
health care provider may need to watch the person take the prescribed drugs. This is
called directly observed therapy. In this case, drugs may be given 2 or 3 times per week,
as prescribed by a doctor.

You may need to be admitted to a hospital for 2 - 4 weeks to avoid spreading the disease
to others until you are no longer contagious.

PROCEDURES

Mantoux tuberculin skin tests are often used for routine screening of high risk
individuals.

Interferon-γ release assays are blood tests used in the diagnosis of some infectious
diseases. There are currently two interferon-γ release assays available for the diagnosis of
tuberculosis:

• QuantiFERON-TB Gold (licensed in US, Europe and Japan); and

• T-SPOT.TB, a form of ELISPOT (licensed in Europe).

Chest photofluorography has been used in the past for mass screening for tuberculosis.

-Monitor vital signs every 4 hours

-Monitor I and O every shift
-Raise the side rails
-Monitor IVF and regulate @desired rate
-Due medication given
 33
DISCHARGE PLAN

Patient: AM Hospital No:

Age: 4o years old Roon No: 233
Impression/Diagnosis: PTB III. DM II, Ostoearthritis
Nurse’s signature:Ormoc, Kriszannie D.