CASE STUDY ON PULMONARY TUBERCULOSIS

DEMOGRAPHIC DATA OF THE PATIENT :

Name : Mr. kailesh

Father’s /husband’s name : S/O Mr. Narottamlal

Age : 31 years

Sex : Male

Occupation : auto drive

Religion : Hindu

Address : 196, shyam nagar, Bhopal

marital status : Married

Diagnosis provisional : tuberculosis

Final diagnosis : pulmonary tuberculosis

Surgery if any :No surgical intervention is done .

HISTORY TAKING :-

Present complain :The patient is having present complain of ;

Severe dyspnoea on exertion even at rest also .

Cough with sputum

Chest pain due to excessive cough

Cold
Upper respiratory tract infection

Weakness , restlessness, weight loss

This all symptoms are persisting since 6yr but from last night it is in peak .

History of present illness : Since 3 month the patient is having problem of

breathlessness , cough, intermittent chest pain , he took treatment from dr. in the
hospital .the medications brought symptomatic relieve and he used to come for follow –
up but since last 8days he developed severe dyspnoea due to congesion as well as during
sleep and he used to get up and sit for long time than it used to be relieved but last night
the symptoms were on peak and he was so uncomfortable because of that the relative
brought him in hospital and after consultation with doctor he was being got admit.

Past history : he has no have any complaint of chronoc disease

Family history : In his family no one is suffering from any major disease
condition neither any person died due to any disease .

Socio-economc status : He is from lower middle class family ,he has his own ‘pakka ‘
house which is having 3 rooms only and well ventilated , he disposes garbage outside the
house there is no particular place for disposing the garbage .he is very friendly and all
like to talk with him , he participate in all religious functions .
Family composition :

S.No Name of the Age Sex Relation Health

member with the status
patient
1. Mr .kailesh 30 years Male Patient Poor
2. Mrs. Parwati 25 years Female Wife Having
joint pain
3. Pooja 2 years Female Daughter Healthy
4. munna 7 years male son healthy

Personal history :

Eating habits :He is pure vegetarian , he usually takes light diet since he
developed this disease .He takes Roti, Dal, rice , any type of vegetable whatever is
available. Sometimes he take fruits , he does not keep fast .

Elimination pattern : He was having good bowel and bladder elimination pattern but
since the problem is more severe now the renal perfusion is also decreased and it is
affecting the bladder elimination .

Any abuse : He used to smoke and sometimes he used to take alcohol but since
last 3 year he stopped taking all these things .

Life style :He lives very simple lifestyles , he does not do any extra activity
like walking or any other exercise.

PHYSICAL EXAMINATION :

Height : 160 cm
Weight : 63 kg

VITAL SIGNS :

Temperature : 99.8®F

Pulse : 42/mt.

Respiration : 44/mt.

Blood pressure : 130/70 mmhg per arterial blood pressure .

HEAD :

Scalp : No scar was seen but the scalp seems to be dry & having  dandruff.

Face : Normal in shape , size and alignment ,a black mole was present on
 chin .

Sinus area : No tenderness present.

Nodes : No nodes are enlarged .

Cranium : Normal

EYES :

Visual acuity : Normal

Visual field : Clear,6/6

Ocular movement : Normal , moves to both sides as well as towards the up and
 down .

Lids : Eye Lides are normal no edema or inflammation is being detected .

Lacrimal glands : The Lacrimal Glands are normal and secretes normally

Sclera : pale
Cornea : No Abnormality detected

Lens and media : Normal , the image forms normally.

Fundus : Normal

EARS :

External structure : Normal in alignment ,

Canal: Normal , no discharge is seen

Tympanic membrane : Normal.

Hearing : Normal , checked by tunic fork.

NOSE :

External structure : normal in alignment ,

septum : No deviation seen

Mucus membrane : Moist , no inflammation seen .

Patency : Good

Olfactory sense : This was normal , checked by using some flavour

ORAL CAVITY :

Lips : Mildly cyanosed , cracked , dry .

Buccal mucosa : Cyanosed and dry

Gums : Pale

Teeth : Unhygienic , yellow stain was present .

Palates and uvula : Normal

Tonsillar areas : No enlargement detected

Tongue : Cyanosed , dry ,

Floor : Normal .

Voice : No hoarseness was present .

Breath : Dyspnoea present , the patient was on oxygen .

NECK :

General structure : Normal in shape and size .

Trachea : Present in central

Thyroid : Normal , no enlargement seen

CHEST AND RESPIRATORY SYSTEM :

Chest shape: Slightly heavy

Type of respiration : Thoraco- abdominal respiration was present .

Expansion : It was fast .

General palpation : On palpation chest movement was present as well as apex impulse
was felt on 5th intercostals space.

Percussion : on percussion no air or fluid detected .

Breath sound : B/L +

CARDIOVASCULAR SYSTEM :
History :

1)Cardinal symptoms :

Dyspnoea : There was presence of marked dyspnoea on exertion ,even with

mild exertion .

Chest pain : It was not that evident but sometimes the client used to be
irritated due pleuritic chest pain

Cough : He was having vigorous cough .\

Expectoration : yes,expectoration was present .

Haemoptysis :There was no presence of haemoptysis ,

Palpitation :There was presence of slightly palpitation .

Syncopal attack : 1 times he had Syncopal attack .

Build and nutrition : He was averagely nourished .                                          

Nails and conjunctiva : Nails were cyanosed .                           .

Thyroid : No enlargement detected .

Oedema : There was no presence of oedema .

Skin : The skin was pallor & brittle .

ABDOMEN AND INGUINAL AREAS :

Contour and tone : Good contour and good muscle tone .

Scars marks : There is no scar marks detected .

Liver :

Spleen : Normal

Kidneys :

Bladder : Normal

Hernias : There is no hardness or swelling over the groin .

Masses : No masses are felt on abdomen

Palpation : On palpation no mass or any kind of hardness is felt , abdomen was

soft to touch .

Percussion : On percussion no fluid or gas collection detected .

Auscultation : On auscultation normal peristaltic movement heard .

GENITALIA AND AREA NODE :No such kind of nodes, abrasion or lesions seen.

RECTAL EXAMINATION :No rashes or any kind of abnormality detected.

MUSCULOSKELETAL SYSTEM :

Gait : Normal

Upper extremities : Both are in normal alignment no extra digits are present and
cyanosis were present on fingers .

Lower extremities: Both are in normal alignment .

Deformities : No such deformities detected .

Range of motion : He was so tired that could not perform the full range of
motion .                                .

NERVOUS SYSTEM :

Mental status : He was well oriented to date , place and time , even he was knowing
the reasons for admission in hospital .                            .

Language : He has no problem in language , no sludge speech .

Motor co-ordination : Motor co-ordination was good .

Lower extremities : Good tone of muscles , no rigidity detected and well co- ordination
present , there is presence of cyanosis .

s. no Investigations Normal value Patients value EVALUATION

1. Haemoglobin 11.5-15.5 gm. 15.2 gm
2. W.B.C 4000-10000/cmm 22,100/cmm More
3. Packed cell vol. 37-45% 45 %
4. Platelet count 1.5-4.0lacs/cmm 2.34 lacs /cmm
5. Blood group - B positive
6. R.B.S 70-140mg/dl 87 mg/dl
7. SGOT 5-40 IU/L 32IU/L
SGPT 3-40 IU/L 47IU/L more

8.
9. S. Bilirubin 0.2-1.2 mg/dl 0.46mg/dl
10. Direct Upto 0.3 mg/dl 0.30mg/dl
11. Indirect 0.2-1.0 mg/dl 0.16mg/dl
12. S. Creatinine 0.5-1.5mg/dl 0.9mg/dl
13. S.na+ 135-145meq/l 137 Meq/L
14. S.K+ 3.5-5 Meq/L 5.1Meq/L more
15. CL- 96-107 Meq/L 95 Meq/L
16. S. Protein 6-8 gm/dl 5.8gm/dl
17. S. Albumin 3.5-5 gm/dl 3.2gm/dl
18. S.Globulin 2.5-3.5 gm/dl 2.6 gm/dl
 19. Bld. Urea 15-40 mg/dl 43mg /dl more
20. Hbsag Negative Negative
21. HIV Non-reactive NR.
22. Blood group - B positive
23. PT –test - 15 sec.
24. Control - 13 sec.
25. INR - 1.11
URINE
ROUTINE
26. Albumin Nil Trace
27. Sugar Nil Nil
CHEST X-RAY :-The chest x- ray shows patchy, inflamed bronchioles, consolidation in
the lungs due to thick sputum. clouding appearance was observed.

Medial treatment : The patient was admitted in ICU and he was on oxygen therapy, the
medications which were being prescribed for him are listed below ;

INJ. Clavum I.V 1.2gm 8hourly

INJ. Aciloc 50mg I.V BD

INJ. Deriphyllin I.V 1 amp 8 hourly

INJ. Prednisone I.V 1 amp OD

INJ. Ibrufen 1apm I.M. BD

Tab Metagard CR 60mg 1 OD

Tab. Alupent 10mg 1 QID

Nebulise with Asthalin & Budecort 6 hourly

Syrup Mucinex 2t
 Nursing outcome Implementation Rationale Evaluation
Assessment diagnosis
Subjective data Impaired gas Patient breathing Give comfortable To extent lung Now patient is feel
patient have complaint exchange pattern will be position to the surface. better he have no
of breathing difficulty related to normal patient. complaint of breathing
objective data- decrease lung difficulty.
I observe patient surface Promote bed rest Reducing 0xygen
breathing pattern and I /limit activity & assist consumption
observe that patient with self care demands during
have breathing activities as periods of
difficulty and its come necessary. respiratory
under the first compromise may
component of virgenia reduce severity of
herson theory symptoms.
Give the inhalation to
the patient. It clean the airway
obstruction.
Instruct & encourage
patient to take deep Deep breathing &
breathing & cough coughing exercise
 every hour promote normal
breathing pattern.

Nursing diagnosis outcome Implementation Rationale Evaluation

Assessment
Subjective data- my Chest pain related to Patient chest pain Give comfortable To proper lung Expected outcome
patient have disease condition will be reduce position to the extension is completely meet
complain of chest patient here
pain To provide comfort
Give continous bed and rest to the
Objective data- rest to the patient patient.
I observe my
patient expression Explain the Proper coughing
coughing exercise. pattern will reduce
the pain
Apply the chest To remove
physiotherapy coughing

Give the medicine

as by ordered
 Nursing diagnosis outcome Implementation Rationale Evaluation
Assessment
Subjective data-my Vomiting related to Patient vomiting Give the To provide Patient feel good
patient have drug induct will be reduce comfortable comfortable and now he have no
complaint of position to patient. maintain sence of complaint of
vomiting Vomiting related to well being vomiting
Objective data- disease process. Instruct the patient
observe that patient to avoid crowd of Some time crowd
doing vomiting relatives may cause vomiting
infront of me sensation
Give the antiemetic
as by ordered Antiemetic to
 prevent the
vomiting p

Subjective data – Alteration in Patient sleep pattern Discourage large This often change
my patient have sleeping pattern will be maintained period of sleep the client ususl
complaint about related to prolonged during day time sleeping pattern
lack of sleep or counghing
heavy ness in eyes. Provide column and Its induct to sleep
Objective data- I quit environment to
observed by patient the patient
condition and
consult with night Remove the cause To provide sleep
staff. with is disturb to pattern
sleeping pattern

Give the medicine To induct sleep

asprescribed by
physician.
 Nursing diagnosis outcome Implementation Rationale Evaluation
Assessment
Subjective data-my Imbalanced Patient nutritional Check the body Note to changes in Patient nutritional
patient have nutrition less then status will be weight regularly body weight status is maintained
complaint of weight body requirement maintain and he take interest
loss and lack of related to frequent Document clients Useful in defining intake of food.
hunger anorexia. nutritional status degree/extent of
from admission and problem &
Objective data- I history of vomiting/ appropriate choice
observed that Weight loss related nausea of intervention
patient have lack of to lack of interest to
interest of food he food intake. Assess client Helpful in
refused to take food usually dietary identifying and
pattern like /dislike specific need
consideration of
Monitor input and individual
out put amount preference may
 improve dietary
Encourage to intake
patient to take more
vitamins protein To improve
diet nutritional status &
promote weight loss

Nursing diagnosis outcome Implementation Rationale Evaluation

Assessment
Subjective data- my Knowledge Patient knowledge Assess client ability Learning depends
patient have deficiency related to will be improved to learn on emotional and
complaint me about misinterpretion of regarding disease physical readiness
his condition information of lack condition Provide interection & is achieved at an
He asked me of information specific written individual pace
question regarding regarding disease. information for
his condition client Written information
relieves client of the
Objective data – I Encourage client to burden of having to
listen the patient verbalize fear/ remember large
question concerns amount of
information.
Teach about disease
process and Provides
medication opportunity to
correct
misconceptions
inadequate finances
may affect coping
Teach about T.B. with maintaining
transmission. health.

To provide
knowledge about
transmission of
infection of T.B.