Liceo de Cagayan University

RN Pelaez Blvd, Kauswagan, CDO

College of Nursing

A Case Study of

Pulmonary Tubercolusis
Submitted To:

Submitted By:

July 26, 2007

I. Introduction

II. Patient’s Profile

III. Nursing System Review Chart

IV. Growth and Development

V. Pathophysiology

VI. Doctor’s Order

VII. Ideal Nursing management

VIII. Actual Nursing Management

IX. Referral and Follow-up

X. Health Teachings

XI. Prognosis

XII. Bibliography
 I. Introduction

Tuberculosis (abbreviated as TB for tubercle bacillus) is a common and

deadly infectious disease caused by mycobacteria, mainly Mycobacterium
tuberculosis. Tuberculosis most commonly attacks the lungs (as pulmonary TB)
but can also affect the central nervous system, the lymphatic system, the
circulatory system, the genitourinary system, bones, joints and even the skin.
Other mycobacteria such as Mycobacterium bovis, Mycobacterium africanum,
Mycobacterium canetti, and Mycobacterium microti can also cause tuberculosis,
but these species do not usually infect healthy adults.

Over one-third of the world's population now carries the TB bacterium, and
new infections occur at a rate of one per second.[2] Not everyone infected
develops the full-blown disease, so asymptomatic, latent TB infection is most
common. However, one in ten latent infections will progress to active TB disease,
which, if left untreated, kills more than half of its victims.

In 2004, mortality and morbidity statistics included 14.6 million chronic

active TB cases, 8.9 million new cases, and 1.7 million deaths, mostly in
developing countries.[2] In addition, a rising number of people in the developed
world are contracting tuberculosis because their immune systems are
compromised by immunosuppressive drugs, substance abuse or HIV/AIDS.

The rise in HIV infections and the neglect of TB control programs have
enabled a resurgence of tuberculosis. Drug-resistant strains have emerged and
are spreading; data show that, from 2000 to 2004, 20% of TB cases were
resistant to standard treatments and 2% were also resistant to second-line
drugs. TB incidence varies widely, even in neighboring countries, apparently
because of differences in health care systems. The World Health Organization
declared TB a global health emergency in 1993, and the Stop TB Partnership, a
coalition of some 500 entities founded in 2000, has developed a Global Plan to
Stop Tuberculosis aiming to save 14 million lives between 2006 and 2015
Overview of the Case

This is a case of Ms. Ritchie Sacote a 26 years old resident of P2 Lumbo,

Valencia City Bukidnon who was admitted at Bukidnon Provincial Hospital in
Malaybalay last July 14, 2008 due to serious manifestations of cough and
dizziness and was diagnosed with Pulmonary Tuberculosis.

We choose Ms. Sacote among all the other patients in the ward because as
we have seen in her condition, her case is very interesting in the sense that by just
assessing her, we could already identify many health problems. We think that she
needed to be taken care of the most.

Objective of the study

This care study aims to know about the disease condition Tuberculosis, its
pathophysiology, its medical management and the nursing interventions that a
student nurse can apply. It also aims to gather pertinent information about the
clients’ health history and how this disease developed.

Scope and Limitation of the study

This study was done during the clinical duty at Bukidnon Provincial
Hospital specifically at the Medical Ward dated July 24-26 2008, 11-7pm shift.
The period of the study is limited only to 3 days thus all events that will happen
after the said period is not included.

The scope of the study includes the factors that predisposes and
precipitates the client to acquire the said disease condition. It also includes
obtaining history of the clients’ present illness. Moreover, as a student nurse, it is
my responsibility to attend to my clients needs and to intervene properly
according to my nursing care plan with the supervision of my clinical instructor.
Patient’s Profile

Name:

Age:
Sex: Female

Civil Status: Single

Nationality: FILIPINO

Religion: ROMAN CATHOLIC

Occupation: none

School Attainment: High school Graduate

Height: 5’1’’

Weight: 42 kgs

Present Address: .

Admission: July 14, 2008

Time: 09:10 AM

Chief of complaints: Dizziness and cough

Diagnosis Pulmonary Tuberculosis

Attending Physician
Vital Signs:

BP: 110/ 70 mmHg

T: 36.4°C

RR: 30 cpm

HR: 75 bpm
FAMILY and PERSONAL HEALTH HISTORY

Ms. -------- was born via normal spontaneous vaginal delivery with the help

of a “mananabang”. She had completed her immunizations while he was still

young. The patient’s family has no history of pulmonary tuberculosis in the family.

As I interviewed her mother, she states that she is the first one in their family to

have this condition. At the age 24 years old was admitted to Bukidnon Provincial

Hospital in Malaybalay because of dizziness, fever and chill before and treated

herself with over the counter medications like Paracetamol. Last January 1, 2008

she was admitted in Malaybalay Polymedic General Hospital for 4 days due to

cough, dizziness, and diarrhea for 2 days. She was taken with chest x-ray last

January 2, 2008 at the same hospital

HISTORY of PRESENT ILLNESS

A week prior to admission Ms. ----------experienced dizziness, shortness of

breath and productive-cough. A week prior to admission, she has shortness of

breathing and cough pain. One day prior to admission, her cough pain had

worsen so her family decided to seek for medical help.

c. CHIEF COMPLAINT

Patient was admitted due to complaints of pain upon coughing and

shortness of breath.
 II. Nursing System Review Chart
Name: Ritchie P. Sacote Date:_July 23,2008
Vital Signs:
Pulse: _75 bpm BP: _120/90 mmhg Temp:_37.4 C Height: 5’1’’ Weight: 42 kgs
EENT:
\ Impaired vision blind
pain reddened drainage Impaired vision
gums hard of hearing deaf
burning edema lesion teeth Hearing loss
Asses eyes, ears, nose
Throat for abnormality no problem
RESP. Shallow, rapid
asymmetric tachypnea
apnea rales cough barrel chest breathing
bradypnea shallow rhonchi RR: 30 cpm
sputum diminished dyspnea Productive cough
orthopnea labored wheezing
pain cyanotic
Asses resp. rate, rhythm, depth, pattern
breath sounds, comfort no problem Pain radiating to
CARDIO VASCULAR The ankle &
arrhythmia tachycardia numbness Right foot
diminished pulses edema fatigue
irregular bradycardia murmur
tingling absent pulses pain Weight loss
Assess heart sounds, rate, rhythm, pulse, blood
pressure, etc., fluid retention, comfort fatigue
no problem weakness
GASTRO INTESTINAL TRACT
obese distention mass Dry skin
dysphagia rigidity pain
Asses abdomen, bowel habits, swallowing,
bowel sounds, comfort no problem
GENITO-URINARY and GYNE
pain urine color vaginal bleeding Red round
hematuria discharge nocturia itchy rashes
Assess urine freq., control, color, odor, comfort/
Gyn-bleeding, discharge no problem
NEURO
paralysis stuporous unsteady seizures
lethargic comatose vertigo tremors constipation
confused vision grip
Assess motor function, sensation, LOC, strength,
grip, galt, coordination, orientation, speech.
no problem
MUSCULOSKELETAL and SKIN
appliance stiffness itching petechiae
hot drainage prosthesis swelling
lesion poor turgor cool deformity
wound rash skin color flushed
atrophy pain ecchymosis
diaphoretic moist
Asses mobility, motion, galt, alignment, joint function
/skin color, texture, turgor, integrity no problem

Place an (X) in the area of abnormality. Comment at the

space provided. Indicate the location of the problem in
the figure if appropriate, using (x)
 III. Growth and Development

SIGMUND FREUD’S PSYCHOSEXUAL THEORY

Freud’s advanced a theory of personality development that centered on

the effects of the sexual pleasure drive on the individual psyche. At particular
points in the developmental process, he claimed, a single body part is particularly
sensitive to sexual, erotic stimulation.
Based on Sigmund Freud’s Psychosexual Stages of development our
client belongs to the genital Stage. The Genital Stage begins at puberty on ward,
when Energy is directed toward attaining a mature sexual relationship. This stage
is also marked by separation from parents, achievement of independence, and
decision making.
Upon assessment, our patient has already developed a healthy
relationship as evidenced by his wife’s care and attention. He was also able to
procreate as evidence of the number of children that he had and also being able
to establish his own family and provide for their needs.

ERIK ERIKSON’S PSYCHOSOCIAL THEORY

Erik H. Erikson (1963-1964), adapted and expanded Freud’s theory of

development to include the entire lifespan, believing that people continue to
develop throughout life. He describes eight stages of development.
Erikson envisions life as a sequence of levels of achievement. Each stage
signals a task that must be achieved. The resolution of task can be complete,
partial, or unsuccessful. Erikson believes that the greater the task achievement,
the healthier the personality of the person, failure to achieve a task influence the
person’s ability to achieve the next task. This developmental task can be viewed
as a series of crises and successful resolution of these crises is supportive to the
person’s ego. Failure to resolve the crisis is damaging to the ego.
 Our patient belongs to the maturity stage in which the central task is
integrity versus despair. The patient has already accepted worth and uniqueness
of his own life and even death for the thought of experiencing circumstances
which brought about his vices and unwarranted pleasure in life. In addition to the
theories mentioned above, our patient has reached the stage of growth and
development wherein he has adapted decline in speed of movement, reaction
time and increased dependence on others.

ROBERT HAVIGHURT’S DEVELOPMENTAL TASK THEORY

Havighurst (1900-1991) theorized that there are developmental task one

must accomplish throughout life. He described developmental task as doing
those things that make up health and satisfactory growth in society. The task is
organically and socially demands. Accomplishing tasks at a lower level, or at an
earlier age, is the first step in the progression toward accomplishing tasks at later
age.
A developmental task is a task which arises at or about a certain period in
the life of an individual, successful achievement of which leads to his happiness
and to success with later tasks, while failure leads to unhappiness in the
individual, disapproval by society, and difficulty with later tasks.
In connection to Havighurst’s age periods and developmental task theory,
our patient belongs to the late maturity period. Mr. Cesar is adjusting to
decreasing physical strength and health, adjusting to retirement and reduced
income, establishing an explicit affiliation with one’s age group, meeting social
and civil obligations, and establishing satisfactory physical living arrangements.
 IV. Pathophysiology
Definition: it is an infectious disease that is characterized by the formation of
tubercules, or granulomas in the lungs.
: it is also characterized by pulmonary infiltrates and by formation with
caseation, fibrosis and cavitation.
Precipitating factor: Myobacterium Tuberculosis

Predisposing factor:

• Lifestyle
• Environment
• Stress

Schematic diagram of tuberculosis

Mycobacterium tubercle bacilli

Droplet nuclei

Inhalation of infected droplet

The bacilli lodge in the alveoli

Inflammation of the aveoli

• Lymph nodes filter drainage

• Primary Tubercle
• Necrosis
• Caseation

Calcified
Liquefaction

Giton Tubercule Cough up

Cavity
 V. Doctor’s Order

DOCTOR’S ORDER RATIONALE

July 14, 2008

To ensure that the patient present

illness is corrected before it will lead to
•please admit patient to PTB serious complications and to prevent
other patient from getting infected with
this highly contagious disease.

•Vital signs every 4 hrs. To monitor the current condition of the

patient especially every after
administration of medications
prescribe.

Blood test is one of the most commonly

•Lab: CBC, U/A used diagnostic tests to reveal
presence of infection and can also
provide valuable information about the
hematologic system of the patient
which prompt to appropriate
administration of medications.

To determine presence of bacterial

infection and use for culture and
sensitivity test for appropriate drug
therapy.

D5LR is a hypotonic solution draw fluid

•IVF D5LR 1L @ 20 gtts/min out of the intracellular and interstitial
compartments into the vascular
compartment, expanding vascular
volume. To maintain fluid and
electrolyte imbalance.
 Note:
This should not be administered
to patients who are dehydrated.

•Refer Accordingly To ensure complication will be avoided.

July 15, 2008

D5LR is a hypotonic solution draw fluid

out of the intracellular and interstitial
•IVF to follow D5LR 1L @ same compartments into the vascular
rate compartment, expanding vascular
volume.

Note:
This should not be administered
to patients who are dehydrated.

July 16, 2008

Patient experienced itchiness through

•Cetirizine 10 mg P.O administration of antituberculosis drug
(INH), therefore this drug is intended to
relieve allergic reaction caused by the
release of histamine.

D5LR is a hypotonic solution draw fluid

out of the intracellular and interstitial
•IVF to follow D5LR 1L @ same compartments into the vascular
rate compartment, expanding vascular
volume.

Note:
This should not be administered
to patients who are dehydrated.

July 17, 2008

 •IVF D5NSS 1L @ 20 gtss/min To maintain fluid balance thus
preventing dehydration

July 18, 2008

Patient experienced itchiness through

•Continue Cetirizine administration of antituberculosis drug
(INH), therefore this drug is intended to
relieve allergy reaction caused by the
release of histamine.

July 19, 2008

•May start INH 400mg 1 tablet, This drug is recommended for patient
OD, PO. Observe for rashes. who has tuberculosis or first line
therapy for patients with active
tuberculosis.

July 20, 2008

•IVF to follow D5NM 1L @ 20 To ensure proper hydration, and to

gtss/min prevent fluid and electrolyte imbalance.

To ensure eradication of
•Continue meds. microorganisms, to prevent relapse and
to prevent drug resistant bacteria.

•For Hgt now To determine presence of glucose in

the patients blood.

•For FBS, lipid profile To determine if patient is positive with

glucose and cholesterol level in his
system.

•Change present IV with plain To ensure proper hydration, and fluid

NSS 1L @ 30 gtts/min balance.
 •May use Chlorpheniramine For management of severe allergic or
maleate 5 mg 1 tablet, TID, PO hypersensitivity reactions.
•

•Hold Cetirizine To prevent patient from taking two

different kind of antihistamine
medication which may results to
adverse reactions.

July 21, 2008

•Run IVF to KVO & then will KVO is intended to prepare patient for
consumed circumstantial incident which will
prompt care givers to administer drug
or blood transfusion therapy.

July 22, 2008

•Continue meds. To ensure eradication of

microorganisms, to prevent relapse and
drug resistant bacteria.

July 23, 2008

•For billing Patient is prepared for

discharge.

July 24, 2008

•Continue meds. To ensure eradication of

microorganisms, to prevent relapse and
drug resistant bacteria.
July 25, 2008

•Shift IVF to D5NSS 1L fast drip, To ensure proper hydration, and to

regulated @ 30 gtts/min prevent fluid and electrolyte imbalance.

•Hold B complex temporarily B-complex is usually administered with

INH to prevent INH-associated
peripheral neuropathy. (patient was
allergic to INH and was temporality
discontinued).

•Chlopheniramine maleate 4g 1 Management of severe allergic or

tablet BID, PO hypersensitivity reactions

•IVF to follow with D5NM 1L @ To ensure proper hydration, and to

20 gtts/min prevent fluid and electrolyte imbalance.
Laboratoty Results

Urinalysis July 14, 2007

Color- Amber  Due to effect of drug

Transparency- Hazy  Normal
Glucose-Trace  Abnormal, may indicate high
blood glucose
Mucous thread- Few  Normal, may be male’s natural
secretion
Bacteria- Moderate  Abnormal, may indicate infection
Calcium Oxidate- moderate  Abnormal, hypercalcemia
pH- 6.0
 Normal
SoGr- 1.030
 Normal

Complete Blood Count July 14, 2007

White Blood Cells- 11,700  Increased, infection

Hemoglobin- 11  Decreased; anemia
Hematocrit- 33  Decreased; anemia

X-ray Results July 15, 2007

Impression: PTB, Bilateral with cavitary shadows in both infraclavicular area.

Atheromatous aorta. Hazy densities all over both lungs. Heart is not enlarged.
Drug Study

Generic Name Isoniazid

(Brand Name) (INH)

Date Ordered 07-19-08

Classification Anti-infectives
400mg 1 tab OD
Dose/ Frequency/
Route
Inhibits RNA synthesis, decreases tubercle bacilli replication
Mechanism of
Action
Specific  To treat Pulmonary tuberculosis
Indication
Contraindication  Should not b given to patients with drug induced liver disease

Side effects Various skin eruptions, fever, lymphadenopathy and vasculitis,

hypersensitivity, nausea and vomiting, GI disturbances, liver
dysfunction. Peripheral neuropathy and anemia

Nursing  Give drugs 1 hour before or 2 hours after meals

Precaution

Generic Name Meloxicam

(Brand Name)

Date Ordered 07-16-08

Classification Analgesic
15 mg 1 tab OD
Dose/ Frequency/
Route
Exhibits anti-inflammatory, analgesic and antipyretic effects by
Mechanism of inhibiting prostaglandin synthesis.
Action
Specific To manage arthritis
Indication
Contraindication  Hypersensitivity reaction to aspirin, meloxicam or other
NSAIDs
 Active or recurrent peptic ulcer
 Severe hepatic failure
 GI or cardiovascular bleeding
Side effects lightheadedness, vertigo, tinnitus, edema, pruritus, skin rash,
anemias
abdominal pain, nausea, vomiting, diarrhea, constipation, flatulence
dyspepsia

Nursing  Obtain accurate history of drug allergies

Precaution

Generic Name Cetrizine

(Brand Name)

Date Ordered 7-16-08

Classification Antiallergics
Dose/ Frequency/ 10 mg 1tab OD
Route
Mechanism of Long-acting non-sedating antihistamine that selectively inhibits
Action peripheral H1 receptors
Specific  To treat Skin rashes
Indication
 Hypersensitivity to Cetrizine or to any of its ingredients or
Contraindication hydroxyzine.
 Severe renal insufficiency
Somnolence, fatigue, pharengitis, dizziness, coughing, epistaxis,
Side effects drowsiness, headache, GI disturbances, hypersensitive reactions,
thickened respiratory tract secretions
 Asses or allergic symptoms
Nursing  Assess respiratory status
Precaution
 Generic Name Chlorpheniramine maleate
(Brand Name)

Date Ordered 07-20-08

Classification Antiallergics
5 mg 1tab TID
Dose/ Frequency/
Route
Competes with histamine for H1-receptor site on effector cells;
Mechanism of decreases allergic response by blocking histamine.
Action
Specific  To treat Skin rashes
Indication
Contraindication  Acute asthma attack
 Patients taking MAOI
 Breastfeeding women

Side effects  CNS: stimulation, sedation, drowsiness, excitability in

children
 CV: hypotension, palpitations, weak pulse,
 GI: epigastric distress, dry mouth
 GU: urine retention
 RESPI: thick bronchial secretions
 SKIN: rash, urticaria, pallor
Nursing  Assess respiratory status
Precaution  Monitor I&O
 Assess for allergy symptoms

Generic Name B-Complex

(Brand Name) (Java)
07-15-08
Date Ordered

Classification Multivitamins and minerals

1 cap OD
Dose/ Frequency/
Route
 Mechanism of  A coenzyme that stimulates metabolic function and needed for
Action cell replication and protein synthesis.
Specific  To prevent peripheral neuropathy
Indication

Contraindication  Hypersensitivity to drug

Side effects  Itching, hyperkalemia, diarrhea, peripheral vascular

thrombosis

Nursing  Assess for signs of B12 deficiency before and periodically

Precaution during therapy.
VI. Ideal Nursing management
 NURSING DIAGNOSIS: Infection, risk for [spread/reactivation]
Risk factors may include
Inadequate primary defenses, decreased ciliary action/stasis of secretions
Tissue destruction/extension of infection
Lowered resistance/suppressed inflammatory process
Malnutrition
Environmental exposure
Insufficient knowledge to avoid exposure to pathogens

Possibly evidenced by

[Not applicable; presence of signs and symptoms establishes an actual

diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Risk Control (NOC)
Identify interventions to prevent/reduce risk of spread of infection.
Demonstrate techniques/initiate lifestyle changes to promote safe
environment.

ACTIONS/INTERVENTIONS
Infection Control (NIC)
Independent
Review pathology of disease
(active/inactive phases; dissemination
of infection through bronchi to adjacent
tissues or via bloodstream/lymphatic
system) and potential spread of
infection via airborne droplet during
coughing, sneezing, spitting, talking,
laughing, singing.
Identify others at risk, e.g., household
members, close associates/friends.
Instruct patient to cough/sneeze and
expectorate into tissue and to refrain
from spitting. Review proper disposal of
tissue and good handwashing
techniques. Encourage return
demonstration.
Review necessity of infection control
measures, e.g., temporary respiratory
isolation.
Monitor temperature as indicated.
Identify individual risk factors for
reactivation of tuberculosis, e.g.,
lowered resistance associated with
alcoholism, malnutrition/intestinal
bypass surgery; use of
immunosuppression
drugs/corticosteroids; presence of
diabetes mellitus, cancer; postpartum.
Stress importance of uninterrupted
RATIONALE
Helps patient realize/accept necessity
of adhering to medication regimen to
prevent reactivation/complication.
Understanding of how the disease is
passed and awareness of transmission
possibilities help patient/SO take steps
to prevent infection of others.
Those exposed may require a course
of drug therapy to prevent spread/
development of infection.
Behaviors necessary to prevent spread
of infection.
May help patient understand need for
protecting others while acknowledging
patient’s sense of isolation and social
stigma associated with communicable
diseases. Note: AFB can pass through
standard masks; therefore, particulate
respirators are required.
Febrile reactions are indicators of
continuing presence of infection.
Knowledge about these factors helps
patient alter lifestyle and avoid/reduce
incidence of exacerbation.
Contagious period may last only 2–3
ACTIONS/INTERVENTIONS
Infection Control (NIC)
Collaborative
Administer anti-infective agents as
indicated, e.g.:
Primary drugs: isoniazid (INH),
ethambutol (Myambutol), rifampin
(RMP/Rifadin), rifampin with
isoniazid (Rifamate), pyrazinamide
(PZA), streptomycin , rifapentine
(Priftin);
Second-line drugs: e.g.,
ethionamide (Trecator-SC), para-
aminosalicylate (PAS), cycloserine
(Seromycin), capreomycin
(Capastat).
Monitor laboratory studies, e.g.,
sputum smear results;.
Liver function studies, e. g., AST/ALT.
RATIONALE
Initial therapy of uncomplicated
pulmonary disease usually includes
four drugs, e.g., four primary drugs or
combination of primary and secondary
drugs. INH is usually drug of choice for
infected patient and those at risk for
developing TB. Short-course
chemotherapy, including INH, rifampin
(for 6 mo), PZA, and ethambutol or
streptomycin, is given for at least 2 mo
(or until sensitivities are known or until
serial sputums are clear) followed by 3
more months of therapy with INH.
Ethambutol should be given if central
nervous system (CNS) or disseminated
disease is present or if INH resistance
is suspected. Extended therapy (up to
24 mo) is indicated for reactivation
cases, extrapulmonary reactivated TB,
or in the presence of other medical
problems, such as diabetes mellitus or
silicosis. Prophylaxis with INH for 12
mo should be considered in HIV-
positive patients with positive PPD test.
These second-line drugs may be
required when infection is resistant to
or intolerant of primary drugs or may be
used concurrently with primary
antitubercular drugs. Note: MDR-TB
requires minimum of 18–24 mo therapy
with at least three drugs in the regimen
known to be effective against the
specific infective organism and which
patient has not previously taken.
Treatment is often extended to 24 mo
in patients with severe symptoms/HIV
infection.
Patient who has three consecutive
negative sputum smears (takes 3–5
mo), is adhering to drug regimen, and
is asymptomatic will be classified a
nontransmitter.
Adverse effects of drug therapy include
hepatitis.
Notify local health department. Helpful in identifying contacts to reduce
spread of infection and is required by
law. Treatment course is long and
usually handled in the community with
public health nurse monitoring.

NURSING DIAGNOSIS: Airway Clearance, ineffective

May be related to
Thick, viscous, or bloody secretions
Fatigue, poor cough effort
Tracheal/pharyngeal edema
Possibly evidenced by
Abnormal respiratory rate, rhythm, depth
Abnormal breath sounds (rhonchi, wheezes), stridor
Dyspnea
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Respiratory Status: Airway Patency (NOC)
Maintain patent airway.
Expectorate secretions without assistance.
Demonstrate behaviors to improve/maintain airway clearance.
Participate in treatment regimen, within the level of ability/situation.
Identify potential complications and initiate appropriate actions.
ACTIONS/INTERVENTIONS
Airway Management (NIC)
Independent
Assess respiratory function, e.g.,
breath sounds, rate, rhythm, and depth, atelectasis. Rhonchi, wheezes indicate
and use of accessory muscles.
Note ability to expectorate
mucus/cough effectively; document
character, amount of sputum, presence
of hemoptysis.
Place patient in semi- or high-Fowler’s
position. Assist patient with coughing
and deep-breathing exercises.
Clear secretions from mouth and
trachea; suction as necessary.
Maintain fluid intake of at least 2500
mL/day unless contraindicated.
Collaborative
Humidify inspired air/oxygen.
ACTIONS/INTERVENTIONS
Airway Management (NIC)
Collaborative
Administer medications as indicated:
Mucolytic agents, e.g.,
acetylcysteine (Mucomyst);
Bronchodilators, e.g., oxtriphylline
(Choledyl), theophylline (Theo-Dur);
Corticosteroids (prednisone).
Be prepared for/assist with emergency
intubation.
RATIONALE
Diminished breath sounds may reflect
accumulation of secretions/inability to
clear airways that may lead to use of
accessory muscles and increased work
of breathing.
Expectoration may be difficult when
secretions are very thick as a result of
infection and/or 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/ intervention.
Positioning helps maximize lung
expansion and decreases respiratory
effort. Maximal ventilation may open
atelectatic areas and promote
movement of secretions into larger
airways for expectoration.
Prevents obstruction/aspiration.
Suctioning may be necessary if patient
is unable to expectorate secretions.
High fluid intake helps thin secretions,
making them easier to expectorate.
Prevents drying of mucous
RATIONALE
membranes; helps thin secretions.
Reduces the thickness and stickiness
of pulmonary secretions to facilitate
clearance.
Increases lumen size of the
tracheobronchial tree, thus decreasing
resistance to airflow and improving
oxygen delivery.
May be useful in presence of extensive
involvement with profound hypoxemia
and when inflammatory response is
life-threatening.
Intubation may be necessary in rare
cases of bronchogenic TB
accompanied by laryngeal edema or
acute pulmonary bleeding.
NURSING DIAGNOSIS: Gas Exchange, risk for impaired
Risk factors may include
Decrease in effective lung surface, atelectasis
Destruction of alveolar-capillary membrane
Thick, viscous secretions
Bronchial edema
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual
diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Respiratory Status: Gas Exchange (NOC)
Report absence of/decreased dyspnea.
Demonstrate improved ventilation and adequate oxygenation of tissues by
ABGs within acceptable ranges.
Be free of symptoms of respiratory distress.
ACTIONS/INTERVENTIONS
Respiratory Monitoring (NIC)
Independent
Assess for dyspnea (using 0–10 scale),
tachypnea, abnormal/diminished breath
sounds, increased respiratory effort,
limited chest wall expansion, and
fatigue.
Evaluate change in level of mentation.
Note cyanosis and/or change in skin
color, including mucous membranes
and nailbeds.
Demonstrate/encourage pursed-lip
breathing during exhalation, especially
for patients with fibrosis or
parenchymal destruction.
Promote bedrest/limit activity and
assist with self-care activities as
necessary.
Collaborative
Monitor serial ABGs/pulse oximetry.
Provide supplemental oxygen as
appropriate.
RATIONALE
Pulmonary TB can cause a wide range
of effects in the lungs, ranging from a
small patch of bronchopneumonia to
diffuse intense inflammation, caseous
necrosis, pleural effusion, and
extensive fibrosis. Respiratory effects
can range from mild dyspnea to
profound respiratory distress. Note:
Use of a scale to evaluate dyspnea
helps clarify degree of difficulty and
changes in condition.
Accumulation of secretions/airway
compromise can impair oxygenation of
vital organs and tissues. (Refer to ND:
Airway Clearance, ineffective.)
Creates resistance against outflowing
air to prevent collapse/narrowing of the
airways, thereby helping distribute air
throughout the lungs and
relieve/reduce shortness of breath.
Reducing oxygen consumption/demand
during periods of respiratory
compromise may reduce severity of
symptoms.
Decreased oxygen content (Pao2)
and/or saturation or increased Paco2
indicate need for intervention/change in
therapeutic regimen.
Aids in correcting the hypoxemia that
may occur secondary to decreased
ventilation/diminished alveolar lung
surface.
 NURSING DIAGNOSIS: Nutrition: imbalanced, less than body
requirements
May be related to
ACTIONS/INTERVENTIONS RATIONALE
Fatigue
Learning
Frequent Facilitation
cough/sputum (NIC) production; dyspnea
Anorexia
Independent
Insufficient financial resources
Assess
Possiblypatient’s ability to
evidenced
ACTIONS/INTERVENTIONS bylearn, e.g., Learning
RATIONALE depends on emotional and
level of fear,
Weight concern,below
10%–20% fatigue, ideal for framephysical
and height readiness and is achieved at
participation
Reported
Nutrition level;
lack
Management ofbest environment
interest(NIC) in an
in food, altered individual
taste sensation pace.
which
Poorpatient
musclecan tone learn; how much
Independent
content; best media and language; who
DESIRED
should OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
be included.
Document
Nutritional patient’s
Status nutritional
(NOC) status on Useful in defining degree/extent of
admission, noting skin turgor, current Written
problem information
and appropriate relieves patient
choice of of
Demonstrate
Provide instruction
weightlaboratory
and degree progressive
and
of weight weight
specific gain
written
loss, toward
the goal
burden
interventions. with
of normalization
having to remember of large
information
integrity for values
patient
ofbehaviors/lifestyle to and
referbe
oral mucosa, ability/inability free
to, of
e.g., signs of
amounts malnutrition.
of information. Repetition
to Initiate
schedule
swallow, forpresence
weight.
medications and
of bowel changes
tones, to regain
follow-up and/or to
strengthens maintain appropriate
learning.
sputum testing for documenting
history of nausea/vomiting or diarrhea.
response to therapy.
ACTIONS/INTERVENTIONS
Ascertain patient’s usual dietary Provides
Helpful inopportunity
RATIONALE identifying specific to correct
Encourage patient/SO to verbalize
pattern, likes/dislikes. misconceptions/alleviate
needs/strengths. Consideration anxiety.of
Nutrition Management
fears/concerns. (NIC)
Answer questions Inadequate finances/prolonged
individual preferences may improve denial
factually. Note prolonged use of denial. may affect
dietary intake. coping with/managing the
Collaborative tasks necessary to regain/maintain
Refer to dietitian for adjustments in health.
Provides assistance in planning a diet
dietary composition.
Monitor I&O and weight periodically. with
Useful nutrients
in measuring adequate to meet of
effectiveness
Teaching: Disease Process (NIC) patient’s metabolic
nutritional and fluid support. requirements,
dietary preferences, and financial
Identify symptoms
ACTIONS/INTERVENTIONS
Investigate anorexia that
and should be May
May indicate
resources progression
affect post/discharge.
RATIONALE dietary choicesorand identify
reported to healthcare
nausea/vomiting, and note possible provider, e.g., reactivation of
areas for problem solving disease or side effects of
to enhance
hemoptysis,
Consult
Teaching: with chest
Disease pain,
respiratory Process
correlation to medications. Monitor fever,
therapy difficulty
(NIC)
to medications,
May requiring
intake/utilization of nutrients. of
help reduce the further
incidence
breathing,
schedule
frequency, hearing
treatments loss,
1–2
volume, consistency ofvertigo.
hr before/after evaluation.
nausea and vomiting associated with
Independent
meals.
stools. medications or the effects of respiratory
Emphasize
Review howthe TBimportance
is transmitted of (e.g., treatments
Knowledge on may a full
reducestomach. risk of
maintaining
primarily
Encourage byand high-protein
inhalation
provideoffor and
airborne
frequent Meeting metabolic
transmission/reactivation.
Helps conserve energy, especially needs helps
carbohydrate
Monitor
organisms, laboratory
rest periods. but diet
may and adequate
studies,
also e.g.,
spread fluid
BUN, minimize
Low values
Complications fatigue
reflect
when metabolic requirements and promote
malnutrition
associated recovery.
withareand
intake.
through (Refer
stoolsto
serum protein, and
or ND:
urine Nutrition:
if infection is Fluids
indicate aid
reactivation
increased needin liquefying/expectorating
for intervention/change
byinclude
fever. cavitation, abscess in
imbalanced,
prealbumin/albumin.
present in these lesssystems)
than bodyand hazards secretions. therapeutic
formation, destructiveregimen. emphysema,
requirements.)
of reactivation.
Provide oral care before and after spontaneous
Reduces bad pneumothorax, taste left from sputum diffuse or
Administer
respiratory antipyretics
treatments. as appropriate. interstitial Enhances
Fever
medicationsincreasescooperation
usedmetabolic
fibrosis, serous
for witheffusion,
therapeutic
needs
respiratory and
Explain medication dosage, frequency regimen
therefore
empyema,
treatments and
calorie
thatmay prevent
consumption.
bronchiectasis,
can stimulate patient
the from
hemoptysis,
of administration, expected action, and discontinuing GI ulceration,
vomiting center. medication
bronchopleural before cure is
fistula,
the reason for long treatment period. truly effected. Directly
tuberculous laryngitis, and miliary observed
Review
Encourage
Refer to potential
small,
public interactions
healthfrequent
agency. with with
meals other spread.
therapy
Maximizes (DOT) nutrientis theintake
treatmentwithoutof
drugs/substances.
foods high in protein and choice when patient isexpenditure
undue fatigue/energy unable or from
carbohydrates. unwilling
eatingbylarge
DOT to take
meals,
community medications
and
nurses is as
reduces gastric
often the
NURSING DIAGNOSIS: Knowledge, deficient prescribed. [Learning Need] regarding
condition, treatment, prevention, most irritation.
effective
self-care, andway to ensure
discharge patient
needs
May be
Review relatedside
potential to effects of adherence
May to therapy.
prevent/reduce Monitoring can
discomfort
Encourage
Lack of SO to bring
exposure foods from
to/misinterpretation ofCreates
include
information a more
pill counts normal
and socialdipstick
urine
treatment
home and (e.g.,
to dryness
share meals ofwith
mouth,patient associated
environment
testing for with therapy
during
presence and enhance
mealtime,
of and
antitubercular
Cognitive limitations
constipation, visual disturbances, cooperation with regimen.
unless contraindicated.
Inaccurate/incomplete information presented helps
drug. meet
Patients personal,
with cultural
MDR-TB may be
headache, orthostatic hypertension) preferences.
monitored with monthly sputum
and problem-solve
Possibly evidenced solutions.
by specimens forofAFB
Request for information Combination
Note: In some INHsmear
states, and there
and culture.
alcohol has
are legal
Stress need tomisconceptions
Expressed abstain from alcohol about healthbeen status
means linked
for involuntary confinement forof
with increased incidence
while
Lack onofINH. hepatitis.
or inaccurate follow-through of instructions/behaviors
care if efforts to ensure patient
Expressing or exhibiting feelings of being overwhelmed
adherence are ineffective.
Major side effect is reduced visual
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT
Refer for eye examination after starting acuity; initial sign may be WILL:decreased
Knowledge: Illness
and then monthly while taking Care (NOC) ability to perceive green.
Verbalize understanding of disease process/prognosis and prevention.
ethambutol.
Initiate behaviors/lifestyle changes to improve Excessive general exposurewell-being and reduce
to silicone dust
risk of reactivation
Evaluate job-related risk factors, e.g.,of TB. enhances risk of silicosis, which may
Identify
working insymptoms
foundry/rock requiring
quarry,evaluation/intervention.
negatively affect respiratory
Describe a plan for receiving adequate follow-up
sandblasting. care.
function/bronchitis.
Verbalize understanding of therapeutic regimen and rationale for actions.
Although smoking does not stimulate
Encourage abstaining from smoking. recurrence of TB, it does increase the
likelihood of respiratory
dysfunction/bronchitis.
VII. Actual Nursing Management

S “Naniwang jud ko karon tungod sa akong sakit (TB), lahi ra akong

lawas kani-adto og karon”, as verbalized by the patient.
O  Loss of weight with adequate food intake.
 Poor muscle tone.
A Imbalanced nutrition: less than body requirements related to
infectious disease, Tuberculosis.
P At the end of 2 days; patient will be able to demonstrate behaviors,
lifestyle changes to regain appropriate weight.
I  Encourage client o choose foods that are appealing to
stimulate appetite.
 Provide diet modifications as indicated; increase protein,
increase carbohydrates and increase calories to establish a
nutritional plan that meets individual needs.
 Emphasize importance of well- balanced nutritious intake to
provide information regarding individual nutritional needs and
ways to meet these needs within financial constraints.
 Develop consistent, realistic weight gain goal to have a
specific weight goal to achieve for.
 Assess drug interactions, disease effects, allergies, use of
laxatives and diuretics to determine which of these factors
affect appetite, food intake, or absorption.
E At the end of 2 days; patient was able to demonstrate behaviors,
lifestyle changes to regain appropriate weight.

S “Kada mo-ubo ko, naay plema nga motaban”, as verbalized by the

patient.
O  Coughing with sputum
 Restlessness
A Ineffective airway clearance related to excessive mucus.
P At the end of 30 mins. – 1 hr.; patient will be able to maintain airway
patency.

I  Encourage deep breathing exercise and coughing exercises

to mobilize secretions.
 Increase fluid intake to at least 2000ml/day within level of
cardiac tolerance (may require IV) to help liquefy secretions.
 Encourage/ provide opportunities for rest; limit activities to
level of respiratory tolerance to prevent/ lessen fatigue.
 Changed position every 2 hours and PRN to take advantage
of gravity increasing pressure on the diaphragm and
enhancing drainage/ ventilation to different lung segments.

E At the end of 30 mins. – 1 hr.; patient was able to maintain airway

adequate and patent airway.
 “Ga sakit ang akong tuo nga paa. Muabot ang sa ti-il ang kasakit” as
S verbalized by the patient

 facial grimace
 protective behavior
O  irritability

Acute pain related to degenation of joints

A

At the end of 30 minutes the patient will be able to report pain is relieved
or controlled.
P

1. provided comfort measures such as change of position to provide

non-pharmacologic pain management.
I 2. encouraged diversional activities such as association with others
but with transmission precaution. R: to divert patients attention
3. provided quiet environment. R: to calm the patient
4. advised patient to take medication on time. R: for therapeutic
effect of the mediction.
5. administered Meloxicam as prescribed by the physician. R: to
relieve leg pain.

At the end of 30 minutes , the patient reported that the pain at his right
E leg was minimized .
 VIII. Referral and Follow-up

After 3 days of hospital care, the proponents of this study were able to
performed proper assessment of the complication of the patient. During
assessment, problems experienced by the patient were identified and
appropriate nursing interventions were designed to address the needs of the
patient. Nursing Care Plans were made; all of which are implemented. Thus, the
nursing interventions done were effective and were able to alleviate the patient’s
condition.

IX. Health Teachings

MEDICATION:

 The patient and significant others were instructed to religiously facilitate

patient in taking the prescribed home medication on time as ordered. He
was also instructed to visit the nearest health center immediately after
discharge for the TB medications that are available for free.
 He was also encouraged to take vitamin supplements, as ordered,
particularly pyridoxine (vitamin B6) to prevent peripheral neuropathy in
patients taking isoniazid.
 It was explained to the patient the importance of continuing to take
medications for the prescribed time because bacilli multiply very slowly
and thus can only be eradicated over a long period of time.
 Encouraged to complete full course of therapy even if patient feels better
to treat disease effectively.

EXERCISE:
  The patient was taught on how to do the proper passive range of motion
exercises for promotion of proper blood circulation and to prevent muscle
atrophy.
 She was instructed to consult health care provider before starting to
exercise.
TREATMENT:
The patient and/or SO were:
 Instructed to plan regular naps and quiet activities to prevent fatigue.
 Encouraged to rest and avoidance of exertion to improve breathing
pattern.
 Instructed and taught effective coughing to facilitate removal of secretions.
 Encouraged to do deep breathing to improve breathing pattern.
BOWELS
 Irregular bowel habits can result from changes in activity and diet or the
use of some drugs.
 Drink plenty of fluids and increase the fiber in your diet through fruits,
vegetables, and grains, as tolerated.
 It may be helpful to take a mild laxative. Consult your health care provider
if you have any questions.
OTHER HOME CARE CONSIDERATION:
The patient &/or significant others were:
 Instructed to maintain patient’s side-lying position, keeping head of bed
elevated to prevent aspiration.
 Instructed to provide meticulous/asceptic care and maintain good hand
washing techniques to prevent infection.
 Encouraged to turn patient every 2 hours as indicated as prolonged
pressure decreases circulation and leads to tissue ischemia and necrosis.
 Encouraged to rest and avoidance of exertion.
  Instructed to improve ventilation in the home by opening the windows in
room of affected person, and keeping bedroom door closed as much as
possible.
 Instructed to cover mouth with fresh tissue when coughing or sneezing
and to dispose of tissues promptly in plastic bags.
 Encouraged to report at specified intervals for bacteriologic (smear)
examination of sputum to monitor therapeutic response and compliance.
 Encouraged follow-up chest x-rays for rest of life to evaluate for
recurrence.
 The significant others (esp. the wife) were instructed to do prophylaxis
with isoniazid for persons infected with the tubercle bacillus without active
disease to prevent disease from occurring, or to people at high risk of
becoming infected.
BOWELS
 Irregular bowel habits can result from changes in activity and diet or the
use of some drugs.
 Drink plenty of fluids and increase the fiber in your diet through fruits,
vegetables, and grains, as tolerated.
 It may be helpful to take a mild laxative. Consult your health care provider
if you have any questions.

OUTPATIENT:
 The significant others were instructed to have a follow up check a week
after discharge and see Dr. Gervacia Kionisala at JR Borja General
Hospital for further evaluation and to check if there are complications on
the patient’s health status.
 She was also instructed to visit the nearest hospital/health center if there
is an occurrence of the disease of illness.

DIET:
The patient and/or significant others were:
 Instructed to eat small frequent meals and liquid supplements during
symptomatic period.
 Encouraged to eat &/or provide nutritious diet to promote healing and
improve defense against infection.
 Encouraged to include have MACKS-P (malunggay, alugbati, camote tops,
kangkong, saluyot and pechay) in his diet because it is inexpensive and
nutritious as promoted by the DOH.
 Encouraged to follow dietary instructions provided at the hospital before
discharge.
 X. Prognosis

GOOD POOR
A. SEVERITY X
B. AGE X
C. MEDICATION X

COMPLIANCE
D. FAMILY SUPPORT X

A.SEVERITY
As for the severity of the patient’s condition, we rated it good since our

patient already demonstrated improvement regarding health status or health

condition.

B. AGE

The patient is already 67 years old, he is relatively old and possesses a

poor immunity that may aid him to recover faster from his present condition.

Relative to this factor, we gave him a poor prognosis.

C. MEDICATION COMPLIANCE
The significant others complied with the prescribed medications. The
patient took his medications on time as ordered by the physician. This may be a
strong indication of a quicker recovery. The significant other was also open to the
health teachings that we imparted. Due to this attitude of the patient and
significant others, we rated this prognosis as good.

D. FAMILY SUPPORT
The patient’s family provides a strong support to him by caring the patient
and watching him by his bedside, making sure that he can be assisted as often
as necessary. Based on these observations, we gave the patient a good
prognosis.

OVERALL
Based on the criteria being rated. Our patient’s overall prognosis is good
with a score of 3/4.