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Nursing Department

MAJOR CONCEPT
MAJOR CONCEPT

INFECTION AND INFLAMMATION

DIAGNOSIS DIAGNOSIS
TUBERCULOSIS

CASE SCENARIO

CASE SCENARIO
Mrs. A.C.L is a 31-year-old female who was admitted last April 15 due to a chief complaint of coughing out of blood.

HX OF
HISTORY PRESENT
OF PRESENT ILLNESS ILLNESS

Student Name: Dela Cruz, Jesfel B. Intensive Practicum Prof. Marilen F. Pacis RM, RN, MAN Prof Basilio L. Bermas Jr. RN, MAN, EdD
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Nursing Department
Two months prior to admission, Mrs. A.C.L. suffered from persistent productive coughing which later persists to coughing
out of blood. On the 15th of April, she was rushed to the hospital with the chief complaint of coughing out of blood. She also
suffered from severe chest pain. Her vital signs upon admission were:
BP: 90/70mmHg RR: 45 breaths/min.
PR: 70bpm Temp: 38.2oC

FAMILY HISTORY
FAMILY HISTORY

(+) alcohol drinker

(+) DM

Student Name: Dela Cruz, Jesfel B. Intensive Practicum Prof. Marilen F. Pacis RM, RN, MAN Prof Basilio L. Bermas Jr. RN, MAN, EdD
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Nursing Department

PATHOPHYSIOLOGY
PATHOPHYSIOLOGY & CONCEPT MAP & CONCEPT

**** DISEASE PROCESS AND/ OR HOW IT COMPLICATE THE INVOLVED SYSTEM. (MAY ADD ADDTL BOXES)

TUBERCULOSIS
Pulmonary tuberculosis (TB) is a contagious bacterial
infection that mainly involves the lungs but may spread
to other organs.
PATHOPHYSIOLOGY:
Infection occurs when a person inhales droplet nucleus containing tubercle bacilli that reach the alveoli of the lungs. These tubercle bacilli
are ingested by alveolar macrophages; most of these bacilli are destroyed or inhibited. A small number may multiply intracellularly and
are released when the macrophages die. If alive, these bacilli may spread by way of lymphatic channels or through the bloodstream to
more distant tissues and organs (including areas of the body in which TB disease is most likely to develop regional lymph nodes, apex of
the lung, kidneys, brain, and bone). This process of dissemination primes the immune system for a systemic response.

RISK FACTORS CLINICAL MANIFESTATIONS DISEASE PROCESS

Coughing up blood
Old age Entry of microorganism through droplet nuclei

Alcoholism Excessive sweating, especially at night

Bacteria is transmitted to alveoli through airways

Low socio-economic Status Fatigue Deposition and multiplication of bacteria

People with weakened immune systems

Fever Inflammation

Student Name: Dela Cruz, Jesfel B. Intensive Practicum Prof. Marilen F. Pacis RM, RN, MAN Prof Basilio L. Bermas Jr. RN, MAN, EdD
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Nursing Department

NURSING CARE MAP NURSING CARE MA

CASE DIAGNOSIS NURSING DIAGNOSIS
NURSING INTERVENTIONS

Ineffective airway clearance related to bloody

secretions as evidenced by Abnormal
- Assess respiratory function noting breath sounds, rate, rhythm, and depth, and use of
respiratory rate.
accessory muscles.

NURSING
- Note ability toASSESSMENT DESIRED
expectorate mucus and cough effectively, OUTCOMES
document character, amount of
sputum, presence of hemoptysis.
Short term goal
- Place patient in semi or high-Fowler’s position. Assist patient with coughing and deep-
After 5 hours of nursing intervention,
breathing Data
Subjective exercises.
patient will be able to:
- -n/a
Clear secretions from mouth and trachea; suction as necessary.
- Maintain patent airway.

- Maintain fluid intake of at least 2500 mL/day- Expectorate secretions without

unless contraindicated.
Objective Data assistance.

BP: 90/70mmHg
Long term COMMUNITY
goalNURSING RESOURCES
ALERTS
RR: 45 breaths/min.
-After 7 days of nursing intervention,
PR: 70bpm
patient will be able to:
Temp: 38.2oC
Watch outbehaviors
- Demonstrate for a feverto that is high (100.4
Refer patient to support groups, health
(+) hemoptysis improve/maintain
F) or lasts 3airway
or moreclearance.
days, abdominal
promotion groups, hospital, clinics,
pain, tingling
- Participate in the fingers or toes, and
in treatment
emergencyregimen,
hotlines.
within the levelpain in the lower chest.
of ability/situation.
- Identify potential complications and
initiate appropriate actions.

Student Name: Dela Cruz, Jesfel B. Intensive Practicum Prof. Marilen F. Pacis RM, RN, MAN Prof Basilio L. Bermas Jr. RN, MAN, EdD