UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION

Salinas Drive Lahug, Cebu City

College of Nursing

Care of a Client
with Pulmonary
Tuberculosis
Submitted to:
Mr. Victor Degamo, RN, MAN
Clinical Instructor

Submitted by:

Medallo, Kirstie Claire BSN-IV

Student
 Introduction
Tuberculosis (TB) is a potentially serious infectious disease that mainly affects
the lungs. The bacteria that cause tuberculosis are spread from one person to another
through tiny droplets released into the air via coughs and sneezes. It also may be
transmitted to other parts of the body, including the meninges, kidneys, bones, and
lymph nodes The disease has become rare in high income countries, but still a major
public health problem in low and middle-income countries.

Mycobacterium tuberculosis is spread by small airborne droplets, called droplet

nuclei, generated by the coughing, sneezing, talking, or singing of a person with
pulmonary or laryngeal tuberculosis. These minuscule droplets can remain airborne for
minutes to hours after expectoration. The number of bacilli in the droplets, the virulence
of the bacilli, exposure of the bacilli to UC light, degree of ventilation, and occasions for
aerosolization all influence to infection of the respiratory system; however, the
organisms can spread to other organs, such as the lymphatics, pleura, bones/joints, or
meninges, and cause extrapulmonary tuberculosis.

Signs of TB may include coughing that lasts three or more weeks, hemoptysis,
chest pain or pain with breathing or coughing, unintentional weight loss, fatigue, fever,
night sweats, chills and loss of appetite. Older adult patients usually present with less
pronounced symptoms than younger patients.

TB is a worldwide public health problem that is closely associated with poverty,

malnutrition, overcrowding, substandard housing, and inadequate health care. Mortality
and morbidity rates continue to rise; M. tuberculosis infects an estimated one third of the
world population and remains the leading cause of death from infectious disease in the
world.

According to WHO, there were an estimated 8.8 million cases and an estimated
1.1 million deaths from TB in 2010 (WHO, 2011). The Philippines is one of the highest
tuberculosis burden countries in the world with nationwide coverage pf directly observed
treatment, short course (DOTS) achieved in 2003. This study reports on the period of
National TB Control Programme (NTP) surveillance data for the period 2003-2011.
During this period, the number of TB symptomatic examined increased by 82% with
94% completing the required 390 cases diagnosed and given TB treatment, 98.9% were
pulmonary TB cases. Of these 54.9% were new smear-positive cases, 39.3% treated.
From 2008-2011, 50, 030 TB cases were reported by non-NTP providers. Annual
treatment success rates were over 85% with an average of 90%; the annual cure rates
had an eight-year average of 82.1%. These surveillance data represent NTP priorities-
the large to treat highly infectious cases to cut the chain of transmission. The
performance trend suggests that the Philipines is likely to achieve Millenium
Development Goals and stop TB targets before 2015. (Vianzon R etal. The tuberculosis
profile of the Philippines, 2003-2011: advancing DOTS and beyond Western Pacific
Surveillance and Response Journal, 2013, 4(2).
11.16.doi:10.5365/wpsar.2012.3.4.022.)

In 2017, there were a total of 1, 600, 000 TB related deaths. Also an estimated
234, 000 children died of TB in 2017 including children with HIV associated TB. People
who have both TB and HIV when they die, are intentionally classified as having died
from HIV.

There are a total of 2, 645 cases in Cebu City and 11, 031 cases for the rest of
Cebu Province, according to the Department of Health Region 7. Their goal is to reduce
TB burden by decreasing TB mortality rate by 95% and TB incidence by 90% by 2035.

Mrs. C.C.N., is a 73 year old female that was admitted to Cebu North General
Hospital due to body malaise. Her physicians believed that she may be immuno-
compromised. She is undergoing treatment for her Pulmonary Tuberculosis (PTB).
Patient Profile:
Name: C.C.N.

Age: 73 y/o

Sex: Female

Status: Married

Address: Banilad, Mandaue City, Cebu

Name of Hospital: Cebu North General Hospital

Date & Time of Admission: July 25, 2019; 12:45pm

Ward and Bed No.: MS Ward; M8 (Isolation Room)

Case No.: 1907-3436

Chief Complaint: Easy Fatigability

Medical Diagnoses: PTB Ongoing Treatment

History of Present Illness:

1 month PTA, patient had an onset of generalized weakness and sought consultation. A
lab test was requested and blood test revealed anemia probably secondary to chronic infection
(PTB). Pt. received two PRBC and improvement was noted. Thus, the patient was discharged.
Patient was then enrolled to TB-DOTS Program.

2 days PTA, patient had recurrence of generalized weakness, anorexia and easy
fatigability was noted. Thus, patient was brought to VSMMC but have been transferred to Cebu
North General Hospital due to lack of vacancy.

History of Past Illness:

The patient cannot recall if she was fully immunized and stated that there was no
immunization during her time. She has no known allergy to food and drugs. She has a
maintenance medication of Losartan 50mg 1tab OD +Vit. B Complex (Neurobion). Patient had
Cesarean Section on 1983, 1986, and 1989. In 2010, she had a Perineal Laceration s/t Trauma
s/p Repair. In 2017, she was admitted at Vicente Gullas due to CAP. Between 2011-2012, she
was admitted at St. Vincent for two weeks due to her Ulcer. In June 2019, she was admitted at a
local hospital (unrecalled) for 7-8 days due to re-occurrence of her pneumonia. After being
discharged, she got admitted at VSMMC just this July 2019 still because of her Pneumonia.
She is also known to be hypertensive and asthmatic according to her sons.

Obstretric History:
Patient is G3T3P0A0L3

Family History with Genogram:

Legend:

Female Male Deceased C- Cancer D-Diabetic A- Asthmatic

P- Patient H- Hypertensive

Patient is known to be hypertensive and

asthmatic. Her mother is known to be
hypertensive and is deceased. On the other
hand, her father has skin cancer and died of
H C
prostate cancer. No other significant history
could be obtained.
A H
P
p
p
Environmental History:
The client lives with her 2 son and her husband in a spacious two-storey house
50 meter away from the highway in Banilad, Mandaue City near Homebuilder Hardware.
Her son shared that they live near the streets, next to the road where pollution is evident
and where air is congested. Garbages in their neighboring houses is rarely collected by
the garbage truck. The area floods a lot when it rains.
Developmental Task:

From the mid-60s to the end of life, we are in the period of development known
as late adulthood. Erikson’s task at this stage is called integrity vs. despair. He said that
people in late adulthood reflect on their lives and feel either a sense of satisfaction or a
sense of failure.

People who feel proud of their accomplishments feel a sense of integrity, and
they can look back on their lives with few regrets. However, people who are not
successful at this stage may feel as if their life has been wasted. They focus on what
“would have,” “should have,” and “could have” been. They face the end of their lives
with feelings of bitterness, depression, and despair.

As we grow older (65+ yrs) and become senior citizens, we tend to slow down
our productivity and explore life as a retired person. Success in this stage will lead to
the virtue of wisdom. Wisdom enables a person to look back on their life with a sense
of closure and completeness, and also accept death without fear.

Client C.C.N. is a 73 year old married female who is residing in Banilad,

Mandaue City. She says that she feels successful as she has done her part for her
community, family, and herself. She feels contented of what she has right now and is
even thankful for having been able to raise her children well. She has no regrets with
her past and has accomplished her life goals. She has succeeded in this stage of
development and achieved integrity and developed the virtue of wisdom.

Gordon's Functional Health Pattern

1. Health Perception and Health Maintenance
Before
Even before, she already considers herself
unhealthy because she is sickly. She has been
taking her maintenance medication which is
Losartan 50mg 1 tab OD+Vit.B Complex
(Neurobion). Client's son takes her BP at
home. Her BP would increase up to 160/100 at
times.
2. Nutrition and Metabolism
Before
Client eats often. She eats oatmeal most of
the time. She rarely eats vegetables. She’s not
fond of sweets, fast food and oily foods. She
would only drink water when needed.
During
She still considers herself unhealthy. She
verbalized that she has productive cough with
greenish mucus secretions and feels easily
fatigued. She’s still taking her maintenance
meds.
During
Client verbalized that she has loss of appetite.
She is in full low salt, low cholesterol, low fat,
and low purine diet. Her oral fluid intake is
limited to 800mL/day.

3. Elimination
Before
Client voids for about 6 times a day and the
color is light yellow. She usually defecates
every day and is usually brown.
4. Activity and Exercise Pattern
Before
The client was advised by her children to
stopped working as a cook in cafeterias so she
only stays at home. She says she walks
around the neighborhood during her free time
and would return an hour before, to her it is
her form of exercise.
5. Cognition and Perception Pattern
Before
Client has been wearing graded eyeglasses,
she says that she is often forgetful and that
she has problems with hearing.
6. Sleep Rest Pattern
Before
Client verbalized that she sleeps for about 8
hours and that she has no problems with
sleeping.
7. Self -Perception and Self-Concept Pattern
Before
Client viewed herself as confident. She
verbalized that she is satisfied with her
appearance but she does not feel good about
her condition.
8. Role and Relationship Pattern
Before
The client has 3 children. Her husband works
in a real-estate. She lives with her children
and husband. She verbalizes that she has a
good relationship with them
9. Sexuality and Reproductive Pattern
Before
The client has her menarche when she was 13
years old. She had her menopause at the age
of 55. She is G3T3P0A0L3M0.
10. Stress Tolerance and Coping
Before
During a stressful event, the client would just
rest or watch television.
11. Values and Belief
Before
The client is Roman Catholic. She used to go
to church every Sunday.
During
No changes during hospitalization except
she's wearing diaper and would consume 1-2
diapers a day.
During
The patient has only been lying because she
feels easily fatigued.
During
No changes during hospitalization.
During
Patient sleeps for about 3-4 hours. She is
easily awakened by the slightest sound.
Sometimes she would be awakened due to
her cough. She also verbalized feelings of
fatigability even with enough sleep.
During
She feels bad because of her condition
because she has been hospitalized many
times and she claims that it affects her self-
esteem. She also said that she loss more than
10kg of her weight in less than a month.
During
She has good relationship with them and
according to her, she has the best support
system.
During
No changes during hospitalization.
During
What stresses her out is her condition. So she
follows what the doctor advises to her.
During
No changes during hospitalization.
Physical Examination:
General Survey:

Received client lying on bed; awake; coherent; on MHBR; with ongoing PNSS 1L
@ 60cc/hr + 90ml KCl drip infusing well @ right arm. Vital signs were as follows: T-
38ºC; P-114bpm; R-26cpm; BP- 100/40 mmhg; O2Sat- 88%

Skin, Hair and Nails

Skin is intact, warm & dry to touch; with no presence of redness and lesions noted; has
poor skin turgor; wrinkles on face noted. Hair is gray and with few strands of black left,
with even distribution and kept at shoulder length with no presence of dandruff noted.
Nails are hard and firmly attached to nail beds but not properly cut and dirty; no signs of
clubbing noted; capillary refill time of less than 3 seconds.
Head, Neck, & Cervical Lymph Node
Face is symmetric. Head is symmetric, round and in midline; hard; with no lesions. Neck
is also symmetric, with head centered. Trachea and thyroid gland are in midline. TMJ
has no swelling, tenderness and crepitations noted. Non-palpable thyroid gland and
lymph nodes noted.
Eyes and Ears
Patient’s pupil is black, equally round and reactive to light and accommodation.
Eyelashes are evenly distributed and curled outward. No discharges & lesions were
present on both ears. Pain and swelling behind the ear noted upon light touch with the
pain score of 5/10.
Thoracic and Lungs
The thorax is the same color as the rest of the body with no presence of lesion.
Crackles noted upon auscultation over the left lung. The respiratory rate is 26cpm.
Cardiovascular
The apical heart rate is 114bpm and has a regular rhythm; no adventitious sounds were
heard upon auscultation.
Breast
Patient’s breast is non-tender and symmetrical; with no lesions or discharges present on
both.
Abdomen
Abdomen has no lesions or rashes. Umbilical is in midline and skin is uniform in color.
Cesarean Section incision scar present.
Musculoskeletal
Client has full ROM when bending and rotating bilaterally. His hands and fingers are
symmetric, non-tender and without nodules. The client is able to shrug shoulders
against resistance slightly due to fatigability; has weak grasp in both hands.
Neurologic
She can identify the number of fingers from both eyes separately. Client can hear the
sound of a ticking watch from both ears. Client can differentiate between salty and
sweet and hot and cold. He scores a 15 on the Glasgow Coma Scale. She can
discriminate between sharp and dull sensations.
 Diagnostic and Laboratory Tests
Specimen Source: Sputum AFB
Date: August 1, 2019 (2nd)

Pus cells/hpf: 90-100/hpf

Epithelial cells/hpf: 10-80hpf
AFB Stain Results: Negative for acid fast bacilli (0.)

AFB Reporting Scale:

0= No AFB/300 visual fields

+N= 1-9 AFB//100 visual fields
1+= 10-99 AFB/100 visual fields
2+= 1-10 AFB/at least 50 fields
3+=>10AFB/at least 20 fields

Test Date Normal Values Patient's Result Interpretation

1. Routine Urinalysis FINDINGS:

COLOR YELLOW YELLOW NORMAL
APPEARANCE CLEAR CLEAR NORMAL
REACTION 4.6-8.0 6.0 NORMAL
SPECIFIC GRAVITY 1.016-1.022 1.010 (L) WELL-HYDRATED
PROTEIN (HEAT & NEGATIVE NEGATIVE NORMAL
HAC) NEGATIVE NEGATIVE NORMAL
GLUCOSE NEGATIVE NEGATIVE NORMAL
KETONES NEGATIVE SMALL UTI/KIDNEY/LIVER DSE.
BLOOD NEGATIVE SMALL UTI
LEUKOCYTES NEGATIVE SMALL UTI
NITRITE NEGATIVE SMALL LIVER DAMAGE
BILIRUBIN NORMAL NORMAL NORMAL
UROBILINOGEN July 26,
2019
(MICROSCOPIC)
RBC/hpf 0-2/hpf 2-4/hpf (H) UTI/KIDNEY/LIVER DSE.
WBC/hpf 0-2/hpf 0-2/hpf NORMAL
EPITHELIAL CELLS RARE RARE NORMAL
MUCUS THREADS RARE RARE NORMAL
AMORPHOUS RARE RARE NORMAL
URATES RARE RARE NORMAL
AMORPHOUS FEW FEW NORMAL
PHOSPHATES
BACTERIA
 Test Date Normal Values Patient's Result Interpretation

2. FINDINGS:
Total Protein 6.3-8.2 4.1 (L) Malnutrition,
Malabsorption, Liver
Disorder, Kidney Disorder

Albumin 3.5-5.0 1.7 (L) Malnutrition,

Inflammation, Shock

Globulin 2.3-3.5 2.3 Normal

July 26,
A/G Ratio 2019 1.5-2.5 0.7 (L) Overproduction of
globulins/underproduction
of albumin

Calcium 8.4-10.2 6.6 (L) Hypocalcemia

Uric Acid 2.7-7.3 4.4 Normal

3. Chemistry Section July 28,

Iron 2019 28-170 14 (L) Anemia
TIBC 250-450 207 (L) Anemia or Hyproteinemia

4. Immunology
Section July 28,
Ferritin 2019 4.63-2014.0 5510.69 (H) Iron storage disorder or
nemochromatosis or
chronic disease process

Female= 4.63-204 ng/mL

Male= 21.81-27.4 ng/mL

Electrocardiographic Record (July 25, 2019)

Diagnosis: Sinus Tachycardia with non-specific ST-T wave changes

Chest AP Portable(July 31, 2019)

Remarks: Atherosclerosis of the thoracic aorta
 Anatomy and Physiology of the Respiratory System

The nose and nasal cavity form the main external opening for the respiratory
system and are the first section of the body's airway- the respiratory tract through which the
air moves. The nose is a structure of the face made of cartilage, bone, muscle, and skin that
supports and protects the anterior portion of the nasal cavity.

The mouth, also known as the oral cavity. is the secondary external opening for the
respiratory tract. Most normal breathing takes place through the nasal cavity, but the oral
cavity cab be used to supplement or replace the nasal cavity's functions when needed. The
pharynx, also known as the throat, is a muscular funnel that extends from the posterior end
of the nasal cavity to the superior end of the esophagus and larynx. The pharynx is divided
into 3 regions. The nasopharynx, oropharynx, and the laryngopharynx. The nasopharynx is
the superior region of the pharynx found in the posterior of the nasal cavity. The epiglottis
is a fact of elastic cartilage that acts as a switch between the trachea and the esophagus.

The larynx, also known as the voice box, is a short section of the airway that
connects the laryngopharynx and the trachea. The thyroid holds open the anterior end of
the larynx and protects the vocal folds. The trachea, or windpipe, is a 5 inch long tube
made of C-shaped hyaline cartilage rings lined with pseudostratified ciliated columnar
epithelium. The trachea connects the larynx to the bronchi and allows air to pass through
the neck and into the thorax. The main function of the bronchi and bronchioles is to carry
air from the trachea into the lungs.

The lungs are a pair of large, spongy organs found in the thorax lateral to the heart
and superior to the diaphragm. The left lung is slightly smaller than the right lung and is
made up of 2 lobes while the right lung has 3 lobes.
 Pathophysiology

HOST ENVIRONMENT
AGENT • Live near the streets, next to the
• 73 years old
• Immunocompromised • Mycobacterium road where pollution is evident and
Tuberculosis where air is congested.
• Asthmatic

DISEASE PROCESS
• Once inhaled, the infectious droplets settle throughout the airways

• Majority of bacilli are trapped in upper parts of airways where mucus-

secreting goblet cells exist

• The mucus produced catches foreign substances in the cilia on the

surface of the cells constantly beat the mucus and its entrapped
particles upward for removal

• This system provides the body with an nitial physical defense that
prevents infection in most persons exposed to tuberculosis

• Bacteria in droplets that bypass the mucociliary system and reach the
alveoli are quickly surrounded and engulfed by alveolar macrophages

•The complement protein C3 binds to the macrophages. Opsonization

by C3 is rapid, even in the air spaces of a host with no previous
exposure to M. Tuberculosis

• The subsequent phagocytosis by macrophage initiates a cascades of

events that result in either successful control of the infection followed
by latent tuberculosis or progression to active disease called Primary
Progressive Tuberculosis.

SIGNS AND SYMPTOMS

• Coughing that lasts three or more MEDICAL MANAGEMENT
weeks • Omeprazole 40 mg 1 cap, OD, PO
• Hemoptysis • Piperacillin + Tazobactam 4.5g, q8h,
• Chest pain or pain with breathing IVTT
or coughing
• Unintentional weight loss KEY NURSING PROBLEMS
• Fatigue 1. Ineffective Airway Clearance
• Fever 2. Impaired Blood Gas Exchange
• Night sweats 3. Imbalanced Nutrition: Less than
• Chills Body Requirements
• Loss of appetite