Nursing Department

Intensive Practicum

A Case Study on
Pulmonary Tuberculosis

Submitted by: Dela Cruz, Jesfel B.

Submitted to:

Prof. Marilen F. Pacis RM, RN, MAN

Prof Basilio L. Bermas Jr. RN, MAN, EdD

OBJECTIVES
General

The general objective of this case study is to broaden our knowledge about the disease and
develop skills on how to render the best possible care to a patient suffering from Pulmonary Tuberculosis.

Specific

 To be able to define Pulmonary Tuberculosis as well as on how it is acquired, factors, signs, and
symptoms.
 To be able to know the pathophysiology of Pulmonary Tuberculosis.
 To be able to know the other problems that the client is suffering right now not only PTB but also
Pneumothorax and Hydrothorax.
 To gain more information about patient’s condition.
 To apply skills learned in the classrooms to actual handling and caring of a patient who suffered
from Pulmonary Tuberculosis.
 To determine the possible nursing intervention that will be a great help in patient’s prognosis.
 To be able to give the appropriate health teaching and better understanding of the disease to the
patient, family, and significant others.

INTRODUCTION
This whole case study is about to discussed Pulmonary Tuberculosis (TB) and few of Pneumothorax
and Hydrothorax. This case will tackle about the disease, patient’s health and of course nursing
intervention.

Tuberculosis is a common and often deadly infectious disease caused by mycobacteria, in

humans mainly Mycobacterium tuberculosis. Tuberculosis usually attacks the lungs (as pulmonary TB)
but can also affect the central nervous system, the lymphatic system, the circulatory system, the
genitourinary system, the gastrointestinal system, bones, joints, and even the skin. Other mycobacteria
such as Mycobacterium bovis, Mycobacterium africanum, Mycobacterium canetti, and Mycobacterium
microti also cause tuberculosis, but these species are less common in humans.

Tuberculosis is spread through the air when people who have the disease cough, sneeze, or spit.
Most infections in human beings will result in asymptomatic, latent infection, and about one in ten latent
infections will eventually progress to active disease, which, if left untreated, kills more than half of its
victims. The classic symptoms of tuberculosis are a chronic cough with blood-tinged sputum, fever, night
sweats, and weight loss. Infection of other organs causes a wide range of symptoms.

Nursing Theory
FLORENCE NIGHTINGALE “ENVIRONMENTAL THEORY”

Air

Nutrition Ventilation

MR.
ADL
Cleanliness Bedding

Light

Florence Nightingale was born to a wealthy and intellectual family. She was known as the Lady with the
Lamp. She believed she was “called by God to help others to improve the well-being of mankind.”

Nightingale is viewed as the mother of modern nursing. She synthesized information gathered in
many of her life experiences to assist her in the development of modern nursing. Her contribution to the
nursing profession was her “Environmental Theory” in which the nurse’s role is to place the client in the
best position for nature to act upon him, thus encouraging healing.

Nightingale viewed the manipulation of the physical environment as a major component of

nursing care. She identified ventilation and warmth, light, noise, variety, bed and bedding, cleanliness of
the rooms and walls, and nutrition as major areas of the environment the nurse could control. When one
or more aspects of the environment are out of balance, the client must use increased energy to counter the
environmental stress. These stresses drain the client of energy needed for healing. These aspects of
physical environment are also influenced by the social and psychological environment of the individual.
 I as a student nurse and part of the medical field, has the role of providing nursing care with the
help of the institutions and personnel involve curing the illness and lower down the factors causing the
patient’s disease with the help of Nightingale’s Environmental Theory.

CHAPTER I – ASSESMENT

A. Nursing Health History

I. Demographic
Name: Mr. ADL
Age: 24 years old
Religion: Roman Catholic
Civil Status: Single
Occupation: Car washer
Nationality: Filipino
Ethnic Group: Ilonggo
Admitting Diagnosis: Pulmonary Tuberculosis, Pneumohyrothorax Right
Sources of Information: Patient, Patient chart and the Significant Others (Mother and the sister)

II. Admission Data

A 22-year-old male patient was admitted to the emergency room last August 21, 2020, accompanied
by relatives with a chief complaint of difficulty of breathing.

III. History of Present Illness

The information that I gathered are second hand as they came from the patient mother and sister. Due to
unknown reason, the patient refused to be interviewed even though based on my observation, he has a
capability to answer my questions.

Last two months, the family observed Mr. ADL is losing weight and has a decrease of appetite but instead
of eating foods he is more on vices, then his condition became worse according to family’s observation.

A month prior to admission, the patient’s condition became more at its worst and his cough became
productive with intermittent spots of blood in the sputum upon coughing. He also started to have night
sweat, became sluggish and spent lots of time sleeping. He was advised by the family to have a check-up
and visit the nearest hospital or clinic, but he refused everything that his family’s suggested, as verbalized
by Mr. ADL’s sister.
Based on the statement of his mother, two days prior to admission, Mr. ADL experienced body weakness,
fatigue, and on the day of admission last August 21, 2020, in Rizal Provincial Hospital, suddenly he was
complaining of difficulty of breathing, one hour after he ate his lunch.

IV. Past Medical History

Referring to the statements made by his sister, Mr. ADL was diagnosed with Pulmonary
Tuberculosis last 2014, 6 years ago. He entered a rehabilitation program sponsored by the local
government in Cavite that will provide the beneficiates with 100% coverage on the six months duration in
curing the disease. The six months duration in curing the disease became successful, he was cured by the
medication given by the sponsored but due to vices like smoking and active drinking of liquor the disease
from the past became active again.

By 2015 the patient has finger clubbing and through the course of my interview, it was confirmed that at
early age, my patient was suspected of heart problem; “Mahina daw po ang puso niya. Lahat din naman
kami, normal na sa amin ang mababa ang dugo (blood pressure) mga 90/70”, as verbalized by the
patient’s sister.

V. Familial History

Last 2012, 8 years ago when his father died from heart attack. I observed that Mr. ADL has a
clubbing finger, through the course of interview it was confirm that all of the siblings have a heart
problem. Then two of his uncles died from respiratory diseases, one is from Tuberculosis, and another is
from lung cancer. His sister also said that it was Mr. ADL twice to be confined in a hospital with a serious
condition.

VI. Personal and Social History

Mr. ADL is a car washer. He is working since 2016, 4 years ago, weekdays; it is near to their house, and
earning 150 pesos per day. He shares some of his earnings to his mother as one of their resources of
foods. He plays basketball with his friends; they also participated in any championship as one team in
their barangay, this is good for recreation. He also has a good voice, according to his sister.

VII. Review of Systems

The data gathered are all coming from the mother as it was the patient subjective complaint.

SYSTEM
 General Generalized body weakness
Skin Dry
Head
Eyes & Ears
Nose Runny nose, with discharges
Throat & Mouth Dry mouth
Neck
Breast
Respiratory Difficulty of breathing, dyspnea upon exertion.
Cough
CVS Dyspnea upon exertion and chest pain
GIT Constipated at times, defecate every other day.
GUT
Extremities Joint pain
Neurologic Weakness
Hematologic
Endocrine Excessive night sweating
Psychiatric Depression, Ignores kind interview

Gordon’s Review of Systems

I. SELF PERCEPTION- SELF CONCEPT PATTERN
In my observation, the patient looks shy. He just minds his own self maybe because he is
still in pain due to chest tube thoracostomy attached on his right chest.

II. ROLE- RELATIONSHIP PATTERN

Mr. ADL is close to his mother. He lives with his mother from the time he was born to
the time where he is right now. All good values that he has was educated by his mother but
during his adolescence stage he became abusive in his body, he became active with many kinds
of vices that are influenced by his friends, these is the reason why he got the disease
Tuberculosis.

III. SEXUALITY and REPRODUCTIVE PATTERN

According to the mother, she does not have an idea about sexual activity of Mr. ADL; she
only knew that Mr. ADL is single and no girlfriend as of now.

IV. COGNITIVE PERCEPTUAL PATTERN

According to the mother, Mr. ADL knows already his condition because he already suffered it
before, last 2014, 6 years ago. But this time it is more complicated.

V. COPING STRESS TOLERANCE PATTERN

Psychosocial (Erik-Erikson)
Adulthood – Intimacy vs. Isolation
Intimacy vs. Isolation is the sixth of eight stages of Erik Erikson's theory of psychosocial development.
This stage takes place during adulthood (ages 19 to 40 yrs).
During this period, the major conflict centers on forming intimate, loving relationships with other people.
Success at this stage leads to fulfilling relationship. Failure on the other hand, can result in feelings of
loneliness and isolation.

Genital Stage
Psychosexual (Sigmund Freud)
According to Freud's theory of psychosexual development. The personality develops in five overlapping
stages from birth to adulthood. In this stage our patient met the needs of each stage and he able to move
successfully into next developmental stage.
 
Cognitive Stage
(Piaget)
According to Piaget, cognitive development is an orderly sequential process in which a variety of new
experiences must exist before intellectual abilities can develop. The Piaget cognitive development process
is divided into five major phases. In each phase the person uses three primary abilities. The assimilation,
accommodation, and adaptation.

VI. VALUE BELIEF AND PATTERN

Mr. ADL is a Roman Catholic, sometimes he visits the church, one ride of jeep from their
house, twice a month.

VII. HEALTH PERCEPTION

Patient regularly goes to barangay health center to have his checkup. He doesn’t have any life
insurance and health card. Patient wants to regain his strength so that he can back to work.

B. Physical Assessment
a. General appearance/survey:
 Patient appeared weak looking but was somehow coherent in high fowlers position due to CTT
attach to his right chest. Mr. ADL ignores my kind interview, but he is willing to cooperate when it comes
in taking vital signs, physical assessment and giving medication which is important. The patient’s skin
was dry especially on the lower extremities. IVF of D5NM 1L + 1 amp of Moriavit at 50cc level was
attached to his right hand.

b. Measurement

FIDINGS NORMAL VALUES ANALYSIS/

INTERPRETATION
(Ht, wt) Height: 5’5” BMI BMI below normal because of
Weight: 101 lbs malnutrition

Vital Signs Temp: 36.0 C Temp: 37 C With some abnormal findings in

PR: 90 bpm PR: 60-100 bpm the respiratory rate.
RR: 29 bpm RR: 16-20 bpm Increase RR; difficulty of
BP: 100/70 mmHg BP: 120/80 mmHg breathing (decrease Oxygen
supply in the body)
c. Head to toe Assessment

BODY PARTS NORMAL ACTUAL ANALYSIS/

FINDINGS FINDINGS INTERPRETATION
A. HEAD
a. Skull Rounded Normocephalic Normal findings
(normocephalic,
with frontal,
parietal and
occipital
prominences)

b. Hair Evenly distributed; Evenly Typical hair type of

thick hair; silky distributed men
resilient hair; no
infestation or
infection; variable
amount of body hair

Symmetric facial
features, palpebral
c. Face fissures equal in Symmetric Normal findings
size, symmetric facial features
nasolabial folds

Shape is round; size

equal
d. Eye/vision
4.1 Eyeball Protects eyes, Round, uniform Normal findings
 anteriorly meet at in size
the medial and
4.2 Lid margins lateral corners of Close Normal findings
eye. symmetrical

Delicate membrane;
covers part of the
outer surface of the
4.3 Conjunctiva eyeball Smooth and pale Undernourished, lack
of vitamins
Outermost tunic,
thick white
connective tissue.
Appears white
4.4 Sclera Pupils constrict Normal findings
when looking at
near objects, pupils
converge when Normal pupil
4.5 Pupils object is moved constriction Normal findings
towards the nose

Hair evenly
distributed, intact
skin

Equal movement Hair evenly

4.6 Eyebrow, lashes, color, symmetry, distributed, Normal findings
quality of hair, placement intact skin

4.7 Eye movement in all directions Equal

movement Normal findings

B. VISION TESTING
a. Visual field When looking Client can see Normal peripheral
straight ahead from his vision
clients can see periphery
objects in periphery

Able to read
b. Visual acuity newspaper Able to read Normal visual findings
newspaper
C. EARS
a. Pinna Same color as facial Same color as Normal ear features
skin, pinna recoils facial skin,
after it is folded pinna recoils
after it is folded

Dry ear wax Wet and

b. External canal grayish-tan color or sticking Normal findings
sticky wet cerumen cerumen with
in various shades of transparent color
 brown/ pearly gray
color;
semitransparent

Responds to Responds to
moderately loud moderately loud
c. Hearing acuity voice tone voice tone Normal findings
D. NOSE Symmetric, normal No deformity, (+) dyspnea, patient
breathing, able to (+) difficulty of have cough which
identify familiar breathing. With reflex is not the only
smell runny nose way to protect our
airways which causes
patient to have runny
nose.
E. MOUTH/LIPS
a. Gums Pink gums; moist Dark gums Gums darkened due to
firm texture smoking history

b. Teeth 32 adult teeth Yellowish with Needs dental work

smooth, white few cavities and
yellowish shiny some missing
tooth enamel teeth

c. Tongue Central position, Central position, No remarkable

pale in color pale in color findings

Pale in color
d. Palate-hard/soft Pink and smooth; No remarkable
freely movable findings
Pale posterior
e. Oropharynx/ Tonsil Pink and smooth wall No remarkable
posterior wall findings
F. CHEECKS Hollow in Indicates malnutrition,
appearance due to weight loss
I. NECK Lymph nodes freely Lymph nodes Normal findings
movable freely movable
J. CHEST Quiet rhythmic and (+) difficulty of Presence of crackles
a. Anterior effortless breathing, with caused by fluid often
b. Posterior respirations; full abnormal sound associated with
symmetric in the right inflammation or
excursions lower lobe infection of the
alveoli.
Indicates respiratory
problems such us TB,
Pneumohydrothorax
Localized pain No air leak on
around drainage system:
thoracostomy manageable incision
site. pain.
 Full and Normal findings
K. HEART Full and symmetric symmetric

L. BREAST
M. ABDOMEN Flat, rounded Flat, scaphoidal Client is not well
(convex) or in shape nourished.
scaphoids It is also due to weight
loss.
N. UPPER EXTREMETIES Equal in size on Equal in size but Client is not well
both sides of the muscular nourished
body; no muscle atrophy evident.
atrophy; normally Unable to move
firm; smooth freely due to Struggling movements
coordinated pain in incision due to wounds,
movements site. incision pain.
O. LOWER EXTREMETIES Equal in sixe on With muscular Client is not well
both sides of the atrophy evident. nourished
body; no muscle Occationally
atrophy; normally stands up for Weakness and pain
firm; smooth short time. (2 hinder client from
coordinated days post-op) actively moving
movements around.

C. Diagnostic Procedures
a. Hematology report August 21, 2020

Test Results Normal Value Analysis

Hemoglobin 110 g/L 140 – 170 g/L Decrease
Insufficient oxygen
circulating in the
bloodstream.
Indicates Anemia due
to blood loss after
surgery.
Hematocrit 0.33 0.40 – 0.50 Decrease
Insufficient oxygen
circulating in the
bloodstream.
Indicates Anemia due
to blood loss after
surgery.
WBC 15.2 x 10 5.0 – 10.0 x 10 Increase
Leukocytosis
Indicates infection
Neutrophils 0.78 0.45 – 0.65 Increase
Acute bacterial
infection
Lymphocytes 0.21 0.25 – 0.40 Decrease
 low absolutely
lymphocyte
concentration,
associated with increase
rates of infection
Monocytes 0.01 0.02 – 0.06 Decrease
Depleted in
overwhelming bacterial
infection
Platelets 320 150 - 450 Normal

b. Chest X-ray August 21, 2020

Impression: Pulmonary Tuberculosis (PTB)

Right sided Pneumohydrothorax

c. Urinalysis August 21, 2020

Color: Yellow
Transparency: S/I Fubid

Chemical Strips

Reaction: 5.2
Specific Gravity: 1.025 (above normal) – dehydration and
contamination
Albumin: Trace

Microscopic

WBC 8-12
RBC 1-3
Epithelial Cells Rare
Mucus treads Moderate
Amorphous Urates Plenty

d. RT Hemithorax August 22, 2020

Ultrasound done on the right hemithorax, there is a significant fluid in the right lower hemithorax.
Minimal fluid is seen with leculations noted of about 36cc. Echoes noted within probably due to air.

Impression: Minimal leculated hydrothorax, right

e. Urinalysis August 22, 2020

 Color: Yellowish brown
Consistency: Soft
Microscopic: No Ova, parasite seen
WBC 4-8
RBC 0-1
Bacteria Plenty – bacterial infection

f. Radiological Report August 23, 2020

Impression: Pulmonary Tuberculosis, Left

Pneumohydrothorax, Right

D. Anatomy and physiology

UPPER RESPIRATORY TRACT

Respiration is defined in two ways. In common usage, respiration refers to the act of breathing, or
inhaling and exhaling. Biologically speaking, respiration strictly means the uptake of oxygen by an
organism, its use in the tissues, and the release of carbon dioxide. By either definition, respiration has two
main functions: to supply the cells of the body with the oxygen needed for metabolism and to remove
carbon dioxide formed as a waste product from metabolism. This lesson describes the components of the
upper respiratory tract.
 The upper respiratory tract conducts air from outside the body to the lower respiratory tract and
helps protect the body from irritating substances. The upper respiratory tract consists of the following
structures:

The nasal cavity, mouth, pharynx, epiglottis, larynx, and upper trachea; the esophagus leads to the
digestive tract.

One of the features of both the upper and lower respiratory tracts is the mucociliary apparatus that
protects the airways from irritating substances and is composed of the ciliated cells and mucus-producing
glands in the nasal epithelium. The glands produce a layer of mucus that traps unwanted particles as they
are inhaled. These are swept toward the posterior pharynx, from where they are swallowed, spat out,
sneezed, or blown out.

Air passes through each of the structures of the upper respiratory tract on its way to the lower
respiratory tract. When a person at rest inhales, air enters via the nose and mouth. The nasal cavity filters,
warms, and humidifies air. The pharynx or throat is a tube-like structure that connects the back of the
nasal cavity and mouth to the larynx, a passageway for air, and the esophagus, a passageway for food.
The pharynx serves as a common hallway for the respiratory and digestive tracts, allowing both air and
food to pass through before entering the appropriate passageways.

The pharynx contains a specialized flap-like structure called the epiglottis that lowers over the
larynx to prevent the inhalation of food and liquid into the lower respiratory tract.

The larynx, or voice box, is a unique structure that contains the vocal cords, which are essential
for human speech. Small and triangular, the larynx extends from the epiglottis to the trachea. The larynx
helps control movement of the epiglottis. In addition, the larynx has specialized muscular folds that close
it off and also prevent food, foreign objects, and secretions such as saliva from entering the lower
respiratory tract.

LOWER RESPIRATORY TRACT

The lower respiratory tract begins with the trachea, which is just below the larynx. The trachea, or
windpipe, is a hollow, flexible, but sturdy air tube that contains C-shaped cartilage in its walls. The inner
portion of the trachea is called the lumen.

The first branching point of the respiratory tree occurs at the lower end of the trachea, which
divides into two larger airways of the lower respiratory tract called the right bronchus and left bronchus.
The wall of each bronchus contains substantial amounts of cartilage that help keep the airway open. Each
bronchus enters a lung at a site called the hilum. The bronchi branch sequentially into secondary bronchi
and tertiary bronchi.

The tertiary bronchi branch into the bronchioles. The bronchioles branch several times until they
arrive at the terminal bronchioles, each of which subsequently branches into two or more respiratory
bronchioles.

The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli are bubble-like,
elastic, thin-walled structures that are responsible for the lungs’ most vital function: the exchange of
oxygen and carbon dioxide.
 Each structure of the lower respiratory tract, beginning with the trachea, divides into smaller
branches. This branching pattern occurs multiple times, creating multiple branches. In this way, the lower
respiratory tract resembles an “upside-down” tree that begins with one trachea “trunk” and ends with
more than 250 million alveoli “leaves”. Because of this resemblance, the lower respiratory tract is often
referred to as the respiratory tree.
Pathophysiology

Precipitating Factors
Predisposing Factors: Etiology:

Mycobacterium
tuberculosis Occupation (health care workers)
 Immune compromised status
Repeated close contact with infected
Severely malnourished
persons.

Economically- disadvantaged or
homeless/ poor housing

Exposure or inhalation of infected droplet

nuclei from infected clients by coughing,
sneezing, talking, laughing and singing

Tubercle bacilli invasion in the apices

of the lungs or near the pleurae of
the lower lobes

Bronchopneumonia develops in the

lung tissue and tubercle bacilli are
ingested by wandering macrophages

Many of the bacilli survived before

hypersensitivity and immunity develops

Surviving bacilli is carried into

bronchopulmonary lymph nodes via
the lymphatic system and may even
spread throughout the body
 Inflammatory response occurs, TB
specific lymphocyte produces T-lytic
enzyme which lyses bacteria and
alveolar tissue

Material (bacteria & macrophage)

become necrotic

Production of cavities filled with

cheese-like mass of tubercle
bacilli, dead WBCs, necrotic lung
tissue
Partial occlusion which
interferes w/ the diffusion
- productive cough Drainage of necrotic materials into of O2 & CO2
the tracheobronchial tree
- phlegm
Areas of the lungs are
PRIMARY INFECTION inadequately ventilated

↓oxygen dyspnea
Lesions heal over a period
carrying
of time by forming scars
capacity
and later being calcified

Tubercle bacilli immunity develops hypoxia

(2 to 6 weeks after infection)
(maintains in the body as long as living bacilli
remains in the body) - pallor

- weakness
With medical intervention:
Inhibits further growth of the
bacilli and the development of - fatigue
- Early detection/ diagnosis of
the disease active infection (bacteria - tachycardia
becomes dormant)
- Multi-antibacterial therapy

- Fixed- dose therapy Reinfection

- TB DOTS (Direct Observed

Therapy) Reactivation of the tubercle
bacilli

Good prognosis
SECONDARY INFECTION
 ↓ immune system

Bacteria becomes
resistant and survives

Active infection
develops

Ulceration of the lesions

in the lungs hemoptysis

Severe occurrence of lesions in Accumulation of

the lungs leading to abscess pus in the chest
cavity
(empyema)

Lung consumption
- chest pain

- fever and chills

↓ alveolar tissue
- excessive sweating
leading to ↓ oxygen
- loss of appetite

DEATH
 CHAPTER II -PLANNING
A. List of Prioritized Nursing Diagnosis

CUES NURSING DIAGNOSIS RANK JUSTIFICATION

Subjective Cues: Ineffective airway 1  Airway must be given the first attention as based on the rule of
- Patient verbalized, “Matagal na akong inuubo. Wala clearance related to ABC which is Airway, Breathing and Circulation. In addition,
namang plema. Nahihirapan akong huminga”. retained secretions in the difficulty of breathing can cause anxiety to the client that is
respiratory tract why, immediate attention must be done. Addressing the
Objective Cues: secondary to bacterial problem to proper health care provider will give patent airway
- Presence of adventitious breath sound (Crackles) infection as evidenced by to the client. Oxygenation is a vital need for every cell, if there
upon auscultation. crackles upon are any problems related to it can easily affect the functioning
-The patient is coughing without phlegm. auscultation. of the individual.
- Oriented  Retained secretions can cause blockage of airway which will
- BP- 90/70 mmHg, CR: 84 bpm, RR: 36 cpm, T-37.5 further cause difficulty of breathing (Fundamentals of Nursing
C 7th ed by Kozier et al. p. 1299)
- Difficulty vocalizing
- Has hallow eyes.
- Bluish nail beds.

Subjective: Hyperthermia related to 2  This demands immediate treatment/care and subsequent

-The husband of the client verbalized, “Naku hindi na infection as evidenced by medical attention, as they can result in delirium and
nawala ang lagnat ng asawa ko, pabalik-balik na lang” increased WBC convulsions. This is an actual problem that needs to be
addressed.
Objective:  Lack of action in this health care problem may cause
-Flushed skin; warm to touch dehydration which may later cause a bigger threat to the health
-Increase body temperature higher than normal range of the client.
-Increased respiration
-The patient is sweating
-T: 37.5˚C

Subjective: Imbalanced Nutrition: 3  This condition needs to be addressed immediately for the client
- The patient is only eating 4 spoons of rice with viand. Less than Body to be able to gain enough strength in performing her usual
- The relative verbalized “Hindi siya nakakakain ng Requirements related to activities.
maayus dahil sa kanyang ubo”. inability to ingest food  The body obtains energy in the form of calories from
because of prolonged carbohydrates, protein and fat. The body uses energy for
Objective: cough as evidenced by voluntary activities such as walking and in involuntary
- The patient weight is 31.5 kilograms. decreased BMI. activities such as breathing. (Fundamentals of Nursing 7th ed by
- Poor muscle tone. Kozier et al.)
- Appears weak.
- Minimal subcutaneous fat.
B. Nursing Care Plan
ASSESSMENT
Subjective Cues:
- Patient verbalized,
“Matagal na akong
inuubo. Wala namang
plema. Nahihirapan akong
huminga”.
Objective Cues:
- Presence of adventitious
breath sound (Crackles)
upon auscultation.
-The patient is coughing
without phlegm.
- Oriented
- BP- 90/70 mmHg, CR:
84 bpm, RR: 36 cpm, T-
31.5 C
- Difficulty vocalizing
- Has hallow eyes.
- Bluish nail beds.
NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Ineffective airway Short-term Goal: Goal met. Within 4
clearance related to After 1 hour of 1. Obtain vital signs of the - Health status is regulated hours of nursing
retained secretions in nursing patient. through homeostatic intervention, the patient
the respiratory tract intervention, mechanisms. A change in V/S was able to maintain
secondary to bacterial patient will be able might indicate health change. patent airway through
infection as evidenced to: the mobilization of
by crackles upon -Nasal flaring and use of secretions as evidenced
auscultation. - mobilize her 2. Observe for respiratory rate accessory muscles indicate by productive cough.
secretions through and rhythm; presence of nasal increased effort is required for
the interventions flaring; and use of accessory breathing.
done by the nurse. muscles when breathing like the
diaphragm and coastal muscles.
- maintain patent
airway through the 3. Perform the Blanch Test. - Blanch test reflects the
performance of at adequacy of o2 circulation in
least 3 the periphery.
interventions.
4. Auscultate the lungs to note -Crackles are intermittent
Long-term Goal: any lung sounds. sounds that occur when air
Within 4 hours of moves through airway that
nursing contain fluids.
intervention, the
patient will be able -Tapping the chest can loosen
to maintain patent 5. Perform Chest physiotherapy. the secretions.
airway through the
mobilization of
secretions as 6. Suction secretion as needed. -Suction removes secretions
evidenced by using a strong pressure.
productive cough.
 7. Increase the amount of oral
fluid intake as ordered by the
doctor.
- Current data indicates that
fluid restriction may reduce
blood volume and decrease
cerebral circulation. The lack
of volume causes the blood to
be thick and sluggish and may
decrease the mobilization of
nutrition and toxins out of the
circulation. Patient should be
maintained in a euvolemic
state rather than a fluid-
restricted state.

8. Administer bronchodilators as - They act on the respiratory

ordered. tract, it opens narrowed
airways.

9. Elevate the head of the bed. - For maximal lung expansion

10. Position the head in the
midline of the body.
that will improve oxygen
delivery.
-Position changes allow free
movement of the diaphragm
and expansion of the chest
wall.

Assessment Nursing Diagnosis PLANNING Nursing Interventions Rationale Evaluation

Subjective: Hyperthermia related to Short-term Goal:  Identify underlying cause (eg.  To know for the right Goal met. After 8 hours
inflammatory response hypothalamic dysfunction, such treatment to be given. of nursing interventions,
-The husband of the as evidenced by warm After 3 hours of as drug overdose and infection). the client was able to
client verbalized, “Naku to touch skin. nursing lessen temperature from
hindi na nawala ang intervention,
lagnat ng asawa ko, - the family of the  Monitor patient’s vital signs. 37.5˚C to 36.8˚C.
pabalik-balik na lang.” client will be able Give particular attention to the
to assess for the temperature.  Temperature of 102˚F-
Objective: causative/ 106˚F (38.9˚C- 41.1˚C)
-Flushed skin; warm to contributing suggests acute infectious
touch factor/s and be able disease process. Fever pattern
-Increase body to participate in one may aid in diagnosis, eg 24
temperature higher than intervention. hour period suggest septic
normal range episode, septic endocarditis or
-Increased respiration Tuberculosis (TB). Chills
-The patient is sweating often precede temperature
- the family of the spikes.
-T: 37.5˚C client will be able
to evaluate effects  Assess for presence of
of hyperthermia posturing or seizures.  To note for further care to be
and be able to given.
participate in at  Monitor/ record all sources of
least 3 out of 4 fluid loss such as urine.  Oliguria and/or renal failure
interventions. may be occurring due to
hypotension, dehydration.

- family of the  Note presence/ absence of  Evaporation is decreased by

client will be able sweating as body attempts to environmental factors of high
to assist with increase heat loss by humidity and high ambient
measures to reduce evaporation, conduction and temperature as well as body
body temperature diffusion. factors producing loss of
and participate in at ability to sweat or sweat gland
least 3 out of 4 dysfunction.
interventions.
 Administer antipyretics.  Used to reduce fever by its
central action on the
Long-term Goal: hypothalamus; fever should be
controlled in patients who are
After 8 hours of
neutropenic or asplenis.
nursing
However, fever may be
interventions, the
beneficial in limiting growth
client will be able
of organisms and enhancing
to lessen
autodestruction of infected
temperature of at
cells.
least 1˚C range
 from that of 39˚C-
41˚C to 38˚C-39˚C
and be free of  Provide tepid sponge baths;  May help reduce fever.
chills. avoid use of alcohol. Note: use of ice water/ alcohol
may cause chills, elevating
temperature. In addition,
alcohol is very drying to skin.

 To support circulating
 Administer replacement fluids
volume and tissue perfusion.
and electrolytes.

 To meet increased metabolic

demands.
 Provide high-calorie diet, tube
feedings or parenteral nutrition.

 To prevent dehydration.
 Discuss importance of
adequate fluid intake.
 Indicates need for prompt
intervention.
 Review signs and symptoms of
hyperthermia (eg. Flushed skin,
increased body temperature,
increased respiratory/heart rate).

ASSESSMENT NURSING GOAL and NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES

Subjective: Imbalanced Nutrition: After 5 days of Goal partially met. After

- The patient is only Less than Body nursing Note real, exact weight; do not These anthropomorphic 3 weeks of nursing
eating 4 spoons of rice Requirements related to intervention, the estimate. assessments are vital that they intervention, the patient
with viand. inability to ingest food patient will be able need to be accurate. These will was able to gain 4
- The relative verbalized because of prolonged to: be used as basis for caloric kilograms.
“Hindi siya nakakakain cough as evidenced by
ng maayus dahil sa decreased BMI. - Verbalize and and nutrient requirements.
kanyang ubo”. demonstrate
selection of foods Family members may provide
Objective: or meals that will more accurate details on the
Take a nutritional history with
- The patient weight is achieve a cessation patient’s eating habits,
the participation of significant
31.5 kilograms. of weight loss. especially if patient has altered
others. to be accurate.
- Poor muscle tone. perception.
- Appears weak. After 3 weeks of
- Minimal subcutaneous nursing
fat. intervention, the The patient encountering
patient will be able nutritional deficiencies may
to: Look for physical signs of poor resemble to be sluggish and
Have weight within nutritional intake. fatigued. Other manifestations
10% of ideal body include decreased attention
weight. span, confused, pale and dry
skin, subcutaneous tissue loss,
dull and brittle hair, and red,
swollen tongue and mucous
membranes. Vital signs may
show tachycardia and elevated
BP. Paresthesias may also be
present.

A pleasing atmosphere helps

in decreasing stress and is
more favorable to eating.

Elevating the head of bed 30

Provide a pleasant environment. degrees aids in swallowing
and reduces risk for aspiration
with eating.

Promote proper positioning. Nursing assistance with

If patient lacks strength,
activities of daily living
(ADLs) will conserve the
patient’s energy for activities
the patient values. Patients
who take longer than one hour
to complete a meal may
schedule rest periods before
meals and open packages and cut
up food for patient.
Determine time of day when the
patient’s appetite is at peak.
Offer highest calorie meal at that
time.
Validate the patient’s feelings
regarding the impact of current
lifestyle, finances, and
transportation on ability to
obtain nutritious food.
require assistance.
Patients with liver disease
often have their largest
appetite at breakfast time.
Validation lets the patient
know that the nurse has heard
and understands what was
said, and it promotes the
nurse-patient relationship.
Chapter III - IMPLEMENTATION
A. Medical Management

1. Drug Study

Generic Name: CEFUROXIME 200 mg TIV q8 hours ANST (-)

Brand Name: CEFTIN
Classification Action Indication Adverse Effect Nursing Consideration
ND nd
2 generation A 2 generation cephalosporin Treatment of susceptible Allergic reaction, oral Ask the patient if he has a
cephalosporin that binds to bacterial cell infection due to group B candidiasis, mild history of allergies to
membranes and inhibits cell streptococcus, E. coli, H. diarrhea, mild abdominal drugs, particularly to
wall synthesis. influenza etc. cramping. cephalosporin and
penicillin.

Generic Name: IPRATROPIUM BROMIDE q4 hours

Brand Name: COMBIVENT, DOUNEB
Classification Action
Anti-cholinergic An anti-cholinergic that blocks
bronchodilator the action of acetylcholine at
parasympathetic sites in
bronchial smooth muscles.
Indication
Maintenance treatment of
bronchospasm due to
chronic obstruction
pulmonary disease (COPD),
bronchitis, emphysema,
asthma.
Adverse Effect Nursing Consideration
Hypotension, insomnia, Monitor Vital signs
metallic or unpleasant Monitor intake and output
taste, palpitations, urine
reaction.

Generic Name: RIFAMPICIN 2 Tablets before lunch and 1 tablet before dinner
Brand Name: MYRIN-P FORTE
Classification Action Indication Adverse Effect Nursing Consideration
Antituberculosis Inhibits RNA synthesis, Initial phase treatment and Disorder of the blood and Explain to the patient to
decreases tubercle bacilli retreatment of all forms of lymphatic system, expect an orange color of
replication TB in category I and II immune system, urine.
patients caused by metabolism and nutrition,
susceptible strains of CNS, eye, GI, skin and Monitor I & O.
mycobacterium. tissues, renal, fever,
 dryness of mouth.

Generic Name: TRAMADOL 50 mg

Brand Name: ULTRAM
Classification Action
Analgesic, centrally- An analgesic that binds to mu-
acting opoid receptors and inhibits
reuptake of norepinephrine and
serotonin. Reduces the intensity
of pain stimuli reaching
sensory nerve ending.
Indication
Uses for management of
moderate to moderately
severe pain.
Adverse Effect Nursing Consideration
CNS: dizziness, vertigo, Monitor vital signs
anxiety, sleep disorder, especially Blood
migraine. pressure.
GI: nausea and vomiting,
constipation, abdominal Monitor input and output.
pain, anorexia.
OTHERS: rash, sweating, Assist with ambulation if
hypotension, urinary dizziness and vertigo
retention. occurs.

Drug: LYSMIX 20 ml / amp TID

Classification
Parenteral nutritional
products
Multivitamins with
minerals used as dietary
supplements
Contents Indication Dossage
Per amp- L-lysine Nutritional supplements Adult: 1 amp BID –
monohydrochloride 20mg, L- TID
histamin monoHCl 4mg, dl- Lysmix 20 ml x 5’s
methionine 10mg, thiamine HCl
(Vit. B1) 1mg, riboflavin (Vit.
B2) 100mcg, pyridoxine HCl
(Vit. B6) 100mcg, taurine 4mg,
dextrose 100mg.

Generic Name: AMINO ACID 20ml/ Ampule TIV q8 hrs

Brand Name: MORIAVIT
Classification Action Indication Adverse Effect Nursing
Intervention
 Calorics (Nutritional Drug) Provides a substrate for
protein synthesis or
increases conservation of
existing body protein.
Total Parenteral Nutrition CNS: Fever
GI: Flushing
GU: Osmotic dieresis
Metabolic: electrolytes
imbalance, weight gain
Musculoskeletal:
Osteoporosis
Monitor body
temperature every 4
hours.
Obtain baseline
electrolyte, glucose,
BUN, calcium and
phosphorus levels
before giving drugs.

2. Treatment

Treatment / Infusion Classification Indication Contraindication Nursing Responsibilities

*Do not connect flexible plastic containers of intravenous
solutions in series, i.e., do not piggyback connections. Such
use could result in air embolism due to residual air being
drawn from one container before administration of the fluid
*Hypovolemia from a secondary container is completed.
*Heat-related
emergencies *Pressurizing intravenous solutions contained in flexible
Plain NSS Isotonic *CHF plastic containers to increase flow rates can result in air
*Freshwater drowning embolism if the residual air in the container is not fully
evacuated prior to administration.
*Diabetic
ketoacidosis(DKA) *Use of a vented intravenous administration set with the
vent in the open position could result in air embolism.
Vented intravenous administration sets with the vent in the
open position should not be used with flexible plastic
contain.
3. Diet

Sample Menu Plan

1am Meal Serving
5am
9am DAT
1pm
6pm

C. Activity and Exercise

Before Hospitalization During Hospitalization Analysis/Interpretation

a. Fluid & Skipping meals most of the time,
Nutrition according to the significant others.
Mr. ADL is more on vices.
His fluid preferences are water,
softdrinks and liquor.
Mr. ADL drinks 3-4 glass of water a
day and can consume Liquor of 3-4
beer a day.
Moderate decrease of the
appetite; can consume about ½ of
the foods given.
Diet as tolerated was advised to
Mr. ADL.
Due to medication given as side
effects such as Combivent and
Rifampicin, there is a decrease of
appetite.
The patient was trained to take DAT
diet to sustain his nutritional needs.

He is more on bread in the morning;

vegetables and fish most of their
meals.

b. Elimination Mr. ADL usually voids large amount Usually voids 2-4 times a day. There is a decrease bowel movement
of urine, 5-7 x a day. due to decrease appetite.
Defecates at least once a day. Mr. ADL defecates every other
day.
c. Safety, Activity Doing his job as a car washer was his
& Exercise form of exercise everyday.
d. Hygiene & The patient takes a bath once a day
Comfort and brushes his teeth twice a day.
e. Rest & Sleep The patient sleeps more or less than 5
hours a day.
f. Substance Mr. ADL is more on vices. He is fun
Abuse of drinking San Miguel Beer and can
consume 3-4 glasses everyday. He
also smokes at least 12-18 sticks of
Hope everyday.
g. Sexual Activity According to the Mother, she doesn’t
have an idea about sexual activity of
Mr. ADL; she only knew that Mr.
ADL is single and no girlfriend as of
now.
There is no exercise at all because Patient’s daily exercise is limited
of CTT attached on his abdomen. because of body weakness and CTT
He habitually sits on bed during attach on his abdomen.
confinement.
Restricted on bed; the patient Dependence related to restricted
can’t take a bath due to CTT done mobility after surgical procedure.
in his right. All hygienic activities
are assisted by SO.
The patient sleeps irregularly. 30 Due to inadequate rest the patient may
minutes of sleeps then awake have decrease body resistance.
again.
Restricted on vices during Restricted vices will lead to
hospital confinement as immediate cure of TB.
recommended by the attending
physician due to treating of TB.
Restricted sexual activity during Restricted sexual activity.
confinement.
D. Surgical Management

Mr. ADL has a fluid (hydrothorax) in his right lung, but when Chest Tube Thoracostomy was performed
last August 22, 2020, there was no fluid extracted, the fluid was noted in the right lung.

Chest Tube Thoracostomy

 Returns (-) pressure to the internal pleural space.
 Remove abnormal accumulation of air.
 Serves as lung while healing is ongoing.
The insertion of chest tube permits removal of the air or bloody fluid and allows re-expansion of the
lungs and restoration of the normal negative pressure in the pleural space. Because air rises, a chest tube
inserted to remove air is usually placed anteriorly through the 2 nd ICS. A chest tube inserted to remove
fluids is placed posteriorly in the 8 th and 9th ICS because fluid tends to flow to the bottom of the pleural
space.

Chest Drainage Container

A water-seal at the end of a chest tube is essential to allow air to escape through the tube but prevent
air from traveling back up the tube and into the pleural space. The water-seal drainage system is placed
below the level of the patient’s chest, taking advantage of the force or gravity to promote drainage and
prevent backflow of bottle contents into the pleural space.
 B. Client’s Daily Progress Chart

August 21, 2020

2:00pm – 10:00pm
 Admitted a 24 years old male accompanied by relatives with a complained of difficulty of
breathing.
 Vital signs are taken and recorded with a BP: 100/70 mmHg, HR: 81 bpm, RR: 35 bpm
 Seen and examined by Dra. Magtoto
 Consent signed and secured
 Tuberculin skin test done; due at 3:30 pm
 IVF of D5NM 1L + 1 ampule of Lysmix inserted and regulated with 31 gtts/min
 Laboratory requested by the attending physician such as; Urine analysis, Ultrasound of right lung,
BUN and Creatinine, and chest X-ray
 Transferred to Charity Medical Ward, bed 22
 Endorsed

August 22, 2020

2:00pm – 10:00pm
 Received on bed with an IVF of D5NM 1L + 1 ampule of Lysmix @ 600ml level
 Conscious and coherent
 Vital signs are taken and recorded with blood pressure of 100/70 mmHg
 A febrile 36.5
 NPO was advice
2:30pm
 Consent signed and secured.
3:00pm
 Undergone CTT @ right lung.
 Vital signs recheck
 Needs attended
 Endorsed

August 23, 2020

2:00pm – 10:00pm
 Received on bed with an IVF of D5NM 1L + 1 ampule of Moriavit X 8 hours @ consuming level
 Vital signs taken and recorded with Blood Pressure of 100/70 mmHg
4:00pm
 Cefuroxime 200mg TIV after negative skin test
6:00pm
 Vital signs recheck with no significance finding
  Needs attended
 Endorsed

August 24, 2020

2:00pm – 10:00pm
 Received on bed with an IVF of 1L @ 400cc level
 Vital signs taken and recorded BP: 90/60 mmHg, PR: 90 bpm, RR: 29 bpm and Temperature:
36.6 C
 With abnormal RR: 29 bpm
 Diet as tolerated maintained
 Due medication given and recorded
4:00pm
 Cefuroxime 200mg TIV after negative skin test
7:00pm
 Rifampicin 1 tablet before dinner
 Vital signs recheck with no significance finding
 Needs attended
 Endorsed

August 25, 2020

2:00pm – 10:00pm
 Received on bed alert, coherent, cooperative.
 With an IVF of D5NM 1L + 1 ampule of Moriavit @ 700cc level and regulated with 31 gtts/min
on the right hand
 Vital signs taken and recorded
 Afternoon care rendered
 Health teaching done
 Medication given
 Needs attended
 No other complaints
 Endorsed

CHAPTER IV – EVALUATION
Discharge Planning Instruction

M- Medications
 Medications should be taken as ordered and prescribed by the physician to avoid complications and
help manage the condition of the patient. The intensive phase is for 2 months, and the maintenance phase
is for 4 months. Medicines are readily available at the health center.

E- Exercise

 Instruct the patient to have a time for deep breathing exercise every day for several times at home
to helps achieved maximal lung expansion and for relaxation.
 Start with exercises that you are already comfortable doing. Starting slowly makes it less likely
that you will injure yourself.
 Immediately stop any activities that might causes undue fatigue, increased shortness of breath or
chest pain.

T- Treatment

 Remind the importance of taking the medication in the right time and dose.
 Sleep in a room with good ventilation.
 Limit your activity to avoid fatigue. Frequent rest is advice.
 Maintained wound integrity on the surgical site.

H- Health Teachings

 Advise to take the medication on time and with the right dosage.
 Semi-fowlers position is advice most of the time for breathing relaxation.
 Avoid close contact with others until the doctor finds it Okay.
 Advise the client to turn your head when coughing. Keep tissues with you and cover your
mouth when you cough then throws the tissues used in the plastic bag.
 Keep your hands clean. Maintain proper hygiene.
 Isolate techniques is one of the best way to prevent the speared of the bacteria; separation of
dining ware.
 Advise the relatives to clean the environment regularly since it is one of the factors that
contribute to the speared of bacteria.
 Discuss to the client and significant others the cardinal signs of infection such as redness, heat,
induration, swelling and separation of drainage.

O- Out- patient follow- up

 Most of the treatment to cure Pulmonary Tuberculosis can be given at home but must be taken as
explained by the health care worker. The family has the responsibility to check the status of the patient
and the progress of it.

D- Diet

 Diet as tolerated is advice by the attending physician, to sustain his nutritional needs.
 High protein diet for tissue repair - meat and green leafy vegetables.

S- Spiritual practice

Mr. ADL’s religion is Catholic, encourage the patient pray daily, go to church regularly and
increase his faith with God Almighty.

NTENSIVE CONTINUATION PHASE

PHASE
Regime Drugs Interval and Drugs Interval and Range of Comments
n Dose Dose Total
(minimum (minimum Doses
duration) duration)
1 INH 7 days/week INH 7 days/week 182 to 130 This is the preferred
RIF for 56 doses RIF for 126 doses regimen for patients
PZA (8 weeks) (18 weeks) with newly diagnosed
EMB or or pulmonary TB.
5 days/week 5 days/week
for 40 doses for 90 doses
(8 weeks) (18 weeks)
2 INH 7 days/week INH 3 times 110 to 94 Preferred alternative
RIF for 56 doses RIF weekly for 54 regimen in situations in
PZA (8 weeks) doses (18 which more frequent
EMB or weeks) DOT during
5 days/week continuation phase is
for 40 doses difficult to achieve.
(8 weeks)
3 INH 3 times INH 3 times 78 Use regimen with
RIF weekly for RIF weekly for 54 caution in patients with
PZA 24 doses (8 doses (18 HIV and/or cavitary
EMB weeks) weeks) disease. Missed doses
can lead to treatment
failure, relapse, and
acquired drug resistance.
 4 INH 7 days/week INH Twice weekly 62 Do not use twice-weekly
RIF for 14 doses RIF for 36 doses regimens in HIV-
PZA then twice (18 weeks) infected patients or
EMB weekly for patients with smear
12 doses positive and/or cavitary
disease. If doses are
missed then therapy is
equivalent to once
weekly, which is
inferior.

Reference: https://www.cdc.gov/tb/topic/treatment/tbdisease.htm?
fbclid=IwAR0FrJqOIUQztNf_xXMyg6kVSyFpKoPV7_E0eo5-TIvSeoRKaRCo0XLNiBU