CARE OF A PATIENT WITH TUBERCULOSIS

A Clinical Paper Presented the the Faculty of the College of Nursing Cebu Normal University

In Partial Fulfillment of the Requirements for the Degree Bachelor of Science in Nursing

Laura Suzanne K. Suarez October 2011

Acknowledgment

The researcher would like to express her deepest gratitude to the following for their overall contribution to the success of this study. Without them, this study may not have been conducted nor would it have been finished. To L, my client, my thank you is not enough to express my heartfelt gratitude for allowing me to come into her life. Without her, this study will not have tackled such a fascinating disorder. Her story will forever be embedded in my memory. To Ms. Bertilia F. Pragados, R.N. our research consultant, who has offered her time and effort in conducting consultations and answering questions. She has patiently guided and taught me in how to compose this case study and how to go about in interacting with the client. Her expertise in the field of psychiatric nursing has greatly contributed to the success of this study. To the Staff of Ward 12, for allowing the fourth year students of Cebu Normal University to enter their institution and extending their warm welcome when we first arrived. Without their kindness and their patience, the experience may have lacked its luster. To Mrs. Antonietta Obiedo R.N., our year level coordinator, for giving the us the opportunity to conduct this study therefore enabling me to enhance my nursing skills especially in the field of psychiatric nursing. Without her dedication to the development of skills of the level four students, this case study will not have been conducted. To my Groupmates, Group 3, section A., for being themselves and making this experience worthwhile. Without them, I may not have had as much fun as I did. To my Parents, for simply being there. Without their presence and their support emotionally, and financially, I would have never had the strength and courage to tackle this study. Lastly and most importantly, To God, our Almighty Father, the creator of all things. His love for everything and everyone has immensely helped mold me into the person that I am today. The very fact that my faith in Him has greatly influenced how I live my life makes Him the one who has most significantly contributed to the success of this study.

Table of Contents TITLE PAGE i DEDICATION ii ACKNOWLEDGMENT iii TABLE OF CONTENTS LIST OF TABLES iv LIST OF FIGURES List of tables ABSTRACT CHAPTER 1 INTRODUCTION 1

Rationale and Background of the Study Statement of the Problem Objectives of the Study Significance of the Study Research Methodology Research Locale Research Design Research Design Research Instrument Research Data Gathering Procedure

CHAPTER 2 PATIENTS PROFILE Background/History Patients Vitae Functional Health Patterns Physical Assessment Organ System Assessment Interpretation of findings

CHAPTER 3 ANATOMY AND PHYSIOLOGY CHAPTER 4 PSYCHOPATHOPHYSIOLOGY AND PSYCHODYNAMICS CHAPTER 5 MANAGEMENT Medical Laboratory and Diagnostic Procedures: Ideal and Actual Drug Study: Ideal/Actual Surgical Perioperative: Ideal and Actual Nursing Summary of Nursing problems Individualized NCP (Physiologic, Psychologic) Independent Nursing Strategies Dependent Collaborative FDAR Charting Discharge Summary with collaborative Nursing Function CHAPTER 6 EVALUATION AND RECOMMENDATION Extent of Goal Achievement Recommendations

BIBLIOGRAPHY APPENDICES A. Assessment Tool B. Clinical Pathway C. Research Articles CURRICULUM VITAE

List of Tables Table No. No. 1.1 1.2 1st dx na results 2nd dx na resuls Title Page

List of Figures Table No. No. 1.1 1.2 Schematic Diagram of the Pathophysiology of Tuberculosis Pathophysiology of Tuberculosis 25 20 Title Page

Abstract Title: Care of a Patient with Rubeola Infection Author: Endrex P. Nemenzo School: Cebu Normal University Degree: Bachelor of Science in Nursing Adviser: Mr. Alain Kenneth S. Ragay, RN, MAN Year Completed: School Year 200-2012

Statement of the Problem: This case study aims to give a comprehensive information to the readers about Rubeola infection. Blah blah blah blah blah blah. Blah blah blah blah.

Methodology: The study was conducted at VSMMC. And everything follows.

Findings: C.A.Q. a female client, married. And everything follows.

Conclusion: How you conclude your study

Recommendations: The researcher recommends strict compliance to the treatment plan.

Chapter I Introduction Rationale and Background of the Study (include everything you wish to)

Statement of the Problem This study is designed to understand the nature and course of the disease process, from its causes to the signs and symptoms as manifested by the client. It is designed to identify the different managements applicable for the patients case. Specifically, this study aims to answer the following questions: 1. What factors have caused the clients condition? 2. What is the pathophysiology of the disease as presented by the patients clinical manifestations? 3. What are the responses of the patient towards the disease in terms of : 3.1 Actual nursing needs 3.2 Potential nursing needs 4. What are the medical and surgical management of the patients disease? 5. What are the nursing interventions appropriate for the patient based on assessed needs? Objectives of the Study

The main goal of this study is to give comprehensive information the readers about Status Asthmaticus. It delves further into the core of the illness, its causes and effects and the problems that arise from this disease ad the appropriate nursing management of such problem. This study is specifically aimed to give thorough discussion of Status Asthmaticus identifying its definition, the etiologic and precipitating factors, anatomy and physiology of the organs involved, its pathophysiology, its presenting signs and symptoms, the medical and surgical management and the specific nursing care to be implemented to alleviate the patients condition.

Significance of the Study The client suffering from status asthmaticus is aimed at deriving enough knowledge of the said disease thereby increasing the awareness and skill in dealing with client. Furthermore, conducting this study would prove beneficial to the following people: Patient

Patients Significant Others

Nurses Student nurses

Society

Future researchers

CHAPTER 2 PATIENTS PROFILE <INTRO TEXT> Background/History

Patients Profile History of Present Illness Assessment Findings

Patients Vitae Functional Health Patterns Physical Assessment Organ System Assessment Interpretation of findings

CHAPTER 3 ANATOMY AND PHYSIOLOGY <INTROTXT> Narrative nya ktung with diagram- ang diagram kai I reflect nya sa list of figures.:)

CHAPTER 4
PSYCHOPATHOPHYSIOLOGY AND PSYCHODYNAMICS <INTROTXT> <KTING SCHEMATIC UNA., THEN NARRATIVE DAYUN AFTER)

CHAPTER 5
MANAGEMENT <introtext> Medical Laboratory and Diagnostic Procedures: Ideal Actual Drug Study: Ideal Actual Surgical : Ideal Actual Nursing Summary of Nursing problems

Ineffective Airway Clearance related to excessive secretions in the tracheobronchial tree secondary to underlying disease condition. <explanation kung ngano> with citations <and everything sa NCP in narrative form>

Ineffective Breathing Pattern related to progressive bronchoconstriction secondary to Status Asthmaticus <same>

********five kabuok ang iyang DIAGNOSIS diri.. basin 5 jud pud ibutang.
Individualized NCP (Physiologic, Psychologic) Independent Nursing Strategies Dependent (2-3) Collaborative (1) FDAR Charting Discharge Summary with collaborative Nursing Function

CHAPTER 6 EVALUATION AND RECOMMENDATION (INTROTXT) This case study was conducted to essentially focus on an extensive

presentation of the nature and therapeutic management of Status Asthmaticussustained by a 54 year old female client. <explain2 lng niya diri>
Extent of Goal Achievement Recommendations

Bibliography Books

Ackley et al. Nursin Diagnoss Handbook. 2nd ed. St. Louis Mosby yearbook, Inc.

Unpublished Articles Page, Bob (2004). Asthma Pathophysiology. Michigan EMS Expo 2004 NREMTP, CCEMT-P, I/C

Internet Sources
Neimark, NF. 2010. Mind/Body Solutions for Surgery retrieved September 04, 2010 at http://www.thebodysoulconnection.com/Newsletter/issue7.html

Appendix A Assessment Tool PHYSICAL ASSESSMENT FORM

NURSING ADMISSION AND ASSESSMENT Name of Student: ______________________Clinical Assignment: ________________ Name of Clinical Instructor: __________ Inclusive Dates: _______________________ A. General Admission Information Name of Patient: ______________________Age: _________ Sex: ____________ Date: __________ Time: _________ Mode: _____________Allergies: __________ TPR: _________ BP: _________ HT: _____ WT: _______Diet: ________________ Sleeping Habits: _____________ CBC: Yes___ No___ Urinalysis: Yes___ No___ Property: Glasses _____ Contact Lenses _______ Dentures ___ Prosthesis ______ Ring __________ Watch Money ______ Other _____________________________________________________ Valuable to Business Office ____________________________________ Physical Appearance: _________________________________________________ ___________________________________________________________________ __________________________________________________________________ Behavior Exhibited: ____________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Content of Conversation: _______________________________________________ ____________________________________________________________________ _________________ Physician In-charge B. Admission Interview 1. Patient s perception of reason for admission: ___________________________________________________________ _____________________________________________________________ 2. Patients symptoms as he/she sees them: _____________________________________________________________ _____________________________________________________________ 3. Problems in daily living created by symptoms (as patient views them) _____________________________________________________________ _____________________________________________________________

4. Past Medical History (especially as it relates to P.I.) a. Medical ___________________________________________________ b. Surgical ___________________________________________________ c. Allergies ___________________________________________________ d. Medication _________________________________________________ e. Traumatic Injuries ____________________________________________ f. Orthopedic _________________________________________________ g. Other (psychiatric, etc.) _______________________________________ 5. Habits a. Smoking _________________Alcohol ____________Drugs _________ b. Eating _____________________________________________________ c. Social Activity _______________________Physical Exercise _________ d. Rest/ Sleeping ______________________________________________ __________________________________________________________ e. Sexual ____________________________________________________ __________________________________________________________ f. Elimination ________________________________________________ 6. Social Economic History a. Native Language: __________________ b. Education: ________________________ c. Occupation ______________________________________________ d. Financial Status (what is the impact of current hospitalization) _______________________________________________________ _______________________________________________________ e. Civil Status: Married_____ Single ______ Divorced ______ Widow ______ f. Living Situation: Lives alone _________________________ Live with others (specify): _________________ 7. Family History: Heart Disease, Cancer, TB, Mental Illness and Others (specify) _____________________________________________________________ _____________________________________________________________ 8. Primary Physicians Admitting Diagnosis (indicate P = Probable and C = Confirmed)

C. Nursing Review of Systems (circle the appropriate symptoms) 1. HEENT: Headaches Eye pain Sinus pain Sore throat Hearing Loss Visions Diplopia Eye infection Blurring Epistaxis Facial pain Bleedinggums Dentures Nasal-tracheal pain Other____________

2. CARDIO-RESPIRATORY: Chest pain (site) ________________________ Chest pain with exertion Dyspnea on exertion Nocturnal dyspnea Edema Hypertension Palpation Known murmur Cough Sputum Hemoptysis Pleuritic pain Diaphoresis Last X-ray _______________________ EKG _________________________ 3. GASTRO-INTESTINAL Thirst Nausea Vomiting Hematemesis Heartburn Difficulty Swallowing Flatulence Constipation Abdominal pain Jaundice Diarrhea Tarry Stool Hemorrhoids Hernia Other__________________________ 4. GENITO-URINARY Dysuria Polyuria Frequency Urgency Nocturia Burning Hematuria Stones a. Female Genital Tract Menstrual History: Age of onset ____________ Frequency ____________Regulation __________ Duration __________ Date of last period ______________ Post menopausal bleeding _______ Age __________ Symptoms _________________________________ b. G ________________ P __________________ Ab ________________ c. Male Genital Tract Penile discharges Lesions Pain Testicular swelling Other ______________________________ Last Serology Test __________________ 5. MUSCULO-SKELETAL Muscle pain Extremity pain Joint pain Back pain Joint swelling Neck pain Stiffness Limited motion Redness Sprains Deformity Others _______________________________________________ X-rays _______________________________________________________ 6. NERVOUS Convulsions Syncope Dizziness Vertigo Tremor Speech difficulty Limp paralysis Paresthesia Muscle atrophy EEG _________________________________________________________ Other _______________________________________________________

7. ENDOCRINE Goiter intolerance Exopthalmus Change in body contour 8. EMOTIONAL Anxiety Depression Fear Anger Frustration Other (specify) _____ Notes:________________________________________________________ _____________________________________________________________ _____________________________________________________________ D. Nursing Observation 1. HEENT a. Symmetry _________________________________________________ b. Eyes and Pupils _____________________________________________ c. Ears ______________________________________________________ d. Mouth and Throat ___________________________________________ e. Lymph nodes _______________________________________________ 2. RESPIRATORY a. Depth and Rate _______________________________________________________ b. Breath Sounds ______________________________________________ c. Chest expansion ____________________________________________ 3. CARDIO- VASCULAR a. Blood Pressure (R)_____(L)______ Lying _______Standing __________ b. Apical pulse rate and regularity _________________________________ c. Pedal pulses rate per minute (R)________________(L)______________ d. Neck vein distension _________________________________________ 4. CHEST a. Anterior chest _______________________________________________ b. Posterior chest ______________________________________________ c. Breasts ___________________________________________________ 1. Breasts and Axillae _______________________________________ 2. Anterior Thorax __________________________________________ 3. Posterior Thorax _________________________________________ 5. GASTRO-INTESTINAL a. Bowel Sounds ______________________________________________ b. Tenderness or rigidity _______________________________________________________ 6. URINARY a. Bladder ____________________________________________________ Tremor Voice change Infertility Heat or Cold

Polydipsia Other ____________

7. SKELETAL a. Joints _______________________________________________________ b. Range of Motions _______________________________________________________ 8. NEURO a. Motor Function 1. Facial __________________________________________________ 2. Extremities ______________________________________________ b. Sensory Function (equal or not equal) c. Equilibrium 1. Balance ________________________________________________ 2. Finger to nose ___________________________________________ d. Reflexes (equal or not equal) 1. Knees ________________________Arms_____________________ 9. CRANIAL NERVE FUNCTION a. Olfactory nerve: (sensory) 1. Sense of smell (coffee, vanilla. Etc.) 1.1 Anosmia ______________________________________ 1.2 Hyperosmia ___________________________________ b. Optic nerve: (sensory) 1. Sense of vision (Snellens chart, newspaper) 1.1 Myopia ______________________________________________ 1.2 Hyperopia ____________________________________________ c. Oculomotor: (motor) 1. Extra-ocular movements/ Pupil reaction to light 1.1 Right eye ________________ 1.2 Left eye _____________ d. Trochlear: (motor) 1. Assess direction of gaze, upward and downward movement of eyeball _______________________________________________________ e. Trigeminal: (motor) 1. Presence of corneal reflexes ___________________________ 1.1 Right eye _______________ 1.2 Left eye__________________ 2. Ability to clench teeth ____________________________________ f. Abducens: (motor) 1. Assess direction of gaze, lateral movements of the eyeballs 1.1 Right eye _______________ 1.2 Left eye ___________________ g. Facial: (Sensory and motor) 1. Sense of taste: Using back of tongue 1.1 Salty ___________________1.2 Sweet ____________________ 2. Facial Expression 2.1 Smile _______________2.2 Puff out cheeks ______________ 2.3 Frown _______________2.4 Raise lower eyebrows __________ h. Auditory nerve: (motor) 1. Sense of hearing 1.1 Right ear _______________1.2 Left ear ____________________

Glossopharyngeal: (Sensory and motor) 1. Sense of taste: Using back of tongue 1.1 Salty _____________________ 1.2 Sweet _______________ 2. Ability to swallow (Use tongue blade to elicit gag reflex) _____________________________________________________ j. Vagus: (Sensory and motor) 1. Hoarseness of voice _______________________________________ 2. Sensation of pharynx ______________________________________ Let patient say ah and observe movement of palate and pharynx k. Spinal accessory: (motor) 1. Movement of: 1.1 Head ________________________1.2 Shoulder _____________ l. Hypoglossal: (motor) 1. Able to stick tongue to midline ______________________________ 10. EMOTIONAL a. Communication _____________________________________________ b. Mood/ Effect _______________________________________________ c. Behavior __________________________________________________ E. Knowledge of Illness 1. Learning Limitations ___________________________________________ _____________________________________________________________ 2. Learning Needs_________________________________________________ _____________________________________________________________ F. Nursing Impressions ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ G. Nursing Problems (in priority) 1. _____________________________________________________________ 2. _____________________________________________________________ 3. _____________________________________________________________ 4. _____________________________________________________________ 5. _____________________________________________________________ H. Discharge Planning 1. Probable Date _________________________________________________ 2. Destination ____________________________________________________ 3. Transportation _________________________________________________ 4. Agencies and Equipment involved __________________________________ _____________________________________________________________ 5. Diet __________________________________________________________ 6. Medications ___________________________________________________ 7. Persons responsible for patient ____________________________________ 8. Family conference ______________________________________________ 9. Anticipated problems ____________________________________________ 10. Home visit ____________________________________________________

i.

Appendix B Clinical Pathway

Endorsement August 20, 2010 Bipolar disorder, most recent episode Mixed Psychotic Features Suicide, homicide, escape precaution Do not allow near stairs

August 31, 2010 Bipolar disorder, most recent episode Mixed Psychotic Features May Go Home with referral For pregnancy test this morning

September 01, 2010 FDAR 1. Focus: Dance Therapy D: Received client sitting on bench near entrance, good mood noted, client is cooperative, desire to express self noted. A: Encouraged client to join the dance therapy, guided client to mess hall, accompanied client to her position in the group, established contract with client in proper behavior during therapy, instructed to follow therapists instructions, encouraged to express personal feelings before and after dance therapy, monitored reaction of client. R: Nalipay ko, as verbalized May Go Home

2. Focus: Music Therapy D: Received client sitting in mess hall, good mood noted, desire to express self noted, cooperativeness noted. A: Encouraged client to join the dance therapy, accompanied client to proper sitting, established contract with client in proper behavior during therapy, instructed to follow therapists instructions, encouraged to express personal feelings before and after music therapy, monitored reaction of client. R: Client participated in music therapy and rendered her own version of a song she wanted to sing.

Appendix C

Research Articles Research Articles Title: Bipolar disorder in late life: clinical characteristics in a sample of older adults admitted for manic episode Authors: Alessandra Benedetti, Pietro Scarpellini, Francesco Casamassima, Lorenzo Lattanzi, Maria Liberti, Laura Musetti and Giovanni Battista Cassano Department of Psychiatry, Neurobiology, Pharmacology and Biotechnologies, University of Pisa, Via Roma, 67, Pisa, Italy Abstract Background Although manic episodes in older adults are not rare, little published data exist on late-life manic episodes. Resistance to treatment and concomitant neurological lesions are frequent correlates of elderly mania. The aim of this study was to investigate the prevalence of hospitalizations due to mania in patients older than 64 years through a period of 5 years in an Italian public psychiatric ward. Moreover, we aimed at describing clinical presentation of elderly manic episodes. Methods A retrospective chart review was conducted in order to describe clinical presentation of 20 elderly patients hospitalized for manic episode; moreover, we compared age at onset, the presence of family history for mood disorders, psychosis and irritability between the elderly group and a matched group of 20 younger manic inpatients. Results Seven percent of the whole inpatient elderly people suffered from mania. Half of those patients had a mood disorder age at onset after 50 years and 5 patients were at their first manic episode. Geriatric- and adulthood mania showed similar clinical presentation but younger people had more frequently a mood disorders family history. Conclusion Half of our older manic inpatients consisted of "classic" bipolar patients with an extension of clinical manifestations into later life; the other half of our sample was heterogeneous, even though it was not possible to identify clearly which patients may have had vascular lesions related to the onset of mania. Source: Depp CA, Jin H, Mohamed S, Kaskow J, Moore DJ, Jeste DV: Bipolar disorder in middle-aged and elderly adults: is age of onset important? J Nerv Ment Dis 2004 , 192(11):796-9.

Title: Nutritional supplement effective against bipolar disorder - Literature Review & Commentary Author: Townsend Letter for Doctors and Patients, May, 2003 by Alan R. Gaby Abstract: Fourteen patients (aged 19-46 years) with a DSM-IV diagnosis of bipolar disorder, who were taking a mean of 2.7 psychotropic medications each, were treated for 6 months with a broad-based nutritional supplement (E.M. Power ), containing the following (daily doses): vitamin A (3,333 IU), vitamin C (250 mg), vitamin D (400 IU), vitamin E (100 IU), thiamine (5 mg), riboflavin (5.5 mg), niacinamide (25 mg), pyridoxine (7 mg), folic acid (400 mcg), vitamin B12 (250 mcg), biotin (25 mcg), pantothenic acid (6 mg), calcium (550 mg), magnesium (250 mg), iron (6 mg), phosphorus (350 mg), iodine (75 meg), zinc (20 mg), selenium (100 meg), copper (3 mg), manganese (4 mg), chromium (250 meg), molybdenum (66 meg), potassium (100 mg), and a proprietary blend (doses not specified) of DL-phenylalanine, L-glutamine, citrus bioflavonoids, grape seeds, choline, inositol, Ginkgo biloba, L-methionine, germanium, boron, vanadium, and nickel. At baseline and periodically thereafter, patients were assessed with the Hamilton Rating Sc ale for Depression (HAM-D), the Brief Psychiatric Rating Scale (BPRS), and the Young Mania Rating Scale (YMRS). For the 11 patients who completed the trial, the mean HAMD decreased (improved) from 19.0 at baseline to 5.4 at the last visit (71% improvement; p < 01); the mean BPRS score decreased (improved) by 79%; p < 0.05); the mean YMRS score decreased (improved) by 60% (p < 0.01); and the need for psychotropic medications decreased by 63% (p < 0.01). In two cases, the supplement replaced psychotropic medication and the patients remained well. The only reported side effect was nausea, which was infrequent, minor, and transient. In general, improvement began within two weeks of starting the nutritional supplement. Comment: This open-label study suggests that a broad-spectrum nutritional supplement can reduce the severity of illness in some patients with bipolar disorder. Although there was no control group in this study, the magnitude of the improvement was greater than one might expect from a placebo effect alone. Other investigators have also found this supplement to be effective for bipolar disorder (J Clin Psychiatry 2001;62:933-935). This product should be used cautiously, as it may potentiate the effect of antipsychotic drugs, possibly increasing their toxicity. Additional research is needed to determine the optimal way to transition patients from psychotropic drugs to nutritional therapy. E.M. Power was originally manufactured by Evince International; it is currently manufactured by Synergy Group of Canada (1-888-878-3467). The monthly retail cost is $68.00. Source: Kaplan BJ, et al. Effective mood stabilization with a chelated mineral supplement: an open-label trial in bipolar disorder. J Clin Psychiatry 2001;62:936-944.

Title: Risk factors in relation to an emergence of bipolar disorder: a systematic review Author: Kenji J TsuchiyaMajella Byrne, Preben B Mortensen Abstract: Keywords:
y y y y y y

affective disorder; bipolar disorder; demographic factors; epidemiologic methods; risk factor; socioeconomic factors

 Objective: There is a consensus that genetic factors are important in the causation of bipolar disorder (BPD); however, little is known about other risk factors in the aetiology of BPD. Our aim was to review the literature on such risk factors risk factors other than family history of affective disorders as predictors for the initial onset of BPD.  Methods: We conducted a literature search using the MEDLINE, PsycINFO and EMBASE databases. We selected factors of interest including demographic factors, factors related to birth, personal, social and family backgrounds, and history of medical conditions. The relevant studies were extracted systematically according to a search protocol.  Results: We identified approximately 100 studies that addressed the associations between antecedent environmental factors and a later risk for BPD. Suggestive findings have been provided regarding pregnancy and obstetric complications, winterspring birth, stressful life events, traumatic brain injuries and multiple sclerosis. However, evidence is still inconclusive. Childbirth is likely to be a risk factor. The inconsistency across studies and methodological issues inherent in the study designs are also discussed.  Conclusion: Owing to a paucity of studies and methodological issues, risk factors of BPD other than family history of affective disorders have generally been neither confirmed nor excluded. We call for further research

Source: Kenji J Tsuchiya, MD Tokyo Metropolitan Tama Center for Mental Health, Nakazawa 2.1.3, Tama, Tokyo 2060036, Japan.