SUBMITTED TO Ms. Sucheta Yangad Asso. Prof.

(med-surg) (med-surg)

SUBMITTED BYMr. Sanvar mal soni Msc. final year

Submitted on- 18th Feb. 2013

HISTORY OF THE PATIENT IDENTIFICATION DATA Name of the patient Age Gender Bed No. Ward IPD No. OPD No. Date of admission Educational status Occupation Monthly income Religion Mother tongue Marital status Address Diagnosis : : : : : : : : : : : : : : : : Mr. Prashant Khatri 50 years Male 08 Male Pulmology Ward 47954 1200059 03/12/2012 8th standard watchman Rs. 10,000/ month Hindu Marathi Married Ram nagar, moshi, Pune. Pulmonary Tuberculosis.

CHIEF COMPLAINTS AND PRESENT MEDICAL HISTORY Mr. Prashant was admitted on 3rd Dec. 2012 at 12 pm with complaints of Breathlessness since 9 days. Cough with expectorant since 1 month. Anorexia. Mild fever since one month. Weight loss. Sweating at night. Fatigue.

PAST MEDICAL HISTORY Patient had the history of dry cough and fever 2 years ago. Pt had no other history of other major disease. PAST SURGICAL HISTORY Client had no history of surgery. FAMILY HISTORY Family tree: father mother

Sister

sister Patient wife

son FAMILY INFROMATION

Daughter

son

Sr. No 1 2 2 3 4 5 6 7

Name of Family Members Mr. kailash khatri Mrs.Rajni khatri Mrs. Shanjna Mrs. Suhana Mrs. shanti Mr. shekhar khatri Mr. rahul khatri Ms. rekha Family income per year

Relationship with patient Father Mother Wife Sister Sister Son Son Daughter

Age (yrs.) 79 75 47 46 43 28 26 24

Education Occupation Illiterate Illiterate 10th pass Graduate 10th pass Graduate 12th pass Graduate

Marital Status Farmer Married House wife Married House wife Married Teacher Married Housewife Married Teacher Married Salesman Married student Married

Health status Healthy TB Healthy Healthy Healthy Healthy Healthy Healthy

: Rs.80,000 approximately. : All the family members have weak IPR. : patient`s mother had the history of Pulmonary

Family interpersonal relationship Family history of illness tuberculosis.

Patients mother had the history of Pulmonary Tuberculosis. There was no family history of any other illness like cancer, arthritis or neurological disorders were not found.

DIETARY HISTORYPatient used to take mixveg diet. He used to take chicken once in a month. He did not use to take green leafy vegetables properly and other veg diet. He used to take meals in lunch time and dinner. He used to take breakfast in morning. He used to take tea four to five times in a day. SOCIOECONOMIC STATUS A) HOUSING Type of house - Small house with 2 rooms made up of bricks. Lighting Lack of proper lighting facility. Ventilation 1 window and 2 doors for ventilation. Water facility Not proper, family used to bring water from municipal tap. Sanitation Lack of sanitation and hygiene. B) FOOD HYGIENE PRACTICES Lack of food hygiene. Not washing hands before cooking and not washing vegetables also before cooking food. Cook food in unhygienic condition. C) PERSONAL HYGIENE PRACTICES Not maintaining personal hygiene. Not taking bath daily. Not washing hands and cutting nails etc. D) COMMUNITY RESOURCES Resources like transportation are available by bus and train. Educational resources are available up to higher education. E) RELIGIOUS PRACTICES Client and his family strongly believe in the god and they worship regularly. They visit temple sometimes. F) FAMILY INCOME & EXPENDITURE Food Rs.2000 per month Clothing Rs.500 per month Education 1000 per month Health Rs.1000 per month HEALTH HABITS Personal hygiene Patient did not use to practice hygienic condition. He used to take meal without washing hand sometimes. He did not use to bath daily.

Activity and exercisesPatient did not use to go for morning walk and other exercises. Sleep and rest Patient used to take sleep 8 hours in night and have some difficulty sometimes during sleep. Elimination Patient have no difficulty in passing urine and stool 1 years ago. Since 1 year he is having difficulty in bowel elimination. Sometimes he has complaints of constipation. Habits Patient used to smoke since 25 years, he used to smoke 20-25 bidi per day. Patient also used to take alcohol since 10 years. He used to drink 180 ml of desi daru per day. Allergies and medications Client doesnt have any allergies from medicines, food, dyes etc.

PHYSICAL ASSESSMENT GENERAL APPEARANCE Level of Consciousness: Orientation: Activity: Body Built: Breath odour Sign of distressdisease. Hygiene and groomingConscious Oriented to time, place and person. patient is less active Thin foul smell patient is confused and asking again and again about his patient does not use to groom independently.

ANTHROPOMETRIC MEASUREMENT 1. Height: 58 VITAL SIGNS 1. Temperature: 99.8F 2. Pulse: 80/min 3. Respiration: 26/min 2. Weight: 56 kg

4. Blood Pressure: 126/76 mmHg INTEGUMENTORY SYSTEM Skin color Dermatitis Allergies Lesions/Abrasions Tenderness /Redness Surgical scar Abnormal growth Cyanosis Jaundice HyperpigmentationHEAD Hair: Color of Hair: Equally Distributed Black and grey Brown No skin infections No skin allergies Absent. No redness and tenderness. Surgical scar not present. No abnormal growth. Not present Not present. Not present.

 Scalp: Pediculosis: Sinus area Nodes-

Dandruff present. Present no inflammation. not present.

FACE Face: Facial Puffiness: Symmetrical Absent.

EYES Eye Brows: Eye Lid/Lashes: Eye Ball: Conjunctiva: Sclera: Puncta: Cornea: Iris: Eye Discharge Use of glasses Pupils Visual AcuitySINUS Maxillary sinus infection Frontal sinus infection EARS Size & shape Position And Alignment RednessNormal & symmetrical. Normal. Absent No No Symmetrical No Redness/ Swelling/Discharge/Lesions Normal Normal/ No Lesions White Red and not swollen Normal Flat Absent No Equally Reacting To Light and normal size Normal

 Discharge Cerumen Lesions Foreign Body Hearing Acuity Use of Hearing Aids-

Absent Present Absent Absent Normal No

NOSE External structures Nasal Septum Nasal Polyps Nasal DischargeORAL CAVITY LIPS Cleft Lips Stomatitis Number of Teeth Dentures Dental Carries Odour of Mouth Gums Palate and uvula Taste NECK General structure Trachea Thyroid Nodes Muscles normal normal not palpable. Enlarged lymph node. normal strength lips are dry.. No cleft lips. Absent 32teeth. Absent Present Foul Smell Weak no inflammation. Patients able to identify the taste. Symmetrical Not deviated Absent Absent

CHEST AND RESPIRATORY SYSTEM Respiratory Rate Thoracic Cage ratio of 1:2 POSTERIOR THORAX Inspection Shape and Summetry ratio of 1:2 Skin Color and ConditionNormal shape. Anterioposterior to transverse diameter in Normal 26 per min. Normal shape. Anterioposterior to transverse diameter in

Exaggerated spine curvature- spine straight aligned palpation Skin is intact, uniform temperature. Chest wall intact, tenderness present over thoracic cavity. No presence of masses. Chest expansion FremitusPercussion Resonance Diaphragmatic ExcursionAuscultation Breathing Sound Respiratory PatternANTERIOR THORAX Costal angle is 70 degree. Skin is intact on anterior chest side. Crackles (rales) at inspiration. Percussion: flatness of chest sound present decreased expiratory excursion. Dyspnea: present (shortness of breath present) Crackles (rales) at inspiration. Rapid breathing with effort. asymmetry restricted lung excurtion (2 cm). decreased chest expansion (2 cm) decreased tactile fremitus.

CARDIO VASCULAR SYSTEM PulsePrecordium No heaves or lift present on palpation. Aortic pulsation absent. Point of maximal impulse Heart Sound Abnormal Heart Sound Murmurs Carotid Pulse Rate Blood PressureCarotid pulse Normal pulsation, symmetric volume. No sound present on auscultation. Jugular vein Not distended. Peripheral pulses Symmetric volume, rate and rhythm. ABDOMEN AND INGUINAL AREA Abdominal Girth Diarrhea / Constipation Counter and tone Scar marks Liver Spleen Kidneys Bladder Hernias Masses78 cm Absent. symmetric. not present.. not palpable. not palpable. not palpable, normal. normal. absent. absent. 5th intercostal space, midclavicular line S1 , S2 Heard Not present. Absent 80/min 126/76 mmHg 80/min

Inspection Size Symmetry Scar Lesions and rednessPalpation Tenderness Fluid Collection Mass/SoftNo tenderness Absent No palpable mass. Protuberant Flat Normal No scar present not present..

No enlargement of liver, spleen. Percussion Ascitis / Peritonitis No Gas /Fluid Collection Tympanic sound present over the stomach area. Dullness sound over the liver. Auscultation Bowel SoundsGENITO URINARY Frequency of Urination Colornormal. Pale yellow. properly heard. Absent

No complaints of Anuria / Hematuria / Dysuria / Incontinence. Catheter Present Urethral DischargeNo No

MUSCULO SKELETAL SYSTEM Range of Motion Joint Swelling / Pain Weakness Extrimity strength EdemaNormal ROM. no inflammation. Present. Equal extremity strength. not present.

NERVOUS SYSTEM Level of consciousness Orientation Emotional state Language Motor coordination Reflexes Conscious, coherent and responsive Oriented to time, place and person Calm, but upon exertion he feels dizzy and answers questions inappropriately. Marathi Normal coordination. Normal

INVESTIGATIONS . DIAGNOSTIC STUDIES

SR NAME OF NO. INVESTIGATION 1. Haemoglobin 2. WBC count

NORMAL VALUE 12-16 gm% 400011000/cumm 40-75 % 20-45 % 0-5 % 0-5% 0-2% 70-120 mg% ----135-145 mEq/L

PATIENT VALUE 12 gm% 15000/cumm

REMARK Normal Elevated

3.

Neutrophils Lymphocytes Eosinophil Monocytes Basophils

60 % 35 % 04 % 02% 00 % 76mg% B positive Negative 138 mEq/L ----Normal Normal

4. 5. 6. 7.

Random blood sugar Blood group HIV Serum sodium

8. 9. 10.

Serum potassium Serum creatinine Serum chloride

3.5-4.5 mEq/L 0.8-1.4 mg/dl 96-106 mEq/L

4.9 mEq/L 0.9 mg/dl 103 mEq/L

Normal Normal Normal

Chest X-ray

Fluid around a lung (pleural effusion) Consolidation of lung tissues. Nodular shadow.

TB Skin Test: 7mm mark at injection site.

Nursing diagnosis:
Impaired breathing pattern related to pleural congestion as evidenced by dyspnea Activity intolerance related to dyspnea as evidenced by decreased walking. Impaired sleeping pattern related to dyspnea as manifested by disturbed sleep. Fear related to disease prognosis as evidenced by anxious depression Imbalanced nutritional status less then body requirement related to lo intake of food as manifested by refused to take food Deficient knowledge related to treatment, follow up as evidenced by lack of awareness.

DAILY PROGRESS OF PATIENT: Day-1 - Maintained rapport with the patient Thorough assessment include physical examination and history collection Checked the vital signs. Nebulization therapy given Deep breathing and coughing exercises given health education given

Day-2. Assessed the patient general condition Checked the vital signs- temp-99.2f,pulse-80b/m,resp-26b/m,BP -126/80mmhg. Deep breathing and coughing exercise done Administered the oxygen supply Fowlers position given Psychological support given Medication give to the patient as prescribed.

Day3 Assessed the patient general condition Checked the vital signs stable Deep breathing and coughing exercise done Steam inhalation given to the patient. Nebulisation given to the patient. Patient improved breathing pattern.

Day-4 General condition is fair. Intermittent oxygen supply administered. Deep breathing and coughing exercise done. Medication given as prescribed. Patient improving the breathing pattern, respiratory rate is 22/min. Oxygen saturation is 98%.

Day5 General condition better. Patient slept well at last night. Routine medication given. Fowlers position maintained Repeater the deep breathing and coughing exercise. Steam inhalation given to the patient 4 times a day. Nebulised the patient. Patient feel comfortable. Repeat X ray done, decreased consolidation.

Day6 General condition improved. Vital signs stable Health education given. Patient discharged from the hospital with prescription.

DIET FOR THE PATIENT However patient need to be very careful about his dietary choices while recovering from this condition. There is a high risk of malnutrition in adults suffering from this condition. Moreover, the deficiency of protein can have a negative impact on bodys ability to fight off tuberculosis. To avoid such problems, patient need to follow a proper pulmonary tuberculosis diet. The key element of a good diet for pulmonary tuberculosis patients is good nutrition. The eating plan should follow with adequate amounts of vitamins, minerals, protein, fiber and other essential nutrients. Given below are the daily recommended amounts to consider when planning a pulmonary tuberculosis diet Given below are some of the healthy foods to include in a pulmonary tuberculosis diet

Whole grains, especially whole wheat pasta, brown rice, whole wheat bread and breakfast cereals

Brightly colored vegetables that are rich in antioxidants, such as carrots, squash, sweet potatoes, peppers and tomatoes

Dark, leafy greens. Fruits that are high in vitamins and antioxidants, especially oranges, lemons, melons, grapefruit, berries, pumpkins and cherries

Fatty fish varieties that are high in omega-3 fatty acids, which include herring, halibut, albacore tuna, sardines, salmon, flounder and mackerel

Dairy products like skim milk and plain yogurt and low-fat cheese Unsaturated fats such as olive oil Iron-rich sources of food, which include eggs (especially the yolk), meat, poultry, nuts and beans

DAILY DIET MENU PLAN FOR TUBERCULOSIS PATIENT. I. An all-fruit diet for three days. Take three meals a day of fresh juicy fruits at five-hourly intervals. II. A fruit and milk diet for further 10 days, adding a cup of milk to each fruit meal. III.Thereafter, adopt a well-balanced diet, on the following lines:-

1. Upon arising: A glass of lukewarm water mixed with half a freshly-squeezed lime and a teaspoon of honey. 2. Breakfast: Fresh fruit, a glass of milk, sweetened with honey, and few nuts, especially almonds. 3. Lunch: A bowl of freshly-prepared steamed vegetables, whole wheat wheat tortilla with butter and a glass of butter milk. 4. Mid-afternoon: A glass of fruit juice or sugarcane juice. 5. Dinner: Raw vegetable salad and sprouts with vegetable oil and limejuice dressing, followed by a hot course, if desired. 6. Bedtime Snack: A glass of milk with few dates. AVOID: Tea, coffee, sugar, white flour and products made from them, refined foods, fried foods, flesh foods, alcohol and smoking. B - OTHER MEASURES 1. Wet chest pack for one hour every morning on an empty stomach. 2. Neutral immersion bath for one hour at bedtime. 3. Fresh air, breathing and other light exercises and yogasanas. 4. Adequate rest and proper sleep. 5. Avoid all worries and mental tensions.

HEALTH EDUCATION AND DISCHARGE PLANNING Client was given health education on various aspects of health, disease condition, its diagnosis, treatment and follow-up during his stay in the hospital and at the time of discharge. 1) DISEASE CONDITION Client was explained about the causes of the Pulmonary Tuberculosis. He was explained about the severity of the disease. He was guided for the prevention of the same condition in the future and maintains food hygiene at home. Special instructions were given on food hygiene.

2) MEDICATIONS Patient was explained about the importance of medications. he was explained about the route, time and dosage of medications. Side effects were told to be reported to the doctor. Follow-up of the treatment was advised. He was advised not to give any medications without doctors order.

3) NUTRITIONAL THERAPY Advised the patient to take more fluid diet. Eat more fiber by eating at least 5 servings of fruits and vegetables every day. Advised the patient to take high protein diet Advised the patient to follow up hygienic practices.

4) BREATHING EXERCISES: Advised the patient to do deep breathing and coughing exercises Explained the patient how to do breathing exercises.

5) HEALTH TEACHING Encouraged client to do at least 30 minutes of walking a day as a form of exercise. Instructed to adjustments in diet, medication and exercise can be made accordingly. Encouraged to stick to the monitoring protocol prescribed by the doctor.

Safety precaution should be maintained to prevent foot injury such as do not wear open shoes or walk barefoot. Adjust of activities to avoid over exertion and fatigue, allow rest periods

BIBLIOGRAPHY 1. Black. M. Joyce, Medical surgical Nursing,8th edition, Vol.-2nd, Saundars Publications, 2009, Pp.1604-1609. 2. Boon A. Nicholas, Davidsons Principles & Practice Of Medicine, 20th edition, Churchill Livingstone Publication, 2006, Pp.695-703. 3. Bennett John V.,Hospital Infectuions 4th edition, Lippincott ,1998, Pp.515-532. 4. Chintamani, Lewiss, Medical surgical nursing, Mosby publications, Pp.569-574. 5. Saunders manual of medical and surgical nursing, Joan luckmann, Sounders Company. 389-920. 6. CIMS. Updated prescriber hand book, 2002; Jan: 76, 74, 206, 306. 7. Patient file.

Dietary management

Progress notes