PATIENTS PROFILE

Name: Eufemia Bugoy Cia Age: 46 y/o Birthplace: Pulangi, Albay Sex: Female Religion: Roman Catholic Civil Status: Married Address: Baras Catanduanes Attending Physician: DR. ESPINOLA

History of Present Illness

Patient s condition started about 6 months prior to consultation, as onset of cough, non-productive and an intermittent fever usually in the afternoon, moderate grade temperature which are not documented. According to her it was relieved by an intake of paracetamol. Patient experienced worsening of the condition, she had productive cough non-bloody with whitish secretions. There is also difficulty of breathing and vomiting. The patient can t eat properly because she has no appetite for food. She also experience stabbing pain on her chest according to the assessment it is 6/10 and it radiates to his back. The patient only took paracetamol for her fever.

Past Medical History

The patient had upper respiratory tract infection when she was a child, she cannot remember. Previously she was not hospitalized. She does not have complete immunizations because according to her it is not available in their place during those days; she has no history of hypertension and Diabetes mellitus. Whenever she had any flu or cough, she uses herbal plants. She does not have any regular medical and dental check-ups. She does not have allergies to whatever kind of foods and medications as far as she knows. Whenever she had fever she takes Paracetamol and Bioflu.

Developmental Task

Generativity vs. Stagnation (Middle Adulthood, 40 to 65 years). Generativity is the concern of guiding the next generation. Socially-valued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. During middle age the

primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity- a sense of productivity and accomplishmentresults. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation- a dissatisfaction with the relative lack of productivity

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 Cshaped cartilage rings reinforce its walls. Elastic fibers in the trachea walls allow the airways to expand and contract during breathing, while the cartilage rings prevent them from collapsing. The trachea divides behind the sternum (breastbone) to form a left and right branch, called bronchi(pronounced BRONG-key), each entering a lung. The lungs The lungs are two cone-shaped organs located in the chest or thoracic cavity. The heart separates them. The right lung is somewhat larger than the left. A sac, called the pleura, surrounds and protects the lungs. One layer of the pleura attaches to the wall of the thoracic cavity and the other layer encloses the lungs. A fluid between the two membrane layers reduces friction and allows smooth movement of the lungs during breathing. The lungs are divided into lobes, each one of which receives its own bronchial branch. Inside the lungs, the bronchi subdivide repeatedly into smaller airways.

Eventually they form tiny branches called terminal bronchioles. Terminal bronchioles have a diameter of about 0.02 inch (0.5 millimeter). This branching network within the lungs is called the bronchial tree. The terminal bronchioles enter cup-shaped air sacs called alveoli (pronounced al-VEE-oleye). The average person has a total of about 700 million gas-filled alveoli in the lungs. These provide an enormous surface area for gas exchange. A network of capillaries (tiny blood vessels) surrounds each alveoli. As blood passes through these vessels and air fills the alveoli, the exchange of gases takes place: oxygen passes from the alveoli into the capillaries while carbon dioxide passes from the capillaries into the alveoli. This process external respiration causes the blood to leave the lungs

laden with oxygen and cleared of carbon dioxide. When this blood reaches the cells of the body, internal respiration takes place. The oxygen diffuses or passes into the tissue fluid, and then into the cells. At the same time, carbon dioxide in the cells diffuses into the tissue fluid and then into the capillaries. The carbon dioxide-filled blood then returns to the lungs for another cycle

Breathing Breathing exchanges gases between the outside air and the alveoli of the lungs. Lung expansion is brought about by two important muscles, the diaphragm (pronounced DIE-a-fram) and the intercostal muscles. The diaphragm is a dome-shaped sheet of muscle located below the lungs that

separates the thoracic and abdominal cavities. The intercostal muscles are located between the ribs. Nerves from the brain send impulses to the diaphragm and intercostal muscles, stimulating them to contract or relax. When the diaphragm contracts, it moves down. The dome is flattened, and the size of the chest cavity is increased. When the intercostal muscles contract, the ribs move up and outward, which also increases the size of the chest cavity. By contracting, the diaphragm and intercostal muscles reduce the pressure inside the lungs relative to the pressure of the outside air. As a consequence, air rushes into the lungs during inhalation. During exhalation, the reverse occurs. The diaphragm relaxes and its dome curves up into the chest cavity, while the intercostal muscles relax and bring the ribs down and inward. The diminished size of the chest cavity increases the pressure in the lungs, thereby forcing air out. A healthy adult breathes in and out about 12 times per minute, but this rate changes with exercise and other factors. Total lung capacity is about 12.5 pints (6 liters). Under normal circumstances, humans inhale and exhale about one pint (475 milliliters) of air in each cycle. Only about three-quarters of this air reaches the alveoli. The rest of the air remains in the respiratory tract. Regardless of the volume of air breathed in and out, the lungs always retain about 2.5 pints (1200 milliliters) of air. This residual air keeps the alveoli and bronchioles partially filled at all times.

Repeated close contact with a person who has active TB Pre existing medical conditions or special treatment (malnourishment)

Living in an overcrowded substandard housing Any person w/o adequate health care (the homeless; minorities, particularly children under age 15 yrs and young adults between ages 15 44 yrs)

PATHOPHYSIOLOGY OF PULMONARY TUBERCULOSIS

Susceptible person

Stimulate bodys immune

May or may not under go Necrotic degeneration (Caseation)

Inhales tubercle bacilli

Initiates systematic local Go back to the Alveoli

Produces cavity filled w/ cheese-like mass of tubercle bacilli, dead WBCs & necrotic lung tissues Liquefies and then may drain into the tracheobronchial tree and coughed up

Lungs Alveoli (Where bacteria deposited and multiply) Spread through the lymphatic system

(Where bacteria deposited and multiply) Neutrophils & macrophages (Isolate & phagocytize bacteria)

Air-filled cavities remain and may be detected on X-ray study

Regional lymph nodes

Bloodstream Body

Most primary tubercles heal by forming scars & calcified lesion (Ghon tubercles) May contain living bacilli that can be reactivated & cause secondary infections

Laboratory and Diagnostic Examination

DATE February 21, 2012 PROCEDURE Hemoglobin Hematocrit RBC count WBC Neutrophils Lymphocytes Basophils Monocytes Eosinophils Platelets Fasting Blood Sugar Urinalysis Creatinine Na K Sputum Test/AFB 44.2-106.08 umol/L 135-145mmol/L 3.6-5.5mmol/L Negative NORMS 120-160g/L 0.38-0.40 g/L 4 2-5.4x 10 5-10x10 /L 81.3% 10.2% 0.1% 7.5% 0.9% 150-450x10 /L 70-110 mg/dl
9 9 12

RESULT

INTERPRETATION and ANALYSIS

per liter

Chest X-ray

The patient had undergone chest x-ray upon admission. The film shows presence of infiltrates or clouds. The right is smaller than the left lung, particularly the lower lobe of the right lung. Impression/Diagnosis Dr. Espinola, the patient s attending physician, who diagnosed the disease as Pulmonary tuberculosis. This diagnosis is supported by the pathognomonic signs that manifested by the patient. These include intermittent fever in the afternoon, difficulty of breathing, coughing, weight loss and chest pain. This diagnosis is supported by the following diagnostic exam such as Culture and Sensitivity of the sputum and chest x-ray

Drug Study
GENERIC / ACTION CLASSIFICATION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING INTERVENTION BRAND NAME

Theophylline

-The main mechanism of action of receptor theophylline is that of adenosine antagonism. - Theophylline is a nonspecific antagonist, antagonizing A1, A2, and A3 receptors almost equally, which explains many of its cardiac some effects of its and antiadenosine

- Mild stimulant -Bronchodilator

For

chronic diseases

- Hypersensitivity - Pregnant.

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

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

obstructive of the airway. -COPD

asthmatic effects. SAlbutamol A short-acting

2-

- Bronchodialtor

-Relief and prevention of bronchospasm in patients airway disease -Inhalation: Treatment of acute attacks of bronchospasm -Prevention exercise-induced of with reversible obstructive

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

-Dizziness, headache.

drowsiness,

fatigue,

Assess

for

any to when

adrenergic

receptor

hypersensitivity albuterol. Be cautious driving.

agonist used for the relief of bronchospasm in conditions such as asthma disease. and chronic obstructive pulmonary

- vomiting, change in taste

-Eat food is a small frequent way. Maintain betaon adrenergic stand by. blocker

bronchospasm. Vitamin B - Support and increase the rate of metabolism. - Maintain healthy skin and muscle tone - Enhance immune and nervous function. - Promote cell growth and division including that of the red blood cells that help prevent anemia. Cefuroxime - Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation of cell step peptidoglycan walls, cell thus wall - Antibacterial Treatment of and - Hypersensitivity to cefuroxime and other cephalosphorine. - GI bleeding - Headache - Nausea - Dizziness - Vomiting of lower - Increased BUN and Creatinine - Observe for signs and symptoms dose; hepatic, with of prolonged and anaphylaxis during first therapy, monitor renal, hematologic function. - Educate the importance of taking the right amount in the right time of medications. eventually Assess for any hypersensitivity. system - Water soluble Vitamin - Encourage patient to take regularly. - Encourage them to go to the doctor before drinking any vitamins. the vitamin

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

synthesis in bacterial inhibiting -Bacteria

biosynthesis. lyse due to ongoing

activity autolytic

of

cell

wall

enzymes

(autolysins and murein hydrolases) while cell wall Guiafen assembly is - Decongestant - Expectorant -Used to relieve and or to hay - MEDICINE IS NOT RECOMMENDED severe coronary high if you have a history of blood severe artery pressure, Nervousness, dizziness, vomiting trouble and Assess for any arrested. - Most decongestants cause response from adrenoreceptor vasoconstriction modulates adrenaline/noradrenali ne levels, b1 is the most stimulating and increases cardiac output, b2 dilates the bronchial walls, and b3 induces lipolysis). FLUIMUCIL (nausil) -Is any agent which dissolves thick mucus usually used to help relieve respiratory difficulties. (hydrolyzing glycosaminoglycans: tending down/lower viscosity of to break the mucinMucolytic -Acute affections abundant secretions. of wet cough. & chronic tract w/ mucus a1, (a2 chiefly responsible for congestion colds, fever. flu, sleeping, headache. nausea, allergies. -Instruct the patient to consult a doctor when the side effects continues. - Be careful when driving or operating machines. - Instruct the patient that they should swallow the medication whole.

treat cough due to

disease, or if you have problems where the supply of blood and oxygen to the heart is reduced also known as ischemic heart disease. -Contraindicated with asthmatic and history of patients with peptic patients -Urticaria, stomatitis. bronchospasm, nausea,

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

respiratory

vomiting. -Aerosol treatment: Rhinitis,

ulceration.

Used in the treatment

containing s).

body

Fluimucil and the other drug effect could for be any influenced or cancelled. Assess allergies.

secretions/component

NURSING CARE PLAN

ASSESSMENT

NURSING DIAGNOSIS

BACKGROUND KNOWLDEGE airway Intermediate Cause: secretions Retained in the

GOAL OBJECTIVES Goal:

and

NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective Cues: - Patient verbalized, Awat na akong piga abo. Dai man ning plema. pati makahangos. Objective Cues: Presence of adventitious sound -The phlegm. - Oriented - BP- 90/70 mmHg, - Difficulty vocalizing - Has hallow eyes. - Bluish nail beds. breath Nasakitan ako

Ineffective

Effectiveness Objective 1: Independent-Facilitative: the 1. Obtain vital signs of the patient. Health status is regulated homeostatic mechanisms. A change in V/S might indicate health change. (Taylor et.al, FON 5 ed. Page 523) Adequacy 2. Observe for respiratory -Nasal flaring and use of accessory muscles indicates increased effort is required for breathing. -Was all the planned nursing are achieving maintaining airway? -Was all the resources - Blanch test reflects the adequacy of o2 circulation in the periphery. Appropriateness -Crackles are intermittent 4. Auscultate the lungs to note any lung sounds. sounds that occur when air moves through airway that contain fluids. (Taylor -Was the interventions mentioned applicable beneficial to are and the of the nurse like time and effort are enough? interventions enough in and patent rate and rhythm; presence of nasal flaring; and use of accessory breathing diaphragm muscles. 3. Perform the Blanch Test. muscles like and when the coastal
th

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

Within 4 hours of nursing intervention, patient will be able to maintain patent airway through the mobilization Inflammatory secretions evidenced of as by

- Was the patient able to through maintain patent airway? -Was the patient able to mobilize her secretions? -Was the patient able to have patent airway?

respiratory tract. Intermediate Cause: response Root Cause: - Bacterial infection

productive cough. Objectives: 1. For 10 minutes, the Health Implication: This condition can cause Respiratory Distress Syndrome (ARDS) results infection inflammatory from combination which the of and 2. After 3 hours Acute relative will the assess

(Crackles) patient is

upon auscultation. coughing without

of the respiratory system.

physical condition of the client by accepting at least 4 done patient. in nursing the interventions to be

response. lungs quickly filled very with extracting stiff.

The become with This

the client will be able her through to mobilize secretions the Objective 2: Independent- Facilitative: 1. Perform Chest physiotherapy. 50 Dependent-Facilitative: 1. Suction secretion as needed.

et.al, FON 5th ed. Page 1386) -Tapping the chest can loosen the secretions. (Taylor et.al, FON 5 Page 1251) -Suction secretions removes through the
th

patient?

fluid and become stiffness, combined difficulties oxygen

Acceptability Was the family willfully accepted the interventions done to the patient.

interventions done by the nurse at least 4. 3. will After

ed.

due to the alveolar fluid creates a need for ventilation. Septic shock is one potential complication. (Black, Medical
th

minutes, the nurse maintain patent airway of the patient through the performance of at least 3

use of a strong pressure.

- Current data indicates 2. Increase the amount of oral fluid intake as ordered by the doctor. that fluid restriction may actually volume reduce and blood decrease

interventions.

Surgical Nursing 7 ed. Page 1896)

cerebral circulation. The lack of volume causes the blood to be thick and sluggish and may decrease the mobilization of nutrition and toxins out of the circulation. Patient should be maintained in a euvolemic than a state rather
th

fluid-restricted

state. (Black, MSN 7 ed. Page 2201)

Dependent-Supplemental: 1. Administer bronchodilators as ordered.

They

act

on

the

respiratory tract, it opens narrowed airways. (Black, MSN 7th ed. Page 1652) For maximal that lung will

Objective 3: Independent-Facilitative: 1. Elevate the head of the bed.

expansion

improve oxygen delivery.

-Position changes allow 2. Position the head in the midline of the body. free movement of the diaphragm and expansion of the chest wall.

Nursing Implications
Nursing Practice
It is essential to be able to understand contemporary nursing practice, which looks at the overall aspects of the nursing profession. This study enhances the quality and effectiveness of nursing care that will rendered to the clients with similar condition. Nursing practice itself could also be evaluated in this case This case study will be beneficial to nursing practices. This implies that the health care providers must become more dedicated in rendering nursing care but there must be no exceptions upon rendering services regardless of the case handled by the caregiver. The greatest impact of the implication is the equality in treatment upon rendering nursing care, that all patients must be entitled to a quality and effective care regardless of who they are and what their health problem is.

Nursing Research
This case study is equipped with useful information, ample opportunities and responsibilities to the nurses, not exempting the affiliating student nurses in order for them to be well-informed and competitive in this field. Research findings will provide them a broader knowledge of the said case and will enhance their skills for them to be globally competitive in the profession.

Nursing Education

Education is one of the important processes of learning because it is continuous and it can help achieve the optimum level of knowledge to every individual in all aspects of life not just in the field of nursing. This case study is accomplish through the thorough research and studies made intentionally for other proponents who will handle same case for them to be encouraged and aim for the best to further go through series of studies. This will also be beneficial to other case studies related or similar to this. The case study could serve as a guide in making more improved and comprehensive study about the case.

Catanduanes State Colleges College of Health Sciences

Department of Nursing

Case Study of Pulmonary Tuberculosis

Submitted by: Carmina A. Aguilar BSN-2B Submitted to: Goyeta Pereyra Clinical Instructor